Scirrhus Recti in India—The Liability of Mistaking ...€¦ · scrotum and penis, much enlargement of the abdo- men, which was dull at the sides, but sympauitic in front, and very

SCIRRHUS RECTI IN INDIA.

THE LIABILITY OF MISTAKING CHRONIC

DYSENTERY FOR THIS DISEASE.

By John D. T. Beckett, M.R. C. S., Eng. ; L.B.C.P., L.S.A., &c.,

Surgeon, Station Hospital, Poonamalee, Madras.

Skrgeant J. S. , at. 31.

The notes of this case commence on Septem- ber 25th, 1883, when he first came under the

notice of the Surgeon, who took charge of him at this station.

Family history.?Parents dead, but no history of cancer in the family as far as he knows.

Personal history. ? Arrived at this station

from Bangalore suffering from inflammation of

the left inguinal glands. At Bangalore he had dysentery and ulceration of the rectum. About a year ago he was admitted to hospital for in-

flammation of the inguinal glands; but there is no certain history of syphilis. No note of any previous admission for dysen-

tery. On admission?It was noticed that he was suf-

fering from considerable tenesmus, with complete inability to retain his fasces, which were liquid and consisting of mucous blood and slime. Under treatment control over the sphincter partially returned, and the motionslost their liquid charac- ter. His condition was one of great debility and considerable emaciation. Coustipatiou fol-

lowed, and the bowels were only relieved by large doses of castor oil, given every other day. Induration of the left inguinal glands and blu- ish red discolouration of the skin over them, with cicatrix and puckering in one part.

October 10th.?There is a note by the Surgeon in charge of the case: "Evidently some constric- tion about the sphincter, which is extremely sensitive and cannot even bear the introduction of the nozzle of a glass syringe for an enema." Ordered Bismuth, Ipecac, and Morphia pills ter die,

October 16th.?Very much emaciated. To

continue pills and warm water enema with some salt dissolved in it.

December 6th.?Swelling of the scrotum first noticed, which the Surgeon in charge thought to be due to mesenteric glandular enlargement and his extreme debility. To have a suspensory bandage. December 12th.? The .oedema has extended

to the penis, but there is no difficulty in micturi- tion. Liquid motions and inability to control

sphincter ani. December 21 st.?I first saw the case in con-

junction with the Surgeon-Major in charge, and who had asked me (in relating the peculiarities of the case) if I could assign a cause to the immense swelling of the scrotum and penis. His geueral and unhealthy appearance, and the

peculiar odour, at once led my thoughts to malig- nant disease. There was great swelling of the scrotum and penis, much enlargement of the abdo- men, which was dull at the sides, but sympauitic in front, and very much emaciation. It, of course, struck me at once that the immense oedema of the scrotum and penis might be due to some obstruction at the prostatic plexus of veins, by some malignant growth in the rectum, which on examination I found to be almost blocked with what I judged to be scirrhus. There was such

narrowing and constriction at the sphincter, which was extremely irritable, that it was difficult to introduce even the little finger. I therefore intro- duced a No. 10 catheter, which passed into a tube- like space, just sufficient to admit it; the sides of this space being hard and solid, and apparently strongly indicative of the suspicious nature of the disease. On the grouud that the bubo, or rather the indurated gland, might owe its origin to syphilis and the disease have spread to the

rectum, calomel fumigations were ordered every morning. To have a light nourishing diet, 4 ozs. Tarragona wine, and 2 eggs. To have also an enema of warm water wheu required, and on account of the great constriction at the sphinc- ter aui, to be injected through a No. 10 gum elastic catheter.

January l'sf. ?Has been getting gradually worse. Abdomen is now much distended with fluid ; penis and scrotum so (edematous, that he has great difficulty in micturition. Calomel

42 THE INDIAN MEDICAL GAZETTE. [Feb., 1887.

fumigations discontinued, and disease changed from dysentery to cancer of rectum.

January 29th.?He died quietly. Post-mortem?Revealed very extensive dis-

ease of the whole of the rectum, which was quite a solid hard mass of scirrhus, excepting a small tube-like rigid opening sufficient to

admit a No. 10 or 12 catheter, and very firmly bound to the fundus of bladder and to the

prostate. On performing left colotomy post- mortem, faeces readily started from the colon, which was considerably distended. Abdomen contained 16 pints of serum. Carefully examin- ed the mucous lining of the small and large gut, but with the exception of one or two little

patches of claret-coloured injection, there was no sign of dysentery having ever existed. Remarks.?That the chronic form of dysen-

tery may be mistaken for scirrhus recti, is

quite evident from the fact of this patient hav- ing been treated for many months for the former disease by medical men who had resided lono- in India, and of course had great experience in dysentery and tropical diseases. The man cer- tainly had all the symptoms one would expect him to have as a sufferer from dysentery, and most prominent amongst which was the pas- sage of blood per rectum; but at the same time other peculiar symptoms were superadded, which were at least suspicious of complication. First, there was always inability to retain his faces ; secondly, a very constricted opening at

the auus ; and thirdly, the passage of liquid fasces over the constricted and abraded sphincter caused him much burning, stinging pain in the rectum and tenesmus. But this one nasty symptom?inability to retain his feces?with a fair pulse and nothing to indicate that the cause of the inability was extreme debility or

the last stage of a disease, when one may ex-

pect such loss of coutrol, was in itself perhaps enough to invite very close atteution to the rectum; and as au instance how one may be rewarded for such attention to this neighbour- hood, I had some time ago in Englaud this same symptom of inability to control the

sphincter aui in a young soldier much reduced by acute rheumatism: he had apparently diarrhoea, his motions escaping into the bed, and astriugents were given to check it, until he

be<*an? to complain of pain over the sacrum

and difficulty of walking on account of that

pain. I judged it right to examine the rectum

with my index finger, and to my surprise I found, not a mass of scirrhus, but such an

accumulation of dried and hardened faces, which, with the aid of a spoon handle, occupied me half an hour in removing, but by which

removal the diarrhoea and sacral pain soon dis-

appeared. Then along with this somewhat

peculiar symptom?peculiar I mean to dysen-

tery, excepting at the last stages?there was

an ugly, angry, and indurated appearance of the glauds iu the left groin ; in fact, when I first saw the condition of these glands, they reminded me of a scirrhus mamma temporarily healed after ulceration.

But when increasing oedema of penis, scrotum, and legs, without the existence of albuminuria appeared, obstruction to the return of venous blood was a certainty ; and yet in this country the minds of surgeons may be sometimes so

occupied with dysentery, that even such obvious signs of another disease, or at least a serious

complication, may pass them by unchallenged. The man was ill a long time, and had he been

the subject of dysentery, ?post-mortem signs would have been seen ; but these signs were

absent, and the only important morbid condi- tion of the intestine was that of the rectum, which was certainly a first-rate specimen of scirrhus. Whether or not he had had dysentery, affecting the rectum more particularly, I am unable to say, because its internal surface was so altered by the deposit of scirrhus, that it was impossible to define ulcerations belonging to any particular class. If we accept a theory that the mau had been a subject of dysentery affecting the rectum, pathologically it might have been the starting point of the disease of

which he died, particularly if it be true that

carcinoma has a local origin. In conclusion, it is quite apparent from the

foregoing remarks on this case, that in dysentery or supposed dysentery, where such anomalous symptoms as those I have detailed are present (although I know how rare they are), that ofteu neglected means of diagnosis should be tried,? viz., examination of the rectum with the finger, not that unpleasant proceeding will do much good as far as the end is concerned, but that it may be some guide in the treatment of the patient, who might be much relieved by treatment directed according to the real nature of his disease; but who would not, I think, get much good from full doses of ipecac from time to time. The con- dition of the rectum in relation with the bladder and prostate, and the great obstruction produced thereby, will of course show that during life, colotomy or excision would have been useless.

Bellary,

December 1886.