milder forms of this very common and painful affection the treatment
consists in thorough cleanliness of the part; the ulcerated surface may
be cauterized with nitrate of silver, and subsequently the application
of the red precipitate ointment or the lotio nigra. Should a vaginal
discharge exist, treatment should be instituted with a view to its
arrest, as the irritating fluid coming in contact with the ulcer would
prevent its healing. The treatment of that variety of ulceration where
the disease is situated partly without the anus and partly within the
rectum, besides the use of the means enumerated above, embraces the
daily introduction of a full-sized bougie made of wax or of yellow
soap. Henry Hartshorne says: "Experience leads me to have especial
confidence in collodion, to which one-fiftieth of glycerin has been
added to lessen its constricting effect." Glycerite of tannin and
tinct. benzoin. comp. have been useful. J. C. Peters[39] recommends the
use of iodoform suppositories. Tarnier[40] dusts the part with the same
drug in fine powder. Créquy[41] has had success with a dressing of
charpie saturated in a solution of hydrate of chloral. For the more
extensive and obstinate forms of ulceration the three methods of
treatment mainly relied on are--by cauterization, by dilatation, and by
incision. The caustics usually relied upon are the fuming nitric acid
and the acid nitrate of mercury, one application of either of these
often exciting healthy granulation. This application is to be followed
by the use of an ointment consisting of thirty grains of calomel and
three grains of morphia to one ounce of lard. If there is much spasm of
the sphincters, extract of belladonna may be added.[42] During this
treatment the bowels should be kept rather loose by the use of compound
licorice powder, and if much pain is experienced an opium suppository
should be used. Dilatation, first practised by Récamier, consists of
the introduction of the thumbs of the operator into the rectum, placing
them back to back, and then forcibly separating them from each other
until the sides of the bowel can be stretched out as far as the
tuberosities of the ischia. On account of the fact that both
cauterization and dilatation are not infrequently followed by relapse,
the method of operation which includes both incision and dilatation can
usually be relied {913} upon. The bowels should be thoroughly emptied
by a laxative, and an enema should be given three hours before the
operation.
[Footnote 39: _Philada. Med. Times_, Nov. 8, 1879.]
[Footnote 40: _Bull. gén. de Thérap._, Sept. 30, 1875.]
[Footnote 41: Ashton, _On the Rectum_, p. 157.]
[Footnote 42: Agnew's _Surgery_, vol. i. p. 418.]
After full anæsthesia the ulcer may be readily exposed. The left index
finger of the operator is then carried into the rectum, and a
sharp-pointed curved bistoury is entered, three-quarters of an inch or
more from the side of the anus, to the depth of an inch or less, and
carried on toward the bowel until the point is felt by the finger
within, when it is made to puncture the mucous membrane, and then to
cut out to the surface. In some cases of deep fissure, before dividing
the sphincter the ulcer may be scraped freely or the entire ulcer may
be removed. The anus should now be well dilated with the fingers, after
which an opium suppository should be introduced and a fragment of lint
or linen well oiled be placed in the wound. The subsequent treatment
consists in keeping the patient in a recumbent position and confining
the bowels with opium. After three or four days a laxative may be
given. No dressing is necessary save attention to cleanliness.
The subcutaneous division of the sphincter has been proposed, but is
objected to on account of the liability of the extravasated blood
retained in the very loose cellular tissue of the part to form abscess.
In one case which Morton operated upon in this manner many years ago a
large abscess formed very rapidly, with serious constitutional
symptoms, which were relieved only after the freest opening and
division of the sphincter.
Should any polypi be found, their removal by ligation or by the knife
is an essential element of success in the operation; retention of urine
is not infrequent after operations upon fissure. When fissure or
ulceration makes its appearance in a syphilitic subject, it will
usually disappear under appropriate constitutional treatment.
TUBERCULOUS ULCER OF THE ANUS is best treated by the topical use of a
weak solution of chloral hydrate.
CHRONIC ULCER OF THE RECTUM.--In this condition the treatment should
include the use of anodyne and astringent lotions, suppositories or
enemata, and the internal administration of Ward's paste--_i.e._
confection of black pepper.
RODENT ULCER OF RECTUM.--In this rather rare, exceeding painful, and
generally incurable malady the patient sometimes dies merely from the
exhaustion of pain. Another mode of death is by diarrhoea; another by
hemorrhage. To quote Allingham:[43] "I have really nothing to offer as
regards treatment; all the various sedatives will be required in their
turn, and in the earlier stage I should recommend excision--not that I
have much hope that you will eradicate the malady, but you will remove
the pain, and for some time the sufferer will be comparatively
comfortable. I think also the application of fuming nitric acid should
be tried with the same object; one of my patients was fairly easy for
three months after I had destroyed the ulcer with the acid." Morton
accomplished the permanent healing of an undoubted rodent ulcer of the
rectum by the complete divulsion of all the involved tissues.
[Footnote 43: Page 30.]
CANCER OF THE RECTUM.--The medical treatment of this affection is
necessarily restricted to efforts to alleviate suffering and to obtain
sleep--anodynes in the form of suppositories of pil. saponis comp. or
of morphine mixed with ext. hyoscyamus in the proportion of a half
grain of the {914} salt to ten grains of the extract. Enemata of warm
water are useful. D'Arpene of Elba has suggested enemata of gastric
juice. The profuse discharge of sanious pus must be met by weak
injection of sulphate of copper and opium or a very dilute solution of
chloride of zinc. Now, as to the use of bougies in these cases, it may
be laid down as a general rule that their employment may be
mischievous, yet in certain cases justifiable--indeed, absolutely
necessary. When the disease is met with in its early stage, has not
ulcerated, is within reach of the finger, and is producing much
contraction of the calibre of the gut, a gum-elastic bougie, thoroughly
lubricated, may be introduced through the contraction. In case this
produces much suffering, the attempt must be abandoned; if not, once or
twice a week is often enough. Where no extensive ulceration exists the
patient can be much helped by this procedure. F. N. Otis[44] has
reported a case of malignant stricture in which he completely divided
the recto-vaginal septum, sphincter ani, and perineum with great
temporary relief to his patient. When large portions of a malignant
mass protrude from the anus, they may be removed by the application of
a paste of arsenite of copper or by the elastic ligature, the
destruction being safe and rapid. The injection of acetic acid into
these growths has been practised, but is useless and harmful.
[Footnote 44: _Arch. Clin. Surg._, 1877.]
As to operative procedure, when the morbid growth is an epithelioma
situated within a short distance of the anal opening an excision is not
only justifiable, but may be recommended. The results show that its
removal from this situation is as frequently successful as is its
removal from the lip. When a cancer completely fills the lumen of the
gut and plugs it so that the act of defecation becomes impossible,
excision of the rectum and the establishment of an artificial anus are
the two operative procedures open to the choice of the surgeon. A
decided reaction of opinion has lately taken place among members of the
profession relative to the latter of these; the few surgeons who did
practise excision of the rectum in cases of cancer were looked upon as
being rather unscientific and unsurgical. Billroth has excised the
rectum 16 times, with 4 fatal cases; Dieffenbach performed it 30 times;
Lisfranc had recourse to this operation as early as 1826; while the
operation has been performed very frequently in this country, and with
success.
Morton says: "In the spring of 1882, I was consulted in the case of a
lady aged fifty-six who had suffered for two years from what were
supposed to be internal hemorrhoids. An examination revealed the
existence of a large scirrhous mass encircling about two-thirds of the
gut, on the anterior part especially, and extending upward three
inches. The patient was worn down by long suffering, but was otherwise
in fair condition of health. With the assistance of Gross and Agnew, I
excised the mass, which included the entire lower part of the rectum.
The wound healed kindly, without an untoward symptom, and the patient
was very soon enabled to leave her home for the seaside, where she
passed the summer. The disease, however, resumed, but without any of
the severe pains which she had had prior to the operation. Death
occurred from gradual exhaustion seven months afterward."
He also relates the following case of excision of the rectum: The
patient, a female aged thirty-five years, first noticed some rectal
{915} irritation about four years ago. This was followed by distressing
pain during defecation and by hemorrhages; finally a tumor, which was
described by her medical attendant as being like an opened umbrella,
protruded, partly at first, then fully, through the anus. The growth
seemed to be spongy in character, and was very vascular. It was removed
by carrying a double-threaded needle through the mass, and thus
ligating it. Upon the seventh day after the operation a hemorrhage
occurred, which was controlled by plugging the rectum. Although the
growth was removed, the patient did not make a good recovery; symptoms
of rectal irritation continued. In September, 1884, the patient
presented herself in a wretched condition, with bearing-down pains and
frequent hemorrhages. Upon digital examination an elevated mass was
readily detected upon the sacral aspect of the bowel. By carrying the
fingers beyond this mass and making traction, it was brought down
within working distance, and was excised along with the entire lower
portion of the rectum. The freshly-cut edges of the gut were then drawn
down and stitched to the mucous membrane just above the anus. The
patient made a good recovery and has a serviceable anus.
R. J. Levis[45] has operated upon two cases of cancerous growth in the
rectum, removing the lower part of the bowel. The first case was that
of a man aged sixty, who made a very good recovery from the successful
operation, although three inches of the gut were removed. The second
case was that of a man aged fifty-two, who had a carcinomatous tumor
the size of a hen's egg at the right side of the rectum. The section of
gut excised was about one and a half inches in length. The patient died
of peritonitis upon the fourth day after operation. At the autopsy
there was no wound found in the peritoneum, the lowest point of which
was one inch above the end of the excised bowel.
[Footnote 45: _Surgery in the Pennsylvania Hospital_, pp. 81-83.]
The etherized patient, his bladder having been emptied, should be
placed in the lithotomy position. If a male, a sound should be passed
into the bladder. An incision is then carried from the centre of the
perineum along the raphé to the anterior margin of the anus, encircling
the latter by two semicircular cuts and continuing the division
directly back to the coccyx. In the female the incision should begin
just posterior to the vagina. If the anus is not included in the
diseased mass, the external sphincter may be spared by raising the skin
and the muscle together and turning them on each side. When the lower
end of the rectum is reached the dissection should be made entirely by
the fingers or by the handle of the knife, tying vessels as they
spring. Double ligatures should be introduced through the gut from its
mucous surface outward, and, when possible, then stitched to the skin
at the margins of the wound. The bowels should be controlled by opium
for the following eight or ten days.
The other operative procedure is lumbar colotomy. This was first
advocated by Amussat in 1839, when he appeared in a treatise upon the
subject entitled _On the Possibility of Establishing an Artificial Anus
in the Lumbar Region_. It is denied that he ever performed this
operation. It has happened to sound surgeons and skilful operators,
when the patient has been very muscular or very fat or when the colon
has been collapsed, that they have been at length compelled to abandon
the search for the gut {916} and to stitch up the external wound.
Allingham states that the cause of failure often is that the colon is
searched for too far from the spine, resulting, in the opening of the
peritoneum, in the starting up into the wound of a mass of small
intestine which baffles the operator very seriously. He, having made
more than fifty dissections, has come to this conclusion: "that the
descending colon is always normally situated half an inch posterior to
the centre of the crest of the ileum (the centre being the point midway
between the anterior, superior, and posterior-superior spinous
processes)." An incision four inches in length should be made midway
between the last rib and the crest of the ileum. The incision may be
made transverse, or, better, obliquely downward and forward, as
suggested by Bryant. Allingham says that care should be taken to
preserve the original length of the incision down through all
structures, lest when the operator approaches the gut he finds himself
working in the apex of a triangle the base of which is the line of the
wound. If the surgeon has reason to expect the gut to be collapsed, an
attempt should be made to distend it with some fluid. The intestine
should be drawn well out through the wound, and a longitudinal opening
an inch in length made in it. The edges of this are to be stitched to
the edges of the skin. Fecal matter is much less likely to flow into
the wound if the sutures are passed through the intestine previous to
opening it. A weak carbolated wash is all that is required as a
dressing. In one case of stricture of the rectum from a scirrhous mass,
in which Morton performed colotomy, an immense cyst of the kidney,
which was somewhat puzzling for a moment, protruded in the wound. After
emptying the cyst the gut was readily discovered and opened.
DILATATION AND INFLAMMATION OF THE RECTAL POUCHES.--This is a
comparatively rare condition of the rectum, called by Physick encysted
rectum, which is treated by bending the end of a probe into a hook,
passing it up into the bowel, and then withdrawing it with its
extremity resting against the surface, so as to engage and draw down
the pouches, the straining or bearing down of the patient assisting in
their extrusion; they may then be incised or cut off with a pair of
curved scissors.
LOSS OF CO-ORDINATION IN THE MUSCLES OF DEFECATION.--In those cases
where it can be ascertained that this curious trouble is not
symptomatic, sympathetic, nor reflex, the treatment must be directed to
the building up of the general health, such as electricity, baths,
asafoetida, and iron. Regular outdoor exercise should be enforced.
SPHINCTERISMUS.--This condition, though frequently attendant upon, may
exist in the absence of, any fissure, crack, or ulcer of the anus. It
is usually associated with constipation. In its treatment magnesia and
rhubarb are to be used, and the diet must be simple, unstimulating, and
taken at regular intervals. A hot hip-bath at night, with the use of a
belladonna suppository, often proves effective. In more obstinate cases
a bougie covered with ointment of belladonna should be used daily. In
still more intractable cases the muscle must be forcibly stretched with
the fingers. In the more obstinate cases which now and then occur it
becomes necessary to completely divide the fibres of the sphincter
muscle, followed by a thorough stretching of the parts.
{917} PRURITUS ANI.--This distressing and vexatious complaint proceeds
frequently from hemorrhoids. When caused by the presence of seat-worms,
they must be dislodged by purgatives and enemata of quassia or of one
composed of one part of carbolic acid to six parts of sweet oil, or of
turpentine and flaxseed tea. An enema of milk of asafoetida answers a
good purpose. If the pruritus is a result of the burrowing of the itch
insect, any wash, ointment, or dressing that evolves sulphuretted
hydrogen will rapidly bring relief. If caused by other parasites, an
application of ung. hydrarg. or red precipitate ointment, followed by a
warm bath, will be all that is necessary. In some it is a symptom of
dyspepsia, in others of a disordered state of the nerves of the anus
independent of local cause: in this case iron, quinia, and arsenic
should be given, and the patient should live an outdoor life as much as
possible. The remedies that have in turn been extolled and abandoned
during the treatment of this distressing condition it would require too
much space to even mention. The following are among the best: Sulphate
of zinc and alum, equal parts, are to be placed in an earthen vessel
and heated until a glassy mass is left, which is to be dissolved in a
little water and thrown into the bowel; palm soap pressed into the
anus, ointments of carbolic acid and morphia or of bromide of potassium
and cosmoline, citrine and other mercurial ointments, and suppositories
containing iodoform. Allingham uses a bone or a metallic plug of
peculiar construction, so as to keep the anus upon the stretch at night
without slipping into the bowel. The pressure which this exerts upon
the nerves and vessels prevents the itching. Hot (not warm) water
pressed against the anus with a sponge, or ten-drop doses internally of
tincture of gelsemium, or washes of dilute hydrocyanic acid or of
chloroform, or ointments of balsam of Peru or of veratria and aconitia,
or the corrosive chloride of mercury in solution applied locally, are a
few of the more reliable among this host.
STRICTURE OF THE RECTUM (NON-MALIGNANT).--The main modes of treatment
of non-malignant stricture of the rectum are two--by dilatation or by
linear incision (rectotomy). Dilatation may be practised by the finger
alone or by the finger covered with hollow rubber covers of various
sizes. These are open at the end, so that the guiding and recognizing
sense of touch may be left to the end of the finger. When the stricture
is out of reach of this method, either gum or metallic bougies must be
used, beginning with the smaller sizes and deliberately and carefully
adding sizes. When the lumen of a stricture is tortuous it is best to
use a long rather flexible rubber bougie having an olive-shaped
extremity. It is not necessary to leave these bougies standing for
hours in a stricture, according to the practice of some; this merely
excites inflammation. Should the stricture be irritable, every second
or third day would be sufficiently often to attempt dilatation. In
constrictions which are firm, but not sensitive, a good plan is to
insert a Molesworth elastic tube and gradually distend it by
hydrostatic pressure; Barnes's dilators have also been successfully
used. When the stricture is elastic and re-forms itself at once after
dilatation, incision should be practised. In those strictures which are
low down, the constriction may be nicked in several places by a hernia
knife, the blade of which is guided along a finger in the bowel; when
high up, a long double-bladed knife must be employed. In syphilitic
strictures, in addition to dilatation, proper alterative treatment is
{918} indispensable. As dilatation has often to be kept up for a long
time, the patient may be taught to practise this for himself.
PERI-ANAL AND PERI-RECTAL ABSCESS.--When acute, and when the surgeon is
called in time, the prompt application of leeches may abort the
abscess, but usually, by the time the surgeon sees it, it is necessary
to apply hot flaxseed poultices as fast as they become cool, keeping
the patient in bed upon light diet. The rule is to open deeply and
freely so soon as the least softening under the poultices indicates
that pus is within reach. After lancing, the poultices should be
continued for a few days: then the deep wound should be packed with a
strip of oiled lint and allowed to granulate from the bottom. As the
fetor of these abscesses is horrible, they should be injected with a
solution of permanganate of potash or liq. sodii chlorinata. When the
chronic variety of this abscess is discovered, it, with all its
sinuses, diverticula, and pockets, should be laid freely open upon a
director and packed with carbolized lint. It is often very necessary in
these chronic cases to use tonic and alterative treatment, such as
cod-liver oil and iodide of iron.
GONORRHOEA OF THE RECTUM.--Undoubted cases of gonorrhoea of the rectum
in the persons of prostitutes have been observed. Burning heat and
great pain are usually felt, with a free discharge of pure pus: the
mucous membrane is always intensely inflamed. The treatment is simple;
an injection of lead-water and laudanum or of sulphate of zinc answers
a good purpose. Primary syphilitic disease of the anus and rectum is
rarely seen, but of course the treatment indicated would be similar to
that laid down for primary syphilis in its usual localities.
IMPACTION OF FECES.--This condition usually occurs among the aged and
in women after parturition and in cases of paralysis. Those persons of
sedentary habits who do not pay sufficient attention to the necessity
of a daily alvine evacuation sometimes find themselves in this
condition. Impaction occurs not infrequently among the insane, and more
frequently among women than men. Allingham states that he has never
seen a case of impaction in a young person; but Wetherill now has under
his care a most obstinate case of this disorder in a young man whose
system has been completely broken down by intemperance in drink.
In paralysis of the rectum of traumatic origin impaction is almost
certain to take place unless great care is taken to prevent it.
Diarrhoea is a very misleading element in these cases, and is a symptom
which frequently deceives those who are not on their guard. The clayey
mass of feculent matter forms a hard ball in the distended bowel,
around which the small loose passages flow. Spasm of the sphincter ani
is the usual accompaniment of impaction, and the muscle should be
gently but thoroughly dilated before means can be used to free the
canal. The finger or the handle of a tablespoon is best to use in the
dislodgment of these masses, and should be oiled before introduction,
the accumulation broken up, and then washed out by an enema of soap,
turpentine, and warm water. Purgatives and hydragogue cathartics
usually fail to give relief, and add much to the patient's discomfort.
The bowel once freed, care must be taken to prevent a reaccumulation,
which very readily takes place, as the bowel in these cases is
distended and has lost tone. To this end frequent enemata of cold water
should be used, and the patient should {919} take a pill of dried
sulphate of iron, sulphate of quinia, extract of nux vomica, extract of
aloes, as recommended by Allingham. The diet should be restricted. An
excellent adjunct to this treatment is the local use of the faradic
galvanic current daily after breakfast. Let the patient lie upon a bed
and apply one pole or electrode to the anus, while the other one is
passed with pressure along the course of the large intestine. Not
infrequently it happens after this has been continued for a few minutes
that a very urgent desire is felt to go to stool. In the case mentioned
of the young man affected with impaction this treatment answered
admirably well, but before its use he had to take a small dose of
croton oil daily to cause an action of the bowels, all milder measures
having proved ineffectual. It is important in these cases to interdict
a sedentary mode of life.
IRRITABLE RECTUM.--A rectum is said to be irritable when it shows an
intolerance of the presence of feces or flatus, causing frequent desire
to go to stool. From such abnormal activity of the part there arise a
burning, uncomfortable impression of fulness and a soreness of the
anus. If after examination it is found that there is no local exciting
cause, a starch enema containing forty drops of laudanum should be
given and retained. This plan of treatment will usually afford relief.
Should the irritability prove to be obstinate, examine the rectum, and
if a spot of redness or increased vascularity be found, touch the spot
with strong nitric acid.
CONCRETIONS IN THE RECTUM.--These occur less frequently than do
impactions, and differ from them in being cylindrical and nucleated,
the nuclei being such bodies as balls or tangled masses of hair, or
coins, buttons, biliary calculi, or the like. Covering these are matted
animal or vegetable fibres or hardened fecal matter. They are not so
readily dislodged as are impactions, and it is necessary to dilate the
sphincter thoroughly and remove them with a scoop. Not infrequently
these bodies are bathed in pus and are very fetid.
PROCTITIS, OR INFLAMMATION OF THE RECTUM.--This may be either acute or
chronic, the latter being a disease of the aged. Allingham recommends
in this variety small doses of Barbadoes aloes to stimulate the bowel,
also such drugs as copaiba, turpentine, and black pepper. As an
injection in the acute form starch and laudanum, or bismuth suspended
in a mucilaginous vehicle, should be used. Probably the use of small,
smooth fragments of ice in the rectum would allay the tenesmus and help
to subdue the inflammation.