Our Diagnostic Resources in Rectal and Allied Diseases. Delivered by request before the Chicago Post-Graduate Medical School, Aug. 30,1893. BY JOSEPH M. MATHEWS, M.D. LOUISVILLE, KY. PROFESSOR OF PRINCIPLES AND PRACTICE OF SURGERY AND DISEASES OF THE RECTUM, KENTUCKY SCHOOL OF MEDICINE, ETC. reprinted from THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION NOVEMBER 11, 1893. CHICAGO: PUBLISHED AT THE OFFICE OF THE ASSOCIATION, 1893. OUR DIAGNOSTIC RESOURCES IN RECTAL AND ALLIED DISEASES. Gentlemen:-When I first received the kind invita- tion from the Faculty of the Chicago Post-Graduate Medical School, through its worthy secretary, Prof. Martin, to deliver this lecture, I must confess that it seemed to me at that time to be impossible, but upon second thought, and by rearranging some other matters, it was made possible for me to be with you this evening. Before entering into my subject, the Faculty will permit me to thank them very cordially for the honor which this invitation confers upon me. Hav- ing been a teacher in a medical college for many years, the compliment is doubly appreciated as com- ing from another Medical Faculty, and one, too, that is the peer of any and all others. It is fit that the shoemaker should stick to his last, and I have, therefore, selected a subject for discussion to-night that may appear to you as being too simple for the occasion, but my apology is that it is the theme that has interested me, to the exclusion of others, perhaps of greater moment, for sixteen years. Then, too, I hope to interest you to the extent, at least, that you will admit it of sufficient importance to be considered. I believe that you will agree with the statement that a diagnosis is of equal importance to the treatment in any and all diseases. Indeed, it is difficult to imagine one treating a disease correctly unless he has properly diagnosticated it. What a pity it is that our schools do not give more attention to the teaching of physical diagnosis, and more's the pity that we see, every day, people suffering and dying without a proper diagnosis having been made. Hav- ing given special attention for sixteen years to dis- eases of the rectum, it will not surprise you to hear 2 that in that time I have met with many, very many cases that had not only been diagnosticated wrongly, but the treatment in consequence was not only incorrect, but engendered much suffering and distress, if not actually causing the death of the patient. I hope that it will not be inappropriate in this connection to recite a case that has just come under my observation: A gentleman was referred to me by two well- known physicians of a neighboring State, for exami- nation and treatment of his rectum. After a careful examination, I was able to decide that the patient was suffering from a well-defined carcinoma which began about one inch above the sphincter muscle and extended as far as the finger could reach. He was able, however, to have a daily evacuation of the bowels, as no strictured surface prevented, and that too with but little pain. A colotomy was not author- ized, and the growth extended too high to be removed. Under the circumstances he was advised to go home and continue palliative treatment. This he did, but I was soon notified that he had fallen into the hands of other physicians who advised him to go to another city for treatment. Upon his arrival there, he wrote back to his former physicians saying that the sur- geon said that he had seven large piles, and that after they were removed he could return home in ten days a well man. The operation was done and he was buried the following Monday. . Either the surgeon's diagnosis was wrong or he greatly deceived his patient. It has occurred to me several times to operate upon patients for cancer of the rectum where a diagnosis of piles had been given. Generally I have attributed the mistaken diagnosis to the fact that the physician did not make an examination, but in one instance, at least, the phy- sician had ligated a portion of the cancerous mass, mistaking it for a hemorrhoid. It is no uncommon thing for a surgeon who does much rectal work to see cases of hemorrhoids, diagnosticated as prolapsus 3 ani, or vice versa; benign ulceration of the gut, designated as malignant, or the reverse; a con- tracted, spasmodic sphincter, called a stricture; a retroflexed womb, made out to be a tumor of the rectum; or an enlarged prostate, called carcino- ma. Nor is it a surprise to the surgeon to have cases referred to him as rectal, when in truth the trouble is a urethral or meatic stricture, or it may be a displaced ovary or pus tube. It has happened to me to see three women who had submitted to an ovari- otomy, whose symptoms failing to clear up, had their trouble explained by detecting disease in the rectum or flexure. One woman was sent to me to have a large rectal tumor removed, when upon examination it was found that she suffered from a displaced uterus only. I have reported two cases of hypertro- phied prostate, diagnosticated as piles. It is only necessary to refer to the fact that every day patients present themselves to the family physician for ad- vice, having been informed that it is most important that they have some rectal 11 pockets " removed, which are slowly but surely endangering their health and mayhap their lives. Nor need I tell you that a great operation has been discovered, invented or found, truly national in character, called the "Amer- ican" operation, which promises relief to the afflicted of whatever kind. It is upon the supposition and the fact that these things are true, that I have selected my subject for this paper. True, you may say that such mistakes can only be made by ignorant men or pretenders. If your statement is true, then I will insist that much of your duty lies in the protection that you can or should give your clientele. But my experi- ence has taught me that your opinion is not alto- gether correct, if I am to anticipate it in the words already expressed. Many in the profession look upon the rectum as a fathomless pit and often let its affections go by without investigation, and many irregulars seeing this have been quick to see the 4 chance and profit by it and enrich themselves. That they have made grave mistakes in practice, we can all attest, but it is our duty to correct the evil and not condone it. The main object, then, of this paper is to try to draw your attention more definitely to the importance of making a correct diagnosis in all rec- tal and allied diseases. By allied diseases is meant affections of other organs which, by continuity or contiguity with the nerve system as a medium of reflex, show symptoms through the rectum, but which in reality have their seat in other organs. One of the most harassing cases that I have ever met was that of a woman who gave the most pro- nounced symptoms of neuralgia of the rectum, yet no relief was ever afforded her until the coccyx was removed. You will agree with me that the rectum is the seat of many diseases. Hemorrhoids, both external and internal, affect the young, old and mid- dle aged. Cancer finds the rectum a favorite seat and syphilis attacks it, often completely obliterating and destroying it. A simple fecal impaction of the flex- ure or rectum may kill, if not diagnoticated, and many have lost their lives from hemorrhage from a capillary pile. Proctitis has often been mistaken for dysentery, and an ulceration (simple) in the sigmoid flexure, called cancer and left alone. You will per- mit me to try to clear up some of these, at least, in a diagnostic way. METHODS OF EXAMINATION. It is not at all necessary to have much parapher- nalia, or many instruments, to make a rectal exami- nation. With the finger and a good light, either artificial or natural, all, or most all rectal affections can be made out. Speculse are generally cumber- some and do but little good; besides they are ex- tremely painful to any diseased rectum. Indeed, I can not recall any rectal affection that can not be made out by the finger's touch, except one, when in reach of the finger. The exception is the one most commonly believed to be the most easily diag- 5 nosticated by the finger. I allude to internal hemor- rhoids. Unless hypertrophied and made solid by plas- tic infiltration during an inflammatory attack, or hardened by atrophic change, they can not be felt when within the rectum, and indeed I have often thought that internal piles that did not protrude, needed but little if any attention, unless it be the ligaturing of a small bleeding tumor that was wast- ing the body by hemorrhage. If you will run over the list of rectal affections, I think that you will sus- tain me in the position that by touch alone, they can be diagnosticated. Polypi are easily detected; a stricture is readily felt; an ulcer quickly recog- nized ; cancer, self apparent; syphilis, clearly trace- able; fistulje, external or internal, clearly seen or felt; an irritable sphincter responds quickly to the touch, and hemorrhage plainly seen; the prostate gland fully within reach, its anatomical bearings easily demonstrated and its pathology made mani- fest; pressure upon the rectum by a displaced uterus, quickly told ; a fallen ovary generally within reach; a prolapsus ani seen without difficulty when extruded; an impacted fecal mass just within the sphincter easily felt. Of course, for determining a proctitis or other inflammatory condition in the rec- tum, a speculum examination is necessary. When natural light is not attainable, the electric small globe is an excellent substitute or the use of head mirror with Argand burner, as used by Kelsey, Cook and others, subserves the purpose well. The position of patient for rectal examinations should be either Sim's, on left side to gravitate contents of abdomen toward diaphragm, or on the back with knees held by Clover's crutch. The anatomy of the rectum must be taken into consideration in a diagnostic way. It is not my intention to enter into a description of its minute blood or nerve supply, but I would call your atten- tion to the fact that it is abundantly supplied with ANATOMY OF THE RECTUM. 6 each. Its vascularity predisposes pt to inflamma- matory changes and its large nerve distribution ac- counts for many reflexes. I am firmly convinced that if the gynecologist and general surgeon, as well as the practitioner of medicine, would oftener look to the rectum as a source of reflex trouble, many vague troubles would be cleared up and many patients benefited thereby. I do not wish to be understood as advocating any wholesale or unwar- rantable "orificial surgery," but simply to call your attention to actual diseased structures when they exist. I believe that when there is a structural change or a true pathological condition existing in the rectum, such condition may be the means of reflecting symptoms to neighboring or contiguous parts, but I do not believe, nor can it be substanti- ated that even if such change is found, it is, or can be, responsible for the many diseases that some hold and are, and that can only be, produced by an actual pathology in the parts affected. Dyspepsia, asthma, eczemas, neuralgia, etc., have a true cause, outside of any orificial conditions, and the short-sighted phy- sician or surgeon who is lured into the belief that operations upon these outlets of the body will be of any benefit, will make a woeful mistake and inflict, perhaps, an irreparable injury upon his patient. In this connection I shall be permitted to insert a letter apropos to the subject, lately addressed to me by one of the leading physicians of Kentucky: "I write to know what this new surgery is that warrants the cutting out (or off) of several inches of the rectum for some supposed or trivial affection. Two men came to our town a few weeks ago and operated upon a young girl (a friend of mine) who is, or was, in perfect health, save a little rectal irri- tation. The operation consisted in cutting deep down into the cellular tissues, and removing a ring and attempting to unite the upper and lower seg- ments by first intention. Of course it was a failure. This was done five weeks ago. It is now healing by 7 granulation and a stricture has resulted, for which dilatation is now being practiced." If this whole subject were not really serious, it would be ludicrous, but inasmuch as unscrupulous individuals are playing upon the innocence or igno- rance of the public, and by their pretense inflicting great damage and unknown distress, it behooves us as physicians to warn them at least of the danger. I am glad to add that this uncalled for and outrageous procedure has been, and is being denounced by all good surgeons. Last Sunday I operated upon a very prominent minister from Texas, the object of the operation being to restore, if I could, a sphincter muscle that had been destroyed by the so-called''American" ope- ration. He told me that he was a subject of asthma and had been advised to go to an institute in Chi- cago for treatment. The treatment (?) consisted of the removal of several inches of his rectum, and a circumcision. A stricture of the rectum followed the- excision and he was anesthetized three times, and that cutting, breaking, etc., was practiced. Upon his discharge, or quitting the institution, he found a perfect inability to control his actions. This gen- tleman is in a deplorable condition, his occupation gone and he expressing a preference for death to the condition he is in. In a late edition of the Journal of Orificial Surgery, published in this city and edited by a gentleman of rare ability, I find these remarks : " Orificial surgery is searching in its action; the effects of the work not only reach out to physical disorders but influ- ence profoundly the state of the spiritual man, as by its aid the lame have been made to walk, the blind to see, the asthmatic to breathe, the dyspeptic to digest, the neuralgic to enjoy a relief from suffering and so on through the list of chronic ailments." So we are to infer, from so distinguished an author- ity as the originator of orificial surgery, that all chronic conditions, wherever found, are directly trace- 8 able to the orifices of the body. Our text-books then go for naught, our pathology all wrong, physiology but a myth, and great authorities have written in vain. If you have witnessed the surgery done upon one of the outlets of the body, viz: the rectum, and have watched the results as I have in many cases, you will confess that the remedy is much worse than the disease, even granting that the disease was cured. I speak now more especially of the chronic ailments of the body, said to have been treated by the opera- tion upon the orifice where no actual disease existed. Surely these men do not know of the great amount of harm being done by the disciples of such a doc- trine. The orificial operation, or the so-called " Amer- ican "■ operation, upon the rectum, consists in the removal of an inch or more of the mucous mem- brane of the gut, a modified Whitehead's operation. It is tedious of execution, attended with much hem- orrhage, the effort to stitch the membrane to the true skin is often futile and the result in many cases an extensive proctitis, an ulceration, or a decided stric- ture, not to speak of incontinence, which follows the operation. I have many letters giving these results, and have had scores of cases under my observation suffering from one or all of these calamities. I therefore maintain that the operation is unwarrant- able and untenable, and would respectfully call your attention to it for a full investigation. In a diag- nostic way, I do not believe that the so-called " pock- ets " or papillae have any significance whatever, as they have been demonstrated by Prof. Edmund And- rews of this city and other learned anatomists and surgeons, to be the rectal pouches (sacculi Horneri) and are normal structures. If, then, it is objection- able to remove these by clipping, etc., how much more unreasonable it is to remove an inch or more of the normal gut for the relief of chronic affections, as dyspepsia, asthma, etc. Kelsey says in the Manual for 1892, that whole opera companies are admitted into this same institution and subjected to the 9 " American " operation for the purpose of improving their voices. REFLEX IMPRESSIONS FROM THE RECTUM. No one will deny that impressions upon other organs are received from the rectum byreflex action. This fact has been abundantly attested by the pro- fession and many articles have appeared on the subject lately. It has been upon this hypothesis, doubtless, that the " orificial surgery " idea originated. That there is some foundation in fact for the theory advanced must be granted, but much false reasoning has resulted in many unwarrantable surgical opera- tions, which have resulted disastrously to the patient. To have reflex action in any case we must have certain and well-defined conditions. They are viz : a, afferent impressions resulting from the influence of a foreign body, or a pathological state, such as inflammation or ulceration, acting as an irritant upon afferent nerves, either in some part of their course or in their peripheric sites of distribution, whether such sites be situated upon the external sur- face of the body, or upon some part of one or another of the mucous surfaces within the body. Thus it happens that the determining cause may be associ- ated with painful impressions, though in some in- stances such impressions may be more or less absent. Worms in the alimentary tract of the child, are just as likely, or more so, to excite to a spasmodic condi- tion (general) than an affection of any outlet or orifice of the body. The second essential in pro- ducingnerve reflex is, 6, that the afferent impressions (painful or non-painful) produced by the irritant or pathological state, should pass from the nerves con- veying through them a related nerve center which, from one or other cause, chances to be in a state of exalted activity, and c, thence be reflected along one or other set of afferent nerves, so as to produce effects of this or that order. As afferent nerves are 10 distributed to glands and to muscles (both involun- tary and voluntary) reflex phenomena may show themselves in one or other of the two principal directions: 1. By the modification of the quantity or quality of some secretion. 2. By the production of spasmodic contraction in certain muscles, either of the involuntary or volun- tary type. Under this process of reasoning, it can be easily comprehended how headaches, neuralgias, etc., can originate from an incoordination of the muscles of the eyeball; or an ugly ulcer in the rectum, especially one embracing the prostate, could make manifest symptoms of cystitis. But it must not be forgotten that the one essential to a reflex action is a pathological condition. Disease, or a change from the normal must exist, such as long continued irritation, congestions, inflammations or ulcerations. At the meeting of the Ninth International Medical Congress, held at Washington, September, 1887, I had the honor to read before the Section of Anatomy, a paper entitled, "The Anatomy of the Rectum in Relation to the Reflexes." Up to that time, very little had been written on the subject, and the further I have pursued the subject, the more convinced I am of its importance, but we must not lose sight of the fact that our premises and conclusions must be based upon strict anatomical and scientific grounds. I will not bore you by attempting to give the anatomy of the rectum, but will make it suffice to say that a diagram of its nervous distribution is easily studied, its anatomical relations plain to understand and its pathology quickly recognized. With these to guide us, a diagnosis based upon a clear understanding of disease can be made out. I therefore regard the anatomy of the rectum, in relation to the reflexes, of the very greatest diagnostic value. Especially should it be borne in mind that, 1, disease and local irri- tation must exist in the rectum ; 2, there must be 11 an afferent nerve fiber; 3, a transferring center, and 4, an efferent nerve fiber, forming a reflex arc. From the nerve supply of the rectum, it can be easily seen that pain would be manifest over the sacrum and coccyx in rectal disease. If disease is limited to the lower part of the rectum, the patient will complain of pain at the end of the coccyx. If disease is in the central part of the rectum, the pain will be in the center or lower part of the rectum, and when the disease is in the upper part of the rectum, the reflex will be in the upper part of same, in the innominate arch, etc. The location of the reflex, therefore, will indicate the part of the rectum in- volved, demonstrating that the nerves to any part of the rectum and to the posterior surface of the verte- bral column opposite these, are given off from the same point in the spinal cord, bearing the same rela- tion as the nerves to a muscle and the skin over it. Bearing in mind these facts, and also recognizing that by contiguity as well as continuity of structure, we can get a reflex impression, many vague condi- tions can be cleared up in a diagnostic way. In the male we are to remember that the prostate gland, bladder, urethra, inguinal gland ; and in the female, the bladder, urethra, uterus, vagina, ovaries and tubes, are especially affected by pronounced rectal disease. In this connection I will call your attention to the external sphincter muscle, as a factor to be consid- ered in making a diagnosis of rectal disease, and also of its importance in a reflex way. My attention to this muscle as a factor in constipation, was first called by Dr. Rich. 0. Cowling, deceased sixteen years ago, then Professor of Surgery in the University of Louis- ville. He believed that many cases of chronic con- stipation could be relieved by the free divulsion of this muscle. He, however, had never practiced it. Upon his suggestion, I tried the plan upon a few pa- tients that would permit it and reported the favorable result to one of the medical societies. In the operation for internal hemorrhoids, I always precede it by a free 12 divulsion of the muscle. Many cases that have suf- fered from the constipated habit have been relieved by the operation, and I have attributed the relief more to the divulsion of the muscle than to the removal of the hemorrhoids. It can be readily seen how this muscle could in a mechanical way interfere with the act of defecation, and in a physiological way prevent the peristalsis of the bowel which it greatly controls. It frequently becomes hypertro- phied by the inflammatory process, and hence is not only easily irritated itself but irritates, when in this condition, all the other contiguous parts. The nerve supply of this muscle is greater than that of any other muscle of the body, which accounts for its great disposition to reflex action. The nerve supply coming from three different sources gives it a clear relation to all the neighboring parts. I have known a simple spasmodic action of the muscle to give rise to symptoms closely simulating proctitis, prostititis, cystitis and in a few cases urethritis, not to speak of reflected back ache, thigh ache, etc. Children often suffer from a constipated habit, accompanied in many instances by extreme pain. The cause of such condition is often overlooked, and we are much indebted to Dr. Morton of St. Joseph, Mo., for an article entitled, "Fissure in Infants," as an overlooked cause of distress in the infant. The fact that such cases frequently existed was attested by Drs. Jacobi, Sadtler and myself, and the importance of their detection is shown in this valuable paper. THE IMPORTANCE OF RECOGNIZING DISEASE IN THE SIG- MOID FLEXURE. For a number of years I have been investigating disease in the sigmoid flexure, and have recorded much of my experience in my book on "Diseases of the Rectum, Anus and Sigmoid Flexure," recently published. Much depends upon the early diagnosis of such cases. From its anatomical construction 13 and situation, it is easily seen that disease there would be much more serious than in the rectum. Total obstruction can much more readily take place and the results prove much more disastrous than from like disease in the rectum. Any pathological condition, from a simple congestion to a malignant growth, may affect the flexure. If early detected, a congestion or an inflammation, can be easily abated, and yet if left alone or undetected, result in struc- tural change such as ulcerations, strictures, .etc., which renders the chance of cure very slim. The sigmoid has been successfully removed for cancer. But the success of treatment of disease here, either benign or malignant, depends entirely upon an early recognition. I shall not enter into detail to prove that the flexure is a common seat of disease, but will take it for granted that it is acknowledged. Nor will I but sim- ply suggest that it is but too infrequently treated, for to this fact, too, you will attest. Of the importance of an early diagnosis and treatment, I am sure you are convinced. The books are singularly silent as to both. It is a very common thing for all irritation in the flexure, either from congestion, inflammation or ulceration, with its coincident discharge and symp- toms, to be diagnosed as diarrhea, dysentery, chronic catarrh, etc., and treated generally per mouth, when a proper recognition of the trouble would reverse the order of treatment and by a few injections into the flexure would relieve. I will make it suffice^or illus- tration to give you the last case of the kind that has fallen under my observation : Mr. J., aged 28, of full, robust habit was referred to me by his attending physician with the statement that the patient was suffering from a diarrhea, or dysentery, which he was unable to control after a treatment of four months. Upon questioning the young man, who was a civil engineer, he related that his trouble began about five months previous while out on the road, not violently at all but as a mode- 14 rate looseness of the bowels, accompanied with some straining at stool. The discharge had never been watery but had always contained some mucus and blood. Although it would appear that this was char- acteristic of dysentery, he had never had an abnor- mal temperature nor had his appetite been interfered with, though he had not indulged it. In four months he had lost forty pounds of flesh and was growing weak. He complained of pain in the left side over the flexure, which was aggravated by pressure. An examination of the rectum revealed but little, yet as a rectal bougie was introduced into the flexure, pain was excited at its point, a disposition to tenesmus, and a desire to go to stool. The proper local treat- ment was given the flexure and the trouble disap- peared in ten days. I shall make it suffice to give the classification of disease found in the flexure, with the most impor- tant points looking to its proper diagnosis. There are two points that I would especially call your attention to in considering inflammation of the intes- tine : 1, the surface of the membrane will be more or less covered with a viscid, glairy mucus, containing pus and imperfectly formed epithelial cells, which may frequently be voided in the form of complete coats of the tube; 2, it is unusual for a chronic inflammation of the intestine to exist in adults with- out coincident ulceration. These two points will aid us materially, especially in differentiating between benign and malignant troubles of the intestine. The following pathological conditions are found in the flexure: 1, congestion ; 2, inflammation ; 3, sim- ple ulceration ; 4, specific ulceration; 5, malignant ulceration or growths; 6, stricture, either malignant or non-malignant; 7, tuberculous ulceration. It is of the utmost importance to diagnosticate each of these, and yet it will often prove to be a difficult thing to do. For instance, if a simple ulceration be mistaken for a malignant one, the proper cure or treatment is not likely to be afforded and, vice versa, 15 if a malignant ulceration is mistaken for a benign one, time is given for such inroads as would render an operation useless. Again, it is very necessary to recognize the dif- ference between a specific ulceration, and that which is either benign or malignant, in order that the con- stitutional symptoms could be rapidly met. You will permit me, therefore, to devote a little time to giving what I consider some essential points in dif- ferentiation : Congestion.-A distinction should be made in a pathological way between a congestion of the flexure and an inflammation, for the former can be relieved, when recognized, before the phenomena of inflam- mation has taken place. In other words, as soon as the irritation, which causes the distension of the blood vessels is removed, a normal condition is im- mediately assumed, when, if the inflammatory product is already thrown out, time must be given for its re-absorption. The symptoms attending a simple congestion of the flexure are very like those of an ordinary colitis, the only difficulty being to decide what part of the colon is affected. Very often a discharge of mucus alone, with or without a dispo- sition to tenesmus, accompanied with slight pain over the flexure, is our only guide. A very simple local treatment quickly relieves these cases. I have seen patients discharge as much as six ounces of mucus a day from this simple condition. Inflammation.-When a congestion has existed for a sufficient length of time to allow of plastic change, the condition is much more serious and difficult of cure. The symptoms are more marked, viz: those of reflex such as pain in the back, colicky pains in the stomach and bowels, often a localized sensation over the left inguinal region, a great amount of flatus, diarrhea, sometimes constipation, straining at stool caused by the feces passing through the inflamed flex- ure. The discharges often assume a dysenteric char- acter, though not so apt to as when the flexure is 16 ulcerated. These patients count themselves invalids and are often treated for chronic dysentery, though no rise of temperature is apparent. The most fre- quent cause of this condition is constipation, as the physiology of defecation will demonstrate. After the re-absorption of the watery constituent of the fecal mass takes place, the remaining dry mass acts as a local irritant which brings about the structural change with the coincident symptoms. Simple Ulceration.-It requires but a step from the inflammatory stage for the changes of ulceration to take place. Indeed, whenever an abrasion takes place in the mucous membrane, the process rapidly advances. It is a much more serious condition than either of the other two, for it represents in ratio the third state of the inflammatory act or, more properly speaking, is the degenerative stage of the plastic deposit. As a result, not only do strictures form when an effort at repair is made, but the tissues may give way and perforation take place. It invites impaction and the reverse may be true, that impac- tion may be the cause. My experience is that impac- tion oftener takes place in the flexure than in the rectum and is much more dangerous. The symptoms attending the ulcerative process in the flexure are plainly visible. In the congestive or simple inflammatory stage, the reflexes are perhaps mild; they are now well marked; the pain was slight; it is now well established; the discharge was principally mucus; it is now muco-purulent and bloody; the actions then infrequent; now frequent. There is great straining at stool and after each action a feeling of exhaustion ; the desire for an evacuation constant but often nothing passes except large quan- tities of gas. The bowel never feels emptied; an uneasiness always in the abdomen. This condition of affairs leads the patient and often the doctor to suspect malignant trouble, as a. rapid waste of flesh takes place and a bad color results, or perhaps a chronic catarrh is diagnosticated and the ordinary 17 treatment given which accomplishes no good. By proper and careful local treatment of the flexure, the disease yields rapidly and kindly. Malignant Ulceration.-The rules laid down for diagnosticating cancer are generally so explicit that the student thinks there exists but little difficulty in coming to a quick and correct conclusion, but the surgeon of experience admits that it is often a diffi- cult problem to solve. The so-called infallible symp- toms fade away as observation leads one to consider them. The disposition to bleed; the peculiar burn- ing, or radiating pain; the odor which by some is said to be pathognomonic, each and all of them may be found absent, and the verdict after all has to be made up by the study of the clinical facts in the case. Even the reliable aid of the microscope on which many rely, will be found futile in the effort to decide the knotty question. Heredity, which many have so earnestly advocated and which is so gener- ally believed to play its part in the affection, will be. found of but little value to us in forming an opinion, and yet it is a life and death issue literally that faces us. If, then, these difficulties surround us in mak- ing out a malignant growth, when the trouble is plainly in view, how much more difficult is the prob- lem when malignant disease is located in the sigmoid flexure and away from sight. That it is a favorite site for cancer no surgeon denies, and with the exam- ples set us by such men as Bull, Lange and Bacon, we realize the necessity of an early diagnosis, in order that the flexure can be removed, for upon sur- gical treatment alone can any hope of a cure be based, when cancer exists in the flexure. The symp- toms of malignancy in cases of this kind are very vague and misleading. The very best surgeons have made mistakes in this direction. It has not been many months ago since a gentleman in an interior town of Indiana consulted me for some supposed bowel trouble, and I gave the opinion that the disease was in the sigmoid flexure and would be the cause of 18 his death. This opinion was concurred in by Dr. G. J. Cook who had seen the case some weeks prior. A short time thereafter, he consulted one of the most eminent surgeons in this country living in Chicago, who assured him that no such condition existed and that his trouble was largely imaginary. The patient died in a short time and an autopsy revealed a can- cer of the flexure that had perforated into the cavity. The following cut represents the tumor removed by an autopsy made by Dr. Cook which verifies the opinion of Dr. Cook and myself in the case: I contend that by palpation and the ordinary external methods of examination, a tumor can not be diagnosticated in the flexure in a person who has a large abdomen if, indeed, it can in the ordinary sized abdomen, and that, granting a tumor could be made out, no significance could be attached that would indicate its nature except upon suspicion. As apro- pos to this subject, let me, at the risk of tiring you, relate a case that I saw with two able physicians not. long ago: The patient was an able-bodied German about 40 years of age, suffering from a total obstruction of the bowels. From the history of the case, his phy- sicians had ruled out acute obstruction or intussus- ception, but they were unable to locate the point of obstruction. I suggested the administration of an anesthetic, and that I might be permitted to intro- duce my hand for diagnostic purposes. This was agreed to, and when the man was fully anesthetized two fingers were first introduced through the sphinc- ter, then four, and finally the whole hand, the mus- cle plainly giving way. Pushing my fingers to the entrance of the sigmoid, I detected a well-formed cancerous growth which filled the flexure and nearly obstructed the opening. An immediate laparotomy was advised and was done. The two points which I wish to impress are: 1, that it was impossible to make a diagnosis here by external means; 2, that by the introduction of the hand it was quickly determined. 19 Malignant tumor found in sigmoid flexure. 20 In many cases, therefore, I believe that this proced- ure should be practiced. When we remember that cancer in the sigmoid may be so insidious as to be fatal without presenting but few, if any, of the ordi- nary symptoms of the disease, often the only symp- tom being obstruction, I believe that the introduc- tion of the hand is the only means by which a correct diagnosis can be effected. It might be sug- gested that the rectal sound tube, etc., might accom- plish the same purpose, but when it is remembered that an obstruction in the flexure can occur from other conditions, as impacted feces, foreign bodies, etc., it takes the feel or touch to determine the question. Tuberculous Ulceration, and Stricture of the Rectum.- I know of no disease or condition of the rectum that is more serious or that calls for a more decided diag- nosis than does ulceration with consequent stricture. Much has been written on this subject and many of the points involved are yet mooted. In the general address on surgery, before the American Medical Association in 1891, which I had the honor of deliv- ering, this was the theme selected. As my views expressed in that paper have received some criticism you will permit me here to make some reply, as the questions involved are mainly diagnostic ones. It is no difficult matter to diagnosticate a stricture of the rectum; in the vast majority of cases it can be felt, for it is generally within reach of the finger. But granting that the upper part of the rectum is strictured and not the lower, instruments can be used for the detection, which is, however, seldom necessary. But it is a very difficult matter to tell the cause of said stricture, or to diagnosticate between the conditions set down as causes of this trouble. I did not in that article, nor do I wish now to appear dogmatic, but you will, I hope, allow me to express an individual opinion, even if it does dif- fer with some of the authorities. The article objected, first, to the classification of stricture as 21 given by some authors; as for instance I believed that "spasm" as a cause should be ruled out. If such condition ever exists which is to be doubted, it was merely from irritation and had no pathology of stricture in fact. 2. That congenital stricture should be classed as atresia, for the idea to be conveyed in writing of stricture is to deal with a pathological change of tissue. I said that although it is frequently stated that dysentery is a common cause of stricture of the rec- tum, I had never seen a case of sufficient worth to convince me of the truth of the statement or, indeed, that it was a cause at all. To substantiate this belief, the following statements were adduced : Prof. John A. Ouchterloney, a distinguished pathologist and teacher, in discussing the subject said: "I call to mind a dead-house experience extending over many years. During the war I made postmortem examinations upon hundreds of cases who died of dysentery, the most malignant form of the disease as all will attest whose observations extend back to war times, and I can not remember to have ever seen a stricture of the rectum as the 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 postmortems 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 rec- tum caused by dysentery." In dealing with dysentery as a so-called cause of stricture, I said that an ideal case for a pension would be when a soldier could show a stricture of the rectum, the result of dysentery contracted dur- ing war, and incidentally remarked that the Pension Office was singularly silent on that point. After writing my address, I noticed in the "History of the War of the Rebellion" that Surgeon General Woodward said : "Stricture resulting from dysenteric 22 ulceration seems to have been much rarer than might have been supposed, and that no case has been reported at the Surgeon General's office, either dur- ing the war or since. That the Army Medical Museum does not contain a single specimen, nor had he found in the American medical journals any case substantiated by postmortem examination, in which this condition is reported to have followed a flux contracted during the Civil War." Again, if dysentery is the common cause of stric- ture that some say it is, why is it that it is not more commonly met in people who have suffered with the disease in warm climates where dysentery is very common, indeed often epidemic, but how many cases of stricture of the rectum have ever been reported in this class by physicians who have had the oppor- tunity of watching their cases for years? It might be suggested as a point in the etiology of stricture that dysentery does not, as a rule, expend its force in the rectum,but in the colon. If this be true, why is it that we do not have the report of cases of stric- ture in the colon, the result of dysentery? Whenever the effect of inflammation is expended in the intes- tines, it affects mainly the mucous membrane and not the submucous tissues. I submit, then, that these evi- dences are quite sufficient in my opinion, to make us careful in forming a diagnosis of stricture, especially in regard to its cause; as not only the treatment depends upon it, but also the life of the patient perhaps. In the classification of stricture of the rectum, given by some, it is claimed that tubercle plays a prominent part. That we meet with tuberculous ulceration of this portion of the gut must be ad- mitted, but it has not been my experience that a coincident stricture always follows. The disposition of tuberculous tissue everywhere is to break down, and before the capacious rectum is filled by such deposit as to constitute a stricture, it will have assumed the ulcerative stage and given way. The only way that 23 such tissue could originate a stricture, in my opinion, would be by cicatrization and such cases are rare, to say the least of them. In no instance have I ever seen a stricture of the bronchi from tuberculosis, and yet we recognize this as a favorite seat for tubercu- losis. I regard the disease of but little diagnostic value in stricture of the rectum. The tubercle bacil- lus can, of course, be detected by the microscope. Syphilitic.-By all odds the most common cause of stricture of the rectum is syphilis, not caused by di- rect inoculation or the extension of chancrous pus into the rectum, as formerly believed by some, and still believed by a few, but by a gummatous deposit, constituting a rectal syphiloma. Indeed, so well con- vinced am I that this is the method in which syphilis shows itself in the rectum, that I have doubted whether chancrous pus ever caused a stricture of the rectum. Granting that such might originate a stricture, it could only occur by infecting the region of the anus and constrict by cicatrization of the sore. This would not be a syphilitic stricture of the rec- tum in fact. Therefore, as a point in diagnosis, it must be affirmed that the constriction is due to sec- ondary, not primary* causes. My table of cases demonstrates that as much as 50 per cent, of stric- tures are due to syphilis. Dr. Straus an eminent surgeon of St. Louis, says that the hospital reports of St. Mark's agree with this statement, he having lately examined said statistics. Cancer, is, undoubtedly, the second greatest factor in producing stricture of the rectum. I have never said, as has been attributed to me by one authority, that outside of syphilis and cancer, there could be no other cause of stricture of the rectum, for in my book on diseases of the rectum, I distinctly say that any irritation sufficiently long continued as to excite to a marked proctitis, especially with ulceration, might eventuate in a stricture, and cite several cases. But I did affirm, and do now reiterate, that these cases are rare compared with syphilis and cancer as 24 causes. I did not say that if a case presenting, did not have cancerous stricture, that it was of necessity of syphilitic origin. What I did say was, that in a case presenting, if the question involved was whether the stricture was caused by cancer, and if it was decided that it was not malignant, then that ninety- nine times out of a hundred, it would prove to be syphilitic. Why? Simply that there is no stricture produced by other causes than syphilis, that resem- bles in the least a cancer stricture. Certainly then, trauma, simple inflammation or even dysentery do not in the least resemble a malignant or cancerous condition, while syphilitic stricture is so closely allied to cancer in its clinical aspect that it is often mistaken for it. Hence I said that if it was decided not to be cancer, in the majority of cases it would prove to be syphilitic and not a stricture from other causes, which is far from saying that if stricture was not cancerous, it was syphilitic. Therefore, I deem it of the utmost importance to be careful and positive in your diagnosis of a rectal stricture, for if the condition be diagnosticated malignant, when benign, you have greatly wronged and terrorized your patient; if a diagnosis of syphilis has been made when the stricture is due to other causes, I quite agree that a stigma may be passed upon an innocent person, but if you should diagnose a syph- ilitic stricture as a simple one, you will leave undone that which might wreck the life of a good man or an innocent woman. But I would rather err on the side of truth and if the truth hurts, you have but done your duty. No man believes in sentiment more than myself, but when sentiment comes between deception and truth in the prosecution of my pro- fessional duties, sentiment must get behind. If I have given you any one point in your diag- nostic resources of rectal and allied diseases, that is worthy of your consideration, and that may be of benefit to one single afflicted person, I am fully repaid.