region abscesses which have not completely healed, or which, having
apparently done so, break out from time to time and discharge pus; or
from the existence of a circumscribed hardness or swelling
unaccompanied by an opening which varies in size and is at times
painful; or if there exist any ulcerated moist openings. To make a
positive diagnosis the tract must be explored by a probe: enter the
oiled, blunt-pointed probe gently into the external opening and let it
find its way along without force, bending the probe if necessary, until
it has traversed the sinus as far as it will go; then pass the finger
into the rectum and feel about for an internal opening or for the point
of the probe. If the finger be introduced first, the relations of the
parts are interfered with and the internal opening, should one exist,
might not readily be found. Sometimes the bottom of the tract does not
correspond in situation to the internal opening, but extends beyond it.
In those cases where no external opening exists, the rectal speculum,
aided by judicious pressure, will discover an issue of pus from a sinus
upon the mucous membrane of the rectum.
In order to illustrate the amount of damage which a small foreign body
may cause when lodged in the rectum, Wetherill relates the following
case, which occurred in his practice at the Pennsylvania Hospital for
the Insane: The patient was a middle-aged man, intelligent, and an
{899} employé of the hospital. "Upon examination of the anal region I
found a small, tender, firm swelling, which did not fluctuate, about an
inch to the left of the anus: this had been forming for about a week,
and there was no history of painful defecation, of exposure to damp and
cold, nor of a blow or injury of the part. Without waiting for the
development of fluctuation, I made a free and deep incision into the
ischio-rectal space, and a large quantity of very fetid pus escaped:
upon introducing a large probe I found that it passed up into the fossa
to a depth of four and a quarter inches and turned but slightly toward
the bowel. Remembering the experience of Allingham, that when the pus
in these cases was very offensive there existed an opening in the
bowel, I questioned the patient again as to pain in the bowel or
painful defecation, which was answered in the negative. No
communication could be found with the finger in the bowel and a probe
in the wound, and poultices were applied, liquid diet ordered, and the
man kept in bed. The cavity was loosely filled with absorbent cotton
and the entire wound (apparently) healed slowly, but kindly, and in
about ten days after operation the patient left the house to all
appearance sound. About a week after the patient returned with the
report that he felt uneasy throbbing in the part, and that there was a
very slight discharge. Upon inspection I found in the surface-line of
the cicatrix a pinhole opening which yielded upon pressure a drop or
two of pus; upon entering a very fine probe it passed into a narrow
sinus to a depth of three and a quarter inches, but no communication
could be made with it with the finger in the bowel. Upon withdrawing
the probe it grated over something which felt like dead bone, about two
inches from the surface. I enlarged the opening, introduced a pair of
fine dressing-forceps, and withdrew a piece of the rib of a chicken
about half an inch in length and sharpened at one extremity to a fine
point. Upon making inquiry I found that he had not eaten any chicken
since the development of the abscess. He then suddenly remembered that
while he was at stool a few days prior to the formation of the abscess
he experienced a sudden pang of very acute pain in the rectum, which,
however, soon passed off. This was no doubt the moment when the piece
of chicken-bone pierced the rectum."
Hemorrhage from the Rectum.
Hemorrhage from the rectum may be accidental, primary, or
secondary--accidental when it follows the ulceration of internal piles
or the erosion of large arterial or venous trunks during the progress
of malignant disease, or when it occurs from the rupture of a rectum
during defecation--a very rare and curious occurrence reported by M. E.
Quénu;[15] primary when it occurs during, and secondary when it occurs
after, a surgical operation upon these parts.
[Footnote 15: _Révue de Chirurg.; Practitioner_, p. 29, Oct., 1882.]
Hemorrhage from the rectum without any structural lesions is quite
unusual, but occasionally copious losses of blood are seen in vicarious
menstruation, and several instances have been reported.
When ligatures separate after operations upon those of broken-down
constitution very copious and dangerous bleeding may occur without any
symptoms save a "sensation of something trickling in the bowel," {900}
a feeling of weight and fulness in the part, with increasing weakness
and syncope of the patient, until he expresses a desire to go to stool,
when suddenly a large quantity of blood escapes.
SECONDARY DISEASES OF THE RECTUM AND ANUS.
This class of affections depends upon constitutional infection, direct
extension of disease by contiguity, by contiguity from disease in
neighboring organs, or by abnormal conditions excited by disease of
remote origin; and are frequently due to changes in the nervous and
vascular supply.
Syphilis of the Rectum and Anus.
True primary syphilitic chancre of the rectum must be an extremely rare
lesion, and could have been acquired only by unnatural intercourse.
There are syphilographers who deny that the hard chancre has ever been
found within the sphincter muscles; but it certainly is not uncommonly
found in the anal region, and oftener among women than men. The table
of Jullien gives 12 instances of this lesion in males, and 1 instance
of chancre of the buttock, out of 77 cases, while among 82 cases
occurring in the opposite sex, 21 were of the anus and perineum and 4
of the buttocks. The French authorities give the frequency of this
condition in men as 1 case in every 119; in women, 1 case in every 12.
Anal chancres are easily overlooked, as they occupy the puckered folds
of the anus, which when not opened out to the fullest extent afford
perfect concealment: they may be either in the form of cracks or slight
fissures, elongated ulcerations, or firm papules. It has been claimed
that the initial lesion has provoked stricture of the rectum, but this
is not probable.
The secondary manifestations of this disease which show themselves in
the anal region are some of the syphilodermata, moist papules, mucous
patches, and moist papillomatous excrescences or condylomata. The
statistical tables of Davasse and Deville[16] in regard to the
occurrence of moist papules and mucous patches in women show that out
of 186 cases they appeared about the anus in 59 and on the perineum in
40. Bassereau's[17] statistics show that in men these lesions occurred
in the anal region 110 times out of 130 cases. These are, of course,
very contagious. Besides true syphilitic warts, which sometimes occur
in this region, it is quite usual to see the anus surrounded and the
entire gluteal cleft filled up with moist, offensive, papillomatous
excrescences, which remain obstinately so long as these surfaces are
permitted to rest in moist contact. Syphilitic stricture of the rectum
is one of the results of a later stage of infection, and occurs oftener
among women than men. It is stated by Jullien that of 60 cases only 7
were men, the remaining 53 women. They are invariably formed as
follows: A gummatous deposit in the {901} submucosa undergoes
ulceration, and the subsequent cicatricial contraction gives rise to
the stricture. Whether the stricture will be valvular or annular
depends upon the extent of rectal mucous membrane involved in the
ulcerative process. The diffuse gummatous infiltration of the
ano-rectal tissues and the subsequent deposition of contractile tissue
are the most usual causes of these specific strictures. The lower
portion of the rectum is commonly the situation of specific
ulcerations, usually of the secondary or tertiary stage, which lead to
the formation of stricture: this occurs more frequently among women
than men, and between the ages of seventeen and thirty years. Gosselin
and Mason regard strictures as the result of chancres, and not as the
result of constitutional infection; but it is known that ulcerations of
secondary syphilis may extend upward from affections about the anus,
and also that gummata do commonly give origin to this condition.
Gummata, and strictures following them, may be distinguished from other
affections on account of the greater distance from the anus at which
they occur, chancres or chancroid ulcers being usually within four or
five centimeters of the anal orifice. Strictures due to gummata are
more apt to occur late in life, but may therefore be easily confounded
with cancer. Condylomata at the anus are often associated with
syphilitic disease of the rectum.
[Footnote 16: _Internat. Encyclop. of Surgery_, vol. ii. p. 508.]
[Footnote 17: _Loc. cit._]
Scrofulous and Tuberculous Affections.
There are cases which yield abundant evidence of struma in the form of
enlarged glands, chronic abscess in the neck, swelling and abscess in
the vicinity of the articulations, and the like, in which ulceration of
the mucous membrane of the rectum has been found: this condition may
result in fistula in ano by erosion, permitting escape of flatus and
excrementitious products into the cellular tissue. A similar result may
follow by erosion of the bowel from a strumous abscess in the
connective tissue around the rectum; both these forms tend to the
production of that class of fistula which has no outlet at the surface,
but which has one or more openings upon the mucous membrane of the
rectum. Thus concealed (for often there is no marked surface indication
of either abscess or fistula), they may remain for a long time
unsuspected and acting as a serious drain upon the already impaired
constitution. The pus in these cases is watery, curdy, and offensive.
These chronic conditions are subject to intercurrent attacks of acute
inflammation, due to the lodgment in the abscess cavity or the
fistulous tract of fecal matter or indigestible solid substances. Any
or all of the abnormalities of this region may be complicated by the
existence of tubercular or scrofulous conditions of the system.
Tubercular ulceration of the rectum is now a well-recognized condition.
Rectal ulceration and tubercular disease of the lungs have not been
found to coexist in any marked preponderating number of tabulated
cases. The frequent association of fistula in ano and tubercular
disease of the lungs has long been recognized, Allingham having found
172 such cases among 1208 cases of fistula in ano.
The pathology of tubercular ulceration of the rectum is graphically
described in _Ziemssen's Encyclopædia_ as follows: "These [ulcerations]
begin in the follicular apparatus with swelling of the individual {902}
follicles and their vicinity from tuberculous deposit. The newly-formed
cells become caseous, the superficial layer of the tubercle breaks
down, and thus ulcerations arise of a round funnel shape. The
enlargement of these ulcerations is probably produced by the constant
formation in the base and edges of the ulcers of new nodules, which
themselves caseate and ulcerate. This process of extension, to which
these tuberculous ulcerations of the intestines exhibit a marked
tendency, takes place chiefly in a transverse direction (girdle-shape),
following the direction of the blood-vessels. The infiltration and
necrosis may advance longitudinally, and, finally, the individual
ulcerations coalesce with each other: in this way may be explained in
part the dentate appearance of the edges of these ulcerations. The
ulceration extends also in depth, although usually the muscular coat
appears to be covered by a thick layer of connective tissue: the
destruction advances slowly in the muscularis, but in the lymphatic
vessels which pierce the muscularis less opposition is presented to the
progress of the tuberculosis; and thus it is not uncommon to find
tubercles ranged one after the other, like links in a chain, from the
base of the ulcer directly down to the serosa. Healing is extremely
rare. The most frequent situation is the lower end of the ileum, but
the process may extend upward to the stomach, or downward, involving
the rectum. There is almost invariably unmistakable signs of
tuberculosis in other organs. It is possibly never primary, but this is
a still-disputed point. It usually occurs with tuberculosis of the
lungs, and when so occurring it is always secondary. The clinical
symptoms of this state are by no means characteristic."
Dwelling upon the subject of intestinal tubercle, it has been suggested
by Klebs[18] that the intestinal disease is produced by swallowing
morbid products derived from phthisical lungs--an hypothesis supported
also by the fact that tubercle in the intestines tends so strongly to
spread downward. "The seat of the deposit is the submucous tissue or
the corium of the mucous membrane: it is certainly subjacent to the
basement membrane, and not contained in the follicles, as Creswell
taught."
[Footnote 18: Jones and Sieveking, London, pp. 593-595.]
Woodward, in his article upon diarrhoea,[19] says: "The lesions,
whether mild or severe, are most generally seated in the cæcum and
colon, but more or less extensive tracts of the small intestine,
especially of the ileum, are often involved also." He continues:
"Tubercular disease of the lung was noted in nearly one-sixth of the
autopsies of fatal cases of forms of flux heretofore described.
Possibly the frequency in chronic cases may be explained by the fact
that protracted intestinal flux forms the development of lung phthisis
in the predisposed."
[Footnote 19: _Med. and Surg. History of the War of the Rebellion_, p.
266.]
The rectal fissure or painful ulcer may be connected with diathetic
causes, as struma or scrofula: it is doubtful if syphilis should be
included among its causes.
Cancer, Malignant Stricture, and Malignant Ulceration.
The forms of cancer met with in these regions are epitheliomatous,
scirrhous, encephaloid, and colloid. Considerable diversity of opinion
has {903} existed as to which variety occurs most frequently; but it is
now probably a matter of absolute knowledge that the epithelial form is
the one most commonly observed, and next to that in frequency the
scirrhous form. Encephaloid and colloid are of quite infrequent
occurrence. Again, as to the sex in which this affection appears the
most often, there is much disparity existing between surgical writers:
it is usually thought to be much more prevalent among women than among
men. This is not the experience of many of the authorities upon this
subject, yet the statistics of the Hôtel Dieu, Paris, furnish
overwhelming evidence in favor of its preponderance in women. Carcinoma
of the rectum, occurring as a primary infiltration in the rectum,
probably occurs oftener in men, but there are among females so many
contiguous structures prone to cancerous degenerations, as the uterus,
the vagina, the ovaries, the Fallopian tubes, tumors and cancerous
masses occupying Douglas's cul-de-sac, that it would seem likely that
they would be more frequently the victims of secondary cancerous
deposit in the bowel or of erosion and extension of disease by
contiguity or continuity. Epithelioma in other situations attacks men
much more frequently than women. This form of disease usually occurs in
middle life and in old age, but to this general rule there have been
many exceptions; it has been seen in children. Allingham quotes its
occurrence in a lad of seventeen, and Gowland in one of thirteen. It
very rarely occurs as a secondary deposit of cancer in a remote region
or organ. In the table of 4000 cases of rectal and anal disease, before
referred to, cancer existed in 105. This disease is usually within easy
reach of the finger, except when the growth is in the sigmoid flexure,
being within an inch or two of the anus or from two and a half to three
inches above it. The epithelial form, when it commences at the anus, is
closely analogous to epithelioma of the lip: from the anal outlet it
spreads upward into the bowel, or it may be primarily seated there.
When occupying the junction of skin with mucous membrane it is
sometimes sluggish, and a long time may elapse before it takes on
aggressive action: induration, nodulation, obstinate fissure, or
fungous growth marks its inception; as the condition proceeds,
infiltration of surrounding structures takes place and large, hard,
irregular masses form, which ulcerate, split, and form cauliflower
excrescences. The rectum becomes blocked with fungoid growths: both
these and the cancer proper are very vascular, and frequent hemorrhages
occur, and an offensive muco-purulent discharge constantly oozes from
the bowel.
Scirrhus of the rectum commences as an infiltration of the submucosa,
which rapidly involves the other elements of the bowel, pushing hard
nodules upward into the lumen of the intestinal tube: these break down
and form ragged ulcers with indurated margins, and bleed profusely. Its
situation is usually not higher than three inches above the anus. It
has a tendency to invade all the neighboring organs and soft
structures, to bind them to itself in a firm, dense mass, and to form
communications with the vagina, bladder, uterus, perineum, and penis.
Abscesses and fistulæ are common complications.
These neoplasms are insidious in their onset, and when seated at some
little distance from the anus do not excite much pain at first. In the
epithelial form the anus presents an abnormal appearance: it is
inflamed and is covered with irritated, hypertrophied tags of
integument bathed in {904} a sanious, offensive fluid. Difficult
defecation, of which the natural form is absent, with inordinate
tenesmus, a sense of weight and fulness in the bowel, and an irritable
condition of the bladder, are among the symptoms. The feces are passed
in little, irregular lumps or broken fragments, or this state is
accompanied by or alternates with small, liquid, offensive stools. As
the diseased action proceeds, very severe local and general pain is
endured: this is of a dull, lancinating character, and affects not only
the diseased bowel, but involves the entire contents of the pelvis,
shoots down the thighs, up the back, and into the penis: frequent and
exhausting hemorrhages take place; the patient exhales a peculiar
sickening odor; his complexion becomes cachectic; his strength fails;
and death ensues, after a variable period of intense suffering, from a
few months to two or three years after the first symptoms appeared. The
modes of termination of life in these cases are--exhaustion, secondary
deposition, septicæmia, peritonitis, and hemorrhage. Stricture of the
bowel and very extensive ulceration attend all of these advanced cases
of malignant rectal disease.
The encephaloid variety is prone to very sudden and rapid breaking
down, and may destroy life within a few months. If the finger be passed
into the bowel in a case of encephaloid degeneration, it will encounter
a large soft tumor occluding the gut: this is a very different
sensation from that imparted to the finger in a case of epithelioma or
scirrhus. In the former there will be felt a crepitating, as though due
to the giving way of a moist, friable substance; in the latter the
touch will perceive dense, irregular nodulations and ragged ulcerations
having very firm margins.
The rectum may also be involved and destroyed by any of these neoplasms
in neighboring organs. A middle-aged woman who was admitted to the
Pennsylvania Hospital in a very advanced stage of epithelioma of the
cervix uteri died from hemorrhage from the rectum and uterus in eight
minutes. At the autopsy it was found that the disease had almost
separated the cervix from the body of the uterus, had involved the
cul-de-sac of Douglas, and had eroded a large opening into the rectum.
Numerous ends of large vessels were observed which had undergone
erosion.
Carcinoma of distant organs does not seem to frequently involve the
rectum by secondary deposition. "In 160 cases of gastric cancer
examined at the Pathological Institution in Prague, Dittrich found
secondary cancer of the rectum only twice."[20]
[Footnote 20: Leube, _Ziemssen's Cyclopæd._, vol. vii. p. 235.]
In these cases of carcinomatous disease originating in the bowel the
neighboring lymphatic glands are indurated and enlarged, and secondary
deposition in neighboring and distant organs is the rule.
The lower portion of the intestinal tract may become involved in
disease by direct extension from the colon, as in dysentery following
enteritis or entero-colitis. Habersham says that diarrhoea arises
generally from an irritated condition of the large intestine, catarrhal
and mucous diarrhoea from slight inflammatory disease closely allied to
ordinary coryza affecting the mucous membrane of the large intestine.
"In the diarrhoea of soldiers the lesions of the large intestine have
been either those of congestion with varying degree of extravasation or
of ulceration more or less extensive. The colon in the former cases has
invariably presented {905} patches of intense congestion, and in
numerous instances extravasation, the amount and intensity varying in
different subjects, in a few the whole mucous surface of the intestine
having a livid red color; in others tracts of more or less intense
congestion at irregular intervals, as in the small intestines, would be
noticed. The ileo-cæcal valve almost invariably presented intense
congestion. The rectum has uniformly presented intense congestion, with
more or less fibrinous exudation. Frequently the presence of fibrinous
exudation was a question of doubt."[21] The entero-colitis or ordinary
summer complaint of infants not infrequently causes a very troublesome
form of proctitis. Besides the ordinary causes of dysentery, Feyrer[22]
states that it is caused by irritation of the solar plexus of nerves,
also by the inhalation of sewer emanations and by the ingestion of
impure water.
[Footnote 21: _Med. and Surg. History of the War of the Rebellion_,
vol. ii. p. 102.]
[Footnote 22: _Times and Gazette_, 1881, p. 87.]
"In dysentery the anus becomes bluish-red, and is even marked with
cracks and rents; it is painful to the touch and tightly contracted. In
the later stages of severe cases it becomes large and gaping; then the
stools are generally discharged unconsciously, and the pain is slight,
paralysis of the sphincter ani having occurred. These symptoms indicate
generally that death is to be expected. In some of these cases the
pathological lesions are limited to the rectum. Dysentery may succeed
typhoid fever."[23]
[Footnote 23: Heubner, _Ziemssen_, vol. i. p. 552.]