when dysentery has existed. Pigment-deposits are encountered in the
large intestine in those who have suffered from repeated attacks of
acute diarrhoea or from protracted flux. They may be seated as diffuse
patches on the general surface of the mucous membrane or may be more
especially localized in the closed glands. The diffuse form of these
deposits is more frequently encountered in the large than in the small
intestine, and is apt to be more intense in the former, producing
darker and more extensive discoloration; hence the ash- and
slate-colored, greenish, and blackish tracts which are so frequently
observed in the cæcum, colon, and rectum."[24] Follicular ulceration of
the rectum sometimes follows chronic dysentery and typhoid fever.
Woodward has observed that a catarrhal condition of the rectum commonly
occurs in typhoid fever cases. Referring to typhoid fever lesions of
the large intestine, Rokitansky[25] says: "The ulcerative process is by
no means confined to the small intestine; we have seen the mucous
membrane of the large intestine riddled with ulcers. They were many of
them of large size, and had clean-cut, non-thickened margins. This
condition, indicating the absence of reparative action, is not nearly
so frequent as that of thickening and induration, which generally took
place to some extent in the edges of the ulcers. The bottoms of the
ulcers are commonly formed by the submucous tissue. Sometimes the
muscular fibres are completely exposed: this, however, is generally the
result of secondary advance subsequent to the reception of the morbid
action."
[Footnote 24: _Med. and Surg. History of War of Rebellion_, vol. ii. p.
308.]
[Footnote 25: Jones and Sieveking, p. 590.]
John Harley[26] calls attention to the intestinal lesions of scarlatina
as follows: "I know of no disease in which the morbid effects are more
{906} uniform. Scarlatina is essentially a disease of the lymphatic
system. It is attended with inflammatory action of this system of
glands, in which are included the agminated glands of the intestine. In
28 cases examined, 8 had the solitary glands of the large intestine
enlarged and inflamed; in 1 there was acute desquamation of the mucous
membrane of nearly the whole of the large intestine. In about half the
cases the large intestine was found healthy."
[Footnote 26: _Med.-Chir. Trans._, vol. iv. p. 102.]
The rectum and anus are frequently subject to attacks, by contiguity,
from diseases in neighboring organs. The most frequent of these is
doubtless that form of ischio-rectal abscess which invades the bowel,
causing fistula in ano. Various neoplasms having their seat in the
tissues or organs near the bowel may obstruct it by simple mechanical
pressure, or may cause inflammation, infiltration, and ulcerative
erosion. Mechanical encroachment by the pressure of a foreign body in
the vagina may cause grave interference with the normal functions of
the lower bowel. At the out-patient department of the Pennsylvania
Hospital in 1880, Arthur V. Meigs, assisted by Wetherill, removed a
large, hollow, glass ball-pessary from the upper end of the vagina of
an aged woman, who declared the pessary had been so placed by a
physician sixteen years before, and had remained ever since, despite
her repeated efforts to remove it with an ordinary table-fork. Upon its
extraction, which was accomplished with difficulty, a small portion of
its surface was found covered with scratches. Its presence had caused
constipation, impaction of feces, and atony of the rectum.
Interference with the rectal functions often follows tedious cases of
labor where the child's head remains long in the perineum.
The Effect of Abnormal Conditions of the Spinal Cord and its Membranes
upon the Rectum and Anus.
"In diseases of the spinal cord and its envelopes there is a great
tendency to constipation, owing to impairment of the secretion of the
intestinal juices. The intestinal movements are usually much affected,
either in the way of increase or diminution, in the former of which the
symptom is a frequent, watery, slimy diarrhoea; as a less common
condition it is even capable of being produced reflexly. Thus in a
patient with chronic myelitis I observed the regular evacuation of a
mucous fluid mass from the intestine as often as his bed-sores were
cleansed; and the like has been seen in dogs after division of the
lumbar cord. Much more commonly there is habitual, even excessively
obstinate, constipation, of which almost all chronic spinal patients
complain. The stool is slowly discharged, dry and hard, and the
evacuation occurs only at considerable intervals and after the
application of energetic remedies. Several causes doubtless contribute
to this: diminution of intestinal secretion and peristaltic
contraction, and probably also weakness of the abdominal muscles of
compression, which is often present. If there is an extreme degree of
weakness, meteorism and accumulation of feces are other consequences.
We do not know exactly from what portions of the cord these
disturbances proceed."[27]
[Footnote 27: Erb, _Ziemssen's Encyc._, xiii. p. 138.]
{907} "There are also in many diseases of the cord disturbances of
evacuation caused by paresis or paralysis of the sphincter ani. In mild
cases simple difficulty in retaining stool for any length of time
exists. There may be also great disturbance of sensibility, so that the
patient does not feel the call, and even if he possess some voluntary
control, he is surprised by the discharge, of which he feels
nothing."[28]
[Footnote 28: Erb, _loc. cit._, p. 139.]
The sphincter ani is affected in cases of myelitis, the usual symptoms
being those of paralysis; the same is true in softening of the cord or
myelo-malacia, and there is also diminished reflex excitability of the
anus.
Paralysis of the bladder and rectum is often delayed in cases of slow
compression of the cord; but if the compression exists to any
considerable extent, involuntary discharges of urine and feces will be
sure to occur. A pressure-myelitis of the lumbar portion of the cord
causes paralysis of the bowel, and in the later stage of some cases of
bulbar paralysis it also occurs.
Early in the course of spinal meningitis there exists a spasmodic
condition of the sphincters: these muscles are also paralyzed in spinal
and in meningeal hemorrhage, and from the pressure of tumors upon the
cord giving rise to paraplegia. "In acute ascending paralysis the
bladder and rectum are generally quite undisturbed in their functions.
In hemiplegia and in hemi-paraplegia specialis disturbances in the
evacuation of the bladder and bowels are almost always present, and in
the acute traumatic cases it is especially common to find severe
paralytic symptoms at the beginning of the attack (complete retention
or complete incontinence, involuntary stools, etc.), which, however,
generally soon recede and give place to lighter, more permanent
trouble, as weakness of the sphincters. Sometimes these disturbances
are very significant."[29]
[Footnote 29: Ibid., _loc. cit._, p. 740.]
The following is an extract from Gower's _Diagnosis and Diseases of the
Spinal Cord_:[30] "The spinal cord possesses centres, situated in the
lumbar enlargement, which preside over the action of the bladder and
rectum. They are probably complex reflex centres: that for the
sphincter ani is the more simple.... But if the volitional path in the
cord is damaged above the lumbar centres, the will can no longer
influence the reflex processes: as soon as the feces irritate the
rectum they are expelled by the reflex mechanism.... If the damage to
the cord involves also the sensory tract, the patient is unconscious of
this process; if the sensory tract is unaffected, the patient is aware
of the action of the bladder or bowel, but cannot control it. It is
often said that there is permanent relaxation of the sphincters, but
this is true only when the lumbar centres are inactive or destroyed. In
this condition evacuation occurs as soon as feces or urine enter; the
urine escapes continuously instead of being expelled at intervals....
We may, however, distinguish between the two states of the rectum by
the introduction of the finger: if the lumbar centre is inactive, there
is a momentary contraction due to local stimulation of the sphincter,
and then permanent relaxation. If, however, the reflex centre and motor
nerves from it are intact, the introduction of the finger is followed
first by relaxation, and then by gentle, firm, tonic contraction."
[Footnote 30: London, 1880, p. 37.]
{908} Morton has at this time in his wards at the Pennsylvania Hospital
two cases of rectal paresis following fracture of the vertebræ. The
first, a lad aged nineteen years, while crossing the Atlantic was
struck during a gale by a spar upon the back about the region of the
lower dorsal vertebræ. From the deformity and from other symptoms there
was undoubtedly a fracture destructive to the normal functions of the
cord. Upon the arrival of the steamer, some ten days after the
accident, the lad was brought to the hospital, where he has remained
for the past eighteen months. Total palsy of sensation and motion has
continued from the time of the accident to the present day, and extends
from the navel downward: the sphincter ani is constantly but feebly
contracted; the finger, when pressed into the anus, encounters slight
resistance, which continues during and after the simple passage of the
finger; very slight pressure, however, against the sphincter causes a
very marked relaxation, which continues so long as this is kept up.
With the removal of the finger the sphincter slowly and fairly
contracts. The second case is also one of vertebral fracture which has
been in the hospital about ten months. In this instance the sphincter
is always found contracted, but it readily yields under finger
pressure, and contracts quickly and regularly in the absence of this
pressure. Constipation and rectal impaction readily occur, and the
bowel requires to be regularly emptied. In another case, at the
Episcopal Hospital, under the care of W. B. Hopkins, there is fracture
of the spine, with total palsy below the seat of injury. The margins of
the anus were found in apposition, but in no firm contraction: mere
contact of the finger appeared to have little or no effect, but slight
pressure upon the sphincter caused a contraction, and very moderate
pressure upon the anus after the introduction of the finger produced
excessive dilatation. The action of the sphincter was in all respects
very tardy.
Two recent cases (August, 1883) of fracture of the dorsal vertebræ have
been admitted into the Pennsylvania Hospital. One, a lad aged ten
years, was struck by a bale of cotton which fell upon him; the other, a
man aged thirty years, fell from a second-story window. In both cases
total palsy occurred at once upon the receipt of injury, and in each
the same conditions of the anus have obtained as before described.
In the convulsive attacks incident to epilepsy the sphincters of the
bowel and urinary bladder are relaxed and the discharges are
involuntary; probably, also, one of the first symptoms indicative of
tumor of the base of the brain is recognized in involuntary rectal
evacuations. Rectal incontinence may be also due to tabes, while atony
and constipation are sometimes noticed as a result of excessive
intellectual exertion (DaCosta). The same may be said of chronic
lesions of the brain and spinal cord. Paresis of the rectum has been
noticed as a result of chronic congestions of the heart and in hepatic
disease. Allingham has observed failing nerve-power as a cause of
rectal atony: the latter, with constipation, is one of the commonest
troubles attendant upon melancholia and the chronic forms of insanity.
Seeley of Ovid, New York, related to Morton a case of paraplegia with
rectal paresis and dysenteric symptoms from malarial poisoning in a
married lady aged thirty years. An examination revealed an immense
rectal impaction. A free administration of quinia was followed by
complete recovery in a few weeks.
{909} Spasm or Spasmodic Contraction of the Rectum and Anus.
Apart from those cases in which spasm is induced by the irritating
stools of diarrhoea and dysentery, or by local ulcerations, fissures of
the anus, and intestinal worms, there are those in which painful spasm
occurs, due to the presence of a vesical calculus: it is also caused by
urethral stricture, impaction of feces, irritations and inflammations
involving the bladder or the adjacent organs. Spasm is also seen in
nervous females, without constipation; also in the varied irritations
of the female genito-urinary apparatus. In cases where spasm is due to
rectal impaction retraction of the anus is frequently seen.
Pruritus Ani.
This most painful, distressing, and obstinate affection belongs to the
class of neuroses, and is simply functional in character, without the
least structural change in the skin or mucous membrane of the anus or
rectum: the itching may be confined to the former or it may extend into
the latter. It may be brought about by a constipated state of the
bowels, but it is more often due to derangements of the digestive
apparatus.
Sufferers from pruritus ani are generally dyspeptics, although the
malady is observed in persons who are otherwise in most robust health.
Overwork, mental and physical exhaustion, have been charged with
producing pruritus, and in some instances spinal irritation seems to
have been unquestionably the exciting cause: now and again, pruritus
ani has been produced by the pregnant condition, and in some cases this
malady has persisted during the entire period of utero-gestation.
Intestinal worms, uterine maladies, rheumatism, and especially gout,
have unquestionably been exciting causes. Some years since a gentleman
having the most intense pruritus, which defied all treatment, was
suddenly relieved of all former distressing symptoms by the passage of
a small vesical calculus, the presence of which had never been
suspected, as no vesical symptoms had at any time existed. Some of the
most aggravated instances of anal pruritus are found in those far
advanced in diabetes mellitus. The nerves of the lumbar plexus in rare
instances have suffered from compression, more or less severe, from
fecal accumulations; in one case of spinal curvature detailed by
Portal[31] the rectum at its upper part was so narrowed by the
encroachment of the false ribs that excessive fecal accumulation
occurred which gave rise to remote pain in the great toe.
[Footnote 31: _Cours d'Anatomie médicale_, tome iv. p. 276.]
Neuralgia of the Rectum.
It seems to be unquestionable that there are instances of pure
neuralgia of the rectum, for in such cases the most carefully conducted
explorations have failed in demonstrating any evidences of disease. The
pain is doubtless reflex, due to depressing causes, to atmospheric
conditions, or to exposure to cold and wet. Neuralgia of the rectum has
also been noticed in malarial {910} poisoning, and especially in those
who have long been victims of intermittent fever. Neuralgia in this
region of the body is also due to general causes, as witnessed in cases
of rheumatism and of the gouty diathesis. Patients now and again
complain of "violent and painful pressure in the rectum, conjoined with
active pains in the perineum and anus and in the sexual parts: these
symptoms probably have a neuralgic character."[32] In many nervous
disorders, but especially in spinal irritations or inflammation, the
rectum is invaded by pains of a neuralgic nature more or less severe,
which are undoubtedly only functional in character. But 12 cases of
neuralgia were observed out of 4000 cases of rectal disease. Anstie[33]
says: "It needs some very powerful irritant to set up neuralgia in any
portion of the alimentary canal: ... this condition has been described
by Ashton.... In one case the patient complained of acute, paroxysmal,
cutting pain extending about an inch within the rectum.... The cause of
this attack was his getting chilled from sitting in his wet clothes."
Curling says that constantly directing the mind to this part of the
body will excite congestion and disease, possibly by producing abnormal
sensations, itching, and superficial inflammation.
[Footnote 32: Erb, _Ziemssen's Cyclop._, vol. xiii. p. 139.]
[Footnote 33: _Neuralgia and its Counterfeits_, p. 130.]
"In patients with piles hyperæmia of the spinal cord may become
habitual, returning regularly and frequently, and this may lead by
degrees to severer disturbance by the development of chronic
inflammation and proliferation."[34] Among some of the reflex troubles
arising from rectal disease are--sterility in women, simulation of
uterine disease, pruritus ani, pseudo-sciatica, pains in the legs and
feet, and impairment of co-ordination in the muscles of defecation.
There is a case reported[35] of a curious pain in the sole of a foot
caused by rectal disease; and another[36] in which irritation of the
eyes was caused by hemorrhoids.
[Footnote 34: _Ziemssen's Cyclop._, vol. xiii. p. 138.]
[Footnote 35: _Med. Times and Gazette_, 1868, vol. ii. p. 175.]
[Footnote 36: Cooper, _Lancet_, 1862, i. p. 625.]
There are some cases occasionally met with of so-called irritable
rectum. Now, a rectum may be irritable because irritated, but in some
of these instances there is no apparent cause. There occur frequent,
small stools expelled with force, but without pain: there must be
abnormal peristaltic action to cause this condition.
The Effects of Cholera and of Certain Poisons and Remedies upon the
Rectum.
After death from cholera there is found congestion and a swollen state
of the mucous membrane of the rectum: in some cases the epithelium of
the entire alimentary canal is almost absent. In slow poisoning by
arsenic the bowels show ulceration, but more particularly the rectum.
After phosphorus-poisoning the large intestine has been found inflamed
and contracted to the calibre of a quill. Among the effects of copper
have been seen ulceration and a peculiar green staining of the rectum;
of lead, no marked change of the mucous membrane except, in some
instances, hardening, but the muscularis was in an advanced state of
hardening and contraction. The action of croton oil is to render the
mucosa very soft and friable. Extensive destruction of the mucous
membrane of the rectum has resulted {911} from poisoning by bichromate
of potassium. The mineral acids and the caustic alkalies, when not
immediately fatal, cause corrosive ulceration of the rectum; the
soluble salts of zinc, tin, bismuth, and antimony produce a like
effect. Corrosive sublimate in its action upon the large intestine
produces a dysenteric condition; similar in their effects are
colocynth, jalap, elaterium, and cantharides. Strychnia causes a deep
violet congestion; alcohol, congestion and thickening; and tobacco,
redness of the mucous membrane with great engorgement of the vessels of
the rectum. One of the results of the long-continued abuse of morphia
is a catarrhal condition of the large intestine, accompanied with
exfoliation of the intestinal epithelium. Some persons are very
susceptible to the action of jaborandi, and in such its exhibition is
followed by hyperæsthesia and dull pain in the rectum and the urethra.
It is interesting to note that an abnormal condition in the rectum may
cause extensive disease in a remote organ; thus, a stricture of the
rectum may cause abscess in the liver. Wilkes[37] exhibited at the
Pathological Society a specimen in which an abscess, a diffuse,
purulent infiltration of the liver, and a gall-bladder filled with
purulent bile were distinctly traceable to the suppuration arising from
an ulcerating stricture of the rectum consisting of dense fibrous
tissue situated about four inches from the anus of a man aged
thirty-seven years. "Any form of suppurative intestinal disease seems
capable of producing hepatic abscesses of a metastatic or pyæmic
character."[38] It has not been found, however, that tubercular
ulceration of the intestines has ever given rise to hepatic abscess.
[Footnote 37: _Soc. Trans._, vol. ii.]
[Footnote 38: Darley, _On the Liver_, 1883, p. 536.]
Examinations and explorations of the abdominal viscera by the hand
introduced into the rectum, having for their object the detection of
tumors or morbid growths, are procedures which have fallen into merited
disrepute, and are mentioned here in condemnation. However, some years
since, Morton, in consultation with (J. Forsythe) Meigs, satisfactorily
demonstrated the absence of a suspected renal calculus by this method.
The distension of the rectum with water, either free or contained in a
rubber bag, in order to facilitate operations upon the pelvic viscera,
has been lately brought into notice by Garson at a meeting of the
British Medical Association. The most significant point brought out at
the meeting was that the water-distended rectum displaced the distended
urinary bladder upward and forward until it occupied a position quite
outside of the pelvic cavity, carrying along with it the peritoneum
both in front and behind. By this method of distension it was found
possible so to raise the peritoneum in front of the bladder as to leave
a clear working space of four centimeters between the upper border of
the symphysis pubis and the edge of the peritoneum: this may prove
useful in suprapubic lithotomy, as well as in operations upon the
uterus and its appendages during laparotomy.
RÉSUMÉ OF THE THERAPEUTICAL AND SURGICAL TREATMENT.
FISSURE OF THE ANUS, in its true sense, is not to be confounded with
ulcerations either slight and superficial in extent, or with more grave
ulcerations involving not only the anus, but the mucous membrane of the
{912} rectum also. The true fissure is a mere linear crack or abrasion
or superficial ulceration. The pain accompanying this condition is out
of proportion to the length and depth of the fissure, varying from
slight uneasiness to as severe suffering as that caused by a deep and
extensive ulceration.
The treatment to be adopted in such cases is first to regulate the
bowels and to insist upon a scrupulous cleansing of the part after each
evacuation. Much sitting is to be avoided and a sedentary mode of life
is to be discouraged. Sometimes a few light topical applications of the
solid nitrate of silver will bring about a cure, or a lotion of the
same of the strength of from two to ten grains to the ounce of water
should be applied with a camel's-hair brush every other morning. The
ointment of the oxide of zinc, combined with any of the local
anæsthetics, will be found useful. As a dernier ressort in obstinate
cases an incision should be made through the fissure, together with a
thorough dilatation of the anal sphincter.