abdomen and great flatulent distention. When a medical
man is consulted the case is, in all probability, and quite
excusably, considered one of diarrhoea of a dysenteric
character, and treated with some stomachic and opiate
mixture, which affords temporary relief. After this condi-
tion has lasted for some months, the length of this period of
comparative quiescence being influenced by the seat of the
ulceration and the rapidity of its extension, the patient
begins to have more burning pain after an evacuation, there
is also greater straining and an increase in the quantity of
discharge from the bowel ; there is now not so much jelly-
like matter, but more pus — more of the coffee-ground
discharge, and blood. The pain suffered is not very acute,
but very wearing ; described as like a dull toothache, and it
is induced now by much standing about or walking. At this
stage of complaint the diarrhaea comes on in the evening as
well as the morning, and the patient's health begins to give
way, only triflingly so, perhaps, but he is dyspeptic, loses his
appetite, and has pain in the rectum during the night, which
disturbs his rest ; he also has wandering and apparently
anomalous pains in the back, hips, down the leg, and some-
times in the penis. There is yet another symptom present
in the later stages, marking the existence of some slight con-
l68 ULCERATION AND STRICTURE OF THE RECTUM.
traction of the bowel, viz., alternating attacks of diarrhoea
and constipation, and during the attacks of diarrhoea the
patient passes a very large quantity of faeces. These seizures
are attended with severe colicky pains in the abdomen, faint-
ness, and not unfrequently sickness.
As the ulceration extends, attempts at healing take place:
these result in infiltration and thickening of the submu-
cuous and muscular tissues, and consequent diminution of
the calibre of the bowel, so that real stricture of various
forms supervenes. Coincident with all this there results a
gradual loss of the contractile power of the rectum, and
almost complete immobility, so that the lower part of the
gut is converted into a passive tube through which the faeces,
if fluid, trickle; but if solid, they stick fast until pushed
through by fresh formations above them. Invariably, also,
there is loss of power in the sphincters. When diarrhoea is
present the patient has little or no control over his motions.
Usually by this time abscesses have formed, or are in pro-
cess of formation, and these breaking, soon become fistulae.
I have seen persons with as many as eight external orifices,
some situated three inches or more from the anus.
On examining these cases of ulceration of the rectum,
various conditions may be noticed, according to the stage
to which the disease has advanced. In the earlier period
you may often feel an ulcer situated dorsally about one and
a half inches from the anus, oval in form, perhaps an inch
long by half an inch wide, surrounded by a raised and
sometimes hard edge; there is acute pain caused on touch-
ing it, and it may be readily made to bleed. With a specu-
lum you can distinctly see the ulcer, the edges well marked,
the base grayish or very red and inflamed looking, the sur-
rounding mucuous membrane being probably healthy; in the
neighborhood of the ulcer may often be felt some lumps,
which are either gummata or enlarged rectal glands. This
is the stage in which the disease is often curable, as I shall
show when speaking of treatment. Later in the progress of
the malady, you will observe deep ulcers, with great thick-
ening of the mucous membrane, often, also, roughening to
a considerable extent, as though the mucous membrane had
been stripped off. At this stage you generally notice, out-
side the anus, swollen and tender flaps of skin, shiny, and
covered with an ichorous discharge; these flaps are com-
,monly club-shaped, and are met with also in malignant dis-
ease; but in the early development of the disease no ulcer-
ULCERATION AND STRICTURE OF THE RECTUM. 169
ation is found near the anus nor at the aperture. It
is in private practice that we have the best opportunity
of seeing these cases early, and I most positively repeat that
the large majority do not commence by any manifestation
at the anus, such as growths or sores; occasionally a fissure
may be the first lesion, and the ulceration extend from the
wound made in attempting to cure it; this is, however, the
exception to the rule, and I will further on relate some
cases to show that what I have stated is correct. So defi-
nite is this external appearance in long-standing disease,
that one glance is sufficient to enable an expert to predicate
the existence of either cancer or severe ulceration; these
external enlargements are the result of the ulceration going
on in the bowel, and the irritation caused by almost constant
discharge. The ulceration may be confined to a part of the
circumference of the bowel, or it may extend all round, and
for some distance, but not usually for more than four inches
up the rectum. It also probably will have traveled down-
ward close to the anus, and then the pain is sure to be very
severe, because the part is more sensitive and more exposed
to external influences and practices.
AVhen the disease has reached this stage, of course, stric-
ture and most probably fistulse will be present, as I have
already mentioned; and possibly, but not frequently, perfo-
ration into the bladder, into the vagina, or the peritoneal
cavity, may occur. The state of the patient is now lament-
able; his or her aspect resembles that of a sufferer from
malignant disease, and no remedy short of lumbar colotomy
offers much chance of even prolonging life. You may
relieve these patients, but can rarely do more; a cure can
scarcely be expected. I have seen ulceration utterly destroy
both the anal sphincters, so that the anus was but a deep,
ragged hole. Here is such a case, which was under my care
at St. Mark's Hospital.
Matilda G , admitted under my care January, 187 1.
She is a married woman, twenty-eight years of age. Five
years ago she was a patient of mine with stricture and ulcer-
ation. She went on tolerably well, and continued so up to
about eighteen months back; since then she has suffered
much; she had constant pain and discharge from the bowels;
she either has constipation or diarrhoea. There is entire
incontinence of faeces. The straining and bearing down are
very distressing; her aspect is worn and sallow; she is not
very emaciated; there is no evidence of syphilis or consump-
170 ULCERATION AND STRICTURE OF THE RECTUM.
tion. On examination a large, ragged, deep hole is seen
instead of an anus; it is surrounded by swollen flaps of
skin, two of which are perforated by fistulae; the hole meas-
ures about two inches each way, and there is not a vestige of
sphincter muscle left. On introducing the finger into the
bowel, it is found quite blocked up by contraction and
thickening; only a very small aperture can be felt, but into
this the end of the finger cannot be passed. Chloroform
being given, she strained down so violently that the strictured
portion of the bowel was forced outside, so that the ulcera-
tion and stricture could be plainly seen. The aperture was
not larger than a No. lo male catheter. I saw this patient
over and over again ; she was always benefited by treat-
ment, but not cured; at length she died in the workhouse.
Years may have elapsed before the dreadful condition I
have been describing has been brought about, but it is one
we only too frequently see at St. Mark's.
Patients suffering from ulceration and stricture are very
liable to attacks of a low form of peritonitis, attended with
considerable abdominal pain, often intense for a short
period. There are generally one or more spots that
are tender on pressure; there is tympanites, often vomiting,
especially on first assuming the erect position in the morn-
ing, and generally the pain is brought on by standing or
moving about; these attacks are sure to end in diarrhoea.
The treatment should be perfect rest in bed, spoon diet, and
opium "may be given freely; fomentations relieve the pain,
but I have not seen any benefit result from counter-irrita-
tion. I have often found that calomel and opium given for
some time is advantageous in these cases.
When making a post-mortem examination in such cases I
have observed effusion into the peritoneal cavity, and often
considerable old and recent adhesions between the intes-
tines; the peritoneum is also thickened. In bad ulceration
you see what great destruction of tissue has taken place. I
found the whole of the rectum and sigmoid flexure involved
in ulceration, and great thickening and contraction of the
calibre of the bowel, caused by the attempt at repair in
various parts.* The connective tissue here and there is so
removed as to leave large bridges of indurated muscle and
roughened mucous membrane; and there is ulceration, so
deep in places that perforation must have occurred but for
the adhesion kindly made by nature to the adjacent parts.
In other situations the muscular coat is laid quite bare, and
ULCERATION AND STRICTURE OF THE RECTUM.
171
I have seen more than one case in which necrosis of the
sacrum has taken place.
The following table of seventy cases which have been
under my care at St. Mark's Hospital exhibits, I think,
many points worthy of consideration: —
Seventy Cases of Ulceration and Stricture of the Rectum, taken
from Mr. Allingha77i' s Practice at St. Mark's IIosj)ifal.
I Constitutional
syjihilis or not.
Yes, tertiary
Yes, nodes
Severe cons.
syph.
No iiistory or
apearance
No syphilis ;
struma
Cons. syph. ,
nodes on fore-
head
No history of
syph.
Cons. syph. ; (8
years)
No symptoms
of syphilis nor
history
Syphilis well
marked
Ditto
Probably,
Sore throat
now
No symptoms or
hist, of syph.
Cons. syph.
No symptoms
or history
No symptoms or
. history
Cons. syph.
None
Stricture a?td ulceration,
luhere _found.
Stricture 2 inches up ;
ulceration above and be-
low
Ulceration from anus ;
stricture 2 inches
Stricture impermeable high
^ up
Severe ulceration and stric-
ture 2 inches from anus
Small ulcer ; stricture t%
inch ; ulceration above
stricture
Stricture 1% inch ; hyper-
trophy of nymphae
Stricture 2 inches ; ulcera-
tion high up
Stricture 3 inches long, %
inch from anus
Extensive ulceration ; two
strictures high up
Stricture 1% inch from
anus ; ulceration above
and below ; hardness
Stricture 2 inches from
anus ; severe ulceration
Stricture just within reach
of finger; no ulceration
between anus and stric-
ture
Stricture two inches ; much
ulceration
Stricture x^/i inch from
anus ; ulceration above
Stricture 2% inches ; bad
ulceration above and be-
low stricture
Stricture j% inch ; ulcera-
tion near anus
Stricture r% inch ulcera-
tion deep above and
below stricture
Simple Stricture 2 inches
from anus ; much indura-
tion but no ulceration
Complications and
observations.
Fistula; mucous tubercles;
primary infection 5 years
since.
Sores on labia ; fistula ;
primary symptoms 5
years ago.
Recto-vaginal fistula; colo-
tomy ; lived 18 months.
No complication ; outside
parts normal.
Outward parts quite npr-
mal ; hymen present ;
under treatment 8 years;
died, exhaustion.
Ulceration very high; colo-
tomy 3 years ago ; now
living.
Fistulae in all directions,
from which great indura-
tion ; colotomy ; success.
No complications ; colo-
tomy successful.
Attempted colotomy (right
side) ; death 56 hours.
Large flaps of skin outside,
and fistula.
Recto-vaginal fistula ; sy-
philis 7 years at least.
Recto-vaginal fistula; anus
not affected.
Fistula; no disease of anus;
came on as abscess.
Anus normal; syphilis 12
years ; had treatment.
Fistula both sides of anus;
large flaps of hypertro-
phic skin; discharging.
Large fibroid polypus; easy
cure.
Dorsal fistula; anus normal;
syhilis 18 mos., rash
scaly, and ulceration on
tongue.
No internal abnormality ;
division and lasting cure.
172 ULCERATION AND STRICTURE OF THE RECTUM.
No.
>f^^
>9
40
20
20
21
30
22
42
P3
28
S4
39
25
24
26
53
27
27
.8^
25
29
33
30
22
31
28
32
31
33
50
34
37
35
22
S6
13
37
28
38
25
39
33
40
37
41
27
42
37
Constitutional
syphilis or not .
F. Cons. syph.
F. Ditto
! ,
F. No history of
I syphilis
F. Syphilis well
I marked
F. ^None
F. I Cons, syphilis
None
F.
Cons, syphilis
None
Cons, syphilis
None
None
Cons, syphilis
F. None
I
F. ;None
F. Cons, syphilis
F. [None
i
F. jNone
F. Cons, syphilis
Ditto
Doubtful ; no
historj' or
symptoms
Cons, syphilis
None
Cons, syphilis
Stricture and ulceration^
•where J'oufid.
Ulceration commencing i
inch above anus, stricture
2 inches
Tight stricture 2 inches ;
ulceration
Very little stricture 2 in-
ches ; superficial ulcera-
tion
Stricture i inch up ; ulcera-
tion severe and deep
Annular cord-like stricture
2 inches ; ulceration near
anus
Stricture 1% inch from
anus ; not much ulcera-
tion
Stricture 2 inches, dense
and long ; ulceration se-
vere j
Stricture tight ; no ulcera-
tion above or below j
Stricture just inside anus ;
no ulceration ; cure b^'
incision and dilation
Stricture 2 inches from
anus; ulceration below
and above.
Stricture 2 inches from
anus ; ulceration severe |
Stricture annular, i^^ in-
ches up ; ulceration se-i
vere
Stricture severe and long,'
commencing i inch fromj
anus ; deep and extensive I
ulceration I
Stricture i]A, inch ; much
soft ulceration I
Stricture 2 inches up;
ulceration above and be-j
low I
Stricture^ inch from anus;
ulceration high up j
Stricture 2% inches up ;
ulceration above and!
below I
Stricture about 2 inches up;
little ulceration
Stricture 2 inches up ;
ulceration above and be-
low I
Stricture ij4 inches up ;
ulceration above and be-
low
Stricture just within reach;
ulceration below
Complications and
observations.
Anus naturaL
Mucous tubercles ; hyper-
trophied nymphse.
Verrucse ; no sores ; speedy
cure.
Fistula ; great induration
and swollen lumps
around anus.
No complication
Large superficial sore in
perineum, extending into
anus ; fistula.
Recto-vaginal fistula, com-
menced after child-birth;
colotomy, success.
Fistula in ano ; syphilis 5
years.
No complication.
Syphilitic rash and sores ; 9
years of sj'philis.
Fistula in ano ; been oper-
ated upon several times.
Procidentia recti ; a curious
case, it comes through
the contraction.
Several large external
growths and three fistu-
lous sinuses.
Outward parts normal ;
died; gradual exhaustion.
No complication.
Rupia ; fistula in ano ; 10
years syphilis.
Haemorrhoids.
Fissure and polypus.
No complication ; 10 years
syphilis.
Fistula through labia and
into anus ; growths.
Fistula in ano ; recto-vagi-
nal fistula.
I Stricture 2 inches; severe Fistula ; growths; colo-
I ulceration tomy ; success.
j Stricture annular, 3 inches None ; cured by incisioa
up ; severe ulceration and dilatation.
Stricture i}^ inch up ; veryjHuge outside growths and
severe ulceration labial fistula ; colotomy ;
I euccess.
ULCERATION AND STRICTURE OF THE RECTUM.
173
Vo.
^^^
43
27
44
30
45
26
46
25
47
35
48
22
49
30
50
30
51
25
52
24
53
28
54
18
55
25
56
32
57
22
58
29
59
63
60
47
6i
50
62
53
63
40
64
34
65
26
66
38
67
29
68
19
Sex
F.
F.
F.
F.
M.
M.
M.
M.
M.
M.
M.
M.
Constitutional
syphilis or not.
None
Cons, syphilis
None
Cons, syphilis
None
Cons, syphilis
Very doubtful
Cons, syphilis
None
Cons, syphilis
Ditto
Ditto
Ditto
Ditto
None
None
None
None
Cons, syphilis
Ditto
None
Cons, syphilis
Ditto
Ditto
None
Cons, syphilis
Stricture and ulceration
where /ound.
Stricture i inch up ; super-
ficial ulceration
Stricture 2 inches up
ulceration slight
Stricture 1% inch up ; se-
vere, deep ulceration
Stricture 2 inches up ;
ulceration above and be-
low
Ulceration, so that the os
and cervix uteri came
through into the rectum
Impermeable stricture 2
inches up
Stricture 2 inches up ; not
much ulceration
Stricture high up ; ulcera-
tion severe
Stricture 2 inches ; ulcera-
tion slight
Stricture i inch up; ulcera-
tion severe
Stricture 2 inches up ;
ulceration only above ihe
stricture
Stricture \% inch ; no
ulceration at all
Stricture 2j^ inches up ;
ulceration severe above
and below
Stricture very high, only
just to be felt; ulceration
very deep
Stricture 1% inch up ; very
little ulceration
Stricture 3 inches up ;
ulceration below slight
Stricture i inch up ; ulcera-
tion above
Stricture only just to be
felt ; ulceration below
Stricture 3 inches from
anus ; much ulceration
Stricture 2 inches above
anus ; ulceration from
anus
Stricture 3 inches ; ulcera
tion all around rectum
Stricture i inch ; ulceration
above and below
Stricture i^ inch ; ulcera
tion severe above
Stricture 2 inches ; ulcera-
tion severe
Stricture i inch, annular ;
slight ulceration
No stricture : all sloughed
away
Complications and
observations.
None ; cured by division
and dilatation.
Recto-vaginal fistula.
Club-shaped growths out-
side around anus
Fistula in ano.
The uterus could not be
returned ; she menstruat-
ed into rectum.
Constipation 3 weeks ; co-
lotomy ; success.
None.
Fistula and outside
growths ; syphilis 5 or 6
years.
Internal Fistula; burrowinsj
up under stricture.
Fistula ; growths ; rupial
rash.
Fistula ; very recent stric-
ture, only noticed 6
months ; indurated sores
on nympha.
Verrucae ; labial abscess.
Haemorrhoids and fistula.
Fistula ; several sinuses ;
colotomy ; success.
Disease of uterus.
Fistula in ano and fissure.
Four fistulse around anus,
one perforating the vagi-
nal wall.
Fistula in ano ; complete
opening below stricture.
Numerous fistulse ; great
debility ; went home and
died.
Several hard ulcerated
growths ; very badly
syphilized, 5 years.
Bad fistula, fecal matter
passing through; colo-
tomy (alive 8 years after
operation) .
Ulceration down to anus ;
fistula in ano.
Stricture almost impass-
able ; colotomy (alive
now, ID years).
Two fistulous sinuses ; bad
condition.
Phthisical ; anus lost all
power.
Phthisis combined with
syphilis h ad played havoc
with him.
174 ULCERATION AND STRICTURE OF THE RECTUM.
No.
Age
Sex
1
Constitutional \stricture and ulceration^
syphilii or not.. where found.
1
Complications and
observations.
69
70
80
50
M.
M.
None
None
Stricture extending from
anus 3 inches up, very
hard
Annular stricture 2 inches
up ; not severe ulcera-
tion
Thought to be cancer, but
dilatation and small
doses of mercury cured
him.
Anus normal ; speedy cure
by division and dilata-
tion.
We may briefly call attention to some important points in
the above table. In 70 patients, 60 were females and 10
males, a large predominance of the former, but not so great
as has been given by some authors. Now you will find on
examining the table that 35 had suffered from undeniable
constitutional syphilis, while 5 had some symptoms, but not
decisive, of ever having had the disease, so I think this
number should be deducted from the whole number 70,
before we consider the statistics of the rest, viz. 65, and we
find 35 were most undoubtedly syphilitic, and 30 as
undoubtedly never had contracted syphilis, and many never
any venereal disease.
The males, though small in number, are worthy of a
moment's consideration ; of the 10 males, 6 had suffered from
some form of syphilis ; but 4 had not, and there was great
probability that they had not been affected by any venereal
disease ; they denied any venereal taint, and I think, from
the way they spoke, and the desire they had not to deceive
me (as I made it a matter of great importance to them, as
regards treatment, that they should tell me the truth), I felt
bound to believe them.
Ten of my cases were subjected to colotomy in the lumbar
region, and for the most part did well, and I believe several
(5 or 6) are now alive. Two of the women have married
since the operation. In one female I attempted to open the
ascending colon, and after a most careful search I failed to
find it, but in mistake opened the duodenum, as it embraces
the head of the pancreas. I like to mention this case, to
show how, in difficult cases, a practiced colotomist may go
astray. This patient had a very enlarged liver, and was in
the habit of tight lacing, so the liver, being pressed down-
ward, carried the ascending and transverse colon diagonally to
the left side, and Xht post-7?iortem examination showed it was
next to impossible to reach the ascending colon from my
ULCERATION AND STRICTURE OF THE RECTUM. 1 75
incision. I must observe that the duodenum when brought
up from a depth is very like the colon. Four hours after the
operation I knew what I had done, as a large and constant
flow of bile took place from the wound ; she vomitted fre-
quently, could take no nourishment, and died on the third
day.
Before and since that operation I have opened the ascend-
ing colon and found no particular difficulty, but there is no
doubt that the ascending colon is more liable to be dis-
placed than the descending. I do not in any way wish to
extenuate my error in the case ; at the time I grieved seri-
ously over it, and I have never forgotten it. I always think
I ought to have made a more careful examination, and to
have found that the liver was enlarged, and came so low
down as the crest of the ilium, and so was almost certain to
push the ascending colon out of place ; further, I now think
I ought by manipulation and percussion to have found that
the ascending and transverse colon was out of position.
However, we may learn more from our errors, if we take
them to heart and study them, than from all our successful
cases. In forty-seven operations the case I have related is
the only one in which I made any mistake or failed to find
the colon.
Of the 30 patients who had never been syphilized, it was
possible that many more, but highly probable that 13, had
never had any venereal affection whatever. Inoculation in
all these cases proved abortive, either there being no
result, or only a small, evanescent pimple appearing.
The cases here mentioned are No. 5, observed for 8 years,
died of exhaustion ; would not submit to colotomy.
No. 7. Colotomy performed with success, all ulcers heal-
ing ; this patient has now been seven years in good health.
No. 16. Had large fibroid polypus with stricture and
ulceration ; removal of polypus and dilatation with incision
effected a cure.
No. 18. Division effected a permanent cure.
No. 25. Colotomy effected cure, patient watched for years
and found well ; eventually, all the strictures being cured,
the wound in the loin was closed.
No. 29. Division of fistula and dilatation of stricture
effected a cure.
No. $6. Fissure and polypus, with ulceration and strict-
ure ; operation, subsequent dilatation ; cured ; some months
after found well.
176 ULCERATION AND STRICTURE OF THE RECTUM.
No. 43. Stricture and ulceration cured by incision and
dilation.
No. 57. Disease of uterus, enlargement of fundus, retro-
version, Hodge, dilatation, cure.
No. 59. Stricture and fistula, ulceration, careful division
of fistula and stricture, cure permanent.
No. 67. Male, annular stricture and ulceration, phthisis,
relief.
No. 69. Stricture very long and hard, gradual dilatation
of stricture, cure, and no relapse.
No. 70. Annular stricture high up, incision and dilatation
of stricture, cure.
With regard to inoculation, I performed it on many
patients in whom severe constitutional symptoms of syphilis
with outside growths existed, and never got a true chancroid
as the result ; I noticed many small pimples and sores,
which healed in a few days, but never a typical soft chancre)
I therefore certainly did not inoculate from a soft sore.
I know many of these patients died after years of treat-
ment, numbers of them being admitted and readmitted into