various consistence. They may be either vascular, or deposited in
consequence of increased vascular action, and afterwards increased by
addition of solid matter. They are to be removed either by ligature or
incision, according to their situation, nature, and attachments.
Foreign bodies may lodge in the rectum—as bones, portions of hard
indigestible meat, &c., introduced by the mouth—or clyster-pipes,
bougies, &c., which have been passed up per anum. From being the source
of constant irritation, and obstructing the functions of the part,
they demand removal. Alvine concretions are now rare; they are usually
situated in the caput cæcum coli, sometimes in the sigmoid flexure, or
in the arch of the colon; they may descend into the rectum, and lodge
there.
Children are sometimes born with the anus imperforate, the extremity of
the rectum being covered merely by integument, or the bowel terminating
an inch or two above the usual site of the anus; or the rectum may be
wholly deficient. In the last case, the colon may end in a blind sac at
the fundus of the bladder, or it may open either into that viscus or
into the vagina.
_Treatment of Affections of the Rectum._—In the treatment of
hemorrhoids, the cause should be removed if possible; and this may
suffice for the cure. When the tumours are recent and small, they may
be made to disappear by the use of astringent ointments or decoctions,
as of galls, kino, oak-bark, and by sedulous attention to cleanliness
of the part. In inflamed tumours, blood may be extracted by leeches or
punctures, and hot fomentations afterwards used. Recent hemorrhoids are
sometimes got rid of at once by the puncture of a lancet,[50] by which
a clot of grumous blood is discharged, with immediate subsidence of
the swelling, and abatement of pain. When constriction of the internal
tumours or folds of bowel by the sphincter has occurred, the tumour
should be replaced if possible. In irritability of the sphincter, a
bougie is sometimes used with advantage; and incision of the muscle,
by which rest is afforded to the parts, will often effect a cure,
after the failure of all other means: this is essential when rugged
ulcers or fissures occupy the orifice; the division may be made on
either side, certainly not in the mesial line. In most cases, the
tumour must be got rid of by the knife or ligature. When the piles are
internal, removal by ligature is to be preferred; the patient being
made to strain, and thereby bring the tumours as low as possible, a
ligature is placed round the base of the swelling, provided its form
conveniently admits of it; otherwise the base is pierced by a fixed
needle armed with a double ligature, the separate portions of which are
applied tightly to the corresponding parts of the base. This operation
is very inconsiderately and indiscriminately employed. It can only be
warrantable when the tumours are so large as to obstruct the orifice so
perfectly as to prevent evacuation, unless they are extruded. Before
proceeding to this measure, the bowels should be emptied by mild and
repeated purgatives, and afterwards all stimuli should be avoided.
It is imprudent to apply ligature to several tumours at once, for
serious consequences will most probably ensue, inflammation of the
bowel, obstinate constipation, and general excitement.[51] Excision of
such piles is contraindicated by the risk of profuse hemorrhage. The
bleeding is into the cavity of the bowel, a coagulum is there formed
which encourages the flow; and from this cause, and the peculiar
situation of the bleeding point, it is with difficulty arrested. When
the tumours are external, ligature may certainly be adopted; but
here there is no objection to the use of the knife, and excision is
much less painful and more speedy. The tumours, along with protruded
portions of the mucous lining of the rectum that cannot be reduced,
and are changed in structure and function, are readily taken away by
the rapid stroke of sharp curved scissors. Or they may be laid hold
of and stretched, and their base divided by one or more sweeps of a
bistoury. The removal of these tumours, or of a portion of the loose
fold of skin or altered mucous membrane which occupies the sphincter
in the direction of the bowel, is in general followed by a cure of the
prolapsus. The sphincter now acts fully, and on the cicatrisation of
the open surface contraction of the tissues occurs to such an extent
as to produce a permanent cure without interference with the internal
parts. Should hemorrhage follow upon the removal of external tumours or
folds, the surgeon has it completely under command. Pressure by a large
graduated compress is generally sufficient.
In inflammation of the rectum, the exciting cause often is not
discovered; when detected it should be removed without delay. In
simple inflammation of the part with violent fever, general bleeding
may be required; and in all cases blood should be abstracted locally
and freely. Leeches are to be applied to the verge of the anus, and
the lower part of the perineum, and hot fomentations afterwards used.
Internal antiphlogistics are at the same time not to be neglected.
In retention of urine, or great irritability of the bladder, in
consequence of the affection of the rectum, the perineum should be
leeched and fomented, perhaps, also, the lower part of the abdomen;
the use of the catheter should be avoided if possible. When induration
takes place in the cellular tissue by the side of the anus, or in the
perineum, suppuration must in all probability occur, and poultices,
with occasional fomentation, are to be used, though only for a short
time; for, as already mentioned, pointing of the matter is not to be
waited for in this situation; incision must be had recourse to early,
in order to prevent bad consequences. Leeching is sometimes used here,
as in purulent formations in other parts, from gross ignorance of the
real state of matters; and sometimes their use is continued after
fluctuation is distinct, and until the pus begins to ooze through the
leech-bites; such is very useless and very dangerous practice; in most
cases the internal parts are extensively destroyed before the matter
comes spontaneously to the surface.
In the carbunculous state of the cellular tissue, near the rectum, with
extensive infiltration, dark integument, and a tendency to sloughing,
an early and free opening must be made wherever matter is suspected
to have formed, however deeply seated, and in whatever quantity, and
whether the parts are indurated or not; nothing but mischief can result
from delay. When the cellular substance is destroyed, the incision
must be proportionally extensive, to afford a free exit for slough
as well as matter. During the suppuration which follows, the system
will require good support, and most probably a free administration of
stimuli.
It has been recommended that, in abscess extending along the gut, the
cavities of the bowel and abscess should be at once laid into one by
incision. I have done so, but always found the cure to be tedious. It
is better that the matter should first be evacuated through an external
opening, that the painful symptoms and constitutional disturbance
should be allowed to subside; and that after the cavity has contracted,
and the extent of the sinus has been ascertained, the operation should
be performed. In the operation the knife is now employed; but in former
times the ligature and cautery were in constant use. The old surgeons
supposed that there was something malignant in the hardness and
callosity attending this disease, and were not contented with opening
the cavities, but endeavoured to dissect out the whole parts; and, if
foiled in this, they finished the work with a red-hot iron. Indeed the
practice of excision was recently in vogue in the Parisian hospitals.
But the operation for fistula has been much simplified. The bowel is
generally so much separated from its connexions as to be incapable of
again adhering, or of furnishing granulations; and, though capable,
healing is effectually prevented by the frequent motion of the parts
caused by the action of the sphincter and levator of the anus. One
side of the cavity is fixed, whilst the other is in motion. It becomes
necessary to lay the cavities of the bowel and of the fistula into one.
This can generally be effected with great ease; a salutary degree of
excitement follows the use of the knife, rest to the parts is procured,
the edges are allowed to retract and adhere to the opposite surface,
and the wound heals quickly from the bottom. The surgeon, in his
operative procedure on these parts, must use both hands equally well,
otherwise he must vary his position, and often put his patient in a
very awkward predicament, more particularly if a female. The patient
is placed in a stooping posture, with the legs unbent, or kneeling on
a chair, and resting his arms on its back, the fundament being turned
towards the light. The surgeon inserts the finger, well soaped and
oiled, into the rectum, and with the other hand insinuates a curved
probe-pointed bistoury into the sinus, using the instrument merely as
a probe. Having reached the extreme depth of the canal, the direction
of the instrument’s point is changed so as to apply its cutting surface
to the coats of the bowel, at that part. The instrument on being thus
passed into the bowel is fixed by the finger, and by drawing both
outwards, the coats of the bowel and the parts intervening between them
and the sinus are divided. All collateral sinuses extending towards
the perineum and buttock must be freely divided, for they cannot be
expected to contract otherwise. Such is all that is necessary in the
generality of cases; but it is evident that the steps of the operation,
and the extent and number of incisions, must be varied according
to circumstances. A great part of the affected bowel may be pulled
down by a director before being cut, as is sometimes done; but the
practice is useless and painful. Should hemorrhage take place, it may
be restrained by stuffing the wound gently with lint; if this fail,
the bleeding vessels are to be secured by ligature; but this is seldom
necessary. The bowels should be well cleared out before the operation,
so that two or more days may pass over without the parts being required
to perform their functions; and, if the bowels are naturally loose,
opiates may be administered. Afterwards copious evacuation is to be
procured by enemata or gentle laxatives. It is necessary to prevent
the external part of the wound from adhering, until the whole has
contracted equally, and begun to be filled up by granulations from the
bottom; and with this view a piece of lint is interposed between the
margins. Stuffing the wound daily with large dossils of lint, smeared
or not with irritating ointments, is attended with much pain, and
certainly impedes the cure. The dressing should be simple and light,
and introduced with gentleness and care. The first should be allowed
to remain undisturbed till spontaneously discharged along with the
feculent matter. In the greater number of cases, a second interposition
of dressing is all that is required. In all cases, dressing should
not be continued long; but as the cavity gradually contracts,
discharging laudable pus, and becoming coated with healthy florid
granulations, the interposed pledgets should be daily diminished,
and soon omitted entirely. If the surgeon continue long to stuff the
wound it cannot contract, will become callous as before, and a fistula
will be reproduced. Injections into the wound, or the application of
lint soaked in a gently stimulating lotion, are often beneficial in
promoting contraction. But, as already stated, most fistulæ get well
after proper incision, with but one or two dressings, and without any
after application excepting abundance of soap and water. During the
cure, the general health must be kept vigorous, and the state of the
bowels strictly attended to.
In ulcer of the mucous lining, with irritability of action in the
bowel, injections of tepid or cold water are useful, by removing
irritating matters from the part. By means of a speculum ani the
ulcer can be readily exposed; it maybe touched occasionally with the
nitrate of silver, in substance or solution, or, if very indolent,
with a solution of the bichloride of mercury. When the irritation is
very great, and the lower part of the bowel frequently in a state of
spasmodic action, the sphincter may be divided so as to allow the parts
to remain quiet; and anodyne suppositories or soothing enemata will
then be used with much greater advantage than previously. To obtain
reparation of breach of structure in any part, rest is a principal part
of the treatment; and in the case of the rectum and other mucous canals
it is preëminently required.
Strictures of the rectum are treated by bougies of wood, plaster, or
elastic gum, introduced at intervals, and gradually enlarged. The
bougie should be smooth in the surface, and rounded at the point;
also slightly curved, so as to suit the figure of the bowel; and
with a narrow neck, so as to remain without the irritation caused by
distention of the sphincter. At first it should be of such a size as
can without much difficulty be pushed past the stricture, and, as this
relaxes, the size of the instrument must be proportionally increased
till it completely fills the bowel when dilated to the natural calibre.
The bougie may at each time be retained from a quarter of an hour to
an hour, according to the feelings of the patient. Suppositories and
enemata are at the same time employed; the latter to clear out the
lower bowels, the former to allay the irritation which accompanies
the disease, and which may be increased temporarily by the bougies.
When the stricture is callous, and will not yield by dilatation, it
may be divided with the knife, and notched at various points of its
circumference; and, when the parts have begun to granulate, recourse to
the bougie will soon effect a cure. When fistula and stricture coexist,
both are got rid of at once by the usual operation for the former, and
by the after treatment peculiar to each.
In malignant contractions of the gut, all that can be done is to
palliate the disease by anodynes, administered by the mouth, or
applied topically. Injections, bland, and occasionally anodyne,
tend to diminish irritation; bougies aggravate the disease. At the
commencement, the diseased parts may be removed by the knife or by
ligature, and relief and exemption follow, at least for a time; but
no operation is warrantable in this or any other cancerous affection,
when the morbid action has gained ground, and the disease is extensive.
Female patients have by some been cruelly treated; the vagina and
diseased bowel have been laid into one loathsome cavity, and though
the patients have continued to pass excrement and discharge through
this cloaca, with the symptoms undiminished, themselves miserable and
obnoxious to others—still such cases have been reported as cures!
In prolapsus ani, the protruded parts are to be carefully reduced,
and kept so by means of a compress supported by a T bandage; often
a spring with a pad is used with advantage. In inflamed prolapsus,
with ulceration of the mucous coat, the patient is confined to the
recumbent posture, and soothing applications employed; and when thus
the irritation has been removed reduction is performed; but the
bowel seldom remains up till after the ulcerations have been healed.
In chronic obstinate cases, the altered parts within the verge are
removed by the knife or scissors with safety; contraction attends
the cicatrisation, and so further protrusion, as already noticed, is
prevented.[52]
By the speculum ani, assisting the eye and finger, the nature and
position of foreign bodies in the rectum are ascertained, and their
removal facilitated. They are to be extracted by the finger, by a
scoop, or by forceps. It has been proposed by some to cut into the
colon from behind, so as to open that part of the bowel which is
unconnected with the peritoneum, when it is distinctly ascertained that
alvine concretions lodge there. This might be put in practice when the
case is clear and the symptoms urgent, but, as already observed, such
foreign bodies are now very rarely met with.
In imperforate anus, when the bowel terminates high, it has been
proposed to cut through the abdominal parietes, and open the sigmoid
flexure, so as to establish an artificial anus. The proceeding is
unwarrantable, both in congenital deficiency and in malignant disease
of the bowel. There is no doubt a possibility of life being thus
prolonged, but it is by no means probable, and scarcely desirable.
In the more common cases, the bowel is opened, and the meconium
evacuated, by a slight and safe incision in the site of the anus.
Even through a considerable depth of soft parts, the impulse of the
fluid in the bowel is distinctly felt during exertion of the abdominal
muscles. If incision through the integuments and cellular tissue
prove insufficient, a sharp-pointed bistoury is pushed onwards in the
direction of the bowel, under the guidance of the forefinger of the
left hand, carefully avoiding the bladder, vagina, and uterus, as also
the vessels within the pelvis. To reach the bowel is an object of
great consequence, yet the risk incurred in its accomplishment must be
considered, and the incisions made within certain limits. The opening
scarcely requires to be kept pervious by the use of bougies, the
functions of the parts being sufficient for the establishment of the
anus.
[Persons often suffer from _pruritus_ or itching of the anus, or in the
parts immediately around. The affection is most common in old people,
and in such as are of a weakly constitution. Women who have recently
ceased to menstruate are also prone to it. The exciting causes are
generally ascarides, hemorrhoidal excrescences, and a morbid state of
the alvine secretions. Sometimes the skin around the anus is covered
with an eruption of papulæ, or even tubercles, the former of which are
often attended with vesication and the discharge of a thin, watery,
irritating humour. Patches of a similar description are occasionally
seen on other parts of the cutaneous surface; as the scrotum, thighs,
back, and even the face and neck.
The pruritus, which is often very troublesome on retiring at night, so
much so, indeed, as to prevent the patient from sleeping for hours,
usually subsides after a few months, but is certain to return from the
slightest irregularity in the diet, from fatigue, loss of rest, or
from exposure to heat. “From constant rubbing the skin about the anus
becomes thick, dense, and furrowed, even when there are no hemorhoidal
tumours. The furrows assume a radiated direction, and converge in the
anus; they vary in number from six to ten, and are from a quarter of an
inch to an inch in length.”[53]
In the treatment of this affection the first object should be to
ascertain, and, if possible, to remove, the exciting cause. Proper
attention should then be paid to the general health, which, as was
before stated, is often much impaired. Under such circumstances tonics
may be demanded, such as iron, bark, or quinine, either alone or
combined with blue-mass, sarsaparilla, or Plummer’s pill. The latter
articles are particularly serviceable when there is an eruption around
the anus. The most useful topical remedies are, a solution of acetate
of lead and laudanum, yellow-wash, the nitrate of silver, and the
ointment of the proto-ioduret of mercury. Cold ablutions also afford
great relief, and are indispensable to the patient’s comfort.
_Neuralgia_ of the rectum, a disease first described, I believe, by
Dr. Montegre, of Paris, in 1812, is occasionally met with. It is most
common in persons of a nervous, irritable temperament, from the age of
thirty to forty-five or fifty, and who are subject to similar attacks
in other parts of the body, particularly the face, stomach, testicle,
or mamma. It is characterised by paroxysms of pain, which is usually
described as of a tearing, burning, or lancinating nature, situated
at the extremity of the rectum, from which it frequently extends to
the sacrum, the loins, pubes, and genito-urinary organs. Defecation
is painful, and the urine is discharged in jets or drops, attended
with a burning or scalding sensation. The attacks commonly subside in
eight or ten hours, but recur with tolerable regularity about the same
period the following morning or evening, though sometimes not until
the second or third day. During the intermissions the patient is, in
great measure, free from pain, and passes his feces and urine without
difficulty. The affection often continues for years, and the paroxysms
are then apt to be more frequent and irregular.
A remarkable instance of this disease is given by the late Professor
Bushe. His patient was a middle-aged physician, of active habits, in
tolerable health in other respects, but of a nervous temperament, and
subject to occasional attacks of neuralgia of the face, stomach, and
testicles. Several times a year he would be seized with pain at the
extremity of the rectum and at the pubes, accompanied with frequent
desire to void his urine; sometimes he suffered excruciating torments
at the end of the penis, or posterior part of the urethra. The attacks
generally subsided in twelve or twenty-four hours, and were almost
always either preceded or followed by neuralgia in other situations.
No remedies were of any avail. In another case—that of a nervous
female, thirty-five years of age—the pain was seated over a spot about
the size of a shilling, on the left side of the bowel, less than half
an inch above the verge of the anus. For weeks the pain would almost
wholly subside, when it recurred with extreme violence; her distress
was generally greatest towards evening, and was always much increased
during defecation. Mr. Mayo of London mentions the case of a man who
laboured for several years under paroxysms of neuralgia of the rectum
and the teeth. The attacks came on frequently during the day, without
any assignable cause.
Neuralgia of the rectum, as other parts of the body, is almost
invariably attended with a deranged condition of the digestive
apparatus, and hence a mild but systematic course of purgation
constitutes a primary object in the treatment. On no account should
the rectum be allowed to become distended with fecal matter. After due
attention has been paid to the secretions of the stomach, liver, and
bowels, the best remedies will be quinine, iron, arsenic, strychnine
or nux vomica, stramonium, the warm bath, and blisters to the sacrum.
During the paroxysm, hot fomentations, anodyne injections, and opiate
suppositories will be beneficial. In spite, however, of these and other
means, the disease often continues for years with little mitigation,
baffling the skill of the surgeon, and compelling the patient to spin
out a miserable existence.—ED.]