ULCER, STRICTURE, ETC.
A solution of continuity, varying from a slight abrasion of the mucous membrane to a marked degree of destruction of tissue, comes within the scope and meaning of rectal ulcer.
A deep-seated, non malignant type of rectal ulceration, complicated with stricture, fistula, etc., is not so very common, and seldom met with outside of hospital practice.
The less serious and more simple varieties, such as may be productive of considerable systematic disturbance through reflex excitability, without attracting much, if any attention locally, are the forms most frequently seen by the general practitioner.
With few exceptions, rectal ulcer is insidious in its nature; in some instances passing on to the stage of stricture, which alone may be the first symptom to cause alarm, as the following recent case will illustrate.
Mr. C⸺, aged thirty-three, married, applied for the treatment of hemorrhoids. He stated that the only inconvenience suffered was from constipation. That the piles did not come out and were never very sore but he had seen a little bloody mucous at times and had a constant desire to go to stool. A free evacuation and relief being obtained only after the feces were made liquid by the injection of warm water.
On the introduction of the finger I found about one-inch and a half from the anus, an annular stricture which almost entirely occluded the bowel, with ulceration and gummata below. More close inquiry elicited the fact that the stools were not much larger in circumference than a lead pencil. He had noticed the trouble not more than two months before. There was a previous history of chancroid at the age of 19, with no constitutional symptoms.
It is claimed that organic stricture does occur without previous ulceration by interstitial deposit and thickening, and ulceration follow. But this must be considered exceptional. The ulcerative process usually precedes, and through efforts at repair, cicatricial bands are thrown out, producing a narrowing and contraction of the canal, either in places or throughout the circumference of the bowel.
Fig. 18.—Rectal Bougies.
Electrolysis may be tried for the relief of stricture before resorting to the usual methods of breaking up by forced dilitation. If divulsion be decided upon it should be complete at one operation. Should the fibrous bands be strong and unyielding, nicking the edges with a probe pointed bistoury is advantageous.
On account of severe hemorrhage and other untoward symptoms likely to follow a complete division of the stricture, the galvano-cautery is decidedly preferable to the common proctotomy knife. A duplicature of the peritoneum coming down to within about three and a half inches of the anus anteriorly, should not be lost sight of in operations on the rectum. The persistent use of bougies will be necessary for a long time after divulsion.
Stricture is mostly of syphilitic origin. Of the seventy cases, tabulated by Allingham, ten of the number were found in men and sixty in women, showing a great predominence in the latter; and none were more than three and a half inches above the rectal orifice.
It is not an easy matter to diagnose between the advanced stages of non-malignant rectal ulcer and cancer. Both may be accompanied by tender, condylomatous growths or flaps of skin outside the anus, bathed with an ichorous fluid. The characteristic, unremitting pain of cancer may be absent in its formative stage, and in this respect insidious in its approach, the same as the non-malignant ulcer.
Allingham speaks of a very rare species of rectal ulcer, which he terms rodent or lupoid, that is superficial, does not implicate the surrounding parts, devoid of hard edges or surface, very painful and only cured by complete extirpation.
I have intentionally omitted the early symptoms and course of rectal ulcer for the purpose of giving audience to Dr. A. C. Hall, who, in a communication to a medical journal, writes the following lucid description:
“Rectal ulcer is a more common disease than is generally supposed. Unfortunately the symptoms are generally obscure, and the patient suffers but very little, if any pain, and consequently consults his physician for some of the reflex symptoms, rather than for the initial disease itself; and very often these reflex symptoms are vainly treated till the patient and physician are both thoroughly disgusted and disheartened. There is one maxim which every physician should always bear in mind, and that is, always suspect rectal ulcer in every case of protracted or chronic diarrhœa. I have reports from eighty-six pension surgeons, in which they estimate that they have examined two thousand cases, where chronic diarrhœa was the alleged cause of disability in applicants for pensions. Of these two thousand cases of chronic diarrhœa, eighty-seven per cent. had rectal ulcers, and fully ninety per cent. of those who claimed chronic diarrhœa as their disability and who had no ulceration were rejected, because their proofs of the disease, aside from the ulceration were too meagre. Thus the strongest and most prominent symptom of rectal ulcer is chronic diarrhœa.
“The diarrhœa is generally more troublesome in the morning. The patient often on arising feels an urgent desire to go to stool. This act is often very unsatisfactory, for he passes very little feces and a great deal of wind. Occasionally these small stools are covered with a jelly-like, or white of an egg substance, or the motion may be only a jelly-like mucous, with no feces. There is generally more or less tenesmus, or a disagreeable feeling, as if the rectum was imperfectly evacuated. Sometimes the patient will be compelled to go out two or three times before breakfast, and he may in the later attempts to have a stool, pass lumpy or scybalous feces, covered with mucous, and often streaked with blood. There sometimes exists, as a symptom of rectal ulcer, a desire to go to stool when cold drinks are taken. But generally the diarrhœa and tenesmus subside soon after breakfast, and the patient has no more trouble until the next morning. A great many, or I might say a majority of those suffering from rectal ulcer consult the physician for some symptom or other that suggests anything else but the rectum, but by close questioning, and following up the symptoms, one can soon tell whether they are reflex or otherwise.
“In cases of rectal ulcer of long standing, there is always more or less cachexia, or peculiar waxy, sallow, unhealthy complexion, which sometimes alone points significantly towards the disease.
“There is often more or less enlargement of the liver and spleen, especially the spleen.
“In advanced cases, the diarrhœa comes on at night as well as morning, and defecation is accompanied with pain and griping. Another almost characteristic sign of rectal ulceration, is alternating diarrhœa and constipation. The bowels remain constipated for a considerable while, then diarrhœa supervenes, and is accompanied by severe and excruciating colicky pains, and often nausea. Persons subject to chronic diarrhœa always dread to take a physic to relieve a temporarily constipated state, for it will almost invariably put them to bed.
“In extreme cases, infiltration and thickening of the sub-mucous and muscular coats supervene, as a result of nature’s effort to repair the lost tissue. This thickening may be so extensive as to threaten and actually produce stricture. It will often convert the rectum into a passive tube, through which feces and fluids trickle, the patient having little or no control over the sphincters.
“The passage of hardened feces and the pressure of internal hemorrhoids and polypi are the most common causes of rectal ulceration. The lodgment of foreign bodies, such as fish bones, cherry stones and plum seeds that have been swallowed, and which act as irritants and produce ulceration.
“In women the pressure of the fœtal head on the rectum during childbirth is a frequent cause of ulceration, likewise the pressure of a misplaced uterus.
“On examination, by means of a speculum, the ulceration will be found about an inch or an inch and a half from the anus, generally on the posterior wall, but often on the anterior wall.
“When the ulcer is on the anterior wall, there is more or less irritability of the bladder, and seminal emissions or impotency. The ulcer itself may be round, oval or elongated, radiating or following the columns of Morgagni. The ulcer may present ragged, interrupted elevated edges, or they may be sharp cut and regular, as though cut with a sharp punch. The edges are sometimes hard and gristly, or may be soft and with no elevation above the surrounding tissues. The surface of the ulcer is often clean, and healthy looking granulations may be seen, or the ulcerated surface may be loosely covered with a greyish, grumous scum, that is offensive, and decidedly unhealthy for the patient. Underneath this scum there is often found an ulcerated spot, that is apparently lifeless, and will require much attention, locally and constitutionally, to prevent its rapid extension. In this form of rectal ulcer there is always more or less marked cachexia. It is the indolent ulcer, occasioned by the gradual breaking down of the tissues, that produces the grave constitutional disturbances and death. It is the small, round, or oval ulcer, with elevated, hardened edges, that produces the many and various reflex nervous symptoms, which are misleading and troublesome.”
Fig. 19.—Rectal Irrigator.
In all cases of rectal ulcer of any considerable gravity, absolute rest, both of the parts and the body, is to be maintained. Hot water irrigations and a complete destruction of the diseased surface by carbolic acid, are the first things to be thought of, together with a liquid diet.
Convert the ulcer into a carbolic acid sore and use an iodoform suppository. In fact the treatment is very similar to that recommended as an after treatment in a bad case of hemorrhoids, with such variations as the ingenuity will suggest. Bismuth, oxide of zinc, eucalyptus, mercury, resin cerates, etc.
Have found no use for iodine, nitrate of silver or acid preparation of iron, which corrode and destroy instruments in the treatment of rectal diseases.