Columbia (Bnitieri^ftj) intljeCitpoflmgork CoUegc of ^f)j>£iicians! anb burgeons! Hibrarp ^1 ' ''t^'h ■ \ DISEASES OF THE RECTUM AND ANUS Designed for Students and Practitioners OF Medicine BY SAMUEL GOODWIN GANT, M.D., LL.D. PuoPESSOR OP Rectal and Anal Surgery at the New York Post-graduate Medical School and Hospitaij Attending Surgeon for Rectal and Anal Diseases to the New York Post-Graduate Hospital; Newport Uospital and New York Infant Asylum and St. Mary's Hospital, Jamaica, Eto. tbird Edition, Revised and Enlarged With Thirty-Seven Full-Page Plates, Twenty of Which are in Colors, and Two Hundred and Twelve Smaller Engravings and Half-tones PHILADELPHIA F. A. DAVIS COMPANY, PUBLISHERS IQTO COPYRIGHT, 1902 COPYRIGHT, 1905 F. A. DAVIS COMPANY [Registered at Stationers' Hall, London, Eng. Press of F. A. Davis Company 1914-16 Cherry Street Philadelphia, Pa. 4> -J C5^ >■ ■ CO THIS WORK AFFECTIONATELY DEDICATED TO MY INSTRUCTOR, FRIEND AND COLLEAGUE, D, B. St. JOHN ROOSA, M.D., LL.D., FOUNDER AND PRESIDENT OF THE FIRST POST-GRADUATE SCHOOL OF MEDICINE. PREFACE TO THIRD EDITION. The preparation of the third edition of this work has neces- sitated a careful revision of the second edition ; typographical errors appearing in the latter have been corrected, and such changes and additions as were found necessary have been made. This edition includes one new chapter, viz. : "Local Anesthesia in the Treatment of Diseases of the Sigmoid, Rectum, and Anus," which the author has been encouraged to add because of the excellent results he has obtained in the radical treatment of these affections under local anesthesia in the office, patient's home, and dispensary. , The author desires to express his deep obligations to Dr. Benjamin E. Dolphin for his valuable assistance, and to the F. A. Davis Company for the many courtesies extended during the preparation of this work. S. G. G. 43 W. FrFTY-SECOND Street, New Yoek City. (V) PREFACE TO SECOND EDITION The advances made in the domain of rectal surgery since the appearance of the first edition of this work have necessitated a complete revision and the addition of much new material. The chapters on "Cancer" and "Colostomy," which in the first edition were written by Mr. Herbert Allingham, have been entirely rewritten and considerably extended in the present edition by the author. To render the volume more worthy of the title it bears, three entirely new chapters have been prepared, namely: "Diseases, Injuries, and Tumors of the Coccyx" ; "Venereal Diseases of the Ano-rectal Region"; and "Recto-colonic Enteroliths and Concretions." In order to more thoroughly elucidate the text, many new and original illustrations have been added to the already large number prepared for the first edition. These additions comprise five full-page colored plates, seventeen full-page black-and-white plates, and one hundred and one smaller en- gravings and half-tones. It will, therefore, readily be seen that the present volume is practically a new work. My thanks are due to my colleague, Prof. Henry T. Brooks, of the New York Post-graduate Medical School, for writing the section on "Examination of the Feces," for cor- recting my manuscript, and for seeing the pages through the press; to Dr. Bertram H. Buxton, of Cornell Medical College, for making the excellent photomicrographs; to my assistants, Dr. Kenneth Keath McAlpin and Dr. Arthur Landsman, for (vii) Viii PREFACE TO SECOND EDITION valuable assistance in consulting literature ; to Mr. R. J. Hopkins and Mr. Herbert B. Reissman, artists, for many of the drawings to be seen throughout the work; and last, but not least, to Dr. B. E. Dolphin for unselfishly aiding me in many ways. I desire to especially thank my publishers, F. A. Davis Company, for their courtesy, Hberality in regard to both illus- trations and letter-press, and their hearty co-operation at every stage of the work. In conclusion, I ask the privilege to assure both the medical press and the profession at large of my grateful appreciation of the generous and cordial reception granted by them to the first edition of this book. I trust this, the second, edition may merit a continuance of their favor. S. G. G. 43 West Fifty-secoxd Street. PREFACE TO FIRST EDITION This treatise is the result of an effort to give to prac- titioners and students of medicine a concise, yet practical, work. I have not attempted to give a detailed discussion of theories and antiquated views of unrecognized value. Of recent years so much has been written upon "Asepsis and Anti- sepsis" and "Rectal Reflexes" that I have deemed it best not to devote separate chapters to these subjects, but have given them sufficient attention throughout the entire work. Two chapters have been written that are new in a work of this kind : one on "Railroading as an Etiologic Factor in Rectal Diseases" and one on "Auto-intoxication from the Intestinal Canal." I have given these subjects distinct chapters, for I am sure that their importance has been very much underrated by writers generally. In the case of words in which a diphthong is employed I have adopted the new orthography. For example, the words hcemorrhoids, fences, diarrhoea, etc., are spelled thus : hemorrhoids, feces, diarrhea, etc. In order to present a comprehensive treatise I have made frequent reference to the standard works on diseases of the rectum and anus and to reprints and monographs too numer- ous to mention. Among the text-books which I have consulted I desire to mention the following: Allingham, Mathews, Cripps, Kelsey, Cooper and Edwards, Van Buren, Ashton, Curling, Ball, Quain, Henry Smith, and Bodenhamer on hemorrhoidal disease. I have, in each instance, endeavored (ix) X PREFACE TO FIRST EDITION to give proper credit to authors, and if I have failed in a single case it lias been unintentional. I was fortunate, indeed, in getting Mr. Herbert William AUingham, of St. Mark's Hospital, London, to write two chapters on "Cancer" and "Colostomy," for I doubt if there is any man living more capable of dealing with these im- portant subjects than he. I wish also to acknowledge my obligations to Dr. J. C. Stewart for valuable assistance rendered in perfecting the many original diagrams and drawings seen throughout the work; and to my friends, Drs. W. F. Kuhn and Daniel Morton, for correcting my manuscript. To my publishers, F. A. Davis Company, I wish to express my gratitude for the many courtesies received. To the Burk & McFetridge Company, who made the many beautiful chromolithographic plates, I will only say that the excellency of their work has surpassed by far my most sanguine expectations. Trusting that my labors may prove to be of some practical value to the profession, I respectfully submit it for their perusal. S. G. G. Kansas City, Mo. TABLE OF CONTENTS CHAPTER I. PAGE Introduction 1 CHAPTER 11. Anatomy and Physiolocy 3 The Large Intestine 3 The Sigmoid Colon 6 The Rectum 8 The Arteries of the R.ectum 14 The Veins of the Rectum 14 The Nerves of tlie Rectum 15 The LjTiiphatics of the Rectum 16 The Muscles of the Rectum 16 The Anus 18 The Perirectal Spaces 18 The Ischio-rectal Eossse 19 The "Rectal A'^alves" (lolds) 19 Physiology 29 Literature 32 CHAPTER III. Symptomatology (Semeiology) 34 Gant's Card-Index History Chart 40 CHAPTER IV. Examination 41 Preparation 41 Instruments 42 Position of the Patient 48 Anesthesia 48 Examination of Eeces 52 Character of Dejecta in Certain Affections 62 CHAPTER V. Congenital Malformations 73 Classification 73 Symptoms 78 Diagnosis 79 Prognosis 81 Synopsis of Cases 82 Treatment 83 Literature 88 CHAPTER VI. Constipation 90 Etiology 90 Symptoms ., 92 Treatment 94 Non-medicinal Treatment 95 Surgical Treatment 102 Gant's Clamp Operation lOi (xi) xii TABLE OF CONTEXTS CHAPTER VII. PAGE Fecal Impactioj? (Coprostasis) 108 Etiology and Pathology 108 Symptoms 109 Diagnosis 110 Prognosis 112 Treatment 112 Synopsis of Cases 116 CHAPTEPv VIII. Atjto-infection and Auto-intoxication fpvOM the Intestinal Canal. 120 The Circulatory System 125 The Kespiratory System 126 The Skin 126 The Nervous System 126 The Bacillus Coli Communis 129 Treatment 136 Literature 139 CHAPTER IX. Cheonic DiaPvPvHEa 140 Symptoms and Diagnosis 143 Treatment 144 Illustrative Cases 147 CHAPTER X. Diseases, InjuPvIes, and Tumors of the Coccyx 149 Malformations (Abnormalities) 149 The Coccygeal Body and its Diseases 152 Coccygodjmia 153 Fractures, Dislocations, Injuries, and Necrosis of the Coccyx 159 Sacro-coccygeal Tumors and Cysts 161 Syphilis and Tuberculosis of the Coccyx 166 Synopsis of Cases 168 Illustrative Case 172 Literature 172 CHAPTER XL Venereal Diseases of the Ano-rectal Region 175 Gonorrhea (Clap) 175 Chancroids (Soft Chancres) 178 Syphilis 179 Condylomata (Venereal Warts, Vegetations, ^iucous Patches, Papillomata, Dermophymata Venerea) 182 Venereal Diseases Caused by Sodomy and Rectal Onanism 187 Illustrative Case 187 Literature 188 CHAPTER XII. Pruritus Am (Itching of the Anus, Itching Piles) 190 Etiology and Pathology 190 Symptoms and Diagnosis 194 TABLE OF CONTENTS xiii CHAPTER XIII. PAGE PEtmiTus Ani (Continued) 197 Treatment 197 Surgical Treatment 205 Illustrative Case 208 Literature 206 CHAPTER XIV. Pkoctitis (Rectitis, Catakkh of the Rectum) and Membranous colo-pkoctitis 207 Acute Proctitis 207 Chronic Proctitis 210 Membranous Colo-proctitis 216 Literature 222 CHAPTER XV. Peripkoctitis (Ano-rectal, or Ischio-rectae, Abscess) 224 Symptoms 226 Diagnosis 228 Prognosis 228 Treatment 229 Literature 232 CHAPTER XVI. Ano-rectal Fistula 233 History 233 Etiology and Pathology 236 Varieties 238 CHAPTER XVII. Ano-rectal Fistula (Cnntlnued) 243 Symptoms 243 Diagnosis 245 Prognosis 248 CHAPTER XVIII. Ano-rectal Fistula (Continued) 2.50 Palliative Treatment 250 Operative Treatment 250 After-treatment 267 Illustrative Cases 270 Literature 284, 285 CHAPTER XIX. The Relation of Phthisis Pulmonalis to Fistula in Ano 275 Differential Diagnosis 278 Treatment ....".. 280 Palliative Treatment 280 Operative Treatment 281 Illustrative Cases 283 Literature 284 xiv TABLE OF CONTENTS CHAPTER XX. PAGE Fecal Ixco>'tixexce 286 Etiology and Pathology 286 Symptoms and Diagnosis 288 Prognosis 289 Treatment , 290 Illustrative Case , 292 Literature 293 CHAPTER XXL Anal Fissure, ok Painful Ulcer (Irritable Ulcer, Sphincter- ALGIA) 294 History 294 Etiology and Pathology 295 Symptoms 300 Diagnosis 303 Prognosis 306 CHAPTER XXII. Anal Fissure (Continued) 307 Palliative Treatment 307 Operative Treatment 312 Illustrative Cases 316 Literature 317 CHAPTER XXIII. Non-malignant Ulceration and Esthiomene 319 Etiology and Pathology 319 Symptoms 331 Diagnosis 334 Prognosis 334 Treatment 335 Palliative Treatment 335 Surgical Treatment 338 Illustrative Cases 343 Literature : 346 Esthiomene 339 Etiology and Pathology 339 Symptoms 341 Diagnosis 342 Treatment 342 Literature 347 CHAPTER XXIV. NoN- malignant Stricture 348 Etiology and Pathology 349 Pathology 357 Symptoms 358 Diagnosis 362 Prognosis 365 Treatment 366 Palliative Treatment 367 OperatiA'e Treatment 367 Illustrative Cases ■ 377 Literature 381 TABLE OF CONTENTS XV CHAPTER XXV. page Pbolapse (Procidentia Recti, Prolapsus Ani) 382 l^tiology fl Pathology fl Classification ^°^ Diagnosis f^' Symptoms ^f Prognosis ^^^ Treatment 390 Palliative Treatment ^90 Surgical Treatment ^^^ Operations for Reduction of the Caliber or Length of the Rectum and Shortening of the Sphincter-muscle 394 Fixation of the Bowel to the Sacro-coccygeal Curve 397 Amputation, Excision, and Resection 400 Illustrative Cases ^^^ Literature ^^' CHAPTER XXVI. External and Internal Hemorrhoids (Piles) 408 History ^^8 Classification 409 Etiology 410 Pathology ^^^ CHAPTER XXVII. External Hemorrhoids (Piles) 418 Symptoms 418 Diagnosis ^j^ Treatment '*^^ Illustrative Cases 422 CHAPTER XXVIII. Internal Hemorrhoids (Piles) 424 Symptoms 424 Diagnosis '*'^" Prognosis ^"^° CHAPTER XXIX. Internal Hemorrhoids (Continued) 429 Palliative Treatment 430 Surgical Treatment 433 Illustrative Cases 468 Literature 471 CHAPTER XXX. Hemorrhage 473 Etiology and Pathology 473 Symptoms and Diagnosis 475 Methods of Arresting Hemorrhage 476 xvi TABLE OF CONTENTS CHAPTER XXXI. page Non-malignant Tumors (Rectal Polyps) 483 Symptoms 495 Diagnosis 496 Prognosis 497 Treatment 497 Illustrative Cases 499 Literature 501 CHAPTER XXXII. Malignant Tumors (CARCiNOiiA [True Cancer] and SARCOiiA) 502 History 502 Classification 505 Carcinoma, Etiology 506 Pathology 510 Sarcoma, Etiology 521 Classification 521 Symptoms 524 Diagnosis 528 Prognosis 533 CHAPTER XXXITI. Malignant Tumors (Vontinued) 534 Palliative Treatment 534 Surgical Palliative Treatment 539 Radical Treatment 541 Proctectomy (Excision) 543 Complications and Sequels 573 Permanent Results 575 Causes oi Death 577 Literature 577 CHAPTER XXXIV. Colostomy (Colotomy, Artificial Anus) 582 Classification 586 Left Inguinal (Iliac) Colostomy (Sigmoidostomy) 589 Transverse Colostomy 598 Right Inguinal Colostomy 599 Left Lumber Colostomy 599 Right Lumber Colostomy 600 After-treatment 600 General Remarks on Colostomy 601 Complications and Sequels 615 Literature 617 CHAPTER XXXV. Closure of Artificial Anus and Fecal Fistula 619 Methods of Closing an Artificial Anus 620 Methods of Closing Fecal Fistula 623 Literature 624 TABLE OF CONTENTS xvii CHAPTER XXXVI. page Netjkalgta (Ner^ti-ache) and Hyperesthesia (Hysterical Rectum) . t)'25 Etiology and Pathology 625 Symptoms 626 Diagnosis 627 Prognosis 627 Treatment 628 Hyperesthesia (Hysterical Rectum) 631 Symptoms 63 1 .Diagnosis 631 Treatment 632 Illustrative Cases 632 Literature 634 CHAPTER XXXVII. Enteroliths and Concretions 635 Symptoms 640 Diagnosis 641 Treatment 641 Synopsis of Cases 642 Literature 643 CHAPTER XXXVIII. Foreign Bodies, Wounds, and Injuries 645 Symptoms 648 Treatment 649 Illustrative Case 650 Literature 652 CHAPTER XXXIX. Sodomy (Pederasty) and Rectal Onanism (Rectal Masturbation) . 653 Rectal Onanism 658 Literature 658 CHAPTER XL. Railroading as an Etiologic Factor in Rectal Disease 660 Irregularities in Living 662 Results of Constipation 665 Erect Position 666 Irregular, Jarring Motion 666 Synopsis of Cases 669 CHAPTER XLL Local Anesthesia in the Treatment of Diseases of the Sigmoid, Rectum and Anus 671 Local Anesthetics 672 Ether Spray, Ethyl Chloride, Liquid Air — 672 Cataphoresis, ( Electricity ) 672 Cocaine and Eucaine 672 Sterile Water G74 Index .- 681 LIST OF TABLES TABLE PAGE I. Synopsis of Eight Cases of Congenital Malformation of the Eec- tum and Anns Treated by the Author 82 II. Congenital Malformations (Cripps) 83 III. Congenital Malformations (Bodenhamer) 83 IV. Two Hundred and Fifty Cases of Constipation Treated by the Non-medicinal Method 101 V. Differential Diagnosis between Fecal Impaction and Carcinoma of the Large Intestine Ill VI. Synopsis of Forty-six Cases of Fecal Impaction Treated by the Author 116-119 VII. Synopsis of Thirty-seven Cases of Diseases, Injuries, and Tumors of the Coccyx Treated by the Author 168-171 VIII. Analytic Table of Diseases of the Coccyx 171 IX. Differential Diagnosis between Tuberculous and Non-tuberculous Fistula 278-279 X. Diiierential Diagnosis of Fissure and Ulceration 305 XI. Cripps's Table of Stricture 352 XII. Author's Table of Stricture 352 XIII. Differential Diagnosis between Non-malignant and Malignant Stricture 364-365 XIV. Differential Diagnosis between Hemorrhoids, Procidentia Eecti, and Polyps 427 XV. Statistics of Cancer 503 XVI. Statistics of Ano-rectal Cancer 504 XVII. Statistics of Intestinal Cancer 504 XVIII. Location of Cancerous Tumors in One Hundred Cases Examined by the Author 511 XIX. Frequency of Intestinal Sarcoma in Different Decades 521 XX. Location of Intestinal Sarcoma in Thirty-seven Cases 521 XXI. Statistics of Operability of Rectal Cancer 564 XXII. Vogel's Modification of Kronlein's Table on the Operability and IMortality of Kraske's Operation 564 XXIII. Statistics of Incontinence following Proctectomy 575 XXIV. Permanent Eesults Obtained from Rectal Excision by Leading Operators of Europe 576 XXV. Synopsis of Fifty-four Cases of Enteroliths and Intestinal Concre- tions Collected by the Author 642 XXVI. Tardieu's Statistics Regarding the Ages and Occupations of Ped- erasts 654 XXVII. Author's Analysis of One Hundred and Seventy Thousand Rail- way Cases 667 XXVIII. Synopsis of Thirty Cases of Rectal and Anal Diseases Treated by the Author at the Kansas City, Fort Scott & Memphis Railway Hospital, from January 1, 1893, to January 1, 1894 669 XXIX. Table of Three Hundred and Twenty Cases of Rectal and Anal Affections Radically Operated upon by the Author in the Office, Patient's Home, Dispensary or Hospital Under Sterile Water Anesthesia 676 (xviii) LIST OF ILLUSTRATIVE CASES CASE ^^<^^ I. Chronic Diarrhea Caused by Ulceration 147 II. Chronic Diarrhea Caused by Rectal Polyp 148 III. Entire Absence of the Coccyx in an Adult (Congenital) 172 IV. Gummata of the Rectum 187 V. Pruritus Ani (Aggravated Case) 206 VI. Complex Fistula with Thirty-seven Openings upon the But- tocks, Eight in the Vulva, and Three in the Rectum 270 VII. Horseshoe Fistula 271 VIII. Blind Internal Fistula 274 IX. Tubercular Fistula (Ligature Operation) 283 X. Tubercular Fistula (Division Operation) 284 XL Incontinence Due to Rupture of the Sphincter-muscle 292 XII. Painful Ulcer Caused by Constipation 316 XIII. Painful Ulcer with Bladder Complications 316 XIV. Painful Ulcer within External Pile 317 XV. Ulceration of the Rectum (Temporary Colostomy) ; Artificial Anus, Closed more than Three Years Later 343 XVI. Ulceration of the Rectum (Curettage and Incision) 344 XVII. Ulceration of the Rectum (Cauterization with Nitric Acid) 345 XVIII. Tubercular Ulceration (Curettage) 345 XIX. Stricture Due to Muscular Band (Internal Proctotomy) 377 XX. Stricture of the Rectum (Posterior Proctotomy) 377 XXI. Stricture of the Rectum, with Almost Complete Obstruction. . . 378 XXII. Stricture of the Rectum (External Proctotomy) 380 XXIII. Stricture Due to Fibrous Band (Gradual Divulsion) 380 XXIV. Prolapse Due to Summer Diarrhea (Cauterization) 404 XXV. Extensive Prolapse of All the Rectal Coats 405 XXVI. Extensive Prolapse (Excision) 406 XXVII. Dwarfed Child Suffering from Prolapse 406 (xix) XX LIST OF ILLUSTRATIVE CASES CASE . PAGE XXVIII. External Hemorrhoids (Thromboti3 Variety) 422 XXIX. External Hemorrhoids (Thrombotic Variety) 422 XXX. External Hemorrhoids (Cutaneous Variety) 422 XXXI. External Hemorrhoids Complicated with Fissure 423 XXXII. Internal Hemorrhoids Treated by the Injection Method 468 XXXIII. Internal Hemorrhoids (Clamp-and-Cautery Operation) 470 XXXIV. Internal Hemorrhoids Complicated with Ulceration (Ligature Operation) 470 XXXV. Polyp Weighing Four Ounces (One Hundred and Twenty Grams) Removed by the Ligature Operation 499 XXXVI. Polyps in a Child Three Years of Age. Removed by Torsion. . 500 XXXVII. Large Fibrous Polyp of Several Years' Standing 500 XXXVIII. Adenoid Polyps. Removed by Clamp and Cautery 500 XXXIX. Neuralgia of the Rectum 632 XL. Neuralgia Due to Scar-tissue . 633 XLI. Neuralgia Due to a Dislocated Coccyx 633 XLII. Hyperesthesia of the Rectum 634 XLIII. Stick in the Rectum. Death from Peritonitis 650 LIST OF PLATES PLATE FACING PAGB I. Congenital Syphilis of the Anus (colored) Frontispiece II. Rectum Injected with Paraffin, Showing Position of Sigmoid and Relation of the Peritoneum to the Sacrum, Rectum, and Bladder 10 III. Levatores Ani as Seen from Above, Showing how they Pass Around the Rectum (colored) 17 IV. Levatores Ani, Side- View, Showing their Relation to the Rec- tum (colored) . l^ V. Rectum, Cut Open, Showing Two "Rectal Valves" 25 VI. Paraffin Cast, Showing Indentations Made by Houston's "Valves" • ■ • '^-o VII. Transverse Section through a "Rectal Valve" 26 yill. The "Rectal Valve," Houston's, Showing Tip 28 IX. Gant's "Valvotomy" Instruments 103 X. Gant's Operation of "Valvotomy" 104 XI. Infectious Condj'lomata Lata Involving the Anus, Penis, and In- terdigital Spaces (colored) i^l XII. Non-syphilitic Condylomata Acuminata (colored) 183 XIII. Condyloma (Acuminatiun) Ani 184 XIV. Medullary Adenocarcinoma and .Proctitis as they Appear throvigh the Proctoscope (colored) 212 XV. Case of Recto-vesical Fistula, Showing Result of Extravasation of Urine into Scrotum and Penis (colored) 241 XVI. Complete Fistula in Ano with Division Operation for same (col- ored) 256 XVII. Painful Ulcer of the Anus (colored) 294 XVIII. Ulceration of the Rectum and Polypoid-like Sentinel Teats (col- ored) ^1^ XIX. Primary Ano-rectal Tuberculosis (colored) 325 XX. Diagrammatic Drawing of Rectal Stricture (colored) 357 XXI. Extensive Complete Procidentia Recti (colored) 382 XXII. Protruded Internal Hemorrhoids (colored) 408 (xxi) xxii LIST OF PLATES PLATE FACING PAGE XXIII. Showing the Vascular Supply of Internal Hemorrhoids (col- ored) 413 XXIV. Microscopic Appearance of Internal Hemorrhoids 416 XXV. External Thrombotic Hemorrhoids (colored) 418 XXVI. Gant's Clamp Adjusted for Excision of Protruding Internal Hemorrhoids (colored) 438 XXVII. Adenoma of the Rectum (Magnification, 8) 484 XXVIII. Adenoma of the Rectum (Magnification, 250) 486 XXIX. Epithelioma of the Anus 502 XXX. Cylindric-Celled Adenocarcinoma of the Rectum 506 XXXI. Carcinoma of the Rectum 514 XXXII. Metastatic Deposit in Lymph-node from Colloid Carcinoma of the Rectum 520 XXXIII. Sarcoma of the Rectum 522 XXXIV. Fibrosarcoma with Multiple Fistulas (colored) 531 y XXV. Metastasis in Inguinal Lymph-node 534 XXXVI. Artificial Anus in Left Inguinal Region (colored) 582 XXXVII. Case of Double Procidentia of Part of Descending Colon and Kectum (colored) G16 LIST OF ILLUSTRATIONS PIG. PAGE 1. Reeto-colonic Diverticulse 5 2. Sigmoid Colon and its Relation to the Rectum 6 3. The Rectum and Sigmoid, Showing Curves, Mesentery, Bladder, and Recto- vesical Fold of Peritoneum 8 4. Lateral "View of Rectum, Showing Mesentery, Direction of Blood-vessels, and Peritoneum Binding the Rectum and Sacrum Together H 5. The Rectum Distended 26 6. Proctoscopic View of "Valves" in an Inflated Rectum 27 7. Allison Office and Operating Table 42 8. Allison Oflice Instrument Cabinet 43 9. The Martin Chair for the Proctoscopy Posture 44 10. Battery and Little Wonder Electric Light 45 11. Little Wonder Electric Light in Position 46 12. Gant's Artificial Light, Table, and Irrigating Apparatus 47 13. Gant's Office Speculum 48 14. Cook's Trivalved Operating Speculum 49 15. Hinged Speculum 50 16. Pratt's Bivalved Operating Speculum 51 17. Mathews's Rectal Speculum 52 18. Sims's Wire Speculum 53 19. Kelly's Colonoscope, Proctoscope, and Anoscope 54 20. Kelly's Proctoscope with Electric-Light Attachment 55 21. Laws's Proctoscope 56 22. Method of Using Various Instruments through the Laws Proctoscope 57 23. Pennington's Proctoscope 58 24. Bodenhamer's Proctoscope iand Reflecting Mirror 59 25. Martin's Proctoscope, with Obturator in Position 59 26. The Exaggerated Knee-Chest, or Mart.n, Posture 60 27. Patient Prepared and in Position for Examination or Operation 61 28. Esmarch's Chloroform-inhaler 62 29. Correct Method of Digital Examination with the Patient in the Lithotomy Posture , 63 30. Rubber Finger-stall for Rectal Examination 64 31. Oxalate of Calcium, Frequently found in Diarrhea 65 32. Cholesterin Crystals 66 33. Narrowing of the Anus without Complete Occlusion 74 34. Closure of the Anus by Membranous Tissue 75 35. Imperforate Anus, the Rectum Terminating far Above in a Blind Pouch 76 36. Imperforate Anus, the Rectum Opening into the Vagina 77 37. Imperforate Anus, the Rectum Terminating in the Urethra 78 38. Imperforate Anus, the Rectum Terminating in the bladder 79 39. Imperforate Anus, the Rectum Opening on the Surface by means of a Fistulous Sinus through the Penis 80 40. Imperforate Rectum. The Anus Natural, but the Rectum Obstructed Above it by a Membranous Partition , 81 41. Showing how the Uterus may Press the Rectum back Against the Bony Struct- ures, Causing Partial Occlusion and Constipation 91 42. A Serviceable Bed-pan 112 43. Barger's Artificial Defecator and Irrigator 113 44. Rectal Scoop for the Removal of Impacted Feces 113 45. Modified Kelly Pad 114 (xxiii) xxiv LIST OF ILLUSTRATIONS FIG. PAGE 46. Diagrammatic Drawing Showing Deviation of the Coccyx Anteriorly 150 47. Diagrammatic Drawing Showing Deviation of the Coccyx Posteriorly 151 48. Gant's Coccygeal Scissors 158 49. Gant's Operation for Coccygogectomy 159 50. Rubber Glove 160 51. Sacro-coccygeal Tumor (Front View) 162 52. Sacro-coccygeal Tumor (Rear View) 163 53. Eczema Marginatum 193 54. Gant's Recto-colonic Sprays 210 55. Hypertrophic Proctitis, Showing Desquamated Fatty Epithelia, Leucocytes, Cal- cium-Oxalate Crystals, and Bacteria 211 56. Kemp's Rectal Irrigator, New Model 216 57. Membranous Colo-proctitis, Showing Membrane Inclosing Fatty and Granular Epithelia and Leucocytes 217 58. Symmetric Ischio-rectal Abscesses 229 59. Complete and Blind Internal Fistulae 234 60. Types of Complete Fistula 235 61. Unusual Types of Complete Fistula 235 62. Unusual Types of Blind Internal Fistula 235 63. Common Types of Blind Internal Fistula 235 64. Blind External and Complete Internal Fistulae 236 65. Complete External and Recto-vaginal Fi.-f nlse 237 66. Complex Horseshoe Fistula with Six Openings on the Surface 238 67. Horseshoe Fistula 239 68. Complex Horseshoe Fistula with Multiple Openings In and Outside the Rectum.. 240 69. Recto-vesical and Recto-urethral Fistulae 241 70. 71, and 72. Ligature Operation for Fistula in Ano 254 73. Allingham's Elastic Ligature Carrier 255 74. Fistulatome 255 75. Right Way to Cut the Sphincter in Operations for Fistula in Ano 257 76. Wrong Way to Cut the Sphincter in Operations for Fistula in Ano 257 77. Gant's Sets of Graduated Probes and Grooved Directors 258 78. Gorget 2;59 79. Allingham's Scissors and Grooved Director 259 80. Proper Method of Using Allingham's Scissors and Director 260 81. Gant's Angular Grooved Director for Blind Internal Fistula 261 82. Method of Using Gant's Angular Grooved Director, First Step 262 83. Second Step 263 84. Third Step 264 85. Simple Horseshoe Fistula Before Operation 265 86. Appearance of Wound After Operation 265 87. Complex Horseshoe Fistula Before Operation 266 88. Appearance of Wound After Operation, the Sphincter-Muscle Being cut but Once 266 89. Small Darmack Gauze Carrier 267 90. Appearance of Wounds Three Weeks After Operation in Case of Multiple Fist- ulae with Extensive Burrowing 271 91. Horseshoe Fis*:ula with Multiple Openings 272 92. Lines of Incisions Showing how the External Sinuses were Made to Communi- cate with Each Other, and with the Rectum and the Sphincters Severed but Once, and then at Right Angle 273 93. Appearance of the Anus where the Sphincter was Cut in Three Places in a Young Woman who Recovered Perfect Control of the Bowel in Six Weeks... 287 94. Showing Fissure Caused by Tearing and Dragging Downward of the Semilunar Valves and the Formation of the Typic "Sentinel Pile" 299 95. Gant's Large Operating Speculum 315 96. Primary Tuberculosis of the Rectum and Anus, Showing Tubercular Deposits... 323 97. Primary Tuberculosis of the Skin and Mucous Membrane at the Anal Outlet.... 324 98. Lupus of the Anus in Young Boy (Unusual) 325 99. Tuberculcsia of the Mesenteric Lymph-nodes 326 LIST OF ILLUSTRATIONS XXV FIG. PAGE 100. Ulceration of the Rectum Caused by Diphtheritic Inflammation 330 101. Kelsey 's Rectal Retractor 334 102. Sims's Rectal Irrigator and Draining-tube 336 103. Insufflator 336 104. Allingham's Ointment Applicator 337 105. Gant's Recto-colonic Ointment Syringe 337 106. Esthiomene, Vegetating Variety (Ano- vulvar Region) 339 107. Diagrammatic Drawing of Annular Stricture 349 108. Diagrammatic Drawing of Tubular Stricture 349 109. Complete Tubular Stricture of the Rectum Due to Chronic Proliferating Stenos- Ing Proctitis 355 110. Appearance of a Cross-section of Strictured Rectum 358 111. Correct Method of Introducing a Rectal Bougie 362 112. Bodenhamer's Rectal Explorer 363 113. Ideal Anal Dilators 368 114. Durham's Rectal Dilator 369 115. Whitehead's Rectal Dilator 370 116. Set of "Aloes" Hard-Rubber Bougies 371 117. Wales's Soft-Rubber Rectal Bougies 372 118. Showing Applicator Passing through Left Inguinal Colostomy Opening and Out at the Anus to Show the Direct Line Between these Points and also the Method of Making Topic Applications to the Rectum from Above 375 119. Appearance of Gut Before Removal 379 120. Artificial Anus One Year After Operation, Showing Contraction from Scars Around the Opening, which Caused Partial Obstruction 380 121. Diagrammatic Drawing Showing Prolapse of the Rectum 382 122. Prolapse of the Mucous Membrane (Partial Procidentia) 383 123. Partial Prolapse in a Young Man 384 124. Typic Case of Extensive Complete Procidentia Recti in Boy Three Years Old (Congenital) 385 125. Typic Case of Extensive Complete Procidentia Recti in Boy Three Years Old 386 126. Case of Complete Procidentia Recti Complicated by Stricture in a Woman 387 127. Prolapsus Ani Truss 392 128. Rectal Plug 393 129. Gant's Operation for Procidentia Recti, First Step 395 130. Gant's Operation for Procidentia Recti. Second Step 395 131. Gant's Operation for Procidentia Recti. Third Step 396 132. Submucous Operation for Procidentia Recti 403 133. Le Roy Indestructible Cautery 404 134. Dwarfed Child Suffering from Extensive Prolapse of the Rectum 405 135. Appearance of Dwarfed Child Eighteen Months After Cure of Prolapse, Show- ing the Effect of Operation and Thyroid Treatment 406 136. Cross-section of Internal Hemorrhoids 414 137. Protruding Internal Hemorrhoids 415 138. Hemorrhoidal Truss 433 139. Clover's Crutch 434 140. Dilatation of the Sphincter Ani 435 141. Gant's Hemorrhoidal and Tissue-forceps 436 142. Severing the Mucous Membrane from the Skin 437 143. Gant's Pile, Prolapse, and Polyp Clamp 438 144. Improved Paquelin Cautery 439 145. Cauterizing the Stump 440 146. Gant's Operating Harness (Back and Front Views) 441 147. Smith's Hemorrhoidal Clamp 442 148. Cautery Blow-pipe for Heating Irons 443 149. Cautery Irons 444 150. Mathews's Pile-forceps 445 151. Thomas's Curved Tissue-forceps 445 152. Correct Method of Ligating Protruding Internal Hemorrhoids 447 153 Earle's Clamp-forceps 454 XX vi LIST OF ILLUSTRATIONS FIG. ' PAG3 154. Gant's Hemorrhoidal and Fistula Syringe 458 155. Showing Submucous Ligation of Hemorrhoids 461 156. Pollock's Hemorrhoidal Crusher 464 157. Herbert Allingham's Pile-crusher 464 158. Appearance of Hemorrhoids Before Crushing Operation 465 159. Appearance of Lower Rectum After Crushing Operation for Hemorrhoids 466 160. Drainage-tube Wrapped with Gauze 477 161. Hollow Vulcanite Drainage-tube 477 162. Benton's India-Rubber Tampon (Modified by Edwards) 478 163. Method of Packing the Rectum with Gant's Modification of the Darmack Gauze Carrier 479 164. Gant's Rectal Evacuator 481 165. Pen Sketch of Ano-vulvar Fibromata 489 166. Embryonic Tissue Removed from Dermoid Cyst of the Sacrum 490 167. Epithelial Tissue Removed from a Dermoid Cyst of the Sacrum 491 168. Elephantiasis of the Ano-vulvar Region 493 169. Adenoid (Soft) Polyp 494 170. Fibrous (Hard) Polyp 495 171. Removing a Polyp with the Gant Clamp 497 172. Gant's Recto-colonic Forceps for the Removal of Polyps, Foreign Bodies, and Dressings 498 173. Carcinoma (Secondary) of Mesenteric Glands 528 174. Showing Amount of Bone Removed by Different Operations in Proctectomy 545 175. Inferior Proctectomy. Herbert Allingham's Preliminary Incisions 551 176. Manner of Isolating the Bowel 552 177. Rectum Freed from its Surroundings, Ready to be Amputated 553 178. Showing Bony Integumentary Flap Held Back while the Growth is Removed and an End-to-End Anastomosis Is Made in Superior Proctectomy 557 179. Showing Method of Amputating the Rectum After it has been Freed from its Attachments in Superior Proctectomy 558 180. Showing Appearance of Wound and Location of the Sacral Anus After Superior Proctectomy 560 181. Proctectomy by the Vaginal Route 566 182. Proctectomy by the Vaginal Route 567 183. Rectal Excision by the Vaginal Route 568 184. Jbhowing Location and Length of Incision in Left Inguinal Colostomy 590 185. Longitudinal Bands and Appendices Epiploicae 591 186. No Mesentery 591 187. Short Mesentery 592 188. Long Mesentery 592 189. Schematic Drawing Showing Variable Lengths of the Mesentery and the Dis- tance tne Bowel can be Pulled Out through the Incision 592 190. Manner of Placing the Mesenteric futures in Left Inguinal Colostomy 594 191. Appearance of Wound and Bowel at the Close of the Operation of Left Inguinal Colostomy when the Gut has not been Opened 596 192. Mesentery Made faut 603 193. Artificial Anus Improperly Made, Showing how the Feces may Escape both through the Opening in the Groin and into the Rectum 604 194. Artificial Anus Properly Made with Spur, Showing the Manner in which All the Feces Find an Exit through the Groin COS 195. Herbert Allingham's Colotomy Clamp 606 196. Removal of Gut with the Allingham Clamp 606 197. Double-Barreled Opening 607 198. Removal of Gut Above the Skin 607 199. Forming the Spur 60S 200. Double Procidentia Following Left Inguinal Colostomy where the Excess of the Intestine and Mesentery were not Amputated During the Operation 613 201. Showing how Procidentia Takes Place through an Artificial Anus when the Mesentery is left Long 614 LIST OF ILLUSTRATIONS xxvii FIO- PAGE 202. Appearance of the Intestine where the Excess of Both Bowel and Mesentery has been Removed to Prevent Procidentia 615 203. Showing Appearance of the Gut with the Excess of Mesentery which was not Removed During the Operation of Left Inguinal Colostomy, and which Per- mits tne Bowel to Protrude from Slight Straining 616 204. Clamp used in Gant's Operation for the Closure of an Artificial Anus. (Exact Size) 620 205. Manner of Applying Clamp in Gant's Operation for the Closure of an Artificial Anus 621 206. Gant's Clamp in Position in Operation for Closure of an Artificial Anus 622 207. Manner of Closing External Opening After the Spur has been Divided in Gant's Operation for the Closure of an Artificial Anus 623 208. Hair Ball (Bezoar) from the Intestine of a Horse 636 209. Enterolith from the Rectum 637 210. Urinary Calculus, Weighing more than Four Ounces, which Projected into the Rectum, Causing Stricture and Recto-vesical Fistula 638 211. Extensive Sloughing and Recto-urethral Fistula Secondary to Extravasation of Urine from Rupture of the Urethra, Caused by a Fall and Direct Violence to the Perineum , f47 ^12 Stick Removed from the Rectum (Half-siae) 651 LITERATURE PAGE Anatomy and Physiology 32 Congenital Malformations (Abnormalities) 88 Auto-infection 139 Abnormalities of the Coccyx 17£ The Coccygeal Body (Luschka's Gland) 172 Coccygodynia 173 Fractures and Dislocations of the Coccyx 173 Sacro-coccygeal Tumors 173 Venereal Diseases 188 Pruritus Ani (Itching of the Anus, Itching Piles) 206 Proctitis and Membranous Colo-proctitis 222 Ischio-rectal Abscess and Periproctitis 232 Ano-rectal Fistula 284 Fecal Incontinence 293 Fissure in Ano 317 Non-malignant Ulceration 34C Esthiomene 347 Stricture 381 Procidentia Recti 407 Hemorrhoids 471 Non-malignant Growths (Polyps) 501 Malignant Tumors 577 Colostomy 617 Closure of Artificial Anus and Fecal Fistula 624 Neuralgia 634 Enteroliths and Intestinal Calculi 643 Foreign Bodies, Wounds, and Injuries 652 Paderasty 658 (xxviii) CHAPTER I INTRODUCTION It is doubtful if any part of the body is so frequently the seat of annoying and painful affections as is the ano-rectal re- gion. The suffering induced by ailments of this class is most intense, and may be local, reflected to neighboring organs or parts far remote. Persons thus afflicted are usually disturbed in mind and body and rendered unfit for the discharge of their social and other duties. Rectal disease is no respecter of persons. It has been encountered in both sexes, at all ages, in all countries, in the various walks of life, and under varying conditions. There are many factors which play their respective parts in the produc- tion of pathologic conditions in this locality. Perhaps the most frequent cause is constipation resulting from irregulari- ties in sleeping, eating, and attending to the calls of Nature ; dissipation, and sedentary life. The well-to-do are frequent sufferers from hemorrhoids, pruritus, and proctitis induced by overindulgence in highly seasoned foods and alcoholic beverages, while the poor are commonly afflicted with prolapse, fissures, abscess, and fistula, caused by exposure, unhygienic surroundings, hard labor, and the poor quality of their diet. Warm climates predispose to rectal ailments because of the prevalence there of dysentery and other intestinal diseases. Disease and tumors of neighboring organs and structures occasionally extend to the rectum, and it is not rare for disease of this organ to be mistaken for prostatic, urethral, vesical, vaginal, or uterine aft'ections. Heredity undoubtedly plays a part in the etiology of rectal affections, but not to such an extent as the writings of some authors on the subject would indicate. The most potent causes of disease in the terminal colon are to be sought in the anatomic construction of the rectum and anus, their functions in life, and their close relation with neighboring organs and the sacrum and coccyx. Disease in the anal region, which at first is of such a nature as to be easilv (1) 2 DISEASES OF THE RECTUM AND ANUS cured by simple remedies, sometimes becomes chronic and in- curable if let alone. In some cases this sad state of affairs may- result from false modesty on the part of the patients, who defer a consultation until suffering compels it. In others the fault lies with the attending physician, who, because of indifference or repugnance, fails to make a proper examination. It is deplorable, but nevertheless a fact, that many physicians are only too glad to avail themselves of the ready-made diagnosis handed out by the patients, and then proceed to prescribe for them accordingly. Happily for these sufferers, the time has arrived when ignorant and careless practitioners are being forced out of the profession. Their places are rapidly being taken by pains- taking men who have been taught the value of making an accurate diagnosis by the newer methods of rectal examina- tion, and the necessity of attending to this class of affections promptly and in a scientific manner. It is gratifying to note the increased recognition of the proctologist by both the profession and the laity, who are be- ginning to realize that most affections occurring in the anal region are speedily amenable to proper treatment when taken in time. Since there is no longer an unexplored, mysterious cavern in the fundament of man, it is to be hoped that the itinerant "Pile Doctor" will die of inanition, and the faithful worker in medicine ''thrive and grow fat'' on fees long delayed, but rightfully his own. CHAPTER II ANATOMY AND PHYSIOLOGY It not infrequently happens that in certain rectal diseases the surgeon is called upon to establish an artificial anus in the ascending, transverse, or descending colon or the sigmoid flexure, depending upon the location of the lesion for which the operation is made, and he is also required to treat other diseases, involving not only the rectum, but other parts of the large intestine. Hence, in a work of this kind, it is essen- tial that the anatomy of the large intestine (excepting the appendix), from the ileo-cecal valve to the anus, should be given. The author will not attempt a description of the mi- nute anatomy of these parts, but will give sufficient informa- tion to enable the operator in this field of surgery to work with a degree of intelligence. The large intestine is that part of the alimentary canal extending from the ileo-cecal valve to the anus. It is so named because, when undistended, it is larger than the pre- ceding portion of the intestine. It is further differentiated from the latter by its nearly constant position, its greater de- gree of fixation, thicker walls, sacculated contour, and longi- tudinal bands. To it are attached the appendices epiploicce. It is five or six feet (1.6 to 1.9 meters) in length, and in its course describes a semicircle. Beginning at the ileo-cecal valve in a blind pouch (the cecum), it passes upward to the Hver (ascending colon), where it makes a sharp turn (hepatic flexure) and extends across the abdomen to the spleen (trans- verse colon). At this point it turns downward (splenic flex- ure), to descend to the upper part of the left iliac region (descending colon), where it makes a number of curves (sig- moid colon), and continues in an irregular manner to terminate at the anal orifice (rectum). It gradually diminishes in size throughout its length. The structure of the cecum; ascending, transverse, and descending colons; and the sigmoid colon is the same. Their, (3) 4 DISEASES OF THE RECTUM AND ANUS coats are four in number, viz. : serous (peritoneal), muscular, submucous, and mucous. The Serous Coat (peritoneal) usually completely surrounds the cecum and the loop of sigmoid colon, while the remainder of the sigmoid colon, the ascending, descending, and trans- verse colon are only partially covered, a part of their posterior surfaces being devoid of peritoneum. The Muscular Coat consists of tv^o layers of involuntary muscular fibers, the outer layer being longitudinal and the in- ner circular. The outer layer, at three equidistant points, is gathered into longitudinal bands half an inch (1.27 centime- ters) wide and about one-twentieth of an inch (1.2 millime- ters) thick, which, on account of their shortness, produce the saccidations of the intestine. The inner, or circular, layer of fibers is comparatively thin and unbroken, being slightly thick- ened between the sacculations. The Submucosa (vascular coat) is a layer of connective tissue immediately beneath the mucous membrane, and in it are found the blood-vessels, nerves, and lymphatics. Its structure is such that the mucous membrane may glide freely over it. The Mucous Membrane is grayish in color, and consists of (a) muscularis mucoscc; (b) stroma, which contains lymphoid tissue, blood-vessels, and nerve-elements ; (c) a delicate mem- brane supporting the columnar epithelium. In the mucous membrane are found crypts of Lieberkiihn and solitary glands or follicles. The former are tubular, very numerous, in close apposition, and open on the surface ; the latter are irregularly distributed throughout the colon, but more abundant at its beginning. The large intestine derives its blood-supply from the ileo- colic, coHca dextra, and colica media from the superior mes- enteric, and the colica sinistra and sigmoidea from the inferior mesenteric. The venous blood is collected by the superior and inferior mesenteric veins, and is then emptied into the portal vein. The Lymphatics of the large intestine are in two sets : one lying under the crypts of Lieberkiihn and the other in the sub- mucosa. The lymphatics of the sigmoid colon empty into the lumbar glands, and those of the other part of the large in- testine open into the mesenteric glands. ANATOMY AND PHYSIOLOGY 5 The large intestine receives its nerve-supply from the sympathetic system. The filaments going to the cecum, the ascending and the first half of the transverse colon are from the superior mesenteric plexus, from the celiac plexus; while the remainder of the colon is supplied by the inferior mesen- teric plexus, a derivative of the aortic plexus. The Omenta frequently cause the surgeon much annoy- ance in operations upon the large intestine by obscuring the view or by constantly protruding through the incision and thus interfering with his work. That portion of the omentum attaching the transverse colon to the greater curvature of the stomach is known as the gastro-colic omentum. It is apron- Fig. l.^Recto-colonic Diverticulse. Photograph of Specimen in the Carnegie Laboratory, which the Author was Permitted to Photograph Through the Kindness of Dr. McAlpin. Tike, and hangs down over the small intestines. It is con- nected on the right with the hepatic flexure, and on the left with the splenic flexure and descending colon, where it is called the omentum colicum. The transverse and sigmoid colons are invariably attached to the posterior abdominal wall by mesocolons, and in 35 per cent, the descending and in 25 per cent, the ascending colons have similar attachments. The cecum, however, never has such a connection. The location of the different parts of the colon is variable, owing to abnormalities and the enlargement of neighboring viscera. Sometimes diverticula (Fig. 1) are found, leading of¥ DISEASES OF THE RECTUM AND ANUS from the colon or rectum, and when distended with feces they may be mistaken for tumors. SIGMOID COLON (SIGMOID FLEXURE) The close relation of the sigmoid colon and rectum, and the frequency with which disease of one extends to the other, necessitate a full description of the anatomy of both in a work of this scope. The Sigmoid Colon (Fig. 2, S) is the irregularly (S-shaped) arranged portion of the large intestine occupying the left iliac Fig. 2.— Showing Location of Sigmoid Colon and its Relation to the Rectum (Schematic). S, Sigmoid Colon; D, Dividing-line Between it and Rectum; B, Rectal Ampulla; A, Anus; V, Anal Canal; L, Part of Sigmoid Loop in the Right Iliac Fossa. fossa. It begins above at the crest of the ilium, and termi- nates in the rectum at the left sacro-iliac articulation or in front of the upper edge of the sacrum. The upper portion has a peritoneal covering anteriorly and laterally; the lower segment has a mesocolon, possesses greater mobility and a double curve, from which the sigmoid colon derives its name. The narrowest part of the sigmoid is at its junction with the rectum (Fig. 2, D). The longitudi- nal muscular bands (slightly developed in infants), which are prominent in the upper part of the sigmoid, become less pro- nounced and thinner in the lower part, where they finally ANATOMY AND PHYSIOLOGY 7 lose their characteristic appearance, their fibers becoming evenly distributed and continuous with those of the rectum. "The mucous membrane of the sigmoid and rectum consti- tutes the greater part of the thickness of the gut-wall in in- fants, and is more firmly attached to the muscular coats than in adults" (Martin). The location of the sigmoid colon is uncertain both in health and disease. This depends upon many things, viz.: (a) abnormalities, (b) its length, (c) length of its mesenteric attachments, (d) distension, (e) pressure of the abdominal expulsory muscles, (f) tumors and distension of the adjacent oigans, and (g) sudden and violent injuries. In the empty state it remains in the left ihac fossa or dips down into the pelvis; but as it fills it extends, with a rotary motion, upward or across the pelvis and well into the right ihac fossa, where it usually remains until the beginning of defecation. In the abnormal state it has been encountered either loose or bound down by adhesions, in nearly every part of the abdomen, some- times as a straight tube and at others twisted into irregular loops. These are unnatural conditions, which are always con- fusing to the surgeon. Many of the most recent writers are in favor of adding to the sigmoid colon that portion of the rectum which lies above the middle of the third sacral ver- tebra. This change in the topography of these parts seems a rational one, because it fixes the dividing-line with greater certainty; and that portion of the intestine above this line, described as the sigmoid colon, has a mesentery, and that below it, described as rectum, has no mesentery. The sigmoid is usually described as being about fourteen inches (36 centime- ters) long, but by the above arrangement from three and one- half to four inches (9 to 10 centimeters) are added to its length. In two hundred subjects examined by Byron Robinson, the longest sigmoid colon encountered was thirty-three inches (85 centimeters) and the shortest five inches (12.5 centimeters), the average length being eighteen and one-third inches (46 centimeters). Its average length was found to be about one and one-half inches (4.8 centimeters) more in men than in women. The Sigmoid Mesocolon is of variable length. It is slightly longer in men than in women and surrounds the sigmoid colon, anchoring it above in the left iliac fossa on the left side of the 8 DISEASES OF THE RECTUM AND ANUS psoas muscle (variable), and below, just above the third sacral vertebra (formerly mesorectum). It is of sufficient length to give a wide range of mobility to the sigmoid loop. RECTUM (RECTUS = STRAIGHT) The inferior portion of the colon and alimentary canal is called the rectum, a misnomer in the human species; the term originated from the usual straight form which this organ pre- sents in the lower animals. It is tubular, devoid of longitudinal bands, and is nar- rowest at its junction with the sigmoid flexure and at the anal Fig. 3.— Paraffln-Injected Rectum and Sigmoid, Showing the Curves, Mesen- tery, Bladder, and Recto-vesical Fold of Peritoneum (from Child Three Years Old). extremity. The largest part of the rectum (ampulla) is mov- able, begins at the crossing of the levator ani muscle, extends upward several inches ; its anterior and posterior walls remain in contact, presenting a transverse slit. In that portion of the rectum below the levator ani muscle (anal canal) its lateral walls are in contact, presenting an antero-posterior slit. Relations of the Rectum. — The rectum is in close apposition anteriorly with the small intestine, recto-vesical pouch, bladder (Fig. 3), prostate, seminal vesicles, and urethra in the male; and with the uterus, vagina, Douglas's cul-de-sac, and small intestine in the female ; posteriorly with the mesorectum, left ANATOMY AND PHYSIOLOGY 9 pyriformis muscle, sacral plexus, internal iliac vessels, sacral vertebrae, coccyx, Luschka's gland, middle sacral vessels, and coccygei muscles. Its length varies from six to eight inches (15 centimeters to 2 decimeters), the latter measurement being more common in advanced life, for, as age increases, the tort- uosity of the bowel is more marked. Beginning in the left iliac fossa, it is continuous above with the sigmoid flexure and termi- nates below at the anus. In rare instances the position of the abdominal viscera is reversed ; in such cases the rectum would necessarily commence on the right side. At its commencement it curves downward toward the right side of the pelvis three and one-half inches (8.8 centimeters), by which it is brought to the median line of the sacrum at a point opposite the third sacral vertebra. It then descends obliquely forward and down- ward for about three inches (7.5 centimeters), at which point it is found opposite the apex of the coccyx; from this point it turns upon itself, backward and downward, for about one and a half inches (3.8 centimeters), thus completing its course at the anus. It is obvious that, in introducing the finger into the rectum, it should be passed upward and forward. Like the hollow abdominal viscera, the rectum has four coats, — peritoneal, muscular, submucous, and mucous, — the first being only partial, while the others are continuous throughout. Ordinarily it is that portion not covered by peritoneum which is the seat of disease. The above description of the direction and different parts of the rectum corresponds to that commonly given by anat- omists. Experience has shown that, from a practical stand- point, this arrangement is not satisfactory. At this writing there is a general tendency among both proctologists and anatomists to consider as the rectum only that portion of the lower bowel situated below the third sacral vertebra, and which is devoid of mesentery. The portion of the large intestine above this dividing-line, which is entirely covered by mesen- tery, and heretofore called a part of the rectum, is now re- garded as a part of the sigmoid flexure (sigmoid colon). The author deems this change a good one, for the reason that, by it, the term "rectum" is applied only to that portion of the intestine which is practically straight and which it prop- erly describes. This division permits the rectum to be subdivided, for 10 DISEASES OF THE RECTUM AND ANUS clinic purposes, into two parts : the movable rectum (prin- cipally ampulla) and the anal canal (fixed rectum). The movable rectum is that portion of the lower bowel which begins on a level with the middle of the third sacral vertebra and terminates at the levator ani muscle. This is the largest part of the rectum, the lowermost part of which is known as the ampulla (Fig. 2, R). It is capable of being moved laterally or vertically. Its anterior and posterior walls He in contact, but it may be distended by inflation, and then appears to be divided into compartments of variable size, de- pending on the number of Houston's "valves" present and the distance between them. Because of this arrangement, Martin suggests that the lowermost chamber be considered as the first rectal chamber; the cavernous area beyond the first valve and below the second should be called the second rectal chamber; and the uppermost, the third, or perhaps fourth, according to the number of "valves" present. The upper rectum is less sensitive than the lower, as is shown by the slight pain caused by extensive ulceration or by malignancy in this region. The anal canal (fixed rectum; Fig. 2, C) is that portion of the rectum lying between the levator ani above and the anus below, and is embraced by the sphincter-muscles. Its lateral walls are in contact except at the extremities, where they diverge slightly. "The length of the fixed anal rectum is variable with a state of activity or passivity, and in a state of activity there are variations in its length of at least one inch (2.54 centi- meters) between a contracted uplifted pelvic floor and that of a depressed floor with anal eversion." (Martin.) The canal is surrounded by the hemorrhoidal plexus. The most painful affections of the ano-rectal region occur usually in the anal canal, and the accompanying pain is due to the contraction of the surrounding muscles and to the generous distribution of nerves in these parts. This portion of the rec- tum never contains feces except during defecation. Peritoneal Coat. — At its commencement the rectum is gen- erally surrounded by peritoneum, which binds it to the sacrum (Fig. 4) ; lower down it covers the anterior surface only, and is then reflected on to the bladder, forming the recto-vesical pouch (Plate II), or to the uterus (Douglas's cul-de-sac). The PLMTE n RBctum InJBctEd with Paraffin, showing Positian af Sigmoid and Relation of ths PBritaneum to the Sacrum, Rsctum, and Bladder [Stick in Bladder] . ANATOMY AND PHYSIOLOGY H uterus and vagina are interposed between it and the bladder in the female. The peritoneum may extend down to within an inch (2.54 centimeters) of the prostate; the distance is liable to variations, depending on the age of the subject and the dis- tension of neighboring organs. In the newborn it may extend to within half an inch (1.27 centimeters) of the anus. The dis- tance increases after the fifth year; in old age with enlarged prostate the peritoneum is found higher up. The distance from the anus to the lower portion of the peritoneal fold has been a subject of much controversy both at home and abroad. The Fig. 4.— Lateral View of Paraffin-Injected Rectum, Showing Mesentery, Di- rection of Blood-vessels, and Peritoneum Binding the Rectum and Sacrum Together. author's observations lead him to believe that two and a half or three inches (6.35 centimeters) in the male and three and a half inches (9.9 centimeters) in the female, with an additional inch (2.54 centimeters) when both bladder and rectum are dis- tended, is about the average distance from the anus to the commencement of the peritoneum. Muscular Coat. — This coat is thicker and stronger than in other portions of the large intestine. It consists of two layers, viz. : circular or inner, and longitudinal or outer. The fibers of the latter are partly prolongations of those of the colon, while the arrangement of some are peculiar to the rectum. 12 DISEASES OF THE RECTUM AND ANUS They are poorly developed in early childhood, more numerous in the anterior and posterior portions of the rectum, and by their action prevent its being thrown into folds as in the colon. They also seem to be more abundant in the upper than in the lower portion. The circular fibers are neither particularly strong nor numerous in the upper rectum, but become stronger and more abundant at the lower end of the rectum. There they form a muscular band about an inch (2.54 centimeters) in width : the internal sphincter muscle. Submucosa. — The submucous coat is a layer of more or less dense connective tissue in which the blood-vessels, nerves, and lymphatics ramify. It is sufficiently lax to permit free gliding of the mucous membrane over it. In inflammatory disease this coat is often thickened, indurated, and rigid, and becomes adherent to the muscular layer and the mucous membrane, frequently interfering with the mobility of the latter. Mucous Membrane. — The mucous membrane of the rectum- is much thicker, more generously supplied with blood-vessels, and glides over the underlying structures more freely than in other parts of the colon. When the rectum is empty, the mucous membrane of the upper part is thrown into multitude of superficial, transverse, velvety folds, which are obliterated when it is distended. From two to seven folds (Houston's "valves") are made more prominent by distension. Because of their importance, these so-called "valves" will be described at length elsewhere in this chapter. The epithelium covering the mucous membrane is of the columnar variety and similar to that of the colon above. The mucous cells, however, are much more plentiful. "The transitional epithelium between skin and rectal mu- cosa is a narrow zone of thick, stratified epithelium, the pecten, containing nerve-elements which the writer believes to be the peripheral ends of nerves concerned with a special rectal sense. The zone varies in width from three to nine millimeters (}/^ to ^/g inch). Its caudal border is about at the junction of the ectal and ental sphincters. The cephalic (upper) border is demarcated by the linea dentata." (Stroud.) Numerous crypts of LieberkUhn are found in the mucous membrane of the rectum, and beneath them solitary lymphoid nodules resembling the solitary follicles of the small intestine. The tubular, or mucus-secreting, cells are so multitudinous ANATOMY AND PHYSIOLOGY 13 that, when viewed through a lens, the membrane presents a honey-combed appearance. The absorbing power of the mucous membrane is remark- able, and is clearly demonstrated by the good results obtained from rectal alimentation and medication. Beginning just above the muco-cutaneous junction (Hil- ton's white line) and extending upward for a distance of eight to fourteen milHmeters (Vs to ^/g inch) are several (four to ten) projecting, longitudinal plicae caused by sphincteric con- traction, and known as the columns of Morgagni. These col- umns are broader above than below, contain muscular fibers (longitudinal), and are difhcult to efface. Suspended between the lower extremities of Morgagni's columns are transverse, cup-shaped folds of the mucous mem- brane from a twelfth to a sixth of an inch (4 millimeters) in depth, which are known as the semilunar valves (sacciili Hor- neri, Fig. 94), the function of which is to collect mucus for the lubrication of the feces. These semilunar valves have been frequently described as pockets. Located at the lower end of Morgagni's columns are several (ten to fourteen) minute ele- vations (so-called papillce), composed chiefly of stratified epi- thelium and a slight amount of connective tissue, each con- taining an arteriole and a nerve-filament. "They are important tactile organs connected with a special rectal sense" (Andrews). It is doubtful if they are invariably present ; at least, the writer has been unable to demonstrate them with any degree of cer- tainty except when they have undergone pathologic changes. Self-styled "orificial surgeons" have written in extenso about these "pockets" (semilunar valves) and "papillae," and would lead both the profession and laity to believe that these structures are most fruitful sources of human suffering, which can be relieved only by "cHpping them out" or "snipping them off." In reality, such is seldom the case. Occasionally the seniilunar valves are found abnormally developed or they became ulcerated or torn, forming a fissure. They sometimes serve as an outlet for fistulous sinuses or as a receptacle for seeds and small particles of fecal matter, caus- ing local and reflected pain. The "papillae" are seldom the seat of disease primarily, but they frequently become enlarged and project into the lumen of the bowel, in cases where the rectum is constantly bathed with irritating secretions from 14 DISEASES OF THE RECTUM AND ANUS disease (cancer, proctitis, etc.) in the colon and upper rectum. They then appear as pyramidal eminences varying from a six- teenth (1.5 milHmeters) to a half inch (1.27 centimeters) in height, the apex being of a grayish color, owing to the absence of blood-vessels, while the lower part is somewhat more highly colored than the surrounding mucous membrane. (Plate XVIII.) ARTERIES The arteries of the rectum are derived from three distinct sources : — 1. The superior hemorrhoidal, from the inferior mesen- teric. 2. The middle hemorrhoidal, from a branch of the inter- nal iliac. 3. The inferior hemorrhoidal, from the internal pudic after it has re-entered the pelvis. The Superior Hemorrhoidal. — This artery descends through the mesorectum and divides into two branches, which course along the posterior wall of the rectum. They are at first su- perficial, but soon perforate the muscular coat and give ofT a number of branches, which anastomose in the mucous mem- brane and submucosa, not only with each other, but with the middle and frequently with the inferior hemorrhoidal arteries. The main branches run parallel with the bowel. This accounts for the slight bleeding from incisions made parallel with the long axis and the profuseness of hemorrhage from those made at a right angle to the bowel. Middle Hemorrhoidal Arteries. — These arteries vary in size and take an oblique course downward to supply the middle third of the rectum. Inferior Hemorrhoidal Arteries. — These vessels send branches upward as well as downward to anastomose with the other hemorrhoidal arteries and to supply the levator ani, sphincter- muscles, and cellular, fatty, and tegumentary tissues in the anal region. VEINS The veins correspond in name with the arteries. The middle and inferior hemorrhoidal veins return the blood from the anal region to the internal iliac. The JieniorrJioidal plexus ANATOMY AND PHYSIOLOGY 15 of enlarged and anastomosing veins is situated in the lower part of the rectum, and from it proceeds the "superior hemor- rhoidal vein," which has no valves, but which returns the blood from the rectum proper to the portal system. Quenu believes this plexus communicates freely with the branches of the in- ferior hemorrhoidal, but has httle in common with those of the middle hemorrhoidal veins. The superior hemorrhoidal vein and its branches pass upward under the mucous membrane for a distance of about three or four inches (7.62 or 10.16 centimeters), then perforate the muscular coat at four or five points, and can be seen on the outside of the bowel. Verneuil has laid much stress on this anatomic fact, claiming that the veins pass through muscular button-holes, which have the power of contracting around them, closing their caliber, and pre- venting a return of the blood to the liver. In this anatomic arrangement, he believes, is to be found the active cause of internal hemorrhoids. NERVES The nerves are derived from the two great classes which go to make up the nervous system : the cerebro-spinal and the sympathetic. Those originating from the former come from the sacral plexus, and those of the latter from the mesenteric and hypogastric plexuses. The muscles of the anal region are supplied by branches of the sacral nerves, while the superficial perineal of the pndic supplies the levator ani and skin in front of the anus. The inferior hemorrhoidal (of the pudic) branch supplies the lower end of the rectum and anus. The pudic is controlled by the same part of the cord as the sciatic. Hence irritation from a fissure or ulcer located within the anus may be transferred down the limbs or to other distant parts. The intimate relation of this nerve to the genito-urinary organs explains the frequency with which disorders of micturition are associated with rectal affections. The upper and middle por- tions of the rectum are much less sensitive than the lower, as has been proven by experiments made by Bodenhamer. The pain increases in proportion as the disease encroaches upon the anal margin; hence disease, malignant or otherwise, situ- ated high up may cause little pain. The sympathetic nerve is distributed to the rectum and anus and is derived from the hypogastric, which is formed by branches from the aortic 16 DISEASES OF THE RECTUM AND ANUS plexus. It also receives branches from the lumbar and sacral plexuses. LYMPHATICS The absorbent vessels of the ano-rectal region are of goodly size and much more numerous than is generally supposed. They consist of two systems, those of the skin and anus being distinct from those of the rectum, the former going to the in- guinal and the latter to the sacral and the lumbar glands. This accounts for the clinical fact of infiltrated inguinal glands from malignancy at the anal margin, and a similar condition of the sacral and lumbar glands when the rectum is involved. Mr. Cripps, however, has recorded two cases of infiltrated inguinal glands when the disease was situated high up in the rectum. The gluteal nodes derive their lymph from the buttocks, and convey it to the iliac nodes. MUSCLES The muscles which are of especial interest in the study of the rectal diseases are six in number, viz. : the corrugator cutis ani, external sphincter, transversus perinei, internal sphincter,, recto-coccygeus, and levator ani. Corrugator Cutis Ani. — This muscle consists of a thin layer of involuntary muscular fibers surrounding the anus, which blend internally with the submucosa and externally with the integument. By contracting, it gathers the skin about the anus into folds. External Sphincter. — This muscle is voluntary, and is situ- ated immediately beneath the integument at the anal margin. It is about three inches (7.62 centimeters) in length, half an inch (1.27 centimeters) broad, and is quite thin. It arises from the tip of the coccyx, and, after surrounding the anus in the form of an ellipse, is inserted into the central tendon of the perineum. The action of this muscle is to close the anal orifice and assist in the expulsion of the feces, acting in conjunction with the abdominal muscles and levator ani. Its nerve-supply is derived from the fourth sacral and the inferior hemorrhoidal of the internal pudic, and the center controlHng it is situated in the lumbar enlargement of the cord. Transversus Perinei. — This muscle arises by a narrow ten- don on the anterior surface of the tuber ischii, and passes PLATE ni.—LEVATORES ANI A8 SEEN FROM ABOVE, SHOWING HOW THEY PASS AROUND THE RECTUM. A, Bladder. B^ Prostate. C, Reotum. B D, Levatores am. ANATOMY AND PHYSIOLOGY 17 forward and inward to be inserted into the central tendon of the perineum at the junction with the anterior insertion of the external sphincter, and, in the female, with the posterior at- tachment of the sphincter vaginae. According to Cruveilhier, it aids in defecation by pressing the anterior and posterior walls of the bowel together, in conjunction with the external sphincter. Internal Sphincter. — This is a fiat, involuntary muscular band formed by a collection of the fibers of the circular coat, lying immediately above the external sphincter. It is from three-fourths of an inch (1.9 centimeters) to an inch (2.54 centimeters) in breadth, and one-sixth of an inch (4.2 milli- meters) in thickness. Its fibers are somewhat finer and paler than those of the external sphincter. Recto-coccygeus Muscle. — United with the internal sphincter muscle are the unstriated bands which arise from the anterior surface of the coccyx, and are known as the recto-coccygeus mus- cle. It embraces the lower end of the rectum in a fork, and draws the rectum upward toward the apex of the coccyx after it is forced down during the act of defecation. Levator Ani (Lifter of the Anus). — The origin and insertion of this muscle, as well as its action, have been the subject of much study and controversy. From the dissections made by the writer, he believes, with Mr. Cripps, that a large portion of its fibers arises from the inner surface of the symphysis pubis and from half an inch (1.27 centimeters) of the anterior por- tion of the white line, and passes obliquely downward and back- ward to be inserted into the sides of the rectum and coccyx. These fibers cross the rectum at right angles two and a half inches (6.35 centimeters) above the anus. The action of the levator ani, in so far as the rectum is concerned, is to compress the sides of the rectum and the neck of the bladder, and in the act of defecation, when the sphincter relaxes to open the anus, it closes the urethra. This explains in part the well-known difficulty of voiding urine and feces at the same time. The accompanying schematic drawings show very nicely the relation of the levator ani to the rectum. (Plates III and IV.) The levator ani also partly forms the floor of the pelvis, giving support to the pelvic organs. In addition to this it has a voluntary sphincteric action, which can be demonstrated 18 DISEASES OF THE RECTUM AND ANUS by introducing the finger into the bowel and requesting the patient to draw up the anus as much as possible, when a con- traction will be felt from one and a half to two inches (3.8 to 5.08 centimeters) above the anus. This action, which Mr. Cripps attributes to the levator ani, would, in part, account for the control of the bowel that is frequently seen to ex- ist after complete destruction of the external and internal sphincters. Again, after certain rectal operations where the sphincter-muscles have been thoroughly divulsed, patients often complain of sudden jerking about the anus, and this is undoubtedly due to the action of the levator ani. THE ANUS The anus is an oval orifice in which the anal canal ends. It is placed about one inch (2.54 centimeters) in front of the tip of the coccyx and between the tuber ischii (above them in the male). It is lined above by mucous membrane and below by integument which is firm, deeply pigmented, and provided with numerous papillae, hairs, and sebaceous follicles, the latter supplying an unctuous secretion with a disagreeable odor. The skin about the anus is gathered into numerous radiating folds by the corrugator cutis ani muscle. The anus may be thoroughly stretched in every direction without permanently impairing its functions. In health, the orifice is closed by the external sphincter; but, in cancer, stricture, extensive ulceration, and other grave diseases of the rectum, this muscle may become worn out or destroyed, and the anus becomes patulous, causing partial or complete in- continence. PERIRECTAL SPACES The rectum is surrounded by loose connective tissue and fascia, the latter derived principally from the pelvic fascia. "Between the rectum and sacrum is a large space, devoid of fat, called the retrorectal space, and between the rectum, semi- nal vesicles, and the recto-vesical fascia is another space of considerable size called the prerectal space'' (Quenu). Wal- deyer, in speaking of the latter space, claims that it is isolated laterally from the retrorectal space by the junction of the parietal and pelvic fascia and above it is lost in the subperi- toneal tissue of the bladder. He does not believe that the PLATE IV—LEVAT0RE8 ANI, SIDE VIEW, SHOWING THEIR RELATION TO THE RECTUM. A A, Levatores ani. B, Rectum. ANATOMY AND PHYSIOLOGY 19 lateral spaces, described by Quenu, are deserving of special consideration. He further says that the anal canal does not come into relationship with any of these spaces. ISCHIO=RECTAL FOSS/E On either side of the lower end of the rectum, between it and the tuber is-chii, are two large spaces filled with fat, and which are called the ischio-rectal fosses. They are triangu- lar in shape, with the apices directed upward and the bases toward the skin. Their depth varies from one and a half inches (3.8 centimeters) in front to two inches (5.18 centimeters) be- hind, and at their lowermost and broadest part they are a little more than an inch (2.54 centimeters) in width. Internally these spaces are in relation to the external and internal sphincters, coccygeus, and levator ani muscles; externally with the tuber ischii and obturator fascia ; anteriorly with superficial and peri- neal fascias; and posteriorly with the border of the gluteus maximus muscles, the investing fascia of which is continuous with the great sacro-sciatic ligament. Within a sheath formed by the obturator fascia are to be found the internal pudic artery, veins, and nerves. The inferior heinorrlwidal vessels and nerves pass through the central portion of the ischio-rectal fossae on their way to the anal canal to which they are dis- tributed, while in the anterior portion of these spaces are the superficial perineal vessels and nerves. The fat and connective tissue filling these spaces act as elastic supports for the rectum and are largely responsible for the lateral walls of the rectum remaining in contact. These foss^ are of surgical importance because of the frequency with which abscesses and Ustulas are found in this locality. THE "RECTAL VALVES" (FOLDS) Houston's "valves," Kohlrausch' s plicce transversalis recti, sphincter ani tertiiis, detrusor fcccinm muscles, superior sphincter. The mucous membrane of the rectum, as previously stated, is thrown into numerous superficial riigce. In the rectum above the anal canal are three or four large, permanent, transverse, or oblique semilunar folds which project a considerable dis- tance into the lumen of the bowel. These folds are at present the subject of much controversy. Some writers maintain that 20 DISEASES OF THE RECTUM AND ANUS they are not always present and, if present, are effaceable by distension ; others are equally positive of their existence in all persons and at all ages, and that they become more prominent in proportion as the rectum is distended. Because of the wide interest which these folds have aroused and the difference of opinion as to their existence, number, location, arrangement, structure, functions, and pathologic significance, they will be described at length and in such a manner that it is hoped the reader may have a clear understanding of them. Cloquet, ]\Iorgagni, and Portal were among the first to mention these folds and to speak of them as "valves.'" Mr. John Houston, of Dublin, was the first writer to clearly describe the "rectal valves'' ; to point out their location, number, and ar- rangement; and to assign to them a function. This he did in a paper published in the Dublin Hospital Reports, in 1830, since which time they have been known as Houston s "valves." Ac- cording to his description, they were usually three or some- times four and occasionally more in numl^er, semilunar in shape with the concavity directed upward, and occupying from one- third to one-half of the circumference of the gut; they were from one-half to three-fourths of an inch (1.27 to 2 centimeters) or more in breadth in the distended state of the rectum, their lateral surfaces horizontal or oblique. Houston held that they were composed of a folding of the mucous membrane inclosing cellular tissue and circular muscular fibers. He described the most prominent "valve" as situated on the anterior rectal wah opposite the base of the bladder and at a point three inches above the anus ; the "valve" next in importance as situated at the upper end of the rectum and projecting from the right wall ; the third as on the left wall midway between these two ; and the fourth, when present, as attached to the bowel one inch above the anus toward the left and posterior wall. The whole ar- rangement was such as to form a sort of spiral tract, giving to the upper rectum a sacculated appearance. He demonstrated the existence of the "valves" by distending and hardening the rectum with spirit and then cutting it open, and maintained that this was the only way by which they were demonstrable. Mr. Houston claimed that the function of these "valves" was to support the fecal column and prevent its too rapid de- scent upon the anal canal, which would produce a desire to stool. He also pointed out that they frequently interfered with ANATOMY AND PHYSIOLOGY 21 the passage of instruments, and, further, that they were a fruitful source of stricture. Shortly afterward Nelaton and Velpeau described a col- lection of muscular fibers encircling the bowel at a point four inches (10.16 centimeters) above the anus, and about one-half inch (1.27 centimeters) in width, thinner posteriorly than ante- riorly. They beHeved this muscular band kept the rectum empty in the intervals of defecation, guarded the upper rectum from a return of the feces, and further prevented complete in- continence after the sphincters had been destroyed. Sappey conceded the presence of this muscle, but maintained that it did not entirely surround the bowel; furthermore, he believed that it was usually found on a level with the base of the pros- tate. Henle agreed with Sappey in regard to the arrangement and location of this muscular band. Hyrtl named this muscle the "spJwicter ani tertius," beheving that it possessed sphincteric action. Chadwick opposed the views of Hyrtl as to the function of the third sphincter, because his experiments convinced him that, in the passive state, the lumen of the bowel at this point was not less than three-fourths of an inch (2 centimeters), and, further, because he was unable to find a well-marked muscle in the location described, but did find two irregular collections of circular fibers : one on the anterior wall at the site of Hyrtl's third sphincter and the other on the posterior wall one inch (2.54 centimeters) above the first. These he named the detrusor fcEcium muscles, and maintained that their function was to aid in the act of defecation by contracting behind the feces and pushing them downward. Kohlrausch, in 1854, vividly described a large, transverse, semilunar fold which did not disappear upon distending the rectum and which was situated about six or eight centimeters (2 to 3 inches) above the anus opposite the third sacral ver- tebra and projected about fifteen millimeters (^/g inch) from the right and anterior walls of the rectum. He called it the plica transversalis recti. His description of this fold corre- sponds to that of the "most prominent 'valve'" as given by Houston. The next most scientific and practical contribution to the literature of the "rectal valves" was made, in 1887, by an Amer- ican, Dr. Walter J. Otis. He described how the "valves" might 22 DISEASES OF THE RECTUM AND ANUS be demonstrated by placing the subject in the knee-chest posture and holding the anus open with retractors, thus allow- ing the rectum to become inflated. The ordinary mucous folds immediately disappeared, but the "valves," or permanent folds, remained prominent, projecting from left to right, one above the other, and dividing the rectum into compartments. His description of the permanent folds agrees, in the main, with that given by Houston as to the shape, dimensions, location, and structure of the "valves" ; but, as a rule, he found only two constant folds, while occasionally a third one, less prominent, could be seen. He held that they did not support the fecal mass, but aided in its expulsion, and, for this reason, he desig- nated them plica recti, right and left. Otis believed that the sphincter ani tertius {superior sphincter) of Hyrtl was simply a collection of circular muscle-fibers, irregular in number and location. Van Buren, in speaking of the "valves," concludes his re- marks by stating that anatomists and physiologists have been equally unsuccessful in assigning to them either certainty of function or constancy of location. Bodenhamer insists that the ''valves'' are accidental folds resembling the valviilce conniventes of the small intestine, and, while admitting that they look like "valves," claims that they lack the essential attributes, and are not sufficiently large and strong to obstruct or dam up the inferior extremity of the rectum. Quenu and Hartmann describe the "valves," and further state that they form a distinct compartment one or two centi- meters (V2 to ^/4 inch) in depth. Kelsey, in summing up his discussion on the presence and functions of the "rectal valves" and third or superior sphincter, says : "From a study of the literature of this question, and from results of dissection and experiments which we have person- ally been able to make, we are led to the following conclu- sions : — "1. What has been so often and so diflferently described as a third or superior sphincter ani muscle is, in reality, noth- ing more than a band of the circular muscular fibers of the rectum. "2. This band is not constant in its situation or size, and ANATOMY AND PHYSIOLOGY 23 may be found anywhere over an area of three inches (7.62 centimeters) in the upper part of the rectum. "3. The folds of mucous membrane (Houston's 'valves') which have been associated with these bands of muscular tissue stand in no necessary relation with them, being also in- constant, and varying much in size and position in different persons. "4. There is nothing in the physiology of the act of defecation, as at present understood, or, in fact, of a certain amount of continence of feces after extirpation of the anus, which necessitates the idea of the existence of a superior sphincter. "5. When a fold of the mucous membrane is found which contains muscular tissue, and is firm enough to act as a barrier to the descent of the feces, the arrangement may fairly be con- sidered an abnormality, and is very apt to produce the usual signs of stricture." Mathews, after citing Houston in regard to the location of the "rectal valves," dismisses the subject as follows: "I deny their existence, and, if they did exist, I would deny that their use was 'to support the fecal mass.' "For many years I have searched for these folds, and I have yet to encounter them. In my opinion, they exist only in the author's mind's eye." Martin states that the prominence of the "valves" is in- creased by distension of the rectum, and that they are com- posed of the mucosa, beneath which is a heavy layer of fibrous tissue, bundles of circular muscular fibers in the middle of the "valves," and at the base arteries and veins for their special nu- trition. These structures, he holds, constitute a typic anatomic ^'valve." He says: "The number of 'rectal valves' is variable. Some subjects have but two, others have four, but 90 per cent, of persons possess three. The uppermost 'valve' is invariably situated at the juncture of the rectum and the sigmoid flexure, which 'valve' is invariably situated on the left; the next lower one is on the right wall, and the lowermost is on the left. The positions of the lower two 'valves' are sometimes anterior and posterior." In regard to their physiologic significance, Martin maintains that the "rectal valves" have a function and are en- dowed with passive and active properties. In this regard he says: "When the muscular elements are relaxed and the gut 24 DISEASES OF THE RECTUM AND ANUS is greatly dilated or else in a lesser measure distended, the 'valve' is passively projected across the channel, to resist the hurried or uncontrolled descent of the feces. The presence of the bands of fibrous tissue under the free margin of the 'valve' provides a guard, or control, to receive and retain the bolus, or, I may say, the 'valves' receive a series of boluses, till sufficient pressure is made to stimulate the complex in- voluntary mechanism of defecation to an expulsion of the feces or to a reversed peristalsis." And again : "If it be the func- tion of the normal 'rectal valve' to beneficently retard the descent of the feces, it is obviously true that it may be the especial property of the 'valve' in certain other than normal conditions to maliciously obstruct the descent of the feces. "There are three forms of 'valvular' obstruction : — "1. Anatomic coarctation of the 'valves' may afford an ex- aggerated physiologic resistance to the descent of the feces. "2. Congenital hyperplasia of tJie 'rectal valve' is a condition classically described as diaphragmatic stricture or membranous septum in the abdominal rectum. "3. Hypertrophy of the 'rectal valve' constitutes the classic annular stricture of the abdominal rectum." Pennington's description of the location and structure of the "rectal valves" agrees with Martin's in its essential points, but he has gone a step farther and shown that, in many in- stances, the longitudinal muscular fibers are prominent in the "valves." "Sometimes the longitudinal muscle spans the base of the "valve" ; and, again, it splits, some fibers following the circular coat and some spanning the base. In some instances it extends well into the tip in all the 'valves.'" In regard to the function of the "rectal valves," Penning- ton says : "From experimental studies made upon the living and the dead, it would seem that the function of these plicae is (1) to prevent the feces from crowding down upon the anus when the bowel is in a passive state, (2) to equalize the press- ure of feces that may accumulate in the rectum from time to time, and (3) to facilitate defecation by giving a spiral motion to the fecal mass." He further believes that, as a result of mechanic and infectious agencies, a sort of chronic inflam- mation may occur in the rectum favoring hyperplasia of the "valves," which sooner or later becomes a factor in chronic con- stipation or obstipation. He says : "The intestinal wall is fre- PLHTE If Rectum Out Dpen, showing Two "Rectal Halves" Situated Hlmast Uirectly Opposite, One Just Mhoue the Other, [Paraffin Cast, shown in Plate III, was Removed from this Specimen.] ANATOMY AND PHYSIOLOGY 35 quently pouched and thinned immediately above the base of the Valve/ and hypertrophied opposite the 'valve's' free bor- der." From the foregoing it will be seen that investigators differ widely in their conclusions as to the constancy, number, location, structure, and function of the "rectal valves," and also that at the present time httle information on this subject is to be gained from text-books on either anatomy or surgery. Most writers on diseases of the rectum and anus fail to men- tion them, or, having mentioned them, ascribe but little or no importance to their existence : opinions which are seemingly founded on clinic experience rather than on original research. In the previous edition of this work the author, after quoting Houston in regard to the number, size, location, and function of the rectal folds ("valves"), gave it as his opinion that they became almost obliterated by distension, a conviction founded principally upon clinic experience without the aid of the proctoscope and rectal inflation. Observations and experi- ments made by him since that time have proven to his satis- ifaction that the converse is true. To determine the location and constancy of the "valves," the author examined the rectum, either distended or empty, in several hundred subjects, both living and dead, by means of the proctoscope, rectal inflation, and digital examination. In addition to this, with the subjects in different positions, he injected post-mortem, with various hardening and plastic prep- arations (formalin, alcohol, plaster of Paris, gelatin, paraffin, etc.), the rectums of twenty-five fetuses : children and adults (Fig. 5). After a sufficient length of time the rectums were removed, cut open, and examined macroscopically. Subse- quently sections of the "valves" were made and examined with the microscope. He also had microscopic examinations made of several sections taken from the "valves" in living subjects. The "valves" taken from these subjects differed in thickness and rigidity. The specimen shown in Plate V was prepared by inject- ing the bowel in situ, under moderate pressure, with paraffin, which was allowed to harden. The rectum was then removed and dried for one week, after which it was cut open and the cast (Plate VI) taken out. The "valves" were very well shown (Plate V), but not in their usual location. They were uncom- 26 DISEASES OF THE RECTUM AND ANUS monly close together, nearly opposite each other, and formed almost an annular stricture. The photomicrographs (Plates VII and VIII) of sections of the "valves," which show their structure very well, were made by Dr. B. H. Buxton, Histolo- gist in Cornell University Medical College, from tissue re- moved from gross specimens prepared by the author. The following description of the constancy, location, and structure of the "valves" is based upon the results of the above researches, which, in the main, confirm the experiments of Houston, Otis, Martin, and Pennington : — In the author's opinion, there is sufficient evidence to war- Fig. 6.— Rectum Distended with Three-per-cent. Formaldehyde Solution (when Hardened and Opened Showed "Valves" Beautifully). rant the assertion that the various folds, muscles, rings, and bands described by Houston, Nelaton, Hyrtl, Kohlrausch, and Otis are one and the same thing, namely : "Houston's valves." When the sphincter-muscles have been destroyed by dis- ease or operation, the "valves" may check the downward course of the feces by projecting into the lumen of the bowel, but not by their constricting powers. In the author's opinion, when incontinence does not follow destruction of the sphincter-mus- cles it is due, not to the "valves," but to the levatores ani, which. are partially under control of the will, and may acquire sphinc- teric action. FLUTE m Paraffin Cast, showing Indentatians made by Houston's "Halves," [Removed from Rectum shown in Plates II and II,] EXPLANATION OF PLATE VII A transverse section through the entire " valve." The thin black line all around is the mucous mem- brane. Beneath this is a lighter layer, the submucous tissue ; while the inner and outer muscular coats, between which no differentiation can be made, are represented by a somewhat darker layer internal to the submucous tissue. Internal to the muscular layers and running up almost to the extreme end of the " valve " is the subserous tissue, consisting of loose connective tissue and fat. The tissue seems to be greatly shrunken and con- tracted, but this contraction could not affect the general distribution of the various layers. It is evident, there- fore, that both the muscular coats run practically up to the extreme tip of the " valve " and must have consider- able influence on its action. ANATOMY AND PHYSIOLOGY 27 Houston's "valves" are permanent anatomic structures (made more prominent by distension), capable of demonstra- tion in either the hving or the dead fetus, infant, child, or adult, except in those instances in which they have been de- stroyed by disease or in which, because of pathologic changes in the gut-wall, rectal inflation is impossible. They are cres- cent-shaped, capable of vertical motion, extend from one-half to two-thirds around the circumference of the rectum (Plate V and Fig. 6), and project into its lumen from three-fourths to one and a half inches (1.9 to 3.8 centimeters). They are directed obliquely to the long axis of the bowel, and are slightly cup-shaped, their concavities looking upward. When Fig. 6. — Proctoscopic Bird's-Eye View of "Valves" in an Inflated Rectum. the bowel is distended, the free margins of the "valves" stand out prominently, and are easily seen through the proctoscope, or they may be felt by the finger during straining. The niiinber of "valves" is variable. Usually there are three, sometimes two or four (Fig. 6) ; in exceptional cases there may be fiive, six, or even seven. When more than the usual number are present, some of them are small, shallow, and less prominent. The location of the "valves" is fairly constant, and is as follows : The upper "valve'' at the junction of the sigmoid colon and rectum on the left rectal wall ; the middle (most prominent, Kohlrausch's plicee recti) "valve" on the right ante- rior wall opposite the base of the bladder and three inches (7.C2 centimeters) or more above the anus; the loiver "valve'' 28 DISEASES OF THE RECTUM AND ANUS on the left side a short distance below the middle "valve." With the patient in the knee-chest posture and the rectum well in- flated, one can sometimes see, by the aid of the proctoscope, all of the "valves" at the same time (Fig. 6). In exceptional cases the "valves" may be located one above the other or almost directly opposite each other (Plate V), completely hiding from view the lumen of the bowel above them. Generally, however, they form a sort of spiral stairway, which gives a rotary motion to the fecal mass on its journey from the sig- moid to the anal canal. The structure of the "valves" has been the subject of much controversy. The difference of opinion has probably arisen from the fact that their structure may vary in the same sub- ject and under the same conditions, and that the make-up of the normal is always different from that of the hypertrophied or diseased "valve." The average "valve" is composed of : (a) mucous membrane ; (b) submucosa (fibrous layer) ; (c) cir- cular muscular layer; (d) longitudinal muscular layer; (e) subserous layer, consisting of areolar tissue and fat, and ar- teries, veins, nerve-elements, and lymphatics. The mucous membrane covering the "valve" is of variable thickness and con- tinuous with the membrane at the base of the "valve" (Plates VII and VIII). It consists of the epithelial lining, the stroma, and the miiscularis miicoscE, which is more prominent here than in other parts of the rectum. The submucosa is composed of white, fibrous connective tissue, sometimes forming a dense layer (Plates VII and VIII), and was first described by Martin, who maintains that it gives support to the "valves," especially when they are hypertrophied. The circular layer of muscular fibers is usually constant, and may extend only a short distance into the "valve" or almost to its tip (Plates VII and VIII). The longitudinal layer is present less often than the circular, and may extend across the base of the "valve" without contributing any fibers to its structure; or it may dip into the "valve," reaching nearly to the distal end (Plate VII). In addition to these structures, Pennington reports finding in the "valve" lymph-nodes, large sympathetic ganglia, epithelial structures imbedded in the loose tissue outside the longitudinal muscular layer, and, in one specimen, white fibrous and yellow elastic tissue in the same locality. EXPLANATION OF PLATE YIU The tip of the " valve " is shown. Lining the outer surface is the deeply-staining mucous membrane, within which is the pale, submucous coat, composed of dense, fibrous tissue. The third layer, staining somewhat more deeply, is the inner circular muscular coat, and internal to this is the outer longitudinal muscular coat. Loose areolar and adipose tissue fill up the interval. The extension of both muscular coats almost to the extreme tip of the " valve " is well shown. PLMTE Tim ■Rs-ctal [HnuBton'sJ Ualue " [Magnificatinn, 25], showing the Mucosa, Sub- mucasa, Circular, and Longitudinal Muscular Coats, as they Pass up to the Tip of the " Halve," ANATOMY AND PHYSIOLOGY 39 While the muscular coat usually enters into the structure of the "valves," the latter are sometimes made up entirely of mucosa and submucosa. The various elements composing the "valves" are, as a rule, more clearly defined in the adult than in the infant. For further information on the functions of the "rectal valves" the reader is referred to the section on the physiology of defecation; and, for their pathologic significance, to the chapters on proctitis, membranous colitis, abnormalities of the rectum and anus, and stricture and constipation. PHYSIOLOGY After leaving the stomach the food enters the small intes- tine, where intestinal digestion takes place. Certain portions having been absorbed, the residue passes onward, in a liquia state, into the large intestine, where it remains about twelve hours, during which time the surplus water is absorbed and the mass assumes the characteristic, solid fecal form in which it is evacuated through the anal aperture. The feces collect principally in the sigmoid colon, where they remain until the beginning of defecation. Because of its shape, attachments, and location, and the fact that it is narrowest at its junction with the rectum, the sigmoid colon is particularly well adapted for this purpose. Foster beHeves that the sigmoid containing the feces is supported by the bladder and sacrum. O'Beirne held to the opinion that the feces were retained in the sigmoid by the narrow muscular ring at its junction with the rectum. This circular constriction is called the spJiincter of O'Beirne. Defecation. — The act of defecation is complicated, and is both voluntary and involuntary. Its beginning and completion are mainly under the control of the will, while the intermediate stage is carried out by an involuntary mechanism. After a certain quantity of feces and gases has collected, the pressure or the stretching of the muscular fibers by dis- tension starts up peristaltic action. This consists of a series of vermicular contractions of the longitudinal muscular fibers, immediately followed by constriction of the circular fibers. The former cause a shortening of the bowel and the latter a cir- cular narrowing. As these worm-like movements extend from above downward, the feces are forced out of the sigmoid colon 30 DISEASES OF THE RECTUM AND ANUS into the rectum. In the rectum the longitudinal and circular muscular layers have each a distinct nerve-supply. That of the former comes from the cord by way of the anterior roots of the upper sacral nerves, continuing with their branches to the hypogastric plexus, and thence to the rectum. The sup- ply to the latter is derived from the vasomotor constrictor area of the cord, proceeding from it by the anterior roots of the lower dorsal and upper lumbar nerves, finally reaching the rectum through the anterior mesenteric ganglia and the hypo- gastric plexus. In the intervals of defecation the sphincter is in a state of tonic contraction. The center which largely controls this mus- cle and the act of defecation is located in the lumbar enlarge- ment of the cord, and may be voluntarily stimulated or in a measure inhibited. Destruction or injury to this part of the cord results in permanent relaxation of the sphincter, while a similar accident to the dorsal region causes only temporary re- laxation, the muscle soon regaining its tonicity. To a certain extent, the sphincter is influenced by a center in the brain, supposedly located in the optic thalamus, and which is usually under control of the will. Certain emotions or sudden fright, however, may result in relaxation of the muscle and the in- voluntary evacuation of feces. The desire to stool follows immediately upon the exit of the feces and gases from the sigmoid and their contact with the mucous membrane of the rectum. The exact manner in which this sensation is induced has never been satisfactorily explained. No one has been able to clearly demonstrate whether it is due to pressure, distension, chemic changes, bacterial action, or other causes. The desire is sometimes created by irritating discharges, sHght or profuse, coming from disease in the colon or upper rectum, and from this it would appear that it does not necessarily depend upon the accumulation of feces in the bowel. The stimulus, however produced, is, according to Kirke, transmitted to the center in the cord, through the hemor- rhoidal and inferior mesenteric plexus, and is then reflected to the musculature of the rectum through the pudendal plexus, resulting in a relaxation of the sphincter, a contraction of the muscular gut-walls, and expulsion of the feces. When the proper time for defecation has arrived, through ANATOMY AND PHYSIOLOGY 31 a voluntary effort the glottis is closed after an inspiration, the diaphragm is forced downward, and the abdominal muscles (especially the internal oblique) are drawn inward, compressing the abdominal viscera and propelling the feces on their down- ward course. Immediately after their exit from the sigmoid they come in contact with the uppermost Houston "valve," on the left rectal wall, where they may be arrested temporarily, or immediately glide off to fall upon the next "valve" on the right anterior wall, and from here, in the same manner, they pass to the lowermost "valve"' on the left side and then to the fixed rectum. This arrangement permits of a sort of rotary and step-by-step descent of the feces, thus giving the levator ani and sphincter-muscles time to prepare for their approach. As the feces are pushed toward the anal canal, the levator ani muscles draw the canal upward and over them. At this point peristalsis and pressure by the abdominal muscles are in- creased, forcing the feces downward, the sphincter-muscle vol- untarily relaxes to allow of their passage, while the levator ani contracts and closes in behind them, thus assisting in the completion of the act of defecation. Every healthy person should have one fecal evacuation in twenty-four hours. The fecal mass should be semisolid in consistence, rounded in form, from four to six ounces (120 to 180 grams) in weight, and consist of about 75 per cent, water and 25 per cent, solids. It does not follow, however, that in- creased or diminished frequency of the stools or slight change in their consistency or composition is indicative of serious im- pairment of health (see page 53). Writers generally agree that, when the desire to empty the bowel is disregarded, the sensation may pass away. Be- cause of this and the fact that by digital examination the rectum is in such cases sometimes found empty, O'Beirne was led to believe that the feces, when not evacuated at the proper time, were returned to the sigmoid by reverse peristalsis. It has been the writer's experience that in nearly all such cases the rectum does contain a fecal accumulation. The author be- lieves, however, that in exceptional cases the feces may be redeposited in the sigmoid colon. To determine this point he has frequently instructed patients not to have a stool, and has examined their rectums at various times during the thirty-six hours following. In most instances digital examination re- S3 DISEASES OF THE RECTUM AND ANUS vealed an accumulation of feces in the rectum, but in a few the eadier examinations revealed a like condition, while those made later showed the rectum to be empty. Further evidences of reverse peristalsis are fecal vomiting in cases of obstruction, the removal by laparotomy of foreign bodies introduced into the rectum some days before, and the discharge, several days after rectal operations, of blood-clots, the presence of which in the rectum previous examination, both digital and procto- scopic, had failed to reveal. Again, the lower rectum may be found empty, but proc- toscopic examination will reveal the feces above and supported by the ''valves." Moreover, if the entire fecal mass is not dis- charged at stool, the remaining portion may sometimes be seen above the "valves." Absorption. — In studying the functions of the rectum one must not overlook the fact that it possesses remarkable powers of absorption and, to a slight extent, digestion. In fact, the constitutional effects of some drugs are most quickly obtained when introduced per rectum, and in some cases a smaller dose is required. Again, the action of the drug per rectum is more certain, because it is less liable to chemic change than when administered by the mouth. The most striking example of rectal absorption is shown in the benefits derived from enemata of warm saline solutions employed after profuse hemorrhage or surgical shock. When for any cause food cannot be taken into the stom- ach, it may be given in liquid and semisolid form per rectum with very beneficial results, except in cases where the mucous membrane has been destroyed by local disease. LITERATURE ON ANATOMY AND PHYSIOLOGY OF THE SIGMOID AND RECTUM Babcock: "Anomalies of the Colon," Internat. Med. Mag., x, p. 129, 1900. Baughman: "Sigmoid Flexure," Mathews's Med. Quart., ii, p. 312, 1895. Bodenhanier: "Physical Exploration of the Rectum," pp. 4-18, 1870. "Valves of the Rectum," ! e 1^ !5 ■* 8 W tl •*- "e 5 ^ -. '*~ « ^ C D. Q V < ta c3 ^^ ..^ y i=: fcl (U ; w. >> u: rt C3 s = t:] CONSTIPATION 103 cles could be distinctly outlined by the finger in the rectum, especially when the patient was requested to draw the anus upward; severing of the coccygeal attachment in this case gave no relief, and a myotomy was subsequently made. This operation was performed as follows : Through a posterior median incision extending from the lower end of the sacrum to within half an inch (1.27 centimeters) of the anus the coccyx was removed, and the muscles severed on either side at the point where they cross the rectum. That portion of the muscles which had extended from the rectum to the coccyx was detached from the rectum and removed. The external wound was then closed with interrupted catgut sutures and dressings applied. The patient promptly recovered from the operation, and was gradually relieved of his constipation. None of the above operations should be employed except as a dernier ressort. Thus far no unpleasant sequels have fol- lowed the above procedures. As far as the author is aware, the operations above suggested for the relief of obstinate constipa- tion due to hypertrophied sphincter or levator ani muscles are here recorded for the first time. When one or more of the "rectal valves'' become so hyper- trophied as to obstruct the passage of the feces, ''valvotoniy" is indicated. The author has performed "valvotomy" sixty times, and in each instance the operation has been followed by complete cure or marked improvement. These good results, however, could not be attributed to "valvotomy" alone, as the operation in most instances was combined with the non-medicinal measures described elsewhere. In performing "valvotomy" it is necessary to divulse the sphincter sufdciently to allow tlie introduction of a very large proctoscope. It is not improbable that in many of these cases stretching of the sphincter aided materially in relieving the con- stipated condition, together zvith the establishment of regular habits. Again, the improvement may be due to an active peri- stalsis secondary to an irritation induced by the clamp, incision, or subsequent ulceration and proctitis. Of the 60 cases above referred to, in 51 the "valves" were divided with the author's "valve" -clamps and in 9 by Martin's operation. In all but 9 the "valve" located upon the anterior rectal wall at the base of the bladder (Kohlrausch's fold) was the chief offending "valve" requiring division. In 6 the "valve" 104 DISEASES OF THE RECTUM AND ANUS situated above this one on the left wall was divided, and in only 3 cases was it found necessary to divide more than two "valves," the lowermost two being the ones usually affected. DIVISION BY THE AUTHOR'S CLAMP The idea of dividing the "valves" by pressure-necrosis was suggested to the author by Pennington, who has devised a clip for this purpose. Working with this idea in view, the author has perfected the applicator and valve-clamp shown in Plate IX. The first clamps made (Plate IX, h and c) were non- fenestrated, about one-tenth of an inch (2.5 millimeters) in width, and constructed for divisions of the "valve" only. Later the fenestrated clamps (A and A') one inch (2.54 centimeters) in length, and varying in width from one-fourth (6.25 millime- ters) to one-half inch (1.27 centimeters), were devised for biting out a piece of the "valve," and this larger clamp has proven the more satisfactory. In order to facilitate their application these clamps are made in two forms, one opening from above down- ward and the other from side to side. The forceps-applicator and clamps are so well shown in the drawings that further descrip- tion of them is unnecessary. Division of the "valves" with these clamps renders the operation very simple. The technic is as follows : After the rectum has been thoroughly cleansed, place the patient in the knee-chest posture and divulse the sphincter with Kelly's conic dilator. A large proctoscope of suitable length is now intro- duced, and the rectum allowed to become inflated, exposing the "valves." The proctoscope is so adjusted that the "valve" to be divided crosses in front of it at a right angle. A clamp to which a long thread has been attached is placed in the applicator and the screw so adjusted that it remains open. The instrument is then introduced through the proctoscope and the clamp slipped over the "valve," when the screw in the end of the applicator is turned to the left until the clamp closes on the "valve" and is freed. (Plate X.) The proctoscope is now removed and the string left hanging out of the rectum to pre- vent the clamp being carried upward by reverse peristalsis when it has cut is way out. The entire operation may be completed in five minutes. Depending upon the amount of fibrous tissue, it requires from four to six days to slough out, during which time the patient suffers but little, if any, pain. Usually the writer requires the patient to remain quiet until the clamp PLMTE X Gant's DpBration af " I/alvatamy," showing Mannsr of Using his Now Forceps Rpplicatar and " UaluE" -clamps. One Clamp is in Position and /Inathsr Placed Dver a " UalvB " Ready to be Freed from the Upphcatar. CONSTIPATION 105 comes away. Not infrequently, however, the operation has been done in his oi^ce and the patient allowed to resume his usual duties, and no ill effects were observed. The patient is restricted to a semisolid diet, and instructed to examine the stools until the clamp is found. After the clamp has come away, examination of the rectum will reveal that the "valve" now stands out less prominently, and is divided by a rounded, V-shaped wound. The after-treatment consists in securing daily semisolid stools and irrigation of the wound with anti- septic solutions. The advantages of the clamp over the cutting operation are as follows : — 1. No anesthetic is required. 2. It is bloodless. 3. It is painless. 4. It is less difhcult, and can be performed in a shorter time. 5. It requires fewer instruments. 6. The patient is not necessarily confined to his bed, and suffers but little, if any, pain. 7. There is no danger of peritonitis. 8. No dressings are required. 9. Recovery is more prompt. 10. It gives better results, because a large section of the obstructing "valve" is removed. Martin's Operation. — In so far as the writer has been able to learn, Martin^ was the first to suggest "valvotomy" for the relief of constipation. He describes the operation as follows : — ■ "The patient should be placed in the proper posture (Fig. 26) and the proctoscope introduced and given into the hand of an assistant. The 'valve' should now be seized by te- naculums on either side of the point selected for section. The knife should be made to transfix the fibrous border of the 'valve' and to divide a few fibers of this tissue and the mucous mem- brane covering it, by cutting its way through the 'valve's' free border. This should be transfixed with the bistoury at a mo- ment when the 'valve' is situated at a right angle to the gut- wall. Caution : If the 'valve' be pulled dowmvard by means of the tenaculums so that it presents an inclined plane toward the ^Philadelphia Medical Journal, August, volume i, page 421, 1899. 106 DISEASES OF THE RECTUM AND ANUS Operator at the moment when the bistoury is made to transfix the conjoined tendon, the superior dense fibrous lamina will have a tendency to force the knife outward and through the gut-wall; hence the necessity of a proctoscope of different length for each "valve," that the proctoscope's end may be car- ried to the "valve" instead of the "valve" being pulled down to the proctoscope and probably to disaster. But a few fibers of the conjoined tendon are to be divided by the bistoury. After the incision is thus started, a scalpel-like knife, provided with a similarly bent handle,^ should be used to deepen the incision. In two places the "valve" should be cut. The instant the con- joined tendon is divided a gaping wound will be presented to the eye. This wound is irregularly pyramidal, and open at its apex ; the two walls running away from the apex consist of the fibrous laminas of the "valve" ; the base is made of the cir- cular muscular fibers ; external to the circular muscular fibers are the longitudinal muscular and the peritoneal coats of the rectum. Should hemorrhage occur, it may be readily stopped by the temporary application of clamps." In his earlier operations Martin allowed the wound to heal by granulation, but more recently he has adopted the plan of closing the wound in the mucous membrane, in order to secure primary union. The sutures used are catgut, and are intro- duced by means of a specially-devised curved needle joined at an angle with a handle and having an eye near its point; this needle is passed down through one edge of the mucosa and brought up through the other, when it is threaded with the catgut by means of a long-handled forceps; it is then with- drawn, carrying the suture, which is finally secured with perfo- rated shot. In this manner a sufficient number of sutures are inserted to close the wound. The operation is completed by tamponing the rectum with non-absorbent cotton dusted over with iron sulphate to arrest bleeding and prevent infection. The patient is then placed in bed, with feet elevated, and ice- bags are applied to the lower spine. The apparent disadvantages of the cutting operation are : — 1. Number of instruments necessary, the great difficulty of performing the operation, and the length of time required for it. 1 The knives used have handles adjusted at such an angle as not to obstruct the operator's view. CONSTIPATION 107 2. Danger of hemorrhage during and after operation. 3. Increased pain caused by inflammation about the wound and retention of gases due to tamponing. 4. Danger of infection, common to closed wounds in this region. 5. Confinement of the patient in bed for a considerable length of time. 6. No part of the obstructing "valve" is removed. 7. Finally, in the author's experience, the results derived from "valvotomy" by the cutting method have not been as prompt or satisfactory as those following division of the "valves" with the "valve"-clamp. CHAPTER VII FECAL IMPACTION (COPROSTASIS) Fecal impaction is the accumulation within the bowel of large, hard, oval, or nodular fecal masses, which resist the natural efforts of expulsion, producing partial or complete obstruction. Enormous collections of clay-like feces, inducing partial or complete occlusion of the bowel, may be located in any por- tion of the large intestine. Of these 60 per cent, will be found in the rectum, 15 per cent, in the sigmoid, 10 per cent, in the cecum, and the remainder in other portions of the colon. Im- paction occurs more frequently in women than in men, and, the older the person, the more likely is he to suffer from this affection. No age is exempt, cases having been recorded in individuals from infancy to seventy years and more. This con- dition might properly be distinguished as acute and chronic- acute when the mass collects in a short time, and chronic when several weeks are required. ETIOLOGY AND PATHOLOGY The most frequent causes of coprostasis are intestinal atony, paralytic affections (locomotor ataxia), large enemata, mineral drugs showing a tendency to accumulate, painful ailments about the anus (fissure), and irregular habits. In children it may result from congenital narrowing of the anus or rectum, and in adults from adhesions following a surgical operation, typhoid fever, stricture, carcinoma, or tumor in a neighboring organ. The quantity and quality of the food taken sometimes becomes an etiologic factor in impaction. This was thoroughly demonstrated during the Irish famine in 1846, when fecal ac- cumulations were frequently caused by eating the peels of potatoes. Again, it has been shown by Monro that the people of Scotland are frequently and similarly affected as a result of eating large quantities of coarse oatmeal. A mass may have for its starting-point a plum-, cherry-, or gall- stone, around which the feces collect like the snow on a snow-ball. Hou- ston's "valves" — when large, thickened, and rigid — may cause (108) FECAL IMPACTION 109 impaction. The author treated one case where the impacted mass rested immediately above the second "rectal valve." In this case the "valve" projected into the caliber of the bowel much farther than is usual, was much thickened, highly in- flamed, and appeared to be the principal cause of obstruction. SYMPTOMS The symptoms vary, depending upon the cause, size, con- sistence, and location of the impacted mass. In the beginning there is constipation ; later, constipation alternating with diar- rhea; and, finally, a diarrhea of the most annoying and per- sistent kind. Because liquid feces are being discharged around or through the fecal tumor, the patient's real ailment is fre- quently not suspected by patient or physician. In some cases the movements have a vile odor. These sufferers are nervous, despondent, and restless ; have a muddy complexion, disagree- able breath, indigestion, barking cough, morning vomiting, cold feet, night-sweats, thirst, loss of appetite, dizziness, some- times jaundice, albuminuria, seminal emissions, varicocele, frequent micturition, sphincteric spasm, "nipple-shaped anus" (Allingham), and inflamed rectal mucosa. The pain from a fecal impaction is local and interrupted when it is small, but becomes continuous and disseminated as it grows larger. The mass produces a sensation of weight and fullness in the rectum, frequent and prolonged straining, and bearing- down pains similar to those experienced during labor. Pain is not confined to the anal region, being frequently reflected to the abdomen, back, neighboring organs, and down the limbs, caused by pressure on the sciatic nerves. In persons suffering from impaction and fecal toxemia the temperature is irregular, the pulse small and weak, and respiration difficult. They have a troubled expression, are anemic, and occasionally completely collapse from exhaustion. There may be local or general peri- tonitis, ulceration, perforation, and fecaloid vomiting in ex- treme cases, due to pressure and occlusion. Fecal accumulations may aggravate any pathologic con- ditions present in the rectum, and frequently produce them directly. The length of time one can live without defecation has been the subject of debate many times, and still remains in doubt. Cases have been recorded where complete occlusion 110 DISEASES OF THE EECTUM AND ANUS from coprostasis had existed for from one week to more than six months (see table of cases). The author has treated sev- eral due to stricture in persons who had not had an evacuation in from two weeks to two and three months, and yet some of them were fairly comfortable and did not seem to worry. Coprostasis is the most frequent cause of paralytic ileus; the collective feces prevents the downward peristaltic action, interferes with proper nutrition and the nerves of the intes- tine, resulting in contraction of the bowel below the obstruc- tion. The length of contracted gut depends largely upon the extent of the impaction. Another serious and frequent sequel of large fecal accumulations is dilatation of the colon. The bowel sometimes assumes enormous proportions. This complication is met with more frequently in cases of recurrent impaction common to elderly persons. Chronic constipation accom- panied by impaction is always an important etiologic factor in chlorosis. The anemic condition is brought about as a result of a general fecal toxemia. Hence the importance of teaching young girls to be regular in going to stool. This toxemia produces a depressing effect upon the mind, and many of these sufferers do not take any interest in business, want to remain secluded, and not a few have suicidal tendencies. In extreme cases it has been known to produce temporary mania, and in young children symptoms simulating cerebrospinal meningitis. Cases have been recorded where auto-infection from fecal ac- cumulation has induced hyperemia- and edema of the brain, congestion of the lungs, and acute parenchymatous degenera- tion of the heart, kidneys, and lungs (von Solder). DIAGNOSIS Fecal impaction is less difficult to diagnose than other varieties of intestinal occlusion, and yet the task is not always an easy one. It is true that, when a hard, large fecal mass uncovered by mucous membrane is situated in the lower rec- tum, a digital examination quickly reveals its nature. On the other hand, when it is partially covered by the mucosa, or when located in the sigmoid flexure or colon, it is often perplexing to make a positive diagnosis. It must be borne in mind that tumors of the intestine, bladder, vagina, uterus, tubes, ovaries, and prostate sometimes cause intestinal occlusion and a long FECAL IMPACTION 111 train of symptoms similar to those induced by coprostasis. When the accumulation is in the rectum it is frequently mis- taken by the experienced finger for carcinoma, because the mass pushes the mucous membrane down in front of it, giving to the touch a sensation similar to that of submucous cancer. The following points should be observed when differentiating between these two conditions : — Table V. Differential Diagnosis Between Fecal Impaction and Carcinoma of the Large Intestine carcinoma Two or more dense, rounded tumors. fecal IMPACTION 1. Single, large, firm, and globular in shape; or numerous, small, hard, and nodular. 2. Usually not covered by mucous membrane. 3. Occupies lumen of the bowel. 4. Of doughy consistence and in- dentable. 5. Not attached. 6. Movable. 7. Occurs at any age. 8. No cachexia. 9. Usually odorless. 10. Comes on suddenly. 11. No previous history of pain or hemorrhages. 12. Not accompanied by discharge of mucus or jelly-like stools. Covered by mucosa except when ulcerated. Projects into the caliber of the intes- tine. Hard and non-indentable. Attached. Non-movable or slightly so. In middle life and old age. Cachexia. Offensive odor. Slowly. Pain always, hemorrhages frequently. Free discharge of mucus and some- times of jelly-like evacuations. Symptoms common to both impaction and carcinoma are constipation in the beginning, diarrhea later, straining, frequent micturition, tumor, and reflected pains. Fecal impaction can be differentiated from gall-stone, enterolith, and pancreatic obstruction by the doughy feel and the large size of the tumor. When a tumor presents in the sigmoid or colon, causing dangerous symptoms of occlusion, and its nature is not apparent after getting the history and making a thorough examination by means of palpation and the colon-tube, the abdomen, intestine, or both should be opened without delay ; then an accurate diagnosis can be made. The rectum and vagina should be examined in all cases of constipation and obstipation to determine if it is the result of an impaction. 113 DISEASES OF THE RECTUM AND ANUS PROGNOSIS Comparatively few cases of uncomplicated fecal impaction terminate fatally. This is especially so where there is no or- ganic disorder. When located in the rectum, coprostasis may induce intense suffering until the mass is removed. Once the bowel is empty, relief is instantaneous, and the patient may return to his business as usual. When the accumulation is the result of a stricture, tumor, or adhesions, the prognosis is not so good; on the contrary, it is extremely bad in most cases. This is because of the danger of operation for temporary relief and the tendency of the impaction to return again and again until the pathologic condition inducing the mechanic obstruc- tion is removed. When the obstructing disease has been eradi- cated, or where a colotomy has been made above it, and the feces are given a free exit, all the elements of danger rapidly disappear. In those cases where the fecal accumulation is not Fig. 42. — Serviceable Bed-pan. recognized, and is allowed to assume enormous proportions, death may at any time ensue, caused by a rupture of the intes- tine or perforation and peritonitis. TREATMENT The treatment in cases of fecal impaction is usually satis- factory, but must be changed to suit the individual case. When the accumulation is small, not too dense, and is located in the lower rectum, it can always be softened and evacuated by fre- quent copious enemata of warm soap-suds containing oil and glycerin. The following is a very satisfactory combination : — - I^ Soap-suds Oj 473 Castor-oil ij 30 Glycerin iij 60 Inject into the rectum every two hours, to be retained as long as possible. If the mass has been in the rectum for some time ; is large, round, or hard and nodular, more radical measures are indi- FECAL IMPACTION 113 cated, for in such cases the tumor is covered with a sHmy mu- cus, and water will not permeate it. Here it is necessary to break up the accumulation into small particles, and then irri- gation (Fig. 43) will enable the patient to evacuate them. This can be done with the fingers, a spoon-handle, scoop, Fig. 43.— Barger's Artificial Defactor and Irrigator. 1, Ready for Introduction; 2, Showing Direction of Currents ; 3. Showing Component Parts of the Instrument. (Fig. 44), or with Gant's rectal forceps. Where the mass has been present a considerable time, causing dangerous symp- toms of occlusion, the sphincter-muscle should be divulsed under general anesthesia,^ and the tumor delivered at once whole or in sections. When located in the sigmoid and colon, Fig. 44.— Eectal Scoop for the Removal of Impacted Feces. a copious injection of the formula previously given should be thrown high, into the bowel by means of the long rubber colon- tube. Occasionally the feces will be discharged in short order. Again, the treatment must be continued one, two, or three days, and sometimes a week, before the accumulation will be » The muscle may be divided under local anesthetization. 114 DISEASES OF THE RECTUM AND ANUS completely evacuated. Massage is a valuable agent in these cases, and, when practiced in an intelligent manner, fecal tu- mors in any part of the intestine may be dislodged, broken up, and pushed downward until they can be removed with the finger or washed out with enemata. Now and then all pallia- tive measures fail, and it becomes necessary to open the abdo- men and make a sigmoidotomy or colotomy, and deliver the mass whole when possible, and in pieces when it cannot be avoided. Adhesions should be broken up, and the wounds in both the intestine and abdomen should be closed immediately. Fig. 45.— Modified Kelly Pad. When the impaction is caused by a stricture or a tumor which cannot be removed, a permanent artificial anus should be estab- lished. Purgatives are always contra-indicated in these cases, because the obstruction is purely mechanic. The author has treated during the past few years 46 cases of fecal impaction. (See. table of cases on pages 116-119.) A careful analysis of these cases develops the following facts: — Sex and Age. — Of the 45 cases, 22 were men and 23 were women. Their ages ranged from 18 months to 76 years. Twenty-six were 35 years or more, while 19 were under that age. FECAL IMPACTION 115 Location. — The impaction was located in the rectum 30 times ; sigmoid and rectum, 5 ; sigmoid, 6 ; colon, sigmoid, and rectum, 1; descending colon, 1; cecum, 1; and transverse colon, 1. Weight. — The fecal accumulations ranged in weight from 4 ounces in a child to 12 pounds in an adult. The length of time these patients went without stool varied from two days to three months. The causes of impaction directly and indirectly were as follows : — Stricture, 4 ; carcinoma, 4 ; pregnancy, 1 ; careless habits, 5 ; congenital malformation of the anus, 1 ; traumatic stricture, 1 ; paresis, 2 ; parched corn, 2 ; fruit- and berry- stones, 2 ; adhesions, 2 ; fibrous bands in rectum, 1 ; chronic constipation, 2 ; and fissure, 2 ; loss of intestinal tonicity, 5 ; retroverted uterus, 1; unknown,. 1; inability to evacuate the bowel after hemorrhoidal operation, 1 ; hypertrophied sphincter, 1 ; gall- stones, 1 ; sarcoma, 1 ; hypertrophied "rectal valve," 1 ; green corn with portion of cob, 1 ; h^qDertrophied levator ani muscle, 1; disseminated polypi, 1; enterolith, 1. The author has recorded these cases with a view to point- ing out the frequency of impaction, or coprostasis ; the neces- sity of its prompt surgical treatment ; and, further, to show the varied affections and conditions which may induce it. 116 DISEASES OF THE RECTUM AND ANUS X r- .E ,_ c^— ■5 « E = C a; D 3 ii'^-'C " rt c o^y" s: CL O.M ^ E T, iU, E o Si o "U E s: tL < ? •3 iU «'5 — OJ C D °^ m > o O) > ra rt 7; I/, Qg-^ US 0.2 E.b c % . o -a •— T3 QJ ^ o W ^ E h ■2"e " m 3 i: « t! M E « ="_ (MS E 2 §5 O u dj *- 1- 5 c^ (J ^.^ E W 2-?? S w # f.S U " J-fc Q E m O 1-i u 73 W) ^ IL, i^ ^2 ° a> o ° & Uo io.s ■B — ^^ (A O O) a t O M UU 01 C i o 0) g^o c "' 3 U !> ^§ •XHS •HDV •3WVM ■ON ::s o >" E !3 !3 O on . .— ^ — E.£ nl — " & °i I- o-o « — ~ join ■So S ;22 3 ^ CO r-t FECAL IMPACTION 117 ■o •s^ ""So. V Q. > a H 6 b £> u i_i2 6 6 &■ b ^ 6 .J J" 0) "" n > > >- TJ ">. > > > > > > (« o o o • 3 -d E 5 U] U o O-N a 0) lU CU ! Tim OF Trea MEN' >) >1 >i CU > >. a) a a 0) C3 CU nS T3 tU > •a ■a S; S: ^ •a ^ 1 T3 ■0 , c o . 'm 3 •^.2 ■<5 . U M _aj 3 i u ^"g CU !^ lis 3" "cS 0. CU w d > o — E « c" en 3 D-'S z s « c •ofc 3~ TO > rt ^~ >,■- E-a O 3 3 _ ii ig J2 > 3 - .>o Q E V T3 OJ .^ ^ 0. c t- I- Cfl 8 ■« -^ -t: E CO cj i; S Ii til B S «-S i° |E-g 1^ 5°| !5 >S d _ c3 '^ .c — 0) txo ^ 'C •a.t: 3 - « 5 3 0. tn ca 11 ^ < u a: H aig •a" 'o-a ■-'> c •a •a .2 E-S So o E Q. . 0) o f-5 ° c" o o 3 C ^8 > a = E D.T3 3^ c 2: 03 -a 3 « CUS- ^ a; £lS 3 t« c« > ■" c« O. u ^" d. CTJ 3 E 3 c3 3 3 3 J3 E.b 3 fa£ o CO ca ? y < u C O cS aj c o Z o U O . o "^ o ^ 8S •2 o d 0.2 s.s- T3 D.CU S So ■^ 0.0. c £-c So c« •a •0 > s aj aJ 3 a> 3 . to — -I E ■a c £ >, oi s« d D-Cfl 3.t; >>!-; :2^ D < ^ . « E 3 3 £ O 3 c < 'B o o 1/1 2 E o 3 'u u ^1 >•■= -o "1 §?c^ •a tj "^ ca c ^ ™ W-2 'E « a ^ '5 U S ij li °d ^s ^1 3 ti aj aj aj.t -J !3 1 Cfl « w V) Vj en en i§ J«: iJi >> r3 ^ o >, ^ ^ >, CU ^ CU •a E CO (3 c3 a a 'a a) E ^1 51 ^g ^ zg E o o E Ol Zg Zg 5^ ■^ 3 «■ — m C (0 Q Zuj 3 "5 > . 3 E 3 j:3 M M rt CTJ > E ° c C3 C3 Id E < S ■a o c o m B E E T3 O c E t- "O 3 •0 E E ^ i" •a > >> > -5 « M 'H 2i . « z > I/) i> a: I t I u z H < u c s ° o o D E 3 ■d o E fe E D.3 D 1) E 3 a) li i d E bi E 3 tj E D d 3 tj o . CO CO (M in cq ''^ co^ CO CO 10 CO t^ (M U3 ■HWVN "-5 ^ § d ^ u of d a: §■ z a ^ -j z u; 3: It U- Z ai ^ cd d •ON C-l CO ■^ lO CD t-- C» C35 N CM o E ^S II "5 o e Up d E T3 16 O u U£ Si o > 6 0) > 0) Oi = « Q — "O O (V73 u ** 3 ta '-' lu a •*- ■^ ta «) Time OF Treat- ment. >> o >, ^ >, >. >, >> >, ^ •a •a •a o 73 73 73 C<1 73 CO , •o •O-OTJ - - cs: „ , a c c 33 ■- D. C o 3 .2; ■B S. 3 ^>, >, "be , a o 5 "E S:2 E _C l« 3 O .s ■5I 73 XI 0) 3 j: u ■o.e j: o H !> ;■' D. >,o. 3 iaoE a to *-• w or i8 ^1 •5& O 3 o E >> > " E.ff« £ . >, rt o *^ §§8 . E w ■^ ao E >, XI « c a. 3 O E _>. ■Ja o £ tU 73 M 3 E >"> ° S 4: < E 3 t 3 73 > .is it ~ j=i 3 en i: ^3 E 0) 3 3 < J z u c _o 3 a s: X c c 81 .^■•3 3 c :.9 £ t; S •c o.ii U- a! 3 D. O r: O E 01 E o- I 3 82 1 o > "a 3' 1 3 - to — a ■5 3 3 c Z e U c ii 3;s E nS O. Q. m D < c o c 3 T3 O u b 3 o a 3 3 o ia ■^ 0) O •- "Se^ 0) w o. 3 biO 73 IE & o 3 73 >> 3 3 3 ^ 3 a) 3 Si ta' E u c a 3 < e-5c E .3 O £1 73 Oi D. X a E ■5 " 3 S := bc tx03 ta % Ol 1 >> 73 « 73 >> 73 1 1 — ' CO —1 lO So 1-^ -a It oS 3-f o LO ^E 0^ ■a 3 O O c C o 3 c D ji ^ iS ^ 3 S: 3 3 3 _ Q Is ii iio n > O > o « E 3 3 O 3 •- 73 E > . 73 3 3 . • Po 73 3 S o >- •a 5 1 3 E 0) T3 3 •a 5 I o u £ I -E E 2 E 3 |i "" z O d 1- E E e' 2 F F E F < P o o 3 3 3 E be 3 3 3 dI uS Qi a: a W a Oi a a •X3S u.' ^ u.' S tU u.' s S tu s •30V s 8 ^ o CO lo 10 t^ •3WVN ol d i/i d •-j ■-; d CQ u Q u UJ H C/) > < Ul H •CM -^ lO CO ^ IN M M CO CO CO 00 FECAL IMPACTION 111) i M JE M-i • 6 ■" E o > o 6 > o > Q. = 1 • c > o E c •5 9 7 > O B o w o E a; 6 > o > o > o •3 taja SEZi s s ^ > (2 a « a E c « a, « E > B 3 Oi a (X E£ ta "ii 2 txo o o ta m M Time OF Treat- ment. >, >. a; >> >. >. >> .:«: >> ca •a •a •a •a 00 CO ■a 73 CO •a •a CO 73 1 . ^ >> 1- 1 r « , . c . ta be o-g 67, o E c 5 c E o ^ 2S Ii c g 0.0 E o c 1 e o o ° 2 ca ta c o — >> ^ ^ bf >)a) a o ■a > c ta o. tj o 73 o 2 c 73 > E m <: IJU a o •a > o >>!5 a) t- E o a. c o. ■a n _o D. C c So be c a) > TJ-C-. III ■o-^ 3 tj'o ■a a) -oxi C S « io> 3 V a. ::■§ 3 °^^ o T3x: c -a ■« •a 3 o ^ s c o 3-0 O, o D. 3 ■" E n la ex ^ m a; ■(- c o o 3 VI .2 '- ^ S) c ta E o la > o S aj D. . >, tfl E*- O 71 o a 3 .hi ta 73 aj C (fl a> i« a ta E = 1 C a> -^ ,«- So. ^^ 0,0 e o. c 1) o o. E o u ^3 > o, E 0) V) as ■2 o E o o S O o U o 3 a; ta a.| ta 73 3 ta < O ^b ■« o •o . aj ^5 d o >> ^ c c o c E ai bj ta 73 c o^ u > •a 3 3 H o E o o -J "5 t a; 1/2 -c S) ■5 c 3 a. 3t aj 5 u..| "o. w a. E 3 x: Of ?^ tfl 73 _aj ^ E : E gxj 2.S |.i < c o c 2i o c 2 £u a) 3 o E > o c ta U u o o. o >.'C E 3 aj aj x: C Pi a >. o D. _aj o. 3 ta Q. ta E c ta U O o. in X : s ii >, ^ .^ >. >, 0) >> ^ ^ >, •a •o 1 CO •o CO o 00 T3 T3 05 eo ^ t- 73 So c . • si E o E iZ o E 3 u "3 •a o Z . O VI ■si ta '^ X ta 3 ■a o Z E 3 73 Z 73 C ta . •g'H z 0) •o o E E F.7^. R R 5> c > o 2 F fi E E nj T3 3 3 O 3 3 1^ < u o V o E !if u h bo o a a a-K a a a a fn OS 0; a)'3i l-l H a •X3S u^ :s u,' u^ S u.' S u.' b S S" u.' •aDV M Q 00 in 05 o (-> 01 CO to IM CO CO CO ■^ •awvN CQ UJ UJ -^ S. ^ z X ^ J z -1 H I ■-) U ^ X U s; Q U (J •ON _p ,^ ^ CO ■^ ^ eo CO '^ Tf< "^ ■^ ■* CHAPTER VIII AUTO-INFECTION AND AUTO=INTOXICATION FROM THE INTESTINAL CANAL This topic is given a distinct caption, because its impor- tance has been very much underrated, and it is a subject which writers on rectal diseases have heretofore ignored. This is surprising when it is remembered that experiments have shown that, in the main, poisons are generated in the colon. Until quite recently the fact that the organism might be poisoned by products generated within it, and even be invaded by microbes from the alimentary tract, was looked upon with much skep- ticism. To-day nearly all physicians admit that such a thing is of common occurrence. Recent investigators have shown that various organs of the body — the brain, liver, lungs, kidneys, etc. — are frequently invaded by the bacillus coli communis and other micro-organisms, and some pathologic condition induced as a result thereof. They have gone a step farther, and demon- strated that disease-producing toxic substances are constantly formed in health, independently of bacterial action. As regards auto-infection from the intestinal canal, there is as yet little direct proof of its existence or as to the manner in which it occurs. Many of our best clinicians and investi- gators, however, express the belief that the cause of many dis- eases, the pathology of which is now obscure, will be explained when we become better acquainted with the part played by the contents of the gastro-intestinal canal. From the author's stand-point, anto-intoxication from the intestinal canal is that pathologic condition depending upon the absorption of poisons generated within the alimentary tract as the result of chemic processes or of putrefactive or fermenta- tive changes of bacterial origin. Auto-intoxication may take place from any portion of the intestinal tract. It is claimed by some that it occurs more fre- quently in the small than in the large intestine, for the reason that here an increased amount of water is present in the feces which is conducive to the solution, absorption, and dissemina- (120) AUTO-INFECTION AND AUTO-INTOXICATION 131 tion of the poisonous agents. On the other hand, there are many who teach that the source of auto-mtoxication is more frequently the large intestine (especially the descending colon, sigmoid, and rectum), because the decreased amount of water renders the feces more nearly solid ; the latter remain longer in contact with the mucosa ; and putrefaction takes place more actively, thus affording a rich soil for the multiplication of sep- tic micro-organisms and their products. These toxic elements are taken up by the circulation, and possibly by the lymphatics, and distributed to all parts of the body. Before the disturbances which may result from the ab- sorption of poisons created within the intestinal canal can intelligently be studied, famiharity with the normal intestinal contents is absolutely necessary. As it is the intention of the writer as far as possible to confine his study of auto-intoxica- tion to the colon, only the gross contents of the large intestine will be given. Grossly speaking, the contents of the colon is made up of refuse products of food, the excrementitious portions of the di- gestive fluid, water, gases, and animal alkaloids (leucomains^), together with myriads of micro-organisms and their products (ptomains^). At present but little is known as regards the ac- tion of these gases and alkaloids in health and disease, and, with few exceptions, the same may be said of the micro- organisms. The author, however, is firmly convinced that just in proportion as physicians become familiar with the toxic agents contained in the digestive fluids and excreta will they understand many diseases which are now called functional sim- ply because of a lack of knowledge of their etiology and pathology. Bouchard has done more and better work along this line than any other man. This author says : "The organ- ism in its normal, as in its pathologic state, is a receptacle and a laboratory of poisons. Some of these are formed by the organism itself, others by microbes, which are either the guests, the normal inhabitants of the intestinal canal, or are parasites at second-hand and disease-producing."' He has shown that the peptones of normal digestion con- tain poisonous alkaloids, and a solution of them as they appear in the stomach as the result of gastric and, lower down, of * From Xei5/cw/ua = white of egg. = From Trrw/ict = corpse. 123 DISEASES OF THE RECTUM AND ANUS pancreatic digestion will, when introduced into the blood of an animal, produce general disturbances and death; and also that a sufficient amount of poison to cause death in a short time is secreted by the kidneys when, from any cause, the poison is allowed to accumulate or is absorbed as a result of the urinary tract becoming denuded of epithelium, anywhere from the tubuli of the kidney to the meatus. When renal suppression results in death, Bouchard at- tributes it to absorption of poisons normally "secreted," and not to an accumulation of urea ; and he says that a "complexity of phenomena is hidden under the name 'uremia.'' " Park, under the caption "Intestinal Toxemia," includes, first, a condition of unusual or at least undesirable activity in the contents of the intestinal canal by which the ptomains of putrefaction, whether due to common or specific forms of bac- teria, are produced in such a manner or in such quantity that they are absorbed through the intestinal mucosa and distrib- uted over the body, resulting in a condition of intoxication. In this form it is not meant to imply that bacteria enter the circulation, but that a more or less profound toxemia is pro- duced. Second, a form in which the common or uncommon bacteria met with in the intestinal canal pass into and infect the living tissues of the patient, producing local and general infection in addition to the toxemia above described. The first form occurs alike in medical and surgical cases. Here, on the one hand, is a demonstration of how an individual may become intoxicated from alkaloidal poisons generated during digestion, and, on the other, as a result of the unusual activity of bacteria ■ — the normal inhabitants of the intestinal canal — and their ptomains. As one becomes more familiar with the almost in- numerable poisons contained in the intestinal tract and their efifect when injected into the lower animals, he is forced to admit that mankind is constantly tottering on the brink of de- struction, and that he need only disobey some of Nature's laws to upset the equilibrium and fall a prey to some of these poi- sons. Our Creator, however, foresaw all dangers, and provided the body abundantly with safeguards with which to destroy or neutralize the poisons, or to eliminate them as soon as they are formed. It becomes apparent, then, that for auto-intoxication to occur two thinsfs are essential : — • AUTO-INFECTION AND AUTO-INTOXICATION 123 1. There must be local or general impairment of phys- iologic action. 2. That poisons are being constantly formed within the organism in health. In all complex organisms every cell has a duty to perform, and the same can be said of those aggregations of cells which are called organs. If the function of a single organ is impaired or destroyed, the economy suffers, and the effect is in direct proportion to the importance of the work normally allotted to that organ. Now, if from any cause, the liver, lungs, skin, kidneys, or blood should become deranged and fail to func- tionate, what is the result? On the one hand, poisons that are being constantly secreted are not neutralized, or, on the other, are not thrown off, but accumulate, enter the circulation (pos- sibly lymphatics), and are distributed throughout the body, causing local or systemic intoxication, as the case may be. Again, the absorption of poisons is facilitated by anything that will cause a lesion of the intestinal mucosa or distend, press upon, or weaken the walls of the intestine, such as the accu- mulation of feces, tumors, strictures, ulcerations, inflamma- tions, operations, etc. As long as the emimctories work in harmony and perform their individual functions, however, and there is no lesion of the intestinal mucosa, all is well ; all poisons, no matter whether they are the product of decomposition or of bacterial action, are rendered harmless, for the reason that they are thrown into a special reservoir (the liver), where they are destroyed or neutralized and afterward discharged from the body. Schiff ascertained that by injecting certain alkaloids into a branch of the portal vein the proportion of poison in the blood as it came from the liver was much lessened. The blood, however, con- stantly takes from the organs poisons as soon as they are formed and renders them inert, especially if they are of bac- terial origin. Recent investigations have demonstrated that the serum of arterial blood contains certain substances (defensive pro- teids, alexins^) which act in one of three ways : first, by kilHng the bacteria (bactericidal) ; second, by attenuating or weak- ening the bacteria; third, by neutralizing or destroying the 1 From fiX^lts = lielp. 124 DISEASES OF THE RECTUM AND ANUS toxins (antitoxin). It has been shown that the blood taken from an animal that has been rendered immune against certain infectious diseases (tetanus, diphtheria, etc.), when injected into another animal or human being renders such animal or person immune to that disease. Thus far investigators have been un- able to isolate any one "defensive proteid" that will prove effective against infectious diseases in general, but it is believed that such will be accomplished in the near future. Hankin classifies defensive proteids (alexins) into two groups : 1. Those existing naturally in animals he calls sozins} It is a noted fact that the rat is immune to certain diseases to which the guinea-pig readily succumbs. 2. Those existing in animals artificially made immune he designates as phylaxins? From the above it becomes apparent that the study of auto-infection is intimately connected with that of immunity. It is at times very difficult to determine in cases of auto- infection and intoxication where health leaves off and disease begins. This is due, on the one hand, to the fact that these poisons are physiologic factors, and, on the other, as soon as the system becomes susceptible they become active pathologic factors. The author has neither the space nor the inclination to classify and point out the pathologic significance of the various poisons generated within the intestinal canal. He will, there- fore, mention only those manifestations which are due to colon infection, are systemic in character, and which are most fre- quently met with. Perhaps the most frequent and immediate cause of auto- intoxication is "constipation," more especially when compli- cated by a fecal impaction. In the latter case there is retention of the feces for a variable time ; as a natural sequence, effete matters accumulate in the bowel and, on retention, undergo chemic changes; poisons of the ptomain and leucomain groups are formed which are as active as any poisons introduced from without, as, for example, typhoid fever and cholera, wherein the specific bacillus runs its entire course in the intestine. As a result of the accumulation of poisons systemic Intox- ication is induced ; it may or may not run a chronic course, depending upon the hygiene of the bowel. If nothing is done 1 From ffu)^€iv — save, keep. ^ From (p\j\a^ = a guardian, protector. AUTO-INFECTION AND AUTO-INTOXICATION 125 to prevent the continued formation and absorption of poison- ous products, their effects soon become manifest in the cHnic pictures with which aU are more or less famihar : anemia. Pa- tients suffering from anemia come to the physician complaining of headache and a feeling of lassitude ; they are impatient and careless in attending to their usual duties ; they do not care to read or talk, but are inclined to melancholia, preferring to be left to themselves ; they are pale, have a greenish-yellow com- plexion and a foul breath. They suffer from a depraved appe- tite, indigestion, palpitation, dizziness, neuralgia, and a host of other symptoms too numerous to mention. Too often they are treated for biliousness, malaria, or grip. They change from one physician to another until one is found who makes a correct diagnosis and succeeds in removing the feces and cures his patient without any medicinal treatment whatever.^ Many patients suffering from fecal toxemia become so profoundly intoxicated that they present an appearance not unlike that of a person afflicted with a malignant growth in an advanced stage. By way of illustration, a study of the phenomena in a case of extreme intestinal intoxication will be made in order to ascertain its effect upon the various systems and skin. 1. Circulatory system. 3. Skin. 2. Respiratory system. 4. Nervous system. THE CIRCULATORY SYSTEM As a result of auto-intoxication there is a disturbance in the circulation : the cutaneous vessels become contracted, thus throwing an increased amount of blood into the central organs and interfering with the general equilibrium. The pulse may ^ In a great many of these cases examination of the urine by Jaffe's test will lead to a correct interpretation of the nature of the disorder by the demonstration of the presence of indican. This test is performed as follows: To a test-tube one-third full of urine add an equal amount by bulk of strong hydrochloric acid; then, according to the size of the test-tube, add 3 to 6 drops of a Vs-per-cent. solution of potassium perman- ganate and agitate the tube gently. If indican is present, the fluid will become darker in color. Should this occur, add about a drachm of chloroform and shake vigorously. If the chloroform is now allowed to settle to the bottom of the test-tube, it will be seen to have taken up the indican and be colored a light or dark blue or even indigo tint, depending upon the amount of indican present. In case of failure of the first examination, it is advisable to repeat the test with varying amounts of the perman- ganate solution; or it may be necessary to precipitate the solids of the urine with a 10-per-cent. solution of sugar of lead, filter, and then treat with acid, permanganate, and chloroform as indicated above. 126 DISEASES OF THE RECTUM AND ANUS be slow and full, or rapid and feeble, depending upon the de- gree of intoxication and its influence upon the nervous system and the muscular fibers of the heart. Frequently the heart is very excitable, and the patients have fainting spells. Some- times, instead of the blood being retained in the central organs, it seems to remain in the extremities and cause dilatation of the veins. Hemorrhoids are almost invariably present in those who suffer from chronic auto-intoxication. THE RESPIRATORY SYSTEM The effects of auto-intoxication upon the respiratory sys- tem are not so numerous and profound as upon either the cir- culatory or nervous systems. Their effects are manifested more quickly, however, and in a more aggravated form when some lung trouble co-exists ; and, vice versa, all lung diseases become markedly worse with the advent of systemic intoxica- tion, owing to deficient oxygenation of the blood. According to recent investigations, it would appear that the colon bacillus plays an active part in the causation of some forms of pneumonia and empyema, but more frequently when there is a lesion of the intestinal mucosa. When the lungs are diseased, the gravity is in direct proportion to the amount of tissue involved; when involvement is extensive and death en- sues, the latter is, in great measure, due to auto-intoxication: a result of the accumulation and absorption of carbonic acid and other poisonous elements that should have been eHminated by the lungs, but chiefly to pulmonary edema secondary to toxic action upon the heart. THE SKIN The skin shows the effect of intoxication by its pale, muddy, unhealthy color; foul-smelling secretions; and in any one of many skin diseases. THE NERVOUS SYSTEM When auto-intoxication exists to any great degree, it be- comes manifest in the form of some one of the many nervous disturbances seen so frequently in every-day practice. One of the most common manifestations is a sensation of drowsiness, due to the effect produced by absorption of one of the intestinal AUTO-INFECTION AND AUTO-INTOXICATION 127 gases, probably sitlpJiureted Jiydrogeii, which is known to have a soporific effect. Though the patients feel drowsy, they are poor sleepers; they roll and toss about the bed, are frequently awakened by horrible dreams, or find themselves wandering about their rooms. On rising in the morning they do not feel refreshed; on the contrary, they are weakened and exhausted, and their clothing is often moistened by a clammy, unhealthy perspiration. The author believes that a very large percentage of head- aches and neuralgias, it matters not where the pain is located, are due to auto-intoxication, for he has many times witnessed their disappearance after the bowels have been completely emptied, without the assistance of a single dose of medicine. Neurologists contend that a number of functional nervous dis- orders result from fecal toxemia. They have shown, from a cHnic stand-point, that some forms of insanity are undoubt- edly caused by auto-intoxication from the intestines, due to the absorption of gases or of poisons of the ptomain and leuco- main groups. Epileptics nearly always have fewer attacks when the colon is kept clean ; indeed, some authorities main- tain that not a few cases can be materially improved if proper attention is paid to the intestinal canal with the object of pre- venting accumulation and absorption of the manifold poisons generated therein. Thus far, in speaking of auto-intoxication, the author has incidentally mentioned constipation and fecal impaction as the prime factors in opening a way for the production and absorp- tion of poisonous products. Justice, however, would not be done to the subject were he to convey the impression that in- fection occurs only when obstinate constipation exists. He has frequently treated patients who were unquestionably suffering from auto-intoxication, and nearly all, if not all, manifested the phenomena previously mentioned. They gave no histor}^ of constipation; but, on the contrary, the intoxication was the result of a chronic diarrhea and other causes which the writer was unable to determine.^ Park states : "There takes place within the intestinal laboratory such a putrefaction as produces ptomains which are at the same time toxic and cathartic in their action, so that the irritating material is expelled by virtue 1 Here, also, examination of the urine by Jaffe's test will render great assistance 'n diagnosis (see foot-note on page 125). 128 DISEASES OF THE RECTUM AND ANUS of the very poisons it has produced ; and it furthermore often happens that the exhibition of a vigorous cathartic — for in- stance, one of the mercurials — will so admirably clean out the entire intestinal canal that not merely is the entire action pre- vented or checked when present, but that a most happy effect is exerted upon septic disturbances commencing elsewhere." The author has personally treated not a few patients suf- fering from chronic proctitis and ulceration of the colon or rectum where the ulcers were small and not unhealthy looking, who also suffered from systemic intoxication. They were very much emaciated, extremely nervous, of sallow complexion, in- clined to be melancholic ; in fact, they manifested all the symp- toms which usually accompany auto-intoxication. Diarrhea is ever a prominent symptom of ulceration, and it complicates matters by distributing the poisonous elements in the feces to any exposed point of the mucosa, thereby facihtating their en- trance into the circulation. Not all cases of ulceration of the rectum and colon, however, are complicated with systemic in- toxication. Many times the poisons are rendered inert or are eliminated before much harm can result. Perhaps the most typic cases of auto-intoxication from the intestinal canal are to be found in patients suffering from stricture of the rectum and colon. In these cases are found the two conditions which par excellence favor auto-intoxication : (a) fecal impaction above the point of constriction, and (h) frequent liquid stools induced by a reflex peristalsis. The former prepares the field by causing ulceration of the walls of the bowel, offering a good culture- medium for the micro-organisms and favoring putrefaction and fermentation. The latter, being liquid, take up the poisons and distribute them. As a result, more poisons are generated and absorbed than Nature can take care of; the system, therefore, becomes saturated. As has already been stated, the sufferers acquire an aspect almost as bad as that observed in individuals suffering from a malignant growth. In fact, any disturbance of the rectum and the colon that will cause a diarrhea or con- stipation predisposes the individual to auto-intoxication and its many evils. In the preceding pages attention has been called to some general manifestations which the author believes are caused by the absorption of septic material from the intestinal canal. AUTO-INFECTION AND AUTO-INTOXICATION 129 BACILLUS COLI COMMUNIS Attention is now directed to the study of a number of diseases in and around the rectum and other organs, which, if not directly caused by intestinal bacteria, are certainly aggra- vated and perpetuated by them. The micro-organism of intes- tinal origin most frequently associated with disturbances in neighboring and distant parts is the bacillus coli communis. This microbe seems to be the chief disturber, and has been found in nearly all the organs of the body and under circumstances that have led investigators to conclude that it unquestionably pos- sesses decided pyogenic properties. Many other germs of known pathogenesis have been proven to be identic with this bacillus; and at present it is considered identic with the fol- lowing organisms : The bacillus Neapolitanus, Breiger's feces bacillus, Passet's bacillus pyogenes fcetidus, the urinary pyogenic bacterium (Clado and Albarran) which Morelle and Krogius considered identic with the bacillus lactis aerogenes, the uroba- cillus septicns, and the septic bacterium discovered by Bouchard. Familiarity with this bacillus is of such importance to both physician and surgeon that it will be discussed in detail. The following description of the appearance, growth, prop- erties, pathogenesis, etc., of the bacillus coli communis is taken from Ball^ because of its brevity : — "Bacillus Coli Communis (Escherich). — Found in the human feces, intestinal canal of most animals, in pus, and Avater. "Form. — Short rods with very slow movement; often associated in little masses, resembling the typhoid germ. "Properties. — Does not liquefy gelatin; causes fermentation in saccharin solutions in the absence of oxygen; produces acid fermentation in milk. "Groivtli. — On potato a thick, moist, yellow-colored growth. Very soon after inoculation on gelatin a growth similar to typhoid. It can also develop in carbolized gelatin, anti withstands a temperature of 45° C. without its growth being destroyed. "Pathogenesis. — Inoculated into rabbits or guinea-pigs, death follows in from one to three days, the symptoms being those of diarrhea and coma; after death tumefactions of Peyer's patches and other parts of the intestine; perforations into the peritoneal cavity, the blood containing a large number of germs. "Staining. — Ordinary stains; does not take Gram. "Site. — The bacillus has been found very constant in acute peritonitis and in cholera nostras. Its presence in water would indicate fecal contamination. 1 "Essentials of Bacteriology," M. V. Ball. Second edition. 130 DISEASES OF THE EECTUM AND ANUS "The growth on potato, the effect on animals, and its action toward milk are points of diflference from the typhoid bacillus." The author has made no personal experiments to deter- mine the pathogenic and pyogenic properties of the bacillus coli communis. For this reason the experiments and arguments of those who have made a special study of this microbe will be quoted in extenso in order to show the part played by this normal inhabitant of the intestinal canal in causing disease under varying circumstances. Roswell Park, in speaking of the bacillus coli communis^ relates the following history concerning it: "It was first de- scribed in 1885 by Escherich, and was first regarded as a saprophyte and intestinal parasite. In 1887 Hueppe found it in the stools of a patient suffering from cholerine. Its positive pathogenic properties were first made known by Lauelle in 1889, then by Tavel, also by Rodet and Roux, who fully estab- Hshed its pyogenic properties." He further says that the colon bacillus is a short, rod-shaped organism which is motile in hanging drop, its motihty consisting of a sort of oscillation, and sometimes with a rapid translation. Its possession of flagella is disputed; at most, it does not have more than three of them, while the typhoid bacillus possesses from eight to twelve or more. It seems to enjoy a sort of commensahsm, possibly even a symbiosis. It practically never exists alone in the healthy intestinal canal, but under certain conditions it is found alone in other parts of the body. Ordinarily it is not virulent; under certain circumstances, however, its virulence varies within wide limits, as is the case when obtained from cholera nostras, and on inoculation it causes death from acute septic infection within twenty-four hours. When derived from intra-abdominal abscesses, it is only slightly infectious. This organism therefore may exist, first, as an exceedingly active agent, producing acute general infection ; second, as a com- mon pyogenic organism, producing local abscess. Pathogenic Action. — To show the pathogenic action of the colon bacillus, the writer quotes from a paper by Dr. William. H. Welch, of Baltimore, read before the Second Congress of American Physicians and Surgeons. He said : — "Tavel's observations of the colon bacillus in connection with wound-infection were followed by a few isolated observa- tions of this organism, either in the unchanged organs of the AUTO-INFECTION AND AUTO-INTOXICATION 131 ho6y or in suppurations, until recently. A. Frankel reports its presence in 9 out of 31 cases of peritonitis. I first came across this bacillus in the organs of the body in 1889-90, in a case of multiple fat-necrosis with pancreatitis, which I reported to the Association of Physicians. As in this case diphtheritic colitis existed, it seems probable that the lesions of the intestine opened the way for the entrance into the circulation of this in- habitant of the healthy intestinal canal. This view subsequent experience has confirmed. "I have almost uniformly failed to find it outside of the intestinal wound when no demonstrated lesion of the mucous membrane existed. I am, therefore, prepared to say that this bacillus is an extremely infrequent invader in intestinal diseases. Moreover, the colon bacillus does not invade the blood and organs in the process of post-mortem decomposition. "The cases in which we have found the colon bacillus un- der circumstances pointing to its pathogenic action have been as follows: Perforative peritonitis, 4 cases; peritonitis sec- ondary to intestinal disease without perforation, 2 cases; cir- cumscribed abscess, 3 cases ; and laparotomy wounds, 6 cases, 'Tts presence several times in pure culture, in laparotomy w^ounds treated aseptically, although apparently not a source of serious trouble, was not a matter of indifference. It was generally accompanied with moderate fever, and with a thin, brownish, slightly-purulent discharge, of somewhat offensive, but not putrefactive, odor. * "The smooth and rapid healing of the wound was inter- fered with. In some of the cases there was evidence of intes- tinal disorder; in others this was not apparent, and infection from without could not be excluded. "For the purpose of the present discussion, perhaps the chief interest of our observations concerning the colon bacillus is that they furnish illustration of the predisposition to infec- tion afforded by intestinal lesions, and also give example of the much-disputed mtto-infection." Park, at the same meeting, spoke of enterosepsis produced by this bacillus in cases of abdominal surgery. He said that, under some circumstances, it either escapes or is carried be- yond its normal limits, and, entering the portal circulation, perhaps the lymphatics as well, appears to set up septic dis- turbances w^hich are typified by the production of septic peri- 132 DISEASES OF THE EECTUM AND ANUS tonitis, and possibly other forms of septicemia in which the peritoneum does not primarily figure : a condition which Drs. Welch and Councilman call colon infection. The author will not attempt to do more than mention a few of the diseases in which the colon bacillus appears to be the most active agent. It has been known to manifest its pres- ence in the following conditions : — 1. Infectious diarrhea. 2. Empyema (following enteritis). 3. Broncho-pneumonia. 4. Endocarditis. 5. Cystitis. 6. Nephritis and pyelonephritis (surgical kidney). Y. Disorders of the liver (icterus). 8. Appendicitis. 9. Periappendical abscess. 10. Perforative peritonitis (also in cases of lesions of the intestine without a perforation). 11. Laparotomy wounds. 12. Strangulated hernia (in fluid of). 13. Perirectal abscess, etc. 14. Cholecystitis. A casual glance at the above diseases in which this germ is knoivn to be an etiologic factor is sufficient proof of its pathogenic and pyogenic properties. Until quite recently it was supposed that this germ did not enter the circulation and produce disease in distant parts unless there was a lesion of the intestinal mucosa. To-day such excellent authorities as Welch, Park, Councilman, and others teach that the bacillus coll communis may enter the circulation and produce distm-b- ances independent of any intestinal lesion. It is quite easy to understand the route by which it reaches and infects the genito-urinary tract and liver. It is not infrequently intro- duced into the urethra and bladder by means of an unclean sound or other instrument, and from thence to the kidneys through the ureters. As to reaching the liver, this normal inhabitant of the intestine very easily finds its way up the in- testine and through the common bile-duct to the organ, where it causes infection. It is remarkable that biliary infection is so rarely encountered. That portion of the subject which more especially con- AUTO-IXFECTION AND AUTOINTOXICATION 133 cerns those who are interested in rectal and anal diseases will now be considered. For a considerable time past the author has inclined to the belief that the colon bacilli, either alone or associated with some other bacteria, frequently cause peri- proctitis and ischio-rectal abscess, and possibly proctitis. If allowed to run an uninterrupted course proctitis often results in abscess, fistula, or a stricture, as the result of diminution of the lumen of the bowel by inflammatory deposits or vicious cicatrization following ulceration. If future investigations prove these intestinal bacteria to be the exciters of the inflam- mation and incidentally of the sequels, they will, in all prob- ability, also furnish an explanation of the cause of a large per- centage of strictures which, when they cannot be assigned to traumatism, syphilis, tuberculosis, dysentery, etc., are at pres- ent classified as due to "unknown causes." In order to obtain the latest information relative to this important subject. Dr. Roswell Park, of Buffalo, and Dr. Will- iam H. Welch, of Baltimore, were asked for opinions as to auto-infection, the part played therem by the colon bacillus, and what role, if any, this bacillus assumes in the causation or continuance of certain local diseases of the colon and rectum, such as proctitis, abscess, etc. The author takes this opportu- nity to publicly thank both Dr. Welch and Dr. Park for the many valuable suggestions contained in their replies, and deems it best to record their answers verbatim. De. Paek's Eeply Buffalo, June 21, 1894. Dk. S. G. Gant, Ninth and Grand Aveiiue, Kansas City, Mo. Dear Doctor: In reply to your favor of the 16th I would say that I send herewith one or two jDapers bearing on the subject of which you write, and that I must refer you also to a book published by me two years ago, entitled "Miitter Lectures on Surgical Pathology," in which I have devoted some little space to the matter of intestinal toxemia. This book was issued by J. H. Chambers & Co., of St. Louis. I regret that I have not a copy at hand which I could send you. The subject is to me one of very great impor- tance, and I am glad that you are going to devote some attention to it in your forthcoming work. I have no doubt that the colon bacillus does play an important role in diseases of the rectum and colon, but it is difficult to say under just what circumstances. In the light of the most recent investigations it occurs to me that perhaps a little too much importance has been assigned to it as the sole factor in these troubles, and that many cases in which it is prominent are due 134 DISEASES OF THE RECTUM AND ANUS to really a mixed infection by which the virulence of two or three different forms is vei-y much increased. It is, however, considered to be identical with the bacillus pyogenes fcetidus, which is a common organism in many cases of perirectal abscess. I have found them in various abscesses around the colon, higher up, and even on the right side, and of these I can say that at the time of opening, at least, the pus seemed to be pure culture of this organism. This ia not true, however, of all cases, by any means, and it may be that in most of them some other organism has been present and has died out, for many of them are of considerable standing. I have also, as reported in one of my papers, found pure cultures of colon bacillus in most cases of periappendical abscesses which I have thus investigated, and I do think that it is a most active factor in this kind of disturbance. I think the circumstances which most co-operate to make this organism virulent are the presence of certain putrefactive organisms combined with habitual constipation. Mere ulceration or abrasion of the mucosa, by itself, I think may predispose to virulence of effect of the organism, but such ulceration is not very likely to be brought about by the said causes which tend to make the organism more virulent. In reply to your third query as to whether the bacillus can enter the circulation through sound membranes, there is every reason to think it can. Numerous investigators have found it under many circumstances, and I con- sider it settled that this is possible. In reply to the fourth question, I think it is the case that the bacillus multiplies more abundantly when the stools are liquid, because such a condi- . tion furnishes a more suitable culture-medium for it, with a more lively dis- tribution; but I really cannot tell which of the two conditions, diarrhea or constipation, is more likely to cause auto-infection. In a general way I think that much depends upon the condition of the other eliminatory portions of the system. For instance, if there be oliguria, I think extra work is thrown upon the alimentary canal; and when to this is added the sluggishness of the skin in many anemic and debilitated indi- viduals, I think everything conspires to make the condition of the intestinal canal Avorse and more active. I think, also, much depends upon dilatation of the stomach, which is often present, in at least more or less degree, and upon the perfection of disposition of the stomach-contents. The presence of lactic and of fatty acids has much to do, I am sure, with the trouble, and yet I certainly cannot tell you just how, nor do I know of anyone who can. Eeasoning from the other direction, I am quite sure one gets valuable suggestions, if not exact knowledge, from the fact that the very best treatment, in my estimation, for operation, and especially for abdominal operations, con- sists largely of carefully purging for several days before the operation itself. This is with reference not only to the colon bacillus, but to all the organisms which inhabit the intestinal canal. If one remembers that the colon bacillus belongs primarily in the intestines, and that it is identical with other forms discovered by various observers, to which different roles have been assigned, one will get a better idea of the possibilities and properties of this organism. I have no doubt there are pure types of colon infection which produce peri- tonitis (this is particularly the case with appendical trouble), but, as every surgeon knows, these cases are not invariably fatal, and many observations • AUTO-INFECTION AND AUTO-INTOXICATION 135 conspire to prove the benefit of clearing out the alimentary canal when this condition is in its incipiency or perhaps merely threatening. I shall await the appearance of your forthcoming book with no little interest, and shall be very glad if in the slightest degree I have helped to call attention to this very important subject. Very sincerely yours, [Signed] Roswell Pabk. (Die. to steno.) De. Welch's Eeplt 935 St. Paul St., Baltimore, June 26, 1894. S. G. Gant, Esq., M.D., Kansas City, Mo. Dear Doctor: My first observation of invasion of internal organs of the body by the bacillus coli communis — and, I believe, the first on record — was reported by me to the Association of American Physicians in 1889, I think (1 have not the reference at hand). This was in a case of multiple fat-necrosis associated with diphtheritic colitis. In the article referred to by you in the Medical News I gave the conclusion reached up to that time. I have no doubt that the colon 'bacillus is a frequent invader of the circulation and internal organs, particularly the lungs, kidney, and liver, in cases with lesions of the intestinal mucosa, and sometimes without such lesion being demonstrable. In the great majority of these cases, in which we are able to demonstrate by culture at autopsy the presence of the colon bacillus outside of the intestinal tract, there is no evidence that such invasion has produced any damage. Micro- scopic sections show colon bacilli often abundantly in the blood-vessels of the kidney, and often in parts without evidence of lesion of the surrounding parts. These facts, it seems to me, justify skepticism about referring to the colon Mcillus as of great importance, as many nowadays do, even when it is present in inflammatory areas. One must consider whether, in such cases with actual lesion, it may not be a secondary invader in parts primarily diseased through some other agency, including other micro-organisms. I have, for example, found the colon bacillus in tuberculous pyelitis and in gonorrheal pyelitis. The primary micro-organisms may have died out and the colon bacillus, which is a resistant micro-organism, may survive alone and keep up the inflammation. Still, there are, of course, observations which leave little doubt that the colon bacillus may exert definite pathogenic action. I contend, however, that not a few cases recorded in which disease has been attributed to the colon bacillus will not stand critical scrutiny in the light of all the facts which are now known. In my paper on "Conditions Underlying the Infection of Wounds" (Transactions of the Congress of American Physicians and Surgeons, volume ii) I express myself with candor as to the pathogenic role of the colon bacillus. I am very skeptical about the prevalent view that the colon bacillus is the cause of appendicitis. Being a constant inhabitant of the intestine, it, of course, is present in the diseased as well as the normal appendix, but in the former case, in my experience, usually in association with unquestioned pyogenic bac- teria. The same has been my experience in perforative peritonitis, contrary to that of some French and Italian observers. The colon bacillus is so widely prev- 136 DISEASES OF THE RECTUM AND ANUS alent, it is so easy to cultivate on all media and at all temperatures, that I cannot help suspecting that often other bacteria were overlooked. As regards the relation of the colon Mcillus to proctitis and periproctitis, I doubt very much whether it is capable of causing either of these diseases in healthy tissue. It is certainly found with gi-eat regularity in perirectal ab- scesses, usually, I think, in combination with other bacteria of proven pyogenic power, but sometimes in pure culture. In the latter case, however, I should suspect previous disease of the part from some other agent, although, given this primary lesion, the colon bacillus may be a factor of importance in pro- ducing and confirming the suppuration. As regards the general subject of auto-infection from the intestinal canal, of course, although the colon bacillns is the most common invader, other bac- teria may likewise enter through this portal, notably the pyogenic micrococci. Definite lesions of the intestinal mucosa here, too, are important predisposing factors, as is illustrated in some cases of secondary infection in dysentery, typhoid fever, etc. As regards the predisposing influence to infection, which may be exerted by absorption of toxic substances, products of decomposition, etc., from the intestinal canal, it seems to me that we have very little definite information, although plenty of speculation. The question of invasion of the colon bacillus and its pathogenic signifi- cance were considered by me in the "Middleton Goldsmith Lecture"' before the Pathological Society of New York at the end of last. April. The lecture has not been published, but will appear in the New York Medical Journal in the course of a couple of months. I must refer you to that for a fuller statement of my views on this subject. Hoping that I may have touched upon some of the points on which you desired my views, I am. Very truly yours, [Signed] William H. Welch. TREATMENT The author will not attempt a detailed discussion of the many remedies that have been suggested for the prevention and relief of auto-intoxication of intestinal origin, but will mention only the more important measures that have been adopted. The treatment should be, in a large measure, prophylactic. Every effort should be made to keep the system in perfect order and the equilibrium maintained ; so long as this is ac- complished, Nature is capable of defending herself against any and all toxic substances generated within the body. Any dis- ease or symptom of a disease that predisposes a patient to auto-intoxication from poisons normally generated within the body must be eradicated at once. There are three essential AUTO-INFECTION AND AUTO-INTOXICATION 137 features that must be constantly borne in mind in the treat- ment of auto-intoxication : — 1. Any condition which predisposes the patient to seh'- intoxication must be remedied. 2. Every possible means should be employed to prevent the abnormal production and absorption of poisons within the intestinal canal. 3. Nature should be assisted in every way to neutralize and eliminate poisons already absorbed. For accomplishment of the first any condition that will erode or weaken the mucosa in any way must be corrected, because it prepares a portal for the entrance into the circula- tion of toxic substances from the intestine. Hence, irritative discharges of all kinds must be corrected, ulcers and fissures must be healed, and hemorrhoids, polyps, and other growths removed. In. fact, any local disease of the rectum and colon must be eradicated, otherwise all efforts directed toward the prevention and relief of auto-intoxication will be of no avail. There are some cases in which no local cause can be ascer- tr.ined. Even in these cases the hygienic condition of the bowel should be improved, so far as possible, by frequent flushings of the colon with sterile water and antiseptic solu- tions. In such instances a cause must then be sought else- where, and in all probability it will be found to be either diarrhea or constipation and fecal impaction. When due to either,' the fine of treatment previously laid down in the chap- ters devoted to these subjects should be carried out. When- ever an irritant is present within the intestinal canal promoting auto-intoxication, the safest plan is to give a vigorous cathartic, a mercurial if preferred, which will cause its expulsion. Laxa- tive tonic treatment must then be instituted and continued for a long or a short period, according to the extent and chro- nicity of the infection. Very often poisonous substances can be eliminated from the system by the constant and liberal use of reputable mineral waters known to have a cathartic action. Sometimes it will be necessary to administer, in addition, a pill composed of aloin, strychnine, and belladonna, or one com- posed of the lactate of iron, extract of nux vomica, and puri- fied aloes, given three times a day. Perhaps the most striking example of the importance of cleansing the intestinal canal is to be seen after abdominal operations. All have observed the 138 DISEASES OF THE RECTUM AND ANUS temperature of a patient suddenly rise two or three days after an operation. The wound being healthy, the surgeon is at a loss to account for the disturbance. Finally, a cathartic is ad- ministered, the bowel is cleansed of accumulated feces, and immediately the temperature returns to normal. In the treatment of auto-intoxication it is necessary to correct errors in diet, prohibit the use of alcoholic stimulants, and have the patient take only such foods as can be digested easily. As a special diet milk is to be recommended. Experi- ence has proven that it is opposed to all sources of intoxication and checks auto-intoxication due to intestinal putrefaction. To prevent the abnormal production and absorption of poisons, intestinal antiseptics, both local and systemic, should be employed. Perhaps the best general antiseptics, either alone or in combination, are the iodides of potassium and so- dium. The author has many times witnessed beneficial results from the continued use of these drugs in cases where the sys- tem was saturated with poisons. Many drugs are highly com- mended as intestinal antiseptics. Such are iodine, creosote, ben- zoic acid, boric acid, salol, resorcin, turpentine, the mercurials, etc. In passing through the alimentary canal many of these undergo changes which diminish their activity before they reach the colon. The best results are usually obtained from drugs which remain unchanged throughout their course, such as bismuth salicylate, salol, iodoform, and naphthalin. When salicylic acid accumulates in the blood and threatens compli- cations, bismuth subnitrate may be substituted. In giving these intestinal antiseptics it is not necessary that the dose should be sufficiently large to kill the bacteria, but large enough to render them dormant, as it were, thereby preventing their multiplication. To neutralize poisons already formed and to prevent fermentation and putrefaction the writer knows of nothing better than bismuth subnitrate in combination with charcoal. He prescribes a powder containing 10 grains (0.65 gram) of each, to be repeated at short intervals until there is evidence of relief, such as a diminution of tympanites and of tenderness over the abdomen. The bismuth seems to prevent putrefactive fermentation, while the charcoal diminishes the toxins. Iodoform may be combined with charcoal or naph- thalin to accomplish the same purpose. To diminish fecal odor and toxicity, Bouchard combines 75 grains (5 grams) AUTO-INFECTION AND AUTO-INTOXICATION 139 of naphthalin with an equal amount of sugar made aromatic with 1 or 2 drops of bergamot. This mixture he divides into twenty powders, and gives one every hour. He claims that putrefaction within the intestinal canal may be completely sup- pressed by this combination. Much can be accomplished in eliminating the toxic condition of the intestines by means of antiseptic sprays and irrigations. The last feature in the treatment consists in assisting Nature to neutralize and eliminate poisons which have already entered the circulation. To accomplish this the emunctories must be in perfect order, for, when the function of any one of the excretory organs is deranged, poisons immediately accu- mulate in such quantities that Nature can neither neutralize nor eliminate them. The blood must be enriched by tonics, the liver and the kidneys stimulated to renewed activity by appro- priate medicines, and the skin kept in order by frequent cold baths, followed by a brisk toweling. In addition to this, pa- tients suffering from auto-intoxication must lead a simple, regular, active, occupied life, and should not be allowed to seek solitude and brood over their condition. LITERATURE ON AUTO-INFECTION Bouchard, Ch.; "Auto-intoxication in Disease." The F. A. Davis Company, 1894. Hickman, J. W., Tacoma, Wash.: "Auto-infection," Medical Sentinel. Ingersoll: The Critique (Denver), Feb., 1899. Keyes, Edward L., New York City: "Nephritis in its Surgical Aspects," Ameri- can Journal of the Medical Sciences, June, 1894. Park, Roswell, Buffalo, N. Y.: "The Importance to the Surgeon of Familiar- ity with the Bacillus Coli Communis," Annals of Surgery, Sept., 1893. "Lectures on Surgical Pathology." J. H. Chambers & Company, St. Louis, 1892. Sternberg, G. M., Washington, D. C. : "The Bacteriology of Pyelonephritis," American Journal of the Medical Sciences, June, 1894. Stuver: Denver Medical Times, Feb., 1899. Verden, J. E., Indianapolis: "Auto-infection from the Intestinal Canal," In- diana Medical Journal, July, 1893. Welch, William H., Baltimore, Md.: "Conditions Underlying the Infection of Wounds," Transactions of the Congress of American Physicians and Surgeons, vol. ii, 1889. CHAPTER IX CHRONIC DIARRHEA DUE TO DISEASE OF THE COLON AND RECTUM In the chapter on symptomatology of rectal disease it is stated that diarrhea (frequent stools) is a common symptom of certain rectal affections. It is the purpose of the present chapter to consider this form of diarrhea in detail, to point out its importance as a manifestation of disease of the lower bowel, and to discuss the local treatment to be employed for its relief. Each year the author treats many patients for the relief of some rectal trouble of which diarrhea is a persistent symptom. These sufferers usually give a history of weeks or months of unsuccessful internal medication, which was undoubtedly due to the fact that the frequent stools were dependent upon local disease of some part of the terminal colon. Those patients coming under the care of the writer were permanently relieved by some trivial operation or by topic applications. The author has also treated patients in whom the irritating- discharges of an antecedent diarrhea caused a rectal disease by passage over the sensitive mucous membrane. In such cases, when the original cause is removed and the rectal disease remains un- cared for, the latter becomes an independent source of irrita- tion, excites peristalsis and frequent stools, and thus produces a condition in every way similar to that from which it origi- nated. Any one of the diseases below enumerated, located either in the rectum, sigmoid, or colon, will cause "chronic diarrhea." For this reason the author will discuss them sep- arately in order that their diagnostic significance may the more fully be pointed out. 1. Chronic proctitis (ca- 4. Malignant disease. tarrh). 5. Prolapse. 2. Stricture. 6. Polyps. 3. Ulceration. 7. Fecal impaction. 8. Deviated coccyx. Chronic Inflammation of the rectum is quite common, and is due principally to the functions of this organ. By the time (140) CHRONIC DIARRHEA 141 the intestinal contents reaches the lower bowel, it is firm and frequently nodular ; it remains in the colon a much longer time than in other parts of the intestine, and during peristalsis is frequently jostled from side to side against the sensitive mu- cous membrane. Again, the feces undergo certain putrefactive changes, thus exposing any unsound portions of the mucosa to the action of septic organisms contained therein; as a result, an inflammation accompanied by frequent discharge of large quantities of mucus is started, which is frequently mistaken for ordinary diarrhea. A Stricture from any cause sufficiently marked to produce mechanic obstruction will cause diarrheal symptoms for two reasons : first, because of ulceration at and above the point of constriction, the nerve-filaments are exposed to the feces, a peristalsis is started and continued, resulting in frequent stools; second, liquid feces pass the obstruction, while those more solid accumulate above it, become hard, irregular in shape, and cov- ered with a glairy mucus. As a result- of pressure exerted by the solid feces, there is constant, but ineffectual, eft'ort to empty the bowel ; the mass acts as a valve, inducing abnormal peri- stalsis and straining, which cause frequent discharges of liquid feces without affording any relief, although most of the pa- tient's time is spent in the closet. Anyone who has done much rectal surgery must have noticed the frequency of chronic diarrhea as a symptom of ulceration of the rectum and sigmoid. When the mucous mem- brane becomes denuded from any cause it soon becomes irri- table, and any little particles of fecal matter lodging at such a point, or the passage over it of an irritating discharge, will prove sufficient to excite frequent and prolonged peristalsis, resulting in tenesmus and frequent stools. Because of the obstruction and accompanying ulceration, diarrhea constitutes one of the most troublesome symptoms encountered in the treatment of cancer of the rectum or colon. The constant straining which these sufferers have to bear is distressing to behold. The author has had under his care many patients suffering from cancerous stricture of the rectum mani- festing the above symptoms who have been treated for diar- rhea for months, rectal disease never having been suspected. Rectal Prolapse, or invagination of the rectum or sigmoid, acts as a source of irritation. It is frequently mistaken and 142 DISEASES OF THE RECTUM AND ANUS treated for chronic diarrhea, because of the frequent discharge of large quantities of mucus. Polyps, when located in the lower bowel, excite an abnor- mal secretion of mucus, which is passed at frequent intervals, and may be mistaken for a chronic diarrhea from other causes. It is a well-known fact that diarrhea is sometimes a symp- tom of fecal impaction, for the reason that well-formed feces cannot get by the impacted mass. After a time the latter acts as a source of irritation, excites peristalsis, and then permits only liquid feces to pass through or around it at frequent in- tervals. A Deformed Coccyx pointing forward or backward may pro- duce symptoms simulating chronic diarrhea as a result of reflex disturbances. Usually it points forward and pushes the rectum inward, thereby offering an obstruction to the free exit of the feces. The author had under his care two patients who, for a number of years, had been unsuccessfully treated for chronic diarrhea. In both instances ulceration, which penetrated the rectum, was present over the end of the bone. In each the coccyx was excised, the opening closed, and the patient made a rapid and uninterrupted recovery. The condition of the rectum in cases of chronic diarrhea depends upon the disease which produces it, as well as the length of time it has existed. When due to a prolapse, polyp, colitis, proctitis, or an impaction, the mucous membrane will ap- pear congested, thickened, and covered with thick glairy mu- cus, pus, or both; when not speedily corrected, the membrane soon loses its smooth, velvety appearance, becomes much thick- ened, indurated, and firmly attached to the submucous tissues, sometimes forming long, tubular stricture. When ulceration, stricture, and malignancy are the cause, the mucous membrane in the earher stages looks very much like that just referred to; when, however, the ulceration begins to extend, it loses its smoothness, and appears ragged to the touch ; when stricture is present the finger introduced into the bowel will meet with many irregular-shaped nodules, cavities, or cicatricial bands, and when passed through the constriction, no matter whether the latter be due to syphilis or cancer, there is felt a sensation similar to that produced by a strong rubber band placed around the end of the finger. CHRONIC DIARRHEA 143 SYMPTOMS AND DIAGNOSIS Pain, tenesmus, and frequent stools are undoubtedly the most frequent symptoms that these sufferers complain of, and they vary considerably; in one case they will be mild, in an- other severe, depending upon both the disease and the extent to which it has progressed. When due to polyps, prolapse, im- paction, deviated coccyx, chronic colitis, or proctitis, the symptoms' are very much ahke; in all probability there will be from six to ten stools daily, accompanied by smarting, burning pain, tenesmus, and eversion of the mucous membrane. When either a prolapse or a polyp is present, in addition to the above symptoms the patient will complain of something protruding from the anus. A microscopic examination of the feces should be made in every case (see chapter on examination), for in this way many valuable points can be gained which will be of assistance in clearing up the diagnosis. The stools are usually liquid or semisolid and composed largely of mucus, which is now and then mixed with pus and blood, when ulceration has com- menced. Some of these patients occasionally complain of pain and uneasiness along the small or large intestine, followed on the morrow by the passage of shreds of mucus or perfect casts of the bowel, which at first appear to be the mucous membrane ; when pulled apart, however, the latter prove to be a thick ex- udation resembling the false membrane seen in diphtheria. Here we have a membranous enterocolitis supposed to be of nervous origin, for its pathology remains obscure. When there is prolonged irritation of the mucous membrane from any of the diseases enumerated,- the sphincters alternately con- tract and relax, causing the patient much annoyance; some- times these muscles become exhausted and remain passive, necessitating the wearing of a napkin to prevent escape of feces. In addition to the symptoms mentioned, there may be reflex disturbances in the neighboring organs, and pains in the back, abdomen, and down the limbs. The most annoying symptoms, however, are almost constant straining and never-ceasing desire to empty the bowel. These sufiferers have a haggard expres- sion, sallow complexion, and hollow eyes; they are extremely nervous, and many acquire the habit of resorting to an opiate for relief of their suffering. It is easy to make a dia^osis in these cases if the his- 144 DISEASES OF THE RECTUM AND ANUS tory is first secured, and then a thorough, ocular, digital, mi- croscopic, specular, and procto-colonic examination made. Chronic catarrh will be recognized by the appeara,nce of the mucous membrane : it is congested, thickened, and covered with thick, tenacious mucus. A sweep of the finger around the rectal wall will easily detect the presence of a polyp, be- cause of its attachment by a long, narrow pedicle. Rectal pro- lapse cannot be mistaken for other conditions because of the everted mucous membrane, globular form of the tumor, the central sht, and the fact that the entire circumference of the bowel is involved. When ulceration is present the mucous membrane is irregular and thickened to the touch, and when a speculum is used the ulcers are readily seen. Malignant dis- ease and stricture are recognized by the diminution in the caliber of the bowel as a result of cicatricial bands or from hard, nod- ular tumors accompanied with ulceration at and above the con- striction. The prognosis of diarrhea dependent upon either chronic ca- tarrh, prolapse, polyp, or deviated coccyx is, under ordinary cir- cumstances, good. When due to benign stricture and ulceration it is good in so far as a fatal termination is concerned. There are cases, however, which will require long treatment, and some in which nothing beyond a fairly comfortable existence can be promised. In malignant disease the prognosis is exceed- ingly unfavorable, and, unless the disease is removed at its inception, death will follow in a short time. The life of cancer patients may, however, be extended and their existence made more comfortable if they will submit to proper treatment. TREATMENT Since the treatment of those rectal diseases, such as chronic proctitis, stricture, ulceration, etc., which give rise to diarrheal symptoms has been given in detail in chapters de- voted to these afifections, it is unnecessary to give here more than a general outline of the treatment. The diet should be restricted to non-irritating, easily di- gestible foods, such as soup, soft-boiled eggs, pure beef-juice, broiled steak, and plenty of milk in those cases in which it does not produce an overabundance of gas. Regular hours for eat- ing, sleeping, exercising, and attending to the calls of Nature CHRONIC DIARRHEA 145 must be insisted upon, for it is a well-known fact that irregu- larities in living are responsible for many of these conditions. There are two essential features in the treatment of chronic proctitis: first, absolute rest in bed; second, absence from the bowel of all irritating ingesta. In addition, the rectum and colon must be flushed daily with copious injections of boiled, filtered water and antiseptic and astringent solutions. The writer has had splendid results from the semiweekly injection through a colon-tube of 20 to 30 grains (130 to 200 centigrams) of silver nitrate to the quart (1 liter) of water. The days on which silver nitrate is not used the colon may be irrigated with alum-water, — say, a teaspoonful (4 cubic centimeters) to the quart (1 liter). There are many other remedies that will render good service. A favorite combination of the author's is biborate of soda, V2 drachm (2 cubic centimeters) ; fluid extract of krameria, ^/a ounce (15 cubic centimeters); water, 3 ounces (90 cubic centimeters), to be injected into the colon and left there for half an hour. Olive-oil, 1 pint (500 cubic centime- ters) ; bismuth subnitrate, 3 ounces (90 grams) ; iodoform, 1 drachm (4 grams), is another time-tried remedy. From 2 to 3 ounces (60 to 90 cubic centimeters) of this mixture, used every other day, has a very soothing and beneficial effect. Un- less the operator is skilled in this work it is not an easy thing to insert the colon-tube, because of the obstruction offered by Houston's "valves," and the tortuosity of the intestine; it is most important to have a good, strong, reliable syringe. A fountain-syringe will do to flush out the rectum, but, when heavy, thick, oily solutions are to be thrown high into the colon, a Davidson or piston- syringe is preferable, for two reasons : In the first place, when attached to the tube, if the end of the latter gets caught under one of the "valves" or a fold of the mem- brane, water can be forced through with sufficient force to over- come the obstruction and the tube will pass upward into the sigmoid and colon. In the second place, the exact amount of medication it is desirable to use can be thrown into the bowel ; on the other hand, when a fountain-syringe is used, if the mixt- ure is heavy, a considerable portion is lost in the tubing. Stricture of the rectum requires both palliative and opera- tive treatment. The object of the first is to alleviate pain and give rest to the patient. It is best secured by keeping the bowel open and clean by flushing with antiseptic solutions, to 10 146 DISEASES OF THE RECTUM AND ANUS be followed by soothing lotions, topic applications, and oint- ments. The best operative procedures for the relief of strict- ure are three in number, viz.: (1) colotomy; (2) posterior proctotomy; (3) dilatation, either gradual or forcible. By the first a new outlet is made for the feces; the diar- rheal symptoms disappear, because the source of irritation and obstruction are removed. In the second and third, relief is obtained because after either operation there is no obstruction to the passage of the solid feces, and the ulceration present which excites peristalsis can soon be cured. In cancer the in- dications for treatment are almost identic with those of strict- ure; about the only exception is when the growth is removed by excision. The treatment of polyps is simple : they are caught, pulled down, clamped, cut off, and cauterized ; or they may be twisted off with a pair of forceps, or ligated and excised. A prolapse, when extensive, will require an operation. The simplest and best is linear cauterization with a Paquelin cau- tery, making the lines half an inch (1.27 centimeters) apart and about two inches (5.04 centimeters) long, extending down and into the sphincter-muscle. Excision of a portion of the rectum has been resorted to, but has not given satisfaction. Mild cases, especially in children, can be cured by astringent injections, such as alum, zinc, and black-oak bark; besides this the patient must assume the recumbent position during defecation to pre- vent too much straining ; during the intervals of defecation the buttocks should be firmly strapped together with adhesive plaster. Simple ulceration of the rectum or sigmoid will heal if kept clean and stimulated by such remedies as silver nitrate, 15 or 20 grains (1.30 grams) to the ounce (30 cubic centimeters) ; the balsam of Peru, fluid extract of krameria, calomel, or the stearate of zinc with iodoform, menthol, or ichthyol. When chronic, it will be necessary to resort to radical measures, and either divulse or incise the sphincter-muscle and curette the ulcers ; the after-treatment consists in keeping the rectum clean and applying stimulating remedies. For immediate relief of fecal impaction the most reliable remedies are copious injections of water, soap-suds, oil, or tur- pentine ; these should be continued every fev/ hours until the fecal mass is removed. When the impaction is in the sigmoid, CHRONIC DIARRHEA 147 massage will sometimes assist in breaking up the accumulation ; on the other hand, when it is situated low down in the rectum and enemata fail to bring it away, it will be necessary to divulse the sphincter, insert the fingers, and break up and remove the mass in sections. When the end of the coccyx is misplaced sufficiently to cause irritation and bring on diarrhea, an incision should be made down to the bone and one, two, or three sections of the coccyx excised, as the case demands. In conclusion, the author wishes to state that he does not believe that all cases of chronic diarrhea are due to disease of the terminal portion of the bowel. He is of the opinion, how- ever, that the source of irritation producing frequent evacua- tions is more frequently located in the rectum than is generally supposed. For this reason he recommends examination of the rectum and colon in every case in which internal medication fails to relieve the diarrheal symptoms within two months. The practitioner who does this regularly will be amply repaid for his trouble; he will make a correct diagnosis and be able to cure many of those sufferers who drift from one physician to another without receiving any benefit. ILLUSTRATIVE CASES Case I. Chronic Diarrhea Caused by Ulceration. — This case is pre- sented because of its interest to both the sui'geon and general practitioner. The patient was a married lady 30 years old. She stated that she had suffered from diarrhea for five years, often going to the closet eight or ten times a day; various medicines prescribed by prominent physicians had been experimented with and patent nostrums had been taken, all to no purpose. A Chinese doctor had been consulted and failed to effect a cure. Osteopathy and Christian Science Avere then tried with negative result. Be- coming discouraged, she appealed to her family physician, who referred her to me for treatment. An examination revealed the presence of several ulcers extending from the upper margin of the external sphincter to the upper por- tion of the internal. They varied in size from the .diameter of a green pea to one inch (2.54 centimeters), the largest one being on the posterior surface. After the patient was anesthetized and the sphincter divulsed, I curetted the ulcers and incised the large one, which was situated directly over the sphincter- muscle. The ulcerated area was then brushed over with silver nitrate. On the third day after operation the patient had a fecal movement. The rectum was then irrigated and silver nitrate again applied to the ulcer. The same procedure was carried out every three days for a month, when the ulcers were entirely healed. During this time there was not the slightest tendency td diarrhea. At the end of six weeks the patient disappeared, and was lost sight 148 DISEASES OF THE RECTUM AND ANUS of for twelve months, when she called at my office and informed me of her entire recovery. Case II. Chronic Diarrhea Caused by Rectal Polyps. — Mr. W. B., photographer, suffering from a chronic diarrhea of four years' standing, came to me with the following symptoms: He had from four to ten dejections daily, which were accompanied by much pain and straining. The stools were always liquid, and consisted largely of mucus. The bowel felt as if some foreign body were within the rectum, exciting almost constant irrita- tion and desire to go to stool. On account of the large quantities of mucus discharged, some local disease of the colon or the rectum was suspected, and a digital examination was therefore at once made. Immediately upon introduction of the finger, a large, soft, polypoid tumor the size of an English walnut was detected. Further examination revealed the presence of another polyp of equal size. The finger could be passed around these growths, and their attachment to the rectal wall was located with little difficulty. Treatment. — The patient was chloroformed, placed in lithotomy-position, and the rectum irrigated. The polyps were seized in turn, pulled downward, and the author's clamp tightly adjusted to the pedicle at its junction with the raucous membrane. That portion of the growth external to the clamp was then excised (as in the operation for hemorrhoids) and the stump carefully cauterized with a Paquelin cautery. The patient was placed in bed and the nurse instructed to keep him quiet for thirty-six hours. On the third day his bowels acted, and he Avas allowed to walk around. At the end of one week he returned to the photograph gallery, and from that time to the present, two years after the operation, he has had no diarrhea. This case is offered for the reason that it proves beyond doubt that the frequent stools were the result of the irritation excited by the presence of the polyps, and not from any abnormal condition of the stomach or small intestine. CHAPTER X DISEASES, INJURIES, AND TUMORS OF THE COCCYX The diseases and injuries of the os coccyx have received but slight attention at the hands of the general practitioner, surgeon, and rectal specialist. The author is not acquainted with a single work devoted to diseases of the rectum and anus or general surgery which contains a description of the various ailments common to this region. Yet he has had many pa- tients come to him who were suffering from intense pain in the rectum — ulceration, hemorrhages, diarrhea, constipation, ab- scess, fistulas, and other pathologic conditions of the lower bowel — induced by a coccygeal tumor, or a deformed, fract- ured, or necrosed coccyx. In every such case a prompt recovery followed the trivial operation necessary for the removal of the irritation. • | The good results thus obtained have induced the author to set apart a separate chapter for the consideration of this class of affections. They will be described under the following headings : — 1. Malformations of the 5. Sacro-coccygeal tumors coccyx. and cysts. 2. Coccygeal body and its 6. Syphilis of the coccyx, diseases. 7. Tuberculosis of the coc- 3. Coccygodynia. cyx. 4. Fractures, dislocations, injuries, and necrosis of the coccyx. MALFORMATION (ABNORMALITIES) OF THE COCCYX It not infrequently happens that there is a congenital de- formity of the coccyx, and occasionally it is entirely absent. The OS coccyx may deviate to either side : lateral curvature; forward against the rectum : anterior curvature (Fig. 46) ; or backward, showing prominently beneath the skin : posterior curvature (Fig. 47). In forzvard deformity the rectum is caught between fecal accumulations and the end of the bone, causing (149) 150 DISEASES OF THE RECTUM AND ANUS ulceration, and sometimes perforation and projection of the tip of the bone into the bowel. In posterior curvature the skin over the bone may be normal, bluish in color, or ulcerated, depending upon the amount of tension and irritation. Symptoms. — Pain in the neighborhood of and over the end of the bone is the most frequent manifestation of a deformed coccyx. It is greatly increased when the patient lies upon a hard cot, sits on a hard chair, or rides in a street-car. When anterior displacement is present, constipation and defecation aggravate the condition. Suffering is greatest just before stool, and is greatly relieved by it. When there is ulceration Pig. 46.— Diagrammatic Drawing Showing Deviation of the Coccyx Anteriorly. and the end of the bone projects into the bowel, there will be discharges of pus, blood, and mucus, and frequently chronic diarrhea. In some instances it has been necessary to fracture the bone or remove it during labor in order to deliver the child. One case of severe scalp wound in an infant, caused during labor by a deformed coccyx, has been recorded. Chorea and other nervous phenomena occur sooner or later in these cases. Treatment. — The offending bone should be removed in the manner described elsewhere in this chapter. When labor is delayed by a deformed coccyx, the bone should be pushed backward with the thumb and fractured. It will give way with a snap. DISEASES, INJURIES, AND TUMORS OF COCCYX 151 Floating Coccyx is the name given to this bone where it is freely movable in all directions and appears to be detached from the sacrum. Such a condition may be congenital or the result of a sudden and severe injury. Treatment. — Because of the location and activity of the ligaments and muscles attached, it is a very difficult matter to fix and retain the coccyx in its natural situation. This may be attempted by sutures or plugging the rectum; the best results, however, are derived from complete extirpation at the earliest opportunity. Fig. 47. — Diagrammatic Drawing Showing Deviation of the Coccyx Posteriorly. Entire Absence of the Coccyx is a rare form of congenital deformity. The author has seen but two cases, and both of these in men who consulted him for relief from some other painful affection of the anus. Both were congenital, and did not interfere in any way with the functions of the anus, rectum, or bladder. Indeed, they did not cause any disturbance of sufficient importance to attract attention to these parts. The place of the bone was filled by dense fascia, with which the ligaments and muscles usually attached to the coccyx appeared to be continuous. The history of one of these cases is given at the end of this chapter. 152 DISEASES OF THE RECTUM AND ANUS COCCYGEAL BODY AND ITS DISEASES Synonyms. — Glandula coccygea ; Luschka's gland ; coccyg- eal gland ; glomeruli arteriosi coccygei. History and Anatomy. — In 1859 Luschka discovered a small body, of split-pea size, upon the inner surface of the second coccygeal segment, just in the interval between the attachments of the levator ani muscle. It was attached by a pedicle composed of small, club-shaped branches of the middle sacral artery and filaments of the sympathetic nerve. Sometimes it appeared as one large corpuscle ; at others it seemed to be composed of a number of corpuscles held to- gether by connective tissue inclosing glandular elements (hence the name), and received its nerve-supply from the coccygeal ganglion. In 1864 Arnold disproved the glandular theory of Luschka by injecting the middle sacral artery, completely fill- ing every part of the coccygeal body, and demonstrating that it was composed of the terminal branches of the artery, and resembled in appearance a bunch of grapes. He then renamed it the ''glomeruli arteriosi coccygei^ Two years later Krause and Meyer verified Arnold's experiments, and claimed to have discovered a similar body in the monkey. Banks, in the same year, demonstrated the constancy of this body, and gave the following description of it: Structure: "It had a gelatinous appearance; one section contained numerous cavities, filled with cells and granules encircled by nucleated fibers, and the twigs of the artery had the usual endothelial lining." Arnold, Krause, and Banks held that the coccygeal body had no specific function beyond being an appendage and a help to the middle sacral artery, as are the caudal and auxiliary hearts in some animals, and neither believed it to be the vestigeal remains of a fetal organ. This gland (or body) resembles in some respects the ca- rotid gland ; the descriptions of it found in modern text-books on anatomy are meager, unsatisfactory, and furnish little in- formation beyond what is obtainable from descriptions given by the original investigators already mentioned. Pathology. — Very little is known of the pathologic changes which take place in this little body. Luschka held to the opinion that the peculiar pains situated in the neighborhood of the coccyx, known as coccygodynia, and which are so com- mon in women, are due to inflammation of this body. He DISEASES, INJURIES, AND TUMORS OF COCCYX 153 further taught that most, if not all, perineal cysts had their origin at this point. Banks was not in accord with the views of Luschka. He believed that the coccygeal body was the starting-point of cysto-sarconiatous tumors. The author is of the opinion that the coccygeal gland occasionally becomes inflamed and swollen from exposure, injury, the pressure of tumors or hardened feces, and inflammatory or other destructive changes of the rectum which extend to this region. It may be that posterior fistulas which have their outlet near the tip of the coccyx are caused by changes in this body; certainly their etiology cannot always be accounted for in other ways. The author has removed two cysts of orange size from the peri- neum, one in a man and the other in a woman, both of which were closely attached to the lower and inner surface of the coccyx, and it is not improbable that they were caused by a degeneration of Luschka's gland. Symptoms. — When inflamed, the coccygeal gland becomes swollen, and tender on pressure. Pain is increased by moving the coccyx and also before and during defecation, especially when the feces are hard and nodular ; it is aching in character and located at the lower end of the spine. Diagnosis. — When the gland is enlarged it can be located with comparative ease by passing the right index finger in the bowel and then backward, when the coccyx is seized between it and the thumb of the same hand on the outside. It varies under such circumstances from pea to cherry size, and is pain- ful when pressed upon. It is quite firm, round, and is slightly movable. Such at least were the sensations imparted to the finger of the author in two cases diagnosticated as inflamma- tion of this body. Treatment. — Relief usually foHows the application of the ice-pack over the coccyx and cold irrigation per rectum. Hot applications and suppositories are also serviceable. When these remedies fail, the coccyx, including the gland, should be extirpated. Relief will be prompt and no unpleasant sequels are likely to follow. COCCYQODYNIA Pain in the coccyx, its joints, or at the sacro-coccygeal articulation is a frequent persistent and painful affection. This condition was first described in a clear and concise manner by 154 DISEASES OF THE RECTUM AND ANUS Dr. J. C. Nott, of New York, in 1844. He not only pointed out the principal manifestations of coccygodynia, but suggested a practical remedy for its permanent relief, namely: that of excision of all or a part of the coccyx. Many writers have given to Prof. J. Y. Simpson, of Edinburgh, the praise for first calling attention to this ailment, notwithstanding the fact that his lecture upon this topic was not delivered until 1859, or nearly fifteen years after the published article of Dr. Nott. Coccygodynia is common to both sexes, but is encountered more frequently in women, especially in those who have borne children. It usually occurs between the ages of twenty and forty and in persons of a nervous temperament; it is rarely met with in old persons and young children. It is found with greater frequency in lean than in stout individuals, because the caudal bone in the latter is fairly well protected from injury by a cushion of fat. Etiology and Pathology. — Coccygodynia may be caused by exposure, rheumatic changes in the ligaments and muscles, caries, or, in fact, anything which results in an inflammation of the coccyx, its periosteum and articulations. Again, it may be induced by spasmodic or prolonged contraction of the vari- ous muscles and ligaments attached to the os coccyx. It is fre- quently induced by fissures, hemorrhoids, and ulceration, as well as by uterine, vaginal, and prostatic disturbance, which excites contraction of the muscles in this region. Coccygodynia may be caused by constipation when the fecal accumulations are hard, nodular, and catch the rectum between them and the bone, pressing the latter backward. It may result from displacement of the coccyx by rectal or coccygeal tumors, from syphilis or tuberculosis of the os coccyx, inflammation of the coccygeal body (Luschka), neuroses of the coccygeal plexus (Payer), and from emotional or intellectual strain inducing hysteria (Bremer). Symptoms. — Increased pain on pressure over the coccyx and when sitting or lying down and when leaning forward. Pain is increased by defecation, and these patients are uncom- fortable when on the cars, horseback-riding, and, in fact, at all times while exercising. Some of them suffer continuously, others at short intervals, and still others have only one or two attacks in a year. The pain is aching in character, and is located over the lower sacrum and coccyx. Persons long DISEASES, INJURIES, AND TUMORS OF COCCYX 155 affiicted with coccygodynia are extremely nervous. The con- dition is aggravated by coughing, sneezing, straining, and any- thing which causes pressure on the coccyx, or produces undue actiz'ity of the muscles attached to it. Diagnosis. — The diagnosis of coccygodynia is easily made by the physician who has learned to be on the lookout for it. Unfortunately for this class of sufferers, their real condition is frequently unrecognized, and they are treated indefinitely for some other complaint. It is essential to examine the rec- tum thoroughly in every case, because pains simulating those of coccygodynia are frequently induced by a variety of diseases situated in this organ. The urethra, bladder, vagina, uterus, and prostate should not be overlooked, for it must be remem- bered that the seat of pain is not always at the seat of the dis- ease. In all doubtful cases in the absence of disease in neighbor- ing organs, with a history of injury to the coccyx, and unbearable, dull, aching pains in this region, aggravated by pressure over the tip of the bone, a diagnosis of coccygodynia should, be made. In order to detect the amount of pain on motion, or whether there is dislocation, deformity, or fracture of the coccyx, the right index finger should be passed into the rectum and then backward until the end of the bone is located and seized be- tween the finger and the thumb, when the desired manipula- tions of the bone may be completed. Coccygodynia and neuralgia of the rectum are frequently mistaken one for the other, and it is extremely difficult to distinguish between them. In the former pain is always intensified during contraction of the muscles attached to the coccyx, while in the latter such activity does not seem to make rhuch difference. Prognosis. — The prognosis of coccygod3mia is good in the majority of cases when it is properly treated. Much better results are to be had from surgical than medical treatment. By means of the former a speedy cure can be had, while by the latter recovery is usually slow and frequently unsatisfac- tory. Treatment. — Non-operative measures will occasionally effect a permanent cure; but in most cases they are of service only because they offer to the patient temporary relief. Rest is essential, and every precaution should be taken to prevent spasm of the coccygeal muscles, thereby reducing pain by 156 DISEASES OF THE RECTUM AND ANUS giving rest to the inflamed joints of the coccyx. This is best accomphshed by hot apphcations or counter-irritants over the sacro-coccygeal region, and by frequent rectal injections of hot water or oil, the latter being preferable because it retains heat the longer. Cold is not desirable, for in this region its tend- ency is to excite muscular contraction. Cauterization with the Paquelin cautery is frequently efficacious. Nott derived some benefit from the citrate of iron in 5-grain doses given three times daily. Bremer condemns operative interference, main- taining that it is as hopeless as neurectomy in facial neuralgia. He prefers moderate morphinism, which, to the author, has greater terrors than the knife. Whitehead insists upon the value of first correcting the disease in the uterus, bladder, urethra, and rectum. Occasionally much benefit is to be de- rived from the prolonged use of general and nerve- tonics, such as iron, arsenic, etc., in combination with remedies that control pain and encourage sleep. Where palliative measures fail to relieve the patient, the surgeon should then be called in. A surgical operation is indicated when there is fracture, dislocation, deformity, necrosis, or periostitis of the coccyx. Surgical Procedures. — Two operations have been devised for the alleviation of painful manifestations about the coccyx (coccygodynia), namely : 1. Excision of all or a part of the coccyx (Nott's operation). 2. Separation of the muscles and ligaments attached to the coccyx (Simpson's operation). Nott's Operation of Excision (Coccygogeetomy). — The opera- tion is given this name by the author because, in his opinion, Dr. Nott was the first surgeon to remove the coccyx for the relief of coccygodynia. The steps in the operation are as fol- lows: 1. A dorsal incision from two to three inches (5.08 to 7.62 centimeters) in length is made directly over the coccyx. 2. The bone is reached by dissections and freed from its mus- cular and ligamentous attachments, care being taken not to injure the bowel. 3. The coccyx is then disarticulated or cut through with bone-forceps, and removed. 4. The wound is closed by sutures after inserting a tube or gauze drain. Simpson's Operation of Tenotomy. — -This operation was first performed by Prof. J. Y. Simpson, and the results following it were very satisfactory. Of late the operation seems to have fallen into disrepute. The tecJmic is as follows: Introduce a tenotomy-knife through a small incision in the skin near the DISEASES, INJURIES, AND TUMORS OF COCCYX 157 tip of the coccyx, and pass it upward along the posterior as- pect of the bone. 2. Next sever all tendinous and muscular attachments from both sides, underneath, and at the end of the coccj'x. 3. Then remove the knife and dress the wound. There is no question but that many cases of coccygodynia can be speedily relieved by this operation, because rest from mus- cular activity is assured. The author prefers the operation of partial or complete excision of the coccyx to that of tenotomy, for three reasons : — 1. In the open or excision method any large vessel severed ■during the operation can be immediately secured. 2. In the tenotomy operation the muscles only are divided, and the inflamed joint is left, to be aggravated by walking and sitting. 3. By extirpation the offending body — be it an elongated, diseased, fractured, inflamed, or dislocated bone — is removed permanently. While the operation of excision is preferable, the original method of performing it has been greatly improved upon. As done in the past, it required many instruments, was bloody, consumed considerable time, — from twenty to thirty minutes, — and a drain was left in the wound, which delayed healing. Gant's Operation of Coccygogectomy. — By this simple pro- cedure all or a part of the coccyx can be extirpated in short order. The operation may be finished in from three to five minutes. It is bloodless, and the only requisites for its per- formance are a specially-constructed pair of strong, blunt scissors (Fig. 48); a large, curved needle; and two or three catgut sutures. Teclinic. — 1. With the thumb and finger grasp the skin and deeper tissue over the end of the coccyx so as to make a fold at right angles to the latter. 2. With one stroke of the scissors cut through these struct- ures down to the bone, making an incision one inch (2.54 centi- meters) long and parallel with the coccyx. 3. Free and lift the end of the coccyx upward with the left index finger, and, by rapid cuts, detach all ligaments and muscles, first from one side, then the other, and finally from the end of the bone, keeping the scissors pointing outward. 4. W^ithout changing the position of the finger, place the 358 DISEASES OF THE RECTUM AND ANUS scissors at a right angle as to the os coccyx- (Fig. 49) and dis- articulate or divide it, as the case requires. 5. Close the wound with two or three interrupted catgut sutures, and dress it with sterile gauze held in place by adhe- sive straps. The author has performed this operation for the relief of pathologic conditions of the coccyx 35 times without an unpleas- ant complication or sequel except in 3 cases. In 1 a fistula re- mained after the operation and refused to heal under local treat- ment. Finally a portion of a silk-worm-gut suture was dis- charged, and the patient promptly recovered. In another, where the wound was dressed with iodoform gauze, a dermatitis ensued, which was followed by sloughing of the tissues over the end of the sacrum until the bone was bare. It required six months to Fig. 48. — Gant's Coccygeal Scissors. They Are Very Strong, and Cut bkin, Muscles, Tendons, and Bone Equally WelL heal the wound; during this time the patient suffered intensely. In the third case plain catgut was used; on the fourth day the patient went to the closet without permission, and while there tore the wound open, thus delaying his recovery several days. Occasionally, when proper aseptic precautions have not been observed, stitch abscesses occur. The author has used wire, silk,, silk-worm gut, chromicized and plain catgut for closing the wounds after this operation, and he very much prefers the latter. The advantages claimed for this method of excising the coccyx are that it is bloodless, painless, can be performed quickly (in from two to three minutes), and with two instruments (scissors and needle) ; primary union can be obtained along the entire cut because drainage is not necessary ; unpleasant sequels have rarely been known to follow it; and, further, because the patients are not required to remain in the hospital more than a week or ten days. DISEASES, INJURIES, AND TUMORS OF COCCYX 159 FRACTURES, DISLOCATIONS, INJURIES, AND NECROSIS OF THE COCCYX The OS coccyx, like other bones of the body, is frequently the seat of injury. Fractures and dislocations of the coccyx are not uncommon, and are usually caused by a blow, kick, fall, or the passage of the child's head during labor. Other injuries — gunshot, stab, and extensive lacerated wounds — are occasionally met with in this region. The author treated a thief who had been shot in the anus while trying to escape; the ball came out near the sacro-coccygeal articula- Fig. 49.— Gant's Operation of Coccygogectomy. tion, carrying part of the bone with it. Bellamy treated a boy who was accidentally shot. The coccyx was torn off, and an opening the size of an orange was made in the rectum, through which gas and feces escaped, and fragments of the bone were plainly visible. Numerous cases of injury to the coccyx, caused by gunshot and bayonet wounds, are to be found in the medical and surgical history of the War of the Rebellion. Symptoms and Diagnosis. — Fractures, dislocations, and in- juries to the coccyx cause a heavy, dull, aching pain in this region, which is made worse by contraction of the attached muscles, walking, and sitting. These sufiferers are relieved 160 DISEASES OF THE RECTUM AND ANUS when lying upon the abdomen. Pressure over the end of the bone causes agonizing pain, both in the region of the coccyx and up the back and down the Hmbs. Suffering is intense during and for a short while after defecation. Hemorrhage is seldom encountered, except in cases where the wound is ex- tensive and involves the hemorrhoidal vessels. Where the rectum has been punctured, both gas and fecal matter escape, producing an offensive odor. Fractures and dislocations im- properly treated fre(juently result in enlargement, ankylosis, and displacement of the coccyx, which, in time, cause coc- cygodynia or neuralgia. Necrosis. — Necrosis of the coccyx, ending in abscess and fistula, is a frequent sequel of injury to this bone. This con- dition may also be the result of syphilis, tuberculosis, and malig- nant diseases. In such cases the amount of bone destroyed is considerable. Again, it may be caused by any disease or in- Fig. 50. — Rubber Glove, Especially Valuable in Rectal Operations. jury which destroys the periosteal covering. The immediate manifestations of dead bone in this region do not differ from a similar condition in other parts. There is a fistulous opening, a discharge of pus, and the grating sound produced by the probe coming in contact with eroded bone. The openings may be single or multiple, and when they become stopped up a chill, rise of temperature, and increased pain follow shortly, caused by the formation of an abscess. Diagnosis. — Fractures and dislocations are easily recog- nized by introducing the finger into the bowel, when the coc- cyx may be seized and examined ; flesh wounds over the bone by their presence, and necrosis by the finding of dead bone by aid of the probe. A clear history of the case goes far toward establishing the diagnosis in doubtful cases. Treatment. — Extensive wounds involving both the soft parts and bony structures demand prompt and careful atten- tion. When the parts are lacerated the edges of the wound should be trimmed, all fragments of bone removed, and the DISEASES, INJURIES, AND TUMORS OF COCCYX 161 wound closed with catgut. Drainage is unnecessary, unless there is danger of leakage from the rectum. When the coccyx is fractured or badly displaced better results are to be had in most instances from partial or complete resection. It is an extremely difficult matter to retain it in place and to secure complete rest by splints, sutures, or other appliances. Skey attempted to retain the coccyx in position in a case of disloca- tion by placing a wire spring in the rectum. This broke, and he then anchored the bone to a wooden splint on the back by means of a silk thread. This did not entirely relieve the pain, but the patient was discharged twenty days later much im- proved. Some surgeons tampon the rectum, but the results have not been satisfactory, for the reason that the tampon does not retain its position, and, in addition, pain is greatly intensi- fied by retention of gases. The author obtained a good result in one case by placing a finger in the bowel and pressing the bone outward. A needle carrying chromicized catgut was then passed through the skin down to the bone, catching the tendinous attachments, and brought out near the point of en- trance, where the suture was tied across a small gauze pad. Pain was relieved immediately, and the patient was discharged in two weeks feeling perfectly well. In exceptional cases properly-adjusted adhesive straps give a sense of support to the parts and diminish pain. When surgical aid is declined, complete rest in bed, a semisolid diet, and hot apphcations over the ano-coccygeal region will do much toward making the sufferer comfortable. If used at all, opiates should be discon- tinued after the first few days. Necrosed bone should be re- moved. SACRO=COCCYGEAL TUMORS AND CYSTS Braune, in 1862-64, published an analysis of fifty cases of tumors involving the sacrum and coccyx, embracing practically all that had been published up to that time. He was the first surgeon who attempted to classify these neoplasms, and to point out the various methods used to destroy them. Holmes, in a practical paper written in 1867, called attention to this class of tumors and the satisfactory results to be had from their total extirpation. Tumors of this region, except dermoid cysts described elsewhere (page 491), are of rare occurrence, and are met 11 163 DISEASES OF THE RECTUM AND ANUS with more frequently by the obstetrician than the surgeon, be- cause they are congenital and noticeable at birth. They belong plainly in the domain of rectal surgery, for the reason that they displace the rectum and anus (see Dr. Lord's case. Figs. 51 and 52), interfering with the performance of their functions. Braune divided them into the following varieties: — 1. Coccygeal tumors in the proper sense. 2. Sacral hygromata. 3. Tail-like formations and lipomatous appendages. 4. Tumors in the adult, the congenital nature of which is not clearly proven. Holmes suggests the following arrangement of these Fig. 51. — Sacro-coccygeal Tumor (Front View). growths: (a) tumors assuming the forms of supernumerary limbs, the result of double fetation ; (b) tumors with fibro-fatty (Hpomata) constituents where congenital duration is not ap- parent; (c) congenital tumors which enter the pelvis, not of fetal origin. In recent years many cases of sacro-coccygeal tumors have been reported, some of which do not seem to fall within the classifications of either Braune or Holmes. Because of their variety, difference in shape, consistence, contents, and eti- ology, a grouping of these neoplasms is extremely difficult. Again, it is frequently impossible to make a positive diagnosis in these cases except by operation or autopsy. For the reasons DISEASES, INJURIES, AND TUMORS OF COCCYX 16'i named, the author will not attempt a rearrangement of these tumors, but will simply point out their principal manifestations, which, after all, are of most importance to the surgeon. Neoplasms of the coccyx may be attached by a broad base or narrow pedicle, and vary in size from a cherry to that of a child's head (Figs. 51 and 52). They may be globular, oblong, and irregular in shape; soHd, semisoHd, or soft; and, when cystic, unilocular or multilocular, with fibrous partitions. Most tumors of this region are congenital, the exceptions being lipomata and supernumerary limbs not visible at birth. Contents. — Nearly all of the various structures of the body Fig. 52. — Sacro-coccygeal Tumor (Rear View). have been found in the different forms of sacro-coccygeal tu- mors and cysts: Fluids, — spinal (spina bifida), albuminous, creamy, red, yellow, straw, or brown in color, — alone or to- gether with cheesy matter, bones (short and long), hair, teeth, muscular fiber, brain-substance, blood, cartilage, fat, mucus, and the bones of the sternum. Again, various appendages may have their origin in these tumors. Supernumerary fingers, toes, hands, feet, arms, legs, and fleshy projections, a tail, and penis have all been seen projecting from growths taking their origin in the sacro-coccygeal region. In most instances congenital sacro-coccygeal tumors are of sufficient size at birth to attract the attention of the physician in attendance. Pithas's case, however, is an exception to this rule.. He amputated a third 164 DISEASES OF THE RECTUM AND ANUS leg attached to the coccyx of a young woman 20 years old. In this case there was only a slight enlargement of the coccyx at birth. Senftleben removed a small hand attached to the caudal bones, and Mason extirpated a lymphadenoma the size of a fetal head. Hutchinson removed a tumor containing a sternum and brain-substance; but one of the most interesting cases of coccygeal tumor is that of Chebbs, in which a fleshy mass, two inches (5 centimeters) long and a half-inch (1.27 centimeters) in diameter, projected from the spine, in the end of which was an orifice connecting with a canal running the entire length of the tumor. It looked exactly like the penis of a boy six years old. The daily press came out with big head- lines telling all about the boy with a tail. As lack of space forbids relation of examples of the different types of sacro- coccygeal tumors, the attention of the reader is next invited to the symptoms produced by these neoplasms. Symptoms. — Displacement of both the rectum and the anus always takes place. Usually they are pushed forward with the vagina and vulva; in exceptional cases the displacement is to the right or left of the median line. The coccyx and lower sacrum are dislocated backward, and are readily noticeable through the integument. The skin may be natural, or bluish, or become ulcerated from pressure when there is great ten- sion. Prolapse of the rectum and uterus and eversion of the anus frequently occur when the tumors expand downward. Constipation is marked, and fissures, hemorrhoids, and ulcera- tion are usually present as the result of pressure and interfer- ence with the circulation. Necrosis, abscess, and fistula of the sacrum and coccyx may result from the same cause. Owing to the attachment of these tumors to the rectum and bladder, and pressure upon the urethra, dragging-down pains are felt in the rectum, and the urine is voided with great difliculty. These patients suffer from neuralgic pains over the coccyx, up the back, and down the limbs. Children afflicted with sacro-coc- cygeal tumors communicating with the spinal cord are subject to convulsions, especially where the contents are evacuated rapidly. When located high up in the pelvis of an infant, such a tumor may be unrecognized, and may produce partial or com- plete intestinal obstruction. Diagnosis. — The diagnosis of sacro-coccygeal tumors is easy in most cases, because of their size and location. In fact, DISEASES, INJURIES, AND TUMOES OF COCCYX 165 all congenital tumors situated posterior to the anus and rec- tum at the end of the spine belong to this class. It is a more difficult matter, however, to determine their exact nature and contents. When soft, fluctuation and impulse on coughing are obtained. ]\Iuch information as to the size, consistency, and attachment of the growth can be gained by rectal and vaginal examination. Occasionahy these tumors are transparent, but more often they are filled with thick, colored fluid, the nature of which is revealed by aspiration. When spinal origin is suspected, considerable fluid should be removed, and, if the surmise is correct, the operation will very probably be followed by convulsions. Tumors situated directly in the median line are nearly always spina bifida; but, if there is still any doubt, the fluid should be examined under the microscope. If chemic examination shows the presence of sugar, this points to the spinal origin- of the neoplasm. Tumors containing super- numerary limbs are easily recognized, and in such cases a diag- nosis of double fetation is justifiable. Prognosis. — The prognosis depends largely upon the nature of the growth and the methods resorted to for its destruction. There is necessarily a large mortality in these cases, because of the magnitude of the operation required for their removal, and, further, because the victims are usually infants possessing little vitality. Treatment. — Non-operative measures have no place in the treatment of sacro-coccygeal tumors. Iodine and carbolic acid have been injected into them, but with the single exception of Strassman's case, which was cured by use of the former, they have failed to benefit the patient. The following are the pro- cedures which surgeons have resorted to in their efforts to re- move or destroy these tumors : (a) tapping, (b) partial resection and ligature, (c) ligature, and (d) complete extirpation. Tapping. — This rarely has any curative effect, and requires to be repeated again and again. When the tumor has spinal connections, the abstraction of fluid is followed by convulsions, sometimes meningitis and death. Partial Resection. — This should be practiced ojily in cases where total extirpation is attempted and found impracticable because of the deep or extensive attachments of the growth. In such cases as much as possible of the tumor should be ligated, and removed after the ligature has been adjusted. 166 DISEASES OF THE RECTUM AND ANUS Ligature. — Ligation is indicated only in cases where the tumor is small and pedunculated. It is a mistake to ligate a large tumor with the expectation that it will slough off. The principal objections to this operation are that the ligature is not, as a rule, applied sufficiently high to include all the sac, and does not always cut its way through, thus leaving the tumor partially severed from its attachment. Complete Extirpation. — This is the most desirable method of getting rid of sacro-coccygeal tumors, unless there are spinal attachments, when they are best let alone. At least one such tumor, however, has been successfully excised. The statistics of Braune, Holmes, and others show that complete removal of these growths gives the best results, and is followed by a much lower mortahty than either of the methods previously described. The technic of the operation is as follows : A free incision is made over the tumor, and the latter is carefully dissected out, separating it from neighboring structures with the finger or blunt scissors. When of a cystic nature, every precaution should be taken not to puncture the retaining wall, and when attached by a pedicle it should be traced upward to its origin, though it passes high up into the pelvis, then extirpated com- pletely. The wound in the peritoneum and the external in- cision should be closed with catgut; if there is great tension on the external wound, silk sutures are better. Primary union will follow. On the other hand, where a portion of a cyst or tumor is left, suppuration and recurrence of the growth are to be expected. Supernumerary limbs which project from a tumor in the coccygeal region should be amputated in the usual way or resected as circumstances demand. Hands, feet, and legs have been successfully removed from these parts in both children and adults after they had attained considerable size. In three of the cases reported by Braune it was necessary to saw through the bony stalk which extended very high in the pelvis. SYPHILIS AND TUBERCULOSIS OF THE COCCYX Both syphilis and tuberculosis are occasionally met with in the sacro-coccygeal region. They attack the periosteum, bone, and sometimes the overlying structures, causing necro- sis, abscess, and fistula. DISEASES, INJURIES, AND TUMORS OF COCCYX 167 Treatment. — These patients require good surroundings, tonic, antisyphilitic, and antitubercular treatment. Dead bone should be removed, the affected parts curetted, and afterward stimulated by applications known to encourage granulation. This chapter will be closed by appending the following table of cases of disease, injury, and tumors of the coccyx treated by the author. Such an analysis may be of service to physicians and surgeons interested in this class of affections. 168 DISEASES OF THE EECTUM AND ANUS n "5. D. •■•a •0 > •a 1 OJ 1 D 1/1 E o Is CO c 8=S E E cq c c C c CO c bS E 5 •a > >. i E t >> b >. >i > Di £ di .- (V - OJ Oj 0/ ^ ■o 'S > Ed. 2..i > > c > > > > > > o i^ c 2 (5 ^ "o OJ .S a a. a a a a a (S a a a a c E E c d 0. E§ ^' 3 c •0 ^ Si c c tjj ttJ 3 T3 3 ■5 3 C c T3 > 3 . 2 <^ 6 01 T3 C Jj" — bjO c C " .- ^T3 °5 ^iS OJ t^ 3"^ 2 ^1 s « _o • -•0 2 c «.9 3 5 D. E 0. c OJ io 5 e-:a •a 3 OJ .Et,2 S8^ c tj 11 •a a 3 •a c a U UJ m ctr ar 03 pj a 5 a U z a ■5 01 > 01 > O i- < > C > 1/) B 3 .- c " bi 3 jj 3 c 5« c &. y^ ■yi 3 aj 'c E •a "S 0. J5 E > i; 3 3 OJ D. o u ttl c JS c 5S. 1/1 c C 13 3 •Os- s -yi 5; 5 3 3 OJ 1 Z ii; z J ul ^ Z < Z t 11 i» ^ , — 5 j; E c i ° 3 c T3 m 1/3 D •0 M C •d c 3 < (J ■^ B X E >< w « s ■5 u s 5 C — >i _« >, >. .£■— 'c 'c S i^ c 01 c ia OJ c _^ 5t3 .— — "t^ .J^ °- n 3 "5 c- U Q li ^ u J u u. U u u. 1 1 H- T3 0:: u I« nj '> c p3 >> Si 'n >, •a T3 •^ xa rt _ p « E& OJ •5 •0 >< >. > OJ ■a a ~ si .^ n £ OJ .2^ .'^•■p < >i >, >. 3 10 _^ CO c-i CI CO 01 CO ■^ CO > •o o CD 1 (N DO o 1J P w CO CO (M C C c •O bfO. c c C c C t/) ~ 1 LU >, >. b >.'*- s >, >, >> >> >> 1 DC OJ a! S rt > > > C 3 O > > > > > o o o o o o-o o o o o o S E «.2 u aj OJ tu CD OJ CD CD ar a a a a a & a a Qi ^ c •a ■a ^ c « 3 O OJ c 13 °d CD ° o CD :2 3 E C o 'S C be ■£ o ^ ■ JJ" o.^ o M 4J c C c "5 H •o [5 OJ E o J3 •og E C > CD i i a. X u ^ 3 ca -a On 1^ CD a) o n a UJ a W a a a a Q? a , 1 a» 'o en c« tt, Uc 0; z 3 M ™ ^" O P c ^ ^ u < y o o n .2 • M .- o o c o 3 O Q. tt) la i:^ o xi t; •a "c |l3 c o 3 « > CD o cj rt 01 o t 3 a. >^ 3 u c o c o o. E « o E C O 3 o! Z z W U Q U I/} > a 1° c o o im .2 B-C > y c . CA O O J3 3 C 5 "" c o li 2 o (/) E o ^ E O OJ >■ « 13 .2 = > — u •o ID CCS •- • tn ^' D E o >. a. > « _ >< O >.3' < u 5 « u S (U CD i •a . o c o c3 t: c •^ So .2° CD .i2 c-= O c . 0-3 r- •+- ca .— § O CJ Cfl 1-8 = E fe o SSx> H LU tL _) < < t£ U. u Q , •o - 1 c-o o r! CD E ■^ 3 ca a! c *^ > O O 1 "" bx 'S V, JJ 'O 1 E c D d ^i •a c c c cj2 — c •a C 3 .2 'c ■a c3 OJ >. >> >. 3 " C3 £ "-> >> CD - ^ •a ■o ■a s: > "" X ■a u E- <1> o o a3 o be o X « ilO (10 M X 3 i; "^ >< be CCS ^ 5c ^•2 >> u >> 3 >, >. o 2 d ^•2 CD y = •«= R >. B§ o o o o -^ CB *- O o 71 CJ Q £ U u tu U U li z U E z c O ta ^ •£ E , o o c cd ^J ■£ ■£ Q. D U u O HI 3 O I 2 ^ o -2 CD 3 O X E to - c» 05 o _ CM (M CM C4 170 DISEASES OF THE RECTUM AND ANUS ^ .^ >. ■a ^ >> .s ^ ■^2 u 3 c OJ ^ Si I« 01 « y eC 0> l/l 3 s OJ tj & ■a 3 V 5: ■a % CM 1 CO ■a ■a Si 1 CO 3 c c c c c c _c c >> nj E c tr, c >. ^ j= a &■ 01 OJ > } OJ ^'^ i > > > s > > > > > u > o OJ u s OJ §5 3 u s 5 ^ a a (S a: (2 Q^ a: a « ex: E •0 c ti i •a c ^ 1 ■a c >. 1 "O c be £3 3 > . Z o c o « S. 3 3 x: c OJ E 01 M E S. u ■0 ra x; Xi-O .XI c .2 -2 II rt J' t/i >>c OJ c E be 1/1 OJ tj c j: 0. c S IS E 0. u E 3 15 •0 c •SE 0) 3 C >,— X3 be c 0) D o c ca 3 XI 3 T3 C « 3 i2 5 E i c 0) > E a ^3 >- 13 u c D. ■a a 3 TJ C 2 > s c a. E bo % 1 > Pi c 15 Q. > "2 0) c .0 15 d ao 1? 3 §5! XI 3 "S.E i| 3 i OJ 3 J) 3 3 D.'O P.C 3 W D. o.g w a til a W a UJ lU D^ m , _ c yi ■+-« « rt OJ z O 6« TJ ot P < «i c S2i c 3 o~ •Sr y ■a .0J in ^ 2 c 13 E OJ u ta . - X be < u _3i . X3 W OJ S c •a 3 n2 3 — c c - .:«: •^ ■^ OJ « '5 O-a u u c u 2 "-> — J U. a U U < D 5 u, CK , , , u > 15 E ■a >■' . 3 .3 c ■5 •a c a .s 'c 'a u '5 >> T3 >. 3 '-' .M C ■ O'O 0) OJ c — XJ b« C " 3 •0 a gj (U & E 5 a E 3 Is oJ rt >< OJ < >> >, 3 d 2 -a & E M >, x; 3 3 U 3 c/1 u >> c -. u to Q o ^ fj 3 ao a, u 2 U u i£ U C u C ^ z o < Q. D .3 S '5o be 0) 1 OJ u J^' u g .M u >. 0, 3 3 o c x: >> Oj U u a. H U u. X u X •X3S (JU vl S S tu tu :s a, ^ u: •30V 03 ■* -* CO CO g CM 10 CO CM CO •OM c^ (N OS CM E5 S S CO M CM CO DISEASES, INJURIES, AND TUMORS OF COCCYX 171 b .-50 ''3 (C c tS . Zj T3 4) .1^ ■a ^ c o la ■a c ■a S ta C ta E 3 3 ta 2 or .E .2 > T3 "4 *::: "c 3 V^ o o 3 o it E O % ta ■c; *;■ "u ■^ t' T3 j: (J QJ >>'5 c c ta i-S| 5j t^ a) E t/i tu c o Z < tu ■- ta 01 m ■S5 ^E E 7, O E fcj) til i o c o tu bn 3 3 o o o >, E aj E 11 c o T3 X! •a 3 o 3 JO o C O o o o be o J3 U * tu C o ta o Z ^K nl c ? o §1 c z o •i| ^ S 3 t- C ta o. o < u to o D.C — W ai J o'a fj fc. O "^ ° t/i Q. °5 ~ o C " £ tao.aj o il « - ;^ !c 3 3 a. 3 Ic 3 y] u «^ C o w la S- o t«~ V5 a. U (/3 z c •a o . 1^ ta S5 ^ ui 3 < u at — Xi i ^8 c 5 2 t«" 5 o 8 o H, o. " c M 15 iM o-o ^ c Q. 3 ° c O-a >, O W D U 1/5 U Ctf 1 ' -■ a: in ^ < w U3 t? IJ o o bjii r- ^ ■- ^E = CDS 0^ (D X >< >. u o tu o c c .3 c >, T3 O >, tj o > X — >,ta "§ o ^ o 1 tJo ^ 0) aj 1^ I' u o O ca ^ -•-• *- Q a Q U U < z O >j < c ta o aj ■& Q. 3 3 aj ^ "o "o U >. Ul o Xo o u S >. JZ o s: ta sz u c. u h4 Q. U) a W •X3S S s S u,' U^ •HOV Oi 5§ cs § 00 •ON ?? s lO § cn c/i 7) t/1 7) yi ^ ■"("■*00< S? 3 «i 5 X H t ,2 X ! '5 >> ^ H ^3o. taM_ e o o ■« 2ta°I""" 2&EaocS2-S'S>.3 Jo'Sooixi— eroxide of hydrogen was forced through one opening, it bubbled out at more than a dozen difi'erent places. Pressure TREATMENT OF ANO-RECTAL FISTULA 271 in the rectum or at any point in the ano-gluteal region caused excruciating pain, and forced out of the sinuses a rather thin, blood-stained discliarge. The patient was placed in the hospital and prepared in the usual way for the opera tioHj which was as follows: One of the main sinuses was laid open and curetted, and a search made for branch sinuses. These and their branches were treated in the same manner. Following out this general plan the operation proceeded until all of the sinuses, superficial and deep, were divided except two which ran high up into the pelvis, and these, because of the danger of injuring the peritoneum, were curetted and cauterized. During the operation it was necessary to divide the sphincter-muscle in three places and remove large pieces of the undermined skin, leaving only that having a sufficient blood-supply. Some idea of the extent of the raw surface left may Fig. 90. -Appearance of Wounds Three Weel