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.