THE ADDRESS ON SURGERY. BY JOSEPH M. MATHEWS. OF LOUISVILLE, KY Delivered at the Forty-second Annual Meeting of the American Medical Association, held at Washington. D. C.. May, /8g/ Reprinted from the "Journal of the American Medical Association," May 9, 1891. CHICAGO: PUBLISHED AT THE OFFICE OF THE ASSOCIATION 18qi. THE ADDRESS ON SURGERY. I am familiar with the fact that it is expected that the general address on surgery read to this Association shall be a resume the advances made in each and every department of the science and art of surgery, since the previous meeting. To have gone over this entire field would have con- sumed more of your valuable time than you would like to grant, and involved a task too burdensome for me to undertake. I, therefore, determined to select some single subject for my address. I was then confronted by the fact that every single sub- ject of importance would be fully discussed in the section on surgery ; hence I was embarassed in selecting one, for the reason that I wished to edify rather than fatigue you. This, then, was the rub. Having confined myself for fifteen years to a special line of practice, it occurred to me that it would be best to select some subject relating thereto, and give my individual opinion and experience in regard to it. Then, too, I had the consolation of believing that no paper of a similar topic would be read before the Associa- tion. I have, therefore, selected as my subject, STRICTURE OF THE RECTUM-ITS ETIOLOGY, PA- THOLOGY, SYMPTOMOLOGY, DIAGNOSIS AND TREATMENT. I realize, in discussing this subject, I shall take positions contrary to the accepted teachings of the day, but I shall not beg for pardon for so doing. 2 I take it that the one great object of the meetings of this Association is to elucidate and discuss sub- jects that are in doubt, those that are mooted, not admitted. The caption of my address may sound homely, but the importance of it as a sur- gical subject should commend the respect and attention of every surgeon here. Its frequency, its terrors, and its dangers, appeal to us for relief. Etiology.-The following classification of the varieties of stricture of the rectum is given by Dr. Kelsey. I believe that for my purpose it is the best classification, as it embraces the varieties as given and agreed to by many different authors. Congenital-. i. Complete, 2. Partial. Acquired: i. Spasm, a. Dysenteric. 2. Pressure from without, b. Tubercular. 3. Non-venereal. c. Inflammatory, d. Traumatic. 4. Venereal, a. Ulceration (either chancroidal, secon- dary or tertiary.) 5. Cancer, b. Due to unnatural vice. c. Neoplastic (gummata, anorectal syphiloma.) The first great division, it will be noticed, is congenital and acquired stricture. In writing of, or dealing with stricture, the idea intended to be conveyed is of a pathological change in tissues, etc., a deviation from the natural brought about by disease ; hence I object to the consideration of congenital malformations of the rectum, or to define them under the head of strictures of the same, for the reason that it is misleading to do so. It will be more to the point to call these, atresias of the gut. Therefore, I shall dismiss this part of the division that he has made. Indeed, excep- tion could also be made to the second division of this grand classification, namely, acquired. I am aware of the fact that the term is often used in the sense herein applied, but to my mind a 3 better term or classification could be used. It is very easy to understand how one can acquire a stricture, the result of venery, but it will be diffi- cult to understand how one could acquire a spas- modic or cancerous stricture. But I will adopt, for the sake of discussion, the above classifica- tion, leaving out the congenital variety. i. Spasm.-To this form of stricture I shall prefer two objections. First, if it be true that such condition ever exists, which I doubt, then it should not be classed as stricture at all, for the reason that no pathological change is manifest to constitute a stricture, and no treatment could be given it per se. In other words, it would be a symptom of some lesion or trouble outside of the one called stricture. Second, I believe that from the anatomical construction of the rectum, it would be utterly impossible for its lumen to be so constricted as to be perceptible as an obstruc- tion, by spasmodic contraction of its muscular fibres. I might add as a third reason, that in all my examinations of this part of the gut, I have never seen a spasmodic contraction that could be called a stricture. 2. Dysenteric.-Although it is frequently stated that dysentery is a common cause of stricture of the rectum, I have never seen cases sufficient to convince me of the truth of the statement, indeed that it was a cause at all. I have many times seen patients who gave me a history of having had dysentery and were treated for a long time for the affection, but a close scrutiny of the case revealed the fact that the so-called dysentery was caused by an already existing stricture and ulcera- tion, the rule here being reversed,-that dysentery was the result, not the cause. If dysentery really be a cause of stricture of the rectum, how very often we would expect to meet with it in our practice, considering the great number of people 4 who have dysentery, especially in the warmer climates. Again, practitioners of medicine know that ulceration proper very seldom exists in the rectum during or after attacks of dysentery. The sloughing in these cases occurs from the gut above the rectum. I do not deny, but I am not con- vinced, that ulceration may sometimes be caused by repeated dysenteries or diarrhoea, but my ex- perience has not taught me that they are frequent, by any means. If a long continued irritation is kept up in the rectum, from any cause, the result would be, of course, an inflammatory exudate, resulting perhaps in ulceration and stricture; but I must confess that in searching for this as a cause, the road to a conclusion has not been plain enough for me to put dysentery in the list as a cause at all for stricture of the rectum. If this disease is a common cause of stricture, as asserted by so many, it occurs to me that the trouble would be often found in the veterans of war. Indeed, I could not imagine a more ideal case for a pension than the existence of stricture of the rectum, the result of a dysentery contracted while in the ser- vice. Yet the pension records are singularly silent on this point. At a late meeting of the Louisville Clinical Society, Prof. John A. Ouch- terlony, a distinguished pathologist and teacher, in discussing the subject of stricture of the rec- tum, said: I call to mind a dead house experience extending over many years. During the war I made post mortem exam- inations upon hundreds of cases who died of dysentery, the most malignant forms of the disease, as all will at- test whose observations extend back to war times, and I cannot remember to have ever seen a stricture of the rec- tum as a result of dysentery. In the two hospitals, to which I was pathologist, there were eleven hundred and fifty beds, and we sometimes made as many as five or six post-mortems a day. After the close of the war, I was for many years pathologist to the City Hospital, but in all my dead house experience, I never saw a stricture of the rectum caused by dysentery. 5 These are the remarks of a very close observer, and my experience certainly coincides with his. 3. Tubercular.-Since the discovery of the tu- bercle bacilli, and the demonstrations that con- vince us of the effect on the tissues, etc., it is self evident that tuberculosis is often met with in the mucous membrane and the structures of the rec- tum. If stricture and ulceration is*the term used, I could make no objection to the classification of tuberculosis as a cause of ulceration. That ul- ceration frequently results from this diathesis or dyscrasia no one could doubt, but that the coincident stricture follows, as from other well known causes, notably syphilis, I cannot agree. The disposition of tuberculous tissue everywhere is to break down. Before the capacious rec- tum is filled with tubercular deposit sufficient to stricture it. it will have broken down from ulceration, etc., and it must be by deposition only that we can conceive of stricture from this cause; because cicatrization is so seldom, and so feeble, in these parts that it would be the rarest accident to find it. In no instance have I ever seen a stricture of the bronchi as the result of tu- berculosis. There would be just as much rea- son to expect it here, or indeed more so, than in the rectum. 4. Inflammatory.-This term is so broad and comprehensive that we must perforce of reason admit it as a cause of stricture of the gut, indeed as the one grand and common cause; for if stric- tures exist from whatever cause, be it trauma, pressure, venery, dysentery, cancer, tubercle, syphilis, ulceration, or what not, it is inevitably due to the processes and products of inflamma- tion-in no other way can a stricture be formed. It might be argued that a lesion or wound exist- ing in the bowel by the reparative process heals and leaves cicatricial tissue, and that stricture 6 was the result of the cicatrix, and not to plastic infiltration of the tissue. In answer, I would say that there could have been no cicatrization if there had been no inflammatory process. Hence, inflammation being the cause of the cicatrix, was in truth the cause of the stricture. It is said, " Any severe form of proctitis resulting in ulcer- ation may be a cause of stricture." To this I freely assent, but the most difficult part of the whole matter is to tell the cause of the proctitis, which is inflammation. It is not to the proposition that I object, but to the supposed cause. For instance, in naming several, the following is given as a cause of stricture: Erosion and ulceration of haemorrhoidal tumors." Now, in the nature of things, how can this be true? A haemorrhoid is, in fact, a tumor, and by friction the mucous membrane on the tumor can become ulcerated. Suppose it does, how can that ulceration produce a stricture of the rectum? As we have intimated, strictures may result from two pathological condi- tions. First, from a deposition of plasma, causing an obstruction, or second, by cicatrization, caus- ing a stricture. Can either of these conditions result from haemorrhoidal tumors being ulcera- ted? Certainly not. The inflammatory deposit would only involve the tumor, and a cicatrix on top of a pile would not amount to a stricture. 5. Traumatism.-Under this head the authors include ulceration following operations or wounds of the rectum, and cite the surgical operation done for haemorrhoids and fistula in ano. In all my practice, I have never seen such result follow either operation. I can understand how the cica- trix resulting from the removal of too much skin from the anal region might cause a stricture of the anus. My friend Dr. W. O. Roberts, of Louis- ville, has told me recently, of operating upon a patient of this kind, the original operation for 7 haemorrhoids having been done by an inexpe- rienced hand. I cannot understand how a sur- geon used to operating in this region, would do an operation that would result in a stricture. But traumatic strictures are, in fact, inflammatory strictures. Inflammation is the result of trauma, so one class would include both. For brevity, this would be best. 6. Venereal.-"Without admitting too much,'' says one author, " it may be safely said that, be- yond dispute, there are three forms of well recog- nized venereal diseases in the rectum, which may result in stricture. These are chancroidal, secon- dary and tertiary ulcerations, either simple, trau- matic, or the result of direct inoculation, and an unusual form of tertiary disease of the general nature of gummatous deposit variously described by different authors, and by Fournier as ano-rectal syphiloma.'' This author leads us to infer that these three venereal causes, namely chancroidal, secondary and tertiary ulcerations, are the most infrequent way that stricture of the rectum can be produced by venery. Allingham reports that out of seventy patients suffering with stricture of the rectum, thirty-five of them had ahistory of syph- ilis. I have frequently said that I believe that more than one-half of the strictures met with in the rectum were the result of syphilis. I have often asserted that in no single instance have I ever seen a stricture of the rectum caused by the healing of a soft sore. I do not believe that it can occur. In this opinion I am partially sus- tained by Allingham, James R. Lane, Alfred Cooper, Coulson, Christopher Heath and others. These three causes are alleged by many to pro- duce their effect by simple trauma or direct inocu- lation. Neither of these can be true. If so, cer- tainly not one in ten thousand cases. Granting that the soft sore could produce an ulceration 8 that might end in stricture, how, I would ask, can the aforesaid pus get into the rectum? It may have occurred, it is not impossible, but granting that it did by direct contact, I do not believe that it would result in a stricture. Instead of secondary syphilis being an unusual cause of stricture of the rectum, I assert that it is the usual and only form that we find this disease pro- ducing or causing stricture of the rectum. Ricord, Fournier, Heath and others believe this, and Mr. Bryant, in his excellent practice on surgery, as- cribes these ulcerations and strictures of the rec- tum as " mainly syphilitic," and says: " Foreign authors describe chancroidal diseases of the rec- tum, venereal but not syphilitic. In this coun- try it is hardly recognized." I certainly agree with this author. To conclude, if I were asked, what is the prime cause of stricture of the rectum, I would answer inflammation. But what causes the inflammation? In many cases I do not know, but ordinarily syphilis, cancer and trauma-if by trauma can be meant a wound or lesion from any or many causes. Outside of the two first named, cancer and syphilis, I am satisfied that no one can tell the cause that originates the stricture. I wish to reiterate, that outside of these two well recognized causes for stricture of the rectum, I am not prepared to admit any othei as a well known, recognized, indisputable cause. Pathology.-In delivering the Bradshawe lec- ture before the Royal College of Surgeons, Ron- don, Mr. Thomas Bryant selected as his subject, " Colotomy." He said : But as a means for giving relief to patients from chronic intestinal organic ulcerations or obstruction from what- ever cause, colotomy was generally, and indeed I may say is still, too much regarded as a dernier ressort, and as a consequence, it was, as a rule, only carried out when all other measures had been tried and proved to be use- less. This position I, in common with some few other 9 surgeons, have, however, never accepted. We have re- garded it as the best means the surgeon has at his dispo- sition for the relief of rectal obstruction from cancers and every disease which is not otherwise removable, and experience has proved that life may by it be saved, when the disease is not cancerous, and prolonged even for years when it is so. Turning to page 605 in Wyeth's Text Book on Surgery, we read: "In stricture of the rectum, when all other measures fail, colotomy is the last resort." Here are two diverse views, by two very distinguished authors. Which is cor- rect? I am decidedly inclined to Dr. Wyeth's opinion (if colotomy is performed at all), and although he has been content with the bare state- ment, without argument, I shall in a few words give you my reasons for differing from Mr. Bry- ant, in his statement and proposition. I quite agree with him in the preference given to lumbar over inguinal colotomy, but I beg to differ as to the need for the operation, and base my belief on the pathology of the disease. Instead of ad- mitting his premise that colotomy is called for the relief of rectal inflammation by cancer and other diseases, and should be performed early in the disease, I shall contend that such a procedure is warranted only in the rarest cases, and then as a dernier ressort only, which he denies. My con- clusions are based upon an observation of several hundred cases of so-called obstruction of the rectum. I shall not found my objections upon the dangers that attend the operation, although every surgeon will admit that some danger at- tends it. I recognize the fact that, under anti- septic surgery, the mortality attending these, as well as all other surgical operations, is re- duced. However, this admission plays no part in rebutting other arguments that are urged for the operation. I will be permitted to remark that, in my opinion, it has become too much the 10 custom, or fad, to do this operation in cases where there is no possible chance of doing the patient any good. Indeed it has become so common, that the moment cancer of the rectum is diag- nosed, colotomy is resorted to. Mr. Bryant states two distinct propositions, namely, " First, the immediate success or failure of the operation turns but little upon the operation itself, if well performed, but upon two main points, the first being the local condition of the bowel above the seat of obstruction, and the second, upon the general condition and age of the patient." Some surgeon once said, that the reason lapa- rotomies for gunshot wounds showed such a low per cent, of recoveries, was that too many were attempting the operation. Mr. Bryant can very well say that the immediate success or failure of colotomy turns but little upon the operation, if it is well performed. The trouble is that if his premise be true, that this operation should not be considered as a dernier ressort in stricture of the rectum, but that it should be resorted to early in the disease, and is the best of all procedures, too many men, accepting his dictum as true, will be doing the operation, when less dangerous meth- ods might accomplish the same results. As to his two main points to be considered before doing the operation, first the local condition of the bowel above the seat of obstruction, I take it that he means whether or not the bowel above the seat of obstruction is invaded by the disease, or if, in consequence of the disease below, has suffered. In my opinion it would have been more to the point to have said, the local condi- tion of the bowel both above and below the seat of obstruction. He says: "If from procrasti- nation, serious intestinal changes have taken place before relief is present, recovery is hardly to be expected," Now I suppose that the dis- 11 tinguished author refers here to cancer or syphilis as the serious causes of intestinal changes. It is quite agreed that these two diseases account for fully two thirds of the obstructions or strictures of the rectum, which, as Mr. Bryant and others would say, would call for colotomy. Suppose the gut above the stricture was not invaded or changed at all, but that below the stricture, in- cipient it may be, there is a slight infiltration by cancerous deposit, is the operation justifiable? I certainly cannot agree that it is. It is admitted that a colotomy is a loathing and disgusting thing. Patients with cancer of the rectum live from three to six years. Many in my practice have lived five years after the disease was first observed. Why subject these people to such an operation during the incipiency of the disease, when it does not stop it ? Again, are we quite certain that there is an infallible sign of cancer? In quite a number of cases I have taken speci- mens from rectal growths, had them examined by microscopists, and pronounced cancer, whose subsequent history revealed the fact that it was not cancer at all. Then, too, in the early stages of cancer, there is not sufficient clinical evidence to base an opinion upon. Certainly for a benign and incipient stricture, or obstruction, if you please, in this locality, colotomy would not be advised. Again, if the disease be cancerous, in its in- cipiency, or otherwise, can the operation of colotomy cure it ? It might be, as Mr. Bryant suggests, the operation could be done much more successfully while the general health is in good condition, but it is not whether one can perform colotomy successfully or not, the prime question is, what good will it do ? A surgeon may do a beautiful operation for stone in the bladder and get the stone, but the patient dies. How then, 12 I would ask, can the establishing of an artificial anus in the side, in any way cure or arrest the in- roads of cancer in the rectum. If, then, it is granted that the disease being constitutional will go on regardless of the opening in the side, I would ask can the colotomy prolong life of the cancerous patient ? In no way possible can it do so, but one, that is by preventing one source of irritation, namely, the passage of faeces over the cancerous mass. The argument would be, the more irritation, the more deposit. In my opinion, this is of very little importance, or consideration in cancer of the rectum. Ma- lignant growths increase by an inherent power, a deposition, infiltration, etc., intrinsic, not ex- trinsic. They will exist in the rectum a long time, acquiring a great size, involving, perhaps, the whole circumference of the gut before the mucous membrane is ulcerated, notwithstanding this " great irritation " is constantly kept up. I dare say if a cancer of the same kind and pro- portion, in the same character of subject, could be watched each day, in one colotomy had been performed, the other without, that no difference could be observed in the rate of progress that was being made. I am forced to this belief after an observation of many years, covering many cases. As I have before stated, my patients have generally lived from four to six years with cancer of the rectum, without colotomy. Do they live any longer with colotomy ? In other words, can any one say, because, colotomy being performed, a patient lives four or six years, that the colotomy was the cause of prolonging his life ? Again, it is claimed that by colotomy much of the pain is the rectum is relieved, in that the faeces having been directed from their natural course. In some instances this may be true, but the rule will not hold good in all. I have known 13 patients to suffer equally as much with pain after, as before the operation, nor is it always true that the faeces are diverted from the natural channel. Much discomfort is often complained of by the patient, after a colotomy, from the faeces lodging in the mass, or strictured surface. In a paper read by Mr. Jessop, on the treat- ment of cancer of the rectum, at the Leeds meet- ing of the British Medical Association, he said : " In cancer of the rectum, the constriction in the majority of cases can be got over for a time, by injections, the introduction of the finger, or bougies, the use of laxatives and the like." This has certainly been my observation. In- deed I have seen many cases where the patient never complained of even constipation or ob- struction. Add to this that many patients of the kind complain of but little, if any pain, especi- ally if the growth is situated above the sphincter muscle, it lessens the cases materially which would call for colotomy. I cannot agree with Mr. Bryant in his state- ment that the operation is demanded for the pur- pose of relieving the local distress, admitting, as he does, that when the disease is in the lower part of the rectum that obstruction seldoms occurs. I have seven cases of cancer of the rectum now under observation, and in but one is pain a factor at all. Admitting that pain is a prominent symp- tom, colotomy does not bring that radical relief which would justify its being done. We have in opium a remedy which will quiet pain effectu- ally, and if the argument be used that we would make an habitue of the patient, I would remark, what is the difference if he is to die so soon? As I have observed, pain in cancer is inherent, caused by the local affection of the nerves, and is not controlled by extraneous circumstances. Hence, of what account is opening the gut at a 14 distant point, if pain is not a great factor in the disease? If, in answer, it is said that it prevents the irritation and pain caused by the passage ot the faeces, I would answer that in many cases this does not increase the pain, and if it does, dilatation will materially prevent it. I saw, this day, in consultation, a lady whose lower rectum, including buttocks, labia, etc., were involved, the gut for six inches tightly strictured, and when asked how much pain she suffered, answered, "Ob, very little,'' and said that the faecal dis- charges caused her no trouble. If, as some would have us believe, colotomy would prevent the extension of the disease, and its consequences, such as involvement of the blad- der, vagina, etc., I would ask how is colotomy to prevent it? It is not the passage of faecal mat- ter over the affected parts that causes this result, but rather the nature of the disease to infiltrate, and break down the tissue. If a cancerous growth is situated above the sphincter muscle, its ten- dency is to extend upwards, and in this event pain is not great, unless some other organs are affected. It is not uncommon that patients come to my office to consult me for some trivial rectal affection and I find, upon examination, a cancer- ous mass, extending all around the rectum, pain being scarcely a symptom in these cases. Of what value would colotomy be here ? Hence I am forced to the conclusions that the operation is not warrantable simply because cancer is found in the rectum, either in an incipient or confirmed state ; nor for the relief of pain simply, unless other complications exist, for we have medicines that will relieve pain ; nor to prevent invasions by the disease, because it would fail of its pur- pose. Infiltration and pathological change can- not be overcome by colotomy. Nor for obstruc- tion or fear of obstruction in the lower rectum, 15 because, as Mr. Jessop says, this obstruction sel- dom takes place, and if it does, it can be relieved by dilatation and other methods. Lastly, I do not believe that colotomy should ever be done for the obstruction of the rectum by cancer, save, perhaps, in a few exceptional cases, and then only as a dernier ressort. Yet in every instance before the operation is done, the nature of it and its con- sequence should be fully explained to the patient, with the assurance that it cannot possibly effect a cure. It is a well recognized fact that colotomy is advised and practiced by many, for other ulcer- ations and constrictions of the rectum, beside those of a cancerous nature. Except under cer- tain conditions, I shall object to this procedure with just as much emphasis as to the operation in malignant stricture. I have stated, in this article, that I do not hold to the theory of chancroidal ulceration, as so vehemently advocated by Zeigler, Mason, Kel- sey, Gosselin and others. My reasons have already been given, but I do hold that syphilis is responsible for more than one-half the cases of stricture of the rectum, and in the manner I have described. But to do a colotomy simply because a patient has a syphilitic stricture of the rectum, is, I believe, unjustifiable. As a proposition, then, I shall maintain that where a syphilitic stricture or strictures exist in the rectum, located within four inches of the external sphincter mus- cle, colotomy should not be done. In supporting this statement, I desire to say that in my opinion, a stricture located within the distance named, can be treated more successfully by other methods. Before leaving the subject of colotomy, as one of, if not the most important of all methods of treatment for stricture of the rectum, from what- ever cause, I beg to call to mind that the statis- tics of Erckelen carefully compiled in 1884, and 16 shown by Treves that 38 in every 100 cases of lumbar, and 46 in every 100 cases of iliac colot- omy died within twenty-one days after the opera- tion. This statement speaks for itself. Stricture from benign causes located within the distance that I have named, should be dealt with in a similar way. Symptoms.-The early symptoms of stricture in the rectum are very obscure and confusing. Indeed no stricture exists at all in the pathologi- cal changes going on in the gut which conduce to this state. The great trouble is that the early symptoms are so masked or entirely nil, that no attention is paid to them by the patient, that when he is forced to consult a physician a very de- cided stricture may exist. The changes made manifest in the rectum are those of inflammation and, if from cancer, the condition of the blood vessels, and the gradual deposit of the morbid material, together with infiltration of the tissue, goes on so slowly and insiduously, that for a long time there are really no symptoms. I have seen many cases where the first symptom noticed was a so-called constipation, obstipation would be a better word, and upon the introduction of the finger a tight constriction could be felt. This may apply to any form of stricture. I have under observation now three cases of this kind. The first symptoms of stricture then are not the discharge of bloody pus, etc., indicative of ulcer- ation, that some describe. Therefore, I must differ from those who place the symptoms of ulcer- ation first, and those of constriction afterward. Ulceration cannot take place, together with the symptoms incident thereto, a discharge of blood, pus or muco-purulent, until the changes of in- flammation have been such that the mucous membrane and sub-mucous tissues have under- gone that change which constitutes ulceration. 17 When this latter condition is established, we have the characteristic discharges-diarrhoea, flatus, the muco-purulent discharge, or rather a muco- bloody discharge first, succeeded eventually by a purulent discharge, and alternating diarrhoea and constipation. The bearing down sensation, to- gether with tenesmus, a reflected pain to the back and down the thighs, an irritation of the kidneys and bladder, and uncomfortable feeling always about the rectum. A passage of small bits, or tape-like actions, are all indications of the disease. I am persuaded that oftentimes stric- ture is diagnosed from this characteristic tape- like action, when in reality the moulding is done by the sphincter muscle in an irritable state, and that no stricture in reality exists. I am satis- fied, too, that many cases of so called chronic con- stipation are due to a narrowing of the lumen of the gut from this cause. This has occurred so often in my practice that I am now in the habit of ex- amining the rectum in every case of chronic con- stipation. This same rule holds good in cases of supposed dysentery, for, as I have observed, dysentery is but one of the symptoms of stricture, and caused by it. I have had but two cases of acute obstruction caused by the chronic condition of the stricture. One in the case of a young lady who failed to re- port to me as often as necessary for a dilatation of the stricture (she would not consent to an opera- tion) and during a summer outing took sick and died from an acute obstruction. The other was a young married woman, in the practice of one of our local physicians. An operation with the knife relieved her. Acute obstruction, as the first symp- tom of stricture, I have never seen, although I have examined a number of patients who com- plained of constipation only, who upon being ex- amined, showed a decided stricture that the 18 smallest finger could not pass. In one instance I found a close stricture at the entrance of the sig- moid flexure. It is truly wonderful to see patients who have strictures of the smallest calibre, who seem to enjoy perfect health, and whose physical proportions and development aie not hurt in the least. It must not be forgotten, however, that these are dangerous conditions and constantly im- peril the life of the patient. Diagnosis.-When the stricture is within four inches of the sphincter muscle, it is easily diag- nosed, be it malignant, benign or syphilitic-the finger will detect it. It is a very different mat- ter, however, to determine its character, and yet, to a certain extent, the treatment depends upon it. I desire to quote from Kelsey the following statement: There is an old and deeply rooted idea in the minds of the profession, that a stricture of the rectum must be either cancerous or syphilitic-an idea founded on error and capable of doing much harm and injustice to inno- cent people. Again and again I have been able to give great comfort to women suffering from this disease by denying the correctness of this idea, and in my own practice, the fact that a stricture is not cancerous adds little weight to the idea that it may be syphilitic. This is so diametrically opposed to my views and observations that I desire to say that, in my opinion, fully sixty per cent, of the strictures of the rectum are due to syphilis. Not venereal in the sense that many would have us believe, namely: by the infection of the rectum by can- chrous pus, or by direct contact, but as a second- ary deposit, the result of constitutional disease. There are but few authors to-day that deny this fact, but in admitting it, class these as exception- al cases. By a late estimate it is calculated that five million people in the United States are sub- jects of constitutional syphilis. If it is admitted that one single case of stricture of the rectum can 19 result from this constitutional disease, it admits the argument. Then taking into consideration the great number affected with it, is it any won- der that we should have the per cent, named as suffering from this manifestation in the rectum ? Mr. Allingham, in tabulating his cases of stric- ture, says: " Thus out of the total number of 99 patients, 52 or more were syphilitic." As a means of diagnosis, the clinical history and observation of the case has much to do with forming a correct opinion. If it is ascertained that the patient has constitutional syphilis, I would con- sider that it was a strong point gained. I do not wish to be understood as saying that in every case where both syphilis and stricture exist, that the latter was caused by the former, but undoubt- edly in the vast majority of cases this is true. Indeed, so firm am I in this belief, that if it is a question between cancer or no cancer, and it i s decided that it is not malignant, 99 out of every 100 cases will prove to be syphilitic; for the rea- son that stricture, the result of benign ulceration, does not resemble in the least stricture from ma- lignant deposition. To the contrary, syphilitic stricture does, to a degree, in its pathology, re- semble malignant growths. To be plainer, ma- lignant disease, and syphilitic disease, invade the rectum as a deposit, infiltration of the sub-mucous tissues, etc. Ulceration here is secondary to the deposit caused by the friction of the passage of faeces, or the breaking down of the tissue, the re- sult of the disease per se. Benign ulceration be- gins with the damage done to the mucous mem- brane, and the plastic infiltration is secondary to it, the reverse of both the malignant and specific disease. Again, as a diagnostic symptom, the touch re- veals a great deal. Allingham says: " There is something peculiar about the feeling of cancer, 20 which the operator's finger rarely mistakes even for simple indurated ulceration." This is the fact, yet if I was called on to describe it, I could not. It is said by many authors that the pecu- liar smell or odor of cancer is pathognomonic. I am certain that I have seen many cancers that did not evidence this peculiar odor. Great stress is also laid on the disposition of malignant growths to bleed, especially when touched or handled. I am just as sure that 1 have seen many cases of cancer that had no such disposition. The swol- len or enlarged glands in the inguinal region can- not be taken as a postive sign or indication of cancer in the rectum, from the fact that they are swollen in many cases of benign ulceration and inflammation. I will again state that pain, in my opinion, is made too great a symptom of can- cer. It depends altogether upon circumstances whether it exists to any degree or not. In cancer the nodular form of the mass is more apparent than in any other trouble. In syphilis, the in- duration is more even and extends with more reg- ularity, and after a time is of a fibrous character and is so indicated to the touch. In simple ul- ceration, the stricture is apt to be annular. As a method of diagnosis, I object to the use of rectal bougies, either metal, soft, or hard rub- ber, to which so many authors call attention. They are exceedingly dangerous, and accomplish no earthly good. I have known two patients killed by the attempt to introduce the common hard rubber English bougie within a stricture of the rectum. The common seat of stricture is within reach of the finger. It is the rarest thing that one is ever found in the movable gut. Grant- ing that one exists there, if there is not a total obstruction, what is the use of an exploration with a dangerous instrument, when the finding of the stricture, or the supposed finding of it 21 would result in no good. A stricture located in the movable gut cannot be dilated. If it be total occlusion or obstruction, it calls for very differ- ent treatment from this. Treatment.-In considering the treatment of this very formidable disease, I shall adhere in the strictest sense to the pathological condition, namely, a stricture. This entirely rules out the treatment of proctitis, or the subsequent ulcera- tion, which is one cause of stricture, and brings us directly to the means of treating that which is the result of said causes. It must be granted that many times ulcerations, which would even- tuate in stricture, are cured before that condition results. This cannot hold good in cancer. Can it in syphilis? I doubt it. In the great majority of cases, we are confronted at the onset with stric- ture, not with the ulceration, so insidious is the disease. The methods practiced to-day for treat- ing stricture of the rectum are: i. Dilatation. 2. Incision. 3. Electrolysis, and raclage. 4. Excision. 5. Colotomy. Of course, under the division I have made, we rule out general treatment. Dilatation.-Kelsey in speaking of dilatation, says. " By dilatation I mean gradual stretching, not forcible divulsion," and adds that the latter is seldom applicable. I must dissent to these views. The gradual dilatation of stricture is objectiona- ble, for the reason that by this form of repeated irritation, more plasma is thrown out and the strictured surface increases. It may be true that some temporary relief is afforded, but upon the contraction of the tissue, which is sure to take place, we have lost more than we have gained. I 22 do not hold to the view that by the passing of bougies through the strictured surface absorption of the tissue is caused, I believe that the converse is true. Why forcible divulsion is seldom appli- cable in these cases, I cannot understand. If a fibrous stricture exists, I am sure that forcible di- vulsion is the best method. In other words, we do, in a few minutes, by immediate dilatation, what it would take weeks to accomplish by gradual dilatation. The fear, in the past, has been haem- orrhage in this operation. To-day we do not fear it, because we understand how to control it. Therefore, I would put but little stress, or no stress at all, upon treating stricture, of whatever kind, by bougies. In fibrous stricture it would do no good; in the malignant one, it would be dangerous. I have abandoned their use altogether. In 1878 I read a paper before the Kentucky State Medical Society, in which I reported a case of close stricture at the entrance of the sigmoid flexure. The plan adopted was to break the sphincter muscle, introduce the hand and arm into the rectum, and reaching the stricture, which bare- ly admitted my index finger, I made a cone of my four fingers and forcibly pushed them through the stricture. It gave way before them, and al- though great shock supervened, the recovery from immediate danger was effectual. I am sat- isfied that a more perfect and radical relief was obtained than if I had done colotomy. Gradual dilatation here was out of the question. I am very positive then in saying that if dilatation of a stricture of the rectum is decided upon, let it be a forcible and radical one. Incision.-I am very partial to incision, or in- cisions, for the relief of stricture of the rectum. Of the two operations recommended, internal and external posterior linear proctotomy, I much prefer the internal. It is urged for the external, 23 which consists of not only going through the strictured surface, but also in dividing the sphinc- ter muscle, that it is all important to get the ne- cessary drainage. I do not think so, and if I did, I believe the ill-effects of dividing the sphincters outweigh the matter of drainage. I cannot be- lieve that the internal incision is as dangerous as it is represented to be by some authors. My plan is to introduce a three or four valve speculum, and, after dilating sufficiently for the purpose, a long sharp knife is used to divide the constrictions of fibrous tissue, down to a healthy base-not only in the median line, but in several places around the circumference of the gut. I then place a tampon, through which I have inserted a metallic tube for drainage, and the escape of gases. This tampon is aseptic, and usually dusted with powdered persulphate of iron. On the fourth day it is removed and the rectum irrigated with a mercuric solution. If the operation is done effec- tually, I have never seen the necessity of employ- ing the bougies afterward, for the purpose of dil- atation. Patients are averse to their use, and they do not accomplish the good claimed for them. My objection to the external operation, al- though I have practiced it often, is that to divide the sphincters when all the tissues are in a dis- eased condition invites non-union, and incontin- ence is nearly certain to follow. The sugges- tion of Weir, to confine the incision to the stric- ture and then to drain the incision by a tube brought out through the skin, at the tip of the coccyx, I do not think will accomplish the pur- pose in many cases; besides, it leaves a channel which may not heal. To divide the sphincters and then employ three or four deep provisional wire sutures between the anus and the strictures, leaving them loose and stuffing the incision with charpie, after the manner of Kelsey, I think un- 24 wise and unsurgical. It is said that one great danger of the operation is septic peri-proctitis, but under antiseptic precautions, the danger, in my opinion, is reduced to a minimum. In one case of malignant disease, in which I did the ex- ternal operation, rapid sepsis took place, and the patient died in twenty-four hours. I do not think either the internal or external operation should be done for malignant growths, unless to- tal, or nearly total, occlusion has taken place. In all cases of non-malignant stricture, syphilitic or simple, either the internal linear proctotomy of the French surgeons, or the external operation as practiced by many, is far more preferable to ex- cision, or colotomy. Electrolysis.-It does appear that where we can so effectually go through a stricture by linear proctotomy atone sitting, that it would be useless to attempt so slow a process as electrolysis. Af- ter a careful review of the subject, I cannot be- lieve that any benefit obtained is brought about by the dilatation from the electrodes used, as suggested by some. If there be a benefit, in fact, it must be attributed rather to what is claimed for it-partial destruction of tissue by cauteriza- tion. To claim radical cures by this method, I must admit, seems untheoretical, if not unsurgi- cal, and yet Dr. Newman and others report many cases of stricture cured by this method. In a paper read before this Association and published in The Journal, he makes the following con- clusion: I. Electrolysis in the treatment of stricture of the rec- tum is not a panacea; on the contrary failures may hap- pen, and probably will,if the stricture is due to carcinoma. 2. Electrolysis will give improvement to the stricture when all other methods have failed. 3. Electrolysis will cure a certain percentage of cases, without relapse, and without the necessity of an after treatment or using bou- gies. 4. The best agents for a cure are through the fibrous inflammatory stricture. 25 Having no personal experience with this method of treating a stricture of the rectum, I am not prepared either to advocate it or disprove the statements made. Excision.-I think a better term to employ here would be extirpation. Excision of a stric- ture of the rectum conveys but a little idea of the operation. I cannot appreciate the idea of excis- ing a benign stricture, not from any serious doubts as to whether it could be done or not, or any dangers attending the operation, but there are methods so much simpler in their nature for the relief of benign strictures, that I cannot con- ceive of a surgeon attempting its excision. Extirpation of the rectum for malignant disease I believe to be an ideal operation. Between the plan of the German surgeons of removing the en- tire rectum up to the sigmoid flexure, and the English surgeons of restricting the operation to a very limited extent, I believe that a middle ground can be established and practiced, based upon a true pathology. It is an axiom in sur- gery that in operating for cancer, the whole growth must be removed, together with the glands that are involved. Let us take this axiom as our guide in rectal surgery. If the growth ex- tends beyond the point where it is prudent to op- erate, it is best not to attempt its removal, except, perhaps, for total obstruction, not with any idea of cure. Cripps makes the point that the opera- tion is of doubtful propriety when the disease in- volves the upper part of the recto-vaginal section, where it is covered with peritoneum. I do not consider this injunction as meaning that it is so dangerous to open the peritoneum, but that this membrane being involved in the disease, renders the operation useless. If, however, there is no fear of the invasion of the peritoneum, an admir- able operation is afforded us by Kraske's sugges- 26 tion, enabling us to remove much of the length of the rectum. The chief argument in favor of his operation is that the entire length of the rec- tum can be removed, without disturbing the sphincter muscles. In continence of faeces, the result of injury to these muscles, is the one great objection to any other mode of operating. Kraske's operation is admirably suited to can- cerous stricture. It consists in resecting the dis- eased part, through an opening made at the left side of the sacrum. This operation, of course, is only applicable in a certain class of cases. For instance, if the sigmoid flexure is involved, it would be of no use. If the stricture is low down, it can be divided with a knife. According to his method, the soft parts are divided in the median line from the second sacral vertebra to the anus. The muscular attachments to the sacrum are di- vided as far as the edge of the opening on the left side. The coccyx is removed, the attachments of the two sacro-sciatic ligaments to the sacrum are cut, and the soft parts drawn to the left side. If still more room is necessary, it may be gained by removing a part of the lower left side of the sacrum. If the bone be divided on a line, begin- ing on the left edge, at the level of the three pos- terior sacral foramen, and running in a curve concave to the left, through the lower border of the three posterior sacral foramen and through the fourth to the left lower border of the sacrum, the more important nerves are not injured and the sacral canal is not opened. In this way, the lower part of the rectum, as far as the sigmoid flexure, may be removed. It will be found in this operation, that the dissection is a very diffi- cult one. Alexander modified this operation, the chief points being that he exsected the coccyx and all of the sacrum necessary to a certain limit. Ex- 27 perimenting with the two, I much prefer Kraske's original operation. I have removed as much as five inches of the rectum, by simply removing the coccyx, making a deep and long dorsal incis- ion, and then practicing a thorough dissection of the gut. The one great object of both of these operations is to keep the sphincter muscles and anus intact. It is true, however, that in some cases the cicatrization is sufficient to establish partial control at least of the actions after the re- moval of the muscles. This was beautifully illus- strated in a case of extirpation which I recently did for cancer. The patient was a man about 60 years of age. The growth extended completely around the gut, beginning at the anus and ex- tending up the rectum for fully five inches. The tissues surrounding the rectum were involved to the extent of three inches. Both sphincters were embraced in the disease. A deep dorsal incision was made through the sphincters and tissues to the sacrum, and brought out over the coccyx. The incision was then made completely around the whole diseased structure, extending from the coccyx, around through the perineum. The gut and sphincters were then carefully dissected out. The vessels were tied as they were uct, drainage tubes placed, and the wound dressed antiseptical- ly. I did not do as the German surgeons sug- gest, draw down the end of the rectum to the skin, attach it by a row of sutures, nor did I do as Allingham and Kripps advise, stitch the gut lightly to the skin, and leave the wound to close by granulation. In lieu of both, I left the wound just as I made it, and made no attempt to either bring the mucous membrane down or to stitch it. When the wound had filled up and healed, the cicatrization afforded him protection against any sudden evacuation of the bowels. I am more and more persuaded that where there is a possi- 28 bility of removing the entire malignant growth from the rectum, excision is far more preferable to colotomy. Excision would remove the dis- ease, thereby having some grounds to hope that it will not reappear. By colotomy we simply palliate the symptoms, leaving the disease in its ravages. Colotomy.-In a paper read before the Ninth International Medical Congress, which convened in this city in 1887, I took exception to colotomy as a means of treating cancer of the rectum. In that paper I said: It is after a careful survey of all the reasons advanced by those who advocate colotomy, in cases of cancer of the rectum, that I am constrained to differ from them and to say that I do not believe that the operation is justified in these cases, except under the rarest circumstances, if at all. I am still of the same opinion. Too many peo- ple are being subjected to this horrible and dis- gusting operation, that could be benefited equal- ly as much, by simpler means. The operation in itself promises but little. Kelsey says: It is the common doctrine taught, that it is to prolong life by the relief of pain, the prevention of obstruction, and in retarding the growth of cancerous disease. To these statements I cannot give my full ap- proval. First, that to prolong life by the relief of pain I answer, in the majority of cases that have come under my observation, and they have been many, there has not been much pain com- plained of. Indeed, it has not been a factor. A young lady just sent to me from the South, with a pronounced cancer of the rectum, says she has never suffered any pain. This is simply repeat- ing what many have said to me. If this, then, be the reason assigned for the operation, these cases would be ruled out, and they constitute the majority. But suppose that pain exists, does 29 colotomy relieve it? It may in some cases, but I am certain that in many it does not. As I have said in this article, pain is within the growth it- self, by the involvement of the nerves. Surely colotomy could not relieve it. It is likely true that the faeces passing over the growth may irri- tate it to a certain extent, but my experience has taught me that if the sphincter muscles are not involved, there is but little pain, and if they are involved, scraping the mass out, according to the Germans, will relieve it, equally as well as colot- omy would. Again, it must be admitted that after colotomy is done, there is no absolute cer- tainty that some of the faeces will not pass down into the rectum. Second, that it prevents obstruction. It will be admitted that the greater number of cancers are located in the lower or fixed part of the rectum. It is a recognized fact, too, that total obstruction from faecal impaction rarely takes jriace; because it is the disposition of malignant tissue to break down after a certain stage. But suppose it does not, and a stricture, total, if you please, results, to cut through it, divulse it, or resect it, would be better than to do colotomy. The first two will promise equally as much, and the last much more. I have never seen a total obstruction by faeces in a cancerous stricture. I have known total obstruction to occur by the closure of a stric- ture. We have means of eradicating this by the three methods mentioned. They are much sim- pler than colotomy, why not do them ? Third, that it retards the growth of cancerous disease. Neither can I subscribe to this proposi- tion. How the establishing of an artificial open- ing in the loin or groin materially retards the growth in the rectum, I cannot understand. I know that it is used as an argument that the stoppage of the faeces over the growth would, to 30 a degree, stop the growth. This is utter falla- cious. The cancer persists in its progressive course of infiltration, ulceration, etc., with as much rapidity after colotomy is performed. Cor- rect statistics of the condition will verify my statement. Admitting that there was truth in the assertion, patients who suffer with cancer to that degree, or extent, requiring colotomy, are not anxious to have their lives prolonged. As a last argument, it is said that colotomy substitutes a painless death for one of great agony. This statement cannot be borne out by facts. Patients who have malignant disease of the rectum usual- ly die of a low and gradual form of peritonitis. I have witnessed a number of such deaths, and they are usually painless. In what way colotomy can substitute a painless death, granting that such a condition exists, I cannot understand. It would appear that they would die very much the same way, whether.colotomy is done or not. So I am forced to conclude that neither one nor all of the so-called arguments in favor of doing colotomy, instead of other methods, for cancerous stricture, can be substantiated in fact. If I were asked, when is colotomy justified in cancer of the rectum, I would answer, rarely, if at all. But if there be total obstruction of the sigmoid flexure from a cancerous mass, and if for any special reason we wish to prolong life a few days, then I believe colotomy would be j ustifiable. I know that this is a radical view to take of the case, and I also recognize that the great majority of surgeons will differ from me, but my conclusions have been formed after a care ful investigation of the subject. But to proceed. Is colotomy to be recommend- ed as a procedure in the treatment of stricture of the rectum ? I unhesitatingly answer, yes. Whenever a stricture other than malignant, espe- 31 cially when caused by syphilis, is located in the movable part of the gut, or in the sigmoid flex- ure, either causing total obstruction or about to cause it, colotc my should be done. If I am asked why, in this in tance, and not in cancerous stric- ture, I would answer, in this we prolong life in- definitely. I see no reason why one should not live many years after the operation done for this condition. A fibrous stricture in the locality named would likely cause death by occlusion, if let alone. It is beyond reach for dilatation, divis- ion or excision. There is nothing in the stric- ture per se to cause death, only in the manner mentioned. It acts as a foreign body, causing obstruction. It can never be reabsorbed. It can- not cause death by infection of the body. Hav- ing blocked the channel, we open a gate-way above for the escape of faeces, and life is pro- longed indefinitely. To do the operation for can- cerous stricture, the disease is neither stayed nor cured. The patient dies and the friends ask, why you did so formidable and disgusting an opera- tion, when you knew that death would so soon ensue. To the contrary, in benign or syphilitic strictures, the patient will live to thank you for doing the colotomy. If, then, it is decided to do colotomy, which of the two operations is prefera- ble, the lumbar or extra-peritoneal, or iliac, or intra-peritoneal ? I think the anatomical phrase used in designating the two should decide it. An operation extra-peritoneal is certain to be prefer- red to one that is intra peritoneal. I am cognizant of all that is said in regard to the perfect safety of opening the peritoneum under aseptic precautions. Nevertheless, it cannot be gainsaid that it is more dangerous to open the per- itoneum than not to open it. I know, too, it is asserted that in doing a lumbar operation, the peritoneum is often opened. This has not been 32 the case in my experience, and in Mr. Bryant's 170 cases of lumbar colotomy, the peritoneal cav- ity was opened but twice. This disproves the assertion. It is urged in favor of the iliac opera- tion, that by it there can be no possibility of the surgeon mistaking the small intestines, duodenum, or stomach, for the large intestine. Just as well say that it is dangerous to attempt to ligate inter- nal haemorrhoids, because there is a possibility of including the prostate gland. A surgeon that could not recognize the stomach from the colon, ought not to attempt a colotomy. If the opera- tion is done for the condition that I have named, namely cancerous stricture or obstruction in the sigmoid flexure, the lumbar operation is also preferable for the reason that it is a greater dis- tance from the diseased part and not so apt to be embraced by it. I have not the time or disposition to argue the pros and cons of this much mooted question. I think Mr. Bryant has met all the objections against the lumbar operation, and I quite agree with him when he says: "Iliac colotomy is not yet proved to be superior to the lumbar operation."