Harveian Lectures on the Mode of Death from Acute Intestinal Strangulation and Chronic Intestinal Obstruction
Authors: T. Bryant
Journal: BMJ (1884)

Continued from page 1060.)IT is not necessary for me to dwell for any time upon cancerous ulcers and strictures of the rectuin, since there is but smalI chance of these not being diagnosed, should a local digital examination be made.Without such an examination, an error may certainly be fallen into, and it is to be regretted that such errors are frequent.Persistent rectal irritation and looseness of the bowels should always induce the medical adviser to make a local rectal examination, and the presence of piles associated with these symptoms should make this examina- tion more imperative.The frequent discharge of mucus ivith the motion demands a local investigation; and, where this discharge has been of long standing, it invariably means some local cause.Steadily increasing difficulty in defiecation, and attacks of "stomach-ache," should always suggest some mechanical obstruction; and when these symptoms are associated with visible peristalsis and perceptible coils of distended bowel, without the passage of mucus or blood, an atnular stricture of the large intestine should be suspected.The passage of blood, with mucus or pus, following upon obstruction, or associated with looseness of the bowels, is strong evidence of ulceration of the bowel, and, when combined with sacral pain, suggestive of cancer.When, witlh the finger, a localised or diffused infiltration of the walls'of the rectum is felt, the diagnosis of cancer is confirmed; for, in the rectum, as elsewhere, a local cancer first shows itself as a local infil- tration of the tissue it attacks ; and, later on, as an infiltration of neighbouring parts, first of the coats of the bowel, and subsequently of the surrounding connective tissue.When the disease is confirmed, the ulcer will be of a raised nodular character, with elevated edges.Simple and syphilitic ulcers and strictures never exhibit these local characters.They simply; show ulcerated surfaces, with more or l-ess decided cicatricial bands or adhesions,.thecicatricial bands at times taking the form of diaphragmatic strictures.Rectal dis6harges, with incontinence of freces, as a rule, indicate ulceration involving the in- ternal sphincter.I have no wish, however, on the present occaSion to dwelI upon the pathology of cancerous strictures, for my object is to bring them, with others, before you in their clinical aspect, and to consider how all tend towards death, and in what way they actually kill.Upon this aspect of the subject, I trust I have been' sufficientlyi explicit, since patho- logical evidence points very clearly to the conclusions I have already laid down, that cancerous, as well as all other forms of stricture, as a rule, cause death by exhau'stion or peritonitis1 the latter being, in the majority of cases, consecutive to eithr"sEloiighing, rupture, or uleera.tion of the overdistended bowel above the; stricture.With these pathological facts before us, let us pass on and consider the indications for treatment.The great difficulty with which the physician or surgeon has to con- tend, in dealing with ulcerations of the rectuiT aor the large ihtestine, is due to the situation of the ulcer and 'the absolute impossibility, on that account, of keeping it quiet, clean, and free from local irritation- three essential points for the healing of all ulcers.In this fact is to be found the reason why ulcers in these parts, of whatever nature, though small, are slow in healing; why extansive fulcerations, if left alone, apparently never do heal; why, in the process of repair, there is so much cicatricial tissiue, and, as a result, contraction; and why, in a general way, all healed or healing exztensive ulcers tend to produce.obstructivechanges.To thedysenteric, simple,.'orsyphilitic[1249] uloetatits: these remarks are patticularly.applicable; to cancerous ulcers, they need not be applied, since in them, when the process of degeneration, and oQfsequeltly of ilceration, commences, it ia always progresive.In all cases of ulcer-of the bowel, therefore, the horizontal-posture, the administration of such food as milk and animal broths with faripaceous compounds-food that supplies fuel to the body, and' nisrishes, iNec. 6, 1884.TABLE I.-ase8 of Lumbar Col4tomyfor Cancer that Died within the Month."Too Late Cases."N. Hospital or Private DNameofPatient.Age.Date of Colotomy, | Disease for which Operation was'