The Etiology and Pathogenesis of Rectal Stricture

It is the object of this communication to demonstrate the following: (1) that syphilis must be considered as a factor in the etiology of rectal stricture, (2) that the pathogenesis of rectal stricture so caused may be identical with that of lymphogranuloma inguinale. As stated by Ravaut, Seneque, and Cachera'5, there are two principal clinical forms of stricture of the rectum, the one associated with chronic elephantiasis of the external genitalia, the second a pure stricture without evidence of elephantiasis. Since the development of a specific skin test by Frei5 in 1925 the picture associated with the first form has become more or less a clinical entity, previously given a great variety of names, such as "maladie de Nicolas et Favre", "subacute inguinal lymphadenitis", "nontuber-culous granulomatous lymphadenitis", but now more commonly known as lymphogranuloma inguinale. It is, however, in regard to the second form of stricture that opinion remains divided. Evidence still is inconclusive as to the etiology and pathogenesis of the affliction. The cause of such stricture has been variously ascribed to the gonococcus, bacillus of Ducrey, bacillus of Koch, streptothrix of Nocard, and more particularly to Treponema pallidum. It can be readily understood that infection of the rectum of any nature resulting in healing by fibrous connective tissue proliferation may result in stricture, and on this account infection by the spirochete of syphilis lends a very pertinent aspect to the consideration of the condition. The so-called "ano-rectal syphiloma" and associated stricture is never found above the ampullary portion of the rectum. One opposed to the probability of syphilis as the etiological agent of rectal stricture might contend that, in view of the fact that syphilis of any other part of the gastro-intestinal tract is an extreme rarity, it is difficult to see why in the case of rectal strictures the syphilitic organism should single out the rectum as a site. The unique location of syphilis of the gastro-intestinal tract would seem to be explained by the nature of the lymph drainage of the genital region. In a recent article in the Journal of the American Medical Association , Cole2 has pointed out that studies made by Barthels and Biber