This is a ,very sedative application, and sores seem to be
benefited by it speedily. Subacetate of lead, belladonna
and opium will be found serviceable; all sorts of astringents
may be employed ; rhatany, friar's balsam, zinc (the per-
manganate), copper, iron, nitrate of silver, etc. The last,
carefully used in not too strong a solution, is one of the most
admirable applications, often inducing in an ulcer a healthy
appearance, and causing granulation. The tartrate of iron
I also employ for the same purpose. Fuming nitric acid or
strong carbolic or chromic acids applied under certain con-
ditions, are potent remedies ; they often allay pain and start
healing processes afresh, but they arig double-edged weapons,
and must be used with great discretion and with a distinct
object in view. In ulceration, when the least stricture
exists, bougies may be always employed, but it must be
remembered that to do any good the greatest gentleness
must be practiced by the surgeon ; indeed, pain ought not
to be caused, although considerable discomfort cannot in
most cases be avoided. A bougie of too large a size should
never be employed ; no greater mistake can be made, than
to suppose that the larger the bougie you can get in the
better ; keep below the size that can be well borne, rather
than at all above it ; in the one case good may ensue, in the
other, irritation and retrogression are sure to take place ;
never give a patient an ordinary bougie to use for himself,
if the stricture be more than two inches from the anus.
I have now seen two deaths occur from patients thrusting
the instrument through the wall of the rectum ; peritonitis
immediately set in, and they expired in great agony. Occa-
sionally, when the constriction is only about an inch or an
inch and a half from the anus, I let the patient have a short
instrument to pass and wear at night, if its introduction can
be accomplished without any severe pain. I employ vul-
canite tubes furnished with a collar, to which tapes are fast-
ened, to keep them in the bowel, and, at the same time, pre-
vent them escaping into the rectum, an accident I have more
than once seen occur ; in one case, indeed, a full-sized
bougie entirely disappeared, and could not be reached by
the finger in the rectum; its distal end could be felt in the
transverse colon; fortunately, after a few trials, I was able
to seize it with a pair of long bullet forceps, and withdrew it
from the bowel; the patient, as may well be imagined, being
not a little frightened. When strictures are slight, and not
very long, but annular, a division in a few places, with the



ULCERATION AND STRICTURE OF THE RECTUM. 1 97

knife, followed by judicious treatment with the tubes, may
be very beneficial and even curative. The division I usually
make at four points, and I take care just to cut through the
induration, and reach the healthy tissues beneath, but not to
go deeper; the ]?owel should be filled with well-oiled lint or
wool for twenty-four hours, and then the tube introduced
and worn, only taking it out for the bowels to act, and to
wash out the rectum with some antiseptic solution. I prefer
Condy's fluid, very dilute, or thymol. I am of opinion that
carbolic acid is always too irritant if strong enough to be of
any service.

Some four years ago a young gentleman, set. 19, came to
me with an annular stricture about an inch from the anus ;
division as I have described, the use of the tube, and general
treatment, cured him in six months, and he has continued
well to this day.

Continuing to consider the progress of these cases, we
come to the more severe kind, where the ulceration is very
extensive, the constriction so bad that there is great diffi-
culty in obtaining any passage through the bowels; no action
taking place without the use of strong purgatives or where,
on the other hand, incontinence of faeces renders the patient's
life a burden to him. The lower part of the rectum will be
now merely a passive tube; all elasticity has gone, and liquid
faeces run away, or there is a perpetual leaking of semi-fluid
motion ; the condition of the sufferer is truly pitiable ;
around the anus large, hard growths exist, and fistulous
passages pass up the bowel, opening into the ulceration,
most frequently below, but sometimes above, the seat of
constriction. These fistulas may be divided, and some tem-
porary relief afforded. If in such cases the fistulas run high
up the bowel, and the tissues are very dense, I much prefer
the elastic ligature to the knife; in fact, I now never employ
the latter in such a case ; the bleeding is sure to be exceed-
ingly free at the time, and great difliculty is found in arrest-
ing it, as the vessels can neither retract nor contract. The
only patient I ever lost from haemorrhage afrer an operation
upon a fistula was a young and delicate man, sent to me from
Ireland, with stricture and numerous fistulas, the whole tissues
being brawny in the extreme. At the operation I had great
difliculty in arresting the bleeding, but concluded that all
was safe ; unfortunately, in the evening there was a recur-
rence ; and my colleague, Mr. Goodsall, succeeded in stop-
ping it with plugging aud styptics; however, on the third



198 ULCERATION AND STRICTURE OF THE RECTUM.

morning a sudden gush took place, and the man died at
once. The induration of the parts prevented the appHca-
tion of any ligatures ; they cut through, or the vessel was so
deeply placed as to be out of reach.

In these later stages of ulceration no good, is derived from
constitutional treatment. Mercury in any form does harm.
Iodide of potassium is unavailing. Tonics to maintain appe-
tite and give tone to the nervous system may be used, and
always cod-liver oil, which may be regarded as concentrated
nourishment ; one need not say that good feeding, with
nutritious, but not bulky, food, is required. I shall discuss
more fully lumbar colotomy in my chapter on cancer.

Stricture of the rectum without ulceration is a somewhat
uncommon affection. We have seen how stricture takes
place after or in conjunction with ulceration. The thicken-
ing of the tissues and the contractions which result from the
attempts at repair must narrow the canal, but it is not so
easy to see how or why a stricture should occur ter se. The
rectum is a tolerably large tube (not like the urethra, where
a very little deposit is sufficient to nearly block up the pass-
age), and a considerable thickening might take place without
causing any great obstruction.

We may, perhaps, suppose that inflammation of the sub-
mucous tissue produces a deposition, and, besides this, or
resulting from this, there is a spasm, t am sure this is often
the case ; I have seen strictures of the rectum so tight that
I could not get the end of my little finger into them, but
when the patients were well under the influence of chloro-
form I have been able to pass one or two fingers through
easily.

How inflammation and thickening are set up in the con-
nective tissue of the bowel it is difficult to say. It may be
that straining to evacuate the contents of the bowel forces
down the upper part of the rectum into the lower, thus caus-
ing an intussusception, and bringing the part within the
grasp of the sphincter muscles, and I have often thought
that this condition may be the starting point of the irri-
tation.

I have in some few cases had a suspicion that the long-
continued pressure of the child's head in labor has been the
exciting cause, bruising of the bowel having, perhaps, taken
place.

Possibly, also, inflammation may be induced by the pass-
age of very dry and hardened faeces, though doubtless this



ULCERATION AND STRICTURE OF THE RECTUM. I99

condition may obtain for years, as it often does in old peo-
ple, without producing stricture.

I have seen one case in which the frequent, and perhaps
rather rough, use of an enema pipe produced a stricture,
This occurred in an elderly lady who had for years given
herself an injection daily. She did not at first suffer from
constipation, but she had been recommended an enema, and
at last she could not get an action without it. I thought in
this instance it was not improbable that the passage of the
bone tube had been the exciting cause of inflammatory
thickening of the bowel.

It may perhaps be said that I have assumed inflammation
to be the cause of the exudation into the wall of the bowel.
I must confess that I have, for I have rarely been able to
detect decided symptoms of inflammation of the rectum pre-
ceding stricture. I have constantly asked patients whether
they have at any time suffered from pain, sensation of burn-
ing, diarrhoea, dysentery, or discharge of matter from the
bowel, and the reply has most usually been in the negative.
On the other hand, I have seen cases of long-continued
proctitis, especially in aged people, not followed by stricture.
The coarse symptoms of stricture, viz., straining and diffi-
culty in discharging the motions, have been already described.
It is stated in some works that the stools are thin, long, and
pipe-like. According to my experience this is not usually
the case in true stricture; spasm of the sphincter, enlarged
prostate gland, and tumors of the pelvis, much more fre-
quently give rise to flattened and thin motions. The most
characteristic feature, in my opinion, is the passage of num-
erous very small, broken pieces; the faeces having no actual
form, and looseness often alternating with this lumpy con-
dition. The discharge in simple stricture is like the white
of an unboiled egg or a jelly-fish, and is passed when the
bowels first act. There is no coffee-ground-looking dis-
charge, so constantly seen in ulceration, nor is there the
morning diarrhoea which we get in that complaint. There
is very rarely any pain experienced in the bowel itself; the
symptoms are generally referred more or less to distant parts,
notably the penis, perineum, bottom of the back, the thighs,
beneath the buttocks, and occasionally the stomach. Fortu-
nately strictures of the lower bowel are generally within
reach and sight, but occasionally they are found high up in
the sigmoid flexure, or still more distant from the anus. In
these cases it becomes a matter of great importance to ascer-



200 ULCERATION AND STRICTURE OF THE RECTUM.

tain the situation of the obstruction, but this is a question I
shall not enter upon here.

A stricture of the rectum resulting entirely from muscular
spastn is what I am very much disinclined to believe in. I
do not deny that such a condition may be found, but to me
it appears to be very improbable, and I feel confident that
in many of the supposed spasmodic strictures there is really
no constriction at all. The operator has been misled by the
bougie catching in a fold of the gut or against the promon-
tory of the sacrum. If you are in doubt about the existence
of a stricture, you should use long and very elastic enema
tube, and inject fluid as you pass it, so as to distend the gut
and remove any intussusception of the upper part of the
rectum. This condition, I think, has often been mistaken
for stricture, as, unless the bougie goes directly into the
aperture of the descended portion of the gut, it gets into the
sulcus at the side, which is a cul-de-sac, and the instrument
cannot be made to pass. I have satisfied myself on several
occasions of the existence of this source of error.

For some years past, in exploring the rectum for stricture,
I have used vulcanite balls of different sizes, mounted on
pewter stems with flattened handles; ,they are easily bent
into any form; they will even bend in the bowel, and by
their use, as in exploring the urethra, you may make certain
of detecting a stricture. For when they pass, or on gently
withdrawing them, the ball is felt to come suddenly, and
perhaps with some difliculty, through the constriction. Its
length also can be approximately measured.

In cases of stricture when there is great spasm with a
small amount of organic disease, much good may be done
by the use of bougies. Before passing the bougie, it is well
to inject into the bowel some sedative, as opium or bella-
donna with oil, and to use a stiff lubricant on the bougie
(such as blue ointment); if the instrument cannot be quickly
passed, it is better not to persevere, as irritation will be set
up and damage done; once set up the spasm and all your
endeavors may be frustrated; the stricture must, as it were
be surprised. I do not like any forcible dilatation in these
cases; you may tear or split the stricture with Todd's dilator,
but you are more likely to get ulceration than permanent
benefit to the stricture. On the same principle I should not
cut, even in the slightest degree, any constriction where no
ulceration existed, save in cases I will describe. If the
stricture is high up, the use of Todd's dilator is dangerous.



Ulceration and stricture of the rectum. 201

I have seen profuse haemorrhage follow its use, and the
bowel might be torn, to the injury of the peritoneum, especi-
ally in women.

In these cases I am also of opinion that retaining a bougie
or tube is not usually advantageous; you may produce ulcer-
ation, and if this should be done you will perhaps irretriev-
ably damage your patient. Gentle dilatation, very gradually
increasmg the size of the instrument, is the only safe treat-
ment. The conical bougie is a good form, as gentle pressure
induces this to enter the stricture more easily, but you should
never cause pain, and you may be sure that if blood or
mucus passes after your manipulation, your patient will have
little to thank you for.

I used to think that twice in the week, or at most three
times, was as often as the instrument ought to be used, but
in obstinate cases its daily use has, in my more recent exper-
ience, been followed by greater permanent good. Still, in
this matter every case must be judged on its own merits,
bearing in mind the axiom "never irritate."

A bad form of stricture, fortunately of rare occurrence, is
that in which the constriction is semicircular or annular, and
feels to the touch as though the bowel were encircled by a
cord. These strictures are so resilient that even if dilated to
their fullest extent, they very soon return to their previous
state of contraction. It is in these alone that I consider
division advisable, but the incisions should be only super-
ficial, aijd dilatation should be commenced on the day fol-
lowing the operation.

When a stricture is well dilated the patient generally
experiences the greatest amount of relief; there is no more
straining at stool; comfortable, good-sized motions are
passed, and many anomalous symptoms vanish. One draw-
back is the rapidity with which all strictures are apt to return;
the relief afforded is even much less durable than that
obtained in stricture of the urethra; the patient should there-
fore be warned never to be long without having the bougie
passed, and certainly, directly any of his old symptoms
recur, at once to obtain treatment; if this advice be acted
upon, but little fear need be entertained of a dangerous
relapse



202 CANCER OF THE RECTUM.

CHAPTER XVIII.

CANCER OF THE RECTUM.

There are very few parts of the human body which may
not be attacked by cancer, but some are more frequently
affected than others, and the rectum is one of the favorite
sites of this disease. Cancer is, m the vast majority of
cases a fatal disease, and when the rectum is the part
affected it usually runs its course in about two years. In
many instances the duration of life is much less. I have
watched a case of encephaloid which terminated fatally at
the end of four months from the earliest symptom of its
invasion. Colotomy was performed by me when I first saw
the patient, two months before death; but in my opinion
it did not delay the progress of the disease one day, although
it afforded relief from excruciating pain. On the other
hand, I have seen a case of scirrhus on the anterior wall of
the rectum, in which the patient lived about four years
and a half. I will briefly record the case.

A man, of not at all unhealthy appearance, came under
my care at St. Mark's Hospital in the year 1865. He had
suffered more or less from symptoms of obstruction in the
bowel for five or six months. An examination per annum
detected a hard, solid mass, appearing to rise from the
neighborhood of the prostate gland; it blocked up the whole
rectum; the surface was irregular, but not ulcerated at all.
I thought it might possibly be a hydatid, although no fluc-
ti^ation could be detected; a long exploring trocar thrust
into it did not reach any fluid. He had suffered entire con-
stipation for twenty days, and his symptoms were so urgent
that I at once performed colotomy. He returned home in
six weeks feeling very well, and he lived for four years and
a half, dying at last from the extension of the disease to
the bladder and consequent exhaustion.

Cancer is commonly a disease of middle life, but I
have seen encephaloid rapidly fatal in a boy of seven-
teen; and some years ago there was in St. Mark's Hospi-
tal, under the care of my colleague Mr. Gowlland, a boy,
not thirteen, with cancer of the rectum. Scirrhus and epi-
thelioma are not very uncommon in old people, and in
them usually run a very slow course, which may be



CANCER OF THE RECTUM. 203

accounted for by the fact that in old persons the vital
forces are sluggish.

It has been said that cancer is more frequent in women
than in men. As regards the rectum, this is directly the
reverse of my experience. In my statistics many more men
are victims than women.

I am in accord with those who do not consider cancer as
an hereditary malady ; it is true that there are very few
families in which cancer has not appeared, more or less
remotely, but that is only because cancer in some form is so
common in human beings. Although I always put the ques-
tion, it has comparatively rarely happened to me to find that
the father or mother, or even grandfather or grandmother,
has suffered from the disease. Often uncles or aunts, or
brothers or sisters, and still oftener cousins and more dis-
tant relations have suffered from cancer ; but the question
of heredity is not thereby affected.

Some varieties of cancer may, in their early stage, be only
and purely local ; but I am afraid that stage is of very short
duration, and that the above statement is hardly, certainly
not practically, true of the more malignant forms. By this
I mean that as soon as a growth exhibits itself, so as to
be noticed by the patient, the disease is already constitu-
tional, and the system is infected.

As a rule, cancer of the rectum is most horribly painful,
the function of the part enhancing the suffering; but I
have seen patients in whom there has not been excessive
pain, particularly in the early period. In the more advanced
stages of the malady the pain often becomes unremitting,
from the fact that many nerves become involved, and are
pressed upon or stretched, the neighboring organs thus
becoming seats of separate pain, even if they are not
actually touched by the growth. I had a patient with can-
cer, which, commencing in the rectum, involved the whole
cavity of the pelvis, and pain down the right sciatic nerve
was one of her most distressing symptoms.

The forms of malignant disease described are epithe-
lioma, scirrhus, encephaloid, colloid, and melanosis. I
think I have placed them in their order of frequency. I
have never seen a melanotic tumor of the rectum. I have
seen many colloid tumors, but I am not sure that ence-
phaloid may not be colloid, or pass into it. From niy own
clinical observations I should be inclined to say that in can-
cer of the rectum it is often very difficult, if even possible,



204 CANCER OF THE RECTUM.

to make any distinction between epithelioma and broken-
down scirrhus. I have seen cancers of the rectum stony-
hard at one part and quite soft at another.

MaHgnant growths are commonly found seated within
three inches of the anus, the most rapidly dangerous being
higher up, about the lower portion of the sigmoid flexure.
When cancer occurs near the anus it may extend upward
beyond the reach of the finger, but more frequently it does
not, and the whole extent of the disease can be ascertained.
It is but rare that any form of cancer commences at the
anus itself — I have seen some cases of epithelomia, but com-
paratively few — nor as a rule does the cancer come grad-
ually down to the anus; in the very latest stages it may do so,
but this is the exception. When it comes down to the anus
it is generally mistaken for piles, and caustics are applied, to
the aggravation of the patient's suffering. There is some-
thing peculiar about the feel of cancer, which the prac-
ticed finger rarely mistakes, even for simple indurated
ulceration. I think it is many years now since I mistook
the one for the other. There is also a peculiar odor which
one cannot describe but which once recognized will rarely
be forgotten. In my opinion the odor is pathognomonic.

Scirrhus and encephaloid commence according to my
clinical experience, in the submucous tissue, and the mucous
membrane may for a time remain quite smooth and
unaffected, though adherent to the growth beneath.

In epithelioma the mucous membranes seems from the
first to be the seat of the disorder, and even when the
growth and thickening have become considerable, the whole
will be found freely movable over the structures beneath.
In scirrhus and encephaloid this is not the case; very early
in the disease it has spread more deeply, and in many
instances it seems very immobile.

Scirrhus is often found as a hard tumor seated in the
rectum over the prostate gland, and although it may not
have arisen from the gland itself nor invaded it at all, yet it
is remarkably adherent to it. In a case in which I removed
a scirrhous nodule, about the size of a large cherry, from
this situation I was obliged to dissect off with the growth
the fibrous capsule of the prostate itself. On microscopic
examination the tumor was declared to be true scirrhus, by
my friend Dr. Wm. Ord. The patient recovered from the
operation and I have not heard of him since, but I should
expect that the growth will almost certainly recur.



CANCER OF THE RECTUM. 205

The more malignant forms of cancer do not exist very
long in the rectum before they poison the blood generally,
and cause secondary deposits in the lumbar glands, groins,
liver, etc. The aspect of countenance which so often
attends the cancerous cachexia is very usual, and seen earlier
in cancer of the rectum than in the same disease of other
parts. In cancerous growths high up, vomiting, frequent
and severe, is an early symptom, even when not much
obstruction exists. The onset of cancer in the rectum is
often marked by very trivial symptoms, hence the disorder
comes upon you as a surprise. A patient may come into
your consulting room complaining of no more than a little
uneasiness in the bowel or a slight morning diarrhoea. He
may look thoroughly healthy and strong, and may really
think himself, save for the slight local trouble, perfectly well,
yet on making an examination you find the disease advanced
beyond all possibility of doing any good.

An elderly Scotch gentleman was sent to me by Dr.
Nisbett, of Gravesend. To all appearance he was the wiry,
healthy-looking Scot. " Hard as nails," he said he was, but
he was a little troubled by irregular action of the bowels;
sometimes costive,sometimes loose; and he occasionally passed
a little blo&d. On examination I found what I really did
not expect, a hard, scirrhous mass in the rectum extending
higher up the bowel than I could reach. By sheer power of
constitution he lived a little more than twelve months from
that interview.

In October, 1878, Mr. Wilton, of Sutton, sent a gentle-
man, aet. 34, to me. He was suffering from some pain in the
back, with a weary sensation after exertion; had small losses
of blood at stool and rather frequent motions^ always in the
morning and sometimes at night. His idea was that he had
piles. On examination I found an epithelioma commencing
just within reach of the finger, and extending, as I found by
careful sounding, at least two inches higher up. The growth
was causing some contraction of the bowel. This patient
was afterwards the subject of secondary deposits in the liver.
He died in October, 1881.

When cancer attacks the uppermost portion of the rectum
or the sigmoid flexure, the disease generally runs a more