[Read before the Philadelphia Academy of Surgery, December 4, 1893.] 
REMARKS UPON THE TREATMENT OF STRICTURE 
OF THE SIGMOID FLEXURE AND OF THE 
FIRST PORTION OF THE RECTUM. 
By JOHN B DEAVER, M.D., 
Professor of Surgery in the Philadelphia Polyclinic, and Assistant Professor of Surgical 
Anatomy, University of Pennsylvania. 
Mr. President and Fellows : My object in offering a few 
remarks upon stricture of the sigmoid flexure and of the first por- 
tion of the rectum this evening is to obtain the views of the 
Fellows present upon this, which is certainly a very important, 
subject, and to place upon record a case of stricture of the terminal 
portion of the sigmoid flexure and of the first portion of the 
rectum, recently under my care, in which the passage of a flexible 
rubber bougie (Wales) but one size, French scale, larger than that 
which had been passed many times before, caused perforation of 
the rectum below the stricture, resulting in the death of the 
patient within twenty-four hours thereafter from peritonitis. In 
order to discuss this subject to the best advantage I may be per- 
mitted to refer to one or two points in the anatomy of the first 
portion of the rectum, also to say a word or two concerning the 
diagnosis of stricture situated beyond the reach of the finger. 
The rectum does not, as is usually described, begin at the brim 
of the pelvis opposite the sacro-iliac synchondrosis, whence it ex- 
tends to about the centre of the third piece of the sacrum and 
descends in front of the sacrum, the coccyx, etc., but commences 
at the terminal part of the omega loop, to which attention has 
been called by Treves as being the shape of the sigmoid flexure, 
and not “S” shaped in answer to the description in the text-books 
on anatomy. Careful examination by myself of many bodies has 
confirmed the above statement. All of the omega loop, which 
includes the first portion of the rectum, occupies the pelvis in the 
adult. It will thus be understood that the first portion of the 
rectum makes with the second portion a decided angle ; therefore, 
an instrument of the calibre of the normal bowel, unless it be a 
flexible one which will pass through the third and the second por- 
tions, will not prove anything regarding the calibre of the first 
portion. Again, from the relation borne between the second and 2 
the first portions of the rectum much may be learned about the 
latter if it be infiltrated, upon introducing the finger into the 
second portion, through the walls of which the infiltration may be 
detected. The best form of flexible rubber bougie is one which is 
hollow, as is the Wales instrument, to the lower end of which can 
be attached a fountain or Davidson syringe, and water thrown 
through this, favoring its passage by drawing out of the way the 
folds of the mucous membrane which would otherwise form an, 
obstruction to its introduction. * . 
The diagnosis of stricture of the second and third portions of 
the rectum is readily made by the sense of touch. When the 
index finger is not long enough to reach beyond the second portion 
with the patient lying on the back, it may be done with ease if the/ 
patient be turned upon the left side and the thighs slightly 
upon the abdomen and the finger introduced into the anus fruhtf 
behind, as the tissues of the perineum can be carried a little 
tance in advance of the web of the index and middle finger. 
Contraction in this part of the bowel can often be diagnosed by 
the introduction of a short, flexible Wales bougie, but the finger 
is the more trustworthy instrument. This, too, is the only portion 
of the bowel where we will all admit that the operation of proc- 
totomy for the relief of a contraction is admissible. The soft, flexi- 
ble rubber bougie is the only instrument that can be carried safely as 
well as surely through the upper portion of the rectum and 
sigmoid flexure. The use of the non-flexible rectal bougie is not* 
only an unsafe instrument, particularly where the stricture is situ- 
ated beyond the second portion of the rectum, but one which may 
mislead the surgeon in making a diagnosis of stricture when it 
does not exist. 
The first portion of the rectum, like the sigmoid flexure, is con- 
nected to the back part of the abdominal cavity by a reflection of 
the peritoneum, the meso-rectum. On account of the bend made 
by the junction of the first and second portions of the rectum it 
can be readily seen how the point of a non-flexible bougie is 
arrested by contact with the wall of the bowel at this point, which 
offers resistance to its further passage, and a diagnosis of a patho- 
logical obstruction made: or it may be that the bowel, owing to 
the meso-rectum, if preternaturally long, will be carried in ad- 
vance of the point of the instrument to or beyond the median 
line in the neighborhood of the pubis, while if the instrument 
by chance should pass into the sigmoid flexure, the latter, owing 
to the meso-sigmoid, may be carried to or beyond the median line 
in the neighborhood of the umbilicus—which, in either event, 
might give rise to the belief that the bougie had passed into the 
bowel beyond, if not through, a supposed stricture. 
There is a question of doubt in the minds of some as to the 3 
possibility of being able to carry a flexible rubber tube or bougie 
through and beyond the sigmoid flexure. This has been tried 
upon the dead body in a number of instances, and, not having 
proven successful, the deduction has therefore been made that it is 
impossible to do it in the living subject. While I am aware of the 
difficulty attendant upon the introduction of an instrument into 
the descending colon in the dead body, due chiefly to the absence 
of muscular contractility.which facilitates the passage of the instru- 
ment, on the one hand, and offers a very decided barrier against its 
introduction, on the other, also to the absence of the normal 
moisture in the shape of the mucus, I cannot admit this to be so. 
We well know that it is much easier to introduce a bougie 
through the normal urethra in the living subject than it is in the 
cadaver, and yet this ought to be more readily accomplished in the 
case of the urethra, where counter-pressure can be brought to bear 
to aid in the introduction of the instrument, than in the case of the 
bowel. I have very satisfactorily demonstrated upon many occa- 
sions the possibility of being able to circuit the sigmoid flexure 
with a soft, flexible tube such as the long flexible rectal bougie 
and the long flexible colon tube. In certain cases of intestinal 
obstruction I regard the passage of a soft, flexible tube into the 
sigmoid flexure, through which water can be thrown and the 
capacity of the lai’ge bowel ascertained, an important aid in the 
diagnosis between obstruction of the small and obstruction of 
the large intestine. 
With the subjective symptoms of stricture of the large bowel 
present, namely, constipation, or may be attacks of diarrhoea, the 
passage of ribbon-shaped stools or of choppy stools covered with 
mucus and blood, or preceded or followed by the passage of mucus 
and blood attended by tenesmus, the lower portion of the rectum 
being intact, as proven by a digital examination, it does not abso- 
lutely follow that a stricture is the cause in all instances, as we 
may see this train of symptoms consequent upon a subacute or 
chronic catarrhal inflammation of the colon, of the sigmoid alone, 
or in ulceration of the sigmoid flexure; therefore, before we can 
get more definitely at the exact condition of affairs it will be neces- 
sary to resort to instrumental interference in the introduction of 
graduated sizes of flexible rubber bougies, when a diagnosis can 
generally be arrived at with a very fair degree of certainty. This 
should be done with all due care, and preferably by one experienced 
in-the use of these instruments, as it has been demonstrated, par- 
ticularly in the case I report to-night, that serious results can accrue 
from even the passage of a soft instrument, which argues strongly 
against the use of non- or semi-flexible instruments. From the 
relation the first portion of the rectum holds to the second, when 
the former is the seat of extensive thickening or the walls contain 4 
a growth, upon digital examination this can usually be detected. 
In this class of cases, as in disease of the second and third portions, 
if in the female, much can be learned by careful digital examiuation 
of the vagina. I have on several occasions been able to feel with 
the finger masses in the first portion of the rectum, as well as the 
presence of a growth which had assumed some size in the terminal 
portion of the sigmoid, by carrying the vault of the vagina well in 
advance of the examining finger, aided, too, by counter-pressure 
made over the abdominal walls. Further, I believe these examin- 
ations are better made without ether/having thus the feelings of the 
patient to guide us and incurring less risk of injuring the bowel. 
Where a mass is suspected in connection with symptoms of 
stricture, which would suggest malignant disease, there is con- 
siderable to be gained, however, by giving the patient ether, under 
the influence of which the abdomen can be palpated more satis- 
factorily. Another means of diagnosis, that of dilating the 
sphincter of the anus and the introduction of the hand into the 
rectum and the sigmoid, I have never had the courage to use. In 
cases of great doubt, rather than resort to the last procedure, I 
deem it more advisable to do an exploratory abdominal section. 
Exploratory abdominal section, however, done for the purpose of 
diagnosis in the questionable cases of stricture of the sigmoid and 
the first portion of the rectum, I am not a strong advocate of, as I 
think that a diagnosis in the majority of cases should be made 
without resorting to so complicated a measure. While I am aware 
of the little risk attending an exploratory abdominal section under 
strict cleanliness, I think the principal objection to be urged 
against it is that it lessens the responsibility of the surgeon as a 
diagnostician. Apart from this, I fear the modern tendency is too 
much iu the direction of exploratory incisions in other regions of 
the body, as well as the abdominal cavity, for diagnostic purposes. 
The operation should be the natural sequence to the diagnosis 
and not the diagnosis to the operation. Perfecting one’s self in 
diagnostic attainments is certainly more creditable to a surgeon 
than to feel forced to have to open the belly cavity to determine 
that which may be done without. 
The majority of cases of benign stricture involving the first 
portion of the rectum are amenable to treatment by either the 
bougie or colotomy. Stricture of the sigmoid flexure, very rare 
except when of malignant origin, is not nearly so favorable for 
gradual dilatation by the bougie. In stricture here located, be it 
benign or malignant, if the inflammatory process has not advanced 
too far to permit of resection and anastomosis, or perhaps circular 
enterorrhaphy, the most that can be hoped for in the majority of 
instances is the establishment of an artificial anus in the loin. 
The choice between iliac and lumbar colotomy must depend 5 
upon the merits of each case; ordinarily I prefer to make the 
operation through the loin. The only advantage I can see in the 
anterior (iliac) operation is the opportunity it affords to determine 
definitely the condition of the bowel, if a resection and anasto- 
mosis or enterorrhaphy is possible, and, if nothing short of an 
artificial anus will suffice, to make it at once. 
In a paper I read before the Philadelphia County Medical So- 
ciety two years ago upon “ Lumbar versus Iliac Colotomy,” I 
took the ground that the lumbar operation was the preferable 
one, inasmuch as the diagnosis of the- condition rendering the 
operation of colotomy necessary should, in the majority of the 
cases, be made without having to open the peritoneal cavity as is 
done in the iliac operation. 
In benign stricture of the sigmoid flexure and of the first por- 
tion of the rectum, I recommend gradual dilatation by means of 
the flexible rubber bougie. When this is not possible, more 
radical measures must be adopted. In malignant stricture of the 
above portions of the bowel the bougie can do nothing other than 
harm; directly, by hastening the diseased process, and indirectly, 
by misleading the patient in having him believe that an operation 
will not be required. I believe the earlier radical operative inter- 
ference in malignant disease of the bowel is instituted the better, 
and that if this practice was followed in all instances, patients’ 
lives would certainly be very materially prolonged, and in some 
cases, the disease perhaps be eradicated by removing it while yet 
local. What holds good in the uterus and elsewhere regarding 
affections of this character, holds equally good in case of the 
bowel, the difficulty being that in affections of the latter organ, not 
exposed to the sense of sight, the diagnosis cannot be made with 
the same degree of certainty as in like conditions of the uterus, 
the breast, etc. 
The advisability of furnishing the patient with a bougie and 
instructing him to pass it himself I am inclined to question ; I 
think this is better done by the surgeon. In addition to instru- 
mental and operative treatment, much is to be gained by constitu- 
tional treatment, particularly if the case be of specific origin ; but 
unless the history clearly points to this we should be careful not 
to push the treatment too far for fear of the debilitating effects; 
by attention to the general health, by the administration of tonics, 
by advising the proper diet, by giving tonic laxatives to have the 
bowels moved daily. 
In cases where tenesmus is excited by the presence of a collec- 
tion of mucus it is advisable to introduce a long flexible rubber 
tube beyond the stricture, through which the bowel can be irrigated 
with warm water or with mild antiseptic astringents. 
The following is the case I have referred to above: F. W. R., 6 
aged about thirty, consulted me July 27tli, stating that he had a 
stricture of the large bowel, for which he was passing at intervals 
of from four to five days Nos. 9 and 11 Wales bougies by the advice 
of his physician. Upon being questioned, he described the symp- 
toms characteristic of stricture of the sigmoid flexure or of the 
latter and the first portion of the rectum. He further stated 
that without the aid of medicine taken internally or the use 
of enemas it was impossible for him to have a passage. 
Digital examination of the rectum revealed nothing other than a 
rather capacious organ. Examination with the bougie showed the 
presence of an unquestionable obstruction nine inches within the 
anus. I advised continuance of the local treatment, but disap- 
proved of his using the bougie himself. I passed a bougie up to 
the time of his last visit to me, when, upon introducing one a size 
larger than the one usually used, namely, No. 12—which I had also 
passed before with but little difficulty—as the point of the instru- 
ment was engaging in the stricture he suddenly lurched forward 
upon the operating chair, and before I could withdraw the instru- 
ment he rebounded, as it were, upon the point of the bougie. This 
was immediately followed by severe abdominal pain. I feared 
the bowel had been penetrated on the anal side of the stricture, but 
was not certain, as the instrument was withdrawn clear of blood ; 
neither was there any blood passed after its withdrawal. I advised 
that he go to the hospital, where he would have the benefit of 
absolute rest and at the same time give me the opportunity of 
having him closely observed. Contrary to my advice he went to 
his place of business, but came back to my office some time after- 
ward, complaining of the pain being as severe as when he left me 
earlier in the morning. He now consented to go to the hospital. 
The pain was so severe as to require large doses of morphine to 
relieve him. He would not consent to an abdominal section, 
therefore I was powerless to do other than administer anodynes, 
counter-irritants, etc. He died the following night. The ab- 
dominal walls remained perfectly rigid, with the absence of tym- 
pany until four hours before he died, when there was pronounced 
distention. An autopsy made shortly after death showed the 
presence of a purulent peritonitis and a linear stricture involving 
the terminal portion of the sigmoid flexure and the first portion of 
the rectum. The bowel immediately below the stricture, which 
was very much dilated, with the wall nearly as thin as tissue paper, 
showed a perforation. Upon opening the bowel there were present 
cicatrices which were evidently the result of ulceration. There 
were present old adhesions in the abdominal cavity in the neighbor- 
hood of the descending colon and sigmoid flexure. Upon opening 
the chest there were present adhesions at the apices of the lungs. 
No further evidence of organic disease. 7 
A few hours before his death, in a conversation with his mother, 
I learned, much to my surprise, that he had for some time back 
been giving himself an enema after each meal; this, to some 
extent at least, evidently accounted for the very much dilated and 
thin condition of the wall of the bowel, rendering it susceptible to 
penetration by the bougie.