DISEASES OF THE RECTUM AND ANUS.
BY THOMAS G. MORTON, M.D.,
AND
HENRY M. WETHERILL, M.D., PH.G.
Diseases of the inferior and terminal portion of the large intestine may be divided into primary and secondary—the former when the morbid cause is local and independent of disease elsewhere, the latter when it is consequent upon or incident to some other bodily affection. Among the primary lesions may be classed congenital malformations, prolapse of the rectum, hemorrhoids, and some varieties of new growths; also diseases caused by local irritations, infection, or traumatism, such as proctitis, ulceration, fissure, non-malignant stricture, chancroidal invasion and primary syphilis, including obstruction of the bowel by impacted feces and foreign bodies. Thread-worms and various cutaneous eruptions about the anus may also be included among the causes of the primary diseases of this portion of the alimentary canal.
The secondary affections are quite numerous, and may be caused by direct extension of disease from the colon, as in the dysentery following typhoid fever, and follicular enteritis, or entero-colitis of children; by contiguity, from diseases in neighboring organs—e.g. ischio-rectal abscess causing fistula—or by changes in the nervous or vascular supply, such as is seen in spasmodic contraction, paralysis, epidemic dysentery, cholera, and the action of certain remedies.
The rectum, the third or terminal portion of the large intestine, has no sharply-defined upper limits: it is usually understood to begin at the sigmoid flexure, opposite the left sacro-iliac symphysis; it is from six to eight inches in length and terminates in the anus. As the sigmoid flexure is the narrowest portion of the colon, so the calibre of the first part of the rectum is narrower than the portion below, where it gradually becomes more commodious, and near the anus presents a peculiar condition of the walls which gives it a capacity for remarkable distension. The rectum, which is somewhat cone-shaped, in its anatomical and pathological characters retains those of the large intestine with slight variation. Upon the upper or first part of the rectum the duplicature of the peritoneum is continued, forming the meso-rectum, which invests the bowel, attaching it to the sacrum. Below this the middle portion of the rectum (extending to the tip of the coccyx) is attached to the sacrum by connective tissue only, but also has a peritoneal investment on the upper portion of its anterior surface.
The third or terminal part of the rectum, which is only an inch and a half in length, and is entirely without peritoneal covering, terminates at the anus. The circular and transverse muscular fibres, mucous crypts, and appendages throughout the rectum are identical with those above, except that the general muscular tunic is thicker; but the longitudinal fibres are less distinctly aggregated into bands than in the colon, being disposed in a more uniform manner, except that, like the circular fibres, they are especially aggregated between the sacculi. The fact that the meso-rectum limits the mobility of the upper and more narrow part of the rectum has led some to locate a third sphincter at this point, but the existence of such an organ has not been generally admitted. Van Buren characterizes it as an organ which "anatomy and physiology had been equally unsuccessful in assigning either certainty of location or certainty of function."1
1 Kelsey, Diseases of the Rectum and Anus, New York, 1882, p. 20.
The anus guards the outlet of the bowel by its double sphincter muscle, which under normal circumstances affords voluntary control, within certain limits, over defecation. The well-known peculiarity of the vascular supply, a sort of erectile tissue being formed by the inferior hemorrhoidal plexus and the passage of some of the efferent veins through the sphincter muscle, by which they are subjected to pressure, is very favorable to the development of certain forms of disease which will be considered among the local disorders. As embryology has thrown considerable light upon the pathology of morbid growths by demonstrating relationships that were previously unsuspected, so a consideration of the development of the lower portion of the intestinal canal may lead to a better understanding of some of its diseases, especially those which are symptomatic or secondary. In early foetal life the third division of the primitive intestine, the pelvic portion, terminates in a cloaca in common with the urachus; subsequently, about the eighth week, a partition (the perineum) is formed which divides the cavity into two portions, the uro-genital sinus and the anal cavity. In the mean time, at an early period a depression occurs on the cutaneous surface at the site of the anus, which deepens progressively until it encounters the primitive intestine, with which it unites at the end of the fourth week, and the continuity of the tube becomes established. It therefore is seen that the rectum in its upper and middle portions is derived from the internal and middle layers of the blastodermic membrane, while its lower third, with the anus, like the buccal cavity, is formed by the external and middle layers.
In its diseases, then, the greater part of the rectum would seem to naturally participate in those of the large intestine, to which it structurally belongs, while its inferior portion and the anus would partake more in the disorders of the general cutaneous system. This peculiarity of development also explains the difference noticed in the vascular supply. The rectal veins are usually divided, like the rectal arteries, into three sets—superior, middle, and inferior. They are arranged so as to form two distinct venous systems, the rectal returning its blood through the inferior mesenteric veins into the portal system, the anal terminating in the internal iliac. The first system is made up of the superior hemorrhoidal, the second of the remaining veins.
The superior hemorrhoidal forms a venous plexus which surrounds the internal sphincter muscle; the inferior hemorrhoidal vein also forms a plexus, but it is subcutaneous and principally below the inferior border of the external sphincter.
There are, however, a number of communicating branches passing along the walls of the rectum from one plexus to the other. The internal hemorrhoidal veins also communicate freely with the branches of the internal iliac around the trigone of the urinary bladder by means of small vessels, which pass through the prostate gland and seminal vesicles. By this method of anastomosis some relief is afforded when there is an obstruction in the portal circulation, which is such a common cause of turgescence of these veins, often resulting in permanent dilatation or hemorrhoids.
At the lower part, or at the junction of the middle and lower third of the rectum, the internal circular fibres of the muscular coat of the intestine become quite numerous, forming what is called the internal sphincter muscle; it is nearly an inch in breadth, and completely surrounds the lowest part of the rectum. It is about an inch above the margin of the anus; its muscular fibres are of the involuntary or unstriped variety; in function it assists the external sphincter in closing the anus and preventing the involuntary escape of the contents of the bowel.
The external sphincter lies directly under the skin and upon the internal sphincter and the levator ani muscle; its fibres encircle the anus: arising from the coccyx, they are inserted into the tendinous centre of the perineum, joining the transversus perinæi, the levator ani, and accelerator urinæ muscles. The sphincter ani is constantly in a state of tonic contraction, but the force of its contraction may be voluntarily increased. In the skin and superficial fascia are found minute branches of the pudic and small sciatic nerves; in the ischio-rectal space the internal pudic nerve; crossing about the centre are the inferior hemorrhoidal nerves, which are distributed to the anus and the lower portion of the rectum; the perineal nerve is especially distributed to the anterior part of the anus.
Thus it is seen that the rectum and anus have vascular and nervous supplies of considerable diversity and importance.
Congenital Malformations.
The simplest form of congenital malformation in this region consists in an anus of insufficient size for the natural demands of the system, but in no other manner abnormal. The most frequent variety of imperforate anus is where complete occlusion is effected by the common integument or by two cutaneo-mucous flaps, which owing to defective development remain united without forming a raphé or perceptible line of union. The rectum is not involved, and when the child strains the contained meconium causes bulging of the part, which disappears under slight pressure, but reappears when again free. In other cases the occluding tissue is very firm, dense, with a disposition to pucker or form rugæ. The sphincter muscle is rarely perfect, and though an artificial anus may be made, years may elapse before the child can control the evacuation. In conjunction with an imperforate anus the colon may terminate in a cul-de-sac, or it may communicate with the urethra, the bladder, or the vagina.
An imperforate rectum has been known to discharge at the umbilicus, upon the face, under the scapula, upon the penis or the anterior part of the scrotum. Sometimes, though very rarely, a common cloaca has been found, as in fowls, common to the rectum and to the genito-urinary organs; and still more rarely the rectum has opened in abnormal sites upon the perineum and upon the buttocks.
The anus may be entirely absent. The rectum may be entirely absent or it may be incomplete, terminating at various distances from the anus. These malformations of the bowel may be associated with a perfect anus, or with any of its imperforate forms, or with a fecal fistula. In occlusion of the rectum the offending structure is in some cases a hymen-like fold of mucous membrane, which, during straining, can be recognized by the finger as a fluctuating protrusion; while in others it consists of a mass of dense fibrous tissue which extends upward from an inch to an inch and a half: in the former there is always found a normal anus; in the latter there is either no trace of anus or one in a more or less rudimentary state. In those cases where the rectum is entirely absent the intestine terminates either in a cul-de-sac or a fecal fistula; very rarely the rectum is replaced by a fibro-ligamentous cord or band which springs from the colon, and, descending toward the bladder, blends with the connective tissue of the part. In the latter the pelvis is always in an imperfect state of development, being much contracted in its lower diameters, and the anus is absent; and Rokitansky and Curling lay stress upon the non-development of the pelvis as a diagnostic guide in determining the absence of the rectum. The passage of a sound into the bladder or vagina is a procedure of some diagnostic value, as if its point impinges directly against the sacrum it may be presumed that no rectum exists. If the malformation is of such a character that the fecal matter can find no exit, a train of symptoms ensues analogous to those seen in the adult affected with intestinal obstruction: the infant cries and is constantly restless, refuses food, vomits, the abdomen distends, and death speedily ensues. A remarkable exception to this rule was the case mentioned by Bodenhamer of a child with absence of the rectum who was not operated on until three months after birth, and who was apparently in perfect health. At the operation the intestine was found three inches from the surface, and the child made a good recovery.
Although the statistics of this class of malformations are somewhat contradictory and confusing, it is safe to state that more male than female children are so afflicted.
The prognosis in the large majority of these cases is grave, for unless the operator can see or feel the fluctuating protrusion, or can recognize it after a very slight exploratory incision, he is working totally in the dark and in close proximity to the peritoneum. Hemorrhage, peritonitis, pelvic cellulitis, and septicæmia diminish the chances for recovery. Indeed, the majority of these cases are scarcely amenable to surgical treatment.
PRIMARY DISEASES OF THE RECTUM AND ANUS.
Prolapse and Procidentia of Rectum and Anus.
These conditions obtain most frequently at the two extremes of life, infancy and senility, but have a very different causation in each. Prolapse of the bowel may be partial or complete—partial when a portion of the mucous membrane is extruded, and complete when the entire rectum appears outside the anal orifice. A predisposing cause in infants is found in the mobility of the bowel—in the fact that it and the sacrum are much less curved than in the adult, and the abdominal viscera are more voluminous: this, associated with the undeveloped state of the muscular system, causes the weight and strain to act directly and forcibly upon the sphincters, and the extrusion takes place. It is often excited by allowing children to sit for a length of time upon the chamber-vessel. It is frequently caused among children by the presence of vesical calculi, by Oxyuris vermicularis, diarrhoea, constipation, dysentery, polypi, and by the long-continued acts of coughing and crying.
In adults and the aged it may be caused by loss of tone of the anus and rectum in chronic diarrhoea and dysentery, or from the energetic action of drastic cathartics, by urinary calculi, the long-continued use of enemata, chronic cough, diarrhoea alternating with constipation, stricture of the urethra, prostatic hypertrophy, tenesmus due to the presence of polypi, and by the pressure of a pelvic tumor. It may accompany procidentia uteri and hemorrhoids. An incomplete, reducible prolapse consists of two or more overlapping plications of normal-looking mucous membrane, sensitive but painless. In these cases there is provoked a hyperplasia of much-elongated connective tissue in the submucous space which undergoes serous infiltration and causes an oedematous condition of the part. In a complete prolapse the entire rectum—all of its component layers—is protruded through the anus. In a recent case the folds of the gut are well marked, but in one where the bowel has remained in this abnormal condition for some time the submucous tissue becomes charged with inflammatory deposit which effaces the plications and causes the bowel to become pale, hard, dry, and tough; and finally pigmentation occurs and the part assumes somewhat the character of true skin. These vary greatly in size, from the slightest protrusion of mucous membrane to a tumor the size of a melon. Usually they are reduced with ease, but their reappearance is occasioned by the slightest tenesmus.
In old age the soft parts of the floor of the pelvis and the anal sphincters lose to a great extent their tone and contractile vigor, and the rectum, also participating in this change, is often unable to withstand the increased thrust of the diaphragm and the compression of the abdominal muscles during defecation; which act frequently demands more exertion on account of a tendency to constipation in advanced life.
In these long-standing cases of senile procidentia it is a matter of experience, verified by post-mortem dissection, that the fibres of the sphincters and of the levatores ani muscles are flattened, pale, and stretched beyond the possibility of contraction, while the entire perineum is in a state of atrophy.
Polypi of the Rectum.
There are two varieties of these—the gelatinoid or soft, and the fibroid or firm. The latter is of rare, the former of common, occurrence, especially in children under the age of twelve years. The fibroid polypus is only found in adults, and is composed of dense connective-tissue elements and blood-vessels. The gelatinoid or soft polypi are also partly composed of connective tissue and vessels, but much finer than in the other: they contain hypertrophied follicles and are covered with spherical epithelium. They resemble nasal polypi, but are more dense. These growths are not malignant in character, but are very troublesome, as they are almost always pedunculated, the stem being from half an inch to four inches in length, which admits of the descent of the tumor within the grasp of the sphincters during defecation, and frequently admits of its escape from the anus. Their presence is not free from danger, as they are very vascular, bleed readily, and are sometimes detached by the breaking of the pedicle during defecation. They frequently bleed spontaneously. The presence of these abnormal growths teases the rectum and brings on tenesmus and frequent desire to go to stool; the feces are flattened, and with them escapes a quantity of glairy red mucus which has been compared to thin currant-jelly. When caught in the grasp of the sphincters they often bleed profusely, and especially is this the case with children so affected. The presence of these bodies is accompanied with a sense of weight and uneasiness in the bowel. They may be single or multiple; they may be round, reniform, oval, fusiform, or irregular; they may be smooth or villous. In size they vary from that of a marble or cherry to that of a small hen's egg, and they are usually found about three inches above the anus, but they vary in position from a point just within the sphincter to one six inches up the rectum. Their presence is usually diagnosticated without difficulty, or, if any is experienced, a digital exploration will reveal them. A child with functional disturbances of the bowels accompanied with frequent hemorrhages should be examined for polypus. One of these growths sometimes unpleasantly complicates a case of hemorrhoids.
A rectal polypus is an adenoma, consisting of dilated glands of Lieberkühn imbedded in connective tissue, also containing nerves and blood-vessels, and is covered with the epithelium of the bowel.
Hemorrhoids, or Piles.
These are usually fibrous when situated below, or vascular when situated above, the sphincter ani muscle. They are conveniently known as external and internal piles, but in some instances it is impossible to say whether these tumors are external or internal. In either variety they are due to an abnormal state of the blood-vessels, and especially of the plexus of superior, middle, and inferior hemorrhoidal veins disposed around the lower extremity of the rectum immediately above the internal sphincter muscle. The inferior mesenteric and internal iliac veins receive a large portion of the blood from this plexus, so that a very free intercommunication exists, around the lower portion of the rectum, between the general venous system and that of the liver. It should be borne in mind that these veins are destitute of valves, and are situated in a very dependent part, which is normally in a high degree of functional activity.
External hemorrhoids are found at the very verge of the anus, and, when not irritated or inflamed, appear like movable, dependent plications of hypertrophied skin. They appear either singly or in groups, but it is nothing unusual to find five or six of them together, and they are not infrequently associated with the internal variety. These pendulous tabs of integument are very prone to inflammation, and they then become exquisitely tender, painful tumors, which vary in size from that of a small pea to that of a pigeon's egg. That portion of the tumor presenting toward the anus is covered with mucous membrane; the other is covered with integument; the former is dark-colored, due to engorgement of its vessels. These, being composed internally of tortuous, dilated veins which have totally lost their normal resiliency, bleed freely on section, but after a time they undergo the following changes: the over-distended vein, of which each is mainly composed, either becomes obliterated by the encroachment of inflammatory deposit or its walls give way and the contained blood escapes; its serum is absorbed, and the tumor now consists of a blood-clot, the remains of a vessel, inflammatory lymph, a hyperplasia of connective tissue, mucous membrane, and integument. It undergoes a still further change by absorption, and remains a permanent pendulous teat of cutaneous and connective tissue, bearing no trace of vascular channels.
On account of the extremely sensitive nature of the mucous membrane and skin of the anus, an inflamed condition of these tumors entails an amount of suffering very disproportionate to their size: there is torture in the act of defecation, constant tenesmus, spasm of the sphincters, a sense of weight and heat in the perineum, and sometimes a swollen, very painful, condition of the raphé, which stands out like a cord.
Occasionally there is a total inability to urinate, combined with a frequent desire to do so. When an attack such as this ends in suppuration of the tumor a radical cure is effected, but a marginal ulcer of the anus sometimes follows. An unclean and neglectful habit provoking constipation, sexual incontinence, over-indulgence in highly-seasoned food or in stimulating beverages, exposure to cold and wet, and the straining attendant upon dysuria, will provoke an attack. No age or sex is exempt from this affection (Gross). It is claimed that before puberty females are more subject to it than males; after that age the reverse obtains, except during pregnancy.
Internal hemorrhoids are round, oval, or sometimes cylindroid-shaped tumors covered by mucous membrane; they are smooth, granular, or rough to the touch, much less sensitive and painful than the inflamed external variety, and are situated within the rectum it may be an inch or two above the internal sphincter muscle. They occur in groups or scattered over the surface of the bowel. In structure they are soft, spongy, vascular tumors composed of dilated and tortuous blood-vessels, the veins predominating over the arteries, their interstices scantily supplied with connective tissue, and their covering is of mucous membrane. In color they are dark red, but when compressed and strangulated by the sphincters they assume a dusky purple hue. After long exposure they take on a pseudo-cutaneous appearance.
The columns of the rectum are the seat of the cylindroid pile, which is brighter in color and much more arterial in its structure than the ordinary variety, and bleeds very freely. Anything which causes stasis and accumulation of blood in the hemorrhoidal plexus of veins predisposes to this very common affection. Constipation is the usual cause; and among others may be named diseases of the liver which cause portal obstruction, pelvic tumors causing engorgement from pressure, the gravid uterus, labor, prostatic hypertrophy, urinary calculi, stricture of the urethra, stricture of the rectum, and rectal tumors. Among other causes are horseback-riding, the erect posture, violent cathartics, seat-worms, dysentery, diarrhoea, dyspepsia, and a sedentary life, with a diet of rich, stimulating food.
These piles do not usually cause much suffering; they vary in size from that of a pea to that of a pigeon's egg, and cause a sense of weight and stuffing in the bowel; but when they are large and numerous they cause severe pain, tenesmus, difficult defecation, spasm of the sphincters, and prolapse of the anus. When the patient is at stool the tumors are forced down and protrude in a bunch, surrounded and constricted by a collar of prolapsed mucous membrane: under these circumstances the tortuous and dilated vessels of which they are composed give way and free arterio-venous hemorrhage takes place. In some cases this happens at every stool, the patient losing from a few ounces to a half pint of blood almost daily until alarmingly depleted. Usually, the protruded piles are easily restored after a motion of the bowels, and so remain until the next one occurs; but in other cases of longer standing and of more gravity the sphincter loses all tone and the piles remain constantly prolapsed. This affection is very chronic, and the subject of it has to regulate his life with the greatest care, as the least unusual effort or excess may provoke an exacerbation. Excepting in the worst cases the general health is not materially impaired. They occasionally become so strangulated as to slough off, which effects a cure, but this is accompanied by grave constitutional disturbance. The disease is rather rare before the age of puberty, but is very common in both sexes in adult life, and is frequently associated with fistula, polypus, fissure, or carcinoma of this region. In females suffering with piles a free hemorrhage from them sometimes takes the place of the menstrual flow. The presence of internal piles causes a sense of weight and fulness and the sensation of a foreign body or of feces remaining in the rectum, with troublesome and obstinate itching about the anus. These symptoms, with the occurrence of hemorrhage from the rupture, erosion, ulceration, or abrasion of the dilated vessels, render the diagnosis easy. Should the piles not protrude, they can readily be made to do so by directing the patient to sit and strain over a vessel containing hot water. If the piles do not appear, a digital examination should be made. Indeed, it would be better to make one in every case of this kind.
About the margin of the anus the superficial veins are prone to great dilatation, and when presenting form masses of a bluish color, often very dark, covered partly by mucous membrane, partly by integument. These are also commonly known as piles.
Dilatation of the Rectal Pouches, or Physick's Encysted Rectum.
This is an uncommon disease, generally occurring in those advanced in years, and consists of an hypertrophy, and sometimes of an inflammation, of the natural rectal sacs. These pouches are quite small in early life, and enlarge gradually as age advances, this condition being favored by the lodgment in them of extraneous substances, such as indurated fecal matter, inspissated mucus, the seeds of fruit, and other undigested masses. Constipation, so usual with the old, predisposes to this affection, as it keeps the bowel distended with hardened feces. The pouches vary much in size, the largest of them admitting the end of a finger. The disease is insidious and slow, but is capable of producing intense suffering should inflammation, suppuration, or ulceration attack them. Sometimes as many as a dozen are involved.
The symptoms, which are rather misleading than suggestive of the disorder, are a sensation of weight and uneasiness just within the anus and uneasy sensations in the rectum, distressing itching, and, after a time, pain following defecation and lasting often for hours. The pain, which is aching and burning in character, is not confined to the parts affected, but radiates down the thighs, toward the back, and into the perineum. An increased secretion of mucus always exists in these cases, but the discharge of purulent matter is uncommon, and its presence indicates the existence of very active inflammation.
It is said that even in the worst cases no spasm of the sphincters occurs. An exploration of the bowel with a blunt-pointed hook affords the only reliable guide to correct diagnosis: this, as it is moved about in the rectum, engages the rim of a sac, which may thus be drawn down through the anus and examined.
Non-malignant Stricture of the Rectum.
In the absence of ulceration or syphilitic infection this is an uncommon disease, and very many of the cases of so-called stricture of the rectum are caused by spasm which always disappears during anæsthesia.
The affection may be described as a narrowing of the lumen of the rectum, more or less circumscribed, by the deposition of inflammatory lymph or fibrous tissue in the mucous, submucous, or muscular tunic of the bowel. It may be due to traumatic causes, such as the introduction of foreign bodies, the frequent and careless use of enema-pipes, or the presence of sharp or irritating substances swallowed, as pieces of shell or bone. It is said to have been caused by indurated feces, but no cases have been published in which this causation is clearly shown. This condition has also been brought about by various operations upon the mucous coat of the bowel, such as the application of nitric acid and other escharotics and the removal of portions of mucous membrane and of hemorrhoids.
Stricture may be secondary and a result of extension of an inflammation outside the bowel, as pelvic cellulitis; and it is frequently caused by syphilitic deposition and by chancroidal invasion—in the former by infiltration, ulceration, and cicatrization, in the latter by unnatural sexual connection, or by infecting vaginal discharge running into the bowel.
When the stricture involves only the mucous tunic, it imparts to the finger the sensation of a ring-like elevation or a valve-like projection, into which the finger enters or beyond which it passes usually without much difficulty; but when it involves the submucous and muscular layers, as after the cicatrization of a large rectal ulcer, the finger encounters a dense fibrous mass which in some cases appears to have no lumen, but in others will admit only the end of the finger. In these grave cases of long standing there occurs considerable dilatation of the rectum above the stricture due to fecal detention and impaction at this point, and hypertrophy of the muscular coat of the bowel produced by long-continued straining and expulsive efforts.
Allingham2 speaks of chronic constipation as a cause, and says, "Straining to evacuate the contents of the bowel forces down the upper part of the rectum into the lower, causing an intussusception; it gets within the grasp of the sphincter muscles, and this may be the starting-point of the irritation." Stricture does not usually follow proctitis, even when the latter is very chronic. The long-continued pressure of the child's head in cases of delayed labor is said to have caused stricture of the rectum.
2 Diseases of the Rectum, p. 195.
This affection is a disease of adult life, and more cases of it occur among women than among men. "If stricture of the rectum is found in a young woman, it is probably due to chancre cicatrices; if it is met with in old women and men, the inference should be that it is either caused by cancer or by syphilitic infiltration and its consequences. Only in those cases in which no cicatricial tissue has been formed—that is, when the contraction is due to the infiltration alone—will the results of the antisyphilitic treatment contribute anything toward rendering the diagnosis more certain."
Stricture of the bowel may exist for months and years without being recognized and without causing the patient much uneasiness; more frequently, however, there is marked uneasiness, with an increased desire to go to stool and a sense of weight or of a foreign body in the bowel. Violent straining accompanies the act. It is given usually as one of the most common and reliable symptoms of this condition that the feces are flattened, ribbon-shaped, or triangular or wire-drawn: in true stricture, according to Allingham, this is not the case, but the characteristic stool consists of small, irregular, broken fecal fragments. When the contents of the bowel happen to be watery, the loose stool is spurted out with great force. In this disease diarrhoea alternates with constipation; the intestines become distended with quantities of gas and feces, which provoke frequent and severe attacks of colic; the appetite and digestion fail; the complexion becomes sallow; the patient emaciates; ulceration sets in, and the patient slowly sinks from exhaustion. Usually, these cases do not give rise to much pain, and what there is, is usually referred to the back, thighs, penis, or perineum. A discharge of mucus resembling white of egg immediately precedes each action of the bowels. Usually, these strictures are within two and a half or three inches of the anus, but sometimes they have been found high up in the sigmoid flexure, and rarely at a greater distance. A syphilitic stricture by direct inoculation is found just within the sphincter muscle, and consists of an infiltration of inflammatory lymph in a circumscribed portion of the submucous tissue. It is tight, highly sensitive, thickened, inflamed, and bathed in pus; there are also constitutional symptoms, as fever, anorexia, and mental irritability. The subjects of this variety are usually women. The tissues composing strictures of the rectum of a very chronic character are found to be gray or bluish-white in color, of very dense fibrous structure, and creaking under the knife when cut, as a piece of cork would do.
Besides the before-mentioned stricture, due to the contraction of a chancroidal ulcer, is another caused by submucous gummata of the ano-rectal region, which is very rare; and yet another, the diffuse gumma, or ano-syphiloma of Fournier, which is the most frequent of all causes of stricture of the rectum. The diffuse gumma is one of the later manifestations of syphilis, and consists in "an infiltration of the ano-rectal walls by a neoplasm of as yet undetermined structure originally, but susceptible of degenerating into a retractile fibrous tissue, and thus giving rise to narrowing of the intestinal calibre to a greater or less extent."
Proctitis, or Inflammation of the Rectum.
Inflammation and suppuration in the lower part of the rectum are even more common than the corresponding affections of the cæcum, and their causes are quite as various. In many cases, no doubt, this affection is traceable to ulceration (perforative or otherwise) of the mucous membrane; in others it probably originates in the connective tissue which surrounds the rectum (periproctitis). The rectum, still more frequently than the cæcum, becomes involved in inflammation and suppuration originating in the various pelvic, and even in distant, organs. Abscesses arising in the abdominal cavity or its parietes are peculiarly apt to gravitate into the pelvis and to communicate with the rectum.
Proctitis in its acute form has some symptoms in common with dysentery, but it differs from it by the absence of abdominal pain, tenderness, and severe constitutional symptoms. The pain in proctitis is usually referred to the sacrum and perineum, and there is frequently dysuria from sympathetic affection of the bladder. This disease may be acute or chronic; the latter form occurs in those advanced in life. Frequent attempts to evacuate the bowels, with great tenesmus, heat, weight, and fulness in the bowel, and a mucous and bloody discharge in the absence of impaction of the rectum, characterize the attack. Should it be protracted and severe, the discharge will become purulent. A digital exploration should always be made to ascertain if any foreign or irritating substance is exciting the inflammation.
The presence in large numbers of Oxyuris vermicularis may excite irritation and inflammation of the rectal mucous membrane, which is sometimes very intense.3
3 Curschmann, Ziem. Encyclop., Am. ed., vol. viii. p. 848.
Inflammation of the anus and buttocks, caused by the application of the leaves of Rhus toxicodendron after defecation, has extended into the rectum and produced proctitis and peritonitis.4 "In some cases of dysentery the pathological lesions are limited to the rectum, which would produce an apparently local inflammation very similar to proctitis. The irritation of unnatural sexual intercourse and the contact of gonorrhoeal poison have been known to excite intense inflammation of the mucous membrane of the rectum, with a copious discharge of pure pus, and accompanied by intense burning pain and great heat of the parts involved."5
4 Case of Dunmire, Philada. Med. Times, vol. xii.
5 Heubner, Ziemssen's Cyclopæd., vol. i. p. 552.
Fissure of the Anus and Rectum.
The painful ulcer of Allingham is quite a common affection, attacking women more frequently than men, and no age is exempt from it. Of 4000 consecutive cases of rectal and anal disease observed by Allingham, 446 presented fissure of the rectum. They are rarely multiple. Their usual position is dorsal, although they may be found at any part of the circumference of the anus, and just within the verge of the anus at the junction of the skin and mucous membrane, extending upward toward the rectum usually not more than half an inch, and appearing as a crack or fissure, often very trifling in appearance, or a club-shaped ulceration, the floor of which will be very red and inflamed if it is recent, but if chronic the floor will be grayish, with hard, well-defined margins. Sometimes there will be found at the external extremity of the fissure a small club-shaped papilla or muco-cutaneous polypoid growth; but this is not to be confounded with the ordinary polypus, nor is it the cause of the fissure, but the result of irritation caused by the latter. In other cases the external site of the fissure is indicated by a very tender and swollen flap of integument, which often becomes the seat of a small but very painful fistula. The club-shaped papilla is said to indicate invariably the existence of fissure.
Fissure of the rectum is often associated with anteversion and retroflexion of the womb. In many of these cases the fissure will heal spontaneously when the malposition is rectified. However treated, the result will not be satisfactory while the uterine trouble remains uncorrected.
Fissure is not infrequently caused by and accompanied with polypi: it may be caused by any accident whereby the verge of the anus is torn or superficially lacerated—by chronic diarrhoea, by violent expulsive, straining efforts, as in labor, by the passage of very hard, dry stools—and very frequently it is syphilitic in origin. The most prominent symptom of this disease is pain, and this is very severe and peculiar in character, coming on in most cases not during the act of defecation, but twenty minutes to half an hour afterward, and is preceded by a hot, burning, throbbing sensation at the anus: then comes on spasmodic contraction of the sphincters, and the patient endures agonizing pain, often for several hours, when relief is gradually experienced, and no pain is felt until defecation again becomes necessary. Now, it has been observed that in some cases where the local lesion is very trifling the pain and spasm are intense and long-continued; in other cases, where spasm and agonizing pain followed every act of defecation, no lesion of the anus or rectum could be found. This led Dolbeau to consider the essence of fissure of the anus neuralgic, and to define it as "a spasmodic neuralgia of the anus with or without fissure." The mental depression is so much out of proportion to the local disease that this may come within Curling's observation, that "mental causes may produce local disease in the rectum."
Rodent, or Lupoid, Ulcer of the Rectum.
This is, fortunately, a rare disease, and is peculiar and distinct from any other form of ulceration in this region. It is not cancerous, although bearing some resemblance to epithelioma. As it first appears it is very like a syphilitic sore, and its situation and the character of the pain might lead to the supposition that fissure existed. Rodent ulcer is usually situated upon the mucous membrane, although it occasionally invades the integument about the anus; its shape is irregular, its edges sharp and well defined, and it does not undermine the neighboring tissues. There is no induration about this sore, as nature does not seem to attempt to limit it or to set up any reparative action, and its surface is red and dry. The surrounding tissues seem quite normal. It is very destructive, and seems to prefer mucous membrane, although sometimes it destroys deeply. It does not cause infiltration; it does not spread by the lymphatic system, forms no secondary deposits, nor does it produce stricture. It may remain in a quiescent state for some time, and a certain amount of cicatricial tissue may form; but it never heals spontaneously, and an exacerbation comes on which destroys in a very few hours the repair which may have been the work of many days. This form of ulceration of the rectum is usually considered incurable; the pain is intense, being compared to that produced by hot iron, and of course being much aggravated by the acts of defecation. Patients so affected die from exhaustion and pain, although recovery may take place, I have known one case entirely cured by complete excision. Spasm of the sphincters is a usual accompaniment, and greatly augments the suffering of the patient. Of the four thousand consecutive cases of rectal disease tabulated by Allingham, only two were cases of rodent ulcer.
Obstruction of the Rectum.
This condition may be caused by foreign bodies introduced into the anus, by indigestible substances swallowed, by impaction of feces, by pressure of tumors external to the rectum, and by intestinal concretions. Any condition which causes loss of muscular and nervous tone in the large intestine favors its obstruction; thus, it is not uncommon in the aged of both sexes, but especially is this the case in women, and in them it often follows parturition. Hysterical, nervous, and debilitated persons are particularly prone to it. The insane, if not carefully watched and regulated, will become the subjects of it. Impaction of feces is a very common cause of obstruction of the rectum, and atony of this organ is usually the primary cause, the feces in these cases being either very hard and dry or clayey and tenacious. These masses are of a more or less globular shape, and, as they irritate the bowel and produce diarrhoea, the practitioner sometimes falls into the error of prescribing doses of opium and the astringents, misled by the appearance of feculent fluid which oozes around the impacting mass. The impaction occurs just above the internal sphincter. Habitual constipation soon stretches the rectum and robs it of expulsive force, and an accumulation of months of fecal matter is sometimes found. The appearance of persons so affected suggests malignant disease: they are cachectic, sallow, dyspeptic, irritable, and nervous. Vomiting, anorexia, thirst, cough, hectic, irregular and profuse sweating, are also among its symptoms. Cases of melancholia and of hypochondriasis have been cured simply by the discovery and removal of rectal impactions. This condition has been mistaken for cancer, phthisis, intermittent fever, and enlarged mesenteric glands. Accompanying impaction, and as a result, is spasmodic contraction of the sphincter ani, which causes the anus to protrude in a nipple shape and to firmly resist the introduction of the finger. Usually, there is no discharge from the anus in these cases. Tenesmus, a sense of weight and of a body present in the bowel, are experienced. Young people are not often subjects of impaction.
Concretions also cause obstruction of the rectum: these are more frequently cylindroid in shape, and sometimes have a nucleus consisting of some firm foreign body. Wetherill reports a case of a young adult, who had been accustomed to the daily ingestion of a substance known as hygienic bread (this substance is made from the husks of grain, and is very coarse: it is used to excite peristaltic action), from whose rectum he removed a very hard ball of this substance which was covered with mucus, but which contained no nucleus. He reports another case in which the offending substance was a globular mass of casein, stained with bile and covered with mucus, and which had for a nucleus a small mass of hardened fecal matter.
Guéneau de Mussy6 reports a case in which there was an occlusion of the rectum by a mass of magnesia, which was so firmly impacted that it had to be removed by a mallet and chisel. A similar case occurred in the practice of Dunlap of Norristown. Fendick7 relates an instance of impaction by a fish-bone near the anus, causing obstruction requiring surgical interference; which illustrates the importance of examining carefully all cases of acute piles and threatened abscess.
6 Medical Times and Gazette, 1879, vol. ii. p. 214.
7 Lancet, 1880, vol. ii. p. 239.
These concretions often consist of animal and vegetable fibres matted together about a nucleus, the latter consisting of the seeds of fruit, fragments of bone or gristle, hair, small coins, or pins. "Enteroliths may lodge in the rectal ampullæ" and cause obstruction. Indigestible substances swallowed with the food may be arrested in the rectum, such as grape-skins, fruit-pits, husks, and fibres, and where there already exists stenosis of the bowel a dangerous form of obstruction may be produced. Jones8 reports a case of chronic impaction of the rectum by plum-stones, which gave rise to trouble in defecation, and at the end of eighteen months produced symptoms of piles; at the end of two years impaction occurred, and the mass was removed by the surgeon. Hazelhurst relates a case of impaction in a negro where two hundred and eighty plum-stones were removed from the rectum after having been there for a week. The records of the Pennsylvania Hospital furnish the following interesting case of obstruction:9 "The patient (a male) stated that twenty years before he swallowed a peach-stone. Two years afterward he had symptoms of rectal irritation, tenesmus, constipation alternating with diarrhoea, and liquid stools, etc. These symptoms had continued ever since. His health had been markedly impaired. A digital examination revealed a hard, stony mass two and a half inches above the anus. Under ether Morton divided the external sphincter, and with a pair of bone-forceps removed, with considerable difficulty, a good-sized peach-stone which was lodged in the rectal tissues. The stone was very sharp at the ends, and had evidently lodged crosswise and become imbedded. The patient was discharged quite well and free from all symptoms."
8 Lancet, 1856, vol. ii. p. 278.
9 Surgery in the Pennsylvania Hospital, Phila., 1880, p. 335.
Gall-stones may cause impaction or they may form the nuclei of concretions. A case of impaction is related by Walker,10 who removed a gall-stone from the rectum which measured three and a half inches in its longest and one and a quarter inches in its shortest diameter; also one by Roberts,11 in which he removed a gall-stone measuring five inches in circumference from the rectum of a woman two weeks after confinement. Mischievous, revengeful, insane, or intoxicated persons sometimes force very curious foreign bodies into the rectum, among which may be mentioned hot iron, bottles, cups, bougies, pieces of wood, stones, a champagne flask, a goblet, slate-pencils, and the tail of a pig with the bristles cut short. Some foreign bodies introduced from below find their way through the sigmoid flexure and lodge in the colon, or they may remain for a long time in the rectum. The cæcum is the favorite resting-place of foreign bodies. Turgis12 removed by linear rectotomy a cup which had been forced into the bowel. These foreign substances, if not promptly removed, set up violent inflammation. Obstruction of the rectum may be caused by vast numbers of round- or thread-worms twining themselves together in a mass; and when this happens in children or in adults of very nervous organization a curious train of reflex symptoms may be developed, among which may be mentioned choreic movements, convulsions, pruritus ani, insomnia, irritability, melancholia, and hypochondriasis. Finally, the rectum may be obstructed mechanically by pressure exerted from without. Such an effect might be produced by morbid growths from the sacrum or ileum; by deposits in Douglas' cul-de-sac; by ovarian disease; by pelvic cellulitis causing stricture of the rectum; by vesical trouble; by ascites with hepatic disease; and by various abnormalities of the uterus, such as inflammation, morbid growths within or upon, simple retroversion or retroflexion, or retroflexion of this organ in a gravid state.
10 Flint, Prac. Phys., 460.
11 Bost. Med. Journ., 1879, vol. ii. p. 116.
12 Société de Chirug., 1878.
Impaction of feces under some circumstances may give rise to extensive sphacelus of the rectum and the contiguous parts from pressure. This is well illustrated in the following case of a woman aged sixty-five, who was found to have an immense distension of the abdomen from ascites, incident to a large omental scirrhus. The patient suffered greatly from the pressure caused by the accumulation of water, and she was tapped. Soon after this an impaction of feces was observed, which probably had been forming for some time prior to her coming under observation. A week or ten days after the tapping the impaction was detected, but not soon enough to prevent the formation of a large slough of the posterior and inferior part of the rectum immediately above the anus. The submucous tissues and the skin, owing to the greatly enfeebled condition of the patient, soon gave way, leaving a large opening which communicated with the bowel. The tissues adjacent were oedematous, red, and painful. The finger carried into the bowel through the anus discovered the slough to have involved a region of at least two and a half inches in diameter.
Cutaneous Eruptions and Parasitic Conditions of the Anus.
These are quite numerous, and they almost invariably produce much distress and excite painful pruritus, which is augmented rather than relieved by scratching or friction of any sort. The application of the leaves of Rhus toxicodendron after defecation is capable of exciting considerable inflammation upon and around the anus, accompanied by small pearly vesicles, which, when ruptured by scratching, seem to spread the disease wherever the contained serum flows. Eczema, when found in the anal region, is usually due to parasitic growth. Erythema intertrigo is caused by the friction of moist opposing surfaces, as between the nates of stout persons, who perspire freely, and infants. The abraded derma exudes a sero-purulent fluid which excites troublesome pruritus. When this condition exists about the anus it causes painful defecation and spasm of the sphincters. Erythema chronicum occurring in this locality is frequently a sequel to chronic eczema and chronic lichen: the skin cracks, is moist, thickens, and the epidermis exfoliates. The proximate cause in both of these conditions is congestion of the vascular rete of the derma. In prurigo podicis papules appear which itch intensely, and when scratched bleed, the summit of each papule bearing a small black scab. If not cured, in time a true psoriasis may develop. Herpes of the anus occurs similar to herpes at the other mucous outlets of the body, and is usually symptomatic of slight disorder of digestion. Wetherill has seen a case of herpes zoster, (var. proserpens,) in which the vesicles extended from the side of the scrotum along the perineum to the verge of the anus. This condition was accompanied with neuralgia of the rectum, painful defecation, and spasm of the sphincters. Furunculi sometimes form at the verge of the anus, causing spasm, pain at stool, and occasionally marginal fistulæ. Various syphilodermata also appear in this region. Gross was the first to describe a condition of trichiasis of the anus—a very irritating complication to fissure—due to a perverted recurvation of the hairs usually found in the anal region. Villermé states that hairs have been found growing from the mucous membrane of the rectum. The colonization of pediculus pubis about the anus occasions a certain amount of irritation. Sarcoptes hominis is sometimes found in this region, having been carried there by hands infested with this parasite. The result is very distressing. The peculiar tracks or burrows made by this little animal, and the use of the microscope, make the diagnosis certain. The Acarus autumnalis, or mower's mite, has been found in the skin of this part, and it is capable of causing great distress. These do not furrow the integument longitudinally, but burrow vertically, and may be picked out of the summits of the wheals, where they appear as small red points.
Ulceration of the Rectum and Anus.
This is a condition very different from fissure or the painful ulcer of Allingham—much more grave, difficult to treat, and, in chronic cases, much less hopeful of cure. It is not an uncommon affection, Allingham's table of 4000 consecutive cases of diseases of the rectum and anus furnishing 190 of the disease under consideration. An ulcer of the rectum may be partly within, partly without, the internal sphincter, but in most instances is found above that muscle, from an inch and a half to two inches from the anus, situated dorsally.
The symptoms are unfortunately obscure and insidious, misleading not only the patient, but also too frequently his medical adviser, and gaining grave headway before a correct diagnosis is reached. Often the very first symptom is a slight diarrhoea every morning as soon as the patient rises, accompanied with a little discharge resembling coffee-grounds; or, again, the discharge is like the white of an egg; in some rare instances pus is formed. At this stage there is little or no pain, but the patient suffers from tenesmus—which is not followed by relief—and a sense of uneasiness in the part. Several stools of this nature or streaked with blood may be passed during the earlier part of the day, after which the patient feels partly relieved, and no more evacuations occur until the following morning, when he again experiences the same train of symptoms; and this repeats itself daily for a long time. Finally, these discharges occur in the evening as well as in the morning, then at various times during the day: his general health begins to give way; the discharge becomes augmented in amount and contains more blood and pus; and he suffers occasional pain from flatulent distension. Local pain in the rectum is now felt, which is not acute, but is very wearying, is augmented by much walking or by long standing, and which has been described as similar to a dull toothache. These ulcers may be multiple, and not infrequently lead to stricture of the rectum, which condition is indicated by the alternation of attacks of diarrhoea and constipation. As the ulcerative process proceeds, nature makes efforts to limit the process, which causes infiltration and thickening of the submucous and muscular tissues, and produces narrowing of the lumen of the intestine, which in time loses its tone and contractile power and becomes a passive tube, utterly unfit to perform its normal duties. The sphincters give way and the patient loses control over his evacuations. Finally, abscesses form, which, burrowing toward the surface, form fistulæ, and may perforate the bladder, the vagina, or the peritoneal cavity. If one of these ulcers be examined while yet in the acute stage, it will be found to be oval in shape, with well-defined edges: the base will be either grayish or very red and inflamed, the surrounding mucous membrane appearing normal. The rectal glands will be found to be enlarged. Should the ulcer be examined at a later stage, it will be found to be much deeper and more extensive, with great thickening and nodulation of the mucous membrane, and looking in places as though the latter had been torn off. At this stage the ulceration may be partial or may involve the entire lower portion of the rectum. The suffering is now intense, and a constant discharge of fetid pus and mucus takes place. The appearance of the anus at this time suggests malignant disease: it is covered with swollen, shiny, tender, club-shaped flaps of integument constantly bathed in an ichorous discharge. The entire rectum and sigmoid flexure have been involved in some cases, while in others necrosis of the sacrum has occurred. Patients suffering from ulceration and stricture are very liable to a low form of peritonitis, attended by intense abdominal pain.
The causation of these ulcers of the rectum is frequently very obscure: some are of syphilitic, others of strumous, origin. Some are of traumatic origin, but more often the patient was in apparent health up to the time of the appearance of the disease. The experience of Allingham would indicate that neither chronic constipation nor dysentery is a frequent forerunner of this malady. T. Claye Shaw,13 in an article entitled "On Some Intestinal Lesions of the Insane," says: "After death are found patches of ulceration sometimes so extensive as to resemble a honeycomb network. The edges are usually slightly raised, and perhaps hardened; but the ulcers are at other times mere local punchings out of the mucous membrane, and there is often a little loose gelatinous material." It is claimed that such disorders are not infrequent among the insane.
13 St. Bartholomew's Hospital Reports, 1880.
It is also claimed that the chronic mechanical irritation from foreign bodies, impacted feces, and the like exert a causative influence in the formation of ulcer of the rectum. Like typhlitis, this affection leads to chronic inflammatory changes in the immediate neighborhood (periproctitis), with the formation of fistulæ and crater-shaped ulcerations, and to the extensive destruction of the mucous membrane, followed by wasting and contraction of the rectum. The healing of these ulcers is much delayed by the fact that the ulcerated and undermined mucous membrane is irritated by the fecal masses which are especially apt to accumulate in the lower part of the bowel and around the anus. We find also hemorrhoidal swelling and ulcerations, which may be regarded as partly a cause, partly a result, of the ulcerative proctitis.
Follicular Ulcerations.
In this condition the most extensive ravages are found in the rectum and sigmoid flexure. The causes are identical with those of catarrh of the large intestine, if we except the follicular disease produced by dysenteric infection. In this form of the disease, at least in its earlier stage, the form of these ulcers is always round and funnel-shaped, with distinct thickening of the edges of the mucous membrane around the ulcers. These appearances may be explained by the mode in which the follicular ulcerations originate: "The solitary follicles become swollen, a result of catarrhal irritation, and the cellular elements accumulate in the reticulum, giving rise at first to nodules which project above the level of the mucous membrane: then the newly-formed tissue-elements become necrosed in consequence of the mutual pressure of the cells upon each other; finally, the apices of the follicular nodules give way and the ulcers are formed. The surrounding mucous membrane bends over downward toward the base of the ulcer, so that the orifices of the crypts look down into the same."14 As the suppurative process extends, particularly in the submucosa, and the tissue surrounding the follicles becomes destroyed, these small ulcers coalesce to form larger ones, and the undermined edges of the mucous membrane project over the base of the ulcers, bleed, and become necrosed. Healing is possible by cicatrization, the borders of mucous membrane becoming applied to the base of the ulcer and gradually drawn together by the cicatricial tissue. Still, this result is extremely rare if the ulcerative process has gained much headway. When, however, a follicular ulcer of some size does heal, cicatricial stenosis may result, followed by chronic constipation, just as in the case of simple catarrhal ulceration. The situation of follicular ulcerations is almost always in the large intestine, and they vary considerably in number: sometimes only a few follicles are thus affected, while in other cases the bowel is crowded with them.
14 Rokitansky, Path. Anat., iii. 1861, S. 226.
The anus and rectum may become the seat of chancroidal invasion. An ulcer of this character fairly within the rectum is very rarely met with, especially in this country, and could scarcely be produced except by unnatural intercourse. They are of not uncommon occurrence in the anal region, and are met with in this situation more frequently among females than among males. Occurring among the former, they no doubt often arise from accidental contact during normal sexual intercourse. When this condition is found in males, it rather indicates at least an attempt at unnatural intercourse. Of 1271 males affected with chancroids, only 3 were found with the disease in the anal region. Out of 388 females similarly affected, 33 were found with chancroid of the verge of the anus. The table of Debauge gives 23 cases among 206 females having chancroid in various other situations. The destruction of tissue in these cases may be very serious should the nature of the ulcer not be recognized, and stricture of the rectum or cicatricial stenosis of the anus might result. Ulceration of the rectum may occur during chronic proctitis; it may accompany advanced states of prolapse and procidentia of the bowel; it may attack a stricture of the rectum and cause peritonitis by erosion. Ulceration may accompany hemorrhoids, or it may attack them and cause dangerous hemorrhage. Finally, a very intractable form of ulceration may follow the clamp-and-cautery operation upon piles. When this untoward result is seen, it is usually due to the fact that the patient has been allowed to move about too soon. Allingham claims to have seen these ulcerated stumps of piles even ten days after operation.
Peri-anal and Peri-rectal Abscess.
The ischio-rectal fossa is peculiarly liable to attacks of inflammation resulting in abscess, as it is filled with much loose connective tissue which supports a considerable amount of fat, and is situated in a region which is constantly exposed to injury both from within and without. It is a very vascular part, being freely supplied by branches of the inferior hemorrhoidal arteries and veins; the latter, being large and destitute of valves, empty into the portal circulation. Abscess in this region is of very common occurrence, and may attack any one at any period of life. It occurs more frequently among men than among women, and usually during middle life.
Abscesses in this situation may be acute or chronic. The former variety may be caused by injury to the anus or to the surrounding parts; by exposure to cold and wet, and particularly by sitting upon damp seats while the body is overheated; by impaction of feces, constipation, and straining at stool. Irritating substances swallowed with the food, such as small pieces of bone, oyster-shell, or the stones of fruit, may excite abscess by their presence in the rectum. Among other causes are general debility, an impoverished state of the blood, the scrofulous and tuberculous diatheses. The disease sometimes occurs in quite young infants. Wetherill reports the case of an infant attacked by an enormous ischio-rectal abscess while nursing from the mother, who was at the time suffering from a succession of boils. Many cases have been traced to sitting upon the outside of damp omnibuses. Hepatic disorders, causing engorgement and stasis of the blood in the hemorrhoidal plexus, have frequently occasioned this condition. These abscesses are not always situated in the ischio-rectal fossa; frequently they are subcutaneous and just outside the anus: in other cases the starting-point may be ulceration of the mucous membrane of the rectum, with escape of fecal matter into the areolar tissue; they also originate in the submucous connective tissue of the rectum. The acute abscess is sudden and very severe in its onset; the pain is continuous, throbbing, and augmented during defecation; dysuria is almost always present, and in some cases there is total inability to pass water. There is local tenderness, dusky redness, and fluctuating prominence, and, if not interfered with, a rupture of the integument will take place and the pus will escape externally. Sometimes their formation is accompanied with a chill or with a succession of rigors: there is always considerable constitutional disturbance, febrile movement, loss of appetite, and malaise. This form of abscess is usually circumscribed and does not burrow irregularly, and sudden relief of pain and distress is coincident with their evacuation.
Chronic rectal abscess corresponds to the cold or chronic abscess in other situations: it is apt to occur among those who are much debilitated or among those of the scrofulous diathesis. These abscesses have little disposition to open spontaneously upon the surface, but they burrow extensively in all other directions—high up along the outside of the rectum, laterally into the tissues of the buttock, or downward and forward into the perineum. The process of formation may occupy many months, and sad havoc may be occasioned before their existence is suspected. They occasion no pain nor distress nor acute febrile movement, but may be accompanied with a hectic condition, erratic sweatings, and rapid loss of strength. Upon examination of the anal region in these cases a painless flat, boggy, crepitating enlargement is the only surface-indication of the probably extensive damage sustained by the deeper structures.
This form of abscess may be of traumatic origin, but more frequently the inflammatory process arises in the cellular tissue of the ischio-rectal fossa; in some cases the morbid action is due to ulceration of the rectum. In either case peri-rectal or peri-anal cellulitis will be induced. When these abscesses are of strumous origin the pus is thin, curdy, and offensive.
Both the acute and the chronic abscesses of this region are often difficult to heal, the external opening remaining permanently patulous, communication with the bowel resulting from internal burrowing and erosion, with the formation of extensive sinuses in all directions, resulting in fistulæ in ano.
Fistula in Ano.
This condition occurs more frequently than any other of the abnormalities of this region, Mr. Allingham finding 1208 out of his table of 4000 consecutive cases of diseases of the rectum and anus. He found also that fistulæ followed rectal abscess in 151 out of 196 cases, the abscesses which healed kindly and gave no further trouble being only 45 in number. A fistula in ano is a linear ulceration with a patulous orifice which discharges pus: it may or may not communicate with the bowel, and it may have more than one external opening. The great majority of fistulæ in this region are caused by abscess, either arising in the submucous areolar tissue of the bowel, or in the subcutaneous connective tissue in the immediate neighborhood of the anus, or in the ischio-rectal fossa, or in an ulcerated state of the mucous membrane of the rectum: in other cases it is congenital, or it may result from the presence of foreign bodies or worms in the bowel, or from puncture of the rectum by pins, scales of shell, fragments of bone, or other sharp substances swallowed with the food. Abscesses leading to fistulæ have followed kicks, blows, or wounds of the anal region: in short, anything which induces an abscess here may result in a fistula, and as in the former more cases occur in males than females, and more during middle age than at any other period, the same is true as to the latter. Fistula is quite common among the phthisical as a result of malnutrition and septicæmia, aided by the constant succussion of the perineum produced by efforts at coughing. Of the 4000 cases previously referred to, 1208 were cases of fistula; "of these, 172 presented more or less marked symptoms of lung trouble, hæmoptysis, cough, or impaired resonance in some portion of the chest."
A fistula may be complete or incomplete. To be complete, it must have two openings (it may have more)—one in the anus or rectum, and one upon the surface. There are two forms of the incomplete or blind fistula—one in which there exists an internal but no external opening, and the other in which there is an external but no internal opening. In complete fistula there may be more than one external opening, and this is in the majority of cases not far from the anus, but it may open in the perineum or upon any part of the gluteal region. When the openings are multiple they usually converge to form a common tract or sinus. The external opening presents nothing to the untutored eye to lead to the suspicion of grave internal trouble: frequently the vent is so minute and valvular or shielded by a thin pellicle as to be entirely overlooked; in other cases a little teat formed of superabundant granulations guards the entrance: there may or may not be discoloration, elevation, or depression of the surrounding integument, and erythema resulting from the irritating nature of the discharge. Inflamed and suppurating follicles in the integument about the anus are not to be mistaken for the orifices of fistulous tracts.
The internal opening in anal fistula is situated between the sphincter muscles, sometimes just within the anus, but oftener about half an inch above; in rectal fistula the internal opening or openings may be at any point above the internal sphincter. These sinuses may be very tortuous, with pockets, blind passages, or diverticulæ, and are known as horseshoe fistulæ when they commence at one side of the bowel and ulcerate around it to a point opposite before making an opening.
Of the two varieties of incomplete fistulæ, by far the least frequent is that where no internal opening exists, but where there are one or more external orifices: these do not invariably even run toward the bowel, but may extend off through the tissues in any direction. In the other variety, where there exists no external evidence of disease, considerable damage may be done before its recognition. Fistula may coexist with hemorrhoids, stricture, ulcer, or malignant growth: it may be a very trivial affair, with the internal but a fraction of an inch from the external opening, or it may be long, deep, and tortuous, with sinuses running in all directions through the buttock.
Usually, fistulæ become worse when not operated upon, but there are cases which have healed without surgical interference—others in which this condition has gone on for many years without getting any worse or without the discharge increasing in amount. The fluid discharged from a chronic fistula loses after a time much of its purulent character and becomes serous and watery; but fresh abscess and inflammation is apt to take place in these cases from feculent matter lodging in the sinus. Those which burrow most readily are the internal fistulæ with large openings, into which the feces are pushed, with the sinus running toward the anus, because of their funnel-shape.
The presence of fistula may be suspected if there are in the anal region abscesses which have not completely healed, or which, having apparently done so, break out from time to time and discharge pus; or from the existence of a circumscribed hardness or swelling unaccompanied by an opening which varies in size and is at times painful; or if there exist any ulcerated moist openings. To make a positive diagnosis the tract must be explored by a probe: enter the oiled, blunt-pointed probe gently into the external opening and let it find its way along without force, bending the probe if necessary, until it has traversed the sinus as far as it will go; then pass the finger into the rectum and feel about for an internal opening or for the point of the probe. If the finger be introduced first, the relations of the parts are interfered with and the internal opening, should one exist, might not readily be found. Sometimes the bottom of the tract does not correspond in situation to the internal opening, but extends beyond it. In those cases where no external opening exists, the rectal speculum, aided by judicious pressure, will discover an issue of pus from a sinus upon the mucous membrane of the rectum.
In order to illustrate the amount of damage which a small foreign body may cause when lodged in the rectum, Wetherill relates the following case, which occurred in his practice at the Pennsylvania Hospital for the Insane: The patient was a middle-aged man, intelligent, and an employé of the hospital. "Upon examination of the anal region I found a small, tender, firm swelling, which did not fluctuate, about an inch to the left of the anus: this had been forming for about a week, and there was no history of painful defecation, of exposure to damp and cold, nor of a blow or injury of the part. Without waiting for the development of fluctuation, I made a free and deep incision into the ischio-rectal space, and a large quantity of very fetid pus escaped: upon introducing a large probe I found that it passed up into the fossa to a depth of four and a quarter inches and turned but slightly toward the bowel. Remembering the experience of Allingham, that when the pus in these cases was very offensive there existed an opening in the bowel, I questioned the patient again as to pain in the bowel or painful defecation, which was answered in the negative. No communication could be found with the finger in the bowel and a probe in the wound, and poultices were applied, liquid diet ordered, and the man kept in bed. The cavity was loosely filled with absorbent cotton and the entire wound (apparently) healed slowly, but kindly, and in about ten days after operation the patient left the house to all appearance sound. About a week after the patient returned with the report that he felt uneasy throbbing in the part, and that there was a very slight discharge. Upon inspection I found in the surface-line of the cicatrix a pinhole opening which yielded upon pressure a drop or two of pus; upon entering a very fine probe it passed into a narrow sinus to a depth of three and a quarter inches, but no communication could be made with it with the finger in the bowel. Upon withdrawing the probe it grated over something which felt like dead bone, about two inches from the surface. I enlarged the opening, introduced a pair of fine dressing-forceps, and withdrew a piece of the rib of a chicken about half an inch in length and sharpened at one extremity to a fine point. Upon making inquiry I found that he had not eaten any chicken since the development of the abscess. He then suddenly remembered that while he was at stool a few days prior to the formation of the abscess he experienced a sudden pang of very acute pain in the rectum, which, however, soon passed off. This was no doubt the moment when the piece of chicken-bone pierced the rectum."
Hemorrhage from the Rectum.
Hemorrhage from the rectum may be accidental, primary, or secondary—accidental when it follows the ulceration of internal piles or the erosion of large arterial or venous trunks during the progress of malignant disease, or when it occurs from the rupture of a rectum during defecation—a very rare and curious occurrence reported by M. E. Quénu;15 primary when it occurs during, and secondary when it occurs after, a surgical operation upon these parts.
15 Révue de Chirurg.; Practitioner, p. 29, Oct., 1882.
Hemorrhage from the rectum without any structural lesions is quite unusual, but occasionally copious losses of blood are seen in vicarious menstruation, and several instances have been reported.
When ligatures separate after operations upon those of broken-down constitution very copious and dangerous bleeding may occur without any symptoms save a "sensation of something trickling in the bowel," a feeling of weight and fulness in the part, with increasing weakness and syncope of the patient, until he expresses a desire to go to stool, when suddenly a large quantity of blood escapes.
SECONDARY DISEASES OF THE RECTUM AND ANUS.
This class of affections depends upon constitutional infection, direct extension of disease by contiguity, by contiguity from disease in neighboring organs, or by abnormal conditions excited by disease of remote origin; and are frequently due to changes in the nervous and vascular supply.
Syphilis of the Rectum and Anus.
True primary syphilitic chancre of the rectum must be an extremely rare lesion, and could have been acquired only by unnatural intercourse. There are syphilographers who deny that the hard chancre has ever been found within the sphincter muscles; but it certainly is not uncommonly found in the anal region, and oftener among women than men. The table of Jullien gives 12 instances of this lesion in males, and 1 instance of chancre of the buttock, out of 77 cases, while among 82 cases occurring in the opposite sex, 21 were of the anus and perineum and 4 of the buttocks. The French authorities give the frequency of this condition in men as 1 case in every 119; in women, 1 case in every 12.
Anal chancres are easily overlooked, as they occupy the puckered folds of the anus, which when not opened out to the fullest extent afford perfect concealment: they may be either in the form of cracks or slight fissures, elongated ulcerations, or firm papules. It has been claimed that the initial lesion has provoked stricture of the rectum, but this is not probable.
The secondary manifestations of this disease which show themselves in the anal region are some of the syphilodermata, moist papules, mucous patches, and moist papillomatous excrescences or condylomata. The statistical tables of Davasse and Deville16 in regard to the occurrence of moist papules and mucous patches in women show that out of 186 cases they appeared about the anus in 59 and on the perineum in 40. Bassereau's17 statistics show that in men these lesions occurred in the anal region 110 times out of 130 cases. These are, of course, very contagious. Besides true syphilitic warts, which sometimes occur in this region, it is quite usual to see the anus surrounded and the entire gluteal cleft filled up with moist, offensive, papillomatous excrescences, which remain obstinately so long as these surfaces are permitted to rest in moist contact. Syphilitic stricture of the rectum is one of the results of a later stage of infection, and occurs oftener among women than men. It is stated by Jullien that of 60 cases only 7 were men, the remaining 53 women. They are invariably formed as follows: A gummatous deposit in the submucosa undergoes ulceration, and the subsequent cicatricial contraction gives rise to the stricture. Whether the stricture will be valvular or annular depends upon the extent of rectal mucous membrane involved in the ulcerative process. The diffuse gummatous infiltration of the ano-rectal tissues and the subsequent deposition of contractile tissue are the most usual causes of these specific strictures. The lower portion of the rectum is commonly the situation of specific ulcerations, usually of the secondary or tertiary stage, which lead to the formation of stricture: this occurs more frequently among women than men, and between the ages of seventeen and thirty years. Gosselin and Mason regard strictures as the result of chancres, and not as the result of constitutional infection; but it is known that ulcerations of secondary syphilis may extend upward from affections about the anus, and also that gummata do commonly give origin to this condition. Gummata, and strictures following them, may be distinguished from other affections on account of the greater distance from the anus at which they occur, chancres or chancroid ulcers being usually within four or five centimeters of the anal orifice. Strictures due to gummata are more apt to occur late in life, but may therefore be easily confounded with cancer. Condylomata at the anus are often associated with syphilitic disease of the rectum.
16 Internat. Encyclop. of Surgery, vol. ii. p. 508.
17 Loc. cit.
Scrofulous and Tuberculous Affections.
There are cases which yield abundant evidence of struma in the form of enlarged glands, chronic abscess in the neck, swelling and abscess in the vicinity of the articulations, and the like, in which ulceration of the mucous membrane of the rectum has been found: this condition may result in fistula in ano by erosion, permitting escape of flatus and excrementitious products into the cellular tissue. A similar result may follow by erosion of the bowel from a strumous abscess in the connective tissue around the rectum; both these forms tend to the production of that class of fistula which has no outlet at the surface, but which has one or more openings upon the mucous membrane of the rectum. Thus concealed (for often there is no marked surface indication of either abscess or fistula), they may remain for a long time unsuspected and acting as a serious drain upon the already impaired constitution. The pus in these cases is watery, curdy, and offensive. These chronic conditions are subject to intercurrent attacks of acute inflammation, due to the lodgment in the abscess cavity or the fistulous tract of fecal matter or indigestible solid substances. Any or all of the abnormalities of this region may be complicated by the existence of tubercular or scrofulous conditions of the system. Tubercular ulceration of the rectum is now a well-recognized condition. Rectal ulceration and tubercular disease of the lungs have not been found to coexist in any marked preponderating number of tabulated cases. The frequent association of fistula in ano and tubercular disease of the lungs has long been recognized, Allingham having found 172 such cases among 1208 cases of fistula in ano.
The pathology of tubercular ulceration of the rectum is graphically described in Ziemssen's Encyclopædia as follows: "These [ulcerations] begin in the follicular apparatus with swelling of the individual follicles and their vicinity from tuberculous deposit. The newly-formed cells become caseous, the superficial layer of the tubercle breaks down, and thus ulcerations arise of a round funnel shape. The enlargement of these ulcerations is probably produced by the constant formation in the base and edges of the ulcers of new nodules, which themselves caseate and ulcerate. This process of extension, to which these tuberculous ulcerations of the intestines exhibit a marked tendency, takes place chiefly in a transverse direction (girdle-shape), following the direction of the blood-vessels. The infiltration and necrosis may advance longitudinally, and, finally, the individual ulcerations coalesce with each other: in this way may be explained in part the dentate appearance of the edges of these ulcerations. The ulceration extends also in depth, although usually the muscular coat appears to be covered by a thick layer of connective tissue: the destruction advances slowly in the muscularis, but in the lymphatic vessels which pierce the muscularis less opposition is presented to the progress of the tuberculosis; and thus it is not uncommon to find tubercles ranged one after the other, like links in a chain, from the base of the ulcer directly down to the serosa. Healing is extremely rare. The most frequent situation is the lower end of the ileum, but the process may extend upward to the stomach, or downward, involving the rectum. There is almost invariably unmistakable signs of tuberculosis in other organs. It is possibly never primary, but this is a still-disputed point. It usually occurs with tuberculosis of the lungs, and when so occurring it is always secondary. The clinical symptoms of this state are by no means characteristic."
Dwelling upon the subject of intestinal tubercle, it has been suggested by Klebs18 that the intestinal disease is produced by swallowing morbid products derived from phthisical lungs—an hypothesis supported also by the fact that tubercle in the intestines tends so strongly to spread downward. "The seat of the deposit is the submucous tissue or the corium of the mucous membrane: it is certainly subjacent to the basement membrane, and not contained in the follicles, as Creswell taught."
18 Jones and Sieveking, London, pp. 593-595.
Woodward, in his article upon diarrhoea,19 says: "The lesions, whether mild or severe, are most generally seated in the cæcum and colon, but more or less extensive tracts of the small intestine, especially of the ileum, are often involved also." He continues: "Tubercular disease of the lung was noted in nearly one-sixth of the autopsies of fatal cases of forms of flux heretofore described. Possibly the frequency in chronic cases may be explained by the fact that protracted intestinal flux forms the development of lung phthisis in the predisposed."
19 Med. and Surg. History of the War of the Rebellion, p. 266.
The rectal fissure or painful ulcer may be connected with diathetic causes, as struma or scrofula: it is doubtful if syphilis should be included among its causes.
Cancer, Malignant Stricture, and Malignant Ulceration.
The forms of cancer met with in these regions are epitheliomatous, scirrhous, encephaloid, and colloid. Considerable diversity of opinion has existed as to which variety occurs most frequently; but it is now probably a matter of absolute knowledge that the epithelial form is the one most commonly observed, and next to that in frequency the scirrhous form. Encephaloid and colloid are of quite infrequent occurrence. Again, as to the sex in which this affection appears the most often, there is much disparity existing between surgical writers: it is usually thought to be much more prevalent among women than among men. This is not the experience of many of the authorities upon this subject, yet the statistics of the Hôtel Dieu, Paris, furnish overwhelming evidence in favor of its preponderance in women. Carcinoma of the rectum, occurring as a primary infiltration in the rectum, probably occurs oftener in men, but there are among females so many contiguous structures prone to cancerous degenerations, as the uterus, the vagina, the ovaries, the Fallopian tubes, tumors and cancerous masses occupying Douglas's cul-de-sac, that it would seem likely that they would be more frequently the victims of secondary cancerous deposit in the bowel or of erosion and extension of disease by contiguity or continuity. Epithelioma in other situations attacks men much more frequently than women. This form of disease usually occurs in middle life and in old age, but to this general rule there have been many exceptions; it has been seen in children. Allingham quotes its occurrence in a lad of seventeen, and Gowland in one of thirteen. It very rarely occurs as a secondary deposit of cancer in a remote region or organ. In the table of 4000 cases of rectal and anal disease, before referred to, cancer existed in 105. This disease is usually within easy reach of the finger, except when the growth is in the sigmoid flexure, being within an inch or two of the anus or from two and a half to three inches above it. The epithelial form, when it commences at the anus, is closely analogous to epithelioma of the lip: from the anal outlet it spreads upward into the bowel, or it may be primarily seated there. When occupying the junction of skin with mucous membrane it is sometimes sluggish, and a long time may elapse before it takes on aggressive action: induration, nodulation, obstinate fissure, or fungous growth marks its inception; as the condition proceeds, infiltration of surrounding structures takes place and large, hard, irregular masses form, which ulcerate, split, and form cauliflower excrescences. The rectum becomes blocked with fungoid growths: both these and the cancer proper are very vascular, and frequent hemorrhages occur, and an offensive muco-purulent discharge constantly oozes from the bowel.
Scirrhus of the rectum commences as an infiltration of the submucosa, which rapidly involves the other elements of the bowel, pushing hard nodules upward into the lumen of the intestinal tube: these break down and form ragged ulcers with indurated margins, and bleed profusely. Its situation is usually not higher than three inches above the anus. It has a tendency to invade all the neighboring organs and soft structures, to bind them to itself in a firm, dense mass, and to form communications with the vagina, bladder, uterus, perineum, and penis. Abscesses and fistulæ are common complications.
These neoplasms are insidious in their onset, and when seated at some little distance from the anus do not excite much pain at first. In the epithelial form the anus presents an abnormal appearance: it is inflamed and is covered with irritated, hypertrophied tags of integument bathed in a sanious, offensive fluid. Difficult defecation, of which the natural form is absent, with inordinate tenesmus, a sense of weight and fulness in the bowel, and an irritable condition of the bladder, are among the symptoms. The feces are passed in little, irregular lumps or broken fragments, or this state is accompanied by or alternates with small, liquid, offensive stools. As the diseased action proceeds, very severe local and general pain is endured: this is of a dull, lancinating character, and affects not only the diseased bowel, but involves the entire contents of the pelvis, shoots down the thighs, up the back, and into the penis: frequent and exhausting hemorrhages take place; the patient exhales a peculiar sickening odor; his complexion becomes cachectic; his strength fails; and death ensues, after a variable period of intense suffering, from a few months to two or three years after the first symptoms appeared. The modes of termination of life in these cases are—exhaustion, secondary deposition, septicæmia, peritonitis, and hemorrhage. Stricture of the bowel and very extensive ulceration attend all of these advanced cases of malignant rectal disease.
The encephaloid variety is prone to very sudden and rapid breaking down, and may destroy life within a few months. If the finger be passed into the bowel in a case of encephaloid degeneration, it will encounter a large soft tumor occluding the gut: this is a very different sensation from that imparted to the finger in a case of epithelioma or scirrhus. In the former there will be felt a crepitating, as though due to the giving way of a moist, friable substance; in the latter the touch will perceive dense, irregular nodulations and ragged ulcerations having very firm margins.
The rectum may also be involved and destroyed by any of these neoplasms in neighboring organs. A middle-aged woman who was admitted to the Pennsylvania Hospital in a very advanced stage of epithelioma of the cervix uteri died from hemorrhage from the rectum and uterus in eight minutes. At the autopsy it was found that the disease had almost separated the cervix from the body of the uterus, had involved the cul-de-sac of Douglas, and had eroded a large opening into the rectum. Numerous ends of large vessels were observed which had undergone erosion.
Carcinoma of distant organs does not seem to frequently involve the rectum by secondary deposition. "In 160 cases of gastric cancer examined at the Pathological Institution in Prague, Dittrich found secondary cancer of the rectum only twice."20
20 Leube, Ziemssen's Cyclopæd., vol. vii. p. 235.
In these cases of carcinomatous disease originating in the bowel the neighboring lymphatic glands are indurated and enlarged, and secondary deposition in neighboring and distant organs is the rule.
The lower portion of the intestinal tract may become involved in disease by direct extension from the colon, as in dysentery following enteritis or entero-colitis. Habersham says that diarrhoea arises generally from an irritated condition of the large intestine, catarrhal and mucous diarrhoea from slight inflammatory disease closely allied to ordinary coryza affecting the mucous membrane of the large intestine. "In the diarrhoea of soldiers the lesions of the large intestine have been either those of congestion with varying degree of extravasation or of ulceration more or less extensive. The colon in the former cases has invariably presented patches of intense congestion, and in numerous instances extravasation, the amount and intensity varying in different subjects, in a few the whole mucous surface of the intestine having a livid red color; in others tracts of more or less intense congestion at irregular intervals, as in the small intestines, would be noticed. The ileo-cæcal valve almost invariably presented intense congestion. The rectum has uniformly presented intense congestion, with more or less fibrinous exudation. Frequently the presence of fibrinous exudation was a question of doubt."21 The entero-colitis or ordinary summer complaint of infants not infrequently causes a very troublesome form of proctitis. Besides the ordinary causes of dysentery, Feyrer22 states that it is caused by irritation of the solar plexus of nerves, also by the inhalation of sewer emanations and by the ingestion of impure water.
21 Med. and Surg. History of the War of the Rebellion, vol. ii. p. 102.
22 Times and Gazette, 1881, p. 87.
"In dysentery the anus becomes bluish-red, and is even marked with cracks and rents; it is painful to the touch and tightly contracted. In the later stages of severe cases it becomes large and gaping; then the stools are generally discharged unconsciously, and the pain is slight, paralysis of the sphincter ani having occurred. These symptoms indicate generally that death is to be expected. In some of these cases the pathological lesions are limited to the rectum. Dysentery may succeed typhoid fever."23
23 Heubner, Ziemssen, vol. i. p. 552.
"Pigmentation is common after dysentery, and also after typhoid fever when dysentery has existed. Pigment-deposits are encountered in the large intestine in those who have suffered from repeated attacks of acute diarrhoea or from protracted flux. They may be seated as diffuse patches on the general surface of the mucous membrane or may be more especially localized in the closed glands. The diffuse form of these deposits is more frequently encountered in the large than in the small intestine, and is apt to be more intense in the former, producing darker and more extensive discoloration; hence the ash- and slate-colored, greenish, and blackish tracts which are so frequently observed in the cæcum, colon, and rectum."24 Follicular ulceration of the rectum sometimes follows chronic dysentery and typhoid fever. Woodward has observed that a catarrhal condition of the rectum commonly occurs in typhoid fever cases. Referring to typhoid fever lesions of the large intestine, Rokitansky25 says: "The ulcerative process is by no means confined to the small intestine; we have seen the mucous membrane of the large intestine riddled with ulcers. They were many of them of large size, and had clean-cut, non-thickened margins. This condition, indicating the absence of reparative action, is not nearly so frequent as that of thickening and induration, which generally took place to some extent in the edges of the ulcers. The bottoms of the ulcers are commonly formed by the submucous tissue. Sometimes the muscular fibres are completely exposed: this, however, is generally the result of secondary advance subsequent to the reception of the morbid action."
24 Med. and Surg. History of War of Rebellion, vol. ii. p. 308.
25 Jones and Sieveking, p. 590.
John Harley26 calls attention to the intestinal lesions of scarlatina as follows: "I know of no disease in which the morbid effects are more uniform. Scarlatina is essentially a disease of the lymphatic system. It is attended with inflammatory action of this system of glands, in which are included the agminated glands of the intestine. In 28 cases examined, 8 had the solitary glands of the large intestine enlarged and inflamed; in 1 there was acute desquamation of the mucous membrane of nearly the whole of the large intestine. In about half the cases the large intestine was found healthy."
26 Med.-Chir. Trans., vol. iv. p. 102.
The rectum and anus are frequently subject to attacks, by contiguity, from diseases in neighboring organs. The most frequent of these is doubtless that form of ischio-rectal abscess which invades the bowel, causing fistula in ano. Various neoplasms having their seat in the tissues or organs near the bowel may obstruct it by simple mechanical pressure, or may cause inflammation, infiltration, and ulcerative erosion. Mechanical encroachment by the pressure of a foreign body in the vagina may cause grave interference with the normal functions of the lower bowel. At the out-patient department of the Pennsylvania Hospital in 1880, Arthur V. Meigs, assisted by Wetherill, removed a large, hollow, glass ball-pessary from the upper end of the vagina of an aged woman, who declared the pessary had been so placed by a physician sixteen years before, and had remained ever since, despite her repeated efforts to remove it with an ordinary table-fork. Upon its extraction, which was accomplished with difficulty, a small portion of its surface was found covered with scratches. Its presence had caused constipation, impaction of feces, and atony of the rectum.
Interference with the rectal functions often follows tedious cases of labor where the child's head remains long in the perineum.
The Effect of Abnormal Conditions of the Spinal Cord and its Membranes upon the Rectum and Anus.
"In diseases of the spinal cord and its envelopes there is a great tendency to constipation, owing to impairment of the secretion of the intestinal juices. The intestinal movements are usually much affected, either in the way of increase or diminution, in the former of which the symptom is a frequent, watery, slimy diarrhoea; as a less common condition it is even capable of being produced reflexly. Thus in a patient with chronic myelitis I observed the regular evacuation of a mucous fluid mass from the intestine as often as his bed-sores were cleansed; and the like has been seen in dogs after division of the lumbar cord. Much more commonly there is habitual, even excessively obstinate, constipation, of which almost all chronic spinal patients complain. The stool is slowly discharged, dry and hard, and the evacuation occurs only at considerable intervals and after the application of energetic remedies. Several causes doubtless contribute to this: diminution of intestinal secretion and peristaltic contraction, and probably also weakness of the abdominal muscles of compression, which is often present. If there is an extreme degree of weakness, meteorism and accumulation of feces are other consequences. We do not know exactly from what portions of the cord these disturbances proceed."27
27 Erb, Ziemssen's Encyc., xiii. p. 138.
"There are also in many diseases of the cord disturbances of evacuation caused by paresis or paralysis of the sphincter ani. In mild cases simple difficulty in retaining stool for any length of time exists. There may be also great disturbance of sensibility, so that the patient does not feel the call, and even if he possess some voluntary control, he is surprised by the discharge, of which he feels nothing."28
28 Erb, loc. cit., p. 139.
The sphincter ani is affected in cases of myelitis, the usual symptoms being those of paralysis; the same is true in softening of the cord or myelo-malacia, and there is also diminished reflex excitability of the anus.
Paralysis of the bladder and rectum is often delayed in cases of slow compression of the cord; but if the compression exists to any considerable extent, involuntary discharges of urine and feces will be sure to occur. A pressure-myelitis of the lumbar portion of the cord causes paralysis of the bowel, and in the later stage of some cases of bulbar paralysis it also occurs.
Early in the course of spinal meningitis there exists a spasmodic condition of the sphincters: these muscles are also paralyzed in spinal and in meningeal hemorrhage, and from the pressure of tumors upon the cord giving rise to paraplegia. "In acute ascending paralysis the bladder and rectum are generally quite undisturbed in their functions. In hemiplegia and in hemi-paraplegia specialis disturbances in the evacuation of the bladder and bowels are almost always present, and in the acute traumatic cases it is especially common to find severe paralytic symptoms at the beginning of the attack (complete retention or complete incontinence, involuntary stools, etc.), which, however, generally soon recede and give place to lighter, more permanent trouble, as weakness of the sphincters. Sometimes these disturbances are very significant."29
29 Ibid., loc. cit., p. 740.
The following is an extract from Gower's Diagnosis and Diseases of the Spinal Cord:30 "The spinal cord possesses centres, situated in the lumbar enlargement, which preside over the action of the bladder and rectum. They are probably complex reflex centres: that for the sphincter ani is the more simple.... But if the volitional path in the cord is damaged above the lumbar centres, the will can no longer influence the reflex processes: as soon as the feces irritate the rectum they are expelled by the reflex mechanism.... If the damage to the cord involves also the sensory tract, the patient is unconscious of this process; if the sensory tract is unaffected, the patient is aware of the action of the bladder or bowel, but cannot control it. It is often said that there is permanent relaxation of the sphincters, but this is true only when the lumbar centres are inactive or destroyed. In this condition evacuation occurs as soon as feces or urine enter; the urine escapes continuously instead of being expelled at intervals.... We may, however, distinguish between the two states of the rectum by the introduction of the finger: if the lumbar centre is inactive, there is a momentary contraction due to local stimulation of the sphincter, and then permanent relaxation. If, however, the reflex centre and motor nerves from it are intact, the introduction of the finger is followed first by relaxation, and then by gentle, firm, tonic contraction."
30 London, 1880, p. 37.
Morton has at this time in his wards at the Pennsylvania Hospital two cases of rectal paresis following fracture of the vertebræ. The first, a lad aged nineteen years, while crossing the Atlantic was struck during a gale by a spar upon the back about the region of the lower dorsal vertebræ. From the deformity and from other symptoms there was undoubtedly a fracture destructive to the normal functions of the cord. Upon the arrival of the steamer, some ten days after the accident, the lad was brought to the hospital, where he has remained for the past eighteen months. Total palsy of sensation and motion has continued from the time of the accident to the present day, and extends from the navel downward: the sphincter ani is constantly but feebly contracted; the finger, when pressed into the anus, encounters slight resistance, which continues during and after the simple passage of the finger; very slight pressure, however, against the sphincter causes a very marked relaxation, which continues so long as this is kept up. With the removal of the finger the sphincter slowly and fairly contracts. The second case is also one of vertebral fracture which has been in the hospital about ten months. In this instance the sphincter is always found contracted, but it readily yields under finger pressure, and contracts quickly and regularly in the absence of this pressure. Constipation and rectal impaction readily occur, and the bowel requires to be regularly emptied. In another case, at the Episcopal Hospital, under the care of W. B. Hopkins, there is fracture of the spine, with total palsy below the seat of injury. The margins of the anus were found in apposition, but in no firm contraction: mere contact of the finger appeared to have little or no effect, but slight pressure upon the sphincter caused a contraction, and very moderate pressure upon the anus after the introduction of the finger produced excessive dilatation. The action of the sphincter was in all respects very tardy.
Two recent cases (August, 1883) of fracture of the dorsal vertebræ have been admitted into the Pennsylvania Hospital. One, a lad aged ten years, was struck by a bale of cotton which fell upon him; the other, a man aged thirty years, fell from a second-story window. In both cases total palsy occurred at once upon the receipt of injury, and in each the same conditions of the anus have obtained as before described.
In the convulsive attacks incident to epilepsy the sphincters of the bowel and urinary bladder are relaxed and the discharges are involuntary; probably, also, one of the first symptoms indicative of tumor of the base of the brain is recognized in involuntary rectal evacuations. Rectal incontinence may be also due to tabes, while atony and constipation are sometimes noticed as a result of excessive intellectual exertion (DaCosta). The same may be said of chronic lesions of the brain and spinal cord. Paresis of the rectum has been noticed as a result of chronic congestions of the heart and in hepatic disease. Allingham has observed failing nerve-power as a cause of rectal atony: the latter, with constipation, is one of the commonest troubles attendant upon melancholia and the chronic forms of insanity. Seeley of Ovid, New York, related to Morton a case of paraplegia with rectal paresis and dysenteric symptoms from malarial poisoning in a married lady aged thirty years. An examination revealed an immense rectal impaction. A free administration of quinia was followed by complete recovery in a few weeks.
Spasm or Spasmodic Contraction of the Rectum and Anus.
Apart from those cases in which spasm is induced by the irritating stools of diarrhoea and dysentery, or by local ulcerations, fissures of the anus, and intestinal worms, there are those in which painful spasm occurs, due to the presence of a vesical calculus: it is also caused by urethral stricture, impaction of feces, irritations and inflammations involving the bladder or the adjacent organs. Spasm is also seen in nervous females, without constipation; also in the varied irritations of the female genito-urinary apparatus. In cases where spasm is due to rectal impaction retraction of the anus is frequently seen.
Pruritus Ani.
This most painful, distressing, and obstinate affection belongs to the class of neuroses, and is simply functional in character, without the least structural change in the skin or mucous membrane of the anus or rectum: the itching may be confined to the former or it may extend into the latter. It may be brought about by a constipated state of the bowels, but it is more often due to derangements of the digestive apparatus.
Sufferers from pruritus ani are generally dyspeptics, although the malady is observed in persons who are otherwise in most robust health. Overwork, mental and physical exhaustion, have been charged with producing pruritus, and in some instances spinal irritation seems to have been unquestionably the exciting cause: now and again, pruritus ani has been produced by the pregnant condition, and in some cases this malady has persisted during the entire period of utero-gestation. Intestinal worms, uterine maladies, rheumatism, and especially gout, have unquestionably been exciting causes. Some years since a gentleman having the most intense pruritus, which defied all treatment, was suddenly relieved of all former distressing symptoms by the passage of a small vesical calculus, the presence of which had never been suspected, as no vesical symptoms had at any time existed. Some of the most aggravated instances of anal pruritus are found in those far advanced in diabetes mellitus. The nerves of the lumbar plexus in rare instances have suffered from compression, more or less severe, from fecal accumulations; in one case of spinal curvature detailed by Portal31 the rectum at its upper part was so narrowed by the encroachment of the false ribs that excessive fecal accumulation occurred which gave rise to remote pain in the great toe.
31 Cours d'Anatomie médicale, tome iv. p. 276.
Neuralgia of the Rectum.
It seems to be unquestionable that there are instances of pure neuralgia of the rectum, for in such cases the most carefully conducted explorations have failed in demonstrating any evidences of disease. The pain is doubtless reflex, due to depressing causes, to atmospheric conditions, or to exposure to cold and wet. Neuralgia of the rectum has also been noticed in malarial poisoning, and especially in those who have long been victims of intermittent fever. Neuralgia in this region of the body is also due to general causes, as witnessed in cases of rheumatism and of the gouty diathesis. Patients now and again complain of "violent and painful pressure in the rectum, conjoined with active pains in the perineum and anus and in the sexual parts: these symptoms probably have a neuralgic character."32 In many nervous disorders, but especially in spinal irritations or inflammation, the rectum is invaded by pains of a neuralgic nature more or less severe, which are undoubtedly only functional in character. But 12 cases of neuralgia were observed out of 4000 cases of rectal disease. Anstie33 says: "It needs some very powerful irritant to set up neuralgia in any portion of the alimentary canal: ... this condition has been described by Ashton.... In one case the patient complained of acute, paroxysmal, cutting pain extending about an inch within the rectum.... The cause of this attack was his getting chilled from sitting in his wet clothes." Curling says that constantly directing the mind to this part of the body will excite congestion and disease, possibly by producing abnormal sensations, itching, and superficial inflammation.
32 Erb, Ziemssen's Cyclop., vol. xiii. p. 139.
33 Neuralgia and its Counterfeits, p. 130.
"In patients with piles hyperæmia of the spinal cord may become habitual, returning regularly and frequently, and this may lead by degrees to severer disturbance by the development of chronic inflammation and proliferation."34 Among some of the reflex troubles arising from rectal disease are—sterility in women, simulation of uterine disease, pruritus ani, pseudo-sciatica, pains in the legs and feet, and impairment of co-ordination in the muscles of defecation. There is a case reported35 of a curious pain in the sole of a foot caused by rectal disease; and another36 in which irritation of the eyes was caused by hemorrhoids.
34 Ziemssen's Cyclop., vol. xiii. p. 138.
35 Med. Times and Gazette, 1868, vol. ii. p. 175.
36 Cooper, Lancet, 1862, i. p. 625.
There are some cases occasionally met with of so-called irritable rectum. Now, a rectum may be irritable because irritated, but in some of these instances there is no apparent cause. There occur frequent, small stools expelled with force, but without pain: there must be abnormal peristaltic action to cause this condition.
The Effects of Cholera and of Certain Poisons and Remedies upon the Rectum.
After death from cholera there is found congestion and a swollen state of the mucous membrane of the rectum: in some cases the epithelium of the entire alimentary canal is almost absent. In slow poisoning by arsenic the bowels show ulceration, but more particularly the rectum. After phosphorus-poisoning the large intestine has been found inflamed and contracted to the calibre of a quill. Among the effects of copper have been seen ulceration and a peculiar green staining of the rectum; of lead, no marked change of the mucous membrane except, in some instances, hardening, but the muscularis was in an advanced state of hardening and contraction. The action of croton oil is to render the mucosa very soft and friable. Extensive destruction of the mucous membrane of the rectum has resulted from poisoning by bichromate of potassium. The mineral acids and the caustic alkalies, when not immediately fatal, cause corrosive ulceration of the rectum; the soluble salts of zinc, tin, bismuth, and antimony produce a like effect. Corrosive sublimate in its action upon the large intestine produces a dysenteric condition; similar in their effects are colocynth, jalap, elaterium, and cantharides. Strychnia causes a deep violet congestion; alcohol, congestion and thickening; and tobacco, redness of the mucous membrane with great engorgement of the vessels of the rectum. One of the results of the long-continued abuse of morphia is a catarrhal condition of the large intestine, accompanied with exfoliation of the intestinal epithelium. Some persons are very susceptible to the action of jaborandi, and in such its exhibition is followed by hyperæsthesia and dull pain in the rectum and the urethra.
It is interesting to note that an abnormal condition in the rectum may cause extensive disease in a remote organ; thus, a stricture of the rectum may cause abscess in the liver. Wilkes37 exhibited at the Pathological Society a specimen in which an abscess, a diffuse, purulent infiltration of the liver, and a gall-bladder filled with purulent bile were distinctly traceable to the suppuration arising from an ulcerating stricture of the rectum consisting of dense fibrous tissue situated about four inches from the anus of a man aged thirty-seven years. "Any form of suppurative intestinal disease seems capable of producing hepatic abscesses of a metastatic or pyæmic character."38 It has not been found, however, that tubercular ulceration of the intestines has ever given rise to hepatic abscess.
37 Soc. Trans., vol. ii.
38 Darley, On the Liver, 1883, p. 536.
Examinations and explorations of the abdominal viscera by the hand introduced into the rectum, having for their object the detection of tumors or morbid growths, are procedures which have fallen into merited disrepute, and are mentioned here in condemnation. However, some years since, Morton, in consultation with (J. Forsythe) Meigs, satisfactorily demonstrated the absence of a suspected renal calculus by this method.
The distension of the rectum with water, either free or contained in a rubber bag, in order to facilitate operations upon the pelvic viscera, has been lately brought into notice by Garson at a meeting of the British Medical Association. The most significant point brought out at the meeting was that the water-distended rectum displaced the distended urinary bladder upward and forward until it occupied a position quite outside of the pelvic cavity, carrying along with it the peritoneum both in front and behind. By this method of distension it was found possible so to raise the peritoneum in front of the bladder as to leave a clear working space of four centimeters between the upper border of the symphysis pubis and the edge of the peritoneum: this may prove useful in suprapubic lithotomy, as well as in operations upon the uterus and its appendages during laparotomy.
RÉSUMÉ OF THE THERAPEUTICAL AND SURGICAL TREATMENT.
FISSURE OF THE ANUS, in its true sense, is not to be confounded with ulcerations either slight and superficial in extent, or with more grave ulcerations involving not only the anus, but the mucous membrane of the rectum also. The true fissure is a mere linear crack or abrasion or superficial ulceration. The pain accompanying this condition is out of proportion to the length and depth of the fissure, varying from slight uneasiness to as severe suffering as that caused by a deep and extensive ulceration.
The treatment to be adopted in such cases is first to regulate the bowels and to insist upon a scrupulous cleansing of the part after each evacuation. Much sitting is to be avoided and a sedentary mode of life is to be discouraged. Sometimes a few light topical applications of the solid nitrate of silver will bring about a cure, or a lotion of the same of the strength of from two to ten grains to the ounce of water should be applied with a camel's-hair brush every other morning. The ointment of the oxide of zinc, combined with any of the local anæsthetics, will be found useful. As a dernier ressort in obstinate cases an incision should be made through the fissure, together with a thorough dilatation of the anal sphincter.
ULCER OF THE RECTUM, OR THE GRAVER FORM OF FISSURE OF THE ANUS.—In the milder forms of this very common and painful affection the treatment consists in thorough cleanliness of the part; the ulcerated surface may be cauterized with nitrate of silver, and subsequently the application of the red precipitate ointment or the lotio nigra. Should a vaginal discharge exist, treatment should be instituted with a view to its arrest, as the irritating fluid coming in contact with the ulcer would prevent its healing. The treatment of that variety of ulceration where the disease is situated partly without the anus and partly within the rectum, besides the use of the means enumerated above, embraces the daily introduction of a full-sized bougie made of wax or of yellow soap. Henry Hartshorne says: "Experience leads me to have especial confidence in collodion, to which one-fiftieth of glycerin has been added to lessen its constricting effect." Glycerite of tannin and tinct. benzoin. comp. have been useful. J. C. Peters39 recommends the use of iodoform suppositories. Tarnier40 dusts the part with the same drug in fine powder. Créquy41 has had success with a dressing of charpie saturated in a solution of hydrate of chloral. For the more extensive and obstinate forms of ulceration the three methods of treatment mainly relied on are—by cauterization, by dilatation, and by incision. The caustics usually relied upon are the fuming nitric acid and the acid nitrate of mercury, one application of either of these often exciting healthy granulation. This application is to be followed by the use of an ointment consisting of thirty grains of calomel and three grains of morphia to one ounce of lard. If there is much spasm of the sphincters, extract of belladonna may be added.42 During this treatment the bowels should be kept rather loose by the use of compound licorice powder, and if much pain is experienced an opium suppository should be used. Dilatation, first practised by Récamier, consists of the introduction of the thumbs of the operator into the rectum, placing them back to back, and then forcibly separating them from each other until the sides of the bowel can be stretched out as far as the tuberosities of the ischia. On account of the fact that both cauterization and dilatation are not infrequently followed by relapse, the method of operation which includes both incision and dilatation can usually be relied upon. The bowels should be thoroughly emptied by a laxative, and an enema should be given three hours before the operation.
39 Philada. Med. Times, Nov. 8, 1879.
40 Bull. gén. de Thérap., Sept. 30, 1875.
41 Ashton, On the Rectum, p. 157.
42 Agnew's Surgery, vol. i. p. 418.
After full anæsthesia the ulcer may be readily exposed. The left index finger of the operator is then carried into the rectum, and a sharp-pointed curved bistoury is entered, three-quarters of an inch or more from the side of the anus, to the depth of an inch or less, and carried on toward the bowel until the point is felt by the finger within, when it is made to puncture the mucous membrane, and then to cut out to the surface. In some cases of deep fissure, before dividing the sphincter the ulcer may be scraped freely or the entire ulcer may be removed. The anus should now be well dilated with the fingers, after which an opium suppository should be introduced and a fragment of lint or linen well oiled be placed in the wound. The subsequent treatment consists in keeping the patient in a recumbent position and confining the bowels with opium. After three or four days a laxative may be given. No dressing is necessary save attention to cleanliness.
The subcutaneous division of the sphincter has been proposed, but is objected to on account of the liability of the extravasated blood retained in the very loose cellular tissue of the part to form abscess. In one case which Morton operated upon in this manner many years ago a large abscess formed very rapidly, with serious constitutional symptoms, which were relieved only after the freest opening and division of the sphincter.
Should any polypi be found, their removal by ligation or by the knife is an essential element of success in the operation; retention of urine is not infrequent after operations upon fissure. When fissure or ulceration makes its appearance in a syphilitic subject, it will usually disappear under appropriate constitutional treatment.
TUBERCULOUS ULCER OF THE ANUS is best treated by the topical use of a weak solution of chloral hydrate.
CHRONIC ULCER OF THE RECTUM.—In this condition the treatment should include the use of anodyne and astringent lotions, suppositories or enemata, and the internal administration of Ward's paste—i.e. confection of black pepper.
RODENT ULCER OF RECTUM.—In this rather rare, exceeding painful, and generally incurable malady the patient sometimes dies merely from the exhaustion of pain. Another mode of death is by diarrhoea; another by hemorrhage. To quote Allingham:43 "I have really nothing to offer as regards treatment; all the various sedatives will be required in their turn, and in the earlier stage I should recommend excision—not that I have much hope that you will eradicate the malady, but you will remove the pain, and for some time the sufferer will be comparatively comfortable. I think also the application of fuming nitric acid should be tried with the same object; one of my patients was fairly easy for three months after I had destroyed the ulcer with the acid." Morton accomplished the permanent healing of an undoubted rodent ulcer of the rectum by the complete divulsion of all the involved tissues.
43 Page 30.
CANCER OF THE RECTUM.—The medical treatment of this affection is necessarily restricted to efforts to alleviate suffering and to obtain sleep—anodynes in the form of suppositories of pil. saponis comp. or of morphine mixed with ext. hyoscyamus in the proportion of a half grain of the salt to ten grains of the extract. Enemata of warm water are useful. D'Arpene of Elba has suggested enemata of gastric juice. The profuse discharge of sanious pus must be met by weak injection of sulphate of copper and opium or a very dilute solution of chloride of zinc. Now, as to the use of bougies in these cases, it may be laid down as a general rule that their employment may be mischievous, yet in certain cases justifiable—indeed, absolutely necessary. When the disease is met with in its early stage, has not ulcerated, is within reach of the finger, and is producing much contraction of the calibre of the gut, a gum-elastic bougie, thoroughly lubricated, may be introduced through the contraction. In case this produces much suffering, the attempt must be abandoned; if not, once or twice a week is often enough. Where no extensive ulceration exists the patient can be much helped by this procedure. F. N. Otis44 has reported a case of malignant stricture in which he completely divided the recto-vaginal septum, sphincter ani, and perineum with great temporary relief to his patient. When large portions of a malignant mass protrude from the anus, they may be removed by the application of a paste of arsenite of copper or by the elastic ligature, the destruction being safe and rapid. The injection of acetic acid into these growths has been practised, but is useless and harmful.
44 Arch. Clin. Surg., 1877.
As to operative procedure, when the morbid growth is an epithelioma situated within a short distance of the anal opening an excision is not only justifiable, but may be recommended. The results show that its removal from this situation is as frequently successful as is its removal from the lip. When a cancer completely fills the lumen of the gut and plugs it so that the act of defecation becomes impossible, excision of the rectum and the establishment of an artificial anus are the two operative procedures open to the choice of the surgeon. A decided reaction of opinion has lately taken place among members of the profession relative to the latter of these; the few surgeons who did practise excision of the rectum in cases of cancer were looked upon as being rather unscientific and unsurgical. Billroth has excised the rectum 16 times, with 4 fatal cases; Dieffenbach performed it 30 times; Lisfranc had recourse to this operation as early as 1826; while the operation has been performed very frequently in this country, and with success.
Morton says: "In the spring of 1882, I was consulted in the case of a lady aged fifty-six who had suffered for two years from what were supposed to be internal hemorrhoids. An examination revealed the existence of a large scirrhous mass encircling about two-thirds of the gut, on the anterior part especially, and extending upward three inches. The patient was worn down by long suffering, but was otherwise in fair condition of health. With the assistance of Gross and Agnew, I excised the mass, which included the entire lower part of the rectum. The wound healed kindly, without an untoward symptom, and the patient was very soon enabled to leave her home for the seaside, where she passed the summer. The disease, however, resumed, but without any of the severe pains which she had had prior to the operation. Death occurred from gradual exhaustion seven months afterward."
He also relates the following case of excision of the rectum: The patient, a female aged thirty-five years, first noticed some rectal irritation about four years ago. This was followed by distressing pain during defecation and by hemorrhages; finally a tumor, which was described by her medical attendant as being like an opened umbrella, protruded, partly at first, then fully, through the anus. The growth seemed to be spongy in character, and was very vascular. It was removed by carrying a double-threaded needle through the mass, and thus ligating it. Upon the seventh day after the operation a hemorrhage occurred, which was controlled by plugging the rectum. Although the growth was removed, the patient did not make a good recovery; symptoms of rectal irritation continued. In September, 1884, the patient presented herself in a wretched condition, with bearing-down pains and frequent hemorrhages. Upon digital examination an elevated mass was readily detected upon the sacral aspect of the bowel. By carrying the fingers beyond this mass and making traction, it was brought down within working distance, and was excised along with the entire lower portion of the rectum. The freshly-cut edges of the gut were then drawn down and stitched to the mucous membrane just above the anus. The patient made a good recovery and has a serviceable anus.
R. J. Levis45 has operated upon two cases of cancerous growth in the rectum, removing the lower part of the bowel. The first case was that of a man aged sixty, who made a very good recovery from the successful operation, although three inches of the gut were removed. The second case was that of a man aged fifty-two, who had a carcinomatous tumor the size of a hen's egg at the right side of the rectum. The section of gut excised was about one and a half inches in length. The patient died of peritonitis upon the fourth day after operation. At the autopsy there was no wound found in the peritoneum, the lowest point of which was one inch above the end of the excised bowel.
45 Surgery in the Pennsylvania Hospital, pp. 81-83.
The etherized patient, his bladder having been emptied, should be placed in the lithotomy position. If a male, a sound should be passed into the bladder. An incision is then carried from the centre of the perineum along the raphé to the anterior margin of the anus, encircling the latter by two semicircular cuts and continuing the division directly back to the coccyx. In the female the incision should begin just posterior to the vagina. If the anus is not included in the diseased mass, the external sphincter may be spared by raising the skin and the muscle together and turning them on each side. When the lower end of the rectum is reached the dissection should be made entirely by the fingers or by the handle of the knife, tying vessels as they spring. Double ligatures should be introduced through the gut from its mucous surface outward, and, when possible, then stitched to the skin at the margins of the wound. The bowels should be controlled by opium for the following eight or ten days.
The other operative procedure is lumbar colotomy. This was first advocated by Amussat in 1839, when he appeared in a treatise upon the subject entitled On the Possibility of Establishing an Artificial Anus in the Lumbar Region. It is denied that he ever performed this operation. It has happened to sound surgeons and skilful operators, when the patient has been very muscular or very fat or when the colon has been collapsed, that they have been at length compelled to abandon the search for the gut and to stitch up the external wound. Allingham states that the cause of failure often is that the colon is searched for too far from the spine, resulting, in the opening of the peritoneum, in the starting up into the wound of a mass of small intestine which baffles the operator very seriously. He, having made more than fifty dissections, has come to this conclusion: "that the descending colon is always normally situated half an inch posterior to the centre of the crest of the ileum (the centre being the point midway between the anterior, superior, and posterior-superior spinous processes)." An incision four inches in length should be made midway between the last rib and the crest of the ileum. The incision may be made transverse, or, better, obliquely downward and forward, as suggested by Bryant. Allingham says that care should be taken to preserve the original length of the incision down through all structures, lest when the operator approaches the gut he finds himself working in the apex of a triangle the base of which is the line of the wound. If the surgeon has reason to expect the gut to be collapsed, an attempt should be made to distend it with some fluid. The intestine should be drawn well out through the wound, and a longitudinal opening an inch in length made in it. The edges of this are to be stitched to the edges of the skin. Fecal matter is much less likely to flow into the wound if the sutures are passed through the intestine previous to opening it. A weak carbolated wash is all that is required as a dressing. In one case of stricture of the rectum from a scirrhous mass, in which Morton performed colotomy, an immense cyst of the kidney, which was somewhat puzzling for a moment, protruded in the wound. After emptying the cyst the gut was readily discovered and opened.
DILATATION AND INFLAMMATION OF THE RECTAL POUCHES.—This is a comparatively rare condition of the rectum, called by Physick encysted rectum, which is treated by bending the end of a probe into a hook, passing it up into the bowel, and then withdrawing it with its extremity resting against the surface, so as to engage and draw down the pouches, the straining or bearing down of the patient assisting in their extrusion; they may then be incised or cut off with a pair of curved scissors.
LOSS OF CO-ORDINATION IN THE MUSCLES OF DEFECATION.—In those cases where it can be ascertained that this curious trouble is not symptomatic, sympathetic, nor reflex, the treatment must be directed to the building up of the general health, such as electricity, baths, asafoetida, and iron. Regular outdoor exercise should be enforced.
SPHINCTERISMUS.—This condition, though frequently attendant upon, may exist in the absence of, any fissure, crack, or ulcer of the anus. It is usually associated with constipation. In its treatment magnesia and rhubarb are to be used, and the diet must be simple, unstimulating, and taken at regular intervals. A hot hip-bath at night, with the use of a belladonna suppository, often proves effective. In more obstinate cases a bougie covered with ointment of belladonna should be used daily. In still more intractable cases the muscle must be forcibly stretched with the fingers. In the more obstinate cases which now and then occur it becomes necessary to completely divide the fibres of the sphincter muscle, followed by a thorough stretching of the parts.
PRURITUS ANI.—This distressing and vexatious complaint proceeds frequently from hemorrhoids. When caused by the presence of seat-worms, they must be dislodged by purgatives and enemata of quassia or of one composed of one part of carbolic acid to six parts of sweet oil, or of turpentine and flaxseed tea. An enema of milk of asafoetida answers a good purpose. If the pruritus is a result of the burrowing of the itch insect, any wash, ointment, or dressing that evolves sulphuretted hydrogen will rapidly bring relief. If caused by other parasites, an application of ung. hydrarg. or red precipitate ointment, followed by a warm bath, will be all that is necessary. In some it is a symptom of dyspepsia, in others of a disordered state of the nerves of the anus independent of local cause: in this case iron, quinia, and arsenic should be given, and the patient should live an outdoor life as much as possible. The remedies that have in turn been extolled and abandoned during the treatment of this distressing condition it would require too much space to even mention. The following are among the best: Sulphate of zinc and alum, equal parts, are to be placed in an earthen vessel and heated until a glassy mass is left, which is to be dissolved in a little water and thrown into the bowel; palm soap pressed into the anus, ointments of carbolic acid and morphia or of bromide of potassium and cosmoline, citrine and other mercurial ointments, and suppositories containing iodoform. Allingham uses a bone or a metallic plug of peculiar construction, so as to keep the anus upon the stretch at night without slipping into the bowel. The pressure which this exerts upon the nerves and vessels prevents the itching. Hot (not warm) water pressed against the anus with a sponge, or ten-drop doses internally of tincture of gelsemium, or washes of dilute hydrocyanic acid or of chloroform, or ointments of balsam of Peru or of veratria and aconitia, or the corrosive chloride of mercury in solution applied locally, are a few of the more reliable among this host.
STRICTURE OF THE RECTUM (NON-MALIGNANT).—The main modes of treatment of non-malignant stricture of the rectum are two—by dilatation or by linear incision (rectotomy). Dilatation may be practised by the finger alone or by the finger covered with hollow rubber covers of various sizes. These are open at the end, so that the guiding and recognizing sense of touch may be left to the end of the finger. When the stricture is out of reach of this method, either gum or metallic bougies must be used, beginning with the smaller sizes and deliberately and carefully adding sizes. When the lumen of a stricture is tortuous it is best to use a long rather flexible rubber bougie having an olive-shaped extremity. It is not necessary to leave these bougies standing for hours in a stricture, according to the practice of some; this merely excites inflammation. Should the stricture be irritable, every second or third day would be sufficiently often to attempt dilatation. In constrictions which are firm, but not sensitive, a good plan is to insert a Molesworth elastic tube and gradually distend it by hydrostatic pressure; Barnes's dilators have also been successfully used. When the stricture is elastic and re-forms itself at once after dilatation, incision should be practised. In those strictures which are low down, the constriction may be nicked in several places by a hernia knife, the blade of which is guided along a finger in the bowel; when high up, a long double-bladed knife must be employed. In syphilitic strictures, in addition to dilatation, proper alterative treatment is indispensable. As dilatation has often to be kept up for a long time, the patient may be taught to practise this for himself.
PERI-ANAL AND PERI-RECTAL ABSCESS.—When acute, and when the surgeon is called in time, the prompt application of leeches may abort the abscess, but usually, by the time the surgeon sees it, it is necessary to apply hot flaxseed poultices as fast as they become cool, keeping the patient in bed upon light diet. The rule is to open deeply and freely so soon as the least softening under the poultices indicates that pus is within reach. After lancing, the poultices should be continued for a few days: then the deep wound should be packed with a strip of oiled lint and allowed to granulate from the bottom. As the fetor of these abscesses is horrible, they should be injected with a solution of permanganate of potash or liq. sodii chlorinata. When the chronic variety of this abscess is discovered, it, with all its sinuses, diverticula, and pockets, should be laid freely open upon a director and packed with carbolized lint. It is often very necessary in these chronic cases to use tonic and alterative treatment, such as cod-liver oil and iodide of iron.
GONORRHOEA OF THE RECTUM.—Undoubted cases of gonorrhoea of the rectum in the persons of prostitutes have been observed. Burning heat and great pain are usually felt, with a free discharge of pure pus: the mucous membrane is always intensely inflamed. The treatment is simple; an injection of lead-water and laudanum or of sulphate of zinc answers a good purpose. Primary syphilitic disease of the anus and rectum is rarely seen, but of course the treatment indicated would be similar to that laid down for primary syphilis in its usual localities.
IMPACTION OF FECES.—This condition usually occurs among the aged and in women after parturition and in cases of paralysis. Those persons of sedentary habits who do not pay sufficient attention to the necessity of a daily alvine evacuation sometimes find themselves in this condition. Impaction occurs not infrequently among the insane, and more frequently among women than men. Allingham states that he has never seen a case of impaction in a young person; but Wetherill now has under his care a most obstinate case of this disorder in a young man whose system has been completely broken down by intemperance in drink.
In paralysis of the rectum of traumatic origin impaction is almost certain to take place unless great care is taken to prevent it. Diarrhoea is a very misleading element in these cases, and is a symptom which frequently deceives those who are not on their guard. The clayey mass of feculent matter forms a hard ball in the distended bowel, around which the small loose passages flow. Spasm of the sphincter ani is the usual accompaniment of impaction, and the muscle should be gently but thoroughly dilated before means can be used to free the canal. The finger or the handle of a tablespoon is best to use in the dislodgment of these masses, and should be oiled before introduction, the accumulation broken up, and then washed out by an enema of soap, turpentine, and warm water. Purgatives and hydragogue cathartics usually fail to give relief, and add much to the patient's discomfort. The bowel once freed, care must be taken to prevent a reaccumulation, which very readily takes place, as the bowel in these cases is distended and has lost tone. To this end frequent enemata of cold water should be used, and the patient should take a pill of dried sulphate of iron, sulphate of quinia, extract of nux vomica, extract of aloes, as recommended by Allingham. The diet should be restricted. An excellent adjunct to this treatment is the local use of the faradic galvanic current daily after breakfast. Let the patient lie upon a bed and apply one pole or electrode to the anus, while the other one is passed with pressure along the course of the large intestine. Not infrequently it happens after this has been continued for a few minutes that a very urgent desire is felt to go to stool. In the case mentioned of the young man affected with impaction this treatment answered admirably well, but before its use he had to take a small dose of croton oil daily to cause an action of the bowels, all milder measures having proved ineffectual. It is important in these cases to interdict a sedentary mode of life.
IRRITABLE RECTUM.—A rectum is said to be irritable when it shows an intolerance of the presence of feces or flatus, causing frequent desire to go to stool. From such abnormal activity of the part there arise a burning, uncomfortable impression of fulness and a soreness of the anus. If after examination it is found that there is no local exciting cause, a starch enema containing forty drops of laudanum should be given and retained. This plan of treatment will usually afford relief. Should the irritability prove to be obstinate, examine the rectum, and if a spot of redness or increased vascularity be found, touch the spot with strong nitric acid.
CONCRETIONS IN THE RECTUM.—These occur less frequently than do impactions, and differ from them in being cylindrical and nucleated, the nuclei being such bodies as balls or tangled masses of hair, or coins, buttons, biliary calculi, or the like. Covering these are matted animal or vegetable fibres or hardened fecal matter. They are not so readily dislodged as are impactions, and it is necessary to dilate the sphincter thoroughly and remove them with a scoop. Not infrequently these bodies are bathed in pus and are very fetid.
PROCTITIS, OR INFLAMMATION OF THE RECTUM.—This may be either acute or chronic, the latter being a disease of the aged. Allingham recommends in this variety small doses of Barbadoes aloes to stimulate the bowel, also such drugs as copaiba, turpentine, and black pepper. As an injection in the acute form starch and laudanum, or bismuth suspended in a mucilaginous vehicle, should be used. Probably the use of small, smooth fragments of ice in the rectum would allay the tenesmus and help to subdue the inflammation.
PROLAPSUS ANI AND PROCIDENTIA.—Prolapsus occurs much more frequently in children than in adults, making its appearance at every movement of the bowels. The child thus affected should not be allowed to sit upon the chamber-vessel and strain, but should lie upon the side or stand, while the nurse should be instructed to draw to one side one of the buttocks so as to tighten the anal orifice. After the motion the protruded part should be well washed in cold water, and afterward with some astringent solution of oak-bark, matico, or a weak solution of carbolic acid applied with a soft sponge. The bowel should then be gently returned and the child be allowed to lie at rest for a while. If there exists intestinal irritation, small doses of mercury with chalk, with rhubarb at night, with wine of iron three times daily, would be indicated. The application of an anal pad and a T-bandage will give sufficient support. If this treatment be carried out a cure usually results in a few weeks. Some cases do not yield to this mode, and then the surgeon has to make trial of ergotin given hypodermically, each injection representing a grain of ergot, which is to be thrown into the submucous tissue of the rectum every second day for two weeks. Should relief not follow its use, cauterization is to be tried. The cauterants usually applied are nitrate of silver, acid nitrate of mercury, and nitric acid. Of these, nitric acid is the best. After anæsthesia is complete every portion of the extrusion should be touched with the acid, care being taken not to bring it into contact with the skin; afterward the bowel is to be freely oiled and returned. To prevent its extrusion the bowel should be filled with soft cotton wool, a compress placed over the anus, and the buttocks strapped tightly together with adhesive plaster. For a general quieting effect the child should be given paregoric. About the fourth day the adhesive plaster may be removed and a dose of castor oil administered, which will bring away the cotton plug with the dejection.
Prolapsus and procidentia in the adult are much less manageable; indeed, these conditions are usually very obstinate. There may exist causes extraneous to the bowel, such as urethral stricture or enlarged prostate or an impacted renal calculus or a calculus of the prostate. The bowel should be searched for polypi or hemorrhoids, and the prolapse may be cured by the removal of the irritating cause. Failing to find any such cause, the surgeon has at his command either cauterization or a removal of redundancy. The former may be by nitrate of silver or acid nitrate of mercury or the actual cautery. It is well not to apply these strong acids to the aged or those who are broken down in health, as very destructive sloughing has followed their use in these cases. When these are used, the same plan as that mentioned in case of prolapse in children should be pursued. Strong carbolic acid may be used in these cases with much less risk of sloughing than when the acid is employed, and it may be applied oftener—indeed, daily if desirable. Van Buren has recommended linear cauterization with the hot iron to the mucous membrane, the bowel contracting as a result of cicatrization. In adults generally, and especially in the aged, all the forms of cauterization are less satisfactory as a means of relief than either of the various modifications of Copeland's operation, which consists in removing by ligation elliptical portions of the mucous and submucous tissues of the prolapsed bowel. The most satisfactory of these is either to excise two or three oval portions of the mucous membrane with flat-curved scissors and bring the edges together with interrupted suture, or to pinch up in several places the redundancy in a Smith's clamp and cut off the folds in advance of the instrument, applying to the stumps the hot iron. Allingham prefers ligatures of horsehair in these operations, and mentions the carbolized catgut in preference to silk. He cautions the operator not to carry his knife into the submucous tissue, as free hemorrhage would inevitably occur.
In old cases of prolapsus or of procidentia that are not amenable to operative treatment much can be done to render them comfortable: the air-dilated gum pessary will sometimes afford relief, or a pad and T-bandage will prevent the parts becoming ulcerated by friction. Neither gallic nor tannic acid answers the purpose so well as acorn flour. The frequent use of cold water to the part is always attended with comfort, and sometimes with relief. In these old cases of great relaxation Nélaton has used strychnia by the mouth, and Weber (of New York) hypodermically, with fair result. Vidal has cured three cases by the repeated use of ergotin locally, hypodermically. In order to bring about a radical cure in these very chronic cases, very decided means sometimes are justifiable. The late Mr. Hey of Leeds was the first to propose a plan by which, through cicatricial contraction and inflammatory gluing together of the various tissues composing the bowel, the anus and sphincter muscle might be strengthened and improved in tone; to which end he proposed to cut away the pendulous flaps of skin around the anus. In cases where these flaps are very redundant a cure is sometimes effected by this procedure alone. Other cases will be benefited by the operation proposed by Dupuytren, which consists in the removal of radiating folds of the skin and mucous membrane at the edge of the anus. To quote from Holmes's System of Surgery: "This operation is effected by laying hold of the fold of skin on each side of the anus with forceps, then with a sharp curved pair of scissors removing both skin and mucous membrane. In very severe cases four or six applications of the scissors may be necessary."
POLYPUS OF THE RECTUM.—The polypi of the rectum are the gelatinoid and the fibroid, but as a very rare occurrence a villous or warty polypus has been found. Polypoid growths are very different bodies, but they are too frequently confounded with true polypi. The only treatment is their removal, and the safest method is by ligation of the pedicle, and either cutting off the growth in advance of the knot or returning it into the bowel. The patient should remain quiet until the sloughing is complete, and his bowels must be confined, otherwise profuse and very troublesome hemorrhage might ensue. Their removal by the clamp and cautery is equally safe. Their removal by torsion or by the scissors is unsafe.
The peculiar villous polypus causes great and exhausting hemorrhage. A case was successfully treated by the application of fuming nitric acid.
FISTULA IN ANO.—In the palliative treatment of this very common malady no great amount of relief can be afforded. Those who are aged and feeble or those who are much broken down will find comfort to attend the free local use of warm water, and the sinuses should be injected with dilute solutions of one of the mineral astringents, the strength of these not exceeding two grains to the fluidounce of water. Cosmoline, simple cerate, ointment of the oxide of zinc, and even fresh lard, make the patient easier, as they prevent friction of the buttocks. One of the forms of the radical treatment consists in the division of all the structures between the fistulous tract and the surface. This may be accomplished either by the use of the knife or by seton. Stimulating injections or cauterization has been known occasionally to permanently close fistulæ in ano; but such plans of treatment are unreliable, and usually unjustifiable. When the fistula is not so high up in the bowel as to render the use of the knife unsafe, this plan of treatment should be adopted. As an invariable preliminary to all operations upon the rectum the bowels should be thoroughly emptied and the patient should be placed under the influence of an anæsthetic. A flexible grooved director should then be carried through the opening of the tract upon the surface and along the tract to its opening in the bowel, should such exist. The forefinger within the rectum will meet the point of the director as it emerges from the internal opening, and the director should be pushed onward and its extremity guided outward until it rests fairly upon the sound integument outside, and all the included structures should be divided along the groove of the director with a sharp-pointed curved bistoury. Should the fore finger in the rectum not discover an internal opening, one should be forced at the very bottom of the tract by rotating the point of the director while making counter-pressure with the end of the finger. Should several fistulæ be found, they should be treated in like manner. Sometimes it will be found that the incision is overlapped by the dusky-red flaps composing its margins, in which case they should be trimmed off with scissors. When the tract extends deeper than its internal opening, the latter should be ignored and the sinus laid open to its very bottom. When no external opening exists, one should be made, and the guide for this incision will be a point of induration felt by the finger at some point not far from the surface. The director entering at this point will find the tract, and should be pushed forward as described above. These opened sinuses should be packed with lint soaked in carbolized oil and confined by a pad and a T-bandage. It is the practice at the Pennsylvania Hospital to apply after division a stick of caustic potassa, allowing it to remain in contact with the cut surfaces for several seconds, after which the wounds are to be packed. This procedure ensures their healing from the bottom. The bowels should be confined for a few days, after which a dose of oil may be given. Besides attention to cleanliness and a daily renewing of the packing no further treatment will be demanded. The hemorrhage attending these operations is usually trifling. Should a vessel spring, a ligature may be thrown around it. When an abundant general oozing occurs, the rectum must be packed and a compress and bandage firmly applied. Should the surgeon prefer the seton operation, he should carry several threads of stout silk or a piece of rubber cord on an eyed probe into the fistula and out of its internal opening, and by tying their ends firmly down upon the enclosed tissues slowly effect the same result as in the cutting operation. When the seton used is silk, the ends should be carried through holes in a round leaden plate or through those of an ordinary button, and tied. These setons are to be drawn tighter every three or four days until the division of the enclosed tissues is complete. The subsequent treatment is the same as in the other operation.
A difference of opinion exists among surgeons as to the propriety of operating for fistula in ano in persons afflicted with tubercular disease of the lungs. The practice of the present day is decidedly in favor of operating, without reference to the condition of the lungs, provided the patient is not too much reduced in strength.
An operation for fistula in ano has been proposed and practised by Reeves, which is a compromise between cutting and ligation. He says: "It consisted in passing a strong and well-waxed silk ligature along the track of the fistula into the bowel. An ordinary surgical probe with an eye in its end carried this thread into the rectum. My bivalve expanding speculum was previously introduced, and by its use there was no difficulty in seeing and seizing the ligature and bringing it out through the anus. The probe was then withdrawn, and the ends of the silk were wound round two strong pieces of wood which were held between the fingers of each hand. An assistant passed a finger on either side of the track of the fistula to steady the tissues and to resist the traction which was put on the silk thread. The two pieces of wood were then drawn toward me with a rapid sawing motion, and the fistula was quickly divided, with the loss of scarcely any blood. Some oiled lint and a pad and bandage were applied in the usual way; and the wound healed well. No anæsthetic was administered, and although the patient did not relish the operation, still it was quite bearable, and what she felt most was a burning sensation, due, doubtless, to the friction of the silk."
HEMORRHOIDS.—The treatment of this form of rectal and anal disease is either medical or surgical according to the gravity of the case and according to the obstinacy with which it resists local and general therapeutic agents. An ordinary acute attack of external piles, such as is often produced by neglect of the bowels, causing constipation, may be treated in the following manner: The patient should rest and avoid stimulating food and beverages. He should employ cold bathing to the part frequently: indeed, great comfort and relief often follow this treatment alone. An ointment of tannic acid, glycerin, and simple cerate, or one containing calomel and extract of opium, will be found useful. Fresh lard, cosmoline, vaseline, cold cream, ointment of the oxide of zinc (benzoated) or an ointment containing extract of opium, extract of galls, and extract of belladonna or stramonium, are some among many agents that have been extolled for their relief. H. C. Wood46 recommends enemata of solution of chlorate of potassium and laudanum. Enemata of lime-water and linseed oil are recommended by Agnew: "One of the very best formulas for allaying the irritation incident to hemorrhoidal affections consists of the following combination: Acetate of lead and tannin, of each fifteen grains; carbonate of lead and extract of stramonium, of each thirty grains; creasote, five drops. With a sufficient quantity of cocoa-butter mould this into fifty suppositories."47 The internal exhibition of the balsam of copaiba, twenty drops in capsules taken four or five times daily, or the use of fifteen drops of liquor potassa rubbed up with half a drachm of the balsam into emulsion, taken three times a day, has been much extolled, as has also the confection of black pepper. Sometimes these various means will cure a chronic or long-standing case of piles, either internal or external. Wetherill has found that the topical application of rectified oil of amber has cured long-standing cases of piles. This oil should not be applied in cases where much inflammation exists, and where the piles are internal the best mode of bringing it in contact with them is to incorporate from three to five minims of the oil with sufficient cocoa-butter to make a suppository. One of these, pushed into the bowel night and morning for a week, will not infrequently cause the piles to shrink up and finally to disappear. The bowels should be kept open with the compound powder of licorice. It should be remembered that magnesia irritates hemorrhoids. Success has followed the internal use of ergotin, of the fluid extract of hamamelis virginica, of the corn blast (ustilago maidis), and of small doses of aloes combined with hyoscyamus. D. Young has had good results follow the internal use of glycerin. Chronic cases of piles have been cured by the application of ointments containing carbonate of lead, creasote, carbolic acid, or iodoform. Ergotin used hypodermically in the vicinity of the anus or injected into the piles has frequently resulted in a complete cure, and the same may be said of the injection of carbolic acid directly into the tumors. In the application of cold water to inflamed piles it should be borne in mind that its forcible impingement upon them in a fine stream acts far more efficiently than the mere bathing them. Some cases do better under the use of warm water or warm sedative and astringent lotions. A warm flaxseed poultice mixed with laudanum is a very comfortable application. In obstinate cases of prolapse Agnew48 recommends the use of a rectal obturator or the use of a hemorrhoidal truss.
46 Philada. Med. Times, Dec. 6, 1879.
47 Surgery in the Pennsylvania Hospital, p. 210.
48 Agnew's Surgery, vol. i. p. 445.
Those who suffer from prolapse of piles should avoid the habitual use of cushioned seats. They should assume a semi-erect posture during defecation, or, when this is attended with difficulty or inconvenience, they should contrive a portable water-closet seat by boring a hole an inch and a half in diameter through a piece of planed board, bevelling it so as to fit the person. These means will often prevent the extrusion of the tumors. After defecation the patient should rest for a little while in the recumbent attitude.
The careful touching of external piles with strong nitric acid is a mode of treatment that has been quite successful in the hands of some surgeons. The intolerable itching of these bodies can be allayed by touching them with tincture of aconite-root or with a concentrated tincture of prickly-ash bark. Freezing them with the ether spray allays the pain and itching for the time being, but these symptoms return with redoubled energy after the effect has subsided.
Should an attack of the external variety of piles not result in absorption, but leave an excrescence, painless but inconvenient, and liable at any time to become inflamed, excision would be in order. Divide the integument by an incision radiating from the anus, separate the skin from the tumor down to its base, and after seizing it with toothed forceps cut it off with scissors curved on the flat. Little flaps or tabs of skin remaining after piles may be snipped off with scissors. It is not well to operate upon external piles unless they obstinately resist all milder treatment. There are frequently venous enlargements containing blood-clot, and when this condition exists proceed as follows: Pinch up the little tumor between the thumb and finger of the left hand; transfix its base with a curved bistoury, and cut out; at the same time, by pressure with the thumb and finger, extrude the clot. Fill the bottom of the little sac with cotton wool, and the operation is complete. It is not necessary in these cases to wait until the inflammation subsides before operating.
The operative treatment of the internal variety may be by strangulation, by the cautery, by the écraseur, and by the use of caustics. The former of these is the safest and most convenient method, and the one usually employed in the Pennsylvania Hospital, and should be performed in the following manner: The lower bowel having been thoroughly evacuated and the patient etherized, the operator should gently but firmly stretch the sphincter. The patient should be placed upon the side, with the upper part of the body prone, the hips elevated, and the thighs flexed upon the abdomen. Transfix the largest tumor with a strong, long-handled tenaculum, cut through the skin at the base with a knife or scissors around its external half, and hand the hook to an assistant, instructing him to make gentle traction. Then encircle the mass with a stout cord if the mass is not too large, or pass a stout needle threaded with a double silk ligature, from without inward, deeply through the base of the pile, drawing it through the mucous membrane on the opposite side; cut loose the needle and tie tightly, so as to completely strangulate the included tissues on either side and leave the ends of the ligature long. Treat all the remaining tumors in a similar manner seriatim, and then with scissors cut away the strangulated bodies to within a safe distance of the ligatures, the ends of which are now to be cut off close. Place an opium suppository in the bowel, and the operation is complete.
When for any sufficiently good reason the patient will not bear the ordinary anæsthetics, it will become necessary to modify the operation as follows: The tumors having been well extruded by enema of warm water or by the efforts of the patient, bend him forward over a chair and direct an assistant to draw aside the buttocks. Then pass the double ligatures as before indicated, but refrain from tying until all the tumors are thus secured, as the operator will find it convenient to draw upon the ligatures to keep the mass of piles within view and working-distance. Then draw down each tumor, cut around its base, and tie as before; cut off the ends of the ligatures and the greater portion of each strangulated tumor, and return everything within the bowel, and follow with an opium suppository. In many cases Morton has used the nitrous oxide gas with the best results. The hook should then be withdrawn, and each knot should be drawn more firmly down prior to its reduplication. Following this procedure, if properly carried out, the tumors will change color, becoming blue, thus indicating complete strangulation.
The operation by the clamp and cautery is a good method when the hemorrhoidal tumors are small. The operation is that of Mr. Cusack of Dublin, and the clamp employed is that invented by Mr. H. Smith of London. This instrument is so well known that a detailed description of it would be unnecessary. In operating with it the tumor is to be drawn well out and the clamp applied close up to its attachment with the bowel. Strangulation is effected by means of the screw which runs through the shafts of the handles. This accomplished, the strangulated portion is cut off with scissors, which should leave a stump three-eighths of an inch long. To this stump apply the actual cautery at a dull red heat, touching its every portion, after which unscrew and remove the clamp and look for hemorrhage. Should any occur, touch the bleeding point with the hot iron. Confine the patient to bed for five or six days and give sufficient opium to confine the bowels. After this time has elapsed administer a dose of oil. Remember that but one pile should be clamped at one time. "The taking two piles into the clamp at once is sure to result in hemorrhage." Do not allow the cautery-iron to touch the clamp. After the operation return the parts within the sphincter and cut off any tabs of redundant integument with scissors.
The removal of internal piles by means of the écraseur was the favorite operation of Chassaignac, but it is a mode of procedure which is now regarded with disfavor by the best surgeons on account of the liability to hemorrhage, and from the fact that troublesome and injurious contractions of the anus have not infrequently followed its use. The employment of iron or copper wire instead of the usual chain has been recommended by those who prefer this mode of operation. The plan adopted by Chassaignac was to pedunculate the piles by tying a ligature around the base and drawing them down. The chain being then applied, the strangulation and crushing off was slowly accomplished by means of the lever of the instrument. It should take from twenty to twenty-five minutes' crushing to accomplish this object.
For the treatment of internal piles by caustics Houston of Dublin used strong nitric acid. A fenestrated speculum should be employed, and the acid should be applied with a piece of wood or with a glass brush, care being taken to limit its action to the tumors, the redundant liquid being mopped up with a swab of lint or prepared absorbent cotton. The entire surface should afterward be bathed in oil. The acid is relied upon to produce a granulating surface, by the healing of which and by the subsequent contraction a cure is sometimes achieved. At best, this plan of treatment has proved tedious and unsatisfactory.
Chloride of zinc and caustic potassa are even more unsatisfactory agents for this purpose than the acid, as they are very violent in local destruction and their action is very difficult to limit. The use of caustic potassa was last revived by Amussat, but failed to find favor from his contemporaries, and soon fell into merited disuse. Van Buren says: "From recent experience with the thermo-cautery of Paquelin, I am disposed to regard it as more manageable than nitric acid, and at least equally efficient." Allingham mentions favorably the strong carbolic acid as a substitute for the nitric as an application to vascular and granular surfaces. The reckless method employed by the older surgeons of cutting off internal piles with the knife or with scissors, without any precautions against bleeding, is merely mentioned in condemnation. Usually no serious symptoms are to be expected after operations for hemorrhoids, but to this general rule there are exceptions. Morton knows of two consecutive cases of tetanus after this operation performed in a hospital in this city, and both terminated fatally. One of the most common occurrences after the ligation of piles is retention of urine, generally lasting for a day or two and requiring the use of the catheter.
HEMORRHAGE FROM THE RECTUM.—Bleeding from these parts is more usually of a venous than an arterial character, but in some cases of hemorrhoids the bleeding is either arterial or arterio-venous. The latter occurs upon the detachment of a polypus, but not necessarily of a polypoid growth. Arterial or mixed bleeding occurs in carcinoma and in rodent ulcer, and also from the stumps of badly-occluded piles. In cases of vicarious menstruation from the rectum the venous blood simply oozes from the surface of the over-congested mucous membrane. This condition should be readily diagnosed by the physical properties of the blood and from the history of the patient. In almost all cases of bleeding near the anus it will be possible to pick up the vessel or the bleeding point on a tenaculum and ligate with silk, which is the most satisfactory method to the surgeon. The rectum has been dragged down with volsella forceps to apply a ligature to a point high up, but in some of these cases the acupressure pin with the twisted suture will be found more convenient. Should hemorrhage occur after the ligation of piles which cannot be checked by ligature, such as a general oozing, pass all the ligatures through a hole made in the centre of a small round sponge, then tie them across a piece of stick (thus constructing a sort of tourniquet), and twist this around. Van Buren cites a case in which a sudden laceration of the integument and sphincter occurred during forcible dilatation in a case of hemorrhoids in a very broken-down subject, with very copious hemorrhage. He passed a sponge armed with a double ligature into the bowel, and, directing an assistant to make traction upon the threads, the bleeding was checked. Injecting ice-water and perchloride of iron into the rectum will often check hemorrhage. Allingham prefers the persulphate of iron to any other styptic for this purpose. Passing fragments of ice into the bowel while holding a lump of ice upon the sacrum sometimes answers a good purpose. In many cases of secondary hemorrhage from large venous sinuses in a state of ulceration it will be impossible to ligate, and the use of the ordinary styptics will be but the waste of valuable time: the bowel must be tamponed as follows: Thread a strong silk ligature through near the apex of a cone-shaped sponge, and bring it back again, so that the apex of the sponge is held in a loop of thread. Wet the sponge, squeeze it dry, and fill its meshes with ferric alum or with persulphate of iron. Pass the left fore finger into the bowel, and upon it push up the sponge, apex first, by means of a metal rod or any other convenient body, fully five inches into the rectum. Now fill the rectum below this with cotton-wool filled with the styptic. The bowel having been completely filled, make traction upon the ligatures (thus spreading out the bell-shaped sponge), while with the other hand push up the packing. If this is carefully done no fear of bleeding need be apprehended. In these cases the patient often suffers from collections of flatus, which may be obviated at the time of packing by placing a flexible catheter in the bowel and packing around it. These plugs should remain for at least five or six days, and frequently eight or ten days are none too long. The packing must then be picked carefully away from the sponge. Agnew's rectal chemise answers the same purpose. In describing its application he says: "Through the openings at the end of the largest-sized gum catheter pass a strong silk thread; take three square pieces of the material usually known as mosquito-netting, placing them one on top of the other; at the centre of these squares or pieces make an opening, and pass the catheter through it, securing the two together by the threads. In applying the instrument the different layers of the chemise must be moistened with water, and afterward well filled with the persulphate of iron. It is then conducted some distance into the rectum on a finger previously inserted; after which it is expanded like a parachute by packing between the catheter and its hood with long strips of lint thrust up on the end of a bougie until the bowel is distended on every side. The catheter will serve to conduct away the flatus, and when, after eight or ten days, its removal becomes necessary, this is very easily effected by drawing out the ribbon-like pieces of lint which were used as packing." Another method is to stuff the bowel with fragments of sponge to which threads are tied, the ends of which, protruding from the anus, facilitate their withdrawal. In conjunction with these procedures the patient's pelvis should be elevated. After excision of portions of the mucous membrane the risk of hemorrhage will be lessened by the surgeon introducing through the edges of each incision a few fine sutures.
Enormous quantities of blood may escape into the bowel after operations without any external symptom being apparent until the patient becomes pallid and weak. In other cases the patient will complain of tenesmus and desire to go to stool, or of a sensation of something trickling into the bowel. Upon the recognition of these symptoms search should at once be made for internal hemorrhage.
Rectal Alimentation.
Before taking leave of this very interesting class of diseases and of their modes of treatment, it seems proper to introduce a few remarks upon the subject of rectal alimentation, as it is now a well-recognized and much-practised means of sustaining those whose stomachs are unequal to the work which in health is so easily and unconsciously performed. In the use of the lower bowel as an absorbent surface of alimentary substances many failures have been reported, a fair proportion of which, it is safe to infer, are due to the methods employed, to the nutritive matters employed, and to the condition of the rectum at the time. Firstly, as to the state of the rectum, it must be empty. Wait a reasonable time, say an hour, after stool, so that the gut may be more passive; have the patient in the recumbent posture; direct him to resist tenesmus and to exert both the will and the muscular power to retain the aliment. The syringe must be of hard rubber, must be rectal-ended, and of the capacity of two fluidounces, and perfect in action.
The preparation to be introduced, after being warmed to a temperature of 98° or 99° F., should be very slowly injected with the syringe, which should be also warmed and oiled. The enema must never exceed in amount two fluidounces. If this be rejected, wait a reasonable time and try again, using a less amount. If tenesmus proves an insurmountable barrier to ordinary means, an opium suppository is to be introduced three hours prior to another attempt. It has been suggested, inasmuch as tenesmus is often relieved by the application of cold to the rectum, to introduce the aliment in that state; but this method is open to the objection that rectal digestion would be much less likely to take place under this condition, as the bowel would then have thrown upon it the additional work of warming up the substance prior to absorbing it.
The usual errors made in applying this means of sustaining the patient are, that the injections are too large, are too rapidly introduced, and are not of the proper temperature. Allowing an interval of eight hours between the enemata would afford three in the twenty-four hours, which method has been found to offer the best results. This must be persevered in at regular daily intervals for the patient to derive its full benefit, and there is reason to suppose that the nervous system gets expectant of these daily hours of support, as it does in the case of our ordinary meal-times. An examination of the well-formed daily stools of patients thus sustained will prove how close the analogy is between this and digestion proper.
Next, as to the substances to be employed. The best of these are milk, eggs, concentrated beef-extracts or beef or chicken peptones, and brandy or whiskey of good quality. These substances may be combined in various proportions to suit the individual requirements of the case. A very good mixture for this purpose is two tablespoonfuls of milk, one tablespoonful of whiskey, and an egg, using both the yelk and the albumen. To this add a little salt. This should be well beaten up and properly warmed.
It is well to persevere in the use of these enemata even though at first most of them appear to be rejected, as after a time, the rectum becoming accustomed to their presence, absorption or so-called rectal digestion may take place. This form of alimentation should be kept in reserve in a case of chronic illness until all other methods of sustaining the patient prove insufficient to support life. It is not contraindicated even in some cases of chronic diarrhoea with persistent vomiting and loss of peptic function, advantage being taken of the intervals between the evacuations to introduce a small and very concentrated nutrient enema. In ordinary cases not complicated by diarrhoea the most convenient times will be found to be about seven o'clock in the morning, three in the afternoon, and eleven at night. Wetherill suggests the possibility of forming with solid extract of beef, pepsin, and pure suet a nutrient suppository which might be retained and absorbed in some cases in which it has been found impossible to retain the enemata. A very small addition of white wax, he thinks, would keep these solid during warm weather; if not, the suet might be replaced by ol. theobroma (as in ordinary suppositories), which is probably as likely to be absorbed as the suet.