The principles and practice of modern surgery

by Roswell Park

Strictures of recent origin may yield to a forcible dilatation, which should, however, be systematically repeated in order to maintain the desired effect. Old, dense, and chronic strictures will require more radical procedures, according to their location and extent. Strictures practically impassable may indicate conditions so extreme as to necessitate colostomy, while in a small proportion of cases conditions will be found so favorable as to justify a resection of the rectum, either from below and from without, or through abdominal section with the patient in the Trendelenburg position. Nearly every stricture is accompanied by more or less ulceration, sometimes in extreme degree.

Dilatation or expansion by some mechanical method is the necessity in every case. Simple in theory its performance is often difficult because of density of the structures, and its danger often pronounced because of the serious surrounding conditions and the possibility of rupture or perforation of the bowel at some weakened part, or of infection and phlegmon following division of the stricture and exposure of fresh, raw surfaces. Various instruments have been devised for dilating rectal strictures, some of which are ingeniously arranged to be used at a considerable height above the anus. Danger attaches to their use in proportion to the amount of force employed and its distance from sight and touch, i. e., from intelligent means of control. The best method is that which permits of exposure through the speculum and more accurate division with knife, scissors, or actual cautery, the latter often being preferable, as hemorrhage is less after its use.

It should be remembered that “once a stricture always a stricture,” and that the tendency of cicatricial tissue to contract is continuous and never ceasing, and that wherever there has been a stricture (and this is true of any tubular portion of the body) there is necessity for constant and more or less frequent later attention. If possible, then, milder methods and those more capable of repetition should be adopted. The best of these is the use of the finger for cases within reach of it, and of the soft-rubber, conical bougies for those placed higher, and for the patient’s individual use. Dilatations should be gradual and increased as rapidly as circumstances permit, and with tight strictures the endeavor should be with each sitting to make some gain until a sufficient size has been attained. Local anesthesia may be required, and is justifiable when needed.

PRURITUS ANI.

This condition, usually accompanied with irritative or ulcerative conditions of the lower end of the rectum, the verge of the anus, and the surrounding skin, is one of intense itching, leading to an uncontrollable desire to rub or scratch, by which temporary relief may be afforded, but which tends to produce excoriation and ulceration. The condition is not primary, but secondary to something else, although the conditions which produce it are widely variant, ranging from the neuroses due to anemia or other causes, to the toxemias of uric acid origin, the local irritations produced by lesser degrees of internal disturbance, or eczema or other itching eruptions on the outside. In corpulent persons eczema and intertrigo from friction are common, and these, combined with irregular tags of skin or remains of old piles, permit of irritation and maceration which still further complicate. Annoyance is usually greatest at night, when the attention is less distracted by other things.

Treatment.

—The treatment should consist in removal of the cause and local relief. The former may be difficult and require prolonged effort. Local relief may be afforded by frequent applications of water as hot as can be borne, with local application, after the parts are thoroughly dried, of a powder containing menthol, a solution containing camphophenique, with the addition of a little chloroform, or by soothing ointments containing carbolic acid, menthol, and orthoform. When there is abrasion of the skin applications of silver nitrate, in 5 per cent. solution, may be made; but when there is multiple ulceration, stretching the sphincter and thoroughly cauterizing or excising the ulcerated surfaces will be more radical and effective.

PHLEGMONOUS AFFECTIONS OF THE RECTUM.

On either side of the rectum, between the dividing folds of the deep pelvic fascia, is situated the ischiorectal fossa, a pyramidal-shaped cavity filled with fat and cellular tissue. This is not only in close relation with the outer rectal surfaces, but is peculiarly liable to infection and acute inflammatory disturbance. Thus it happens that ischiorectal or perirectal abscesses are of frequent occurrence, often of marked violence, and not without their peculiar dangers. Infection may travel from the rectum, or the first excitement may occur in one of the mucous or skin follicles at or near the anus. The consequence is what the patient ordinarily calls a boil, which to the surgeon is a phlegmon, first limited by the walls of the cavity within which it rises. So long as the phlegmonous process be confined within these walls it is acutely painful.

The local signs of such an abscess are redness and infiltration of the exterior surface, swelling, which becomes quite distinct, and pain and tenderness, of which the patient may complain bitterly. The local soreness is so extreme that defecation becomes difficult or almost impossible. Any attempt at digital examination of the rectum will give rise to extreme pain.