concretions. A case of impaction is related by Walker,[10] who removed
a gall-stone from the rectum which measured three and a half inches in
its longest and one and a quarter inches in its shortest diameter; also
one by Roberts,[11] in which he removed a gall-stone measuring five
inches in circumference from the rectum of a woman two weeks after
confinement. Mischievous, revengeful, insane, or intoxicated persons
sometimes force very curious foreign bodies into the rectum, among
which may be mentioned hot iron, bottles, cups, bougies, pieces of
wood, stones, a champagne flask, a goblet, slate-pencils, and the tail
of a pig with the bristles cut short. Some foreign bodies introduced
from below find their way through the sigmoid flexure and lodge in the
colon, or they may remain for a long time in the rectum. The cæcum is
the favorite resting-place of foreign bodies. Turgis[12] removed by
linear rectotomy a cup which had been forced into the bowel. These
foreign substances, if not promptly removed, set up violent
inflammation. Obstruction of the rectum may be caused by vast numbers
of round- or thread-worms twining themselves together in a mass; and
when this happens in children or in adults of very nervous organization
a curious train of reflex symptoms may be developed, among which may be
mentioned choreic movements, convulsions, pruritus ani, insomnia,
irritability, melancholia, and hypochondriasis. Finally, the rectum may
be obstructed mechanically by pressure exerted from without. Such an
effect might be produced by morbid growths from the sacrum or ileum; by
deposits in Douglas' cul-de-sac; by ovarian disease; by pelvic
cellulitis causing stricture of the rectum; by vesical trouble; by
ascites with hepatic disease; and by various abnormalities of the
uterus, such as inflammation, morbid growths within or upon, simple
retroversion or retroflexion, or retroflexion of this organ in a gravid
state.
[Footnote 10: Flint, _Prac. Phys._, 460.]
[Footnote 11: _Bost. Med. Journ._, 1879, vol. ii. p. 116.]
[Footnote 12: _Société de Chirug._, 1878.]
Impaction of feces under some circumstances may give rise to extensive
sphacelus of the rectum and the contiguous parts from pressure. This is
well illustrated in the following case of a woman aged sixty-five, who
was found to have an immense distension of the abdomen from ascites,
incident to a large omental scirrhus. The patient suffered greatly from
the pressure caused by the accumulation of water, and she was tapped.
Soon after this an impaction of feces was observed, which probably had
been forming {892} for some time prior to her coming under observation.
A week or ten days after the tapping the impaction was detected, but
not soon enough to prevent the formation of a large slough of the
posterior and inferior part of the rectum immediately above the anus.
The submucous tissues and the skin, owing to the greatly enfeebled
condition of the patient, soon gave way, leaving a large opening which
communicated with the bowel. The tissues adjacent were oedematous, red,
and painful. The finger carried into the bowel through the anus
discovered the slough to have involved a region of at least two and a
half inches in diameter.
Cutaneous Eruptions and Parasitic Conditions of the Anus.
These are quite numerous, and they almost invariably produce much
distress and excite painful pruritus, which is augmented rather than
relieved by scratching or friction of any sort. The application of the
leaves of Rhus toxicodendron after defecation is capable of exciting
considerable inflammation upon and around the anus, accompanied by
small pearly vesicles, which, when ruptured by scratching, seem to
spread the disease wherever the contained serum flows. Eczema, when
found in the anal region, is usually due to parasitic growth. Erythema
intertrigo is caused by the friction of moist opposing surfaces, as
between the nates of stout persons, who perspire freely, and infants.
The abraded derma exudes a sero-purulent fluid which excites
troublesome pruritus. When this condition exists about the anus it
causes painful defecation and spasm of the sphincters. Erythema
chronicum occurring in this locality is frequently a sequel to chronic
eczema and chronic lichen: the skin cracks, is moist, thickens, and the
epidermis exfoliates. The proximate cause in both of these conditions
is congestion of the vascular rete of the derma. In prurigo podicis
papules appear which itch intensely, and when scratched bleed, the
summit of each papule bearing a small black scab. If not cured, in time
a true psoriasis may develop. Herpes of the anus occurs similar to
herpes at the other mucous outlets of the body, and is usually
symptomatic of slight disorder of digestion. Wetherill has seen a case
of herpes zoster, (var. proserpens,) in which the vesicles extended
from the side of the scrotum along the perineum to the verge of the
anus. This condition was accompanied with neuralgia of the rectum,
painful defecation, and spasm of the sphincters. Furunculi sometimes
form at the verge of the anus, causing spasm, pain at stool, and
occasionally marginal fistulæ. Various syphilodermata also appear in
this region. Gross was the first to describe a condition of trichiasis
of the anus--a very irritating complication to fissure--due to a
perverted recurvation of the hairs usually found in the anal region.
Villermé states that hairs have been found growing from the mucous
membrane of the rectum. The colonization of pediculus pubis about the
anus occasions a certain amount of irritation. Sarcoptes hominis is
sometimes found in this region, having been carried there by hands
infested with this parasite. The result is very distressing. The
peculiar tracks or burrows made by this little animal, and the use of
the microscope, make the diagnosis certain. The Acarus autumnalis, or
mower's mite, has been found in the skin of this part, and it is
capable of causing great distress. These do not furrow the {893}
integument longitudinally, but burrow vertically, and may be picked out
of the summits of the wheals, where they appear as small red points.
Ulceration of the Rectum and Anus.
This is a condition very different from fissure or the painful ulcer of
Allingham--much more grave, difficult to treat, and, in chronic cases,
much less hopeful of cure. It is not an uncommon affection, Allingham's
table of 4000 consecutive cases of diseases of the rectum and anus
furnishing 190 of the disease under consideration. An ulcer of the
rectum may be partly within, partly without, the internal sphincter,
but in most instances is found above that muscle, from an inch and a
half to two inches from the anus, situated dorsally.
The symptoms are unfortunately obscure and insidious, misleading not
only the patient, but also too frequently his medical adviser, and
gaining grave headway before a correct diagnosis is reached. Often the
very first symptom is a slight diarrhoea every morning as soon as the
patient rises, accompanied with a little discharge resembling
coffee-grounds; or, again, the discharge is like the white of an egg;
in some rare instances pus is formed. At this stage there is little or
no pain, but the patient suffers from tenesmus--which is not followed
by relief--and a sense of uneasiness in the part. Several stools of
this nature or streaked with blood may be passed during the earlier
part of the day, after which the patient feels partly relieved, and no
more evacuations occur until the following morning, when he again
experiences the same train of symptoms; and this repeats itself daily
for a long time. Finally, these discharges occur in the evening as well
as in the morning, then at various times during the day: his general
health begins to give way; the discharge becomes augmented in amount
and contains more blood and pus; and he suffers occasional pain from
flatulent distension. Local pain in the rectum is now felt, which is
not acute, but is very wearying, is augmented by much walking or by
long standing, and which has been described as similar to a dull
toothache. These ulcers may be multiple, and not infrequently lead to
stricture of the rectum, which condition is indicated by the
alternation of attacks of diarrhoea and constipation. As the ulcerative
process proceeds, nature makes efforts to limit the process, which
causes infiltration and thickening of the submucous and muscular
tissues, and produces narrowing of the lumen of the intestine, which in
time loses its tone and contractile power and becomes a passive tube,
utterly unfit to perform its normal duties. The sphincters give way and
the patient loses control over his evacuations. Finally, abscesses
form, which, burrowing toward the surface, form fistulæ, and may
perforate the bladder, the vagina, or the peritoneal cavity. If one of
these ulcers be examined while yet in the acute stage, it will be found
to be oval in shape, with well-defined edges: the base will be either
grayish or very red and inflamed, the surrounding mucous membrane
appearing normal. The rectal glands will be found to be enlarged.
Should the ulcer be examined at a later stage, it will be found to be
much deeper and more extensive, with great thickening and nodulation of
the mucous membrane, and looking in places as though the latter {894}
had been torn off. At this stage the ulceration may be partial or may
involve the entire lower portion of the rectum. The suffering is now
intense, and a constant discharge of fetid pus and mucus takes place.
The appearance of the anus at this time suggests malignant disease: it
is covered with swollen, shiny, tender, club-shaped flaps of integument
constantly bathed in an ichorous discharge. The entire rectum and
sigmoid flexure have been involved in some cases, while in others
necrosis of the sacrum has occurred. Patients suffering from ulceration
and stricture are very liable to a low form of peritonitis, attended by
intense abdominal pain.
The causation of these ulcers of the rectum is frequently very obscure:
some are of syphilitic, others of strumous, origin. Some are of
traumatic origin, but more often the patient was in apparent health up
to the time of the appearance of the disease. The experience of
Allingham would indicate that neither chronic constipation nor
dysentery is a frequent forerunner of this malady. T. Claye Shaw,[13]
in an article entitled "On Some Intestinal Lesions of the Insane,"
says: "After death are found patches of ulceration sometimes so
extensive as to resemble a honeycomb network. The edges are usually
slightly raised, and perhaps hardened; but the ulcers are at other
times mere local punchings out of the mucous membrane, and there is
often a little loose gelatinous material." It is claimed that such
disorders are not infrequent among the insane.
[Footnote 13: _St. Bartholomew's Hospital Reports_, 1880.]
It is also claimed that the chronic mechanical irritation from foreign
bodies, impacted feces, and the like exert a causative influence in the
formation of ulcer of the rectum. Like typhlitis, this affection leads
to chronic inflammatory changes in the immediate neighborhood
(periproctitis), with the formation of fistulæ and crater-shaped
ulcerations, and to the extensive destruction of the mucous membrane,
followed by wasting and contraction of the rectum. The healing of these
ulcers is much delayed by the fact that the ulcerated and undermined
mucous membrane is irritated by the fecal masses which are especially
apt to accumulate in the lower part of the bowel and around the anus.
We find also hemorrhoidal swelling and ulcerations, which may be
regarded as partly a cause, partly a result, of the ulcerative
proctitis.
Follicular Ulcerations.
In this condition the most extensive ravages are found in the rectum
and sigmoid flexure. The causes are identical with those of catarrh of
the large intestine, if we except the follicular disease produced by
dysenteric infection. In this form of the disease, at least in its
earlier stage, the form of these ulcers is always round and
funnel-shaped, with distinct thickening of the edges of the mucous
membrane around the ulcers. These appearances may be explained by the
mode in which the follicular ulcerations originate: "The solitary
follicles become swollen, a result of catarrhal irritation, and the
cellular elements accumulate in the reticulum, giving rise at first to
nodules which project above the level of the mucous membrane: then the
newly-formed tissue-elements become necrosed in consequence of the
mutual pressure of the cells upon {895} each other; finally, the apices
of the follicular nodules give way and the ulcers are formed. The
surrounding mucous membrane bends over downward toward the base of the
ulcer, so that the orifices of the crypts look down into the same."[14]
As the suppurative process extends, particularly in the submucosa, and
the tissue surrounding the follicles becomes destroyed, these small
ulcers coalesce to form larger ones, and the undermined edges of the
mucous membrane project over the base of the ulcers, bleed, and become
necrosed. Healing is possible by cicatrization, the borders of mucous
membrane becoming applied to the base of the ulcer and gradually drawn
together by the cicatricial tissue. Still, this result is extremely
rare if the ulcerative process has gained much headway. When, however,
a follicular ulcer of some size does heal, cicatricial stenosis may
result, followed by chronic constipation, just as in the case of simple
catarrhal ulceration. The situation of follicular ulcerations is almost
always in the large intestine, and they vary considerably in number:
sometimes only a few follicles are thus affected, while in other cases
the bowel is crowded with them.
[Footnote 14: Rokitansky, _Path. Anat._, iii. 1861, S. 226.]
The anus and rectum may become the seat of chancroidal invasion. An
ulcer of this character fairly within the rectum is very rarely met
with, especially in this country, and could scarcely be produced except
by unnatural intercourse. They are of not uncommon occurrence in the
anal region, and are met with in this situation more frequently among
females than among males. Occurring among the former, they no doubt
often arise from accidental contact during normal sexual intercourse.
When this condition is found in males, it rather indicates at least an
attempt at unnatural intercourse. Of 1271 males affected with
chancroids, only 3 were found with the disease in the anal region. Out
of 388 females similarly affected, 33 were found with chancroid of the
verge of the anus. The table of Debauge gives 23 cases among 206
females having chancroid in various other situations. The destruction
of tissue in these cases may be very serious should the nature of the
ulcer not be recognized, and stricture of the rectum or cicatricial
stenosis of the anus might result. Ulceration of the rectum may occur
during chronic proctitis; it may accompany advanced states of prolapse
and procidentia of the bowel; it may attack a stricture of the rectum
and cause peritonitis by erosion. Ulceration may accompany hemorrhoids,
or it may attack them and cause dangerous hemorrhage. Finally, a very
intractable form of ulceration may follow the clamp-and-cautery
operation upon piles. When this untoward result is seen, it is usually
due to the fact that the patient has been allowed to move about too
soon. Allingham claims to have seen these ulcerated stumps of piles
even ten days after operation.
Peri-anal and Peri-rectal Abscess.
The ischio-rectal fossa is peculiarly liable to attacks of inflammation
resulting in abscess, as it is filled with much loose connective tissue
which supports a considerable amount of fat, and is situated in a
region which is constantly exposed to injury both from within and
without. It is a very vascular part, being freely supplied by branches
of the inferior {896} hemorrhoidal arteries and veins; the latter,
being large and destitute of valves, empty into the portal circulation.
Abscess in this region is of very common occurrence, and may attack any
one at any period of life. It occurs more frequently among men than
among women, and usually during middle life.
Abscesses in this situation may be acute or chronic. The former variety
may be caused by injury to the anus or to the surrounding parts; by
exposure to cold and wet, and particularly by sitting upon damp seats
while the body is overheated; by impaction of feces, constipation, and
straining at stool. Irritating substances swallowed with the food, such
as small pieces of bone, oyster-shell, or the stones of fruit, may
excite abscess by their presence in the rectum. Among other causes are
general debility, an impoverished state of the blood, the scrofulous
and tuberculous diatheses. The disease sometimes occurs in quite young
infants. Wetherill reports the case of an infant attacked by an
enormous ischio-rectal abscess while nursing from the mother, who was
at the time suffering from a succession of boils. Many cases have been
traced to sitting upon the outside of damp omnibuses. Hepatic
disorders, causing engorgement and stasis of the blood in the
hemorrhoidal plexus, have frequently occasioned this condition. These
abscesses are not always situated in the ischio-rectal fossa;
frequently they are subcutaneous and just outside the anus: in other
cases the starting-point may be ulceration of the mucous membrane of
the rectum, with escape of fecal matter into the areolar tissue; they
also originate in the submucous connective tissue of the rectum. The
acute abscess is sudden and very severe in its onset; the pain is
continuous, throbbing, and augmented during defecation; dysuria is
almost always present, and in some cases there is total inability to
pass water. There is local tenderness, dusky redness, and fluctuating
prominence, and, if not interfered with, a rupture of the integument
will take place and the pus will escape externally. Sometimes their
formation is accompanied with a chill or with a succession of rigors:
there is always considerable constitutional disturbance, febrile
movement, loss of appetite, and malaise. This form of abscess is
usually circumscribed and does not burrow irregularly, and sudden
relief of pain and distress is coincident with their evacuation.
Chronic rectal abscess corresponds to the cold or chronic abscess in
other situations: it is apt to occur among those who are much
debilitated or among those of the scrofulous diathesis. These abscesses
have little disposition to open spontaneously upon the surface, but
they burrow extensively in all other directions--high up along the
outside of the rectum, laterally into the tissues of the buttock, or
downward and forward into the perineum. The process of formation may
occupy many months, and sad havoc may be occasioned before their
existence is suspected. They occasion no pain nor distress nor acute
febrile movement, but may be accompanied with a hectic condition,
erratic sweatings, and rapid loss of strength. Upon examination of the
anal region in these cases a painless flat, boggy, crepitating
enlargement is the only surface-indication of the probably extensive
damage sustained by the deeper structures.
This form of abscess may be of traumatic origin, but more frequently
the inflammatory process arises in the cellular tissue of the
ischio-rectal fossa; in some cases the morbid action is due to
ulceration of the rectum. {897} In either case peri-rectal or peri-anal
cellulitis will be induced. When these abscesses are of strumous origin
the pus is thin, curdy, and offensive.
Both the acute and the chronic abscesses of this region are often
difficult to heal, the external opening remaining permanently patulous,
communication with the bowel resulting from internal burrowing and
erosion, with the formation of extensive sinuses in all directions,
resulting in fistulæ in ano.
Fistula in Ano.
This condition occurs more frequently than any other of the
abnormalities of this region, Mr. Allingham finding 1208 out of his
table of 4000 consecutive cases of diseases of the rectum and anus. He
found also that fistulæ followed rectal abscess in 151 out of 196
cases, the abscesses which healed kindly and gave no further trouble
being only 45 in number. A fistula in ano is a linear ulceration with a
patulous orifice which discharges pus: it may or may not communicate
with the bowel, and it may have more than one external opening. The
great majority of fistulæ in this region are caused by abscess, either
arising in the submucous areolar tissue of the bowel, or in the
subcutaneous connective tissue in the immediate neighborhood of the
anus, or in the ischio-rectal fossa, or in an ulcerated state of the
mucous membrane of the rectum: in other cases it is congenital, or it
may result from the presence of foreign bodies or worms in the bowel,
or from puncture of the rectum by pins, scales of shell, fragments of
bone, or other sharp substances swallowed with the food. Abscesses
leading to fistulæ have followed kicks, blows, or wounds of the anal
region: in short, anything which induces an abscess here may result in
a fistula, and as in the former more cases occur in males than females,
and more during middle age than at any other period, the same is true
as to the latter. Fistula is quite common among the phthisical as a
result of malnutrition and septicæmia, aided by the constant succussion
of the perineum produced by efforts at coughing. Of the 4000 cases
previously referred to, 1208 were cases of fistula; "of these, 172
presented more or less marked symptoms of lung trouble, hæmoptysis,
cough, or impaired resonance in some portion of the chest."
A fistula may be complete or incomplete. To be complete, it must have
two openings (it may have more)--one in the anus or rectum, and one
upon the surface. There are two forms of the incomplete or blind
fistula--one in which there exists an internal but no external opening,
and the other in which there is an external but no internal opening. In
complete fistula there may be more than one external opening, and this
is in the majority of cases not far from the anus, but it may open in
the perineum or upon any part of the gluteal region. When the openings
are multiple they usually converge to form a common tract or sinus. The
external opening presents nothing to the untutored eye to lead to the
suspicion of grave internal trouble: frequently the vent is so minute
and valvular or shielded by a thin pellicle as to be entirely
overlooked; in other cases a little teat formed of superabundant
granulations guards the entrance: there may or may not be
discoloration, elevation, or depression of the surrounding integument,
and erythema resulting from the {898} irritating nature of the
discharge. Inflamed and suppurating follicles in the integument about
the anus are not to be mistaken for the orifices of fistulous tracts.
The internal opening in anal fistula is situated between the sphincter
muscles, sometimes just within the anus, but oftener about half an inch
above; in rectal fistula the internal opening or openings may be at any
point above the internal sphincter. These sinuses may be very tortuous,
with pockets, blind passages, or diverticulæ, and are known as
horseshoe fistulæ when they commence at one side of the bowel and
ulcerate around it to a point opposite before making an opening.
Of the two varieties of incomplete fistulæ, by far the least frequent
is that where no internal opening exists, but where there are one or
more external orifices: these do not invariably even run toward the
bowel, but may extend off through the tissues in any direction. In the
other variety, where there exists no external evidence of disease,
considerable damage may be done before its recognition. Fistula may
coexist with hemorrhoids, stricture, ulcer, or malignant growth: it may
be a very trivial affair, with the internal but a fraction of an inch
from the external opening, or it may be long, deep, and tortuous, with
sinuses running in all directions through the buttock.
Usually, fistulæ become worse when not operated upon, but there are
cases which have healed without surgical interference--others in which
this condition has gone on for many years without getting any worse or
without the discharge increasing in amount. The fluid discharged from a
chronic fistula loses after a time much of its purulent character and
becomes serous and watery; but fresh abscess and inflammation is apt to
take place in these cases from feculent matter lodging in the sinus.
Those which burrow most readily are the internal fistulæ with large
openings, into which the feces are pushed, with the sinus running
toward the anus, because of their funnel-shape.