bowel where it joined the hemorrhoids, appeared to be so cartilaginous
in places, that I expected hard ridges would be left; but they all
disappeared and softened down by the use of eucalyptol, buckthorn and
stramonium ointment. At one point a small polypus sprang up, which
withered from the injection of a few drops of pure carbolic acid, like a
tender sprout, after being frozen, under a scorching sun.
The lady could not repress her feelings of emotion, in expressing
gratitude for the services rendered, but gave way and freely cried.
Although in rather poor circumstances, she did not think a charge of
fifty dollars sufficient and afterwards returned, saying that she felt
that she would not die happy unless I was better paid, and insisted upon
my taking another “twenty.”
RESUMÉ.
Do not operate during an attack of piles.
Operate with the tumor, or tumors, on the upper side.
Handle the parts with extreme gentleness and deliberation.
See all that can be seen and treat all that can be treated without the
aid of a speculum.
Protect the under parts from excoriation by waste and overflow of
medicine.
Evacuate the bowels previously and constipate for four days after
operation on large growths, or when several small tumors are taken at one
time.
Hot water sponge compresses, _early_, _often_ and _continuously_, are
indispensable and unequaled for the relief of a pain, swelling and
soreness. To be effective it should be applied as hot as can be borne.
Wait until the soreness disappears before performing a second operation.
This will require from one to two weeks, according to the extent of the
first operation and the physical condition of the patient.
Take great pains and care to perform a neat operation. A certain amount
of ingenuity and tact are required, which, unfortunately, all do not
possess. If a bungling job be made, the bowel punctured, a pile injected
on one side only and the surfaces excoriated, do not attribute an
unnecessary amount of pain and suffering to the preparation used or the
method employed.
As a general alterative and curative agent in many diseases, and
particularly to relieve and prevent hemorrhoidal congestion in rectal
troubles, sulphur in small doses, persisted in for some time, probably
has no equal. The most convenient form for administration is a palatable
tablet (Wyeth & Co.), containing 2½ grains, or 5 grains with 1 grain of
cream of tartar. Reference to the learned articles on the physiological
and therapeutical uses of sulphur, by Dr. John V. Shoemaker, published
in the _Dietetic Gazette_, Sir Alfred B. Garrod in the _Lancet_, and in
Ringer’s hand-book of therapeutics, will be amply repaid.
[Illustration: FIG. 10.—Position for operating, or making a rectal
examination. Engraving kindly furnished by Sharp & Smith, who manufacture
one of the best office and operating chairs combined, on the market. It
works without “cranks,” “levers,” or “ratchets.” Upholstering is entirely
protected during an operation.
It is unnecessary for a lady to disrobe herself for examination, or
suffer immoderate exposure. A cloth cover should be used, when a lady
patient is placed on the chair, the same as in gynæcological practice.]
RECTAL EXAMINATION.
The first step to be taken in making an examination of the rectum, where
disease of this organ is present or suspected, will be to obtain a
history of the case as given by the patient, supplemented by questions
naturally suggested. This will furnish an idea of what might be looked
for, but the patient’s interpretation will often be found quite erroneous
and misleading.
Should there be an undue protrusion at stool, pursue the same course
recommended for the examination of internal hemorrhoids. If protrusion
be absent, direct the patient to lie on the side with knees drawn up,
separate the buttocks and inspect the anus; or, in other words, all that
presents to view externally at the terminal orifice of the rectum. Now
draw down and evert the mucous membrane at the verge with the thumbs,
asking the patient at the same time to extrude the parts as much as
possible. This will enable you to see all there is half an inch or more
above the entrance.
Next, anoint the finger, pass in gently and examine all the surface
limited by the sphincters, a distance upwards of not over an inch,
being careful lest you be deceived by the mobility of the tissue, when
introducing the finger, and a small marginal growth be carried up and
appear as one of internal origin.
Any one familiar with vaginal examinations can detect a rough or a broken
mucous membrane, an indurated spot or prominence as soon as touched.
Next, feel above the internal sphincter, keeping in mind the anatomy of
the parts, turn the finger slowly, posteriorly you can hook it behind the
muscle. Here is situated the bottom or floor of the rectum which forms a
cul-de-sac (Fig. 11). By asking the patient to strain down moderately,
its surface will be thrown up against the end of the finger and in this
manner properly explored.
[Illustration: FIG. 11.—Lateral section of rectum; normal curve. R.
Rectal pouch. C. _cul-de-sac_ of the rectum. E. S. External sphincter. I.
S. Internal sphincter. H. Hilton’s white line. P. Position of prostate
gland.]
A digital examination reveals, in the normal state, a soft, velvety,
unbroken mucous membrane, the parts pliable and yielding, with no reflex
excitability of the sphincters. The position and sensibility of the
uterus should be noted in the female, and size of the prostate gland in
the male of advanced years.
The first three or three and a half inches of the rectum can be brought
within reach of the finger. Explorations farther up will require a rectal
sound and a long tubular speculum. Nine-tenths of all rectal ailments are
found within the first two inches. Therefore, few general practitioners
will ever be called upon to treat anything beyond the reach of the finger
or the scope of a common speculum.
All hemorrhoids of any appreciable size, or other tumorous growths in
the same vicinity, will show at defecation and can be treated while the
parts are extruded. All abrasions, ulcerations, indurations, etc, are
discoverable by the sense of touch. Hence, it will be seen that the uses
of the speculum are narrowed down to a few in number. Namely: in that
of bringing to view for observation and treatment diseased surfaces
previously located; small, soft hemorrhoids and other minor affections
which may have escaped detection by a careful digital examination.
Then, in view of the foregoing facts, and in consideration of the
anatomical formation of the parts, being a collapsable tube, highly
sensitive and extremely difficult of accessibility, quite unlike the
vaginal canal, which is closed at one end, more capacious and dilatable,
and designed by nature to be approached from the exterior, a speculum
should be so constructed as to not only be easy of introduction and
withdrawal, but to exclude all the surface except a limited portion, and
permit the greatest amount of available light possible to fall on the
exposed part shown _in situ_.
The greatest barrier to the successful use of a speculum is the unruly
external sphincter and the excessive mobility of the mucous and
muco-cutaneous surfaces. The upper margin of the external sphincter
terminates beneath the junction or the skin with the mucous membrane,
which place also marks the beginning of the internal sphincter and its
junction with the external muscle by a more dense connective tissue,
sometimes appearing as a white line at the muco-cutaneous junction called
the white line of Hilton.
According to Dr. Andrews, Hilton has demonstrated that the locality where
the two muscles join by the intervention of this fibrous ring forming the
anal verge, the junction of the skin and mucous membrane, and the exit of
the branches of the pudic nerve, is identical.
[Illustration: FIG. 12.—Author’s Rectal Speculum.]
The internal sphincter is a collection of the circular fibres of the
muscular coat of the bowel, about five-eighths of an inch in width,
and constitutes in reality the terminus of the gut. For the external
sphincter is a thin band of distinct and separate muscular fibres,
elliptical in shape, between three and four inches from its anterior to
its posterior extremity, and expands out around the margin of the anus
like the flaring end of a trumpet; with its superficial layer in close
relation to the skin which it draws down in radiating folds.
With this understanding of the anatomical relations, it will be seen
that the external muscle contributes so slightly to the length of the
canal, that it might be considered wholly on the outside, where it guards
closely the entrance, and is nowise concerned in an examination with a
speculum except as a feature of incumbrance.
To correct an erroneous idea that there is any considerable depression
or space intervening between the muscles, we mean, when we say between
the sphincters, the distance bounded by the fibrous ring uniting the two
muscles below, and the upper portion of the internal muscle above. More
simplified, we mean all the surface included between the upper margin of
the internal sphincter and its junction with the external muscle at the
anal verge.
All examinations with a speculum should be preceded by an enema of
warm water to wash away the mucous and retained feces in and about the
sphincters. Let the patient lie on either side, turning partially on the
chest, with knees drawn up, the one uppermost more firmly flexed on the
abdomen, and hips so elevated that the speculum, when introduced points
or inclines downward, and admits of strong natural light to fall in
parallel rays to its axis.
Warm the speculum by _dry heat_ over a single blast kerosene stove, where
gas is not convenient. A suitable kerosene stove is an indispensible
adjunct to an office for heating instruments, water, etc., causing no
smell and leaving no deposit of sut on the bottom of vessels as done
by gas or alcohol. Use _white_ vaseline as a lubricant; everything that
tends to whiteness helps the sight. The vaseline may be squeezed from a
tin-foil tube, and the finger not soiled in preparing the speculum for
insertion.
[Illustration: FIG. 13.—A suitable Kerosene Stove for office use. It is
clean, safe, cheap, portable and has perfect combustion.]
To prevent the loose tissue from rolling up and being pushed in with the
speculum, the patient may assist by holding the upper buttock away, while
the physician introduces the instrument with one hand and retracts the
opposite buttock with the other.
Introduce slowly, giving time for the muscles to relax, bearing in mind
that all movements about the rectum and anus must be extremely easy and
gentle. The proximal end of the slot must be carried and kept above
the external sphincter during the entire course of the examination. It
matters not what kind of a speculum is being used, the value of the
instrument will greatly depend upon its power to hold this muscle out of
the way.
A closed end speculum, with a proportionate slot and smooth corners, can
be slowly rotated without any difficulty where the mucous membrane is not
very loose and baggy and no prominences in the route. But if a hemorrhoid
be in the way it will immediately drop in the slot and further progress
is thus impeded.
When examining above the internal sphincter, especially posteriorly,
where the bottom or floor of the rectum forms a cul-de-sac, direct the
patient to strain down a little; this effort will throw the mucous
membrane out into the speculum, at the same time spreads out and smooths
its surface. In looking through a speculum this cul-de-sac of the rectum
sometimes appears as a vacancy behind the internal sphincter, and has
been mistaken and treated as an ulcer cavity. It often contains a liberal
supply of mucous.
FISTULA.
Fistula in the recto anal region so far exceeds that in any other
locality, that its overwhelming predominence here almost entitles it to
the exclusive right of the term; while, to those who have given this part
of the physical organism special study, the word itself, calls to mind a
local condition of disease that is anything but an easy one to manage.
In point of frequency fistula is next akin to hemorrhoids, but a much
less desirable complaint to treat. Allingham states that the number of
cases occurring in hospital practice is greater. That two-thirds of
all the cases operated upon of the in patients at St. Mark’s Hospital,
London, were fistula. The most frequent cause assigned being abscess. A
failure of the abscess to heal, leaving a sinus or sinuses, is explained
by the presence of loose areolar tissue and fat, excessive mobility of
the parts by the action of the sphincters, respiration, coughing and
sneezing, and a strumous diathesis.
In consequence of an occasional failure of the muscles to regain their
power after division by the knife, elastic ligature or galvano-cautery
wire in the treatment of fistula, leaving the subject in a pitiable
state of incontinence of feces, which has resulted in several well
authenticated cases in suicide, new and rational methods have been
devised for the relief of this very troublesome and unpleasant affection.
Kelsey says: “A permanent incontinence of feces is _always_ considered
by the patient a very poor exchange for fistula, which was causing
comparatively little suffering and annoyance.”
The fact that such a deplorable condition does sometimes follow complete
section of the sphincters, and that we have no means of knowing
previously when it may or may not occur, I submit the question to all
thinking, conscientious and painstaking physicians: Should we not seek
the adoption of any efficient means of treatment, whereby such risk is
wholly avoided?
About the first of March, 1890, Daniel Mc., aged 35, who a few months
before had been operated upon by a reputable surgeon for a simple,
uncomplicated fistula, sought my acquaintance, exhibited his condition
and related his experiences.
The fistula originated from a small abscess, with its internal opening
between the sphincters, the external scarcely an inch outside the anus,
and was not of long standing. The operation consisted in a division of
the external muscle with the greater portion of the internal; he was
put on a liquid diet, bowels confined for fifteen days and kept in a
recumbent posture.
The incision was slow in healing, between three and four months; his
health, which was formerly good, has been greatly impaired ever since
the operation. The external sphincter has lost its power altogether and
the internal muscle greatly weakened, which necessitate the wearing
of a clout whenever the bowels become a trifle loose, and he lives
in constant fear of soiling himself by allowing the escapement of the
least quantity of flatus. The time lost, the money expended, and the
unfortunate condition in which he finds himself eight months after the
operation, have so thoroughly embittered him against the cutting process,
that he spares no pains and loses no opportunity to influence every one
with whom he comes in contact, against all such heroic and uncertain
measures.
For the purpose of obviating these very unsatisfactory and highly
objectionable results, we have a choice of any one, or all of three
different methods, viz: treatment by injection, treatment with the
fistulatome, and treatment by the galvano-cautery as practiced by Dr.
Shotwell; who, fully appreciating the dangers of muscular section, has
hit upon a plan both new and commendable.
[Illustration: FIG. 14.—Varieties of Fistula. (Gosselin.)]
The sub-cutaneous, or sub-mucous fistula can be cocainized and slit up
with a pair of scissors, and the tract cleansed and cauterized with
a solution of carbolic acid, a comparatively trivial affair; but the
external blind, the internal blind, the complete, the complete with
diverticula etc., are varieties which call forth a decidedly greater
amount of ingenuity and thought in bringing them to a successful issue.
The treatment by injection, sometimes classified as a “non-operative
method,” has been so successful in the hands of many, that it is stoutly
affirmed that any case curable by the usual heroic methods is equally
curable by this method. Different preparations have been used, chief of
all being carbolic acid, ranging in strength from 50 per cent. up.
In adopting the carbolic acid treatment, probably the better way after
preparing the sinus, will be to use a 95 per cent. the first time
and subsequently a 50 per cent. solution; protecting the parts from
excoriation by any suitable unguent and absorbent cotton. Hot water
compresses to relieve pain and reduce swelling. Iodoform, Eucalyptol,
etc., in the _interim_. Judgment will be required in not making too many
irritant applications and granulation thus hindered for want of rest.
The object is to destroy the pyogenic membrane by the cauterizing effects
of the acid and get up a granulating carbolic acid sore. It may be
necessary to evacuate the bowels and constipate for several days to give
the muscles rest, or resort in extreme cases to divulsion. The sinus
must have constant, free external drainage until the healing process is
complete. Allingham recommends the introduction of the small end of a
bone collar button to keep the orifice open, with a hole drilled through
its centre for drainage.
As a preliminary step the external orifice should be dilated with a
laminaria tent or other appropriate means. The fistulous tract explored
with a common probe and thoroughly cleansed with hot water introduced
through a flexible silver canula; which is also used for the injection of
a 5 or 10 per cent. solution of cocaine to obtund the sensibility.
[Illustration: FIG. 15.—Bone Stud]
Concerning the carbolic acid treatment Allingham says: “Since the
publication of my last edition I have cured many patients by dilitation
of the sphincters and the use of the bone stud and carbolic acid. One
practical point I would mention. The further the external aperture is
from the sphincter the more likelihood is there that the sinus will heal.
This is shown as well in the cases of spontaneous cure as in my own
successes. You must always enjoin rest after a strong application, and
watch that not too much inflammation be set up.”
The fistulatome shown in fig. 16, is a contrivance which is perhaps
destined to take the lead in the treatment of fistula generally. It is so
constructed that the fine cutting blades close on themselves, while the
instrument, which is probe pointed, is being introduced, but immediately
open on withdrawal, and thus catch up and cut through the fistulous
membrane.
[Illustration: FIG. 16.—Fistulatome with blades extended.]
Who the inventor of this clever device is, I have been unable to
ascertain, having seen it claimed by three different physicians, one of
whom speaks of curing 76 per cent. of all cases treated by one operation.
That is by drawing the fistulatome through the tract once. Cases of long
standing require that the instrument should be turned at right angles
and drawn through the second time and possibly repeated later on, or a
tenotome employed to scarify any remaining indolent sinus.
It will be readily seen, however, that a fistula with a side pocket,
branch or diverticulum, would hardly be reached by this method; although
the blades are so formed that they draw the membrane of a dilatable
pouch to them from the sides. In such cases a little ingenuity would be
required in finding these diverticula, for the purpose of scarifying them
with a tenotome.
The preparation of the sinus and the after-treatment are the same as
already mentioned. Also evacuation of the bowels and constipation by the
use of an opium suppository, even to the dilitation of the sphincters,
if thought necessary to bring about a cure. In rare instances, where
divulsion has been practiced and while yet under the influence of
anæsthesia, it might be advisable to lay open the cavity by cutting
_from_ the sphincters, pockets traced, scarified and partitions divided.
[Illustration: FIG. 17.—Flexible Silver Canula.]
In relation to treatment, Andrews says: “The truth is, that anal fistulæ
have a natural tendency to recovery, and are held back from it mainly by
two things.
1. “The unfavorable effect of the undrained septic fluids within the sac.
2. “The tightness of the external opening, which prevents free drainage,
and keeps the sac distended with this putrid pus.
“It is demonstrated by Dr. Mathews on the one hand and by the experiments
of quacks on the other, that by controlling these two conditions, many
cases will heal spontaneously. It follows that among the thousands of
patients subjected to cutting operations by surgeons for this disease,
there are many who might be cured by much milder means.”
Shotwell’s operation consists in straitening out of the fistulous tract
with a steel probe, having an eye at its distal end, which is carried
entirely within the bowel whether the fistula is complete or not. He next
pierces the solid structure about three-eighths of an inch farther from
the anus with a lance-pointed probe also having an eye near its end,
parallel with the first probe, until its end is seen penetrating the
bowel a little beyond.
The eyes of the probes are then threaded with the opposite ends of a No.
24 platinum wire about ten inches in length, and both probes withdrawn,
leaving the wire _in situ_ forming a loop; both ends are now secured
to an electrode, the current turned on and the loop drawn through the
partition. Little, if any, dressing is required, but the bowels must be
kept locked up for at least a week. This of course involves the use of
general anæsthesia.
A word to the beginner, in the prevention and detection of fistula. Since
abscess is the most prolific source, proper attention to the abscess by
poulticing, early lancing, the sinus washed with hot, heavily carbolized
water, allowed free drainage, the bowels evacuated, constipated and the
muscles put at rest for a few days, will doubtless be successful in
forestalling its almost certain fistulous sequence.
Dr. Hoyt strongly recommends divulsion of the sphincters, immediately
after opening the abscess, as an unfailing remedy in preventing fistula.
Annoyance by itching, a slight discharge and soreness at times in a
circumscribed spot, with previous history of abscess, might be considered
a sure sign of fistula. But the patient may give the same symptoms
with no knowledge of previous abscess, or other cause pointing to the
formation of a fistula. Yet, on inspection, a small opening with pouty
lips, or a closed cicatricial depression not much larger than a pin-head,
will be found. This is the external ring or opening of a fistula, and if
closed, may resist the introduction of a probe sufficiently to create the
belief that no sinus exists.
ULCER, STRICTURE, ETC.
A solution of continuity, varying from a slight abrasion of the mucous
membrane to a marked degree of destruction of tissue, comes within the
scope and meaning of rectal ulcer.
A deep-seated, non malignant type of rectal ulceration, complicated with
stricture, fistula, etc., is not so very common, and seldom met with
outside of hospital practice.
The less serious and more simple varieties, such as may be productive of
considerable systematic disturbance through reflex excitability, without
attracting much, if any attention locally, are the forms most frequently
seen by the general practitioner.
With few exceptions, rectal ulcer is insidious in its nature; in some
instances passing on to the stage of stricture, which alone may be
the first symptom to cause alarm, as the following recent case will
illustrate.