that of a pea to that of a pigeon's egg, and cause a sense of weight
and stuffing in the bowel; but when they are large and numerous they
cause severe pain, tenesmus, difficult defecation, spasm of the
sphincters, and prolapse of the anus. When the patient is at stool the
tumors are forced down and protrude in a bunch, surrounded and
constricted by a collar of prolapsed mucous membrane: under these
circumstances the tortuous and dilated vessels of which they are
composed give way and free arterio-venous hemorrhage takes place. In
some cases this happens at every stool, the patient losing from a few
ounces to a half pint of blood almost daily until alarmingly depleted.
Usually, the protruded piles are easily restored after a motion of the
bowels, and so remain until the next one occurs; but in other cases of
longer standing and of more gravity the sphincter loses all tone and
the piles remain constantly prolapsed. This affection is very chronic,
and the subject of it has to regulate his life with the greatest care,
as the least unusual effort or excess may provoke an exacerbation.
Excepting in the worst cases the general health is not materially
impaired. They occasionally become so strangulated as to slough off,
which effects a cure, but this is accompanied by grave constitutional
disturbance. The disease is rather rare before the age of puberty, but
is very common in both sexes in adult life, and is frequently
associated with fistula, polypus, fissure, or carcinoma of this region.
In females suffering with piles a free hemorrhage from them sometimes
takes the place of the menstrual flow. The presence of internal piles
causes a sense of weight and fulness and the sensation of a foreign
body or of feces remaining in the rectum, with troublesome and
obstinate itching about the anus. These symptoms, with the occurrence
of hemorrhage from the rupture, erosion, ulceration, or abrasion of the
dilated vessels, render the diagnosis easy. Should the piles not
protrude, they can readily be made to do so by directing the patient to
sit and strain over a vessel containing hot water. If the piles do not
appear, a digital examination should be made. Indeed, it would be
better to make one in every case of this kind.
About the margin of the anus the superficial veins are prone to great
dilatation, and when presenting form masses of a bluish color, often
very dark, covered partly by mucous membrane, partly by integument.
These are also commonly known as piles.
{885} Dilatation of the Rectal Pouches, or Physick's Encysted Rectum.
This is an uncommon disease, generally occurring in those advanced in
years, and consists of an hypertrophy, and sometimes of an
inflammation, of the natural rectal sacs. These pouches are quite small
in early life, and enlarge gradually as age advances, this condition
being favored by the lodgment in them of extraneous substances, such as
indurated fecal matter, inspissated mucus, the seeds of fruit, and
other undigested masses. Constipation, so usual with the old,
predisposes to this affection, as it keeps the bowel distended with
hardened feces. The pouches vary much in size, the largest of them
admitting the end of a finger. The disease is insidious and slow, but
is capable of producing intense suffering should inflammation,
suppuration, or ulceration attack them. Sometimes as many as a dozen
are involved.
The symptoms, which are rather misleading than suggestive of the
disorder, are a sensation of weight and uneasiness just within the anus
and uneasy sensations in the rectum, distressing itching, and, after a
time, pain following defecation and lasting often for hours. The pain,
which is aching and burning in character, is not confined to the parts
affected, but radiates down the thighs, toward the back, and into the
perineum. An increased secretion of mucus always exists in these cases,
but the discharge of purulent matter is uncommon, and its presence
indicates the existence of very active inflammation.
It is said that even in the worst cases no spasm of the sphincters
occurs. An exploration of the bowel with a blunt-pointed hook affords
the only reliable guide to correct diagnosis: this, as it is moved
about in the rectum, engages the rim of a sac, which may thus be drawn
down through the anus and examined.
Non-malignant Stricture of the Rectum.
In the absence of ulceration or syphilitic infection this is an
uncommon disease, and very many of the cases of so-called stricture of
the rectum are caused by spasm which always disappears during
anæsthesia.
The affection may be described as a narrowing of the lumen of the
rectum, more or less circumscribed, by the deposition of inflammatory
lymph or fibrous tissue in the mucous, submucous, or muscular tunic of
the bowel. It may be due to traumatic causes, such as the introduction
of foreign bodies, the frequent and careless use of enema-pipes, or the
presence of sharp or irritating substances swallowed, as pieces of
shell or bone. It is said to have been caused by indurated feces, but
no cases have been published in which this causation is clearly shown.
This condition has also been brought about by various operations upon
the mucous coat of the bowel, such as the application of nitric acid
and other escharotics and the removal of portions of mucous membrane
and of hemorrhoids.
Stricture may be secondary and a result of extension of an inflammation
outside the bowel, as pelvic cellulitis; and it is frequently caused by
syphilitic deposition and by chancroidal invasion--in the former by
{886} infiltration, ulceration, and cicatrization, in the latter by
unnatural sexual connection, or by infecting vaginal discharge running
into the bowel.
When the stricture involves only the mucous tunic, it imparts to the
finger the sensation of a ring-like elevation or a valve-like
projection, into which the finger enters or beyond which it passes
usually without much difficulty; but when it involves the submucous and
muscular layers, as after the cicatrization of a large rectal ulcer,
the finger encounters a dense fibrous mass which in some cases appears
to have no lumen, but in others will admit only the end of the finger.
In these grave cases of long standing there occurs considerable
dilatation of the rectum above the stricture due to fecal detention and
impaction at this point, and hypertrophy of the muscular coat of the
bowel produced by long-continued straining and expulsive efforts.
Allingham[2] speaks of chronic constipation as a cause, and says,
"Straining to evacuate the contents of the bowel forces down the upper
part of the rectum into the lower, causing an intussusception; it gets
within the grasp of the sphincter muscles, and this may be the
starting-point of the irritation." Stricture does not usually follow
proctitis, even when the latter is very chronic. The long-continued
pressure of the child's head in cases of delayed labor is said to have
caused stricture of the rectum.
[Footnote 2: _Diseases of the Rectum_, p. 195.]
This affection is a disease of adult life, and more cases of it occur
among women than among men. "If stricture of the rectum is found in a
young woman, it is probably due to chancre cicatrices; if it is met
with in old women and men, the inference should be that it is either
caused by cancer or by syphilitic infiltration and its consequences.
Only in those cases in which no cicatricial tissue has been
formed--that is, when the contraction is due to the infiltration
alone--will the results of the antisyphilitic treatment contribute
anything toward rendering the diagnosis more certain."
Stricture of the bowel may exist for months and years without being
recognized and without causing the patient much uneasiness; more
frequently, however, there is marked uneasiness, with an increased
desire to go to stool and a sense of weight or of a foreign body in the
bowel. Violent straining accompanies the act. It is given usually as
one of the most common and reliable symptoms of this condition that the
feces are flattened, ribbon-shaped, or triangular or wire-drawn: in
true stricture, according to Allingham, this is not the case, but the
characteristic stool consists of small, irregular, broken fecal
fragments. When the contents of the bowel happen to be watery, the
loose stool is spurted out with great force. In this disease diarrhoea
alternates with constipation; the intestines become distended with
quantities of gas and feces, which provoke frequent and severe attacks
of colic; the appetite and digestion fail; the complexion becomes
sallow; the patient emaciates; ulceration sets in, and the patient
slowly sinks from exhaustion. Usually, these cases do not give rise to
much pain, and what there is, is usually referred to the back, thighs,
penis, or perineum. A discharge of mucus resembling white of egg
immediately precedes each action of the bowels. Usually, these
strictures are within two and a half or three inches of the anus, but
sometimes they have been found high up in the sigmoid flexure, and
rarely at a greater distance. A syphilitic stricture by direct
inoculation {887} is found just within the sphincter muscle, and
consists of an infiltration of inflammatory lymph in a circumscribed
portion of the submucous tissue. It is tight, highly sensitive,
thickened, inflamed, and bathed in pus; there are also constitutional
symptoms, as fever, anorexia, and mental irritability. The subjects of
this variety are usually women. The tissues composing strictures of the
rectum of a very chronic character are found to be gray or bluish-white
in color, of very dense fibrous structure, and creaking under the knife
when cut, as a piece of cork would do.
Besides the before-mentioned stricture, due to the contraction of a
chancroidal ulcer, is another caused by submucous gummata of the
ano-rectal region, which is very rare; and yet another, the diffuse
gumma, or ano-syphiloma of Fournier, which is the most frequent of all
causes of stricture of the rectum. The diffuse gumma is one of the
later manifestations of syphilis, and consists in "an infiltration of
the ano-rectal walls by a neoplasm of as yet undetermined structure
originally, but susceptible of degenerating into a retractile fibrous
tissue, and thus giving rise to narrowing of the intestinal calibre to
a greater or less extent."
Proctitis, or Inflammation of the Rectum.
Inflammation and suppuration in the lower part of the rectum are even
more common than the corresponding affections of the cæcum, and their
causes are quite as various. In many cases, no doubt, this affection is
traceable to ulceration (perforative or otherwise) of the mucous
membrane; in others it probably originates in the connective tissue
which surrounds the rectum (periproctitis). The rectum, still more
frequently than the cæcum, becomes involved in inflammation and
suppuration originating in the various pelvic, and even in distant,
organs. Abscesses arising in the abdominal cavity or its parietes are
peculiarly apt to gravitate into the pelvis and to communicate with the
rectum.
Proctitis in its acute form has some symptoms in common with dysentery,
but it differs from it by the absence of abdominal pain, tenderness,
and severe constitutional symptoms. The pain in proctitis is usually
referred to the sacrum and perineum, and there is frequently dysuria
from sympathetic affection of the bladder. This disease may be acute or
chronic; the latter form occurs in those advanced in life. Frequent
attempts to evacuate the bowels, with great tenesmus, heat, weight, and
fulness in the bowel, and a mucous and bloody discharge in the absence
of impaction of the rectum, characterize the attack. Should it be
protracted and severe, the discharge will become purulent. A digital
exploration should always be made to ascertain if any foreign or
irritating substance is exciting the inflammation.
The presence in large numbers of Oxyuris vermicularis may excite
irritation and inflammation of the rectal mucous membrane, which is
sometimes very intense.[3]
[Footnote 3: Curschmann, _Ziem. Encyclop._, Am. ed., vol. viii. p.
848.]
Inflammation of the anus and buttocks, caused by the application of the
leaves of Rhus toxicodendron after defecation, has extended into the
{888} rectum and produced proctitis and peritonitis.[4] "In some cases
of dysentery the pathological lesions are limited to the rectum, which
would produce an apparently local inflammation very similar to
proctitis. The irritation of unnatural sexual intercourse and the
contact of gonorrhoeal poison have been known to excite intense
inflammation of the mucous membrane of the rectum, with a copious
discharge of pure pus, and accompanied by intense burning pain and
great heat of the parts involved."[5]
[Footnote 4: Case of Dunmire, _Philada. Med. Times_, vol. xii.]
[Footnote 5: Heubner, _Ziemssen's Cyclopæd._, vol. i. p. 552.]
Fissure of the Anus and Rectum.
The painful ulcer of Allingham is quite a common affection, attacking
women more frequently than men, and no age is exempt from it. Of 4000
consecutive cases of rectal and anal disease observed by Allingham, 446
presented fissure of the rectum. They are rarely multiple. Their usual
position is dorsal, although they may be found at any part of the
circumference of the anus, and just within the verge of the anus at the
junction of the skin and mucous membrane, extending upward toward the
rectum usually not more than half an inch, and appearing as a crack or
fissure, often very trifling in appearance, or a club-shaped
ulceration, the floor of which will be very red and inflamed if it is
recent, but if chronic the floor will be grayish, with hard,
well-defined margins. Sometimes there will be found at the external
extremity of the fissure a small club-shaped papilla or muco-cutaneous
polypoid growth; but this is not to be confounded with the ordinary
polypus, nor is it the cause of the fissure, but the result of
irritation caused by the latter. In other cases the external site of
the fissure is indicated by a very tender and swollen flap of
integument, which often becomes the seat of a small but very painful
fistula. The club-shaped papilla is said to indicate invariably the
existence of fissure.
Fissure of the rectum is often associated with anteversion and
retroflexion of the womb. In many of these cases the fissure will heal
spontaneously when the malposition is rectified. However treated, the
result will not be satisfactory while the uterine trouble remains
uncorrected.
Fissure is not infrequently caused by and accompanied with polypi: it
may be caused by any accident whereby the verge of the anus is torn or
superficially lacerated--by chronic diarrhoea, by violent expulsive,
straining efforts, as in labor, by the passage of very hard, dry
stools--and very frequently it is syphilitic in origin. The most
prominent symptom of this disease is pain, and this is very severe and
peculiar in character, coming on in most cases not during the act of
defecation, but twenty minutes to half an hour afterward, and is
preceded by a hot, burning, throbbing sensation at the anus: then comes
on spasmodic contraction of the sphincters, and the patient endures
agonizing pain, often for several hours, when relief is gradually
experienced, and no pain is felt until defecation again becomes
necessary. Now, it has been observed that in some cases where the local
lesion is very trifling the pain and spasm are intense and
long-continued; in other cases, where spasm and agonizing {889} pain
followed every act of defecation, no lesion of the anus or rectum could
be found. This led Dolbeau to consider the essence of fissure of the
anus neuralgic, and to define it as "a spasmodic neuralgia of the anus
with or without fissure." The mental depression is so much out of
proportion to the local disease that this may come within Curling's
observation, that "mental causes may produce local disease in the
rectum."
Rodent, or Lupoid, Ulcer of the Rectum.
This is, fortunately, a rare disease, and is peculiar and distinct from
any other form of ulceration in this region. It is not cancerous,
although bearing some resemblance to epithelioma. As it first appears
it is very like a syphilitic sore, and its situation and the character
of the pain might lead to the supposition that fissure existed. Rodent
ulcer is usually situated upon the mucous membrane, although it
occasionally invades the integument about the anus; its shape is
irregular, its edges sharp and well defined, and it does not undermine
the neighboring tissues. There is no induration about this sore, as
nature does not seem to attempt to limit it or to set up any reparative
action, and its surface is red and dry. The surrounding tissues seem
quite normal. It is very destructive, and seems to prefer mucous
membrane, although sometimes it destroys deeply. It does not cause
infiltration; it does not spread by the lymphatic system, forms no
secondary deposits, nor does it produce stricture. It may remain in a
quiescent state for some time, and a certain amount of cicatricial
tissue may form; but it never heals spontaneously, and an exacerbation
comes on which destroys in a very few hours the repair which may have
been the work of many days. This form of ulceration of the rectum is
usually considered incurable; the pain is intense, being compared to
that produced by hot iron, and of course being much aggravated by the
acts of defecation. Patients so affected die from exhaustion and pain,
although recovery may take place, I have known one case entirely cured
by complete excision. Spasm of the sphincters is a usual accompaniment,
and greatly augments the suffering of the patient. Of the four thousand
consecutive cases of rectal disease tabulated by Allingham, only two
were cases of rodent ulcer.
Obstruction of the Rectum.
This condition may be caused by foreign bodies introduced into the
anus, by indigestible substances swallowed, by impaction of feces, by
pressure of tumors external to the rectum, and by intestinal
concretions. Any condition which causes loss of muscular and nervous
tone in the large intestine favors its obstruction; thus, it is not
uncommon in the aged of both sexes, but especially is this the case in
women, and in them it often follows parturition. Hysterical, nervous,
and debilitated persons are particularly prone to it. The insane, if
not carefully watched and regulated, will become the subjects of it.
Impaction of feces is a very common cause of obstruction of the rectum,
and atony of this organ is usually the primary cause, the feces in
these cases being {890} either very hard and dry or clayey and
tenacious. These masses are of a more or less globular shape, and, as
they irritate the bowel and produce diarrhoea, the practitioner
sometimes falls into the error of prescribing doses of opium and the
astringents, misled by the appearance of feculent fluid which oozes
around the impacting mass. The impaction occurs just above the internal
sphincter. Habitual constipation soon stretches the rectum and robs it
of expulsive force, and an accumulation of months of fecal matter is
sometimes found. The appearance of persons so affected suggests
malignant disease: they are cachectic, sallow, dyspeptic, irritable,
and nervous. Vomiting, anorexia, thirst, cough, hectic, irregular and
profuse sweating, are also among its symptoms. Cases of melancholia and
of hypochondriasis have been cured simply by the discovery and removal
of rectal impactions. This condition has been mistaken for cancer,
phthisis, intermittent fever, and enlarged mesenteric glands.
Accompanying impaction, and as a result, is spasmodic contraction of
the sphincter ani, which causes the anus to protrude in a nipple shape
and to firmly resist the introduction of the finger. Usually, there is
no discharge from the anus in these cases. Tenesmus, a sense of weight
and of a body present in the bowel, are experienced. Young people are
not often subjects of impaction.
Concretions also cause obstruction of the rectum: these are more
frequently cylindroid in shape, and sometimes have a nucleus consisting
of some firm foreign body. Wetherill reports a case of a young adult,
who had been accustomed to the daily ingestion of a substance known as
hygienic bread (this substance is made from the husks of grain, and is
very coarse: it is used to excite peristaltic action), from whose
rectum he removed a very hard ball of this substance which was covered
with mucus, but which contained no nucleus. He reports another case in
which the offending substance was a globular mass of casein, stained
with bile and covered with mucus, and which had for a nucleus a small
mass of hardened fecal matter.
Guéneau de Mussy[6] reports a case in which there was an occlusion of
the rectum by a mass of magnesia, which was so firmly impacted that it
had to be removed by a mallet and chisel. A similar case occurred in
the practice of Dunlap of Norristown. Fendick[7] relates an instance of
impaction by a fish-bone near the anus, causing obstruction requiring
surgical interference; which illustrates the importance of examining
carefully all cases of acute piles and threatened abscess.
[Footnote 6: _Medical Times and Gazette_, 1879, vol. ii. p. 214.]
[Footnote 7: _Lancet_, 1880, vol. ii. p. 239.]
These concretions often consist of animal and vegetable fibres matted
together about a nucleus, the latter consisting of the seeds of fruit,
fragments of bone or gristle, hair, small coins, or pins. "Enteroliths
may lodge in the rectal ampullæ" and cause obstruction. Indigestible
substances swallowed with the food may be arrested in the rectum, such
as grape-skins, fruit-pits, husks, and fibres, and where there already
exists stenosis of the bowel a dangerous form of obstruction may be
produced. Jones[8] reports a case of chronic impaction of the rectum by
plum-stones, which gave rise to trouble in defecation, and at the end
of eighteen months produced symptoms of piles; at the end of two years
impaction occurred, and the mass was removed by the surgeon. Hazelhurst
relates {891} a case of impaction in a negro where two hundred and
eighty plum-stones were removed from the rectum after having been there
for a week. The records of the Pennsylvania Hospital furnish the
following interesting case of obstruction:[9] "The patient (a male)
stated that twenty years before he swallowed a peach-stone. Two years
afterward he had symptoms of rectal irritation, tenesmus, constipation
alternating with diarrhoea, and liquid stools, etc. These symptoms had
continued ever since. His health had been markedly impaired. A digital
examination revealed a hard, stony mass two and a half inches above the
anus. Under ether Morton divided the external sphincter, and with a
pair of bone-forceps removed, with considerable difficulty, a
good-sized peach-stone which was lodged in the rectal tissues. The
stone was very sharp at the ends, and had evidently lodged crosswise
and become imbedded. The patient was discharged quite well and free
from all symptoms."
[Footnote 8: _Lancet_, 1856, vol. ii. p. 278.]
[Footnote 9: _Surgery in the Pennsylvania Hospital_, Phila., 1880, p.
335.]