REPORT OF A CASE OF STRICTURE of the RECTUM, THE PROBABLE RESULT OF A SPECIFIC VAGINITIS. BY LEWIS H. ADLER, Jr., M.D., LATE RESIDENT PHYSICIAN, UNIVERSITY HOSPITAL, PHILADELPHIA, PENNA. FROM THE Medical and Surgical Reporter, June 29, 1889. From the Medical and Surgical Reporter, June 29, 1889. REPORT OF A CASE OF STRICTURE OF THE RECTUM, THE PROB- ABLE RESULT OF A SPECIFIC VAGINITIS. BY LEWIS H. ADLER, Jr., M.D., LATE RESIDENT PHYSICIAN, UNIVERSITY HOSPITAL, PHILADELPHIA, PENNA. The usual causes of stricture of the rectum —when not carcinomatous in nature—are : syphilitic infection; traumatism, in the shape of the introduction of foreign bodies ; the careless use of clyster-pipes; and the various operations upon the mucous coat of the bowel, as well as any inflammation or ulceration arising in other ways. Both gonorrhoeal and leucorrhceal discharges may become potent factors in producing this painful affection. Such was the only assign- able cause of the stricture in the following case, which I wish to record : — Mrs. S. H. M.; aet 27 ; white; a widow, whose occupation was that of a housekeeper, was admitted into the University Hospital in November, 1888, suffering, as she stated, with a lacerated perineum and some rectal trouble, which gave her intense pain every time she had a movement of the bowel. Her family history was good, and showed no evidence of malignant disease, either of the 1 2 rectum or elsewhere. As a child, she had the various diseases of childhood ; otherwise she was healthy. She first menstruated at 13, and was always regular—she was married at 16, and two years later left her husband, owing to family trouble. Two children were the result of this union. The last child was born in the early part of 1879. Both labors were difficult. Instruments were resorted to in the delivery of the first child. Both children presented by the head. It was in the first labor that she was torn, and she thinks the tear was increased at the birth of the last child. She suffered more or less from this trouble, owing to the loss of control over the con- tents of the bowels; but by means of anodynes and careful diet she managed to keep costive. Every two or three weeks she would take an aperient. She was advised to have an operation performed, but refused. Such was her condition up to three years before her admittance into the hospital, under the care of Professor Wm. Goodell. Her present trouble began in 1885. At the solicitation of a man in the town in which she lived, she had sexual intercourse with him, which resulted in a violent attack of specific'vaginitis. Not long after this trouble began, the movements of her bowels caused more pain than ever—so much so, that the thought of going to stool would drive her wild with fear. Instead of resort- ing now to anodynes, and a diet that would 3 produce hardened feces, she did all in her power to render them easy of passage. She grew steadily worse, and, though advised to come to the city and undergo an operation, she steadfastly refused. Her stools were now typical of stricture of the rectum. It was not until the end of 1888, when life had become more than a burden, that she consented to come to the city and have Dr. Goodell examine her. An exami- nation made at this time revealed a com- plete tear of the perineum through the sphincter ani muscle, and a stricture of the rectum of moderate width near the anus. Its lumen was very much contracted, barely admitting the end of a finger. From the dense, fibrous feel of the stricture, it evi- dently involved all three coats of the intestine. The treatment in this case was general, as well as local. The pain from the stricture was allayed, in a measure, by cocaine which was used most efficaciously in the form of a suppository, and the bowels were kept in a soluble condition by regulating the diet, and by the administration from time to time of enemata or of mild laxatives. Medicines of a tonic character were freely exhibited. After one week’s stay in the hospital the woman was etherized, and the stricture was forcibly dilated by means of fingers, by Dr. Goodell. An opium suppository was inserted, to allay pain after the stretching had been completed. 4 The treatment now resorted to in order to restore the part to its normal calibre was the introduction of well oiled bougies every second or third day and finally every day. Previous to their use, a suppository of cocaine was inserted in the rectum, and this did much to prevent pain, though it did not entirely stop it. The cocaine was also used before and after each movement of the bowels. Iodoform suppositories, containing 2y2 grains each, were ordered to be inserted both night and morning, in order to disin- fect the parts as much as possible. Not quite a month after the forcible dila- tion of the stricture, under ether, the patient was discharged and advised to con- tinue the above treatment and come back to the hospital in the course of a month or so. At that time she was able to have a stool with comparative comfort; the feces passed being nearly of normal calibre. Dr. Goodell does not intend to operate upon the tear of the perineum until the strict- ure is fully dilated. At the present writing the woman has not presented herself at the hospital, but when last heard from through her family physician, she was doing well. It is true that hardened feces may occa- sion stricture; but the history of this woman, whose bowels of necessity had been kept costive ever since her first child was born—that is for over eight years before the stricture appeared—seems to show that this is not necessarily the case. It is equally true, 5 that a stricture may exist for months and years, without causing a patient any uneasi- ness,1 but this is the exception to the rule; and I, therefore, take it that, in the case just described, the evidence points to a specific origin of the stricture. 41 N. Twelfth St. 1 Ihos. G. Morton, M.D., and Henry M. Wetheril], M.D., Pepper’s System of Medicine, Vol. II., p. 886.