the subjacent vertebræ. It is usually situated in the lumbar region,
sometimes in the dorsal, and often over the sacrum. The size of the
swelling varies according to the age of the child, and the extent of
deficiency in the parietes of the spinal canal. The spinous processes
are either imperfect or altogether wanting, and over the space so
formed the tumour is situated. Its contents are usually of a serous
character, thin and colourless; sometimes they are turbid and flaky.
The parietes seem to be a continuation, or protrusion, of the membranes
of the spinal chord, thickened and somewhat altered in structure,
and usually in close contact with and adherent to the integuments.
By pressure the size of the tumour is diminished; but, if firm or
long continued, unpleasant effects are apt to result. There is often
debility of the lower limbs, and the disease is not unfrequently
coexistent with hydrocephalus. Children with this affection seldom live
more than a few years.
The application of gentle, uniform, and continued pressure affords
support to the parts, and prevents increase of the tumour; and, under
this palliative treatment, life may be both rendered more comfortable
and prolonged. It has been proposed to combine continued pressure with
occasional puncturing of the cyst by means of a fine needle, with
the view of diminishing the tumour and ultimately obtaining entire
obliteration of the cyst. The practice has been made trial of, and the
result may warrant repetition; caution, however, is necessary, for the
too free opening of the tumour is often followed by a rapidly fatal
issue. A case occurred to me not long since, in which the tumour, of
large size, was situated over the sacrum. The fluid was evacuated by a
small trocar and canula, the parietes shrank, and a very satisfactory
cure resulted.
AFFECTIONS OF THE RECTUM AND NEIGHBOURING PARTS.
_Of Hemorrhoids or Piles._—Piles are blind, furnishing no discharge,
except a mucous or puriform fluid; or open, pouring out a greater
or less quantity of blood from time to time. They are usually of
small size, invested by the mucous membrane, thickened, congested,
and consequently of a dark colour; and either within the sphincter
or projecting externally. Internally, they may sometimes consist of
blood, coagulated or not, effused between the mucous and muscular coats
of the intestine; but in general their inner structure is venous,
at least in the first instance. Branches of the hemorrhoidal veins,
ramifying near the inner surface of the gut, become varicose, probably
from their superior trunks being compressed by hardened feculent
matter or other obstructions. The varix protrudes the superimposed
mucous membrane; and at first the excrescence is composed of the
dilated venous trunks containing fluid blood, and invested by the
membrane, which inflames, thickens, loses its villous character, and
discharges a vitiated secretion. In this stage the tumour is easily
compressible, and by pressure may be made to disappear almost entirely,
the communications between the varicose vessels and the trunks above
being still unobstructed. But inflammatory action is soon kindled in
the incommoded venous branches, as frequently happens in varix of
the lower extremities; their coats become changed, are thickened,
effuse lymph externally and internally, adhere to one another, and
are ultimately matted into one confused and solid mass; the contained
blood coagulates, becomes fibrinous, the whole tumour feels hard and
firm, and often is exceedingly painful. At length all traces of venous
structure disappear; the tumour seems to consist chiefly of effused
lymph, condensed cellular tissue, and coagula.
In not a few instances, however, the contents of the veins remain
partially fluid, and a communication exists between the vessels of the
tumour and those of the surrounding parts.
That such is the usual structure of piles I am convinced, from repeated
and careful dissection of the tumours.[48]
The neighbouring parts often swell and inflame. Sometimes one or two
tumours only exist; or they occur in numbers, clustered together, and
form a large irregular mass, inflamed, and often ulcerated. Acute
pain is experienced in the part, when touched and after straining at
stool; by straining too, such as are attached within the sphincter are
pushed out, together with folds of the mucous membrane, and, if allowed
to remain, are constricted by the sphincter, swell in consequence,
ulcerate or slough, and discharge blood. The bleeding often is very
violent in such cases, or when the tumour is punctured; the blood
flowing in great quantity, and in a rapid stream. The hemorrhage is
often periodical, both in males and females; in the latter, it would
seem occasionally to take the place of the menstrual flux. The soft
bluish tumours that are compressible, and fluctuate when large, furnish
blood more readily and profusely than the hard and tuberculated.
Much irritation is produced by piles, and some of them are more
irritable than others. There are often extensive excoriation of the
nates around, and profuse discharge from the raw parts, particularly
when the tumours are external. In such cases, flat, hard, warty
excrescences often form in the cleft of the nates, and increase the
irritation; and these are termed fici, mariscæ, and condylomata.
In internal piles, a frequent desire to go to stool is induced, and
more or less of the mucous coat of the rectum is protruded and swollen.
The tumour, along with the protruded portion of bowel, may become
strangulated if not replaced. By such or other causes inflammation is
excited, which often extends to the neighbouring parts, and terminates
in abscess; but this is not so apt to occur from tumours seated high in
the rectum as from those about the verge of the anus.
The usual cause of piles is obstruction to the return of blood in the
hemorrhoidal veins; and this may be occasioned by advanced pregnancy,
habitual distension of the colon and sigmoid flexure, with hardened
feces, or tumours of the abdominal viscera.
_Inflammation of the Rectum_ is attended with excruciating pain,
burning heat, and a feeling of contraction, increased very much when
the parts are thrown into action by evacuation of the contents of the
bowel, or of the bladder. The heat may be felt on introducing the
finger, with the view of examination; by doing so, dreadful torture is
produced, and such manipulation should not be had recourse to unless
there is a suspicion of foreign matter lodging in the part, by removal
of which the action might be cut short. The bladder is often affected
sympathetically; there may be frequent desire to empty it, or else
retention of its contents: this latter occurrence not unfrequently
follows operations on the bowel, as for the removal of hemorrhoids,
by ligature or extensive incision, which is neither warrantable nor
requisite. The inflammation extends to the cellular tissue round the
rectum, with swelling and increased pain; the pain is aggravated by
pressure, and the patient is unable to sit erect. As the painful
symptoms abate, puriform discharge from the membrane of the gut takes
place, and often is very profuse. The morbid action sometimes extends
to the other intestines, attended after a time with mucous or even
bloody evacuations. When the affection is confined to the rectum, the
feces and vitiated secretion are distinct from each other, and the
former are usually of their natural appearance; but when the other
intestines participate, to a greater or less extent, the feces are
fluid, and intimately mixed with the morbid secretion.
Ulceration of the mucous coat, with continued discharge, often
supervenes. Sometimes the peritoneal coat of the bowel is affected
secondarily, and then the pain is much more acute and more aggravated
by pressure.
Patients affected with hemorrhoidal swellings,—the action of whose
bowels is irregular, and in whom the vessels about the anus are
congested,—are peculiarly liable to inflammation and abscess in the
rectum or its neighbourhood, from the application of cold or wet to the
surface, particularly that of the lower part of the body. Ascarides
often produce violent irritation in the extremity of the rectum, both
in children and in adults; and the morbid excitation is communicated
to the bladder, as will afterwards be noticed. Not unfrequently the
inflammation is induced by a foreign body, either lodging in the cavity
of the bowel or imbedded in its coats—as hardened feculent matter,
alvine and biliary concretions, bones of small animals, needles, pins.
Effusion often takes place into the loose cellular tissue round
the bowel, with hard swelling, followed by unhealthy and extensive
suppuration. Rigors generally precede the formation of matter, and
violent fever almost always attends, abating, along with all the
painful feelings, on evacuation of the fluid. Still the discharge
continues, and the patient is kept uncomfortable and unhappy.
Resolution can very rarely be produced; suppuration is the almost
uniform termination of the action, and in persons of bad habit this
sometimes occurs in these parts without any assignable cause, and
without previous warning. The purulent collections are often very
extensive, both externally and internally, the integuments are all
undermined, and in some cases it is difficult to ascertain the depth of
the abscess, even with the aid of a long probe.
Owing to the loose nature of the texture surrounding the gut, abscesses
near the anus often attain a great size, and extend deeply before
there is much external indication of their existence; a hardness is
felt on pressing the fingers deeply by the side of the tuberosity of
the ischium; this is at first obscure, but gradually becomes more
developed; and at last a small dark red spot appears, indicating that
the matter has approached the surface, and is most superficial at that
part. But the surgeon should not wait for the pointing here, as the
matter may burrow much previously, and abscess form in the substance
of the sphincter, or exterior to it. If the matter does not cause
ulceration of the coats of the intestine, and escape into its cavity,
pointing takes place, and the pus is discharged externally, in general
through a small opening. The matter is of a very offensive odour. The
external aperture, and even the whole cavity of the abscess, may be at
a distance from the gut, but in most cases the matter is close to it:
its coats are denuded, and often ulcerated through. The surrounding
degree of induration, the quantity of contained matter, the extent of
the cavity, and the situation of the opening, vary almost in every
instance.
Cases occur of induration, often very extensive, in the neighbourhood
of the anus, on one or both sides, with dark discoloration of the
integuments, and burning pain. The affection resembles carbuncle.
The precursory symptoms are soon followed by partial suppuration,
and extensive sloughing of the cellular tissue. At first there is
excitement of the system, but symptoms of debility, and flagging of
the vital powers, soon present themselves—irregular pulse, delirium,
disordered stomach, hiccough, vomiting, and cold extremities. The
disease is one of great danger, and the patient can be saved only by
free and early incision, and the judicious employment of stimulants.
In some instances the inflammation is merely superficial, seated merely
in the integuments, and followed by slow collection of matter.
It is indeed seldom that a cavity formed by abscess near the anus
fills up entirely, however large and free the opening into it may have
been. The parietes contract, but the hardness around is not entirely
dissipated; the opening may close for a little while, but is soon found
again discharging, and may continue to do so for months or years. A
sinus is thus formed. Fresh collections and openings, either externally
or internally, are apt to occur, with extensive induration of the
cellular tissue, and disease of the gut. Instead of a single sinus, a
number of collateral ones are formed, all running into the main canal,
like branches to a common-sewer, or by-lanes opening into one spacious
street. The disease is one of frequent occurrence amongst females; and
often from a false sense of delicacy its existence is not declared till
it has advanced to a state of truly horrible perfection.
_Fistula_ is generally the consequence of abscess in the cellular
substance near the anus. By the term is understood a sinus or track,
with narrow orifice and hard parietes, discharging thin gleety matter.
If the track extends from the cavity of the gut to the surface, flatus
must often pass through the narrow and tortuous canal, and, from a
peculiar noise being produced by its passage, the name of Fistula has
probably been adopted. The term cannot be properly applied to recent
cavities of abscesses, but only when their sacs have contracted,
their lining has become callous, and their discharge thin and almost
colourless.
The fistula may be one of three varieties—blind external, blind
internal, complete. The first denoting that the sinus opens externally,
but does not communicate, either at its origin or elsewhere, with the
cavity of the bowel. The second, that it communicates with the bowel,
but does not open externally. The last, that it both communicates
with the bowel and opens externally. Some contend that fistulæ are
always complete, that they commence from within, and that the internal
opening is always at one particular point; but such, according to my
experience, is far from being the case.
Fistulæ occur in children, though rarely; generally in people advanced
in life. The cavity of the sinus, after long continuance, becomes
coated with an expansion resembling mucous membrane, and secretes a
discharge of mucous character.
In every case, it is necessary that the surgeon should ascertain, as
accurately as possible, the extent and nature of the fistula; and,
with this view, examination with the probe is requisite. The probe is
introduced into the canal, when the fistula is an external one, and
directed through its windings, so as to discover its direction, length,
and divarications; the guidance of the instrument is facilitated,
and the information augmented, by the forefinger being placed in the
rectum. Sometimes all the by-paths cannot be detected, until the
orifice of the canal is enlarged. When the fistula is complete, the
probe, entered at the external extremity, can be passed into the bowel
so as to be felt by the finger in the rectum; but it must be remembered
that the internal opening is not always at the inner termination of
the sinus, but often seated more externally—the cellular tissue being
destroyed to a considerable extent above it, so as to form a large
unhealthy abscess, communicating with the main track of the fistula.
But the gut may not be opened into, though denuded to a large extent,
and forming part of the walls of the sinus; and in some instances, the
sinus may not come within a considerable distance of the bowel.
An internal fistula is more difficult of detection. The symptoms
leading to a suspicion of its existence are—puriform discharge from
the bowel, increased on going to stool, and then accompanied with
tenesmus; pressure on the side of the anus, causing pain, and sometimes
an augmentation of discharge; and in many instances hardness, deeply
seated, is felt. On introducing the finger into the rectum, the
aperture in the coats of the bowel is perceived, or a part of the
bowel feels more boggy and tender than the rest; through this point
a curved probe, introduced along the finger, may be passed into the
sinus, and being then directed downwards, reaches the outer extremity
of the canal, causes the integuments to project, or is readily felt
from the surface. The internal opening is usually immediately within
the sphincter, seldom higher.[49] The discharge, in general, is
rather profuse, the bowel is very irritable, desire to evacuate it
is frequent, and the feces are often tinged with blood. There is a
sensation of itching about the fundament, the heat of the parts is
felt by the patient to be increased, he is unable to bear pressure
there, and sits on one buttock: in most cases the bladder sympathises
considerably. The giving way of the bowel may be produced by ulceration
commencing in the mucous membrane, but is more frequently the result of
inflammatory action in the surrounding cellular tissue. The aperture
is the seat of acute pain when pressed upon, and during evacuation
of the bowel. Great light is thrown on such cases by the use of a
proper speculum. But its introduction can seldom be borne in cases
of inflammation, abscess, or recent fistula. In ulceration of the
coats within the sphincter it is useful. Considerable information
can certainly be obtained by the finger; but to the sense of touch,
however acute, it is better, when admissible, to add that of vision.
The speculum, made of silver or steel, and having its internal surface
highly polished, is introduced gently into the anus, and expanded
fully; and by changing the situation of the instrument, and holding a
light so as to illuminate the interior, the surface of the bowel for
five or six inches above the anus can be examined accurately, as if it
were an external part of the body.
Simple indurations and contractions of the lower part of the bowel
follow long-continued irritation and inflammation of its parietes. The
part is not an uncommon seat of stricture, and sometimes the bowel is
constricted at two or more points near each other; frequently the
stricture is extensive and firm, in other cases it is narrow,
consisting merely of a thin band. It is often complicated with fistula;
if so, the internal aperture is immediately above the stricture, and
is caused by ulceration; abscess sometimes forms above the stricture,
destroys the coats of the bowel at that point, burrows around, and not
unfrequently points at a great distance from its origin; or sloughing
and ulceration may take place in the coats of the bowel, and feculent
matter be discharged through the opening of the abscess. In females,
the vagina may be opened into in consequence of unhealthy suppuration
in the cellular tissue, between that organ and the gut.
[Illustration]
The existence of stricture is in general readily ascertained by
examination with the finger; its most common situation is here shown;
the medical practitioner must not suppose that every obstruction,
however slight, to the passage of a bougie into the bowel is owing to
organic disease; the top of the sacrum naturally projecting forwards
on the commencement of the rectum, in some degree opposes the entrance
of any large body, and this circumstance is laid hold of by the
unprincipled or ignorant; the patient is very often declared to labour
under stricture of the bowel, when none exists. Some practitioners
discover stricture in almost every patient with disordered digestion;
the whole digestive apparatus is certainly thrown into disorder by
obstruction in the lower part, but this obstruction is fortunately
rare. In cases of tight stricture, the bowels are distended with feces
and flatus; and if evacuation is not procured vomiting ensues, followed
by enteritic symptoms, as in strangulation of the higher bowels. The
gut above the stricture is always more or less dilated.
The symptoms which lead the surgeon to suspect the existence of
stricture, are—difficulty in voiding the excrements; a long time
occupied in the evacuation, with pain and much straining; small thin
portions of feculent matter coming away, when the matter is consistent;
discharge of puriform fluid, mixed with a slimy mucus; itching and heat
in the parts; and irritability of the urinary organs.
Strictures of the urethra and rectum often coexist, as exemplified
by the following case:—A middle-aged man, when in Holland, laboured
under a very deep and extensive fistula in ano. Sinuses were divided in
all directions, and some healed; one, however, remained open, leading
towards the gut from near the tuberosity of the ischium on the left
side. He was desired to keep this open by means of bougies, which,
as many were used, he manufactured himself out of cloth and plaster.
On one occasion a portion passed deeply, and could not be extracted;
but his alarm at this occurrence was appeased on being told that the
foreign body would be absorbed. His condition at that time was very
miserable; and inflammation was often excited in the parts, with fresh
collections of matter. At the same time, he laboured under stricture
of the rectum and urethra. He applied to me fifteen years after the
commencement of the disease. Then the most troublesome symptom was a
constant itching in the perineum, and round the anus, preventing sleep,
and causing much excoriation from involuntary scratching; besides, he
was annoyed by seminal emissions, and frequent desire to make water.
I first divided a small internal fistula, and some time afterwards
operated on a large complete one; in the latter instance, a foreign
body was felt deep in the wound, the incision was extended, and a large
portion of bougie, firmly impacted, was with some difficulty withdrawn.
Some days after, other portions of bougie were extracted along with
numerous hairs; and these continued to be discharged for many weeks.
The symptoms were much relieved. An occasional itching remained, but
disappeared after the cure of a very bad stricture in the urethra. He
recovered perfectly from the complication of diseases.
_Schirro-contracted Rectum_, a malignant and truly horrible disease,
may be the consequence of inflammatory action, or of neglected
stricture. The neighbouring parts are involved in cartilaginous
induration; the surface of the bowel is lobulated and ulcerated, its
cavity is contracted, and the discharge is profuse, sanious, bloody,
and putrid; there is frequent desire to void the contents of the gut,
but in general nothing but flatus and puriform fluid is evacuated;
when feces do pass, dreadful pain is excited, and continues for some
time. The difficulty of voiding feculent matter becomes greater and
greater, frequent attacks of ileus occur, and in one of them the
patient expires. During the progress of the disease, the functions of
the bladder become disturbed; change of structure in it and in the
vagina takes place; and frequently the cavities of the rectum, bladder,
and vagina are laid into one by inveterate and malignant ulceration.
The affection is more common in females than in males, and rarely
occurs in young persons. The countenance has the sallow hue peculiar to
carcinoma, and in the advanced form of the disease becomes still more
cadaverous from profuse discharge of matter and frequent hemorrhage.
The cellular tissue, anterior to the rectum, is liable to become the
seat of tumour. Malignant medullary formations occasionally form here,
causing most distressing symptoms; by displacing the bowel they may
obstruct its canal, and simulate stricture or schirro-contraction.
_Prolapsus Ani._ Folds of the lining membrane of the lower portion of
the rectum are apt to protrude during evacuation, as already mentioned,
in those labouring under hemorrhoids. These are readily replaced,
and the painful feelings relieved, if the attempt be made before
swelling and engorgement of the vessels and cellular tissue take place.
Protrusion, however, is sometimes to a great extent; the sphincter is
relaxed, and the lower part of the bowel is retained within it with
difficulty; indeed there is often more of the lining membrane of the
gut without the sphincter than within it. The mucous lining becomes
insensible, thickened, and white; and the patient is subject to attacks
of inflammation, with additional swelling, excoriations, and ulcers
of the parts. Slight protrusion is very common, and patients who
have long laboured under it are in the habit of reducing the bowel
after every stool, in the intervals wearing a supporting bandage.
They are subject, however, to constant uneasiness, and more or less
puriform discharge from the parts; often there is a flow of blood
while at stool; the health is undermined, and comfort diminished;
all exertions are gone through with difficulty, and undertaken with
reluctance. During exertion protrusion is almost certain to occur, and
apt to be increased. The part most commonly prolapsed in time becomes
hard, thick, and in a measure insensible; and new folds appear on
extraordinary straining at stool, in coughing, or any exertion of the
abdominal muscles.
[Illustration]