CHAPTER L
.
THE LARGE INTESTINES AND THE RECTUM.
ANOMALIES OF THE LARGE INTESTINE.
The more common _congenital anomalies_ of the various divisions of the colon have to do mainly with the presence of _diverticula_ and _atresiæ_, or possibly total _absence_, due to defects in development. Diverticula are much the more common. Some degree of constriction is not particularly infrequent, but complete absence of even a section of the colon is an extremely rare anomaly.
The _acquired anomalies_ have to do with disease processes or results of injury. _Displacements_ may be the result of old adhesions and distortions; of _chronic constipation_, _i. e._, fecal impaction and resulting overloading, with sagging, stretching, and complete change in shape and position; with displacement due to enlargement of other organs, _e. g._, the liver, stomach, spleen, uterus, or, in milder degree, with the gradual but inevitable and chronic results of tight lacing. The causes which produce a gradual _enteroptosis of the transverse colon_ are not supposed to concern the surgeon, yet the condition may precipitate acute obstruction which will necessitate his urgent participation in its final treatment.
There are no diseases peculiar to the large which do not also concern the small intestine, and no surgical diseases peculiar to it which have not been considered in the foregoing pages. It is not, therefore, necessary to make even a brief summary of the surgical diseases peculiar to the large intestine. Of well-known lesions, however, in this location there is perhaps a little worth emphasis in this place. The most serious surgical conditions of the large bowel, aside from the acutely obstructive, are those pertaining to expressions of tuberculosis, syphilis, actinomycosis, dysentery in one or other of its tropical forms, and cancer. There is a condition also of either acute or chronic _colitis_ or mucocolitis which may assume such extreme degree as to necessitate a colostomy made at the cecum (appendicostomy) for the purpose of more perfect irrigation and physiological rest. The amount of suffering, as well as of toxemia, which may proceed from a seriously inflamed colonic mucosa, must be at least once seen in order to be fully appreciated. Such a condition is characterized by local and general suffering, with septic and copremic symptoms, as well as by tenesmus and the passage of numerous small or larger and more infrequent amounts of blood-stained mucus, sometimes of almost pure blood. As an illustration if one recall what may be seen in case of a violently inflamed conjunctiva or pharyngeal mucous membrane, and realize that this condition is duplicated through a large portion of the colon, a more vivid picture of what it actually represents can be afforded. When exposed to inspection, as it may be when the rectum and the sigmoid are involved, it will be found to bleed at the slightest touch and to freely discharge large quantities of thick mucus. While such a colitis is usually treated by non-operative methods an anesthetic is sometimes required for its more perfect diagnosis and recognition, as well as for such local applications as can scarcely be made without it.
TUBERCULOUS AND SYPHILITIC ULCERATIONS OF THE COLON.
Tuberculous and syphilitic ulcerations of the colon may be localized and relatively insignificant, or numerous, disseminated, extensive, and serious. In extreme cases of this kind the entire colonic mucosa will be involved and the amount of distress thus occasioned be scarcely controllable. These are the cases which, failing to yield to ordinary therapeutic measures, justify colostomy at the cecum, for the purpose of temporary exclusion of the large intestine and its physiological rest, as well as its more perfect local treatment by the irrigation and suitable local applications thus permitted.
STRICTURES OF THE LARGE INTESTINE.
Strictures of the large bowel have the same etiology as those of the small bowel, and are to be recognized by the same general indications, of which increasing obstipation, perhaps with alternating attacks of diarrhea and increasing difficulty in evacuation, are unmistakable features. The nature of a stricture is not always to be foretold before the exploration which it will necessitate. No stricture of the large intestine which is above easy reach from the anus can be successfully treated by any save operative methods, _i. e._, by abdominal section and proper attention to whatever may be thereby revealed. Thus at one time bands may be divided or some external mass removed by pressing upon the bowel (_e. g._, a uterine myoma), or there may be found an associated tumor, malignant or benign, whose complete removal is both possible and permissible, or at other times a malignant stricture so complicated that only an entero-anastomosis, for temporary relief, can be effected.
CANCER OF THE LARGE INTESTINE.
Cancer of the large intestine spares no part of its length or lumen. Primary _cancer of the cecum_ may commence in the region of the appendix, and has frequently been mistaken for a chronic appendicitis. If the transverse bowel be involved there may be more or less sagging or fixation, while at the flexures obstruction is more easily produced. Such growths in time become sufficiently prominent to be easily recognized from without, but then they have usually gone beyond the time when radical operation can hold out much promise. In the large, as in the small, intestine radical operations are, however, often successful, and always in proportion as they are made early and thoroughly. When extirpation is impossible anastomosis will offer a temporary substitute (Fig. 589).
[Illustration: FIG. 589
Cancer of cecum, showing ulcerating growth protruding interiorly and obstructing. (Dr. E. A. Smith.)]
OBSTRUCTION OF THE LARGE INTESTINE.
Chronic obstruction of the large bowel is usually due to one of the causes above considered. Acute obstruction of the colon is the result either of precipitation of an acute condition upon the base of an old chronic trouble, of invagination, of volvulus, or possibly of one of the other mechanical contortions not included in either of these expressions.
_Intussusception_ is most likely to occur either at the ileocecal valve or in the region of the sigmoid. _Volvulus_ is more common in the latter region. It is here due to relaxation of natural ligamentous supports, to overloading and stretching, or is possibly permitted by some congenital condition. Volvulus in this section having once occurred the patient is liable to its subsequent recurrence. So well known now is this fact that surgeons have endeavored to take special precautions against it, which unfortunately have not been brilliantly successful. It has been suggested, for example, to anchor the sigmoid to the anterior abdominal wall, or to resect a portion of it, to anastomose it with the cecum, as well as to reef the mesosigmoid. Desirable as such operative relief may be, all of these methods present inherent objections, while those which include absolute fixation of the sigmoid perhaps predispose it to subsequent obstruction from other causes. At present it would appear that a _sigmoidopexy_ is probably the best procedure, in order to prevent local recurrence, in a sigmoid volvulus which has once been exposed by operation, care being taken to fasten it well up to its outer side, as well as posteriorly, in order that there may be no vacant spaces in these directions.
THE RECTUM.
GENERAL CONSIDERATIONS.
The rectum was for too long a time relegated to the care and almost sole interest of the itinerant charlatan, or the somewhat ambitious, though scarcely more honest, specialist, who preyed alike upon the suffering and ignorance of patients, until the practice of rectal surgery was almost a mark of disgrace. From this unfortunate condition it was rescued by the organized effort of honest men, until now, in the light of their researches, the rectum has been shown to be both the site of numerous, easily discernible, and serious, alike mysterious and reflex lesions, all deserving careful study. The connection between the sensory nerves with which its terminal inch and a half are freely endowed and the vasomotor nerves throughout the body is easily shown by their influence, for instance, upon the respiration and the circulation, and in these respects some important lessons have been learned from the charlatans. We have learned, for example, that general vasomotor spasm, with its evidence in coldness of the extremities and pallor of the surface, may often be overcome by so simple a measure as stretching the sphincter; while to cure lesions which produce more or less sphincteric spasm is to frequently restore general circulatory tone. Again, what may be accomplished in stimulating respiration by dilatation of the sphincter has been shown to be of the greatest value in patients breathing badly under an anesthetic.
The “orificialists,” then, while making absurd and impossible claims, have nevertheless taught us considerable concerning the value of recognizing the importance of sphincteric spasm. Their claims concerning so-called “pockets” and “papillæ” are untenable and absurd, and the expression which they have taught many of the laity that they are sufferers from “rectal pathology” indicates alike their ignorance of good English and good surgery. That papillæ do become, under certain circumstances, exquisitely sensitive and are occasionally in need of the cautery or the scissors, as well as of the general relief afforded by stretching the sphincter, is undoubtedly sometimes true.
The itinerant “pile-drivers” and charlatans of their class have done more harm than good, and yet even from them the honest practitioner has learned that “it pays” often to give attention to the rectum. As a source of various disturbing and particularly distressing reflexes there is scarcely any portion of the body of equivalent area which can furnish so many. The relief to mental conditions, amounting often to pronounced melancholia, which follows cure of rectal lesions, is often astonishing, all of which shows that the rectum is well worth the attention of the scientist, and especially of investigation in every case where the slightest complaint is made.
All of which properly leads up to the subject of _rectal examination and how to make it complete_. Much can be learned here by use of the educated finger, as well as in the vagina, and the surgeon should cultivate that tactile sense which will orient him so soon as the finger-tip comes in contact with a morbid or diseased surface. In this way it is possible to detect ulcers which are within reach by the finger alone, without having to use the speculum, at least to make a diagnosis sufficient to indicate what further procedure is required. The rectum and lower bowel should be thoroughly emptied. It is safe to assume that exquisite sensibility and pronounced sphincteric spasm are the result of morbid conditions. The use of a local anesthetic will in many instances be sufficient to permit at least of a preliminary digital examination, the suggestive characteristics especially sought being the general size of the rectal tube, infiltration or fixation of its walls, and the presence of stricture, tumor, or other impediment to insertion of the finger, including pronounced spasm at the anus. The presence of bloody mucus or pus should also be noted. In addition the rectal surroundings should be examined and the presence of any phlegmon, fistula, sinus or other evidence of present or past disease, including old scar, either of ulcer or incision, should be noted. The degree of pain as well as of hypersensitiveness produced should also be noted. With tact and gentleness satisfactory knowledge of the condition of the parts within reach may be obtained.
A rectal bougie may be used should suggestions of the presence of stricture be present. Rectal bougies are usually made of soft rubber of various sizes, with tips variously shaped, of which the tapering and conical are the most useful. One of these may be anointed and gently introduced, the endeavor being to guide it first in the middle line along the course of the rectum and then gently toward the left as the rectum swerves in this direction as it comes down from above. With such a bougie the presence of a stricture beyond reach of the finger may be detected. When recognized its nature is, however, still left in doubt, to be decided by the history or other features of the case. There is never excuse for roughness in handling a rectal bougie, since perforation or serious injury might result.
The next method of more complete examination of the rectum is through one of the various forms of specula, from the so-called rectal speculum, with its blades only a couple of inches long, to the more formidable proctoscope or sigmoidoscope, with their possibilities or artificial illumination, etc. According to the nature of the lesion and the sensibility of the surface exposed various specula may be used, with or without an anesthetic. For the majority of purposes local anesthesia is sufficient. One will furthermore often need the aid of position. The ordinary digital examination may be made with the patient upon the side or back. When an ordinary speculum is used a position corresponding to Sims’ for gynecological work is far preferable. For more thorough work when the long, tubular instruments are used, the knee-chest position is necessary. The specialists have devised certain elaborate chairs, instruments, and methods by which exceedingly complete and satisfactory exposures of twelve or fifteen inches of rectal and colonic mucosa can be made. What is written here, however, is not for their purposes, but rather for those of the general practitioner, who must work with ordinary means and methods. The knee-chest position, for instance, can be assumed upon the ordinary table or it may be facilitated by certain additions made to a regular operating table. With all these facilities and the peculiar skill which specialization produces it is possible to make striking demonstrations of the valvular arrangement of the rectal mucosa, and of the varying degrees of obstruction which mucous folds or cicatrices may produce, as well as to successfully dilate or divide them. In the hands of a limited number of skilled surgeons local treatment of obstipation, as well as of various other conditions of the sigmoid or upper rectum, has become extremely satisfactory. These are, however, in the writer’s estimation, methods and procedures which are scarcely within the domain of the general practitioner or even the general surgeon, as they require a degree of peculiar facility and an amount of time which can scarcely be expected of him. Therefore the conditions and methods of treatment here considered will be limited to those intended for general use.
CONGENITAL DEFECTS AND MALFORMATIONS OF THE RECTUM AND ANUS.
The lowermost portions of the intestinal tube are by far the most common sites of congenital anomalies and defects. These rarely occur in the direction of excess, rather of atresia or entire deficiency. The lower end of the alimentary tube is differentiated from the balance of the original neurenteric canal, and connected with the exterior, in ways similar to those followed at its upper extremity. The canal itself should early become obliterated at a point whose site is marked by that small collection of lymphoid tissue known as the _coccygeal_ or _Luschka’s body_, corresponding in this respect and location to the pituitary body at its other extremity. The rudimentary rectum is then connected with the surface by the formation of a depression and disappearance of tissue in just the same way that the mouth is formed, and as about the mouth we find atresia or incomplete communication, so we may find the same condition in various expressions about the termination of the rectum. Moreover, there may occur also more or less arrest or abnormal development of the tissues which eventually shut off the rectum from the genito-urinary tract. In consequence, we have various degrees of rectal _atresia_, and, finally, actual _imperforation_. Beyond this we may more rarely meet with complete absence of the rectum, and even of some portion or of nearly all of the entire large intestine. In one case under my observation this entire tract was represented by little more than a mere cord.
[Illustration: PLATE LII
Cancerous Stricture of Rectum. Bowel Laid Open for Inspection.]
The mildest degree of such malformation refers to partial occlusion of some portion of the rectum, or extreme smallness of its natural opening, either of which constitutes essentially a stricture of congenital origin, which may be sufficiently tight to barely allow passage of meconium. Such strictures may escape notice for a considerable length of time and will always tend to produce dilatation and consequent displacement of bowel above.
Ordinary _imperforate anus_ is produced by its closure by a more or less thick, membranous diaphragm, which may act, in some cases, like a thin but imperforate hymen, or, in others, be so dense and massive as to act more like a plug than a partition. The thinner the diaphragm and the more perfect its structure as such the simpler the case, for it simply needs perforation, with sufficiently frequent subsequent dilatation to maintain the proper size of the aperture.
Complete _absence of the anus and the lower end of the rectal pouch_ may be so marked that scarcely a dimple indicates the point where the anus should be found. In these cases the external sphincter may or may not be present, while the rectal pouch may present loosely in the pelvis, or be defective, or attached to some portion of the abdominal wall, the intervening space being filled with indifferent tissue. The fact that there appears to be a slight anal depression is to be taken for nothing more than an indication of what should be found, and signifies nothing regarding the deeper condition.
A somewhat mitigated expression of this last defect is seen when the anus is normal, with a more or less complete sphincter, but where a distinct partition separates this pouch from the rectum above. This, again, may vary considerably in thickness. If, then, fluctuation be detected the condition may prove less unfavorable for the little patient, since at this point communication may be easily established. Too often, however, this diaphragm is dense and tough. When successfully perforated, like the hymen, it may allow a slow dribbling of material, and will require constant attention and dilatation. Figs. 590 and 591 portray these conditions in some of their expressions.
[Illustration: FIG. 590
Rectum ending in a blind pouch. (Kelsey.)]
[Illustration: FIG. 591
Rectum ending in pouch; anus normal. (Kelsey.)]
The _anus_ itself is by no means a fixed anatomical opening, and its position may vary considerably. It may be found anywhere along the middle line of the perineum or even in the sacral region.
Another variety of complication is, with the conditions represented as above, a practically imperforate anus or rectum which nevertheless opens into one of the _other pelvic cavities_--the vagina, the bladder, or the urethra. In female infants an opening into the vagina may be of a size sufficient to serve its purpose, even throughout life. This condition has occurred in ignorant women who became wives and mothers, and were never conscious of anything abnormal. When the rectum communicates with the urinary passages meconium will escape with the urine. When the opening is in the urethra it is not so serious, and patients live to adult life, whereas when the bladder is thus involved the ureters will become infected and the patient eventually dies of a terminal infection of the kidney.
There is a somewhat reversed condition similar to this where the urinary passages connect with the rectum or with the colon.
Most of the anomalies above catalogued produce conditions of acute intestinal obstruction within the first two or three days of the newborn infant’s life. The condition is perhaps first made known by the nurse’s failing to note the presence of meconium upon the diapers. A suspicion of such a condition should prompt immediate investigation, which should be made with the little finger or with a soft catheter properly anointed; the finger making the best probe for purposes of orientation. The first thing is to determine the patulency of the anus. This established, the next procedure is a determination of the rectal condition and of possible communication with other passages. In this the presence of a small sound or metal catheter in the urethra and bladder may be of assistance. If a fluctuating sac presenting downward can be discovered in the location of the rectum its character may be assumed, and, after exploring with an ordinary aspirating needle, one may, if meconium be discovered, leave the needle _in situ_ for a guide and with sharp scissors or pointed knife passed along it carefully cut into the sac, and then gradually enlarge the opening until it be given a sufficient size. The surgeon is fortunate in this respect who has a case of imperforate rectum so simple as to permit of doing this and finding it sufficient.
Every completely obstructed case becomes instantly a surgical one, whose outcome depends not on the operator alone, but on the actual anatomical condition. There is justification, therefore, in going to almost any extreme in the endeavor to open up a passage-way, for no danger can be greater than that of failing to establish it. After a careful search of the pelvis, aided by anesthesia and a metal instrument in the bladder, if no trace of large bowel can be found or if tissues be so dense as to completely mask the anatomical details, then as a last resort an artificial anus may be made in the left inguinal region, if there be no reason for not violating the usual rule and opening the large bowel in the right groin. _Colostomy in an infant_, under these circumstances, is always a hazardous and serious matter, but it offers the only resource. It is made in exactly the same way as enterostomy described previously, and the operation requires no special description here. Very young infants thus affected make bad subjects, and operation should be performed as expeditiously as possible. Considering the danger of leakage it would be well if practicable to wait a few hours after attaching the intestine to the abdominal surface before opening it, in order that the peritoneal cavity may be more perfectly protected.
Even those cases where the rectum communicates with the urethra or bladder should have a natural anal opening. In cases where communication is into the vagina it may be proper to wait until youth or adult age is reached, when more may be accomplished.
INJURIES AND FOREIGN BODIES IN THE RECTUM.
The rectum may be the site of injuries of various kinds from both extrinsic and intrinsic causes. When weakened by disease it may be burst by accumulation and straining, or it may be the site of perforation of ulcer, just as may any other part of the intestine. Although well protected from most directions it may suffer from penetrating wounds, such as stab or gunshot. It is occasionally injured in fractures of the pelvis, and possibilities of such injuries should be excluded in such cases. It may also be lacerated during parturition. The sphincter and even the muscular tube itself sometimes suffer. It has been indifferently wounded or punctured in operations, especially for stone in the bladder and in prostatectomy.
In the absence of disease a laceration occurring in any of these ways may be repaired by prompt suture, although to make a suitable exposure may require an extensive removal of sacrum, or the performance of a laparotomy with the patient in the Trendelenburg position. The rectum is also frequently injured by accidental or intentional introduction of _foreign bodies from without_. Museums, especially the foreign, are full of collections of foreign bodies which have been removed from the rectum, most of which have been placed there with intent, malicious or otherwise. They include objects of all imaginable character, shape, and size, some which are easily introduced and are also easily removed; others which have been passed inward under no small difficulties are removed only with a more or less formidable operation, or have even determined the death of the individual. The ignorant have peculiar superstitions, and the criminal most vicious tendencies, toward the insertion of such foreign bodies, and the complications that may be brought about are too numerous to be rehearsed here.
On the other hand, by actual accident serious injuries may be produced; as in one case under my observation where a boy of twelve fell, in the squatting position, over an iron picket nearly one inch in diameter in such a way as to permit it to pass into the anus, scarcely bruising the mucous membrane, yet entering the pelvis for nearly six inches, penetrating the anterior wall of the rectum, the posterior wall of the bladder, and bruising its anterior wall without perforating it. One feature of the accident was the carrying into the bladder of a piece of his trousers. In this case I opened the abdomen in order to be sure that there was no abdominal complication, closed the major part of the wound, and drew a good-sized drainage tube through from just above the pubes out through the anus, after removing the piece of cloth above mentioned. The boy made a perfect recovery.
The danger in all these cases is of infection, either of the bladder or of the pelvic cellular tissue. In the female similar perforating injuries may involve the vagina or the other female organs.
Some of these accidents or conditions above recounted take place during intoxication. The recurrence of tenesmus, pronounced rectal pain, the appearance of blood either at the anus or in the urine, should in every instance prompt a thorough investigation of the rectum, if necessary under an anesthetic.
PROCTITIS.
Under the term proctitis are comprised acute inflammations of the rectal mucosa, which are characterized by discharge of mucus, mucopus, and perhaps blood, and accompanied by more or less tenesmus, pain, and sphincteric spasm. The conditions which produce proctitis are those which lead to ulceration. It may be the result of a downward extension of trouble from above, as in mucocolitis, dysenteric, tuberculous or other forms of colitis, or it may be the result of infection from below (_e. g._, gonorrheal). An inflamed rectum may be more or less easily exposed for study through some form of speculum (see above), and a more perfect picture of the actual condition thus presented to the eye than can be seen elsewhere, save in the mouth and pharynx, of the effects which serious and even ulcerative inflammation may produce in the way of congestion, swelling, bleeding, and actual breaking down.
_Gonorrheal proctitis_ is not common, yet it may occur either by extension or by direct infection, and will be of an acute type. The other forms may vary in severity according to their cause and duration.
=Symptoms.=--The symptoms differ only in degree, and include the features already mentioned. There are soreness, tenderness, and often pain, especially when the lower part of the rectum, with its numerous sensory nerves, is involved, while reflex pains are referred to the sacrum and the lower part of the back. Sensation of local heat and of soreness is generally noted, while the patient is more or less tortured by frequent desire to evacuate the bowel, but passes perhaps a little bloody mucus with the accompaniment of tenesmus and straining. In acute cases the condition is an exceedingly painful one.
=Treatment.=--Treatment should be begun by a search for and removal of the cause. Relief is afforded by local anodynes, of which the hot sitz bath is one of the most comforting, and by hot rectal lavements of soothing antiseptic fluid, such as linseed tea, to which a little thiol or ichthyol has been added. These should be retained as long as possible, then ejected. Local anodynes may be furnished through the medium of suppositories containing opium, or preferably some of the milder local anesthetics, such as orthoform. Cases which do not quickly yield to this form of treatment should be anesthetized in order that complete exposure of ulcerated areas and vigorous local treatment may be accomplished. A brushing of the entire surface with a 2 or 3 per cent. solution of silver nitrate will frequently be followed by relief, which will be further furnished by sufficient stretching of the sphincter to overcome its painful spasm. The diet should be so regulated as to leave a minimum of undigested residue that may irritate the lower bowel, and laxatives should be so administered that there shall be no coprostasis in the colon, but that whatever enters it shall be speedily extruded. The specific forms of proctitis require specific treatment, for which there is perhaps nothing better than the silver preparations, either the mild, like argyrol, or the active, like solutions of silver nitrate.
ULCERATION OF THE RECTUM.
The causes of the formation of ulcer in the rectum nowise differ from those of ulcer elsewhere about the body. They may be summarized as _catarrhal_, _i. e._, more pronounced and local extensions of non-specific inflammation of the mucosa, which, in certain areas, assume more intense and later infective and degenerative form (in this way are formed the so-called catarrhal ulcers); _specific_, including primary chancre, which is rarely met with high up in the rectum, or the later expressions, varying from mere mucous patches which may abound both within the rectum and around the anus, to the deeper, more destructive, and usually tertiary ulcerations, with destruction of tissue, extensive involvement of surface and most pronounced tendency to subsequent cicatricial contraction when they begin to repair.
What has been said regarding syphilitic ulcer is true also of _chancroid_, which when found in this region involves most frequently the anus, but which may extend or even be seen as a primary lesion higher up.
_Tuberculous ulcers_ are not infrequently primary, usually the accompaniment of advancing and ulcerative infection of the intestine above, or secondary, as frequently occurs when the more innocent forms suffer a secondary tuberculous infection, becoming thus converted into lesions of pronounced type.
_Typhoid ulcers_ in the rectum are rare, but those connected with _dysentery_ are common, especially in localities where tropical or other forms of the disease prevail. The innocent tumors within the rectum, such as polypi and adenomas, etc., tend to break down because they are kept continually macerated and exposed to contamination. Even innocent hemorrhoidal tumors are extremely prone to suffer in this way because their epithelial covering is thin and they are exposed to both external and internal contamination. Finally every malignant tumor which grows into the rectum tends to break down, and sooner or later to present an ulcerating surface. The causes of rectal ulceration are then seen to be various. Nearly everyone of them may be an exaggeration of a condition first producing an acute proctitis.
_Ulcers occupying the anal region_ are usually compressed into a linear form and present rather as cracks or linear abrasions. These are known as _fissures_ and are spoken of as _fissures in ano_ or _rectal fissures_, according to their situation. These fissures occupy the most sensitive portion, _i. e._, the lower inch and a half of the rectum, and become in time irritable, erethistic lesions, whose sensibility is constantly enhanced by the reflex spasm of the sphincter which they produce. An essential part of the treatment of every such case is dilatation of the sphincter, as well as the destruction of the irritable surface, even the former alone often sufficing for the milder cases. Anal fissures, like corneal ulcers, give rise to exquisite pain and annoyance, and produce irritability and general distress. Their treatment is so simple that there is no excuse for allowing patients thus to suffer.
To a peculiar form of combined infiltration and ulceration involving the lower part of the rectum, the anus, and, in females, more or less of the vulva, the French have given the name _esthiomene_. It has been considered due to more or less mixed forms of infection, including those of chancroid, syphilis, tuberculosis, and other undescribed types. It is a mixed infection, and not necessarily of the same type in all cases. It is usually seen in old syphilitic subjects or in prostitutes. It produces more or less deforming lesions, and sometimes such active and protuberant granulations as to cause it to be mistaken for epithelioma or condyloma. It is essentially chronic, and its most striking characteristic is the combination of ulcerative and hyperplastic processes which it presents. Clinically it is a chronic ulcer, with thickened and deformed base and with all the possible consequences or complications of ulcer in this region.
The other forms of ulcer above mentioned appear singly or multiply in any and every possible location, pronounced types presenting extreme pictures of an ulcerated, inflamed, partially destroyed tube, which needs only to be seen before recognizing the advisability of a colostomy for the purpose of rest of the inflamed surfaces.
=Symptoms.=--The symptoms of rectal ulceration are essentially those of proctitis, mild or severe as the case may be, with local pain, and escape of pus and blood. Much depends upon their location, _i. e._, whether within the sensitive area or not. Ulcer low down in the rectum, no matter how produced, will always cause a disproportionate amount of suffering, because of the reflex sphincteric spasm which it produces. On the contrary, ulcers high up give rise to little or no suffering, and may be discovered only after a history of discharge of blood or pus prompts a thorough local examination. Therefore, without reference to the feature of _pain_, every statement that mucus, pus, or blood is discharged from the rectum should lead to an examination, sufficiently thorough to detect and expose the cause and permit of proper treatment. Should local anesthesia prove unavailing for this purpose a general anesthetic must be administered. Thus the non-specific, the syphilitic, and the tuberculous ulcers may be scraped and cauterized, care being taken not to perforate. If ulcerating tumor is found it should be operated upon at once. Sometimes, however, by these examinations unsuspected conditions are revealed such as to give the case a serious aspect. In this event a second anesthetic, with operation, will be necessary. For all ordinary purposes, however, sufficient specula, curettes, the actual cautery, and applicator, by which suitable local treatment can be made to the affected surfaces, should be provided.
=Treatment.=--As indicated above in the treatment of proctitis there is need also for various local anodynes and soothing applications. Physiological rest for the inflamed bowel is imperative. Finally, in extreme cases, it has been shown that it is best to open the colon above the seat of the principal disturbance, doing this even on the right side should the whole large intestine be involved, and by thus relieving it of its duties enable more complete physiological rest and local treatment.
STRICTURE OF THE RECTUM.
The inevitable consequences of any of the serious forms of ulceration above described are, if recovery ensues, and usually even if it does not, the formation of cicatricial constrictions by which varying degrees of rectal stricture are produced. Rectal strictures, then, are to be grouped as:
1. Those due to previous and more or less active, morbid intrinsic processes;
2. Those due to the presence of organized exudate, tumors, or other compressing causes from without;
3. Those due to traumatism.
The _symptoms and signs of rectal stricture_ include those of ulceration and obstruction, or difficulty in defecation. A history of alternating constipation and diarrhea, with perhaps tenesmus, and with discharge of pus or blood, will prove the presence of some obstruction. One characteristic feature met with in some strictures is the passage of stools which when solid or semisolid have a characteristic tape- or cord-like shape, as though extruded through a constricted passage-way. This is not a feature necessarily present, and may be produced even in non-malignant cases, as when the rectum is obstructed by uterine myomas.
With respect to any suspected rectal or colonic stricture it is necessary to determine: (1) Its existence; (2) its location; (3) its character; (4) any other circumstances bearing upon the case which might affect the question of treatment. The latter is particularly important when the question of syphilis is raised.
The above features are determined by careful physical examination for which the finger alone may be sufficient, or which may require instruments and postures already described.
=Treatment.=--Treatment of rectal strictures is necessarily mechanical, but will depend in large measure upon their cause and extent. Thus a stricture produced by conditions extrinsic to the rectum proper might require abdominal section and removal of a pelvic tumor or other similar operation. Many a patient with retroflexed uterus will complain of a rectal condition which is essentially one of stricture, the overturned uterine fundus being forced against the rectum and pressing upon it, demanding not a rectal operation but one for suspension of the uterus. The obstipation which is produced by ptosis of the sigmoid, or by hypertrophy and abnormal arrangement of the folds and rectal valves, may necessitate operation upon the colon (coloplication or colopexy) or a careful division of hypertrophied mucosa through the proctoscope, as used by one skilled in its manipulation.
[Illustration: FIG. 592
Stricture of rectum. (Bryant.)]
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.
=Treatment.=--Could every perirectal abscess be distinctly recognized and properly treated in its comparatively early and localized stage there would be few cases of residual trouble. This treatment consists of early and extensive incision, made externally and directed to the centre of the phlegmonous mass, sufficiently _deeply_ also to reach it. The evacuation of even a small amount of pus, followed by more or less blood, will give prompt and immediate relief, and bleeding may be encouraged rather than checked for purposes of local depletion. Such incision may be in most instances made with freezing spray or local anesthesia. In children and exceedingly nervous patients it would be better done under general anesthesia, in order that it be done thoroughly. It is in patients who decline such early relief, or who, from ignorance or inattention have not received it, that ischiorectal abscesses sometimes assume serious proportions and become extensive phlegmons, breaking down anatomical partitions in the pelvis, burrowing extensively in various directions, since there is considerable fatty and cellular tissue both inside and outside of the pelvis in this region. Thus the surgeon may not see such a case until the entire buttock is involved, or until the process has gone perhaps even farther. Relief now must come from radical application of the same principles, by the aid of general anesthesia, multiple incisions with counteropenings, use of drainage tubes, etc. The patient now is fortunate if perforation into the rectum has not already occurred so that no pus is discharged from the bowel. If this has not yet happened it will probably be prevented by the above measures; but when it has, and a fistulous communication has already been established, it may be sufficient to thoroughly cleanse the infected cavity to see both it and the fistula close by granulation in the course of time. Wide external incisions are necessary in these cases, for complete access to the deep fossæ must be made. In more pronounced cases the pus evacuated will be extremely offensive, and there will be found masses of necrotic tissue, sloughs of fascia, and evidence of extensive local gangrene. Such putrid cavities must be thoroughly cleaned out, and will then be found to quickly resume a healthy aspect when treated by packing with gauze saturated in brewers’ yeast.
The more chronic and slower expressions of this condition are usually connected with local _tuberculous_ disease. In fact every _phlegmon which has passed the acute stage is favorably situated for tuberculous infection_, and becomes in time a tuberculous lesion, which is to be treated on the general principles elsewhere enunciated. These fistulas are often seen in consumptive patients, and apprehension has widely prevailed that the pulmonary disease might be aggravated by radical attention to the fistula. This was only when such attention was made incomplete. To divide the fistulous passage and leave its raw surfaces unprotected and in contact with tuberculous tissue is to invite the spread of infection. To do the proper thing, on the other hand, _i. e._, to radically dispose of all tuberculous tissue and so treat both fresh and old surfaces that a new infection is not invited, is not to make a patient worse in any respect, but to relieve him of at least one focus of disease. There is, therefore, no reason why rectal fistulas should not be radically treated even when they occur in consumptive patients.
RECTAL FISTULAS.
Rectal fistulas are always the consequence of ischiorectal abscesses left to open spontaneously in either or both directions. They may occur also without the preëxistence of a distinct phlegmon, as, for instance, when a small ulcer in the rectum gives way and permits the gradual extension into the perirectal tissues of a mildly ulcerative or suppurative process.
Rectal or anal fistulas are classified as _blind external_, _blind internal_, or _complete_, according as they open and discharge themselves or show a complete passage-way from the rectum to the exterior. They may be small and single, or numerous and extensive. Old and especially chronic tuberculous cases are seen when the whole gluteal region is honeycombed and perforated by numerous fistulas, some of which probably connect with the interior of the bowel. I have seen such openings as low as the knee and as high as the dorsal spines, as the result of extremely insidious advance of tuberculous granulation and its subsequent breaking down. In such cases a history of an acute phlegmon occurring years previously may be obtained.
A _blind external fistula_, simple or complicated, naturally discharges its pus upon the exterior. It may be accompanied by little or no local tenderness or pain. A _blind internal fistula_ makes itself known by a certain amount of rectal tenderness and by the discharge of pus with the stool, or at other times of pus which may possibly be blood-stained. Here there may be a history of old trouble, with external evidences of it, which suggests that exterior communication has been shut off while that with the bowel remains. In _complete fistulas_ there is discharge not only of purulent material, but of more or less of that which is distinctly fecal, while gas sometimes escapes through them. Such a statement made by a patient is of itself significant. A fistulous passage may be surrounded by more or less infiltrated and inflamed tissue, or it may appear much like a duct. While always causing more or less annoyance, it may produce symptoms which seriously disturb. (See Plate LIII.)
=Treatment.=--The treatment of rectal fistula in any of its forms is distinctly surgical and should always be radical. A blind internal fistula can be discovered only with the speculum.
Every such fistulous passage should be split up and its tubular portion thoroughly excised or destroyed with a sharp spoon or caustic. Furthermore it should be followed to its ultimate ramifications. For this purpose it is of great assistance to first inject it with methyl-blue solution, or something else which shall stain it and make it recognizable wherever it may extend. To incise a superficial and external fistula is a simple matter, for which local anesthesia alone may suffice; but to deal radically with an extensive fistulous tract requires dilatation of the anal sphincter and such thorough investigation, with complete relaxation of the patient, that general anesthesia is needed. Now with a probe identifying the tract, and the knife and spoon made to follow it, or by identification of the stained tissues colored as above mentioned, the surgeon should proceed to the extreme of every morbid passage-way, dilating, cutting, trimming, scraping, as may be needed; while after the work is done every particle of disturbed raw surface should be cauterized with some reliable caustic (such as pure carbolic followed by alcohol) so as to sear the surface and prevent the possibility of reinfection.
To do this operation thoroughly necessitates sometimes multiple and extensive incisions, with a fierceness of action which may cause surprise. It is, however, the only effective way in which to proceed.
[Illustration: PLATE LIII
Illustrating Various Forms of Rectal and Anal Fistulas, and the Conventional Methods of Dealing with Them. (Bernard and Huette.)]
One source of doubt and disappointment is met occasionally in the radical treatment which requires division of the sphincter, for to completely divide this muscle is to practically paralyze it and leave the patient thereafter with fecal incontinence more or less marked. Such accidents leave more or less disabling consequences. Usually they are avoidable, for it is rarely necessary to cut completely through a sphincter muscle, it being possible to avoid the necessity by partial division, with perhaps more complete exposure above and below. Even in those instances where it seems unavoidable if the muscle be first vigorously stretched, and thus temporarily paralyzed, it may then be safely divided, provided it be neatly and completely sutured _at once_, and the parts kept at rest for a few days, the intent in stretching the muscle being partly to so weaken it that it shall be temporarily disabled. It was suggested years ago by Jenks, of Detroit, and later by Kelly and others, to make a complete excision of the entire fistulous tract and then to treat this as any other fresh wound, closing it completely with sutures. The method is good in theory and occasionally applicable, and should not be neglected when circumstances favor its practice.
Every fistulous tract, simple or complicated, not promptly and neatly closed, should be dressed with gauze, with or without yeast, balsam, or some one of the other local applications recommended elsewhere in this work.
PROLAPSE, PROCIDENTIA, AND INVAGINATION OF THE RECTUM.
Prolapse of the rectum is observed in two degrees, either as a mere _eversion of its mucosa_, which, however, may be profuse and extreme, or as an actual _escape by process of invagination_ through the anus of some portion of the rectal tube, with all its coats, including in well-marked cases even its peritoneal covering. The former is more common in children as the result of diarrhea, colitis, the presence of pin-worms, or other parasites, or any other cause which produces tenesmus and frequent straining, with consequent relaxation of the anal sphincter. It is amenable to treatment and is usually of insignificant proportion. It is also frequently seen in adults in connection with internal hemorrhoids, which are extruded with every stool, carrying with them more or less mucosa, and which are usually returned within the rectum by the patient at the conclusion of the act of defecation.
The more complete form of prolapse by true _invagination_ is rarely seen, save in adults, and in consequence of some serious preëxistent condition, such perhaps as complete laceration of the perineum in the female, paralysis of the sphincter from previous accident, or from the existence of spinal-cord disease. Here and in extreme cases several inches of bowel may be extruded from the anus, and to an extent scarcely permitting spontaneous or even individual restoration. So complete a form is permitted only by some previous lesion of the pelvic floor, while the mesorectum and even the mesosigmoid become gradually stretched and useless. The lower portion of the rectum is by far the more muscular, and such a condition requires that its intrinsic muscles yield also with those around them.
_Prolapse_ is a condition of general and usually slow development rather than of abrupt onset. It is made known by the presentation at the anus of the bright-red mucosa of the rectum, where it pouts and protrudes, forming a tumor of varying size, with more or less tender surface, which, with gentle coaxing pressure, is easily made to return within the rectum. It can usually be made to appear by straining effort on the part of the patient. Boys with phimosis, who are in consequence made to strain every time they urinate, will frequently present minor degrees of the condition, perhaps oftener than when the rectum itself is at fault, as the act is so frequently repeated. The oftener such protrusion occurs the more relaxed becomes the anus and the more irritated the presenting surface, until ulceration and even keratosis may result. Chronic constipation of children or adults will also produce the same effect. The presence of hemorrhoidal tumors or of polypi, or even of parasites, causes the same result.
The most pronounced and complete types of invagination produce a condition in which reduction is perhaps not possible and procidentia is constant. There may form here a pouch around the rectum, containing loops of bowel, bladder, or ovary, or there may even occur a perirectal hernia.
While patients nearly always become more or less accustomed to the condition it nevertheless is distressing in proportion to its size and the individual’s temperament.
=Treatment.=--Treatment depends entirely upon the nature and extent of the condition. Mild forms occurring in young children may be easily obviated by attention to their stools, by circumcision if needed, or by the use of a five-grain capsule of ergotin inserted as a suppository, it having the effect of invigorating the involuntary muscle and stimulating the sphincter. Cases not amenable to the milder methods become surgical and the treatment is then apportioned to the extent of the lesion. If connected with hemorrhoids or other tumors it becomes a part of their treatment and is to be dealt with at the same time. Occurring apparently independently the milder forms will often yield to the proper use of caustics. The actual cautery being preferable, it is applied in streaks up and around the rectum, in such a way that, when the ulcers thus formed cicatrize, the rectum shall be shortened by cicatricial contraction as by a series of loops drawn up to shorten it. When permitted by rupture of the perineum and more or less combined perhaps with cystocele, repair of the perineum, rather than attention to the rectal condition itself, will be demanded, while the latter may be combined with an operation for rectocele by excision of an elliptical portion of the vaginal mucosa and the approximation of its edges into a line of sutures. This will reduce the capacity of both the vagina and the rectum and a double indication be thus met. Acute inflammation sometimes follows exposure of a prolapsed rectum and it may slough, thus leading to spontaneous recovery, the process not being without its dangers of thrombosis and septic infection. This procedure may be imitated by a surgical excision of the entire prolapsed portion, always with great caution so that if peritoneal surfaces be exposed they be protected from infection. It has been possible in many instances to completely excise the protruding portion, and then to apply a double row of sutures similar to those used in intestinal resection, only with attention first to the peritoneal rather than the mucous surface, in such a way as to excise several inches of the prolapsed bowel and thus meet the indication. Nevertheless cases where this can be done are exceptional.
Pratt has suggested a _temporary_ purse-string suture of the anus, effected by a curved needle, completely circumscribing the anal opening, but kept between the skin and the mucous membrane, to be brought out through the same puncture at which it was inserted. The finger of an assistant being passed into the anus, the suture is now tied around it. This may be used as supplementary to linear cauterization above mentioned.
Numerous methods of _proctopexy_, or elevation and fixation, have been devised. Fowler, for instance, made an incision half-way between the anus and the point of the coccyx, and after separating the rectum from the latter and the sacrum inserted two fingers in the rectum, holding it up while its posterior wall was forced into the external wound and there held by heavy sutures of kangaroo tendon. By further incision he brought out the ends of these sutures on each side of the coccyx and tied them across the bone, thus by traction bringing the rectum up into position.
_Colopexy_ has been practised as a more radical measure for the same purpose. As advised by Bryant the abdomen is opened by an incision parallel to Poupart’s ligament on the left side and one inch above it, and the prolapse is reduced by firmly pulling the rectum upward. It is then secured to the peritoneum about it, and is held by quilting sutures, which include the entire muscular coat of the bowel. Save in exceptionally favorable cases one or the other of these methods may be considered preferable to the complete amputation above described.
HEMORRHOIDS; PILES.
Hemorrhoids constitute perhaps the most common and, in some respects, uncomfortable or distressing disease of the rectum. The term implies a varicose condition of the lower veins, sometimes those of one set of hemorrhoidal veins being involved, at other times nearly all of them participating. They are spoken of as _external_ or _internal_. In the former case it is the external hemorrhoidal veins alone which are involved, and usually only two or three of them, although occasionally one sees outside the anus, as within, a general involvement of the entire venous distribution. A _pile_, then, is essentially a venous angioma, or a single varicosity, and its peculiar features are due solely to its location.
Any vein thus involved is liable to the same dangers and accidents as veins in other parts of the body. Thus it may undergo dilatation, thrombosis, and suppuration, while the ordinary consequences of the latter condition may follow here, as elsewhere, with this difference alone, that when the middle and upper hemorrhoidal plexuses are involved the thromboseptic process, should it occur, follows the _portal vein_, and the first metastatic abscess that forms occurs _within the liver_. Thence it may spread to other parts of the body in classic form.
The hemorrhoidal veins, save those at the verge of the anus, are more or less entangled among the fibers of the levator ani and the sphincter. These muscles are thrown into a condition of more or less spasmodic contraction when the veins are so involved. In consequence more pressure is made upon the veins themselves, and the conditions of spasm and venous engorgement react upon each other in a vicious circle, each tending to make the other worse. Hence the great advantage of _stretching the sphincter_ in any operation save that for a small external pile.
Hemorrhoidal angiomas may appear as single tumors or in multiple form surrounding the lower part of the rectum. The most common cause for their occurrence is chronic constipation. Occasionally the first exciting agent is some violent strain in defecation, or possibly the actual rupture of a small vessel, but such constant overloading of the rectum as obstructs its return circulation conduces to engorgement and the other conditions may easily follow. A small pile may be brought into existence in brief time, but a general hemorrhoidal condition is one of slow development. Chronic cases are always accompanied by further changes involving the surrounding connective tissue and the overlying mucosa, both of which become thickened and infiltrated, while ulcers form frequently upon the latter, and the occurrence of those linear ulcers which are ordinarily called _fissures_ is very frequent. This gives an additionally distressing feature to these cases. As the condition goes on and the angiomas increase in size there is an increasing tendency to prolapse. This may be temporary or constant, _i. e._, it may occur with the straining effort at stool or it may result in a condition of permanent protrusion at the anus of the engorged mucosa; or, if the sphincter has finally become prolapsed a true prolapse of the rectum may result. A mucous surface thus constantly exposed to irritation will nearly always be more or less ulcerated and tender, while hemorrhages in either variety are common. It is not an infrequent event, then, for a patient to lose a number of ounces of blood with or just after stool, and sometimes the blood loss is even excessive. There is then added to the local condition a secondary feature of anemia and its attendant consequences which are sometimes extreme, and may even make operation somewhat hazardous. The lower inch and a half of the rectum is the portion particularly supplied with sensory nerves, and, under these circumstances, the irritated area becomes erethistic and painful and the patient’s suffering may be extreme. This is the so-called “_pile-bearing area_,” as it is within it that the hemorrhoidal condition is practically confined. Even a small individual pile connected with one of the little external veins may give rise to a disproportionate amount of discomfort.
There has been so much quack literature upon this general subject that ignorant patients are very likely to say that they have piles, no matter what may be the local condition. A statement to this effect should, first of all, provoke a physical examination with the finger, then with the speculum. The educated finger will easily detect the presence of the rugosities or tumors produced by internal piles, the external being always self-evident. The coexistence of ulceration will be indicated by an extreme degree of sphincteric spasm and of tenderness. It should be remembered that, along with hemorrhoids, there may coexist fissure, ulcer, painful spasm, prolapse, and, in long-existent cases, even cancer. The average patient with cancer of the rectum will go to his physician saying that he thinks he has piles.
=Treatment.=--Treatment needs to be something more than merely local in aggravated cases, as it should also be more comprehensive. Patients who have thus long suffered have almost inevitably contracted the constipated habit, postponing defecation whenever possible because of pain and tenderness, and perhaps the hemorrhage accompanying it. The large bowel has, therefore, become weakened, and attention should be given to it as well as to the general digestive process.
_Locally_ very mild degrees of purely temporary disturbance may be sometimes acceptably and temporarily treated by the use of suppositories containing some soothing and anodyne drug, as well as ergotin, the latter being valuable because of its constringent effect upon the bloodvessels. A five-grain gelatin-coated pill of ergotin makes a satisfactory suppository for the young, under these conditions.
A freshly formed, external hemorrhoid, which may attain a size no larger than that of a pea, but which will seem to the patient as large as a bird’s egg, is best treated by _open division_, turning out the blood or clot contained within the dilated vein, which will quickly obliterate, so that recovery will be complete within two or three days. This may be done under local anesthesia and with prompt relief. There have been methods in vogue, especially among the charlatans and some of the specialists, of treating external and the more localized internal conditions by _injection of carbolic acid_, either pure or reduced with a little glycerin. A few drops are thrown into the tumor with a hypodermic needle, the effect being to promptly coagulate the contained blood, the intent being to produce a final cure by absorption of the clot and obliteration of the veins. This, in fact, is the secret method long employed by the travelling charlatans and often connected with the name of Brinkerhof. It is uncertain in action, and the production of a clot under these conditions is by no means always free from danger, nor is the relief prompt. What is desired is to empty the vein and turn out the clot rather than to provoke its production. The method is rarely practised by judicious surgeons, who have too often seen serious sloughing and even general septic disturbance follow it.
For the _radical relief_ of distinctly hemorrhoidal conditions there is no satisfactory method save the operative. So many measures have been devised in time past that it is necessary here to be selective and only mention one or two. On general principles every pile is a venous tumor, and there is no reason why it should not be treated like any other tumor, _i. e._, by _enucleation or excision_. The same is true of the area which contains a number of such tumors, _i. e._, the so-called pile-bearing area. Hence, surgeons of the largest experience have practically discarded the more bungling methods and have applied to these conditions the same radical measures which they recommend elsewhere.
One important feature which should always be practised is thorough _dilatation of the sphincter_, not only for reasons above described, but because of the facility with which the surgeon then exposes the diseased tissues. Any distinct tumor or series of them may, for instance, be seized, isolated, and dissected out, either by an elliptical incision of the mucosa or by a more blunt dissection with scissors. The base, or pedicle, if sufficiently large to justify it, may be ligated before the incision is completed, after which catgut sutures may be used to close the opening in the mucosa. When the tumor is small the suture may be made to include the bleeding points so that even a ligature is not required. A more radical method of extending this same principle to the entire pile-bearing area, especially when prolapsed, or to so much of it as is affected, is the so-called _Whitehead’s operation of excision_, which practically consists in trimming off a ring of exposed mucosa, with its clusters of enlarged and more or less pendulous veins. This ring extends from the mucocutaneous border, at the verge of the anus, to a point perhaps 1¹⁄₂ inches above, the intent being to separate the mucosa and the tumors from the fibers of the sphincter, which can be practically effected in such a way that sphincter control is not lost. Hemorrhage will be free for a few moments, but is always within control. Larger vessels which spurt may be twisted or tied, while oozing surfaces are included within the row of catgut sutures, which is later placed in such a way as to unite the divided mucous tube with the skin border at the anus. The operation is, in effect, an annular excision of the lining of the rectum, and as such proves satisfactory. There is about it this temporary disadvantage that the pile-bearing area thus removed is also the sensitive area, and that for a few weeks, at least until nerve communications have been reëstablished, there is a lack of peculiar or normal sensibility about the parts which is annoying, and may perhaps lead to some incontinence, but this soon passes away. The measure is the most satisfactory of all for well-marked cases of hemorrhoids associated with more or less ulceration and prolapse.
An occasional dilatation, scattered here and there around the lower end of the rectum, perhaps with a mild degree of ulceration, is usually very satisfactorily treated by a method which it must be confessed would be rarely used on the exterior of the body, and yet which proves quite serviceable here, namely, the _actual cautery_. The consequences of its application are obliteration of the vein, cicatricial contraction of the overstretched tissues and eventual relief.
[Illustration: FIG. 593
Multiple polypi of rectum. (Potherat.)]
Other methods of operation include the use of the _clamp and cautery_ for removal of considerable masses, a method ordinarily less satisfactory than excision, and the use of the ligature, with or without incision of the mucosa at the base of the tumor, it being thus cauterized and expected to separate by sloughing, an uncertain procedure. None of these methods, nor others not worth mentioning, compare with the newer methods of excision.
Much has been recently written concerning the advantage of local anesthesia in doing these operations. This seems to have been advocated largely for effect, although external tumors can be treated by cocaine applications or by the ordinary injections of cocaine or one of its substitutes. It is claimed that the infiltration of the surrounding tissues with normal salt solution affords an effective local anesthetic. Mere local anesthesia is not sufficient for thorough work upon parts not easily visible, and the actual stretching of the sphincter is half the battle in dealing with these conditions. This cannot be thoroughly accomplished without general anesthesia. Consequently for any well-marked hemorrhoidal condition chloroform offers decidedly the preferable method, not alone from considerations of comfort, but from the standpoint of permitting more thorough and effective work to be done.
After these operations it is advisable to place within the grasp of the anus a stiff rubber tube wrapped with gauze. It permits the escape of flatus without distress to the patient, and it effects a better coaptation of surfaces recently united by suture than would otherwise be secured. Such a tube may be left _in situ_ for from six to thirty-six hours.
TUMORS OF THE RECTUM.
The rectum is the frequent site, more especially in children, of _polypoid degenerations_ similar to those seen in the nose. In consequence there are formed the so-called _rectal polypi_, which, in origin, consistence, and course correspond to the common nasal polypi. Such a pedunculated tumor may attain considerable size, especially when solitary, while, on the other hand, the mucosa may be studded with small pedunculated growths, giving the appearance represented in Fig. 593.
Pathologically these polypi are originally of myxomatous or adenomatous type. They may bleed easily and may be passed with stool. In their multiple and smaller expressions they give rise rather to rectal uneasiness and tenesmus than to more distinct symptoms. On the other hand an isolated tumor, so pedunculated as to become gradually stretched out, may attain considerable size and give rise to all the sensations of a foreign body in the rectum, with constant tenesmus and desire to expel it, while it may even present at the anus or bleed freely.
Only exceptionally will these tumors be recognized previous to examination, which, however, should easily disclose their characteristics. Isolated polypi should be removed, either by being twisted off or by excision and ligature of their bases. General polypoid degeneration may be treated with the curette or with the actual cautery. In all these instances surgical intervention in some form will be required.
Other _benign tumors_ in the rectum are mainly of the _adenomatous_ type. Owing to their location it is rare that they are seen early by one competent to judge of them. In consequence the surgeon sees them usually as more or less ulcerated, sometimes extensive growths, perhaps bleeding freely, and much changed by maceration and by compression from their original condition.
In such cases it becomes a question of importance to distinguish between the benign and the cancerous growths. This is not always easily done, especially when they are high up and ulcerated. The matter is usually decided by the presence or absence of actual infiltration around the base of the growth, and perhaps the involvement of lymph nodes. A movable tumor with an infiltrated base is usually clinically benign, nevertheless it should be radically removed. It is in many of these instances that one may see expressions of transformation of adenoma into carcinoma.
=Cancer of the Rectum.=--This will be considered here rather from its clinical side; hence what is said refers alike to sarcoma and carcinoma, the latter being far more common. _Carcinoma of the rectum_ may assume the type either of epithelioma, as when it begins low and spreads upward, or of adenocarcinoma, when it arises from that portion of the tube not lined with squamous epithelium.
It usually begins _insidiously_, and for a considerable length of time furnishes scarcely any recognizable symptom. The first indications noticed by the patient are usually more or less frequency of stool, with tenesmus, and the passage of mucus, perhaps stained with blood, rather than of fecal matter. By the time those conditions are noticed there will usually be more or less mechanical difficulty of defecation, due to the presence of the tumor and obstruction of the rectal tube. Pain may be a long-deferred feature, and local soreness may be absent until late in the case or until its terminal stage, when the growth is above the peculiarly sensitive part of the rectum, _i. e._, when it does not approach to within 1¹⁄₂ inches of the sphincter. As time goes on there is more and more suffering in the rectum, with backache, referred pain, while the tenesmus and other local conditions cause increasing distress. It often happens that it is not until this period is reached that the patient consults a physician, and then he usually goes with the statement that he is suffering from piles.
[Illustration: FIG. 594
Epithelioma of anus and rectum. (Grant.)]
So frequently is this the case, and so prone are many practitioners to accept such a statement, that the proper examination which should permit the recognition of the condition is perhaps not made until the patient is really in a pitiable condition. _I do not recall ever having seen a case of cancer of the rectum which had not been regarded, by some physician as piles, and in most cases locally treated by him, usually without any adequate local examination_, and usually also until the time had passed when a radical operation could be practised with any degree of hope. The first examination at least will be digital, and if the malignant growth be within reach of the finger it should be possible to appreciate it, to estimate its size, degree of attachment, and the amount of infiltration, as well as the extent to which it is breaking down. A soft, rapidly growing cancer will give a fungous sensation to the finger, while the more dense, scirrhous forms produce hard masses, growing in irregular shapes, sometimes involving one side of the bowel, sometimes appearing in annular form, and tending sooner or later to produce malignant destruction. The only difficulty would be in cases seen exceptionally early or in those beyond reach. The circumstances above detailed should lead to a careful _proctoscopic examination_ with suitable instruments, perhaps in the knee-chest position, when the growth is not easily appreciated from below. _Any complaint of tenesmus, with discharge of blood and mucus, with more or less pain and tenderness, local or referred, demands an examination sufficiently careful to reveal the nature and extent of the lesion and indicate the treatment._ If such an examination call for an anesthetic, it should be administered. Practically every rectal cancer is a malignant ulcer by the time it is recognized, ulceration being favored by warmth and moisture.
=Treatment.=--There are few malignant lesions anywhere about the body which require more good judgment in treatment than cases of cancer of the rectum. So much depends upon their location, their extent, the degree of infiltration, the age and general condition of the patient, that it is almost impossible to lay down succinct rules. The question of treatment hinges, first, upon the location and extent of the lesion; is it operable or is it not? When the lymph nodes of the pelvis or the groin are noticeably involved it is practically too late, under any circumstances, to hold out prospect of radical cure. When the disease has extended far above reach of the finger it is again late to expect much even from radical measures. When the prostate, the floor of the bladder, the vagina, or any of the pelvic viscera are involved it is again too late to justify them. There are wide differences of opinion between surgeons as to the propriety of extensive operations in serious cases. Mild cases are certainly much benefited and even actually cured by early and thorough removal, but this occurs too infrequently, because such cases are rarely seen sufficiently early.
The class of cases universally acknowledged to be inoperable, so far as radical measures are concerned, are nevertheless much benefited and their lives prolonged by a _colostomy_, the effect being to provide an easy and manageable outlet for fecal discharge, and to avoid the irritation and attendant difficulties associated with an obstructed and malignantly ulcerated rectal outlet. The surgeon has to select between some method of excision and colostomy. My own opinion is growing in favor of the latter, save when the prospect of complete excision is good. The opening is more manageable, the progress of the disease seems much checked, patients have better fecal control and live in far greater comfort, while their lives are placed in less jeopardy, and, in general, are actually prolonged. Thus a colostomy performed in a well-marked case of inoperable cancer of the rectum may permit of prolongation of life for two or three years, something not often attained by any other method of treatment.
Of the various _radical operations_ some are made from below, _i. e._, by the perineal route, some by the so-called sacral route, and some from above. Of the latter it may be said that occasionally an annular cancer of the rectum is seen so favorably located that by opening the abdomen with the patient in the Trendelenburg position it is possible to make a complete excision of the growth, to remove enlarged lymph nodes, and to make an end-to-end reunion with success. In a case in my own practice nearly six years have elapsed since this operation was done, and the patient, a young woman, is still absolutely free from the disease.
Through the _perineum_ the lower portion of the rectum may be attacked either by splitting the sphincter and dividing it posteriorly, completely dissecting out the gut from its surroundings, removing all infiltrated tissue, and then, by dividing the bowel above the growth, amputating the lower part. It may be possible to bring down the upper end and attach it to the mucocutaneous border of the anus, reuniting the divided sphincter, and aiming for a restoration to something like the original condition, which under quite favorable conditions is attainable. At other times it will be impracticable to thus attach the lower end of the tube because it has been too much shortened, and in these cases it should be brought out through a posterior incision just below the tip of the coccyx, or higher up if the bone has been removed. Here the rectal outlet is placed posteriorly, but is devoid of a sphincter. Something like sphincteric action can be provided by giving it a third or half of a revolution on its axis before fastening it to the external wound. After this expedient more or less control of solid fecal matter is afforded.
The more complete and radical operations, associated with the names of Kraske and other operators, include removal of the coccyx, and of the lower portion of the sacrum, which are usually completely excised, although certain “trap-door” operations have been devised. If the sacrum be not cut away above the third sacral foramen there is not much damage done to the nerves, while sufficient room is afforded for any removal that is justifiable. Some operators open the peritoneum, others attempt to avoid it. If the growth be attached to that membrane it becomes necessary. If peritoneal invasion can be avoided it is desirable. It is possible to completely expose the contents of the pelvis through such an opening, while from this direction, the gut being withdrawn after the peritoneum is divided, the pouch of Douglas may be opened and further removal of diseased tissue be effected. In all these operations the endeavor should be to disturb the mesosigmoid and the mesorectum as little as possible, in order to not interfere with blood supply, for reasons already mentioned when discussing the mesentery.
In all these operations contamination of the wound should be avoided, especially of the peritoneum, by clamping or ligating the bowel, or by amply packing and by every possible additional precaution. Bowel should be divided between two clamps and the divided edges at once thoroughly cleansed with compresses and with hydrogen peroxide.
One may read in the works on operative surgery descriptions of most extensive and elaborate operations of this general character, and of extensive and even daring feats of removal, where portions of the bladder, of the tubes, of the ovaries, even the uterus, have been removed. It has seemed to me that the surgeon should avoid operative gymnastics, especially in this region, so far as possible, and confine himself to measures which if successful would improve conditions rather than complicate them. My own judgment then is that in any case where so formidable an operation would be attempted by some, the best interests of the patient will be served rather by simple colostomy.
_Early_ operations upon cancer of the rectum afford comforting prospects. It is not so much to the discredit of surgery as to the discredit of the patient’s judgment, and of the carelessness of the practitioners who first see these cases, that cancer of the rectum has become such a _bête noir_ and is justly regarded as so serious and unpromising a measure.[60]
[60] It becomes a question of importance just when and where we should cease to attempt operation on the colon from above or on the sigmoid from below; in other words, the exact location of the tumor should decide the measure when it can be accurately determined. Moreover, a wide margin of bowel on either side of any new-growth which is about to be resected should be excised. The question of blood supply to the margins of the wound thus made is also of importance, as the most ideal operation in appearance may be marred by gangrene due to lack of sufficient blood supply. When there is sufficient uninvolved gut below the tumor to permit of complete operation within the abdomen it is not advisable to do anything from below; but there are some cases in which anything like complete removal can only be effected by a combination of abdominal and sacral routes. A thorough extirpation should be made above the growth as well as of the involved tissue below. Those vessels which require ligation should be tied accurately at the level of their division, and no ligation of trunks or larger vessels should be attempted at any distance from the line of division. If this be carefully carried out and the divided mesentery, with its ends, and all the fat between the rectum and the sacrum be carefully dissected out, there will rarely be difficulty in making an end-to-end reunion of the divided bowel.
It is rarely necessary to include a colostomy with this procedure; in fact, when a permanent opening has become necessary there is little possibility of removing the main growth. Colostomy is a procedure for the hopeless cases; resection is rarely to be thought of as an alternative. It should be an early not a late measure, the reverse being true of colostomy, though even this should not be _too_ late.
=Colostomy.=--Colostomy for relief of rectal cancer is not a radical operation, but in many cases is far more humane and satisfactory than are those alluded to above. The intent is to make an opening in the left side of the groin at a point where it is easily made. There are two methods of performing colostomy here. One is to make an opening through the abdominal wall, attach to it the presenting surface of the sigmoid or colon, and either open it at once or some hours later, when adhesions have cemented the desired union. Such an opening may be made for emergency purposes under local anesthesia, but when the colon is movable, and when the disease has not yet involved the area thus exposed, or any portion above it, a more desirable method is a deliberate one. An opening is made such as is usually made on the right side when operating upon the appendix. The bowel thus being accessible is divided between two clamps, while the end of the lower segment is inverted and closed with chromic or silk sutures, after which it is dropped back. This leaves the upper portion with its open end corresponding to the abdominal opening, into which it is fastened by a series of sutures, being attached to the peritoneum and to the deep musculature rather than to the skin, for if it be brought out too freely and attached externally there is greater tendency to prolapse and subsequent discomfort. Into the opening thus afforded a large-sized rubber or bent glass tube is inserted for a few inches, around which gauze is packed, and every effort is made to conduct fecal matter to the exterior, as well to protect, at least for a few hours, the wound itself from fecal contamination. Improvements in this technique have been suggested, such as tying into the bowel a curved glass tube, thus conducting its contents into a rubber bag or receptacle placed outside the dressing. Another method which has been suggested by Stewart is to connect the interior of the colon by a Murphy button with a rubber bag or rubber dam upon the outside of the abdomen, by which protection for this purpose can be afforded.
This operation makes a complete and final division of the colon, and permanently excludes the rectum with its cancerous involvement. It is not, therefore, in this respect, a radical measure. The result, however, is that if the rectum be washed from below each day it is kept far cleaner and freer from contact with irritative foreign material than it otherwise would be. Furthermore, being disused it tends to undergo to some degree a species of physiological atrophy, and, in consequence, the cancer grows more slowly, if there do not occur an apparent temporary cessation of malignant activity.
By suitable management of the artificial anus, including the deliberate emptying of the bowel every morning and the use of protective pads for receptacles, it can be made far less disagreeable than patients ordinarily fear (Figs. 595 and 596).
[Illustration: FIG. 595
Gleason’s pouch and supporter.]
[Illustration: FIG. 596
Colostomy pad and bag, worn as is a truss. (Kelsey.)]
The colostomy opening in the abdominal wall should be made as small as practicable lest there occur not only more or less ventral hernia through the weakened outlet, but even, as I have seen in one case, a most extensive prolapse of the colon, in which two or three years after performance of the operation the colon could be made to prolapse to an extent of twelve or fifteen inches.
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