hemorrhoids. He stated that the only inconvenience suffered was from
constipation. That the piles did not come out and were never very sore
but he had seen a little bloody mucous at times and had a constant
desire to go to stool. A free evacuation and relief being obtained only
after the feces were made liquid by the injection of warm water.
On the introduction of the finger I found about one-inch and a half from
the anus, an annular stricture which almost entirely occluded the bowel,
with ulceration and gummata below. More close inquiry elicited the fact
that the stools were not much larger in circumference than a lead pencil.
He had noticed the trouble not more than two months before. There was a
previous history of chancroid at the age of 19, with no constitutional
symptoms.
It is claimed that organic stricture does occur without previous
ulceration by interstitial deposit and thickening, and ulceration follow.
But this must be considered exceptional. The ulcerative process usually
precedes, and through efforts at repair, cicatricial bands are thrown
out, producing a narrowing and contraction of the canal, either in places
or throughout the circumference of the bowel.
[Illustration: FIG. 18.—Rectal Bougies.]
Electrolysis may be tried for the relief of stricture before resorting to
the usual methods of breaking up by forced dilitation. If divulsion be
decided upon it should be complete at one operation. Should the fibrous
bands be strong and unyielding, nicking the edges with a probe pointed
bistoury is advantageous.
On account of severe hemorrhage and other untoward symptoms likely to
follow a complete division of the stricture, the galvano-cautery is
decidedly preferable to the common proctotomy knife. A duplicature of the
peritoneum coming down to within about three and a half inches of the
anus anteriorly, should not be lost sight of in operations on the rectum.
The persistent use of bougies will be necessary for a long time after
divulsion.
Stricture is mostly of syphilitic origin. Of the seventy cases, tabulated
by Allingham, ten of the number were found in men and sixty in women,
showing a great predominence in the latter; and none were more than three
and a half inches above the rectal orifice.
It is not an easy matter to diagnose between the advanced stages of
non-malignant rectal ulcer and cancer. Both may be accompanied by tender,
condylomatous growths or flaps of skin outside the anus, bathed with
an ichorous fluid. The characteristic, unremitting pain of cancer may
be absent in its formative stage, and in this respect insidious in its
approach, the same as the non-malignant ulcer.
Allingham speaks of a very rare species of rectal ulcer, which he terms
rodent or lupoid, that is superficial, does not implicate the surrounding
parts, devoid of hard edges or surface, very painful and only cured by
complete extirpation.
I have intentionally omitted the early symptoms and course of rectal
ulcer for the purpose of giving audience to Dr. A. C. Hall, who, in
a communication to a medical journal, writes the following lucid
description:
“Rectal ulcer is a more common disease than is generally supposed.
Unfortunately the symptoms are generally obscure, and the patient suffers
but very little, if any pain, and consequently consults his physician for
some of the reflex symptoms, rather than for the initial disease itself;
and very often these reflex symptoms are vainly treated till the patient
and physician are both thoroughly disgusted and disheartened. There is
one maxim which every physician should always bear in mind, and that
is, _always suspect rectal ulcer in every case of protracted or chronic
diarrhœa_. I have reports from eighty-six pension surgeons, in which
they estimate that they have examined two thousand cases, where chronic
diarrhœa was the alleged cause of disability in applicants for pensions.
Of these two thousand cases of chronic diarrhœa, eighty-seven per cent.
had rectal ulcers, and fully ninety per cent. of those who claimed
chronic diarrhœa as their disability and who had no ulceration were
rejected, because their proofs of the disease, aside from the ulceration
were too meagre. Thus the strongest and most prominent symptom of rectal
ulcer is _chronic diarrhœa_.
“The diarrhœa is generally more troublesome in the morning. The patient
often on arising feels an urgent desire to go to stool. This act is often
very unsatisfactory, for he passes very little feces and a great deal
of wind. Occasionally these small stools are covered with a jelly-like,
or white of an egg substance, or the motion may be only a jelly-like
mucous, with no feces. There is generally more or less tenesmus, or
a disagreeable feeling, as if the rectum was imperfectly evacuated.
Sometimes the patient will be compelled to go out two or three times
before breakfast, and he may in the later attempts to have a stool, pass
lumpy or scybalous feces, covered with mucous, and often streaked with
blood. There sometimes exists, as a symptom of rectal ulcer, a desire
to go to stool when cold drinks are taken. But generally the diarrhœa
and tenesmus subside soon after breakfast, and the patient has no more
trouble until the next morning. A great many, or I might say a majority
of those suffering from rectal ulcer consult the physician for some
symptom or other that suggests anything else but the rectum, but by close
questioning, and following up the symptoms, one can soon tell whether
they are reflex or otherwise.
“In cases of rectal ulcer of long standing, there is always more or less
cachexia, or peculiar waxy, sallow, unhealthy complexion, which sometimes
alone points significantly towards the disease.
“There is often more or less enlargement of the liver and spleen,
especially the spleen.
“In advanced cases, the diarrhœa comes on at night as well as morning,
and defecation is accompanied with pain and griping. Another almost
characteristic sign of rectal ulceration, is alternating diarrhœa and
constipation. The bowels remain constipated for a considerable while,
then diarrhœa supervenes, and is accompanied by severe and excruciating
colicky pains, and often nausea. Persons subject to chronic diarrhœa
always dread to take a physic to relieve a temporarily constipated state,
for it will almost invariably put them to bed.
“In extreme cases, infiltration and thickening of the sub-mucous and
muscular coats supervene, as a result of nature’s effort to repair the
lost tissue. This thickening may be so extensive as to threaten and
actually produce stricture. It will often convert the rectum into a
passive tube, through which feces and fluids trickle, the patient having
little or no control over the sphincters.
“The passage of hardened feces and the pressure of internal hemorrhoids
and polypi are the most common causes of rectal ulceration. The lodgment
of foreign bodies, such as fish bones, cherry stones and plum seeds that
have been swallowed, and which act as irritants and produce ulceration.
“In women the pressure of the fœtal head on the rectum during childbirth
is a frequent cause of ulceration, likewise the pressure of a misplaced
uterus.
“On examination, by means of a speculum, the ulceration will be found
about an inch or an inch and a half from the anus, generally on the
posterior wall, but often on the anterior wall.
“When the ulcer is on the anterior wall, there is more or less
irritability of the bladder, and seminal emissions or impotency. The
ulcer itself may be round, oval or elongated, radiating or following the
columns of Morgagni. The ulcer may present ragged, interrupted elevated
edges, or they may be sharp cut and regular, as though cut with a sharp
punch. The edges are sometimes hard and gristly, or may be soft and with
no elevation above the surrounding tissues. The surface of the ulcer
is often clean, and healthy looking granulations may be seen, or the
ulcerated surface may be loosely covered with a greyish, grumous scum,
that is offensive, and decidedly unhealthy for the patient. Underneath
this scum there is often found an ulcerated spot, that is apparently
lifeless, and will require much attention, locally and constitutionally,
to prevent its rapid extension. In this form of rectal ulcer there is
always more or less marked cachexia. It is the indolent ulcer, occasioned
by the gradual breaking down of the tissues, that produces the grave
constitutional disturbances and death. It is the small, round, or oval
ulcer, with elevated, hardened edges, that produces the many and various
reflex nervous symptoms, which are misleading and troublesome.”
[Illustration: FIG. 19.—Rectal Irrigator.]
In all cases of rectal ulcer of any considerable gravity, absolute
rest, both of the parts and the body, is to be maintained. Hot water
irrigations and a complete destruction of the diseased surface by
carbolic acid, are the first things to be thought of, together with a
liquid diet.
Convert the ulcer into a carbolic acid sore and use an iodoform
suppository. In fact the treatment is very similar to that recommended
as an after treatment in a bad case of hemorrhoids, with such variations
as the ingenuity will suggest. Bismuth, oxide of zinc, eucalyptus,
mercury, resin cerates, etc.
Have found no use for iodine, nitrate of silver or acid preparation of
iron, which corrode and destroy instruments in the treatment of rectal
diseases.
FISSURE, OR IRRITABLE ULCER.
Of all the diseases of the rectum, considering the apparent
insignificance of the lesion, this heads the list as a pain producer.
Fissure has characteristics peculiar to itself and I do not think, as is
claimed, that its location, just above the muco-cutaneous junction or
Hilton’s line, where the nerve supply is the greatest, explains these
characteristics; neither do I think it of traumatic origin.
No other ulcer, wound or abrasion in the same locality produces the pain
that identifies a fissure.
[Illustration: FIG. 20.—Fissure, complicated with polypi.]
It might be compared to a rhagade or chap in the web between the toes or
fingers. In its recent state it presents the appearance of a longitudinal
tear of from three to five-eighths of an inch in length, looking raw and
bloody, with ragged and somewhat everted edges; and may be complicated
with polypi (Fig. 20), or a hemorrhoid occupy its base, called the
“sentinel” pile.
It is aroused from its slumbers by a mechanical disturbance of the
slightest nature, hence the name irritable. The act of defecation being
followed by a dull, sickening, sometimes lancinating pain lasting
three hours or more, incapacitating the subject from labor. The mere
introduction of the finger may produce a deathly pallor and possibly
syncope.
Ask the patient to extrude the parts, then gently pull down the mucous
membrane and apply a ten per cent. solution of cocaine to the tract with
a camel’s hair brush or silver canula attached to a hypodermic syringe;
carrying the solution fully to the top of the fissure, which may be out
of sight. If any unguent has been used about the fissure it should be
subjected to a hot water irrigation before using the cocaine, as cocaine
will not take effect on a greasy surface.
When the tract is sufficiently anæsthetized to introduce a speculum,
apply on the end of a probe wrapped with cotton, 95 per cent. carbolic
acid, and prescribe the following ointment for daily use:
℞ Acidi Salicyl. ʒ ss
Vaselini ℥ ss
M.
If unsuccessful after making two or three thorough applications of
carbolic acid, inject into and beneath the bed of the fissure, in a
sufficient number of places to encompass its length, possibly two, a few
drops of the hemorrhoidal compound; and produce a slough. The object is
to destroy the original ulcer and convert it into some other form that
will heal. I have never seen a resulting sore from carbolic acid that was
slow to heal.
A physician who had been a great sufferer from the effects of a fissure
informed me that he had been etherized twice and the sphincters
thoroughly stretched, and had submitted to incision three times, all of
which had proved fruitless, and was finally permanently cured by the use
of salicylic acid and vaseline.
[Illustration: FIG. 21.—Ointment Applicator.]
PROLAPSUS RECTI.
A prolapse of all the coats of the rectum, amounting in some instances
to complete invagination, is of such rare form, occurring mostly during
infancy, that it might be considered practically out of the list of
rectal ailments.
Prolapse of the mucous coat of the bowel is not an uncommon affection,
and is a frequent complication of internal hemorrhoids. When the
hemorrhoids are cured the prolapsus usually disappears.
It is natural for the mucous membrane at the lower end of the rectum, by
its loose attachment to the muscular coat through the cellular layer, to
roll down and become somewhat everted during the act of defecation. It is
only when this condition becomes excessive and the protrusion so great
that it does not return of its own accord, that it is called prolapsus of
the first degree and treatment required.
Should it occur independently or persist after the removal of piles, a
cure may be easily effected by the injection of from eight to ten minims
of a ten per cent. solution of carbolic acid, beneath the mucous membrane
in the cellular structure, at points where it is desirable to take up
a fold. The needle may be introduced in a line with the axis of the
rectum, varying from one-fourth, one-half of an inch or more from the
muco-cutaneous junction, and even as high up as the upper margin of the
internal sphincter.
This can be done while the membrane is prolapsed, or through the slot
of a speculum. The latter is preferable on account of the sides of the
slot limiting the distribution of the medicine. Anything that will excite
an adhesive inflammation or a change in the cellular coat will have a
similar effect.
The following preparation is effective:
℞ Acidi Salicyl.
Sod. Bibor. ā ā ʒ i
Glycerinæ ℥ i
M.
Take six drachms of this preparation and add carbolic acid 40 minims.
If it be desirable to remove a thickened fold or bunch-like appearance
of the mucous membrane, inject the same as you would piles, using the
hemorrhoidal compound. It will slough off neatly and heal readily. It is
peculiar of the injection of internal piles or of the same strength of
medicine into or beneath the mucous membrane, that it tightens and takes
up a slack of the membrane permanently, without apparent lessening of
the calibre of the gut. It is also peculiar of the treatment and cure
of internal hemorrhoids by injection, that no cicatrix, cicatricial
tissue or contraction results, unless the operation has been extensive,
involving both sides, and an active inflammation has been excited by
extraneous causes.
RECTAL POCKETS AND PAPILLÆ.
Concerning the frequency of the diseased conditions to which the names
rectal pockets and papillæ are applied, and their being such prolific
sources of mischief as claimed by those who first caught up the craze and
exaggerated the facts, a few brief comments may not be out of place.
That there are such morbid changes, and that they are more or less
hurtful through reflex excitability can not be successfully disproved.
That their appearance suggests the titles they have received is also
undeniable. And the fact of their having been brought to notice in an
irregular way, does not militate in the least against the existence of
such affections, or the fitness of the terms used to designate them.
If it be true, as stated by enthusiasts on the subject of rectal pockets
and papillæ, that they are frequently found in old, deep-seated, chronic
diseases, where the presence of rectal trouble is never suspected by any
local signs, we have, then, a sufficient reason to account for their
having escaped the notice of specialists.
Andrews makes a labored effort, and with apparent success, to show that
the so-called “pockets and papillæ” are normal structures. That the
pockets are the _sacculi Hornei_ (Fig. 22), which are little depressions
situated just above and intimately connected with the verge of the
anus, caused by the reticulated arrangement of bands of muscular and
connective tissue, beneath a delicate mucous membrane and deepened by
the corrugating action of the sphincter ani. That the papillæ are little
dot-like prominences frequently found between the lower ends of the
_sacculi Hornei_, and when somewhat enlarged resemble in appearance the
_carunculœ myrtiformes_ of the vagina. That these little papillæ, with
their adjacent “pockets,” constitute the so-called “pockets and papillæ”
of the itinerant.
[Illustration: FIG. 22.—S. _Sacculi Hornei._ P.P. Papillæ, magnified
three diameters. (Andrews.)]
[Illustration: FIG. 23.—P. _Bone fide_ rectal pocket with adjacent
papillæ, not magnified at all.]
I have seen just what Dr. Andrews very correctly describes, and will say,
after carefully reading his explanation, I am fully convinced that he
never saw what is meant by the discoverer of rectal pockets and papillæ.
And further beg to say that the doctor must concede that there are
others, who are not itinerants, capable of identifying a diseased surface
when they see it, and pointing out its place of location.
[Illustration: FIG. 24.—Other varieties of papillæ and a simple form of
rectal pocket.]
It will be seen by a reference to the appended clipping, that Andrews has
been making his microscopical dissections nearly an inch below where
true rectal pockets are found. And I can conscientiously attest that true
papillæ bear no resemblance, in the least, to his papillæ or _carunculœ
myrtiformes_ at the anal verge.
[Illustration: FIG. 25.—Represents figure 22, showing reticulated
arrangement under post mortem relaxation. C.C.C. Columnæ recti. S.
Sacculi Hornei. P.P. Papillæ. (Andrews).]
Rectal pockets are doubtless a duplicature of the mucous membrane,
forming cul-de-sacs with their mouths looking upwards. They are removed
through a speculum by raising the outer wall with a blunt hook and
excised with a pair of scissors, or slit through their center with a
knife, and carbolic acid applied to the remaining flaps.
[Illustration: FIG. 26.—Author’s Knife-hook for slitting down pockets.]
Papillæ may be seen in three different forms. One, a white, flat or
sessile process, resembling the half of a split pea, but not quite so
large. Another, a small, white, rather stiff projection on either side
of a large pocket. The other, a slender, perfectly flexible, worm-like
vegetation, possessed of a white or transparent top, Figs. 23 and 24.
They appear to spring out of the mucous membrane similar to a polypus,
and can be snipped off at their base with little loss of blood and
trifling pain.
“The usual location of pockets and papillæ is at a point about an inch
from the anus, at the upper margin of the internal sphincter, where the
large distended pouch of the middle portion of the rectum is abruptly
puckered down to the narrow limits of its last inch.
“These pockets are curious formations, and have received very little
attention from writers upon rectal disease, and they have been almost
entirely overlooked by anatomists, as well as pathologists. Whether they
belong to the anatomy or not, I am unable to state with any certainty,
but I know for certain, however, that they are not always present. I know
also that they can almost always be found in cases of old, deep-seated,
chronic diseases, and that the removal of these pockets in this class of
cases is followed by the most happy results.
“When these pockets are present, they always occasion a spasmodic
contraction of the sphincter ani, a condition which is most frequently
observed in those cases that are developing some deep seated
constitutional disease. Their removal in this class of cases is
invariably attended by more or less improvement of the patient’s general
condition and circulation.
“In form and character these pockets may be long and narrow channels,
and ulcerated at the bottoms; short (cul-de-sacs) or broad mouthed and
pointed at the bottom. These pockets create a great amount of irritation
to the nervous system. No matter what shape, condition or location they
may be in, by reflex irritation they produce a long train of nervous
symptoms that cannot be remedied until they (the pockets) are removed.
“Papillæ are conical processes of mucous membrane, of variable size,
shape and location. They have no relationship with rectal pockets, for
they very frequently exist independently of them.
[Illustration: FIG. 27.—Pratt’s curved scissors.]
“I look upon these conditions as being the most mischievous of rectal
disorders, because they always occasion a tonic spasm of the internal
sphincter, and this alone makes excessive demands upon the powers of the
sympathetic nerve. They are common in all forms of chronic disease. I
know of no reason why these conditions, which I have described should
have been so long overlooked, and their importance have remained
unappreciated.
[Illustration: FIG. 28.—Long blunt hook.]
“Unless it be that their presence is unattended by local symptoms,
and hence they have failed to attract the attention of either patient
or the physician. But in view of the fact that they occur in so many
chronic conditions, and the additional fact that marked benefit almost
invariably follows their removal, I insist upon it that no obstinate
case of chronic disease has been properly examined until their presence
or absence has been ascertained. The most happy and the most marvelous
results that I have ever seen in the practice of medicine and surgery
have followed the removal of pockets and papillæ, and in thus bringing
them to your notice, I do so in the confident belief that a proper
appreciation of their importance on your part will add materially to your
resources in battling with disease, and in helping those who apply to you
for relief.” (Pratt.)
PRURITIS ANI.
Excluding all discoverable local causes whereby the presence of this
obstinate affection may be explained, such as piles, ulcer, fistula,
oxyuris vermicularis, eczema marginatum, etc., and take the disease
unalloyed, or as it may exist in a state pure and simple, and assure a
patient thus afflicted that he can be quickly and permanently cured,
would not only be presuming too much, but would be stepping beyond the
legitimate bounds of all past recorded experiences.
To furnish something of an idea to those who are not already familiar
with this seemingly trivial yet rebellious complaint, I here quote the
language of Dr. Hoyt, who uses words somewhat extravagantly in the
beginning but palliates his feelings down later on with _lotio niger_.
“With what anguish its unhappy victims battle through innumerable
sleepless nights fighting this demon of so-called local epilepsy, with
its long array of itching, burning, exuding, corroding, exhausting,
and blaspheming characteristics, as though they had been brewed by the
chemistry of hell. The whole organization becomes a chaotic discord, the
disposition is cruelly warped, the countenance shows a sad picture of
living woe, the carriage is nearly lost to all laws of equilibrium, and
the complete being merges into a throbbing phantom of despair, trembling
upon the very threshold of idolized suicide.
“Of course I speak of the most aggravated cases, instances that seldom
occur within the experiences of general practitioners. Wherefore
then these phenomena? What is the mighty influence that yields so
much distress, as all these objective symptoms are but an appearance
outflowered by some subtle and specific force. The meager literature
upon this subject hobbles upon the crutches of hypothetical inferences,
telling you _perhaps_ it is capillary congestion or chronic proctitis,
or neurotic hyperæsthesia or eczema, or malaria, suggesting a panoramic
array of remedial agencies all unsatisfactory, thereby confessing to a
sad condition of helpless empiricism.