242 Perkins'1 case of Stricture of Art. V. Case of Stricture of the Rectum and Colon. By Cyrus Perkins, M. D. of New-York. The subject of the following case, one of our most valued citizens, was 48 years of age, spare in bis person, of vigorous intellect, and sedentary habits. In the month of August, 1826, he complained to me of a difficulty in evacuating the feces; which were passed either of a very diminutive figure, or in a liquid form only ; and often required repeated efforts, each day, to render the state of the bowels in any degree comfortable. He was occasionally reliev- ed by such mild purgative medicines as quickened the motion of the bowels, and produced liquid stools. But the difficulty soon returning, I suspected the existence of stricture, and en- deavoured to ascertain the fact, by introducing my finger up the rectum; but was unable to reach the seat of disease. I then proceeded to examine the parts with a bougie, prepared by strips of linen wound on a flexible piece of whalebone ; the strips being first dipped in a composition of wax and lard, melted; and, to render the instrument softer, it was, at last, repeatedly immersed in the same composition, till brought to the proper size. On introducing this flexible bougie, which was nearly three fourths of an inch in diameter ; a resistance v^^perceived five inches up the rectum, which seemed indeed, ^Kirst to termi- nate in a blind pouch ; but by changing the direction of the instrument repeatedly, guided in part by the hand and feel- ings of the patient, it was carried up, evidently through the. Rectum and Colon. 243 a strictured portion of the gut, two or three inches higher, till there seemed to be no further resistance. This operation was repeated, for several successive days, with the evident effect of dilating the rectum in the straitened part. Still the patient was not essentially relieved ; and the conclusion was inevitable, that a stricture was to be sought for higher up. Recourse was, accordingly, now had to a longer bougie, pre- pared in.a similar manner, but smaller in size, and tapering to a point, somewhat less than one third of an inch in diam- eter. After repeated unsuccessful attempts, this instrument, guided as before, principally by the hand of the patient, was at length carried up nearly twelve inches, where its further progress was arrested. It was retained in this situation till it occasioned considerable uneasiness, when it was removed, and was immediately followed by a slight discharge of faeces. On examining the bougie, it appeared that the point, which had taken a short turn toward the left of the patient's body, was strongly impressed by a stricture; »and that the body of the instrument, had also the impression of two contractions of the rectum lower down ; the one about five, and the other ^^en inches from the anus. At these places the instru- ment was flattened, as though bands were drawn across the rectum. It was thus rendered certain, that there existed three strictures, the upper and principal one in the sigmoid flexure of the colon, and at such a height as to render its treatment by bougies embarrassing at least, if not dangerous. It was repeatedly attempted to dilate the stricture, by the pressure of water contained in a portion of sheep's gut. But we en- tirely failed in effecting our purpose, from being unable at such an unmanageable height, to introduce the gut sufficient- ly into the strictured part. The wax bougie, prepared as before described, and made quite flexible towards the point, was the only mechanical contrivance we could render useful. During the progress of the disease, the patient frequently complained (^Run about the upper stricture, oftentimes very severe. TJs, as he believed, occurred whenever fecu- lent matter, or t"n wind, passed the strait. This pain was always mitigated by pushing up the bougie, so as to produce 244 Perkins' Case of Stricture of gentle distension of the bowel, at or near the stricture; and by the same means, the passage of feculent matter was pro- moted. So sensible was the patient of the relief thus afforded him, that he often retained the bougie for several hours togeth- er ; flattering himself that what was now merely yielding him a respite might, by perseverence, work a permanent cure. The immediate and uniform effects of the bougie, made it evident that some of the most distressing symptoms of the disease, arose from a spasmodic state of the muscular coat of the intestine ; occasioned, no doubt, by an irritation arising from the permanent stricture. The occasional severe pain, was unquestionably from spasm ; and the relief afforded by the bougie, was from its gently distending force subduing an inordinate contraction of the muscular fibres; on the same principle that spasm, and the pain arising from it, are always relieved, whenever pressure can fairly be applied to the part affected. Thebougie procured stools, in this case, by fatiguing the muscular fibres below the stricture, and thus bringing those immediately above it, by continuous sympathy, into the same condition ; so that, for the time, they could present no further impediment to the ordinary function of the bowel. For months the bougie was daily resorted to. In some instances the patient retained it for many hours together, and generally with uniform convictions of its utility. So that he sometimes flattered himself that the disease was gradually yielding. He was at length, however, repeatedly admonish- ed of the deception, by indulging too freely in his diet. Severe pain, obstinate constipation, and sometimes vomiting, during the last two or three months, had several times threat- ened a sudden and fatal termination. In the progress of the disease, 1 had occasion to prescribe a variety of medi- cated suppositories and enemas, sometimes with a view to evacuate the- bowels, and at other times, for the purpose of allaying irritation and spasms. The tobacco in infusion, as well as in the form of suppositories, I oft^^Biund useful in answering both these indications; but itbeM^ inconvenient, from the difficulty of controlling and gradSning( its effects. For the last six or eight weeks of this case, it became ne- the Rectum and Colon. 245 cessary to resort to pretty active cathartics. Salls and senna, or castor oil, were taken as often as every third or fourth day. The latter, on the whole, was found prefera- ble ; and was taken in such doses as to produce pretty copious stools. But whatever cathartic medicines w'ere ad- ministered, considerable pain was experienced about the loins during their operation ; and a good deal of irritation and uneasiness remained there, and in the course of the rectum, for some time afterwards. To relieve these dis- tressing symptoms, various expedients, such as fomentations, tepid bath, &.c. either afforded but partial relief, or totally failed, till I resorted to opiate suppositories, which were uniformly attended with most happy effects; not only terminating, as by a charm, all these pains, but at the same time, putting to rest a most uncomfortable sensation, often complained of, about the perinaeum and glans penis. The quantity of opium necessary for this purpose, was from one to three grains, according to the urgency of the occasion. My patient early learnt the importance of a rigid adherence to the course of diet I had pointed out. Which was to avoid much solid food, and depend principally on gruels, beef, and chicken teas, broths, soft eggs, jellies, fresh fish, &c. His drink was to be toast-water, barley-water, black tea, &,c. avoiding all ardent spirits and wine. But, debilitated by a constantly irritable state of the system, and a consequent want of regular and quiet rest-emaciated too by the same cause, by anxiety of mind and spare diet, he sometimes reasoned himself into the belief, that it was not only safe, but expedient to indulge occasionally in a little more substantial food. These impressions having taken root, and at the same time, urged on by the solicitations of a craving appetite, his rea- soning would now and then result in a good dinner. Such had repeatedly been a cause of much suffering, and such was the cause of the last fatal attack. Within an hour after eat- ing a dinner of solid food, and rather indigestible in its kind, he was seized with the most frightful spasms of the intestines ; and I found him soon after, literally writhing iiragbny.* * Mr. White, of Bath, in his valuable Observations on strictures of the Vol. IV. No. 2. 32 246 Perkins'* Case of Stricture of This was on the 31 st of March last, at 4 p.m. For immedi- ate relief, under circumstances so urgent, I resorted to liberal doses of laudanum, large anodyne fomentations to the abdo- men, and warm bath; which, in the course of two hours had diminished, somewhat, the acuteness of suffering; still the pain was great, and the abdomen had become considerably swollen and tense. In the evening a medical gentleman was desired to attend in consultation. The patient was now more free from pain, but could not be moved without the recurrence of severe spasms. He had not been able to lie down for the last five hours, nor change his posture in any way from the position in which he at first placed himself; sitting in an armed chair, with his body bent forward, and compress- ing his bowels with both hands. He was, at length, removed to bed with great difficulty, and considerable increase of pain. An opiate was now directed, and the fomentations to be con- tinued through the night, as occasion might require. April 1st. The patient had passed a restless night, with little sleep. The abdomen was tense, with considerable sore- ness. The drinks, which were toast-water and barley-water, during the night, had sometimes been rejected from the sto- mach. And during the day, the patient remained in so irri- table a state, as to reject every thing, except a weak alkaline solution. Fomentations were repeated, and enemas. April 2nd. The last night was passed without much re- pose, though a large anodyne had been administered. The stomach, however, had become somewhat more retentive. Two other gentleman were joined in consultation ; and, as there had been no evacuation of the bowels for three days, castor oil was prescribed in repeated doses, to be aided by stimulating enemas. The oil was retained till several doses rectum and colon, p. 83. observes, that he has reason to believe, that two patients with strictures, lost their lives suddenly by a similar indiscretion. "Eating and drinking more freely than ordinary one day, they were seiz- ed with symptoms of iliac passion, and both of them died in a short time ; no passage through the bowels could be obtained." the Rectum and Colon. 247 had been taken, but without effect; and the clysters were re- turned unaltered. The stomach was again more disturbed, and a large epipastic was applied. During the evening and night, the patient was distressed by obstinate hickup and oc- casional vomiting; and a dark fluid, resembling coffee, in colour, was thrown up in considerable quantities. April 3d. The plan which had been adopted having en- tirely failed, it was decided to commence the use of calomel, 10 grains every two hours. This was pursued during the day, but without producing any relief. At evening, the hickup was almost unremitting, and the vomiting had increas- ed. The ejected fluid was darker, and contained numerous brown membranous flocculi. An anodyne was prescribed, and I left the patient at 12 o'clock, more composed, but evi- dently sinking. At 2 o'clock, on the morning of the 4th, [ was called to him ; and, on informing him of the near ap- proach of death, he expressed great satisfaction that he was so soon to be released from his sufferings. He expired at 3 o'clock. At nine o'clock, six hours after death, the body was exam- ined in the presence of the gentlemen who had been in atten- dance. On laying open the cavity of the abdomen, the vis- cera were found completely glued together, by recently effused lymph, and generally adhering to the peritoneum. There were several pounds of turbid serum, and a considerable quantity of well-formed pus. The small intestines were dis- tended with flatus, and the colon with scybala of various size, and prodigious hardness. This intestine was, in no part, en- larged; and, from the left extremity of its arch downwards, was preternaturally contracted. Looking into the pelvis, the bladder of the urine was seen empty, and the rectum diminutive in size, and snugly trussed down to the bone by a thickened peritoneum ; not passing up the centre of the hollow of the sacrum to its promontory, but taking a course obliquely to the left of the patient's body, up the sacro iliac symphysis. At and somewhat above the brim of the pelvis, the colon was found to be contracted to a very small size. Here was 248 Perkins'1 Case of Stricture of the principal stricture. It felt like a hard cartilage, for a about two inches in length, and was closely and firmly bound down by a morbidly thickened peritoneum. The vestiges of high inflammation were almost equally conspicuous through- out the whole cavity ; and a fluid was seen oozing from about the centre of the stricture; so that, at this point, it was either actually ulcerated before the examination, or was in so tender a condition, as readily to give way in attempting to remove a portion of the intestine from the body. On exam- ining the part after its removal, the two lower strictures, or rather contractions, in the rectum, were found to be produced by a thickening and tension of the peritoneum merely, over its anterior surface; whereas all distinction of coats seemed to be lost, at and about the upper and main stricture, except the villous, which was thrown into irregular folds, and could readily be expanded. The calibre of the bowel at this part, was reduced to about one third of an inch in diameter. The peritoneum, with the other coats, and some portion of the cel- lular membrane around, were assimilated, thickened, and in- durated ; constituting, so far as I could judge, a carcinoma- tous state of the parts. Indeed, there seems to me, sufficient reason for doubt, whether there be any just ground for dis- tinction, between what has been denominated the indurated stricture of the rectum and colon, and the scirrhous stric- ture ; which are admitted by writers of the most extensive observation, to be " apparently similar."* As to a diagno- sis founded on the circumstance of " pressure of the bougie being generally useful in the one, and inadmissible in the other," it seems to me, quite vague and unsatisfactory, f These circumstances may depend merely on the stage of the disease. While the parts remain nearly insensible, the bougie affords temporary relief; but when a preternatural sensibility has been awakened, the bougie becomes inadmissible. During the attendance in this case, it was proposed in con- sultation, to cut down on the colon in the left iliac region, * See Calvert's excellent Practical Treatise passim; et al. f Idem, p. 132. the Rectum and Colon. 249 and endeavour to prolong the patient's life by establishing an artificial anus. This was advocated on the ground, 1st. That the case was otherwise desperate. 2nd. That the operation might afibrd some hope.-That it was practicable; that cut- ting into the abdomen had been repeatedly done without serious consequences ; that it would be more likely to dimin- ish than increase the inflammation ; that possibly the stricture might be acted on mechanically, from the opening in the colon above ; and that, though an artificial anus would be a serious reduction of the value of life, the duty of ihedical men required them to do all that could afford a rational prospect of prolonging it, even on the worst terms. The proposal, however, was opposed on various grounds, and overruled. It was considered, 1. That the state of the intestines, and the situation, extent, and nature of the stricture, could not be sufficiently known to warrant the measure. 2. That the symptoms of a high state of irritability and inflammation, already present in the abdomen, admitted no probability of success. 3. That patients do not long survive an artificial anus, under circumstances incomparably more favourable than the present: and lastly-That, should the operation suc- ceed, against all other objections, it could prolong life on such conditions only, as would render it burthensome to the possessor.* These considerations appeared to me decisive at the time; and in my judgment, were strengthened by the post mortem examination. The proposal of such an operation, I am persuaded, can never be received with favour. A patient would not, and ought not to submit to it, so long as a ray of hope remained of living without it; and when this was extinct, the case would be desperate in every view. I cannot there- fore but express my conviction that a disease, like the above described, will never submit to the control of art. It is a calamity from which there is no refuge but the grave. P. S. June 18th. Since writing the above, I have been called to visit in consul- * On consulting1 the patient, this last objection was, in his mind, insu- perable. 250 Hoffman's Case of Malformation of the Heart. tation, with Dr. H. A. Riley, Mrs. C-, who had for some days been labouring under the urgent symptoms of constipated bowels. There was great pain, tension and soreness of the ab- domen, with nausea and vomiting. During the three days I at- ended this patient, the most active treatment proved unavailing. For the last twenty-four hours, a dark fluid was thrown from the stomach without nausea. She expired yesterday. On examination, soon after death, the stomach was inflamed, and nearly the whole tract of small intestines, from the duo- denum downwards, was in a state nearly approaching spha- celation, but there were no adhesions. The colon was in- flamed, and greatly distended, from its head to a point just above its sigmoid flexure, where it was suddenly contracted and indurated, constituting a stricture which had evidently been of long standing. Its structure, in my judgment, was scirrhous, and similar to that in the case above related. The adipose membrane, in contact with the part, had become involved in the disease; and the lower part of the strictured portion was ulcerated, so as to allow feculent matter to es- cape into the general cavity. The bowel below the stricture was preternaturally contracted.