COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX641 39085 RCo64 .B21 1887 The rectum and anus; RECAP :U'^mmmm^mmM: CLINICAL MANUALS FOB Practitioners and Stu])ents OF Medicine. rrontispiec^ i . oaiaest cti i\Zi: PLATE I. [Frontispiece.) Epithelioma Ani with complete Kectal Fistula. THE Rectum and Anus: Their Diseases and Treatvient. BY CHAELES B. BALL, I r " M.Ch., Univ. Diib., F.E.C.S.I. SURGEON TO SIR PATRICK DUN'S HOSPITAL; UNIVERSITY EXAMINER IN SURGERY ; AND MEMBER OF SURGICAL COURT OF EXAMINERS, ROYAL COLLEGE OP SURGEONS, IRELAND. WITH 54 ILLUSTRATIONS AND 4 COLOURED PLATES. // r 7^eXj-t>v - ^^JU^ -^. PHILADELPHIA : LEA BROTHERS & CO., \_Late Henry G. Lea's Son cfc Co.] PUBLISHERS. Established 1785. 3 5-1 / ?? ? 3 PEEFACE. The voluminous literature which has, from time to time, appeared on the diseases of the lower bowel, renders it necessary that some explanation should be given why an addition is made to the already long list. Improvements in wound treatment within the past few years have produced such important changes in the practice of surgery generally, that in almost all branches of the subject it has become necessary to modify hitherto expressed views, and recast our teaching in several essential particulars. To this general rule the surgery of the rectum forms no exception ; and if in the following pages the busy practitioner succeeds in finding a fair account of our knowledge of this subject, as it exists at the present date, the aim of the author will have been accom- plished. One of the most pleasing duties in connection with a work of this kind, is the expression of indebtedness to professional friends for valuable assistance. To the medical officers of the Richmond Hospital, Dublin, I am much indebted for allowing me to make use of their invaluable collection of original drawings : vi Diseases of the Rectum and Anus, from this source several of the chromo-lithographs and wood-cuts have been obtained. I would also acknowledge with thanks the per- mission accorded to me to make use of specimens in the Hunterian Museum ; the Museums of Trinity- College, Dublin ; the Eoyal College of Surgeons in Ireland, and of King's College, University College, Middlesex, and Steeven's Hospitals. From Professor Purser and Dr. P. S. Abraham, I have received much assistance in the pathological part of the work. To my colleagues, Dr. T. E. Little, and Dr. W. G. Smith, I am greatly indebted for the interest which they have taken in the work, and the care with which they supervised the pages as they issued from the Press. C. B. BALL. 16, Loivev Fitzwilliam Street, Dublin. September, 1887. CONTENTS. CHAPTER -PAGE I.— The Diagnosis of Rectal Disease .... 1 II.— The Congenital Malformations of the Rectum AND Anus 18 III.— Proctitis 47 IV.— Periproctitis 54 v.— Rectal Fistula 66 VI.— The Relations of Pulmonary Phthisis to Rectal Fistula 104 VII.— Ulceration of the Rectum 109 VIIL— Irritable Ulcer or Fissure of the Anus . 127 IX.— Non-malignant Stricture of the Rectum and Anus 138 X.— Symptoms of Non-malignant Stricture of the Rectum 155 XI.— Treatment of Non-malignant Stricture of THE Rectum . 170 XII.— Syphilis of the Rectum and Anus . , .179 XIII.— Prolapsus Recti 188 XIV.— The JEtiology of Piles 216 XV.— External Piles 224 XVI.— Internal Piles 233 XVII.— The Clinical Relations and Complications of Internal Piles ....... 237 viii Diseases of the Rectum and Anus. CHAPTER PACE XVIII.- -Palliative Treatment of Internal Piles 217 XIX. —Operative Treatment of Internal Piles 254 XX, -Benign Neoplasms of the Rectum and Anus 280 XXI. -Malignant Neoplasms of the Rectum and Anl^s 'W XXII.- -The Pathology of Malignant Neoplasms of the Rectum and Anus 307 XXIII.- -Symptoms of Rectal Cancer . 328 XXIV. —Treatment of Rectal Cancer 335 XXV.- — Colotomy , 3i1 XXVI. -Pruritus Ani 371 XXVII. -Atony of the Rectum 378 XXVIII.- -Irritable Rectum and Neuralgia 381 XXIX. —Injuries of Rectum and Anus . 386 XXX. —Foreign Bodies in the Rectum . 390 XXXI. —Diverticula of the Rectum . , 396 LIST OF PLATES. PLATE I Front\spiece. Epithelioma Aiii with cotni^lete Rectal Fistula PLATE II To face jiage 112 Fig. 1.— Lupoid Ulceration of Rectum. Fig. 2.— Hsemorrhoidal Ulceration of Rectum. PLATE III To face page 1S2 FiK. 1.— Acquired Eczema from old-standing Pruritus Aui. Fig. 2. — Conrlylomata of Auus. PLATE IV To face page 242 Fig. 1.— Prolapsed and Gangrenous Internal Piles. Fig. 2. — Prolapsed iLternal P'le3. The Rectum and Anus: THEIR DISEASES AND TEEATxMENT. CHAPTER I. THE DIAGNOSIS OF RECTAL DISEASE. The early diagnosis of rectal disease is attended in some instances with difficulty, partly from the fact that patients suffering from these diseases do not seek the advice of the surgeon until they have suffered for some time, when the severity of the pain, considerable loss of blood, or great difficulty in defaecation, over- comes the repugnance to local examination. In other cases, more especially in commencing malignant disease, where early diagnosis is of such paramount importance, the subjective phenomena may not in the first instance point to the rectum as the seat of lesion. It is essential, therefore, that the surgeon should pay particular attention to those symptoms which, although not directly pointing to disease of the lower bowel, are frequently caused by such condition ; and when the statements of the patient render it probable that rectal disease exists, he should insist on a complete local examination. Amongst the more vague symptoms which should arouse the suspicions of the medical attendant we may enumerate the following : Slight morning diarrhoea, which continues for a long time, alternatmg with attacks of consti- pation ; flatulent dyspepsia ; sense of weight about the B-~23 2 The Rectum and Anus. [Chap. I. pelvis ; dull pain about the sacrum, with pain or oedema of the left leg. This last symptom is one to which Hilton has drawn particular attention.* Pro- gressive anaemia may be the result of abundant and frequently repeated hfiemorrhage from the rectum, which sometimes continues for a considerable time before it is noticed by the patient, the loss occur- ring painlessly at time of defsecation. And, again, owing to the close sympathy between the uterus and adjacent mucous tract, disease of the latter may lead to the erroneous impression that the cause of the patient's suffering is to be found in the organs of generation. I have lately had under my care a woman who had been for months under treatment for uterine disease without benefit, and whose symptoms were at once and permanently removed by the division of the base of a small rectal ulcer. Similarly we sometimes find that irritability of the bladder is the symptom to which the patient directs special attention. In order to elucidate the symptomatology as fully as possible, it is well, in the first place, to let the patient describe his case in his own words, then, by a few well-directed but not leading questions, we may be able to complete the history. The questions to be asked may be usefully directed in reference to the following principal points. Pain. — Inquire if the pain is severe or nof? Whether it is situated in the rectum, oris complained of elsewhere? What is its relation to def secation 1 Is it worse during evacuation, shortly afterwards, or is it independent of the act ? Is itching, sense of ful- ness, or heat, complained of? Protru<«ioii. — Is there any swelling or pro- trusion at the anus % Does tliis occur only at defseca- tion, or does it appear at irregular times % Does it * " Rest and Pain," p. 283. Third edition. Chap. I.] Rectal Examination. 3 disappear spontaneously, can the patient return it, or is it constantly present % Disctiarg'e. — Bloody, mucous, or purulent? Foetid % Mixed with faeces % Occurring before or im- mediately after defsecation^ or independent of the act % Faeces. — Diarrhoea, or constipation % Consistence ] Of normal size % Tape-like, or lumpy % Having now clearly obtained the subjective pheno- mena, we should, if there is a suspicion even of rectal disease, insist on a complete local examination. Under no circumstances is the attendant justified in pre- scribing without careful examination, although often he will be asked by his patient to prescribe something for " the piles." I have seen a case of extensive malignant disease of the rectum, which had passed all hope of useful treatment under the care of a medical man, who had rested satisfied with the statement of the sufferer that she was suflfering from piles, and who never had made an examination. Of some diseases the symptomatology is tolerably diagnostic ; as, for instance, if the patient has severe pain continuing for some hours after defsecation, if the motions are small and tape-like, and if they are streaked on one side with bloody mucus, there is a very strong probability that there is a painful fissure present ; but without examination we cannot possibly say that the fissure is the only rectal disease ; indeed, in a large proportion of cases we find more than one pathological condition present. £xamiiiatioii. — If possible the patient should have the bowel emptied by an enema immediately beforehand. In some cases this is absolutely essential ; as, for instance, where it is necessary to use a speculum for the exploration of the higher portions of the mucous membrane. Position. — By far the most convenient position for ordinary examination is the semiprone of Marion 4 The Rectum and Anus. [Chap. i. Sims. The patient lies on a rather high couch on the left side, tlie right shoulder turned away from the surgeon, the left arm brought backwards from under the body, and the right thigh well flexed upon the abdomen. By separating the buttocks we obtain a good view of the anus and surrounding skin ; patho- logical changes in which are easily noticed. By gently feeling the anal margin, we may be enabled to detect deep-seated hardness, which may be due to the pre- sence of a fistula ; tenderness at any part of the circumference will serve to direct our attention to that portion more particularly. By drawing open the anus and directing the patient to bear down, a good view will be obtained of the muco-cutaneous junction ; the condition of sphincter as to laxity can be observed, and any discharge noted both as to quality and quantity : a full view of external and sometimes of internal piles being also thus obtained. By separating the radiating folds of the anus, we may be enabled to see the commencement of fissure, a small external pile frequently serving to direct our attention to this lesion. The presence of fistulous openings and the more obvious anal diseases, together with the existence of oxyurides, may also be determined. A digital exami- nation should now be instituted, and it is by this means that the most important information is to be obtained, the educated finger being able to recognise with cer- tainty almost all varieties of rectal disease. In order, however, that the fullest information may be obtained, it is evident that familiarity with the normal parts is essential ; the surgeon should bear distinctly in mind what he is about to look for, and prosecute his exami- nation in a definite and systematic manner. Having filled the nail with soap, he should cover the finger well with some stiff" lubricant : ordinary oil is not satisfactory. This may appear a small matter, but it makes the difierence between little or considerable Chap. I.] Digital Examination. 5 pain to the patient, and, as a result, passiv^eness or resistance to the examination. The thymol, or eu- calyptol jelly, sold in collapsible metal tubes for obstetric purposes, answer the purpose admirably ; and, moreover, have the advantages of ready port- ability and asepticism. The finger should now be introduced by a gradual boring motion, with a direction, at first, slightly forwards. This should be carried out slowly, so as to give the sphincters time to relax ; if attempted suddenly, spasm will to a certainty be induced. As the finger enters, the condition of the sphincter may be noted ; i.e. whether it is relaxed, normal, or spasmodically contracted. A firm, long-continued resistance is very characteristic of spasm, the result of chronic irritation. The finger should now be steadily passed up to the fullest extent, and by telling the patient to bear down forcibly, the rectum can be explored for a considerable distance. Malignant infiltration, or stricture, can be detected, if situated within reach. By sweeping the finger round the mucous membrane its condition can be noted ; a general smooth- ness, and absence of the normal folds indicating atony. Ulceration may be recognised ; and the attachment of polypi can be felt. In examination for this disease it is of importance that the investigation should be con- ducted as directed, from above downwards ; as, other- wise, the tumour may be pushed up out of reach, the pedicle, in these cases, often being of considerable length. Fsecal accumulation in the rectal pouch is, of course, recognised without difficulty; and the condition of the surrounding contents of the pelvis should also be noted. The finger is now partly withdrawn, passing the pulp round the entire circumference of the mucous membrane as this is done, the internal openings of fistulas and ulceration being carefully felt for. As the margin is approached internal piles may be perceived, 6 The Rectum and Anus. [Chap. i. but the fact should always be remembered that internal haemorrhoids, unless they have been previously thickened by inflammation, are extremely hard to recognise by the touch ; indeed, the surgeon is more likely to be deceived by the sensation conveyed to the finger by internal piles than by any other rectal disease. I have frequently seen cases in which these growths, although scarcely appreciable to the touch, were found, upon ocular examination after dilatation of the sphincter, to be of considerable size. This is, no doubt, due to the fact that they are so soft and movable that they resemble closely in feel the normal columns and folds of the mucous membrane. Where, however, they have been thickened, either by present inflammation or by the growth of connective tissue in them, no difficulty can be experienced in their detection. Immediately inside the anus we may be able to feel the upper portion of a painful ulcer ; and can some- times recognise the fact that the extreme sensitiveness is confined to one portion of the surface. Having now completed our digital examination we can usually come to a fair conclusion as to the nature of the case. Should an examination by the speculum be deemed necessary, I am decidedly of opinion that it should be prosecuted under the influence of an anaes- thetic, as without the assistance aff'orded to us by this means but little additional useful information can be ob- tained. The great number of specula which have been introduced is, I think, a strong indication of the difficulty that has been experienced in their use. If we attempt to use one without anrosthesia we find that the patient suffers considerable j)ain, he strains violently, the rectum contracts round the speculum, the mucous membrane prolapses into the orifice, and but little can be seen. If, therefore, further examination is necessary ; Chap. I.] Use of Specula. or if, as a result of our digital examination, we come to the conclusion that operative measures may be required, it is advisable to give an anaesthetic, preferably" aether ; having previously got the consent of the patient to complete at the same time any necessary operation. Anaesthesia having been pro- duced, and the sphincter completely dilated, we can, without difficulty, institute an examination with a speculum ; by far the best is some modification of the duckbill of Marion Sims, such as recommended by Van Biiren, which has a notch to receive the sphincter, and a handle by which it can be held well out of the Fig. 1. — Hegar's Eetractor (scale \). operator's way.* Or the retractors of Hegar, which are used by obstetricians, answer the purpose admirably (Fig. 1). For a complete view of the entire circumfer- ence of the mucous membrane of the bowel for a distance of a few inches from the anus, Allingham's four-bladed speculum will be found useful (Fig. 2). It is to be introduced closed, and gradually expanded to the de- sired extent, and then fixed by turning the thumb- screw. It has the fj^reat advantao^e of being; self- retaining, thus leaving both hands free for any necessary manipulations. Artificial light may sometimes be required in making these examinations, and for this purpose the little electric lights, now commonly sold by instrument * " Diseases of Kectrnn," p. 392. 8 The Rectum and Anus. [Chap. I. makers, worked by four specially-constructed Leclanche elements, answer admirably. By this means the bowel, as far as it is distended by the speculum, can be thoroughly illuminated, and the surgeon enabled to diagnose any morbid conditions of the mucous membrane that may be present. For extensive Fig. 2. — Allingham's Four-bladed Speculum (scale \). a closed. Bopen. examinations by means of specula, it is best to re- tain the patient in the lithotomy position by means of Clover's crutch (Fig. 3). The tubular vaginal specula I have not found of much use in rectal surgery. If, however, dilatation of the sphincter has been thoroughly accomplished during anaesthesia, the last two inches of the rectum can be brought sufficiently well into view, without any instrument beyond the fingers or Chap. I.] Dilatation of Sphinctek. simple retractors. No single step in the practice of this department of surgery has done so much as the introducing of forcible dilatation of the sphincter as an aid to the diagnosis and treatment of rectal disease. And the credit of the establishment of this practice, as a means of diagnosis, and as a preliminary step in rectal operations, is undoubtedly due to Van Buren of i^ew York.* Dilatation of the sphincter, for curative purposes, was first recommended by Kecamier for cases of fissure,! but it diflfered in some respects from the way in which Fig. 3. — Clover's Crutch, for retaining a patient in tlie lithotomy position. the operation is now conducted ; it was more a knead- ing of the spasmodically contracted sphincter. This was carried out first with one finger, afterwards with two fingers, in the rectum, and the thumb outside. This pinching of the muscle was done at regular intervals and frequently repeated, to which he applied the term massage cadence. Although it would appear that his results were at the time good, the method fell into disuse ; and the objections to its adoption were further increased by the modification of the operation *'' Diseases of Rectum," p. 207. t Academy of Medicine of Paris, 1829. lo The Rectum and Anus. [Chap. i. proposed twenty years later by Maisonneuve. He first introduced the index finger, then one by one the others, till finally the whole hand passed the sphincters, then by closing the fist, and suddenly with- drawing the hand, the dilatation was effected. This would appear to justify the appellation of barbarous, so frequently since lavished on the operation of dilata- tion; but as at present practised it is essentially a scientific and safe procedure, unattended with the extensive bruising and laceration which must of ne- cessity have attended the method of Maisonneuve. The only argument which can be urged against it is, that it may be followed by temporary incontinence. I have, however, only seen it upon one occasion gi\ e rise to any serious trouble, and then it only continued for a few weeks. Most authors who have had large ex- perience do not even allude to this unpleasant sequela. The way in which this operation should be practised is as follows : First one and then the other thumb should be insinuated into the anus, the other fingers being laid flat over the buttock on either side ; care should be taken to introduce the thumbs high enough to stretch the entire external sphincter ; then by firmly grasping the tuber ischii on each side, dilatation of the anus should be gradually but firmly proceeded with, several minutes being occupied in the process ; the muscle will be found by degrees to give way, and after a time the sense of resistance will disappear. In order to eff'ect this a very considerable amount of force is necessary. It is well also to adopt the plan advocated by AUingham,"* of dilating as well in the antero-pos- terior direction. The resistance offered by the muscle is soon at an end, and we can examine the interior of the bowel without further trouble, and perform whatever operation is required with ease and certainty. The mucous membrane is occasionally slightly torn, and * " Diseases of Kectum," p. 128. Fourth edition. Chap. I.] Results OF Dilatation. ii ecchymosis exists about the anas for a few clays ; but no trouble is to be apprehended from either. The partial paresis of the sphincter, if the operation has been fully carried out, usually lasts for about a week. This is a point of very great importance in the treatment of operation cases, as the physiological rest so afforded to the part tends, in a very marked manner, to favour healing. And, moreover, the after pain is minimised, the chief suffering being caused by the pinching of the wounded and tender parts by the sphincter muscle ; this, of course, is absent where hyper-distension has been efficiently performed. Retention of urine, which formerly was a frequent source of annoyance after these operations, is now comparatively seldom seen. The explanation of the atony of muscle produced by stretching is a point of considerable interest ; we find many examples of this condition in human pathology, the most familiar being the atony induced in the bladder by a hyper-distension with urine ; and we know that, in this case, after a catheter has been used to relieve the accumulation, the muscular fibres of the vesical wall do not at once recover their tone. Similarly we have further examples in the intestinal tube caused by flatulence and fsecal accumulation, and in the gravid uterus from hyper-secretion of liquor amnii. What is the immediate cause of this temporary paresis % is it due to alterations in the muscular fibres themselves, or is it due to changes in the nerves sup- plying them % Probably the result is attributable to changes in both of these structures. That altered innervation is preseut we know by the fact that then we have diminished sensibility, and in cases where the trunks of large nerves are stretched forcibly for thera- peutic purposes, we frequently find a more or less complete paralysis of the muscles supplied. Here it is, of course, evident that no injury Las been inflicted on the muscular fibres themselves. 1 2 The Rectum and Anus. [Chap. i. In the female, if a suspicion exists of disease in the vagina or uterus, the surgeon should institute such examination as will satisfy him of its nature. Dr. Horatio Storer, of Boston, has recommended the eversion of the rectal mucous membrane through the anus by means of the fingers passed into the vagina, and pressing on the recto- vaginal septum ; this method is, however, comparatively useless, as only a small portion of the anterior wall can by this means be brought into view. Possibly in some cases the small perinseal pile, which is tolerably common in women, can be everted and its attachment made out by this means. The diagnosis of disease which is situated beyond the reach of the finger is attended with very consider- able difficulty ; but fortunately by far the greater majority of cases of disease which present themselves to us are situated within three or four inches of the anal margin, and are consequently well within reach. So difficult is it to diagnose disease which is situated high up, that Syme wrote " that there is good reason to suspect the honesty of a man who pretends to enter a stricture which is beyond the reach of the finger." By directing a patient to stand up, and at the same time to make a violent expulsive effort, at least an inch more of the canal can be felt than by the or- dinary examination ; and sometimes, with one finger in the rectum and the other hand making deep pressure above the brim of the pelvis, as in the bi-mannal examination adopted by obstetricians, additional in- formation may be gained. Bougies are instruments to which recourse is had when we wish to estimate the calibre of the upper portion of the rectum or end of the sigmoid flexure, and a great variety have been introduced ; the one in common use, made of gum-elastic and rather stiff, is undoubtedly the worst form, and its use is attended with Chap. I.] Bougies. 13 considerable danger, perforation of the gut having frequently followed its introduction, the low degree of sensibility of the upper portions of mucous membrane favouring this accident ; indeed, in many recorded cases the perforation has been occasioned by the patient passing a bougie himself. The best instrument of the kind is the boicgie a boule, in which the top is made of ivory or hard rubber, and mounted on a very flexible thin whale- bone stem (Fig. 4) ; by means of the finger it can be guided up the rectum and directed through a stricture. Allingham recommends pewter stems. Or the bougie recommended by Kelsey* may be used, which is made of soft red rubber, similar to the flexible catheter. This instrument is so pliable that injury of the rectal wall would be with it almost an impossibility ; and, as it is a perforated tube, it is pos- sible to inject tepid water through it should the point become engaged in any of the folds of mucous membrane. By this means the obstructing portion is lifted away from the end of the bougie, and progress can again be made. The intro- duction of any of these instruments is one of considerable difficulty, and it requires quite as much practice as the passage of an urethral catheter j the danger of per- foration is as great, and the result of such an accident very much more serious ; in ^^- I'T^I^®' tlie one case a fatal peritonitis will in ibie Bougie, all probability be started, while in the other a false passage will probably be the result. * "Diseases of Rectum and Anus," p. 56. 14 The Rectum and Anus. [Chap. i. At best, however, these instruments as means of diagnosis are of no very extended value, and it is only in occasional cases that we can get absolute evi- dence of a stricture high up by these means ; namely, when we feel the point of the instrument grasped and held by the constricted intestine. With the olive-headed bougie previously recommended, we may in rare cases be enabled to get important evidence of the length of a stricture and to define its limits. When the bulb at the end has passed through the stricture, its end can be felt free in the intestine above ; and as it is with- drawn it comes suddenly down on the upper termina- tion of the constriction, and so indicates the distance from the anus. The colonoscojye of Bodenhamer, or the endoscope^ are of no practical utility, owing to the very limited portion of mucous membrane which is brought into view. The only other means of exploring the higher por- tions of the rectum is by the introduction of the whole hand, and this is a proceeding which within the last few years has been more frequently adopted, owing chiefly to the writings of the late Professor Simon, of Heidelberg, to whom undoubtedly is due the credit of first having introduced the method as a means of diagnosis ; although several cases are previously on record of the hand having been introduced into the rectum for the purpose of removing foreign bodies. This operation, which obviously is one of consider- able severity, must not lightly be undertaken ; but in properly selected cases is a most valuable aid to diagnosis and treatment. The conditions which ren- der this proceeding advisable may be classed under two heads: first, those in which disease is thought to be present in the upper part of the rectum and sig- moid flexure ; and secondly, those in which it is adopted as a means of diagnosing diseases of the other pelvic Chap. T.] Manual Examination. 15 and abdominal organs, and it is probably in the latter cases that the best results have hitherto been obtained. . The diagnosis of stricture at the upper portion of the rectum or termination of the sigmoid flexure, is not easily made, even with the hand in the rectal pouch, the muscular intestinal wall contracting so strongly on the hand, and the folds into which the normal mucous membrane is thrown serving to obscure the diagnosis. Walsham^ records cases in which the diagnosis was not made by this means, where post-mortem examina- tion proved the presence of stricture of the sigmoid flexure. The directions given by Simon are as follows, t As a preparatory measure the entire large intestine should be thoroughly cleared out. This is best done by the hydrostatic method which is so strongly recom- mended by Hegar, and is accomplished as follows : The patient is placed in the knee-elbow position, so that gravity may assist the operation, and a long flexible tube is introduced into the rectum. To this is attached one end of a flexible rubber tube two feet long, and a funnel is connected with the other end. The funnel is now held well above the patient's body, and warm water slowly poured into it. In this way, several quarts of water may be intro- duced, and the entire colon thoroughly distended. When this is subsequently evacuated, it washes out all the contained faeces. An anaesthetic should now be administered, preferably aether, to profound narcosis; the patient placed in lithotomy position, and the sphincter stretched. Two fingers should now be fully introduced, and, by degrees, the third and fourth, and finally the thumb, in form of a cone. By a gTadual * St. Bartholomew's Hospital Reports, vol. xii. p. 223 ; 1876 : " Some remarks on the introduction of the whole haLvi into the rectum." t Langenbeck Archiv f . klin. Chir. , vol. xv. p. 1 ; 1872. 1 6 The Rectum and Anus. [Chap. i. Loring motion the knuckles can now be made to pass the sphincter, steady pressure being made with left hand above pubes ; several minutes being occupied in this procedure. In order to facilitate the introduction, incision is sometimes necessary. When the hand has fully entered the rectum it should be held quiet for a short time, till spasm subsides, and then slowly pressed onwards, the fingers being alter- nately opened and closed, so as to dilate the intestine. Simon limits the distance to which the knuckles should be introduced as 17 to 19 cm. (7 to T^ inches), but the fingers may be extended well up into the sigmoid flexure. Other surgeons, however, have passed the hand higher up, Walsham, who has made a number of experiments on the dead subject, having shown that the hand may be passed into the descend- ing colon without producing injury ; but the prudent surgeon will never allow the hand to pass the rectal pouch, as the peritonaeum is a comparatively inelastic membrane, and if the hand is passed entirely within that portion of the intestine which is surrounded by this membrane, grave danger will be encountered. Indeed, the cases in which this operation has been followed by fatal rupture are tolerably numerous. Weir* records two, Dittellf one, and HeslopJ two. In the latter cases the rupture took place through an ulcer in the neigh- bourhood of a stricture, and would suggest greater caution in the manual exploration for disease of the in- testine itself than for the purpose of investigating the other pelvic and abdominal viscera. Of the structures felt through the intestinal wall the most important is the bladder in the male. In the female the uterus and uterine appendages can be more thoroughly explored by this than by any other method. The * New York Medical Record, IMarch 20th, 1875. t London Medical Record, July 15tb, 1875. X Lancet, May 11th, 1872. Oiop. T.] Manual Examination. 17 iaternal iliac vessels with their branches can also be traced. \^''alsham has pointed out the import- ance of examining cases of gluteal aneurism in this way, so that exact knowledge may be obtained as to whether the disease is confined to the exterior of the pelvis, a plan which would manifestly determine the nature of operative proceeding. The bony wall of the pelvis can also be investigated ; and with the finger in the sigmoid flexure, the lower end of the left kidney and the last rib on the same side can be ex- plored. Some American surgeons speak of feeling the spleen and sweeping the hand over the under surface of the liver. Such procedures, if possible, must be attended with such extreme danger that I cannot conceive any circumstances which would justify a prudent surgeon in resorting to an explora- tion of the kind. Allingham"* has frequently per- formed this operation, and speaks very favourably of it. He mentions one case of great interest, in which he found by this means, and completely stretched, a band of false membrane or peritonaeum which was binding down the bowel as it crossed the brim of the pelvis. The obstruction was removed, and the patient recovered. This examination can be much more readily prac- tised on women than on men ; but even in the latter, if the hand is tolerably small, and due caution be used, much information can be gained. The smaller the operator's hand is, the better; the limit assigned by Simon being a tolerably liberal one, 25 cm, (9| in.) greatest circumference. After the operation slight in- continence sometimes is experienced, but it seldom lasts over a few days. If an incision has been rendered necessary it is better to pass a couple of deep sutures to keep the sides of the wound in apposition, and so hasten healing. *" Diseases of Kectuin," p. 9. Fourth edition. c— 23 i8 CHAPTER II. THE CONGENITAL MALFORMATIONS OF THE RECTUM AND ANUS. Viewed either from an embryological or surgical standpoint, congenital malformations form one of the most interesting of all the subjects connected with the contents of the present voluma And although it is true that the number of such cases coming under the observation of any one surgeon will probably be small, as they are all somewhat rare, still it is essential that all medical men should be thoroughly familiar with the varieties and the treatment required, as the saving of life in some of the forms is mainly dependent upon the promptitude with which surgical aid is in- voked. In order to arrive at an understanding of the method of production of the various forms, it will be necessary for us briefly to refer to the development of the intestinal tract ; it will, however, be possible here only to refer to the more important facts. For fuller details the reader must be referred to the systematic works on Embryology. The mesenteron or central portion of the alimentary tract is formed from the hypoblast, and consists, in the first instance, of a simple tube which ends at the anterior extremity of the embryo in a blind sac, while at the posterior extremity a similar cul-de-sac is formed. This tube of hypoblast represents only what is to constitute the mucous membrane of the aliment- ary tract, the other coats of the intestine being subse- quently formed by this hypoblastic portion becoming enveloped in a layer of mesoblast, which differentiates Chap. II.] Congenital Malformations. 19 inta two portions, the outer forming the peritoneal covering, while the inner develops into the muscular and connective tissue elements of the intestinal wall. An invagination of epiblast at the anterior ex- tremity of the embryo meets and communicates with the anterior portion of the mesenteron ; this, which is called the stomodteum, constitutes the mouth ; while a similar depression of the epiblast at the posterior extremity, called proctodseum, forms the anal orifice, and communicates with the mesenteron. It will be necessary to study this proctodseam a little more in detail. If a human embryo about the sixth week be examined, it will be found that immediately in front of the coccygeal eminence, which at that period of development is relatively very prominent, a slight elevation surrounded by a furrow is to be seen • from this eventually will be developed the anus and generative organs, but as yet they are not differ- entiated. At about the eighth or ninth week the anus will be separated from this cloacal opening, and the rudiments of the perinseal septum will have been formed ; and in an embryo of about ten weeks, when the genital organs will have been so far developed that it is possible to determine sex, the anus also will have been fully formed and separated by a distinct septum from the structures of the anterior perinseum. The anal depression continues to deepen until it reaches the mesenteron, with which it becomes continuous, and so the patency of the extremity of the intestinal tract becomes established. In the higher vertebrates this intercom- munication becomes so complete that no permanent trace of the junction is left, except a change in the character of the epithelium. According to Balfour,* a perma- nent fold marks the hypoblastic section of the cloaca from the proctodseum proper in birds, and in this class * "Comparative Embryology,'' vol. ii. p. 641. 20 The Rectum and Anus. [Chap. ii. of vertebrates the proctodseum is further complicated by the development from it of the bursa Fahricii. The perinseal septum, which is such a characteristic feature of the higher mammalia, in the human subject forms a very complete barrier between the anterior and posterior perinseum. This is practically illus- trated by the way in which extravasation of urine is sharply limited to the front portion of this space, while for the same reason abscess connected with the rectum seldom makes its way forward. Most of the malformations of the rectum are to be referred to arrested development or irregular growth of the proc- todaeum or mesenteron ; and it is a remarkable fact how frequently, when any of these malformations are present, there is also a failure of development of the perinseal septum, and a tendency for abnormal com- munication to occur between the intestinal tube and the genito-urinary system. This possibly is due to the fact that in early foetal life the proctodseum is portion of the genito-urinary tract_, from which it subsequently becomes differentiated. The proportion of children born with congenital de- fects of the termination of the intestine is small. The statistics of Zohrer at the Vienna Lying-in Hospital, and of Collins of the Dublin Lying-in Hospital, jointly reach to a record of 66,654 deliveries, and of these only three were born imperforate. Other observers show a rather larger proportion, but sufficient has been said to demonstrate that the abnormality is by no means common. The proportion of males to females is 241 to 184.* The most practical classification of rectal malfor- mations is that given by Papendorf, and with slight modifications adopted by Bodenhamei', MoUiere, Esmarch, Kelsey, and other writers. He gives the following nine varieties. * " Leichtenstern's Statistics." Chap. 11.] Varieties of Malformation, 21 First variety. — Preternatural narrowing of the anus at its margin, and occasionally extending some distance above this point. Second variety. — Complete occlusion of the anal aperture by simple membrane or by the common integument. Third variety. — No anus whatever, the rectum being partially deficient and terminating in a cul-de- sac at a greater or less distance above its natural outlet. Fourth variety. — The anus in this variety is normal, the rectum at a variable distance above it being either obstructed by a membrane or completely occluded for a greater or less distance. Fifth variety. — The anus opens at some part of the perinseal or sacral region, instead of at its normal position. Sixth variety. — The rectum opens into bladder, urethra, or vagina, sometimes forming a complete cloaca, the normal anus usually being absent. Seventh variety. — Rectum normal, with the exception that either the ureters, the vagina, or uterus, open preternaturally into it. Fig:hth variety. — The rectum is entirely wanting. Ninth variety. — Where rectum and colon are both absent. In these cases there is sometimes an opening leading to the intestine at some other part of the surface of the body. It will be seen that in the first three varieties the development of the proctodseum is principally at fault, while in the others the malformation is of a more complicated character. First variety : cong^enital stenosis of the anus. — Of this malformation but few cases are re- corded. According to Bodenhamer, however, it is more common than generally supposed, as many of the 2 2 The Rectum and Anus. [Chap. ii. minor cases are not considered worth recording, and it is probable that others undergo spontaneous cure, the efforts of the child to pass faeces being sufficient to produce the necessary dilatation. It is possible that this condition might be mistaken for the effects of congenital syphilis ; but the series of symptoms indicating the latter disease are usually sufficiently characteristic. Varieties. — The anus may be simply too narrow and incapable of sufficient dilatation. When this is the case the symptoms usually do not develop until the child is some months old, the anus, unless the con- striction be extreme, being sufficient to permit the soft and semifluid faeces of early infant life to pass. When, however^ the child begins to take solid food, and the faeces become harder, an accumulation is likely to take place in the rectum. I have seen a case of this kind in a child aged three years, in whom nothing abnormal was noticed until the patient was seized with great straining and slight catarrhal dysentery. Upon examination it was found that the anus was incapable of dilating to more than the size of about a No. 8 catheter, and that the rectum was ])lugged with a mass of hardened faeces ; a slight in- cision and subsequent mechanical dilatation rapidly cured this case. In other instances the anus may be partly oc- cluded by a membrane i-esembling the hymen, the opening in which may be so small that it will only admit a tine probe, or the membrane may simply exist as a fold which does not interfere with the opening of the anus to any a])preciable extent. Such folds, manifestly of congenital origin, are not un- frequently met with during the examination of the rectums of adults for other affections. When so slight as tliis tliey are of no surgical significance, and the patients are probably unconscious of their existence. Chap. II.] Partial Occlusion of Anus. 23 The treatment of congenital anal stenosis must be conducted on the same lines as those laid down for acquired stricture. There is, however, a much better prospect of doing permanent good by mechanical dilatation than in those cases in which the stricture is due to cicatricial contraction. The best of all bougies is the mother's index hnger introduced daily into the bowel. Mr. Morgan* records two remarkable cases in which a curious congenital malformation produced a partial occlusion of the anus. In the first case, '■'• a male child, aged six months, was taken to the hospital on account of the pain which he suffered whenever motions were passed. The pain was such as to cause the child to cry continuously before and after the bowels were relieved. The body was well formed and otherwise healthy, but on examining the anus, which was of usual size and in proper position, there was found to be a band of tissue passing from a point corresponding to the apex of the coccyx to the median raphe of the scrotum, with the posterior ex- tremity of which it was continuous. The band was about three-quarters of an inch long, and was attached at both ends, the remainder forming a thick free cord which lay below the aperture of the anus ; while from the centre of the band there ran a small branch of similar tissue which was attached to the skin of the left buttock, and was about half an inch in length. The skin which covered the central band exactly resembled that of the scrotum, shrinking and con- tracting upon stimulation, and it was so placed that any matter passed per anum must cause it to be stretched, thus accounting for the pain which attended every relief of the bowels. The whole band was removed by cutting the attached ends with the scissors. The wound healed at once, and the child * Laticet, Oct. 22, 1881. 24 The Rectum and Anus. [Chap. II. was relieved of all pain." Mr. Morgan's second case was somewhat similar. " On examining the parts there was seen a small thick band, passing from the median raphe of the perinaeiim in front to the de- pression between the buttocks posteriorly, and broadest behind. At a spot corresponding to the anus on either side of the band was a depression ; that on the right side was patent, and admitted a probe to pass into the anus ; that on the left side, though similar in appearance, proved to be only a cul-de-sac. Motions passed freely, but caused much distress. The band was snipped off, and the child was relieved of pain." Mr. Cripps states* that he has seen a similar case under the care of Mr. Wiliett. Second variety: complete occlusion of the anal aperture by simple membrane or by more fully formed skin (Fig. 5). — In this variety the anus may simply be occluded by a structure which is in many respects similar to the hymen. And its presence is not incon- sistent with the complete de- velopment of the sphincter and other portions of the termin- ation of the rectum. It would appear to be due to an ad- hesion or skinning over of the surface of the anus, the rest of the proctodjsum being normally formed. Diagnosis. — It will be noticed that the child passes no meconium ; and that it is constantly straining, and apparently in pain. An inspection of the anal region shows that there is a protrusion at the anus, especially if the child * Diseases of Rectum and Anus," p. 25. London, 1884. Fig. 5, — Second Variety of Congenital Malformation. Complete occlusion of the anal aperture. Chap. II.] Absence of Anus. 25 strains ; and if the covering be very thin the colour of the meconium can be cli.stinctly seen through the membrane : fluctuation is also distinct. The cure of this case is as simple as the diagnosis. A crucial in- cision with snipping off the angles is sufficient to give exit to the meconium and to cure the child, at all events when supplemented by the occasional passage of the tip of the mother's linger as a bougie. Third variety : no anus whatever, the rectum beings partially deficient, and termi- nating* in a cul-de-sac at a greater or less distance above its natural outlet (Fig. 6). — In this variety there are many different degrees, the simpler forms resembling the more marked examples of atreesia ani, the rectal cul-de-sac descend- ing well down into the pelvis, and reaching to within a short dis- tance of the skin \ while in the more severe forms the rectum may terminate high up in the pelvis. The appearance of the perinseum varies somewhat in these cases. In some a rinof of darker-coloured skin points out the position where the anus ought to have been ; while in others a little button of skin is to be found in the same place, or even a pendulous tumour. In others, again, the ridge of skin forming the raphe of the anterior perinseum is continued in an unbroken line back to the coccyx, no mark whatever being visible to indicate the site of the anal orifice. Associated with this latter condition other abnormal relations of the pelvic structures are sometimes met with. The external genital organs may be nearer the tip of Fisr. 6.— Third Variety of Congenital Malforma- tion. No anus what- ever, the rectum termi- nating in a cul-de-sac. 26 The Rectum and Anus. [Chap, ii. the coccyx, and otherwise abnormally developed ; the tiibera ischii may be abnorm.ally close to- gether ; and the pelvis altogether manifestly smaller than natural. When any of these latter conditions are observed, it renders the prognosis very formidable, as the probability is strong that the rectal cul-de- sac is situated a long distance above the perinseum. This form of malformation is usually early diagnosed, as the attention of the parents or nurse is attracted by the fact that the child's bowels have not moved, and a mere inspection serves to establish the cause of the constipation. If unrelieved, the child soon becomes restless ; it is manifestly in great pain, straining a great deal, and, at a later period, faecal vomiting comes on, and death soon follows. In some rare instances, how- ever, life may be prolonged for several weeks, the fsecal vomiting alternating with the swallowing of milk. Treatment. — The duty of the surgeon in these cases is clear : in the first place he should attempt to reach the rectal cul-de-sac by perinseal incision, and the sooner this is attempted after the diagnosis is made the better, as in all cases of intestinal obstruction delay means a fatal result. If we wait until the abdomen is distended with gas, and the little patient is much run down, death will be the inevitable sequence. In selecting the form of operation it is of the utmost importance to determine the position of the rectal cul-de-sac as far as possible. Unfortunately this is seldom possible with any degree of accuracy. If the pelvis is of normal shape, and the genital organs in natural position, if on crying or straining there is a distinct protrusion in the anal region, then the probability that the pouch is within easy reach is strong. The protrusion may usually be incited by tickling or ])inching the skin of the perinseum, but the administration of purgatives for such purposes is to be absolutely interdicted. It has been recommended Chap. II.] Pelvic Measurements. 27 by some surgeons to delay the operation for a day or two if the symptoms are not very urgent, in order to give an opportunity for the rectum to become more distended and prominent. Such advice is quite erroneous, as, in the first place, the meconium in the bowel becomes less by the absorj^tion of fluid, and, what is more important, while we are waiting, the time may slip away when alone a chance of success exists. Before undertaking any operation it is well briefly to review some of the more essential anatomical arrange- ment of the pelvic viscera, as success will in great measure depend upon the care exercised by the surgeon. The rectum descends in the hollow of the sacrum, closely applied to that bone, and, except at its upper part, is uncovered by peritonaeum posteriorly. In front the peritonseal pouch descends to a much lower level, while its close relations to the genito- urinary organs anteriorly would prove an additional reason for selecting the posterior aspect for exploration. The following are the measurements of the infant's pelvis, as given by Bodenhamer. From one tuberosity of the' ischium to the other, 1 inch to 1 inch 1 line ; from tip of coccyx to symphysis pubis, 1 inch 1|^ lines to 1 inch 3 lines ; and from the tip of the coccyx to the promontory of the sacrum, 1 inch 1 line to 1 inch 2 lines. The object of the surgeon in operating on these cases is to reach the bowel by direct incision from the perinseum. Formerly it was the custom to use a trocar and cannula, which was driven into the perinseum in the direction where the rectal cul-de-sac was supposed to be. No doubt, occasionally, the bowel was opened, and exit given to a small quantity of meconium, but even when this result was attained the opening was too small to serve as a permanent vent, while, frequently, fatal injuries were inflicted, the peritonseum, bladder, and even the common iliac vein, having been opened by the instrument. 28 The Rectum and Anus. [Chap. ii. Method of operating^. — The little patient being held in the lithotomy position, an incision should be carried from a little behind the root of the scrotum right back to the tip of the coccyx, taking care to keep accurately in the middle line. The pelvis should be from time to time during the progress of the operation explored with the finger, in order to try and feel the bulging of the rectal pouch, and the incision carried deeper at its posterior extremity than in front. It has been recommended to keep a sound in the bladder of the male, or in the vagina of the female, and, occasionally, this may be of use in recognising the parts where the dissection is carried deeply, but, under ordinary circumstances, if care be taken to keep well back in the hollow of the sacrum, the danger of wounding the genito-urinary organs is trivial. When the light is good the proximity of the rectum has been sometimes determined by the colour of the meconium showing through, but, generally, the finger will be the best means of detecting the gut. Having found and opened the intestine, the meconium should be evacuated, and, if possible, the recommenda- tion of Amussat followed, to bring down the bowel, and carefully stitch the edges of the intestine to the skin wound, and, where necessar)'-, the bowel should be cleared well from its pelvic attachments in order to allow this to be done. In stitching the intestine to the wound, great care is necessary to pass the sutures so deeply through the surrounding structures that no cavity can possibly be left outside the rectum in which fluids could collect ; the danger of septic periproc- titis, in great measure, depending upon the amount of success with which the suturing is done. If it be found impossible to close the deeper parts of the wound completely by sutures, one or two small drainage tubes should be passed to the bottom of the incision. The method of bringing down the njucoua Chap. II.] Removal of Coccyx. 29 membrane, and sutui'ing it to the skin, introduced by Araussat, is a vast improvement upon the older method, by which the incision was made simply into the rectum, and the faeces allowed to escape over the open wound. Not alone were the immediate dangers of fsecal extravasation into the areolar tissue of the pelvis great, but, even should the patient survive, difficulty more or less great is almost certain to result from the contraction of the cicatrix producing stricture. It will still, however, occasionally happen that the termination of the rectum is situated so high up that it may be found impossible to bring down the mucous membrane to the skin without an amount of traction which would tear the gut. Under these circumstances it is necessary to keep the wound open by means of a metal tube, or other similar contrivance ; but such cases are not likely to terminate successfully. In order to render the dissection more easy, Amussat recommended the removal of the coccyx ; "^ and the procedure is still more strongly advocated by Yerneuil. f As the latter has shown, not only does the removal of the coccyx assist much in the search for the occluded rectum, but it also enables the intestine to be more readily attached to the wound, as the latter is by this means much nearer to the cul-de-sac. In this variety of malformation there sometimes exists a cord, con- sisting of the outer tunics of the bowel, leading from the cul-de-sac to the normal site of the anus, and which will be more particularly described when dis^ cussing the next variety. Should this be present, it may, as has been pointed out by my colleague, Pro- fessor Bennett, J form a valuable guide to the pervious portion of intestine. If it be found impossible to * Quoted by Bodenhatner, " INIalformations of the Anus and Rectum," p. 147. New York, 1860. t Med. Times and Gazette, July 5th, 1873. J Transactions of Academy of Medicine in Ireland^ vol. i, p. 150. 30 The Rectum and Anus. [Chap. ii. reach the rectum by carefully dissecting up in the direction of the promontory of the sacrum, and should a careful digital examination of the rest of the pelvis, as far as it can be explored, fail to indicate any fluctuating tumour resembling the distended intestine, unquestionably the proper surgical course is to perform colotomy, and most surgeons are now agreed that laparo-colotomy is preferable in these cases to the retro- peritonaeal operation in the lumbar region. I would refer the reader to the chapter upon colotomy for a fuller discussion of this subject. Dr. McLeod has suggested * that after the performance of laparo- tomy, instead of bringing out the intestine at the abdominal wound, the perinseal incision should be continued so as to open the peritonseal cavity, and the intestine should then be forcibly drawn down, opened, and fastened to the skin of the perinseum, the ab- dominal wound being closed ; the object being to make the artificial anus in the perinseum instead of in the anterior abdominal wall. It does not appear that this operation has been practised ; nor do I think that in the majority of cases it would be practicable. In a few recorded cases it has been attempted to establish a perineal anus subsequent to colotomy, after the wound has healed, by passing a sound down the rectum, and attempting to cut upon this from the perinaeum ; the results, however, have been far from encouraging. What I would propose doing in these cases where perinseal exploration has failed, is to open the abdomen, preferably in the left linea semilunaris, introduce a finger into the abdominal cavity, and trace down the rectum ; if it is found to descend well into the pelvis, the search from the perinaeum should be again instituted, and with the additional guide of a finger in the peritonaeal cavity it may probably be successful, in which case the * British Medical Journal, vol. ii. p. 657 ; 1880. Chap. II.] MuL riPL E Obstr uc tions. 31 abdominal exploration will not have much increased the risk ; if, on the other hand, the pervious bowel terminates above the pelvis, all hope of making a perineeal anus should be for ever abandoned, and a colotoniy completed. Fourth variety : in this form the anal portion, although apparently normally formed, ends in a cul-de-sac, the rectum terminating: at a variable distance above this point (Fig. 7). — Sometimes the tubes are sepa- rated by a more or less thick membrane, Avhile at other times there is a considerable length of intestine impervious. Of this malformation there are several interesting varieties ; in one form the obstructions are mul- tiple, and the important bear- ing that these cases may have upon operative treatment is obvious, the obstruction con- tinuing after the apparently complete division of a m-em- branous septum. Of these Bodenhamer has collected a number of examples.* Thus, Friedberg mentions a case of a new-born female child whose anus was well formed, but the anal canal was closed a little above the sphincter. The attempt made to open it by puncture produced no evacuation of meco- nium, and the child died six days after birth. At the autopsy the walls of the intestine were found adhering to each other and closely united in two different places. Schenck records a case in which the rectum above a natural anus was closely united * Loc. cii.^ p. 162. Fig. 7. — Fourth. Variety of Congenital Malforma- tion : anal portion ending in a cul-de-sac, rectum terminating in a blind ex- tremity. The Rectum and Anus. [Chap. II. at two places, as if glued together, and at two other points the rectum was occluded by two annular mem branous septa ; while Yoillemier reports a case in which the rectum was divided by membranous septa into four distinct compartments, the anus remaining normal ; and Dr. Bushe, of New Yoi'k, and Goeschler, of Prague, both give cases in which a double obstruction existed. In other cases, instead of the two constituent portions of the rectum abutting one against the othei', they may pass parallel to one another, the lower portion passing usually in front. Cases of this kind are recorded by Amussat,* by Godard,t and by Curling, j. In Godard's case the rectal portion was attached to the coccyx, while the anal portion passed up in front of the prostate gland. These cases are especially interesting, as they unquestionably indicate that the malformation is due to the fact that the proctodseum has failed to meet the mesenteron, and that they cannot possibly be due to an obliteration of the rectum after complete development. In connection with these cases must be noted the classical case recorded by Amussat (Fig. 8), ,5 in which the anal portion communicated with the vagina, while the rectum ended in a cul-de-sac. I have not met with a description of any similar instance to this, which is given with great detail by Amussat. Not only is this case interesting from the nature of the * "Sur la possibilite d'etablir une ouverture artificielle," etc. Troisieme Memoire. Paris. 1843. t Gaz. Mid. de ParU, 1856. X "Diseases of Rectum," p. 200. § Loc. cit. Tig. 8. — Congenital Mal- formation : rectum end- ine in a cul-de-sac, anal portion opening into vagina (Amussat). Chap. II.J A MUSS ax's OPERATION. ^iZ malformation, but also for the success of the treatment adopted. An incision was made behind the aaus ; and the rectum having been reached, it was separated from its connections, brought down, and stitched to the skin, this being the iirst occasion upon which this procedure, now so well known as ""Amussat's opera- tion," was performed The anus was left untouched, and the communication with the vagina not interfered with. The patient made a good recovery, and was married at the age of twenty-one years. Two theories are put forward to account for the usual condition met with in the fourth variety of malfor- mation : one that it is due to failure of meetins: between the mesenteronand the proctodeeum ; and the other that it is due to an intra-uterine inflammatory occlusion of the fully developed intestine. The supporters of the latter view point to the fact that in many of these cases there is to be found a cord manifestly continuous with the outer tunics of the bowel con- necting the two pieces of gut. Unquestionably this cord is very frequently present, but it by no means follows that its presence presupposes a pervious in- testine. On the contrary, its presence can be shown with much greater probability to iiave a developmental origin ; the mesenteron which originates from the hypoblast, as before mentioned, forms the upper portion of the rectum, but from it the mucous mem- brane alone is developed, a layer of mesoblast subse- quently surrounding the tube to form the muscular and other external portions of the intestinal wall ; consequently, when the development of the cul-de-sac of mesenteron becomes, from any cause, arrested, it does not follow that the growth of the other tunics originating from the mesoblast should be arrested also ; and when there is no mucous coat to be sur- rounded, it can be readily understood how this portion of mesoblast can form itself into the rounded cord. D— 23 34 The Rectum and Anus. [Chap. it. Again, we must remember liow exceedingly rare it is for a mucous canal to be obliterated by inflamma- tion, unless attended with a very considerable super- ficial loss of substance. The only instance that I know of in which a mucous canal is obliterated during the process of development in the human subject is that of the urachus, but even in this case evidence of the mucous membrane, and even small mucous cavities, are still found in the cord which forms the remains of this fcetal structure. I have recently had an opportunity of carefully examining a case of this kind from a patient under Professor Bennett's care in Sir Patrick Dun's Hospital, in which, after failure to meet the rectum by perinaeal incision, a colotomy was performed, but the result was fatal. In this instance there was a very firm and strong cord extending from the cul-de-sac to the anal portion ; a microscopical examination of this cord showed it to be composed entirely of muscular and connective tissue, without a trace of mucous membrane. I was also able to deter- mine another important point in this case. If the anal depression is composed alone of proctodseum, it is obvious that, as it originates entirely from the epiblastic layer of the embryo, it should have its surfaice covered with scaly and not columnar epithe- lium. I consequently obtained a small piece from the fundus of the anal depression, and made sections of it. There was not a trace of glandular epithelium to be seen in it, so that, in this case at any rate, the conclu- sion was unavoidable that the malformation was due to the fact that the mesenteron did not descend low enough for the proctodaeam to meet it ; and that, I believe, is the explanation of the majority, if not all, of these cases. The diagnosis of the fourth variety of malfor- mation is not so likely to be made at an early date as in the previous form, a mere inspection of the anus Chap. II.] Fifth Variety of Malformation. 35 revealing nothing abnormal. And it is only when continued constipation exists, attended possibly with vomiting and meteorism, that the surgeon's attention is usually directed to the case. If an attempt is made to pass a probe or the tip of the little finger up the rec- tum, the condition will at once be recognised, the anal portion of the intestine seldom extending more than a very few lines from the outlet. An attempt should be made to feel, if possible, the upper cul-de sac, so as to form an opinion as to the distance intervening between the two portions of the bowel. As these cases are seldom diagnosed until grave symptoms have become developed, it is obvious that the prognosis is usually more unfavourable than in the last variety. The treatment of this variety does not differ in any essential respect from what has been already de- scribed for the third variety. In all cases an incisiwi should be made from the anal depression back towards the coccyx, and the rectum sought for and opened, and stitched to the site of the normal anus. Even in those cases in which a septum alone intervenes between the two portions of intestine, the incision should be preferred, as where an attempt has been made to puncture with a trocar and cannula a valvular and inefficient opening has been formed in some cases, while in others serious injury has been inflicted on the peritonaeum or other pelvic viscera. As in the last instance, if the surgeon fail in finding the rectum, colotomy is the sole resource for saving the infant's life. Fifth variety : tlie anus is conapletely absent, or rnclimentary, and tUe rectnni terminates io a cutaneous opening: at some other situation than the normal one. — As might be anticipated, there is a very considerable amount of variety met with in the situation at which the 36 The Rectum and Anus. [Chap. II. abnormal anus opens, while in some cases more than a single orifice exists. It has been suggested that these cases are due to the formation of fistulse, similar to the fistulas found in connection with stricture of the rectum, but this view may at once be disposed of by the fact that no evidence of suppuration exists ; and the channel is lined with mucous membrane instead of granulation tissue, clearly demonstrating that these cases are congenital malformations in the true accepta- tion of the word, and not of pathological origin. Bodenhamer, who has made these cases a distinct class from the following, in which the abnormal anus is situated in one of the other mucous tracts, has collected a number of interesting varieties, but as space will not allow me to go into details, the reader, for further particulars, must be referred to Bodenharaer's work .* The positions at which these openings have been described are indeed various, as may be gathered from the following list of the more important situa- tions : (1) within the prepuce, the rectum being continued as a narrow channel under the raphe of the perinseum and under surface of the penis (Fig. 9) ; (2) at the symphysis pubis ; (3) at the root of the penis ; (4) at the posterior portion of the scrotum ; (5) at the fourchette in the female ; (6) at various portions of the perinfeum ; (7) in the right gluteal region ; (8) in the loin ; and (9) through a perforation in the sacrum. These last cases, when viewed in the liglit of modern * " Congenital Malformations of the Rectum and Anus." York, 1860. Fi^. 9. — Congenital Mal- formation : the rectum ends in a narrow channel •whicli opens beneath the prepuce (Cruveilhier). Chap. II.] Post-Anal Gut, 37 embryological knowledge, possess a special interest. Bodenhamer mentions three of them : two recorded by M. De La Faye,"^ and one recorded by M. la Coste.f Unfortunately there does not appear to be any allusion in these cases to the relation of the abnormal anus to the termination of the neural canal. In the lower vertebrates there is a distinct communication between the mesenteron and neural canal known as the neurenteric canal, which is a very distinctive feature during the early periods of development, and which, when the communication with the neural canal is cut olF, which occurs at an early period, constitutes a prolongation backwards of the intestine behind the anus. This, which is termed the post-anal gut, has also been observed in birds and mammals ; and, according to Kolliker,| in the young embryo of the rabbit, the post-anal gut, or pars-caudcdis intestini, is a very conspicuous struc- ture, terminating in a small vesicle posteriorly. As in the case of the lower vertebrates, this caudal intestine undergoes a very rapid oblitera- tion during the process of development. Bal- four § attaches great weight to the presence of the neurenteric canal and post-anal gut, as throwing light upon the ancestral form from which the chordata have been evolved, and he considers that the anus as at present found in the vertebrates is of comparatively recent evolution ; for, as he states, the post-anal section of the alimentary tract cannot always have been devoid of function, as is shown by the following facts : (1) by the constancy and persistence of this obviously now functionless rudiment; (2) by the greater develop- ment in the lower than in the higher forms ; (3) and by * " Principes de Chirurgie,'' p. 358, P,aris, 181], t "Bulletin de la Societe Medicale d'Emulation de Paris," p. 417 ; October, 1822. t "Embryologie,"p. 878. § " Comparative Embryology," p. 267. London, 1881. 38 The Rectum and Anus. [Chap. 11. its relation to the formation of the notochord and sub- notochordal rod. He therefore conchides that in the ancestral type the anus was situated at the termina- tion of the post-anal gut. I have alluded at some length to this subject, in the hope that should any examples of these (cases where the rectum perforates the sacrum) be met with, they may be made the subject, if possible, of a detailed anatomical exami- nation. The prognosis of these cases in which the anus is only abnormally situated but remains pervious, is mani- festly very much better than those in which occlusion exists; and in some cases it may be unnecessary to con- template any operative interference, the abnormal anus being quite sufficient for all purposes. But in other instances, and apparently in the majority of the re- corded cases, the termination of the rectum and the aperture were quite too narrow to permit of efficient evacuation of the bowel at a later period of life, though possibly allowing the semifluid meconium to pass off" in early infancy. Operation can, however, here be undertaken with a very much greater chance of success, as it is no longer necessary to search for the rectum, a probe through the abnormal opening indi- cating the position of it. If the probe indicates clearly that the pouch of the rectum descends down close to the normal position of the anus, the best course will be to naake an incision down to the rectum, clear it round, and bring it down, after the method of Dieffenbach, and stitch it to the skin. The abnormal passage should now be closed, if possible, as if it is left open there will be a constant tendency for nature to close up the artificial anus, and continue the use of the abnormal one. For this purpose the use of the actual and potential cauteries have been recom- mended, but they do not appear to have answered the purpose properly ; probably the best course is to dissect Chap. II.] Sixth Variety of Malformation. 39 out the narrow abnormal tube, and bring the parts together by deep sutures. Vicq D'Azyr recom- mended the introduction of a director into the rectum from the abnormal anus, and the incision of tlie parts, up to the normal situation of the anus, a metal tube to be retained, and the rest of the wound allowed to heal. Possibly where the abnormal anus was situated close to the normal position, this method might be with advantage adopted. When the rectal pouch can- not be proved to be near the perinseum, as is likely to be the case in those instances where the abnormal anus is situated at a considerable distance from the usual site, no attempt should be made to reach the bowel from the perinaeum, but, if absolutely necessary, the abnormal opening might be dilated. And in the rare form in which more than one anus is present the recommendation of Ashton* may be followed with ad- vantage ; not to interfere if either is sufficiently large to provide for efficient evacuation ; but if both orifices are very minute an incision through the septum, as in the treatment of rectal fistula, will probably prove an efficient form of treatment. Sixtli variety: tlie anus being: absent or only rndimentary, the rectum terminates in some of the mucous passag^es of the g^enito- urinary system. — The subdivisions are: (1) where the communication is with the bladder {atresia ani vesicalis) ; (2) where it opens into the urethra (atresia ani urethralis) ; and (3) where the ab- normal anus is situated in the vagina {atresioj ani vaginalis). It is remarkable the frequency with which the sixth variety of malformation is met with. According to Leichtenstern's statistics,! out of a total number of 375 cases of malformation of the rectum 40 per cent, were of this variety j and in * "Diseases of the E^ctiun," p. 327. t Ziemssen's Cyclopsedia, vol. vii. p. 485. 40 The Rectum and Anus. [Chap. II. Bodenhamer's statistics, out of a total of 287 cases 85 were of the sixth form. This large proportion is exceedingly remarkable when we remember that in the adult the se})aration between the rectum and anterior perin sen m is so exceedingly definite ; and I am not aware tliat an}- satisfactory explanation has been offered to account for this marked tendency of the rec- tum to communicate with the genito-urinary apparatus in cases where the anus is undeveloped, unless, in- deed, it be due to the method of development of the proctodseum {see page 19), or a tendency to reversion to the cloacal types of the birds and lower mammalia. Atresia ani vesicalis (Fig. 10). — The communica- tion between the rectum and bladder in these cases consists usually of an exceed- ingly narrow canal having its termination at some part of the trigone of the bladder by a minute orifice, while in very rare cases the communication has been near the fundus, and when this is the case the open- ing has been found to be more free. The diagrnosis of these cases is usually sufficiently simple. With the symptoms dependent upon the occluded rectum will be found a small quantity of faeces passed with the urine, sometimes only in sufficient quantity to stain the water of a green colour. Tlie fact that the meconium is intimately mixed with the urine, and that it only appears duiing urination, will at once distinguish this variety from the atresia ani urethralis. The prognosis, as might be expected in these cases, is eminently un- favourable. From the fact that the bladder is in the Fig. 10, — Congenital Mal- formation : rectum end- ing in bladder (atresia ani vesicalis). Chap. II.] AtR ESI a AnI Ur E THR A LIS. 4 1 young infant an abdominal viscus, it will be readily understood that the termination of the rectal pouch is probably situated in such a position that any attempt to reach it from the perinseum will prove a failure, although two successful cases of this operation are mentioned by Bodenhamer.* If, however, nothing is done, death will be the inevitable result, as in the majority of cases the opening is so small that but a small quantity of meconium can pass ; and even where the opening is somewhat larger, although possibly life might be prolonged while the fseces remained semi- fluid, a fatal cystitis will eventually be produced. M. Martin, of Lyons, has suggested! an operation for the relief of this form, viz. to incise the neck of the bladder as in the operation for lithotomy, and then to continue the incision on into the rectum. Granting that this operation might in a few cases be feasible, the result would be of very questionable utility, as if successful it would leave the patient with a urinaiy and faecal fistula. I believe that the true scientific procedure in these miserable cases would be to per- form a laparo-colotomy, and then to cut the colon completely across, as recommended by Madelung ; closely suture up the lower end after inversion of the serous membrane, and bring the upper end out at the wound to make an artificial anus. Although this pro- cedure would leave the patient with an abdominal anus, it would have the advantage of restoring the functions of the bladder. Atresia ani urethralis (Fig. 11). — In this form the canal leading from the rectum, instead of opening into the bladder, communicates with some portion of the urethra. As in the former case, the opening is generally by an exceedingly minute orifice, so that but a small quantity of meconium can escape. In this * Loc. cit., p. 232. t " Dictionnaii'e des Sciences Medicales, " tome xxiv, p. 127. The Rectum and Anus. [Chap. II. variety it comes more or less in the intervals between urination. When the urine is passed, although the tirst that is evacuated may be stained, it afterwards comes quite clear. In the treatment of this form, the probability of reaching the bowel from the perinaeura is much greater, and this should always be attempted ; moreover, the presence of a subsequent recto-urethral fistula is a much less serious condition than a communication between the rectum and bladder, the former being frequently curable ; or, at any rate, not directly threatening life, while the latter is generally beyond the range of surgical aid to cure, except by establishing an arti- ficial anus, and is likely to prove fatal. This is the most suitable place to consider a form of rectal malformation which I have not hitherto seen described. It is one of atresia ani in which a diverticulum from the rectum passes forward, and becomes re- lated to the urethra without opening into it. Of this remarkable malformation I have only the following case to record. In the spring of the present year (1886), I saw, in conjunction with my colleague Professor Finny, a medical man in this city, who, after having suffered for some days from an intermittent fever, de- veloped an inflammatory swelling at the root of the penis and deep in the scrotum. He told us he had suf- fered from some pain while the bowels were being moved and asked me to delay examining the rectum till he was under ether. Upon making an incision into the swelling, a gangrenous and abominably foetid abscess was opened, apparently in connection with the left Fi :. 11.— Congenital Ma'- formation : rectum end- ing in urethra (atresia ani urethralis). Chap. II.] Atresia Am Vaginalis. 43 crus penis. Passing my finger now into the rectum, I was surprised to find a membranous stricture imme- diately within the anal verge, through which, how- ever, the finger readily passed, and above it I could detect a diverticulum of the rectum passing off in the direction of the situation of the abscess. I forcibly dilated the anus and membranous stricture ; subse- quently fsecal matter in small quantity passed from the wound at the root of the penis. Although he developed septic pneumonia and other symptoms of wound infection, he eventually, after a protracted and severe illness, made a good recovery. After the operation we were informed by his mother that he had been born imperforate, and was operated upon by the late Dr. Fleetwood Churchill. There was never any mixture of fseces with the urine. He is now quite free from any trouble, and I believe the diverticulum has been obliterated by the inflammatory process. Atresia ani vaginalis (Fig. 12). — In this form the rectum terminates at some part of the posterior wall of the vagma, either having a toler- ably large and free aperture, quite sufficient for the evacua- tion of the intestinal contents, or more rarely the rectum ends in a cul-de-sac, the communi- cation with the vagina being by means of a narrow pipe-like tract. The points at which the rectal orifice may open are various, either immediately within the fourchette (Fig. 13) at the entrance of the vagina, or high up in that canal ; and cases have been recorded by Papendorf and Ainsworth,* in which the communication between * Quoted by Bodenhamerj loc. cit., p. 227. Fig- 12,— Congenital Mal- formatioa : rectum end- ing in vagina (atresia ani vaginalis). 44 The Rectum and Anus. [Chap. ii. the rectum and vagina was by a double orifice. If the rectum ends by a true vaginal anus, as is most frequently the case, the patient experiences but little discomfort ; and many cases are on re- cord in which women have married and borne large families while suffering from this malformation. One such case has come under my notice. The woman was the mother of six children, and did not suffer the slightest inconvenience. The anus opened into the lower portion of the vagina, and was so far provided Fig. 13. — Vulvar Anus in a Child aged 19 months. The opening is immediately within the fourchette, and is well provided with a sphincter. with a sphincter that the top of the finger, when introduced into the rectum, was tightly grasped. There was not the least incontinence, and the bowels acted regularly every day. It will thus be seen that this variety of malformation is the one in which the prognosis is most favourable, many of the cases, as in the one above recorded, requiring no operative interference, while in others the fact that a more or less free outlet exists for the meconium relieves the case of its urgency, and enables the surgeon to act with delibera- tion and choose his own time for operative interference, when the little patient has gathered some strength. Amongst the operations which ha\'e been suggested for the treatment of vaginal anus, the following may be mentioned : M. Vicq d'Azyr has recommended Chap. IT.] RlZZOLfs OPERATION: 45 a similar procedure to that stated in discussing the last variety, namely, to make an incision from the vaginal opening to the site of the normal anus, and then to introduce a cannula into the rectum, and allow the anterior part of the incision to heal up. Yelpeau simply made an opening into the rectal pouch, without dealing in any way with the vaginal portion. DiejQfen- bach and Barton"^" recommend that the rectal cul-de- sac, when present, should be dissected free by perinseal incision, and stitched to the skin margin, thus shutting off the vaginal portion from the intestinal tube alto- gether ; and then closing the vaginal orifice, or not, according to circumstances. By far the best plan, how- ever, that has been hitherto suggested, is that of Rizzoli.f An incision is carried from the lower margin of the vaginal anus through the perinseum backwards towards the coccyx, care being taken not to open the intestine. The termination of the rectum, with its vaginal orifice, is now to be carefully dissected out, and the abnormal anus is to be transplanted to its natural situation ; the perinaeal and vaginal wounds are to be brought together by deep sutures, thus re- storing the recto-vaginal septum. The great merit claimed for this highly ingenious procedure is that it retains intact the outlet which Nature has formed, and which, therefore, will probably have sufficient sphincter action to avoid incontinence of fseces, and is less likely to be followed by stricture than where any other operation has been performed. The formation of a proper recto-vaginal septum is also an important matter in preventing uterine trouble in after-life. Dr. Aveling has recorded a very interesting case of this malformation, in which, after a series of operations, a very brilliant result was obtained. | The malformation * Medical Recorder, vol. vii. p. 357 ; Philadelphia, 1824. t "System of Surgery," Gross, vol. ii. p. 605. Sixth edition. X Lancet, Dec. 20, 1884 ; p. 1085. 46 The Rectum and Anus. [Chap. ii. remained undetected until the child was five weeks old, when Sir Prescott Hewett operated by making an opening at the natural situation, and attempting to close the vulvar orifice by caustic, without success. At the age of seventeen she came under Dr. Aveling's care, and he endeavoured to close the vulvar anus by plastic operation. In the first instance this object was defeated by the passage of a hard mass of faeces, which tore away the sutures. A second opera- tion of similar nature proved more successful, the opening being reduced to the size of a goose-quill. A third operation was performed, a small cylindrical speculum being introduced into the artificial anus to ensure the exit of flatus by that route, and so keep the vulvar wound at absolute rest. The result of this operation was completely successful in shutting off the intestinal tube from the vulva. As hardened faeces still accumulated in the diverticulum which existed in front of the artificial anus, and as this portion of gut was unable to evacuate its contents, a still further operation became necessary for its obliteration. An incision was carried through the skin of the perinseum and vulvar mucous mem- brane up to but not including the site of the previously occluded anus. The mucous lining of the diverticuhim was carefully dissected away, and the perinseum closed by deep sutures. In this way a firm recto-vaginal septum was formed, and the patient completely cured. This case demonstrates very forcibly the absolute necessity of ado|)ting efficient means to obliterate the abnormal channel, as well as establishing an opening at the natural situation ; and I believe that in similar cases it would be well to do both operations at the same time. Seventh variety: in which the rectum and anus are normal in situation and calibre, but in which the ureters, vagina, or Chap. III.] Proctitis. 47 uterus opens into the intestinal tube. — Boden- hamer has collected seven cases in which the ureters are described as terminating in the rectum, the bladder being absent. In these cases the position at which the opening took place was at the reflection of the peri- tonaeum. Such cases are, at present at any rate, be- yond the reach of useful operati^^e interference. The same authority has also collected nine cases in which the vagina terminated in the rectum. In several of these pregnancy and successful parturition took place ; but in one only is it stated that operation with a view of establishing a separate vagina was attempted and successfully carried out. It does not appear, however, that there would be greater difficulty in ojDerating upon these cases than in those of the con- verse condition already described, where the rectum opens into the vagina. The eighth and ninth varieties of Bodenhamer, in which the entire rectum is absent either alone or con- joined with more extensive congenital malformation of the intestinal tube, are beyond the scope of this volume to discuss. CHAPTER III. PROCTITIS. Inflammation of the rectum may be the result of injury, or it may be due to various specific influences. In this country, however, its occurrence from these latter causes is not by any means frequent. The mucous membrane of the last part of the in- testinal tube is more liable to injury from matter contained in the faeces than any other part of the gut, because, in the first place, owing to absorption of the 48 The Rectum and Anus. [Chap. in. more fluid parts, the fsecal mass has now become more solid and resisting, so that when the rectal wall con- tracts firmly upon it in the expulsive effort, any hard particles which project, such as pieces of bone, glass, and such like, ai-e liable to lacerate the delicate mucous membrane. Again, as the calibre of the tube so sud- denly diminishes at the junction of the rectal pouch with the anus, hard substances projecting from the faecal mass are more liable to penetrate this portion than any other of the entire intestinal tract. I have seen cases of stercoral abscess following perforation at this situation by a pin which was swallowed acci- dentally, and also by a fish-bone ; and most authors on rectal surgery allude to similar cases. The intro- duction of foreign bodies intentionally or accidentally through the anus (which in a later chapter will be more fully alluded to) is an obvious cause of local traumatism. Inflammation of the rectum may be due to any of these injuries, and when arising in this way has a tendency to spread past the limits of the bowel con- stituting the condition elsewhere described as peri- proctitis (page 54). The varieties of inflammation not directly due to injury are the catarrhal, the dysenteric, and the gonorrhoeal. Of simple catarrhal inflammation we may recog- nise two varieties, acute and chronic. Acute catarrhal proctitis presents many symp- toms in common with dysentery, and the difference is ratherone of degree than kind. I shall, therefore, confine the term to those cases in which the inflammatory process is limited to the rectum, and in which the abdominal pain and constitutional symptoms of typi- cal dysentery are absent. As such we not infre- quently meet with cases, especially in children. The symptoms are great tenesmus ; with the frequent Chap. III.l SeQUELM OF CATARRHAL PROCTITIS. 49 passage of small quantities of Lloody mucus, at first mixed with ftieces, and then alone ; at the same time there is vesical irritation, and general sense of heat and weight about the pelvis, resulting from the inflam- mation of the mucous and submucous tissue, oedema is present, and frequently, in consequence, a partial prolapse takes place, resembling the chemosis met with in acute inflammation of the conjunctiva (ectrojnon recti ; Iloser)._ •Catarrhal proctitis, is in all respects analogous to the localised inflammation of other parts of the intestinal tube, such as gastro-duodenal catarrh, typhlitis, colitis, etc., and it may terminate in several ways. In the vast majority the disease subsides completely in a few days, but it may, if severe, be accompanied by inflammation of the structures out- side the rectum {periproctitis), which may eventuate in abscess and fistula. Or, again, the disease may merge into the chronic form, or be followed by ulceration more or less deep. The frequency with which inflammation of the intestinal mucous membrane is accompanied with considerable bloody discharge has been noticed by Cohnheim ;* he suggests that, from the fact that during the process of digestion the chyle vessels of the mesentery always contain red blood corpuscles, it may be inferred that the intestinal mucous membrane is one of the regions of the body where the passage of blood corpuscles through the walls of the vessels takes place with special facility. Amongst the causes which give rise to this disease, epidemic influences are undoubtedly occasionally notice- able, but in many cases direct local irritation can be made out, such as the presence of large numbers of oxyurides, neoplasms in the rectal wall, intussus- ception, or other forms of rectal disease and f sepal * Leube ; Ziemssen's Cyclopsedia, vol. vii. p. 363. E-23 5© The Rectum and Anus. [Chap. in. accumulation. The latter acts either by its direct mechanical effect or by chemical action, the result of putrefactive changes. In some persons, certain articles of food, as high game or old cheese, always give rise to a slight amount of irritating rectal catarrh ; or the use of large quantities of purgative medicines may produce a like result. Esmarch has pointed out the fact that the long-continued action of damp and cold may produce this disease, and states that it is common amongst coachmen, who sit for a long time on wet seats. As a complication of child-bed and various forms of uterine disease, it may also be observed. Chronic catarrhal proctitis. — Where acute catarrhal proctitis has merged into the chronic form, the symptoms become somewhat modified ; the acute pain and tenderness give place to rather a sense of weight and fulness than actual pain. The discharge also l)ecoraes altered ; instead of consisting of a tolerably intimate mixture of blood and mucus, as is found in the acute form, it becomes more purulent, and if blood is present it exists as streaks in the pus, which have evidently arisen from ulcerations of the mucous membrane rather than from a general oozing from the inflamed surface. On inspection the mucous membrane appears more thickened and indurated, but the cedeuia is less. Ulceration of the surface is also more frequent in the chronic form. Dysenteric proctitis.— Of the specific inflam- mations, dysentery is much the most important, and although not always confined to the rectum, this portion of the intestinal tube is more or less affected in all cases ; and sometimes the typical lesions are only to be found here. But few o])portunities offer themselves to civil surgeons in these countries of investigating this disease during its acute stages ; but amongst Anglo-Indians and others who have resided for a long time in tropical climates, the chronic Chap. III.] GONORRHCEAL PROCTITIS. 51 form and some of the important sequelae are not un- frequently met with. For a full account of dysentery T must refer the reader to the systematic treatises of medicine, as a detailed investigation of this subject would be quite beyond the intention of the present work. Oonorrhoeal proctitis. — As a result of gonorrhoea, the rectum occasionally becomes the seat of acute purulent inflammation. In women this may occur in consequence of the discharge escaping from the vagina and trickling over the anus ; the liability to secondary infection being greatly in- creased by the presence of prolapse of the mucous membrane, piles, fissure, or relaxation of the sphincter from any cause. In men, and in women in whom the anus is normal, the disease probably only origi- nates as a result of the direct introduction of virus within the sphincter. Rollet* reports a case in which a man who was suffering from gonorrhoea inoculated the rectum by the introduction of a finger for the purpose of causing a motion. Boniere,t on the other hand, states that, although the anus is easily in- fected, the express introduction of gonorrhoeal virus through a tube into the rectum showed that the mucous membrane was only slightly susceptible to this form of inflammation. According to Lebert| the symptoms are as follows : Gonorrhoea of the rectum causes congestion and swelling of the mucous mem- brane, and is attended by a lyurulent discharge. The constant sense of pressure, burning, and itching in the anus is much increased on each evacuation of the bowel, and sometimes there are very severe spasmodic attacks of pain in the anus, and extending even to the bladder. Excoriations and fissures are very * " Diet. Enc. des Sciences Med." t "Arch. Gen. de Med.,'" April, 1874. X Ziemssen's Cyclopaedia, vol. viii, p. 808. 52 The Rectum and Anus. [Chap. hi. liable to form in the folds of the anus, and render the evacuation of the bowels still more painful. Gonorrhoea of the rectum has, however, happily a decided tendency to get well in a few weeks. Exceptionally the inflammation spreads to the sub- mucous connective tissue, and in this way gives rise to the formation of abscess or even fistula in the neigh- bourhood. Much more frequently we observe slight erythematous irritation of the skin around the anus. Sometimes papillary outgrowths may subsequently develop. The diagnosis of gonorrhoeal proctitis, as distinguished from other forms of inflammatory affec- tion of the rectum, presents obvious difficulties, but can generally be arrived at from the circumstances of the case : the co-existence of urethral discharge ; the profuseness and purulent nature of the discharge fro in the rectum ; and the symptoms of extreme rectal irritation alluded to above. Before, however, making an absolute diagnosis, the existence of the specific microbe of gonorrhoea {Micrococcus gonorrhcecB, or gonococcus) in the pus dis- charged should be verified. The detection of this organism by the microscope is now a tolerably easy matter ;* and, in any case of suspected gonorrhoea of the rectum, its presence should be sought for. Diphtheria of the anus isnoticed by Trousseau* as occurring during the course of diphtheria in the pharynx and trachea ; but is only secondary to the more usual form, and is an indication of profound implication of the system by this terrible disease. Having now discussed the various forms of inflammation of the rectum, I would speak of their treatment. In dealing with acute proctitis the first essential * Klein, "Micro-Organisms and Disease," p. 77. Third edi- tion, 1886. t Clinical Med., New Sydenham See, vol. ii. p. 515. Chap. III.] Acute Proctitis : Treatment. 53 is to evacuate the canal, and tliis should be accom- plished by the administration of purgatives, not by enemas, owing to the pain that the latter occasion and the danger which exists of spreading infection up the intestine. Some saline will usually ])rove most suitable, preferably sulphate of soda, or sulphate of magnesia in some form, such as the more potent- mineral waters ; or the effervescent sulphate of soda will be found an easily taken and satisfactory aperient. Such powerful drugs as gamboge, jalap, etc., must be carefully avoided. Where it can be taken without much nausea, castor-oil will fulfil every requirement. Abso- lute rest in bed is essential, and the occasional use of a hot hip-bath will give relief. The diet should be carefully regulated. All food leaving a copious faecal residue is to be avoided ; and during: the acute stage the patient should be restricted to milk, strong meat- soups, and eggs. If there is much tenesmus, injection of two ounces of mucilage of starch with a few drops of tincture of opium, may be used ; but as a rule it is better not to use opium or morphia to any great extent, as, owing to its tendency to produce constipa- tion, the disease may be aggravated. A suppository, consisting of 5 grains of iodoform, with ^ grain ex- tract of belladonna, made up with oil of theobroma, will be found useful. In dysentery, in addition to the foregoing, the use of ipecacuanha in large doses is indicated ; and, where there is much exhaustion, the free use of stimulants. Where inflammation of the rectum has become chronic, astringents must be employed. Nitrate of silver, 5 grains to two ounces of water, may be intro- duced into the bowel, followed in a few minutes by a large enema of warm water to wash out the rectum ; or liquor bismuthi with glycerine of starch, in the proportion of two drachms of the former to two ounces of the latter, will sometimes check the dischaige of 54 The Rectum and Anus. [Chap. iv. pus ; and where the discharge is foetid, the following formula maybe tried : R Liquor, carbonis detergent . . . ^ ii. Tr. krameriae. . . . . . 5 ^v. Mucilag. amyli ad 3 iv. An ounce to be injected night and morning. For the sequelae of proctitis the reader is referred to the chapters on periproctitis, ulcer, and stricture. CHAPTER IV. PERIPROCTITIS. Inflammatory changes originating in the mucous membrane may spread to the loose areolar tissue sur- rounding the rectum ; or the inflammation may com- mence primarily in the tissues on the outside of the bowel ; giving rise in one of these two ways to the affection which is termed periproctitis. Of the former we can recognise two very distinct varieties : first, that which is due to septic infection, and is con- sequent on the direct absorption from a wounded surface of poisonous matter similar to that which pro- duces, in the recently-delivered female, parametritis and puerperal peritonitis ; and, secondly, circumscribed phlegmon, resulting from spreading of the inflammation through the rectal wall, or more commonly subsequent to a perforation of the gut, the result of an ulcer or of direct traumatism. Septic periproctitis is a very dangerous dis- ease, and is not infrequently the cause of death after rectal operations. The clinical features of this condi- tion are in many respects similar to those of puerperal septico-pypemia, and like that affection, may present themselves in various degrees of severity. Chap. IV.] Limited Periproctitis. 55 In the more serious cases, after a stage of incubation lasting a few days the patient is seized "with rigors, quickly followed by general and con- siderable febrile disturbance, with high temperature and rapid pulse. Profuse perspirations oocur at irregular intervals, causing the temperature to fall temporarily ; pain is complained of in the region of the pelvis, and in many cases this rapidly increases and involves the lower portion of the abdomen ; the patient lies on the back, with legs drawn up ; meteorism is present, and the face presents an aspect of great anxiety, a train of symptoms clearly indicating involvement of the peritonseal serous membrane ; when this has occurred, death, in the great majority of cases, soon terminates the patient's sufierings. Other symptoms indicating the septico-pysemic state are sometimes to be met with, as an erysipelatous blush on the buttocks ; the deposit of diphtheritic patches on the mucous membrane of the rectum ; the involvement of some of the synovial cavities or of the pleural and pericardial sacs ; and the occurrence of metastatic ab- scesses in many parts of the body. In the milder cases of septic periproctitis the disease may be somewhat more limited in extent, and consist in a diflfuse pelvic cellulitis, without involvement of the ])eritonaeal cavity or evidence of septic manifestations in other parts of the body. This condition is analogous to the parametritis or pelvic cellulitis of the puerperal state; and, like it, may end in resolution, but much more frequently terminates in somewhat diffused sup- puration. Matter formed in this way accumulates in considerable quantity in the loose areolar tissue situated between the recto-vesical fascia and the peri- tonaeum, and may point near the anus, finding its way down posteriorly between the two levator ani muscles ; or it may escape through the sacro-sciatic notch ; or, passing upwards, appear as an iliac abscess. In other 56 The Rectum and Anus. [Chap. iv. cases suppuration commences in the pelvic lymphatic glands. Of the pathology of this affection but little can positively be stated. A large volume might be filled with an account of the various theories and discus- sions which have occupied obstetricians as to the aetiology and pathology of the septic febrile conditions subsequent to childbirth, but the probability is that in most instances at any rate the first important lesion is a lymphangitis of the pelvic lymphatic vessels. In those cases in which the disease is limited to a diflfuse pelvic cellulitis, the limitation is due either to the lalocking up of these vessels by thromboses, as Yirchow has pointed out ; or to the filtration power of the glands situated in the hollow of the sacrum being efiicient. When neither of these conditions serves to stop the spread of the disease, the implication of the great lymph space of the peritonseal cavity rapidly ensues. 1 recently lost a patient upon whom I had performed linear proctotomy ; and as the case was typical of the lesions we have been considering^ 1 will briefly describe as much of his case as bears on tlie present subject. The patient, a man aged sixty-three years, was admitted into Sir Patrick Dun's hospital with piles, fissure, and a history of obstruction in the rectum. Digital exami- nation revealed the presence of a tumour occupying the hollow of the sacrum, and compressing the rectum towards the bladder. As the finger could be passed above the upper limit of the growth, an attempt was made by linear proctotomy to remove the tumour, or at any rate to relieve the obstruction, the symptoms being so urgent tliat either this operation or colotoiny was indicated. The incision was made in the usual manner, and, by means of the finger and scoop, the tumour, which proved to be in part cystic, was broken Cha p. I V . ] Sep tic Per ipr oc ti tis : Tk e. i tment. 5 7 down, and as much as possible removed, the obstruction being completely overcome. As htemorrhage was free the rectum was plugged with a sponge, which had been wrung out of carbolic lotion (2 percent.) and the wound dressed with absorbent cotton dusted over with ferrous sulphate. On the following clay the plug was removed, the rectum and wound irrigated with carbolic loticm. This treatment was directed to be repeated every three hours. The case went on well till the morn- ing of the fourth day after operation, when the patient complained of pain ; he had a rigor, followed by a rise of temperature to 102-8° Fahr. ; the lower part of the abdomen became tumid and tender ; later on the same day he was restless, with high temperature alternating with profuse perspirations. He died on the sixth day after operation. At the autopsy the usual signs of purulent peritonitis were present, the peritonseal cavity of the pelvis being full of thin serous pus, and the coils of intestine being glued together with recent lymph ; the loose areolar tissue of the pelvis, more particularly that situated between the folds of the meso-rectum, being infiltrated with pus. Several of the lymphatic glands of the pelvis were also much inflamed, and in two instances suppurating. The extreme limit of the operation wound was separated by a considerable distance from the peritonaeum. The tumour in this case will be again referred to in the chapter on neoplasms, as there are some points of interest about it. That the cause of death in this case was due to septic infection there can be no reasonable doubt, and the post-mortem appearances were in all respects similar to those found in the majority of instances of puerperal septico-pysemia. As far as treatment is concerned, we can do but little in the more severe forms of infection. Where matter forms in the neighbourhood of the rectum, free 5$ The Rectum and Anus. [Chap, i v. incision, followed by irrigation with some antiseptic solution and free drainage, should at once be adopted. Where the peritonaeum has become implicated, opium in full doses is indicated, with the double object of relieving pain and lessening peristaltic action. The application of an ice-bag or cold-water compress to the abdomen will sometimes relieve suffering ; and again in other cases, warm moisture in the shape of stupes and poultices will be found more comfortable. The prophylactic treatment, however, holds out to us better hopes of success. We frequently find surgeons say that there is no use in adopting anti- septic measures in rectal operations, owing to tlie necessary escape of faecal matter into the wound. It is true, certainly, that where faeces are extravasated into areolar tissue, and have no free exit, considerable irritation and suppuration are set up ; but a ster- coraceous abscess formed in this manner is essentially different from the more diffuse inflammation and involvement of the venous and lymphatic systems characterising the true septic poisoning. If the extra- vasation of faeces has free exit, so that it merely passes over a wounded surface, such as is left after the division of a fistula, no undue inflammation is pro- duced, and we find under these circumstances wounds implicating the rectum healing as well and as rapidly as in other parts of the body. In the minor operations, such as the removal of piles by ligature or cautery, septic periproctitis is of extreme rarity ; but antiseptic precautions should not on that account be dispensed with. In the more severe operations, such as extirpa- tion of poition of the bowel, or extensive incisions implicating the rectal wall, septic infection is not infrequent, so that it is necessary for the surgeon to adopt the fullest antiseptic precautions. In the fii-st place, thorough drainage is essential, and this is to be ensured by having the external wound sufliciently Chap. IV.] Antiseptic Precautions, 59 free, and, in cases where sutures are necessary, the introduction of rubber drainage tubes between them; this will be found especially necessary in opera- tions where only a small portion of the lower rectum is removed, and in other operations where the mucous membrane is sutured to the skin. In some cases where deep sutures can be passed, so as to completely obliterate the cavity of the wound, drainage tubes may be dispensed with. In the next place, thorough and frequent cleansing of the wound must be attended to ; this may most effectually be accomplished by irrigation several times in the twenty-four hours,* with a solution of corrosive sublimate (1 in 2,000). A light pad should now be applied over the anus and wound, and retained in position by a T-bandage, care being taken that the pressure is not so great as to retain discharge. The pad may be made of any of the usual antiseptic and absorbent materials, salicylic wool fulfilling all the indications admirably. All plugging of the wound should be avoided, except when applied in the lightest manner, to keep the edges of a wound from uniting too rapidly, as in fistula, or when haemorrhage renders plugging a neces- sary evil ; and under these circumstances the most extreme precaution must be taken that the materials used are not only aseptic, but powerfully antiseptic. In the case of the patient I have above recorded, I am of opinion that we must add this, as another example, to the long list of cases in which sponges used in surgical practice for plugging wounds have given rise to a fatal blood-poisoning. With sponges, simple washing with carbolic lotion is not sufficient ; where necessary, they should be boiled in dilute nitro-hydrochloric acid before being used, and kept in a glass jar of corrosive sublimate solution (1 in 1,000). * Volkmann recommends continuous irrigation, but this is difficult to carry out satisfactorily. 6o The Rectum and Anus. [Chap. iv. In rectal surgery, the only condition which justifies the use of the sponge-plug is a haemorrhage which cannot be arrested by any more simple means. Circiimscribecl periproctitis, which is secon- dary to changes in the rectal wall, is undoubtedly due in the great majority of cases to perforation, either the result of ulceration or direct traumatism ; but some- times an abscess may occur external to the rectum without any perforation, as a direct result of acute inflammation of the mucous membrane. We have examples of abscess produced in this way in other organs ; for instance, in the neighbourhood of the urethra in gDnorrhoeal inflammation ; and iliac abscess, the result of perityphlitis following inflammation of the mucous membrane of the csecum. Abscess so formed may burst externally, or both through skin and mucous membrane. Where perforation of the gut has taken place extravasation of a minute quantity of faeces is suffi- cient to produce a considerable f mount of inflamma- tion, and as a result suppuratic n. Abscess produced in this way discharges from time to time a little matter into the bowel, constituting an internal rectal sinus, and in this way may continue for a consider- able time in a passive condition; but much more fre- quently it makes its way to the skin as well, and, opening there, forms a complete flstula. Inflammation originating external to, but in the neighbourhood of the rectum, in which the bowel escapes, or is at any rate only secondarily affected, presents itself under several conditions. Pott,* in his classical treatise on fistula in ano, enumerates three distinct varieties of this inflammation, or phyma, as he calls it : the phlegmonoid, the erysipe- latous, and the gangrenous ; and clinically these three forms may easily be distinguished. As I believe this * Earle's edition, vol. iii. p. 49. Chap. IV.] ISCHIO-RECTAL AbSCESS. 6i classification to be founded on a correct pathological generalisation, I adopt it. _ - The phlegmonous abscess is the commonest of these varieties : the loose, fatty, areolar tissue which fills the ischio-rectal fossa being peculiarly prone to suppura- tion, the great movability of the parts no doubt also predisposing to this result. Although met with at all ages, ischio-rectal abscess is more particularly a disease of middle life, and more common in men than in women. It occurs most frequently in those who from some reason are run down and out of health, as the result of long-continued and emaciating illness, over- fatigue, intemperance, etc. ; and we may often be able to trace an exciting cause, such as an injury, exposure to cold, or the straining necessary to pass a hard fsecal mass. A very frequent cause is slight external fissures, similar to the chapped nipples which so commonly give rise to mammary abscess. The formation of acute ischio-rectal abscess is attended in the majority of cases with some fever, and the constitutional disturbance is generally out of all proportion to the local disease. The pain is severe, and is increased by defsecation ; there is frequently irritability of the bladder, stranguary or retention of urine being not uncommon symptoms. Its situation is most frequently on the lateral aspect of the anus, and it presents itself as a prominent, tense, red, and shining swelling, in which fluctuation is distinctly to be felt. As to the treatment of ischio-rectal abscess, it must differ according to the stage and intensity of inflammation. During the earlier stages, a bladder filled with ice, and moulded to the anal region, will b( found to give considerable relief ; but when matter has formed, incision should at once be performed. This is of great importance in these cases, as if done early enough in abscesses which. have originated outside the 62 The Rectum and Anus. [Chap. iv. rectum, we may be enabled to prevent the formation of fistula ; or in those cases in which we cannot stop the formation of an internal opening, or in which such is already present, we may be enabled to limit to a con- siderable extent the amount of burrowing of the matter, and its extension upwards underneath the mucous mem- brane. Speaking of the prevention of fistiila by early opening, Allingham,* whose experience in the treat- ment of these diseases is so great, speaks as follows : *' If the patient will allow me to act in my own way, I can almost guarantee that no fistula shall result. The following is the method to be adopted : The patient must take an anaesthetic, as the operation is very painful. 1 first lay the abscess outside the anus open from end to end, and from behind forwards, i.e. in the direction from the coccyx to the perinseum. I then introduce my forefinger into the abscess, and break down any secondary cavities or ioculi, carrying my finger up the side of the rectum as far as the abscess goes, probably under the sphincter muscles, so that only one large sac remains. Should there be burrowing outwards, I make an incision into the buttock deeply at right angles to the first. " I then syringe out the cavity, and carefully fill it with wool soaked in carbolic oil, 1 in 10 or 12. This I leave in for a day or two, then take it out, and examine the cavity, and dress again in the same manner ; but, in addition, I now use, if I think it necessary, one or more drainage tubes. In a re- markably short time these patients recover ; the sphincters have not been divided, and the patient therefore escapes the risk of incontinence of faeces or flatus, which sometimes occurs when both the sphinc- ters are incised." The important element in the above treatment is undoubtedly the free opening and the breaking * Loc. cit., p. 15. Chap. IV.] Marginal Abscess. 63 down the loculi into one cavity. "When this is complete the thorough powdering of the interior with iodoform, as recommended by Billroth, and the immediate in- troduction of drainage tubes, together with the appli- cation of an antiseptic absorbent pad, instead of plugging with wool and carbolic oil, will be found, I think, to give the best results. Instead of ischio-rectal abscess running the acute course above described, we sometimes meet with a chronic or cold abscess in this locality. This is mostly found in strumous individuals, and is at- tended with but little pain or uneasiness of any kind. The treatment to be adopted may be similar to the above j or, as in one case which was re- cently under my care, hyper-distension of the cavity with carbolic lotion, as recommended by Mr. Callen- der, left nothing to be desired. A much less severe form of abscess than the ischio-rectal just described, is that known as the marginal abscess of French authors. This may originate in several ways, but the most frequent is by the suppuration of an external pile ; in other instances it is more like a form of furuncle, origi- nating in some of the mucous follicles of the anal margin, resembling a hordeolum in the eyelid ; and again in other instances the suppuration starts from the base of a small external fissure or tear. These minute suppurations, owing to the extreme sensitive- ness of the anal margin, are attended with consider- able pain, but are not otherwise generally of con- sequence. Incision is the proper treatment, and the best way to do it is to pass the index finger into the rectum, and, with the tip of the thumb outside, the little tumour can be perfectly steadied, and the point of a lancet or small knife passed through it. As it is painful, local anaesthesia by ether spray should be used. 64 The Rectum and Anus. [Ciiap. iv. The marginal abscess, originating in a pile; sometimes leaves a small superficial fistula, which will be alluded to farther on, but the furuncle does not usually leave any fistulous trace behind it. Erysipelatous perijyroctitis is a diffuse inflam- mation starting in the skin surrounding the anus, and presenting the characters of this disease in other parts of the body. As it presents no essential peculiarity in this region, we need .not further allude to it here, except to mention that a subcutaneous abscess may result from it requiring the above treatment. Gangrenous inflammation of the tissues sur- rounding the rectum is a very formidable disease, and may be attended with fatal result, or where recovery takes place, there is a great destruction of tissue, with the consequent troubles attending the contraction of cicatrices. This disease may com- mence in the skin and rapidly spread to the under- lying connective tissue, or the skin may be only secondarily affected, the deeper structures being first implicated. It occurs amongst the well-to-do, who consume large quantities of animal food, and drink too much alcohol, and is almost exchisively confined to the male sex, exposure to wet and cold being sometimes noted as an exciting cause in the recorded cases. Thei^ is a livid tumefaction in the posterior portion of the perinseum, attended with considerable pain ; if the disease spreads deeply into the pelvis, pressure on tlie sacral plexus may give rise to reflected pain. Fever of a low type is present, with brown furred tongue, quick weak pulse, and in severe cases delirium supervenes. The skin covering the swelling sloughs generally at several points as in ordinary carbuncle, to which this disease bears great resemblance ; as the cutaneous slough separates, masses of dark gangrenous tissue are brought into view, discharging an offensive ichorous fluid rather than normal pus. Chap. IV.] Gangrenous Periproctitis. 65 After separation of the gangrenous tissues, a great chasm is left, which heals but slowly ; and re- lapses, with extension of the disease, are common. According to Furneaux Jordan, who has published an interesting clinical lecture on this disease,* per- foration of the rectum is rare. No doubt this is due to the very slight anastomosis which exists between the vascular supplies of the rectum and the surround- ing structures. The treatment should be prompt ; early and deep incisions must be made in lines radiating from the anus ; frequent syringing with solution of chlorinated lime, or corrosive sublimate (1 to 2000), or the appli- cation of charcoal poultices to keep down foetor, will be of use. And where any tendency to spread is recog- nised, chloride of zinc, or some other powerful escha- rotic, may be employed. At the same time the patient's strength must be supported by liberal allow- ance of milk, strong beef-tea, eggs, etc. ; and the ad- ministration of alcohol is usually indicated. In making the diagnosis of abscess in connection with the rectum, the surgeon must bear in mind that suppuration, symptomatic of other diseased structures, may present in the posterior perinseal region. This is especially the case with urinary abscess, and with col- lections of matter originating in the female gene- rative organs. Suppuration in connection with disease of the bony pelvis or vertebrae may also point beside the rectum. * Brit. Med. Journ., Jan. 18, 1879 ; p. 73. p— 23 66 CHAPTER Y. RECTAL FISTULA. Of the diseased conditions consequent on the affections detailed in the last chapter by far the most important are : Rectal fistulae, which present them- selves to our consideration in considerable variety, and from their great frequency, and the discomfort they produce, constitute a subject of great interest to the surgeon ; it is, therefore, to be little v/ondered at that, in looking through the voluminous literature on this subject, the names of most of the great masters of surgical art are to be found. According to the statistics of St. Mark's Hospital, as given by Allingham,* out of 4,000 cases taken consecutively, and without selection, from the out-patient department, there were 1,057 persons suffering from fistula, and 196 from abscess of which 151 eventuated in fistula, so that the disease constitutes considerably over one- fourth of all the cases presenting themselves as out- patients. Mr. Allingham also tells us that an examination of the records of the in-patients at the same hospital, during several years, shows that two- thirds of those operated on were cases of fistula. As the author very justly points out, statistics of this kind must be taken with some reservation, as we frequently find fistula co-existing with other forms of rectal disease; in some instances the accompanying disease being of a trivial nature, as external piles, etc. ; while in others the fistula may be only secondary to more grave pathological changes, such as malignant disease or simple stricture. Another element of error which must not be lost sight of is that St. Mark's has * "Diseases of Rectum," p. 12. Fourth edition. Chap, v.] Causes of Fistula. 67 a special reputation for the cure of fistula, so that many patients suffering from this disease go there, and so the list is swelled. At the DuVjiin general hospitals, although fistula is common, it is by no means the commonest of rectal diseases ; and, in my own practice, it has not furnished more than one-sixth of rectal operation cases. The use of the term fistula (a pipe), so common now in general surgery, originated probably in the special variety now under consideration, and amongst the older suro-eons the term was confined to those cases in which the tissues immediately surrounding the ulcerating tract had become much indurated and thickened, the effects of long-continued inflammatory changes. Kow, however, it is used in a broader sense, and is applied to any abnormal communication between a mucous canal and the external skin, or between two mucous surfaces ; the term " incomplete fistula " being used where the fistulous tract has only one aperture, either mucous or cutaneous. The exciting cause of rectal fistula may occa- sionally be a penetratiug wound, but very much more frequently it is the result of suppuration, any of the varieties of abscess described in the last chapter commonly eventuating in this condition. AYhy an abscess situated in this reo'ion is more likelv to become fistulous than abscess situated in other parts of the body, is a question of considerable interest, but the true explanation is not far to seek. In the first place, the looseness and free niotion of the tissues in the ischio-rectal fossa tend to prevent rapid closure of an abscess cavity, in the same way that we see sinuses remainincr for a loner time unclosed in the axilla or female breast ; and where a cutaneous opening alone exists this must be taken as the prin- cipal cause, but where there is a mucous aperture, a very much more potent influence is brought to bear; 68 The Rectum and Anus. [Chap. v. namely, the constant trickle of mucus and thin fseculent matter along the track of the fistula. We must also bear in mind the peculiar vascular supply of the rectum, the veins being without valves. Hence it is that as man occupies the erect position, a con- siderable amount of congestion of the lower end of the bowel is frequently present, which we well know seriously impedes the process of cicatrisation. Of the complete muco-cutaneous fistulas connected with the rectum, the best practical division is accord- ing to the position of the internal opening ; and we find there are three situations in which this opening may be found : in the first and most simple case, the fistula is subcutaneous, the inner opening being situated superficial to the external sphincter, at the anal verge. To this alone should the term fistula in ano be confined. Next we may find the opening situated between the two sphincters ; this is probably the most common variety. And, lastly, we have the fistula in which the opening into the rectum is situated above the internal sphincter, traversing, therefore, the so-called " superior pelvi-rectal space of Richet." The first of these three varieties corresponds with the fistules sous-tegumentaires of Molliere, and the latter two with the fistules sous-musculaires. The super- ficial fistula has its origin in the marginal abscess before alluded to, and is generally very minute, and productive of little inconvenience ; it may be alto- gether superficial, or extending through a few fibres of the external sphincter : as, however, it does not open directly into the cavity of the rectum, the escape of tiatus and fluid faeces does not take place, conse- quently secondary suppuration is uncommon. So little is the irritation, that occasionally we see the internal surface of the fistulous tract cicatrise, and then it remains as an epidermis-lined tube, like the hole for an ear-ring, and ceases to give annoyance. Chap, v.] Fistula : Internal Opening. 69 The ordinary form of complete rectal fistula is the result of abscess in the ischio-rectal fossa, either primary, or secondary to changes in the rectal wall, and the position occupied by the internal opening is tolerably constant, being situated between the two sphincters. The external opening is subject to more variety, but is generally within one inch from the anal verge, though occasionally at a considerably greater distance, as in the groin or thigh. The posi- tion of the internal opening in this variety is a subject of very considerable importance, as, unless acquainted with its usual situation, the surgeon may fail to find it ; the reason for this being, that in most cases the mucous membrane of the bowel is separated from the mus- cular wall for a variable height above the orifice, so that the opening is not really at the highest point to which suppuration has extended, as one might be led to expect. In eighty cases which M. Eibes* had an opportunity of examining post mortem, in none was the internal opening situated at a greater height than 5 or 6 lines from the verge of the anus, and in many it was not so high. Velpeau tabulates the result of thirty-five post-mortem examinations as follows : In four the internal opening was one inch and a half frcin the anus, in one it was three inches, and in thirty a few lines from the anal outlet. Sir B. Brodie goes so far as to say : " The inner orifice is, I believe, always immediately above the sphincter muscle, where faeces are liable to be stopped, and where an ulcer is most likely to extend through both the tunics." Sir B. Brodie was of opinion that a primary perforating ulcer was always essential to the production of that form of abscess liable to terminate in fistula, and he did not admit the possibility of abscess from without causing fistula by secondary perforation of the rectum ; * Revue Medicate Historique et PMlosophique, liv. i. p. 174. Paris, 1820. yo The Rectum and Anus. [Chap. v. however, Syme held the opposite view, and expressed the o[)imon that the abscess formed before the in- ternal opening, as has a,lready been pointed out in the preceding chapter. There is no doubt that both these causes may operate. Where the abscess is the primary affection, the point at which it will pene- trate the muscular wall of the rectum depends chiefly, in my opinion, upon its relation to the levator ani muscle. If superhcial to this muscle it is jDre vented from reaching the gut at a point above the insertion of the levator ani muscle, as it cannot well perfo- rate the fascial structures which cover this structure upon both sides ; it therefore makes its way through the insertion of this muscle. Once having passed the muscular wall it distends the loose submucous tissue ; but although considerable separation of the mucous membrane may take place, this structure is generally perforated in the neighbourhood of the situation indicated. Where, however, the abscess originates above the levator ani muscle in the superior pelvi- rectal space, the matter may separate the rectum from its loose connections for a considerable distance u|> wards, and open into the lumen of the bowel at almost any point. In these cases of pelvi-rectai fistula the cutaneous orifice is usually situated posteriorly, the al)scess having passed between the posterior portions of the levator ani muscle ; whereas in ischio-rectal fis- tula the cutaneous opening is most frequently lateral. Again, in examining a case of fistula by means of probe with the finger in the rectum, the diagnosis can be made between the superior pelvi-rectal and the ordinary (ischio-rectal) fistula in which the orifice is high up, by the fact that in the latter the probe can be felt to pass, in the greater part of its course, immediately under the mucous membrane, while in the former the entire thickness of the gut is felt to inter- vene between the finger and probe. Chap, v.] Rectal Sinuses. 71 Of the incomplete fistulse, two varieties are de- scribed ; to these the terms "blind internal" and *' blind external " have been applied. These names are most confusing, and, were it not that they have received the sanction of long usage, would not be referred to here. In order to prevent misconception, it is necessary to state, however, that the blind in- ternal fistula is that in y^^hich there is a mucous, but no cutaneous opening ; and the blind external fistula is merely a sinus with, a cutaneous aperture, but no opening in the mucous membrane ; although this is the generally accepted way in whicb these terms are used, Chelius and a few other authors reverse this arrangement. I have very frequently found students transpose the names, a mistake which, considering the nomenclature, is scarcely to be wondered at. In the following pages the terms " internal and external rectal sinus " will be used, as more clearly indicating the conditions referred to. Internal rectal sinus may therefore be defined as a suppurating tract, communicating with the cavity of the rectum by means of an opening in the mucous membrane ; its origin may be due to similar causes to those which produce the complete fistula, and, indeed, it is frequently only the preliminary stage of the latter condition, an internal rectal sinus, if left to Nature, sooner or later forming an opening iu the skin, and thus forming the complete fistula. The external rectal sinus is the result of an abscess which has commenced in the structures ex- ternal to the rectum, not, of course, stercoral in its origin, which has broken or been opened externally, and which, from causes previously enumerated, is prevented from healing in the ordinary manner. The direction of the sinus may be towards the rectum, and sometimes ulceration will transform this also into a complete fistula, but in other cases the tract leads 72 The Rectum and Anus. [Chap. v. away from the rectum into the upper portions of the ischio-rectal fossa. Owing to the difficulty which is experienced sometimes in detecting the intei-nal opening of a complete fistula, the diagnosis of external rectal sinus has been more frequently assumed than its exist- ence proved. The study of dissected specimens has, however, completely determined the existence of this condition ; but it is very much rarer than the complete fistula. The tract of a fistula is seldom straight, and the calibre generally varies at different parts of its course. This irregularity is one of the most important reasons why difficulty is experienced in making a probe tra- verse the full extent of the fistulous channel. We some- times find a sharp angle in the course, the cutaneous extremity at first leading away from the rectum, and then takinof a sudden turn towards the bowel. This is probably due to the fact that the changed course is rendered necessary by the fistula following for some distunce the direction of the levator ani muscle. And, again, it is common to find pouches, or diverticula, communicating with the main tract. These diver- ticula sometimes become blocked up, forming the foci of fresh suppuration which may perforate the skin at a distance from the original orifice, so that we sometimes meet with cases of fistula in which numerous external openings exist. I have seen in one case as many as twenty-two external openings, the whole of the buttock on both sides being riddled with fistulous tracts, a condition which has not iiia])tly been compared by Mr. Allingham to a miniature rabbit warren. Increase in the number of internal openings is extremely rare, and it never exists to the same extent as is the case with the cutaneous orifices, but sometimes two or more openings may be recognised in the mucous membrane. In the case above-mentioned only one internal opening was discoverable. Chap, v.] Structure of Fistula. 73 Of these complex fistulce, as they have been called by Hamilton, one important variety remains for consideration, namely, the " horse-shoe fistula/' In this the external and internal openings are on opposite sides, the tract running round the margin of the anus subcutaneously ; this may be due to abscesses starting in both ischio-rectal fossse simul- taneously ; or it may simply be the result of the bur- rowing of matter from an abscess in the first instance unilateral. Et is to be recognised by the discovery of the external and internal apertures upon opposite sides, and by the induration which marks the path of the fistula. Histologically considered a fistula resembles in structure an indolent ulcer. Its surface is covered by unhealthy granulations in part, and in others granulations are wanting ; frequently we see at the external orifice a flabby sentinel granulation protrud- ing, which, when present, renders the opening much more obvious. Immediately surrounding the granu- lation is a layer of fibrous tissue, which is sometimes of extreme density, feeling almost of cartilaginous hardness. This is found only in fistulse of long stand- ing, and is due to the proliferation of the connective tissue elements at the base of the granulations in abortive attempts at healing. It is remarkable the i-apidity with which this hardness disappears when the fistula is healed. The most marked example of this condition that ever came under my notice was in a man who had had fistula for lifteen years. He had a hard warty growth about one inch from the anus, and |-inch in diameter, w^hich was at- tended with but little discharge ; from this point a hard ridge could be felt passing deeply. This wart was so firm and elevated, that it suggested to more than one surgeon who saw it the idea that it w'as epitheliomatous : a probe, however, 74 The Rectum and Anus. [Chap. v. could readily be passed into tlie rectum, and simple incision sufficed to effect a permanent cure. I saw this patient a year after tlie operation, and the cicatrix was as soft and elastic as the neighbouring skin, no trace of the warty protrusion remaining. The older surgeons looked upon the thickening as a new growth, which it was necessary to remove. Hence arose the term of cutting out a fistula, and so freely was this done that in many cases incontinence of fseces was produced, and the patient was rendered very much more miserable by the cure (!) of his fistula. The symptoms of which fistulous patients complain vary accordingly as to whether there is active suppura- tion ffoinij on or not. The abscess from which the fistula originates is, if acute, extremely painful : though sometimes, as before noticed, a cold or chronic abscess may occur in this locality, in which case the initial pain is slight, and the first symptoms noticed by the patient are discharge or involuntary escape of flatus, and, more rarely, a small quantity of fieces. With a fistula fully established little pain is experienced, but con- siderable annoyance is occasioned by the soiling of the linen with discharge, which is generally accompanied with an unpleasant odour. There is generally some tenesmus, and the fseces may be stained with blood, etc., except when the case is one of external rectal sinus. A person suffering from fistula is always liable to attacks of secondary suppuration, due to blocking of the tube by small particles of faeces or exuberant growth of the granulations. This, of course, is at- tended with pain, until a new opening forms or is made by the surgeon, or until, as sometimes hap- pens, the passage of the original fistulous tract becomes re-established. Fistula in some persons, more particularly those of a nervous temperament, produces an amount of Chap, v.] Diagnosis of Fistula. 75 depression and constitutional disturbance altogether out of proportion to the local disorder ; their minds being impressed with a feeling of physical weakness, rendering them miserable and unhappy. The diagnosis of fistula is generally attended with but little difficulty, although sometimes the small size of the external orifice renders it difi&cult of detection ; and in others the great induration and prominence may give rise (as in the case above detailed) to the suspicion of epithelioma. Cases of the latter kind show how important, as an adjuvant to diagnosis, the 2:)0sitive detection of an internal opening may be. A difficulty may possibly arise in determining whether a fistula is connected with the bowel or with the genito-urinary organs ; but in the majority of cases no such difficulty should arise. Rectal fistulse usually open in the posterior perinseum, while those in con- nection with the urethra open anteriorly ; at any rate, a probe introduced into a fistula will show to which side of the jDerinseal septum the tract lies. This perinseal septum is a very definite structure, and is seldom per- forated by suppuration, so that it may be generally assumed that abscess posterior to it is associated with the rectum. In urinary fistulse the escape of urine along the tract will serve to establish the diagnosis. The fistula of the superior pelvi-rectal space may be diffi- cult to recognise. If the opening into the rectum can be found ^^^.th the probe and finger in the bowel, or if fsecal matter escapes at the orifice, the diagnosis is obvious ; but under other circumstances it may be impossible to distinguish this form from sinus following parametritis or connected with diseased bone. The enetliocl of examination for the purpose of diagnosis of rectal fistula is one of the most im- portant points in connection with the discussion of this subject. 76 The JRectum and Anus. [Chap. v. In order to examine a patient with suspected fistula he should be placed lying on the side, preferably that on which the external opening is situated, with the legs well drawn up towards the abdomen. If the external orifice is prominent, or if there is a sentinel granula- tion present, it will be obvious ; but where small, and situated between folds of skin, pressure with the top of the finger will usually cause a little drop of matter to exude, and so demonstrate its position. Careful feeling with the finger will also frequently tell us the direction which the tract takes. A probe should be now passed along the fistula, and in doing this considerable care is requisite, and the utmost gentleness should be observed, always remembering that the ■|:>robe is to be directed by the channel it is passing through, and not by the hand of the surgeon. It is well to be provided with one of the flexible spiral metal probes, and also with ^, very fine silver probe, for the investigation of tortuous and very narrow fistulse : sometimes, also, by bending the point of the ordinary probe, it will be found to pass with greater facility. The probe having been passed, the finger should be introduced gently into the rectum ; and it is a matter of considerable importance that this should be subsequent to the passage of the probe, as, if the finger is introduced into the rectum in the first instance, a spasm of the sphincter muscles is set up, which will greatly increase the difficulty of passing the probe. It will be frequently found that, as the top of the finger passes the sphincter muscle, the end of the probe is felt free in the cavity of the rectum, thus demonstrating the fact that the fistula is com- plete. In other cases the mucous membrane is felt to intervene between the tip of the finger and the probe, and the latter can be passed freely over a con- siderable surface, showing that the mucous membrane has been separated to a large extent from the muscular Chap, v.] Fistula : Internal Opening. 77 walls of the rectum. In these cases the internal opening generally exists, but it may be hard to find ; the usual fault being that it is looked for too high up. Careful palpation with the pulp of the finger will sometimes, if the sense of touch is delicate and has been educated, determine the orifice, while at othere it may be brought into view by simply everting the mucous membrane of the anus. Should a doubt still exist as to the completeness of the fistula, injection of milk may be had recourse to, a speculum having pre- viously been introduced into the rectum, when of course the a]:)pearance of milk in the bowel will set the question at rest ; or, with the finger in the rectum, a few drops of a strong solution of iodine may be injected along the fistula ; and if there is an internal orifice present, a brown stain will be perceived on the finder. If none of these methods demonstrate the inner opening, the case must be looked upon as one of external rectal sinus, but when the fistulous tract passes through the muscular wall and separates the mucous membrane from the outer coat, a mucous orifice may nearly always be found. Should this, however, not be the case, the failure will be of little moment practically, as the same plan of treat- ment applies to both. Where the entire substance of the rectal wall intervenes between the finger and probe, or where the probe is guided away from the rectum along the anal fascia to the upper portion of the ischio-rectal fossa, the case is one either of external rectal sinus, or of fistula originating in the superior jDelvi-rectal space. We must, therefore, in these cases go farther, and try and find the cause, such as diseased bone, etc. ; and in the fem.ale a vaginal ex- amination may show us a uterine or ovarian origin. Where there are numerous external openings it is necessary to carefully probe all these so as to deter- mine whether they are all connected and the direction 78 The Rectum and Anus. [Chap. v. which they take. The upper limit of the separation of the mucous membrane should also be made out, and search should be made for more than one internal orifice, if such is likely to be present. The diagnosis of internal rectal sinus is more difficult generally than the forms we have been con- sidering. In this form the fseces will be smeared with pus, or blood, and a boggy swelling is to be felt at some portion of the anal circumference. If the in- ternal orifice can be felt, or seen, through a speculum, a bent probe may be introduced into it, and made to protrude in the perLaseum. Having made the diagnosis of complete fistula, we must, before proceeding to treatment, satisfy ourselves as to the yjresence or absence of other important diseases, and, of these, changes in the rectum itself hold a first place. The co-existence of fistula with other patho- logical conditions in the lower bowel has been already alluded to ; but I cannot too fully impress on the junior practitioner the necessity of examining for stricture, malignant disease, hsemorrhoidal and other tumours, in every case that comes under his notice. A thorough physical examination of the chest should also be made, the co-relation between phthisis and fistula being of extreme importance. Any serious disease of the kidney should be eliminated before recommending operation ; albuminuria in this, as in almost all other surgical procedures, being a very un- favourable indication. Where the inconvenience produced hj fistula is but slight, there is sometimes considerable difficulty in getting a patient to consent to the treatment necessary for cure ; but it may be taken as a general rule that the longer a fistula is left without being efficiently dealt with, the more tortuous and complicated it becomes, and the more difficult will any subsequent procedures be. Chap, v.] Treatment WITHOUT Incision. 79 The treatment to be adopted may be conducted upon two principles : (1) by trying to excite healthy action in the fistulous tract, and so produce its ob- literation ; (2) by the division of the structures inter- vening between the rectum and the fistula by some means. Of the former, but little can be said in its favour. The process is slow and the result uncertain \ where- as, by division of the septum the result is generally eminently satisfactory. In exceptional cases, however, where the patient has a very great dread of any cut- ting operation, and when he is willing to give up a sufficient time to the treatment, a cure by the milder means may, in the first instance, be attempted ; but for this to be attended with any reasonable prospect of success the fistula must be of somewhat recent origin, and unattended with any considerable amount of induration. Indeed, the occasional occurrences of spontaneous recovery, or cure resulting from the slight amount of irritation produced by the passage of a probe, show that operation is not always essential ; but so rare are these cases, that the surgeon should recommend the more certain and speedy method by division except under the circumstances above stated, and where the fistula is uncomplicated, or is obviously an instance of external rectal sinus. The essential elements of treatment, where the attempt is made to obliterate the fistulous tract without division, are : rest, free drainage, and the use of antiseptic and stimulating applications to the suppurating tract. The patient should be con- fined to the horizontal position, either in bed or on a sofa, this being a most important condition, as it re- lieves congestion. A firm pad, well supported by a T- bandage, should also be worn for the purpose of limit- ing the motions of the anus due to alteiTiate contrac- tion and relaxation of the levator ani. For the So The Rectum and Anus. [Chap. v. pui'pose of clearing out the fistula dilatation should be employed by the introduction of a piece of sea tangle, or some other species of dilator, which should pass to the bottom of the tract. This not only renders the application of antisej)tics and the introduction of a drainage tube easy, but the stretching of the walls affords a useful stimulus, and frequently initiates the healing process. AUingham recommends the thorough swabbing out of the fistula with strong carbolic acid, and the passage of a full-sized soft rubber drainage tube right to the bottom. As the case progresses, the drainage tube may be shortened down and finally removed, or, instead of the tube, a bone shirt-stud, perforated through the centre, may be buttoned' in to ensure the patency of the external orifice. The application of carbolic acid may have to be repeated, or some other antisejDtic may be used with advantage, such as ethereal solution of iodoform, corrosive sublimate solution, nitrate of silver, or tincture of iodine ; but although success may at first appear to follow this line of treatment, division will have very frequently to be adopted subsequently. AUingham, who has had such extensive experience in fistula, and who has tried this plan of treatment more fully probably than any other surgeon, states his experience thus:* "Altogether I find I have had twenty-one successful cases, and a considerable number in which I have failed to effect a cure after a prolonged at- tempt, therefore I cannot say the prospect is very encouraging." To Pott is undoubtedly due the credit of having demonstrated the fact that a simple incision^ convert- ing the tubes of the fistula and rectum into one, is gene- rally sufficient to effect a permanent and complete cure. Previous to his writings, if any operation was at- tempted, it was one of partial or complete excision of * Loc. cit., p. 26. Chap, v.] Incision of Fistula. 8i the entire fistula ; for instance, Cheselden recom- mended that one blade of a polypus forcejjs should be passed into the fistula, and the other into the rectum, and then the entire portion included was cut out with a scissors. Such a proceeding is wholly unnecessary, and justly merits the term " barbarous/' which has since been freely applied to it. Since the classical treatise on fistula in ano of Pott appeared, considerable inge- nuity has been displayed in attempts to improve on the means to be adopted for dividing the structures intervening between the rectum and fistula ; but be- fore considering these, it may be useful to discuss the rationale of the treatment. In the first place, the effect of incision is to ensure free drainage, and the prevention of any accumulation of pus in the deeper parts, in the same way that we see incision cure sinuses in the breast, or those following bubo, etc., but a like result can be obtained by the careful introduc- tion of a drainage tube, so that we must look for other and more potent reasons for the necessity of incision in this disease, and these are to be found in the action of the sphincter muscles. If we undertake the cure of urethral fistula the result of stricture of that tube, every surgeon knows that his efi'orts will be futile until the stricture is removed, the urine trickling through the fistula, and so keeping it o])en ; but once the stricture is fully dilated, the fistula can gener- ally be closed without much diificulty. Now, the sphincters of the anus produce a similar efi'ect in the rectum : as they are tightly closed except during an attempt at defsecation, there is a frequent dis- charge of flatus, rectal mucus, and occasionally slight amount of faecal matter through the fistula, effectually keeping it open. Incision through the portion of muscle below the tract, by stopping for a time all retention of gas and fluid, tends to promote^ healing. And, again, the mechanical action of the sphincter G— 23 82 The Rectum and Anus. [Chap. v. muscles in constantly pulling on and moving the fistula, prevents its repair in the same way that we see a sinus in close relation to a tendon in the hand or foot kept open by the constant action of the muscle. If a splint is so applied that the tendon is kept at rest, the sinus will soon close : in the same way inci- sion quiets for a time the sphincter, and allows repair to go on. Forcible dilatation of the sphincter, no doubt, produces a temporary paralysis sufficient to prevent retention of gas, and to keep the muscle at rest, and may, therefore, in exceptional cases, be found a useful adjunct to the treatment by drainage tube, but as it requires the administration of an anaesthetic, it is better to at once proceed to the more certain plan of division. Division of the intervening septum between the fistula and the bowel may be effected in a variety of ways : the knife, the elastic ligature, the thermo- cautery, the galvanic ^craseur, and the wire ecraseur of Chassaignac, all having their advocates. The opera- tion which is recommended by Pott, and which is practised still upon a large scale, is performed with a curved blunt-pointed bistoury ; the knife having been passed through the fistula, and the index finger of the operator's left hand introduced into the rectum, the probe point is felt for ; if it has passed through the internal opening into the cavity of the rectum, it is rested against the pulp of the finger, and both with- drawn together with a sawing motion, the intervening structures being thus divided ; if, however, the in- ternal opening cannot be made out, the blunt point of the knife being felt outside the mucous mem- brane, a very little pressure will suffice to make it penetrate this soft structure, and then the operation can be completed as before. This operation has been modified in many ways, as accidents may happen during the performance of it : the surgeon is apt to Chap. v.] Incision OF Fistula. 83 wound his finger ; and sometimes, when the fistula is very hard and callous, the knife breaks. All risk of the former may, however, be obviated by sub- stituting for the finger a speculum, a gorget, or even a tallow candle. A preferable mode of operating where the internal opening is situated low down, is by passing along the fistula a probe-pointed flexible director (Fig. 14), the end of which can be hooked out at the anus by means of the left index finger, and the parts divided by running a knife along the groove of the instrument. The pulling down the director gives the patient a little pain if general ansesthesia has not been induced, but this is more than counterbalanced by the Fig. 14, — Brodie's probe-pointed Fistula Director. fact that the parts situated on the director can be frozen with ether spray previous to division. Ailing- ham figures and describes an instrument which he has devised for performing this operation.* It con- sists of a director and spring-scissors. There is a button on one blade of the scissors, which runs in the groove of the director, and from which, when once introduced, it can be only removed at the end next the handle. He uses this for fistula situated high up, where difficulty would be experienced in bringing the end of the director out at the anus. I think that where simple division is required a knife is much to be preferred, except under special circumstances, and in no case of fistula that I have ever met with did I consider the use of scissors called for. When either of the foregoing cutting operations is decided upon, the patient should be prepared by having his bowels well cleared the day before the * hoc. cit., p. 42. 84 The Rectum and Anus. [Chap. v. operation, care being taken not to provoke a diarrhcEa, and the rectum should be washed out with an anti- septic enema immediately before he is ph\ced on the table. He should lie on the left side, with the knees well drawn up to the abdomen, and if an anaesthetic is used, it is well to tie up the right knee by a band passing round the neck and thigh : a strong calico bandage folded lengthwise three or four times answers the purpose well, and will be found to aid very materially in retaining the patient in proper position. A still more convenient plan is to retain the patient in the lithotomy position by means of Clover's crutch. {See page 9.) In making the section the surgeon should take care that the incision passes at righb angles to the anal margin, as if the cut goes obliquely through the mu co-cutaneous tissue, leaving the edges bevelled, healing will be much retarded, and incon- tinence more likely to result. In dealing with complex fistitlSB the surgeon must be guided by the individual peculiarities of each case. Where there are numerous external openings it is the safest plan to slit up all the sinuses at the same time, but where more than a single internal opening exists the case is different. If numerous incisions be made in the external sphincter, more or less incontin- ence will be a probable result ; so that the safer plan of treatment to adopt in these cases is to incise the sphincter on one side only in the first instance, and to attempt to cure the other fistulse by the application of caustics and use of drainage tube, the physiological rest afforded to the part by the incision already made lending powerful assistance to tlie treatment, so that success may be looked forward to with a considerable deg»'ee of confidence. Should, however, any fistulous tract remain unhealed after the one incised has cica- trised, a secondary operation will weaken the s[)liinctor less than if the sections are made simultaneously. Chap, v.] Fistula Operations, 85 Where the mucous membrane is separated from the musadar tunics of the rectum for a considerablo distance above the internal opening, professional opinion is somewhat divided as to tlie proper course to i)ursue. Allingham states most positively that the incision must extend to the uppermost limit of the sup- purating tract.* Curling advises a similar procedure ; while Syme, Brodie, and many others, state that it is sufficient to divide the hstula between the two openings, and that the upper portion will heal, I believe the best rule of treatment lies between these extremes. If in the first instance the ordinary incision is made, the sui-geon can watch the progress of the case, and it Avill frequently be found that, as granulation proceeds, the pouch between the mucous membrane and muscular wall will fill up ; but if it is not healing satisfactorily, slight ])ressure will be sufficient to make a few drops of matter exude, indicating its position, and, by passing a fine probe-pointed knife up, division of the mucous membrane can be effected with almost no pain to the patient, as the mucous membrane above the external sphincter is possessed of but very slight sensibility. I have on several occasions adopted this plan with excellent results. The careful watching for small suppurating tracts communicating with the original wound, constitutes, in my mind, one of the most important parts of the after-treatment of these cases. Where the edges of the fistula are very indurated and callous, it will promote more rapid healing if the tract is scraped with a sharp spoon, or the plan of operation which has been termed the " back cut " by Mr. Salmon may be adopted sometimes with ad- vantage. He recommends that, after division in the usual way, a linear incision should be made through that portion of the sphincter muscle which lies out- side the tract of the fistula, hereby adopting the * " Diseases of the Rectum,'' p. 93. 86 The Rectum and Anus. [Chap. v. operation customary for the treatment of ordinary anal fissure. Where the edges are much undermined, or where, after division, there is a tendency to curve inwards, it is advisable to cut off the overhanging margin of skin. In the treatment of horse-slioe fistula just referred to, it will be found advisable to incise the sphincter only on the side of the internal opening ; and open up the sinus extending round the anus, so as to allow of its being dressed from the bottom throughout its entire extent. The treatment of external rectal sinus must vary according to the direction and extent of the sup- purating tract. If a jDrobe is found to pass through the muscular wall, so that the mucous membrane alone intervenes between the finger introduced into the rectum and the probe passed along the sinus ; then, by perforation of the mucous membrane at the usual situation of the internal opening, the sinus should be transformed into a complete fistula, and the ordi- nary operation for division of the sphincter performed. If, however, the external sinus, when it impinges against the levator ani muscle, be directed by that structure away from the rectum, instead of the usual course down between the sphincters, division of the sphincter is wrong in theory, and futile in practice. The proper course will undoubtedly be to enlarge freely, by incision, the cutaneous orifice, and by dressing carefully from the bottom a satisfactory result will in all probability be obtained. Internal rectal sinus always demands opera- tive interference, and the sooner this is adopted after the diagnosis has been made, the better for the patient ; for, if left alone, the matter burrows, and may produce a considerable amount of separation of the rectum from the surrounding structures before the skin gives Chap, v.] Deep Fistula : Treatment, 87 way, converting it into a complete fistula. In making an external opening into the suppurating cavity, ditliculty may be experienced from the fact that even slight pressure may empty the matter into the rectum, and so the indication of fluctuation may be lost : it is, therefore, better to introduce a suitably bent probe from the rectum into the abscess, and then the blunt extremity of the probe can with ease be cut down upon from without, and the case treated as one of complete fistula. The deep fistula which runs through the muscu- lar pelvic diaphragm, formed of the two levatores ani, and then, traversing the superior pelvi-rectal space, perforates the muscular coat of the rectum at a con- siderable distance from the anus, presents much more difliculty in treatment than those which we have hither- to been discussinsf. If the intervening tissues between the rectum and fistula are divided with the knife, the risk of serious haemorrhage is encountered, as it in- volves the incision of a considerable portion of the highly vascular intestinal tunics : it will be well, there- fore, in these cases, to substitute for the knife the cautery, the galvanic or wire ecraseur, or the elastic ligature. Gerdy has recommended a form of clamp founded on the principle of the enterotoDie of Dupuy- tren, by which the division of the deeper parts can be gradually accomplished. It is claimed for this instrument that should a fold of peritonaeum exist in the structures to be divided, a limiting peritonitis would be produced, and so the danger of opening the peritonseal cavity obviated. In this respect, no doubt, it has advantages over the knife, cautery, or ecraseur, but not over the elastic ligature, which is more certain and more rapid in its action, and can be applied with less pain and annoyance to the patient. {See page 93.) When a sinus opening beside the anus is found to be connected with diseased bone, or is due to 88 The Rectum and Anus. [Chap. v. pathological changes in the genito-urinarj apparatus, the treatment must be conducted on general surgical principles, which it would be out of place for us to further discuss here. As to the after-treatmeiit of division of the sphincter, there are some important points for con- sideration. Heemorrhage is seldom troublesome where the sphincter has been divided for ordinary fistula, but occasionally it is somewhat free. This is gener- ally the case, as Gross has pointed out, where the edges of the fistula are very much indurated, and is no doubt due to the fact that the divided vessels are unable to retract and contract as they do in normal tissues. A parallel example is to be seen in the very free bleeding frequently following the division of the thickened cicatrices left after a severe burn. If any vessel is to be seen spouting, it should, of course, be secured with a ligature, but in general the application of cold and pressure, or the application of the thermo- cautery Avill be found sufiicieut. Van Buren recommends that the surface of the wound left after incision should be dusted over with ferrous sulphate, which not only stops bleeding, but, according to him, forms an adherent crust over the surface, so imitating the natural healing under a scab. It is well, too, I think, to combine the ferrous sulphate with iodoform : a mixture of equal parts of these drugs dusted over the surface forms the best possible dress- ing that can be applied. A piece of iodoform gauze or salicylic cotton should be lightly placed in the wound, a morphia suppository having previously been intro- duced into the rectum. A pad of some antiseptic absorbent should be now applied ; the sanitary pads made of wood wool, impregnated with corrosive sub- limate, and sold for the purpose of absorbing menstrual discharge, are admirably suited for use after this as after many other rectal operations. All is fixed with Chap, v.] Fistula : Delayed Healing. 89 a T-bandage, applied with sufficient firmness to limit tlie motion of the anus, and so keep the parts at rest. If the bowels have been well cleared out before the operation, and no discomfort is complained of, it will be well to let matters rest until the third day, when a mild unirritating aperient should be prescribed, such as compound liquorice powder, some of the saline mineral waters, or^ where the patient has not a very great dislike to it, castor-oil. Immediately before the bowels move, it will conduce much to the patient's comfort if he have a hot hip-bath, so that the dressings may be thoroughly well softened and loosened. As soon as the rectum is evacuated, the wound should be gently and completely cleansed, and a fresh dressing applied, consisting of a little antiseptic cotton. After the first dressing, however, it will render the subsequent treat- ment easier if the cotton wool is covered with iodo- form ointment. The patient should be kept in bed, and a nourishing but unstimulating diet ordered, in which milk forms a large item. Until the process of cicatrisation is M^ell established, the wound should be dressed daily, preferably immediately after the bowels move ; and a careful watch for any suppu- ratincr tract discharc-ino; into it should be maintained. The process of healing is, as a rule, somewhat slow, and is liable to sudden arrest after it has hitherto progressed favourably. The causes of this delayed healing are many. In the first place, the frequent distension and soiling of the wound by the passage of feeces is, of course, impossible to obviate, but much may be done by ensuring a soft motion at regular intervals, at the same time taking care not to establish a diarrhoea. Another important factor is the congestion of the lower portion of the rectum, so common in these cases, and due, as pointed out by Verneuil, to the anatomical disposition of the A^eins. These vessels, which are des- titute of valves, pass obliquely through the muscular 90 The Rectum and Anus. [Chap. v. ■walls of the rectum by openings which are unpro- tected by tendinous rings, so that they are compressed by the muscles when contracting to empty the bowel. Where this congestion is considerable, healing is much retarded, the wound resembling a varicose ulcer of the leg, which is sometimes so difficult to heal. Precisely the same treatment will be found to apply to both, the most essential element of which is rest in the recumbent position : tliis, by relieving the vessels of the weight of the contained column of blood, materially assists the healing. After the first three or four days it is not necessary to keep the patient in bed, but the recumbent posture should be maintained on a couch for the greater part of the day, until cicatrisation is completed. Stimulating applica- tions will be found of great service in these sluggish cases which become indolent : such as balsam of Peru, compound tincture of benzoin, elemi ointment ; or sometimes lotions of sulphate of zinc or ferrous sul- ])hate will answer better. If not progressing satisfac- torily, it is a good plan to vary these applications ; or more potent stimulants may be tried, such as red oxide of mercury, nitrate of silver, or even nitric acid. When other means have failed, change of air, particularly to the seaside, will frequently cause these indolent sores to assume a healthy surface and rapidly heal. This is especially true of hospital patients sent to a convalescent home in the country. When the fistula has been the result of a mar- ginal abscess, and when the tract passes through the fibres of the external sphincter, a small ulcer may remain unhealed after treatment by division, present- ing the character of the painful fissure of the rec- tum. It is to these cases that the " back cut" of Mr. Salmon is so eminently suitable in the primary opera- tion ; but if this has not been done, and a fissure results, the proper line of treatment is to incise the Chap. V.J Incontinence of Fmces. 91 floor through the fibres of the sphincter, as in the case of a spontaneous fissure. Should tuberculosis be present, as evidenced by livid edges, undermined and infiltrated skin, a thorough scraping with a sharp spoon, and liberal use of solid nitrate of silver is indicated. Under the term " trichiasis recti," Gross * has described a condition which retards healing of these wounds. It is, as the name implies, analogous to the trichiasis of the eyelid, the margins of skin becoming turned inwards. The hairs which grow in the neighbourhood of the anus are directed against the wound, and so a source of irritation is kept up. The treatment should consist in the removal of the cutaneous margins, or, where this is not considered advisable, careful epilation. Secondary suppuration occurring in the proxi- mity of the wound will of course delay the healing pro- cess, and the surgeon should always be on his guard for this complication. Any complaint from the patient of pain about the incision or any increase of the dis- charge calls for the most minute examination of the part, and if any secondary focus of suppuration be found during the after treatment, it should be opened from the original wound without delay. An unpleasant sequela to the operation for fistulg is a certain amount of incontinence of faeces when fluid, or of flatus. This is happily of rare occurrence, and only follows extensive operations, such as those required for the superior pelvi-rectal fistula, or where more than one division of the sphincter has been rendered necessary. Where it exists to any extent it is productive of great annoyance to the patient, possibly more than the original fistula, the cure proving worse than the disease. Much can be done to remedy this by the judicious use of the cautery ; if the sharp * "System of Surgery, "_vol. ii. p. 602. Sixth edition. 92 The Rectum and Anus. [Chap. v. point of Paquelin's therm o-cautery be applied to the cicatrix of the operation wound, contraction will follow, giving tone and increased power to the sphincter and decreasing the size of the anal outlet. In this way this troublesome complication can generally be relieved ; but cave is obviously necessary not to cauterise the anal margin to too great an extent, as an intractable form of stricture might be the result. L-igature for the cure of rectal fistula where the material used is inelastic has but little to recommend it ; it is impossible to tie a silk ligature so tight that it will completely cut through and strangulate all the tissue which requires division in an ordinary case of fistula ; and many plans have been devised to try and improve this method of treatment, such as hanging weights to the ligature, and the use of the tourniquet of Mr. Luke, by means of which the ligature could be screwed up tighter every day. These plans entailed so much suffering on the patient that they are now completely discarded ; and the elastic ligature has come to be the only form that is now used in the treat- ment of this disease. Although occasionally practised by other surgeons, the use of an indiarubber band for effecting division of tissue in surgery has been promi- nently brought under the notice of the profession by Professor Dittel of Vienna; the great differencebetween division effected by this means and that produced by the inelastic ligature being that the latter, if including a large amount of tissue, sinks into it, and soon ceases to constrict the vessels, the central portion soon regaining its suspended vitality, separation thus being stopped. With the elastic band, on the contraiy, the pressure is maintained, as the cord cuts its way through the constricted structures, so that a comparatively thick mass of tissue can be divided by this means with one application of the indiarubber band. What, then, Chap, v.] Elastic Ligature. 93 are tlie relative merits of the knife and tlie elastic cord in the treatment of rectal fistula % The knife possesses many advantages, which may be briefly enumerated as follows : Division is quickly accom- pli slied ; pain can be obviated by anaesthesia ; where the fistula is complex the secondary channels can be at th'3 same time laid open ; and the after treatment is almost painless. On the other hand, if the fistula is a deep one, the use of the knife may be followed by considerable haemorrhage. The advocates for the elastic lE§:a,ture claim for it that there is no haemorrhage. This is a matter of considerable importance where the fistula penetrates deeply, and also in those rare cases of so-called haemor- rhagic diathesis where severe bleeding is apt to follow a trivial incision. It is stated by those who have had large experience in this plan of treatment, that contrary to what one might expect, the pain attending the ulceration of the band through the soft parts is slight, the patient being often able to go about his occu- pation during treatment. Too rapid closing in of the wound by primary union of the pp.rts divided is im- possible. In my experience, this danger when the knife is used is more to be read of in books than seen in actual practice. The difficulty that the surgeon has to experience is more frequently due to a want of reparative action than to too great activity in the process of cicatrisation. The time occupied in treat- ment by elastic ligature is not longer than when sim})le incision is practised. The average time the elastic ligature took in cutting out, as estimated by Ailing- ham, from an experience of ninety cases, was about six days ; but nevertheless the total time of treatment is not increased, as healing goes on in the deeper portions of the wound as the rubber band sinks into the constricted tissues. Another advantage claimed for it is that patients who have an insuperable dread 94 The Rectum and Anus. [Chap. V. of any cutting operation will sometimes submit to the application of an elastic cord. If, then, we try to define the cases that experi- ence has proved are most suitable for treatment by elastic ligature, we find that its use is somewhat limited. In the first place, the fistula must be simple, i.e. un- complicated with sinuses. This, it may be remarked, is a matter not always easy of diagnosis before comTnencing operation. Probably the most suitable cases are those in which the patient is debilitated by phthisis or other chronic disease, or those in which the patient is unable to lie up during treatment, or in which there is known to be a hsemorrhagic tendency. Where the fistula is deep elastic ligature may with advantage be combined with the knife, the latter being used for the superficial structures and the elastic cord for the deeper parts where vessels of consider- able size exist, and where difficulty might be experi- enced in securing them if divided by the knife. The application of the elastic ligature is best efiected in the manner recommended by Allingham. Fig. 15.— Allingham's Instrument for the Introduction of Elastic Ligature. He uses solid rubber cylindrical cord y^ of an inch in diameter, and so strong that it cannot readily be broken by pulling. For its introduction he has devised a very ingenious instrument (Fig. 15), which consists of a curved blunt-pointed probe with a deep notch near the Chap, v.] Elastic Ligature. 95 extremity. This is fitted in a handle, and a cannida slides on the probe, so that once a loop of the ligature is caught in the nobch the cannula is slipped up and the ligature prevented escaping until released by the cannula being drawn down again. The instrument can be fitted with a sharp-pointed probe instead of the blunt point where it is necessary to transfix tissues. In order to apply a rubber cord to a case of simple complete fistula, this instrument, fitted with the blunt point, is passed through the fistula, and the index finger of the left hand introduced into the rectum, carrying a loop of elastic ligature stretched over the tip. The point of the instrument can now readily be passed between the tip of the finger and the ligature, and the latter slips into the notch. The cannula is now pushed up and the instrument withdrawn ; by this means the ligature is drawn through the fistula, one end hanging out of the rectum and the other out of the external orifice. Both ends are now passed through a small pewter ring made for the purpose, and by pulling, the cord is stretched to the required extent. The pewter clip is compressed with a strong forceps, the excess of cord cut off, and the operation is finished. This method is incomparably superior to the other plans previously devised, such as that recommended by Dittel, which is to introduce a grooved director up the sinus, and along this a needle threaded with the liga- ture is passed, by means of the left index finger in the rectum a loop of the elastic cord is to be hooked down, and the needle withdrawn along the fistula. The pew- ter clips answer admirably for fastening rubber cord, as if it is knotted it is apt to slip. Should, however, these clips be not at hand, the elastic band may be firmly held by a piece of strong silk applied in the following manner : It should be laid on the skin be- tween the anus and external orifice of the fistula, and the ends of the elastic made to cross it at right angles. 96 The Rectum and Anus. [Chap. v. The ligature is now pulled quite tight, and the silk tied firmly round the ends of the elastic band where they cross. This answers well, but as it requires the help of an assistant to tie the silk while the rubber is extended, it is not so handy as the clips. After the application of an elastic ligature, but little after treatment is required; it will be frequently found that by the time the cord separates the wound is superficiaL Mr. Reeves* has suggested a plan of division of the septum in rectal fistula, which he designates by the not very happy term " immediate ligation." Ho recommends that a strong ligature should be passed with one end through the fistula and the other out at the anus : the ends then being firmly held, by a to- and-fro motion the ligature is made to saw its way out. This manoeuvre resembles the obstetric operation by which, in impacted transverse presentation, the neck of the foetus is sawn through with a strong piece of whip-cord. Mr. Reeves claims for this that it is free from hsemorrhage ; and that healing from the bottom progresses favourably. The same author has also made a suggestiont which may, in some cases, be of service, more especially where the external opening is situated at a long dis- tance from the anus, and that is, after thoroughly dividing and scraping the fistula, to bring the sides together by sutures passed deeply in the hope that by obtaining primary union the tedious process of healing by granulation may be obviated. Recently Dr. Stephen Smith | speaks very favour- ably of this method. He advocates the complete ex- tirpation of all the granulation tissue, and then bring- ing the opposed surfaces accurately together by moans * Med. Times and Gazette, June lo, 1878 ; p. 649. t Brit. Med. .Jmirnal,. p. 917 ; 18S1. X Nexo York Med. Journal, June 12, 1886. Chap, v.] Thermo- Ca uter y. 97 of (1) a saddler's stitch of carbolised silk passed about three-quarters of an inch from the margin deeply through the sides, and extending the entire length of the wound ; (2) a few points of interrupted suture passed umderneath the wound; (3) a fine catgut con- tinuous suture to the edges of the incision. In a few cases I have tried this plan, and in un- complicated cases of fistula consider it a very great improvement. If we fail in obtaining primary union, the fact will be indicated by an escape of pus from the deeper parts of the wound about the third or fourth day ; under these circumstances all the sutures should be removed at once, any adhesions broken down with a probe, and the wound dressed from the bottom. The patient will then be in the same position as he would be if no attempt had been made to obtain primary union, whereas, if we succeed in obtaining healing, the gain is a very considerable one. The tliermo-caiitery of Paquelin (Fig. 29, page 205) is an instrument which has rendered very great service to rectal surgery. Indeed, no operation in this special department, where the occurrence of haemorr- hage is possible, should be undertaken without having this most useful appliance at hand. In principle it de- pends upon the well-known power which platinum (in common with some other metals) has of causing, when heated, the rapid oxidisation of volatile hydro-carbons, and it consists essentially of hollow platinum points, of various shapes, fitted upon metal tubes. In the inte- rior of each of these is a smaller tube, ending inside the platinum point, where it is covered with a small piece of firm platinum-wire gauze. By means of a rubber hand-bellows, air is made to pass over benzole, contained in a bottle, and the air now charged with benzole vapour is conveyed by means of rubber tubes to the inner tube of the instrument. If, now, the platinum point be heated in the flame of a spirit lamp. H— 23 98 The Rectum and Anus. [Chap. v. burning of the benzole vapour will take place in the interior of the cautery, the products of combustion passing down the outer tube. As long as the supply of air and benzole va[)Our is maintained, the point will remain hot, and the degree of heat can be regu- lated to a nicety, from a bright white to a dull red or black heat, according to the rate at which the air is propelled through the benzole bottle. In using this instrument care must be taken that it is not too hot, a dull red heat being the most suitable, as if it is more intense than this, the tissues will be protected by a thin tilm of steam, in the same way that a drop of water assumes the spheroidal state, and will not boil when placed on a white hot platinum dish. The result of this will be that either the tissues will not be sufficiently divided, or if the point is firmly pressed, it cuts through without charring the divided vessels sufficiently to stop bleeding. Th« treatment (^fistula by this cautery appears to meet with more favour in France than in this country, both "Verneuil and Pozzi speaking highly of it ; and in deep fistula it can be used with great safety and cer- tainty to open up thoroughly the ramifications of a suppurating tract in complicated cases. In simple cases, however, the methods before alluded to will gener- ally be found more satisfactory in practice. When the knife is used the cautery may prove a useful addition, either to check bleeding from vessels divided by the incision, or to continue the section through deeper parts where serious haemorrhage is to be appre- hended. The galvanic ecraseiir can be used for the treatment of simple fistuln, but it is not suitable for making the secondary sections necessary in eom)»lox cases ; and the requisite cumbrous battery limits greatly its utility. When, however, it can be readily obtained, it does its work cleanly and expeditiously. Chap, v.] FiSTUL/E BiMUCOS/E. 99 The wire or chain ^.craseur is difficult to apply, and its only advantage, freedom from haemorrhage, can be quite as well or better ensured by the elastic ligature or cautery ; so that I do not recommend its use in the treatment of rectal fistula. Fistulous communications between the rectum and other mucous tracts (lisnilse bimueosae) may be con- veniently classified into three divisions : (1) In which some portion of the bladder or urethra is penetrated ; (2) where the female genital organs are implicated ; and (3) where a fistulous channel is established between some other portion of the intestinal tract and the rectum. 1. Re€to-vesical, and recto-iirethral fis- tuJae may result from a variety of causes, of which the following may be enumerated : Direct traumatism. This will most commonly result from, or be occasioned by, an accident attending some surgical operative pro- ceeding. Thus, perforation of the bladder through the rectum for the relief of retention of urine, entails of necessity this condition ; but in the great majority of cases this perforation closes rapidly when once the normal channel for the evacuation of the bladder is restored. But where it has been found necessary to tie in a cannula, or where the obstructionin the urethra con- tinues for long, a fistulous communication may be estab- lished. Penetration of the vesical wall may also result from the forcible introduction of an enema pipe or other foreign body through the anus. The most fre- quent traumatic origin, however, is undoubtedly the accidental wounding of the rectum in the operation for lateral lithotomy. Suppuration originating in the structures sur- rounding the rectum or urethra, may, by opening both these mucous tracts, result in the formation of a fistulous communication; such is occasionally the case with prostatic abscess. loo . The Rectum and Anus. [Chap. v. Malignant disease, whether originating in the tissue of the rectum or in its immediate proximity, is undoubtedly the most frequent cause of an abnormal communication being established between these two organs. This subject, however, will be more fully considered in the chapter upon neoplasms. Primary ulceration of the bladder of a non- malignant type must be admitted as a cause, though it is an extremely rare one ; a few cases having been re- corded in which urinary calculi escaped by this means into the rectum, and were discharged through the anus. In the female, recto- vesical fistulse are, as might be anticipated from the anatomical relation, excessively infrequent. Simon has noted one case * which was subsequent to a difficult labour, and was attended with occlusion of the upper two-thirds of the vagina. In other instances it would appear that the cause of the abnormal communication has been the simultaneous opening of an abscess into both rectum and bladder. Two cases of this nature have been put upon record by Simpson, t The symptoms of this condition are extremely distressing. The escape of urine into the rectum causes excoriation of the anus, and great irritability, but if the opening into the bladder is sufficiently large to permit the entrance of fseces, the suffering of the patient is usually almost intolerably severe, cystitis of an afjcjravated form beins; the inevitable result. I have, however, seen one case of the kind in which, although a small quantity of faeces passed into the cavity of the bladder, but little irritation was produced, the diagnosis of the condition being first made by the appearance of striped muscular fibre as a urinary sediment ; this was accounted for by the escape * Arch. klin. Chir., Bd. xv. p. 111. t Obstet. and C4yiiecolog. Works, pp. 814—816. Edinburgh, 1871. Chap, v.] ReCTO-VeSICAL FiSTULA. lOl from the bowel of small particles of incompletely- digested meat. The treatment of this condition must vary with the extent and nature of the fistulous communication. Where the size is moderate, and the surrounding tissues normal, an attempt should be made to close the opening by a plastic procedure ; but where there has been very extensive destruction of the i-ecto-vesical septum, or where the surrounding tissues are infiltrated, especially if that infiltration has the clinical features of malignancy, the proper course is undoubtedly to divert the faecal current from the rectum by the establishment of an abdominal artificial anus. The operation of closing recto-vesical fistula is practised much in the same way that the cure of vesico-vaginal fistula is effected. The bowel having been well cleared out, the patient is placed in the semi- prone position of Marion Sims ; ether administered ; and the sphincter thoroughly w^ell dilated. This last is a most essential step in the performance ; indeed, it is only by its means that the operation is rendered possible. Should sufficient room not be available, more may be gained by an incision carried backward through the sphincter towards the coccyx, and a large- size duck-bill speculum introduced, so as to bring the rectal wall well into view. The edges of the fistula are now thoroughly pared, care being taken that the whole circumference of the orifice is vivified, and the edges brought together by a number of sutures passed through, the entire thickness of the recto-vesical septum . Afterwards the bladder should be frequently evacuated by the catheter if necessary, so as to prevent over-distension ; and the sutures removed on the fourth or fifth day. The bowels may be kept confined for a week or ten days by the use of opium, and with this object in view the diet should be so regulated that excrementitious .matter be reduced to a minimum : it I02 The Rectum and Anus, [Chap. v. is better^ indeed, that it should consist almost entirely of milk. The recumbent position ought to be main- tained until union is firm. Dittel * has advocated an exceedingly ingenious operation for the cure of recto-vesical tistulse in the male, the steps of which are, to a certain point, similar to his operation for the removal of calculus from the bladder where lithotrity is contra-indicated, and when the condition of the prostate gland renders its section inadvisable. The steps are as follows : A sound having been introduced through the urethra, he makes a transverse incision in the perinaeum in front of the anus, and then carefully dissects between the rectum and prostate, and tlien between the rectum and bladder. When the fistula is met, it is divided, and the rectal and vesical oritices separately sutured. This operation would appear to promise excellent results, but as far as I can learn it has not been performed sufficiently often to justify conclusions as to its merits. I have personal experience of but one example of this operation. The patient, a man, aged 40 years, was admitted into Sir Patrick Dun's Hospital under the care of my colleague, Professor Bennett. He had slipped down a hay-stack and impaled himself upon a pitchfork, one prong of which entered the anus, penetrating the rectum and membranous urethra; the other prong slipped up beside the scrotum, without doing any injury. The result was a tolerably large recto-urethral fistula. Dr. Bennett operated by the method above detailed ; the fistula having been divided, the urethral and rectal orifices were separately vivified and sutured, and a drainage tube introduced into the wound ; in this instance, however, probably owing to the large amount of cicatricial tissue present about the fistula, the * London Medical Record, p. 139 ; July 15th, 1878. Cbap. V.J Anus Preternaturalis in Ano. 103 posterior wall of tli63 rectum and anus unfortunately sloughed, and the operation failed in closing the abnormal communication. For the consideration of recto- vaginal fistuliB the reader is referred to the Sj^ecial works on obstetric surgery. Fistulous communications between the rectum and some other portion of tiie intestinal tract are extremely rare. Esmarch* describes the formation of an anus preternaturalis in ano as a sequela to extensive prolapsus recti. "Where the jtrolapse is considerable, a pouch of peritonaeum descends through the anus at the anterior aspect of the protrusion, and in this pouch a bundle of small intestine is not infrequently situated. If now this becomes sufficiently constricted to induce gan- grene, a fistulous communication between the rectum and small intestine may be a possible result. An artificial anus so formed differs in no material respect from a similar condition elsewhere. If the discharge is light in colour and contains a larrje proportion of but-little-digested food, and if there is progressive marasmus, the probability is that the portion of small intestine implicated is high up, and consequently of a kind where, if unrelieved^ a fatal termination must be looked for soon. An attempt might be made to cure it either by means of the enterotome of Dupuytren, or by resection of the intestine. According to Schi^oederf a direct communication between the small intestine and rectum has been pro- duced intentionally by the surgeon in order to cure an artificial anus in the posterior vaginal cul-de-sac, the * Pitha u. Billroth Handbuch. der allgemeinen und speciellen Chirurgie, Bd. iii. p. 149. t Ziemssen's '' Cyclopaedia of the Practice of Medicine, " vol. x. p. 531. I04 The Rectum and Anus. [Chap. vi. idea being to divert the discharge from the vagina into the rectum, where the power of retaining f?eces will exist ; and the method adopted is with an intestinal shears, one blade of which is passed into the rectum, and the other into the small intestine. The communi- cation having been established, the vaginal opening may be closed. A far preferable plan, however, of treatment, which, according to Schroeder, has been suc- cessfully performed by Heine, is to re-establish com- munication between the two ends of small intestine. A few cases have been noted of communication having been formed between other parts of the intestine and the rectum. McCarthy* records a com- munication between the vermiform appendix and rectum ; and recently I have had a case of this nature at Sir Patrick Dan's Hospital. A man, aged forty, was admitted with symptoms of violent peritonitis, of which he died, and at the post-mortem it was found that the vermiform appendix was firmly adherent to the upper portion of the rectum. An abscess had formed in the adhesions, which ruptured, and gave rise to the fatal peritonitis. CHAPTER YI. THE RELATIONS OF PULMONARY PHTHISIS TO RECTAL FISTULA. The connection between phthisis and rectal fistula is a subject of extreme importance, and well deserving of separate consideration. A considerable amount of difference of opinion, however, prevails amongst authors as to the relations that exist between these two diseases. Physicians, in treating of phthisis, rarely mention fistula ♦ Path. Trans., Lond., 1876 ; p. 161. Chap. VI.] Intestinal Tuberculosis. 105 as a common complication, while, on the other hand, surgeons who have written on the subject of fistula have generally noticed its frequent co-existence with pulmonary disease. This, no doubt, is due to the fact that patients often undergo treatment for phthisis without mentioning to the physician the presence of fistula, whereas, if the surgeon is consulted for the rectal disease by a person suffering from phthisis, the latter condition will, in the majority of cases, be sufficiently apparent. AUingham has noticed patients who have come to St. Mark's Hospital to be treated for fistula while they are attending at other hospitals for their cough, having said nothing about their rectal trouble at the latter institutions. ^Ye meet with fistula in phthisical persons under two distinct conditions, which we may distinguish as the tuberculous fistula ; and the simple fistula occurring in the tuberculous patient : the former being the result of a true tuberculous ulceration of the lower end of the rectum, and the latter occurring as a result of emacia- tion and absorption of fat in the ischio-rectal fossa, similar to that which we find in other debilitating diseases. The researches of Koch upon the Eetiology of tuberculosis have thrown important light upon tuber- cular ulceration of the intestinal tract. According to him,* intestinal tuberculosis may exist either as a primary disease, or secondary to pulmonary phthisis, the first arisincj bv the introduction into the intestinal tract of the flesh or milk of tuberculous animals, and the latter in consequence of the .person swallowing sputum containing tubercle bacilli. It is obvious that persons suftering from pulmonary tuberculosis who have any expectoration must frequently swallow some of the microbes, but yet only a few of these * " Mittheilungen aus dem Kaiserlichen Gesundheitsamte," Band ii. io6 The Rectum and Anus. [Chap. vi. individuals are affected with intestinal ulcers. Koch suggests as an explanation of this difficulty, that this may be due partly to the fact that the intestinal raucous membrane is not very susceptible to infection by the bacilli, and also to the slow development of the tubercle bacillus, he having cultivated the microbes of intestinal tuberculosis only nine times in a period of six months. Experiments with bacillus anthracis have shown that the fully-developed bacilli were destroyed by the gastric fluids, but that the spores passed through and subsequently developed ; and Koch concludes that possibly the same may be true of the tubercle bacillus ; and that it is only in those cases where the spores are delayed, from some cause, for a sufiiciently long time in the intestinal canal, that the bacilli develop and form intestinal ulcers. When once developed, the tuberculous ulcers contain vast numbers of the bacilli. In one case* which he records they were found in great quantities in the floor of intestinal ulcerations, although they existed only in small numbers in the ])ulmonary cavities. According to Lichtheim and Gaffky,t the fseces of persons suffering from intestinal tuberculosis contain numbers of bacilli. The latter of these authorities lias drawn the following conclusions from a number of observations on this subject. In health, and in non- lyibercular illness, no tubercle bacilli could be found in the faeces ; in phthisis, w^here the si)utum con- tains bacilli, none Avere found, except where symptoms cf intestinal ulceration were present, and then they were abundant. He also found in fseces two other forms of bacilli, which were stained blue by Ehrlich's method, but they differed in shape from the tubercle bacillus. Professor G. Sormani has published some interesting * Koch, loc. cit. Case II., p. 35. t Koch, loc. cit.,\x 34. Chap. VI.] Tubercular Fistula. 107 experiments on the artificial digestion of, and other conditions influencing the life, of these organisms.* The stomach of a pig recently killed, and ke]>t without food for forty hours before death, was the source of the gastric juice employed. Complete physiological digestion not only destroys the vitality of the bacillus of tubercle, but its form also. The destruction of the bacillus is not among the first phenomena of digestion, rather among the last to happen ; that is to say, these organisms are, among organised substances, the least easily attacked by the digestive juices. A digestion of too short duration, or of little activity from scarcity of gastric juice, or from insufficient acidity, does not attack the bacillus of tuberculosis, and in such case it maintains its virulence nearly unaltered. The knowledge of this, according to Sormani, helps to explain the frequent association of intestinal tuber- culosis with pulmonary phthisis. The stomach of the tubercular patients, little active, as"a rule, from catarrh due to the fever, and possibly to the remedies, is of so weak digestive power that it readily allows these bacilli to pass unaltered, so that they may subsequently become the foci of intestinal tuberculosis. The symptoms of tubercular fistulas are tolerably diagnostic : the internal opening is easily felt \ is large, sometimes being the size of a threepenny piece, or even larger ; it is irregular, and the mucous mem- brane surrounding it is infiltrated, and feels to the finger elevated and knobby. The external opening is also large, and the surrounding skin is much un- dermined ; the skin itself is congested and livid, and the edges have a tendency to curl inwards. The discharge is thin and curdy. The occurrence of tubercular fistula as a primary * Annali Univ. di Mediciiia, Aug., 1884 ; and Lond. Med. Becord, March 16, 1885. io8 The Rectum and Anus. [Chap. vi. affection, without pulmonary or other manifestation of the disease, is extremely rare. I have, however, seen one case, which I believe to have been of this nature. A boy, aged ten years, came under my care in January, 1878, with a complete fistula : the inner opening, wliich was situated in the usual position, was large and rugged ; the edges were indurated and elevated ; the external opening just admitted the tip of my little finger, and the skin was undermined for a distance of three-quarters of an inch from the margin ; it was thinned and livid. The discharge was some- what profuse, but thin and curdy. His general health was otherwise very good, and there was not the sliglitest indication of pulmonary mischief. I divided the sphincter in the usual way, and then thoroughly scraped the granulations with a sharp spoon, cut away the thinned margin of skin, and cauterised the surface with nitrate of silver. The wound healed rapidly and perfectly, and I have since (five years after the operation) learned that the boy has remained well. Since the investigations of Koch, we should, I think, establish the fact of the presence of the bacillus before accepting the diagnosis of tubercular fistula in any given case, its existence in discharge being possible to demonstrate by the same methods as are employed in investigating sjmtum.* i^liouid a, phthisical patient be operated on for fistula? — Yery different opinions are held "by surgeons upon this point. Some say, " Do not operate, because, if you cure the fistula, the pulmonary mischief will be aggravated by stopping the dis- charge;" while others say, " If you operate, the wound will not heal." The former objection is one which is now properly disregarded as belonging to the period of surgery * Smith, The Lancet, June, 1883 ; p. 1108. Chap. VII.] Causes of Ulceration. 109 when issues, setons, and moxte, were in high repute ; but the latter is sometimes an important considera- tion. If the fistula is tubercular, it is obvious that simple incision will fail. Something more must be done, as in the instance above described, and in cases of simple fistula, where the pulmonary mischief has much advanced ; and where cough is frequent, failure would be the probable result, the constant cough causing such frequent movement of the anus, that the rest so necessary to repair is impracticable. On the other hand, when the lung disease is slight and not extending, and where the patient is not much run down, it is well to operate, especially where the fistula is simple ; and the removal of a source of irri- tation and suppuration by this means will frequently result in very great benefit. No definite rule can, however, be laid down in these cases. The surgeon must be guided in recommending operation by the in- dividual peculiarities of each case that comes under his notice. CHAPTER YII. ULCERATION OF THE EECTUII. TJlceratiox of the rectum is a tolerably common affection, and we find that in addition to the causes which tend to produce this destructive disintegration in this situation in common with other parts of the body, several special aetiological influences act more particularly upon the lower bowel. Of predisposing causes the most potent is conges- tion, and just as we see ulceration following, varicose veins in the leg, so enlargement of the hsemorrhoidal no The Rectum and Anus. [Chap. vii. veins is the common precursor of rectal ulceration. In order to fnlly appreciate this, we must take into consideration the anatomical arrangement of the blood- vessels of the lower bowel. Of the arteries, which are distributed to this portion of the intestinal tract, the most important is the superior ha^morrhoidal. This vessel, which is a branch of the inferior mesen- teric, passes down between the folds of the meso- rectum, where it divides into two branches, which form loops, curving downwards, and from which the parallel rectal arteries described and delineated by Quain, are given off. These vessels pass down in the columns of Glisson, which are vertical folds of mucous membrane, from six to eight in number, but liable to some variety in size and distinctness, terminating immediately inside the anal margin. The blood supply of the mucous membrane is almost entirely derived from these vessels. The veins which return the blood from the rectum pass with the arteries upwards to the inferior mesen- teric vein, and so their blood finally passes into the })ortal circulation. In passing through the rectal wall, the haemorrhoidal veins penetrate small openings in the muscular coat, about four inches above the anus, unprotected by any tendinous ring ; and Verneuil, who has drawn special attention to this arrange- ment, considers that the pressure to which these veins must of necessity be subjected during defseca- tion is a fertile cause of haemorrhoids and conges- tion. In common with other radicles of the portal system, these veins are destitute of valves, so tliat in the erect position which man occupies the weight of the column of blood contained in tlie vessels tends powerfully to produce stasis in the smaller terminal branches ; and again during defaecation the pass;ig6 of the fcccal mass along the rectum, tightly contracted around it^ and in a direction opposed to that by Chap. VII.] Causes of Ulceration: hi whicli the current of blood is returning, must be admitted as a frequent although temporary cause of congestion. Lastly, [obstruction to the poi'tal circu- lation through the liver must not be overlooked. It will thus be seen that the anatomical arrange- ments tending to produce congestion of the lower bowel are numerous and important, so that a very trivial exciting cause may start an ulceration which may prove very intractable. Undoubtedly, one of the most frequent exciting causes is a direct traumat- ism, and this may be produced in a great variety of ways. Injury sufficient to induce the ulcerative process may originate from without, as from the in- troduction of foreign bodies through the anus, but very much more frequently the initial laceration is caused by the contents of the intestine, and where the bowels have become much confined, the effort to extrude the hardened faecal mass may result in a tearing of the anal margin, which, instead of heal- ing healthily, remains as a more or less permanent ulcerated surface ; or, as Bushe has pointed out, a fold of mucous membrane may be prolapsed, and so pressed upon by the indurated faeces, that it loses its vitality, and sloughs off. Pieces of bone, nut- shell, and similar hard substances contained in the fteces, may also injure the d-elicate mucous membrane sufficiently to induce ulceration. Another traumatic origin which has been described is the pressure of the fcetal head duiing child-birth. This cause has been assigned for the greater frequency of non- malignant stricture, resulting from ulceration, in the female. Various operations, as the removal of a hsemorrhoid, or the division of fistula, prove to be the direct exciting caiases of ulceration not unfre- quently, especially where the patient is allowed up too soon, or when the bowels are permitted to be- come constipated during after-treatment. 112 The Rectum and Anus. [Chap. vii. The rupture or sloughing of an internal hsemorr- hoid may also be the starting-point of this process. The classification of ulcers (at all times a matter of difficulty and vagueness) cannot be more definitely arranged in the rectum than in other parts of the body ; there are, however, some forms which appear sufficiently characteristic to warrant special notice. Of these the more important are : The haemorrhoidal, the follicular, the tubercular, the lupoid, the dysenteric, the irritable, and the syphilitic. The hseiiiorrlioidal ulcer.— Under the above heading Rokitansky * describes ulceration due to congestion, in which, no doubt, some traumatism is the immediate exciting cause. This form resembles, in all respects, the varicose ulcer of the leg, and is characterised by marked chronicity, elevated irregular edges, and a tendency to bleed. Its situation (Plate II., Fig. 2) is usually well within the external sphincter, and confined to the mucous membrane ; it does not implicate the anal verge. The amount of pain that the patient suffers is slight, in this respect contrasting markedly with the irritable ulcer or fissure ; the reason is, no doubt, that in the first place it is situated out of the grasp of the sphincter ; and secondly, the sensory nervous supply of the mucous membrane is very much less than at the margin of the anus. The complications with which this form of ulcera- tion may be associated are in the first place the perforation of the gut, and the establishment of an internal rectal sinus or complete fistula as a result ; secondly, if the destruction of the deeper coats of the bowel be considerable, a stricture may be formed during the process of cicatrisation ; or, again, the ulcer may, by passing across the anal margin, and exposing some of the delicate nerve fibres, be associated with a true irritable ulcer. * "Path. Anat.," vol. ii. p. 107. PLATE II. Fig. 1. — Lupoid Ulceration of Rectum. Fii-. 2.— Iljcmorrhoidal Ulceration of Rectum. rid Ji^urgess ch ii Chap. VII.] HEMORRHOIDAL Ulcer: Treatment. 113 Syniptoms. — The amount of discomfort oc- casioned by litiemorrhoidal ulcers is slight. There is tenesmus with frequent passage of a sinall quantity of fseces, generally more noticeable in the morning, with pus, and occasionally bleeding, more or less severe. The educated finger introduced into the rectum will, without difficulty, determine the number and extent of these ulcers ; or, after dilatation of the sphincter under an anaesthetic, a good view can be obtained of them with a rectal speculum. The treatment of this form of ulceration is not very satisfactory. Rest in the recumbent position is neces- sary for the same reason that we prescribe it in varicose ulcer of the \eg. The bowels should be kept regular, preferably by some of the saline minei^al waters given in sufficient quantity to ensure one soft motion daily. At the same time the diet should be so regulated that the fseces may be as unirritating as possible ; indeed, an exclusive milk diet may some- times be advantageous. For local treatment an in- jection of liq. bismuthi, 5ss. ; liq. morphise, min. xv. ; mucilag. amyli ad ^ii., night and morning, will be found of service ; or, where a more powerful astringent appears indicated, a solution of nitrate of silver in water, 2 or 3 grains to the ounce, may be tried. In other cases the introduction of iodoform ointment, by means of Allingham's instrument (Fig. 16), will answer Fig. 16. — Allingham's Screw Ointment Introducer. (Scale \.) better ; and, where the rectal ulceration is compli- cated with irritable ulcer, division of the sphincter may become necessary. 1—23 114 The Rectum and Anus. [Chap. vii. In cases where the amount of ulceration is extreme, and where the above treatment fails to relieve, colo- tomy should be contemplated, the object being in this case to afford physiological rest to the part, and so enable the healing process to progress, by diverting the faecal How from the rectum. This is undoubtedly sound surgery. Where a joint is diseased we stop its functional activity by a splint. And in cases of intractable ulceration of the larynx, Bryant has advocated the performance of tracheotomy for a like purpose, w^th excellent results. We should remember that when performed in this way as a remedial measure the prognosis is much more favour- able than when the operation is called for in a patient worn down by long-continued intestinal obstruction or open rectal cancer ; and should the ulceration in the lower bowel heal, steps may be taken to close the artificial anus. Allingham in his table of ulcer and stricture of the rectum gives two cases (Nos. 7 and 25) in which, after colotomy, the rectal ulceration healed ; and in the latter he states that the lumbar opening was sub- sequently closed, the fyeces passing normally ; and at the meetins: of the International Medical Congress at Copenhagen, Bryant strongly advocated colotomy as a curative treatment of rectal ulceration. Dr. Bridge and other surgeons have recorded similar cases. An interesting variety of ulceration, probably more nearly related to the hsemorrhoidal than any of the other varieties enumerated, is that which originates within the lacunae (sinuses of Morgagni) just above the external sphincter, probably from the lodgment and decomposition of faecal debris. These little pockets are situated between the columns o< Glisson, and are formed by the anal valves, which have a faint resemblance, as pointed out by Ribes, to the semilunar valves and sinuses at the aortic and Chap. VII.] Ulceration of Lacunm. 115 pulmonary openings. The lacunae are very variable both in number and extent, in some cases constitut- ing diverticula {the encysted rectum) ; while in others they are scarcely recognisable. Physick first drew attention to the occurrence of this form of ulceration.* A very instructive instance of this disease is quoted by Kelsey, which was recorded by Dr. Vance, f " A lady, aged eighteen, had suffered for more than a year from all the symptoms of fissure ; had been frequently examined to no purpose, and was reduced to a very miserable state. On examination, the integu- mentary folds were congested, thickened, and oedema- tous, doubtless as a result of scratching ; but there was no trace of anything like a fissure. The lining membrane was searched with the utmost care, but no lesion of any sort was revealed, except slight hyper- trophy of the sphincter. A second painstaking review of every part of the rectum gave the same result, and the author was about to abandon the hope of finding any local lesion when, as a matter of form (for there was no evidence of disease about them) he determined to pass a probe into each of the pouches. The probe could not be forced into the first one, and with the second he fared no better ; but with the third, after an inefiectual attempt, the probe passed into the sac- culus. No sooner had it entered, however, than the patient screamed with pain, there was a spasmodic retraction of the levator ani and sphincter muscles, and the part was forcibly withdrawn from view. The site of the sacculus felt as if a buck-shot had been embedded in the tissues, so hard and swollen was the part. A small probe-pointed tenotome was carefully passed along the canal, and as soon as the sensitive point was touched the handle was brought down, and the edge of the knife made to sever the inner wall of * " American Ency. of Pract. Med. and Surg.," Art. Anus. 1836. t Medical and Surgical Reporter, Aug. 14th, 1880. ii6 The Rectum and Anus. [Chap. vii. the sacculus and expose the diseased point. This done, the cause of the suffering was revealed. On the left side of the anus, and at a point where there had been no unusual sensibility, an indurated ulcer had formed Fig. 17.- -Ulcers originating in the Sinuses of Morgagni. A, Small internal pile ; b, three small ulcers ; c, glass rods indicating poeition of unalfccted sinuses. within one of the little pouches. When the sacculus was opened and the ulcer exposed, it seemed very much like an ordinary fissure of the anus ; but before cutting it open there was no evidence whatever, save the symptoms the patient complained of, to indicate the existence of such a lesion." Ulceration of this kind, although extensive, may produce but trivial symptoms, as is shown in a case Chap. VII.] Albuminuric Ulceration. 117 upon which I recently made a post-mortem examina- tion. The patient, a man aged sixty, was for several weeks in Sir Patrick Dun's Hospital siiifering from Bright's disease, from which he eventually died. During his stay in hospital he never complained of any uneasiness about the rectum, and as there was no indication to excite suspicion, no rectal examina- tion was made. I injected the vessels of the rectum for anatomical purposes, and on slitting up the bowel was surprised to find three well-marked ulcers imme- diately inside the external sphincter. They have manifestly commenced in the little sinuses, two of which remain unaffected, and are indicated by pieces of glass rod. It will be observed, on reference to the woodcut (Fig. 17), that none of these ulcers invade the anal margin, with its numerous sensory nerves; hence the complete absence of symptoms in this case, as contrasted with the extreme agony attending the ordinary irritable ulcer. In connection with this case it may be well to inquire whether there is anything more than an accidental relation between ulceration in the lower bowel and disease of the kidneys. Bartels* says degeneration of the blood-vessels of the intestinal mucous membrane is certainly a very common con- dition with amyloid disease of the kidney, and ex- tensive ulcerative destruction of the mucous mem- brane is by no means a rare consequence thereof. He considers that intestinal ulceration has a direct sequen- tial relation to diseased kidney, and he states that follicular ulceration of the large intestine is not in- frequently associated with amyloid changes. Dicken- son also, in the Croonian Lecture for 1876, mentions intestinal ulceration as one of the rare complications of renal disease. FollicuIa,r ulceration may occur in any part * Zicmssen's Cyclopaedia, vol. xv. p. 522. ii8 The Rectum and Anus. [Chap. vii. of the large intestine, but the seat of election of this disease is undoubtedly the rectum and sigmoid flexure, sometimes affecting only a few follicles, while at others the ulcers are very numerous and extensive (Fig. 18). They arise as a result of inflammation of the mucous membrane either catarrhal or dysenteric, and are imme- diately due to the breaking down and necrosis of infil- trated and swollen solitary follicles. As to the patho- logical anatomy of this disease, when seen in the early stage, before ulceration sets in, the follicles appear tumid, and raised above the surface of the mucous mem- brane, due to the i)roliferation of the cell contents. This proliferation proceeds with such rapidity that sphacelus of the follicle takes place, and as the slough sepai-ates an ulcer is left. At first the ulcers are of a small size, and are of a more or less circular outline ; tlie margin is con- siderably raised, and the base is formed of the submucosa. Occasionally, by in- crease and coalescence of two or more follicular ulcers, a considerable loss of substance results, but more fre- quently the dimensions remain limited. Cicatrisa- tion progresses somewhat slowly, and where the Fig. 38. — Follicular Ulcera- tiou of Rectum.* Museum Royal College of Surgeons in Ireland. Chap. VII.] Rectal Tuberculosis. tiq destruction of tissues is considerable, may lead to stenosis of the bowel. Tlio diagnosis of these ulcers during life must, from their very nature, be difficult and obscure, but their jjresence may be suspected when the symptoms of intestinal inflammation })ersi8t for a long time, es- pecially when there is frequent ha-morrhage. When low down in the rectum they ma}^ be felt with the finger, or seen through a speculum. In some in- stances we find in the discharges masses of inspissated mucus, which represent the form of the ulcer. These are compared by Bamberger to frog-spawn or boiled sago-grains, and have been shown by Virchow to con- sist, in part at any rate, of particles of imperfectly digested starch. Tubercular ulceration. — Intestinal tuber- culosis and ulceration may be either a primary dis- ease, or it may be secondary to similar changes in the lungs. In the first instance the cause is, in all probability, a direct inoculation by the ingestion of bacilli in the food ; and in the second the sputum which the patient swallows, as pointed out by Klebs, is the probable source of infection. When implicating the rectum, tubercular ulceration may, in the generality of cases, be recognised by the following characters : the size of the ulcer is usually considerable, and in position it is found in the rectal pouch, or invading the anus ; the shape is generally irregularly oval, the long axis being parallel to the vessels, which in this part of the bowel are vertical, whereas in. the other parts of the intestine they are transverse. The edges of the sore are much under- mined and ragged, and there is considerable infiltra- tion of the mucous membrane in the immediate neighbourhood. It is impossible to draw any definite line between the limited tubercular ulcers met with in this region and the more extensive destruction I20 The Rectum and Anus. [Chap. vii. of tissue which have been descriVjed as lupoid ulcer. Tubercular ulcers of the large intestine manifest a strong tendency to perforate the bowel (Fig. 19). Chap. VII.] Lupoid Ulceration. 121 Hence it is that fistula is such a common result as a sequela to this disease when situated in the lower portions of the rectum; and similarly, when higher up, perforation may not unfrequently originate a fatal peritonitis. For a further consideration of rectal tuberculosis the reader is referred to the chapter on the connection between fistula and pulmonary phthisis. Lupoid ulceration.— Under the names " rodent ulcer," " lupus of the vulvar anal regions," and I'esthiom^ne, a number of cases have been described, in which the essential element is a chronic intractable form of ulceration in the neighbourhood of the anus and genital organs. Tlie first description of lupus in this region, more particularly implicating the vulva, and the difieren- tial diagnosis of this condition from syphilis on the one hand and carcinoma on the other, was by Huguier, in 1848, who, under the term V esthiomene^ described a number of cases that he had met with. Like lu[)us in other parts of the body, we find considerable variety in the tissues aff'ected, and the mode of progress of the disease. For practical pur- poses, it may be well to classify these under two heads : the superficial, or serpiginous; and the hypertrophic. Amongst the published cases, the greater number appear to have been of the latter variety. A s an example of the great ravages of this disease, the following case, given in a valuable paj^er by Dr. Angus McDonald* on this subject, may prove of interest : " The case came under my notice after it reached an extreme degree of advancement : it had then lasted some six or eight years ; the destruction of tissue was terrible in extent. I have reason to know that it is the same case as that referred to by Duncan, in * Edinburgh Medical Journal, April, 1884 ; p. 910. 122 The Rectum and Anus. [Chap. vii. * Duncan and West,' p. G56. Of it (at the time when he saw the case, which at least was a year before I was introduced to the patient) Dr. Duncan says : ' A case to which I was called some years ago is, so far as I know, so unprecedented in the amount of destruction as to be worth describing. I only saw it once in consultation. The disease was at one time regarded as cancerous. The ])atient, aged about forty, had had the disease for at least five years, and she lived many years after my visit. While the disease was already extensive, she liore a child. On the hips, just beyond the ischial tuberosities, were long scars, thin and bluish, of healed ulcers. The entire ano- perinaeal region was gone, there being a hollow space as big as a foetal head. The urethra was entire, as well as the mucous membrane between it and the cervix uteii, which was healthy. Except the anterior portion of the vagina, no trace of it, or of the anus or rectum, was discoverable ; behind the cervix uteri the bowel opened by a tight aperture, just sujfRcient to admit a finger ; when the faeces were hard, she could keep herself clean, but only then. Although the extent of ulceration was severe, the patient was attending to her household duties.' To this graphic description of the case I can fully subscribe, with this addition, that latterly the ulceration went still higher up into the pelvis, leaving the bowel hanging loose for some distance from the upper level of ulceration, giving it the appearance of the torn sleeve of a coat. This patient lived two and a half years after the time referred to by Dr. Duncan, and died of exhaustion and diarrhoea. Notwithstanding this shocking amount of and prolonged continuance of ulcerative action, there was no involvement of inguinal or other glands." Allingham uses the term " rodent," or " lupoid," for an intractable form of ulceration, of which his Chap. VII.] Lupoid Ulceration. 123 records show several cases similar to, although scarcely so extensive as, the case detailed by Dr. McDonald. Through the kindness of Dr. K. McDonnell, I recently had an opportunity of seeing a case of this kind, which was under his charge in Steeven's Hospital, Dublin, in the person of a policeman, aged thirty-five years. In this case an extensive and deep ulceration extended round the margin of the anus, with the exception of a small part on the left side. Spreading more in an antero-posterior direction than laterally, it passed up into the interior of the rectum for a distance of about one and a half inches, com- pletely destroying the entire thickness of the bowel (Plate II. Fig. 1). A thorough scraping with the sharp spoon and cauterisation was only followed by temporary benefit, and the ulcer was subsequently excised. A careful microscopic examination of the parts removed showed several giant cells, but no tubercle bacilli were found. The term ''rodent" is objectionable, as it is asso- ciated with a tolerably definite form of ulceration in other parts of the body, which is obviously not identical with what Mr. Allingham describes as occurring at the anus or in the rectum ; for, in the first place, rodent ulcer is essentially a disease of advanced life, while the cases given by Mr. Allingham vary in age from 17 years to 42. Secondly, he says, " Neither its edge nor its base is at all hard," while we know^ that a rodent ulcer of the face has always a layer of infil- trated tissue surrounding the ulcerated surface ; and the fact stated by him that he has noticed repair taking place very rapidly, when suddenly all the granu- lations melt away, and the ulcer assumed its former character, is an occurrence familiar to surgeons in the case of lupus, but not at all consistent wdth the general progress of rodent ulcer, wdiich is one of continued and chronic extension, without any effort at repair. 124 The Rectum and Anus. [Chap. vii. N >> =^fl - 03 CO rt. c.^ CO- ^ O) , o c3 _ H O "Co So OQ e <* ce ■- • • «'5 <'^ — >q §-" e* Lupus is a term which, in the present state of our knowledge, it is somewhat difficult to define. Pos- sibly the recent discovery by Koch of the tubercle bacillus in the giant cells of lufjus may enable us to Chap. VII.] Dysenteric Ulceration. 125 limit more precisely in the future this disease. For the present, at any rate, it would appear that the recorded cases of the form of locally malignant ulcerations to which I have been referringr, are more nearly related to lupus than to other diseases.* Dysenteric ulceration. — As a sequel to true epidemic dysentery, loss of substance may result ; but it is probable that many of the museum specimens which are stated to be instances of dysenteric ulcera- ation are incorrectly described. We must bear in mind that the symptoms of ulceration of the rectum, from whatever cause arising (e,^. continued diar- rhoea, with the discharge of blood-stained mucus) can hardly be distinguished from the milder cases of dysentery ; and it is impossible, with our present knowledge, to draw a hard and fast line between simple catarrhal and true dysenteric inflammation. The changes resulting from diphtheritic dysentery have, however, been fully investigated, and the process of ulceration is admirably described byZiegler(Fig. 20). In recent cases the mucous membrane is highly con- gested and swollen, and generally beset with minute ex- travasations of blood. The epithelial surface is overlaid with a glairy blood-streaked mucus. This presently becomes more slimy and blood-stained, and interspersed with flaky fibrinous shreds and films, which indicate the beginning of a superficial necrosis of the mucous membrane. Soon the necrosis is made sufficiently evident by the appearance of erosions and losses of substance. In slighter cases the necrosis and loss of substance are, at first, merely superficial, but the deeper struc- tures are successively attacked, and in severe cases the whole of the glandular layer of the mucous mem- brane at particular spots may perish. The necrotic tissue is reduced to a turbid mass, in which the * "Special Pathological Anatomy," p. 288. 126 The Rectum and Anus. [Chap. vii. structural elements, and the nuclei of the cells, soon cease to be recognisable. The parts which undergo necrosis seldom cover any great extent of surface, and are often confined to the prominent ridges and folds of the mucous membrane. These look dirty grey or black, while the intervening parts are still livid or dark red ; in other cases the necrotic tissue takes the form of a flaky more or less adherent coating, or, more rarely, of broad, continuous sloughs. The under- lying tissue is, in all cases, densely infiltrated with cells. The infiltration may extend through the entire thickness of the submucosa, and may at length invade the muscular layers. When the mucosa is removed, open ulcers are of course left behind. These may vary in their depth and extent. Sometimes over a great part of the bowel the mucous membrane remains only in narrow strips, or islands. The disease may become arrested at any of the various stages of its course, and repair then begins. And when the ulceration has been deep, atrophic cicatrices may result. During this process of cicatri- sation a mucopurulent discharge takes place, con- stituting what has been called chronic dysentery, or coeliac flux ; and it is in this stage that British surgeons most frequently meet with this disease in persons who have returned invalided from warmer countries. In these cases ulceration of the rectum can frequently be diagnosed by digital examination, or seen by means of a speculum, and the treatment will requii-e much patience and care. For the ulcerations due to syphilis the reader is referred to chap, xii,, and the irritable ulcer is a subject of such im})ortance that I propose to devote a chapter to its special considera- tion. 127 CHAPTER YTIT. IRRITABLE ULCER, OR FISSURE OF THE ANUS. In the whole range of surgery there are but few- diseases which, while of very limited extent, produce such extreme misery to the patient, and none in which surgical treatment is attended with more certain success than in the affection under consideration. In order to intelligibly elucidate the eetiolog^y of this remarkable disease, and before entering on the train of symptoms so characteristic of irritable anal ulcer, it will be necessary for us to review the more important anatomical features of the termin- ation of the bowel. The outlet of the intestine is closed by two sphincter muscles, the external being subcutaneous, and consisting of an elliptical band of fibres closely surrounding the anal verge. The internal sphincter consists of the normal circular fibres of the rectum considerably increased in number, and averaging about two lines in thickness at the lower extremity, and gradually merging into the circular coat of the rectum above. On the outer side, these muscles are separated by the attachment of the levator ani, the fibres of which are more intimately connected with the external sphincter; and on the inside these two sphincters are in close apposition, and the line of demarcation cor- responding accurately with the junction of the skin and mucous membrane. According to Hilton, this is in^ dicated by a white line, which is generally to be seen, although in some cases it is very much better marked than in others. Hilton has also pointed out the im- portant fact that the nerves, principally branches of 128 The Rectum and Anus. [Chap. viii. the pudic, which come down below the internal sphincter, pass out between the muscles at the junc- tion to become superficial in this situation (Fig. 21). These nerves are very numerous, and he makes the ingenious suggestion that this is due to the peculiar physiological fact that the normal state of these Pig. 21.— Nervous Supply of Anus. (Hilton.) a, Mucous membrane of rectum; 6, skin near the anus; c, externa! sphincter mu.ecle ; d, internal spliincter muscle ; e, line of seiiaration of the two sphincters; /, the overlying white line marking the junction of the two sphincters ; g, nerve supplying the skin near the anus, whicli it reMChes My passing first externally to the rectum and then through the interval hetween the two sphincters ; h, flap of mucous membrane and skin reflected hack. muscles is a condition of contraction instead of relaxa- tion. This theory would appear to receive support from the somewhat analogous arrangement in the bladder, as we know that the most sensitive portion of that viscus is at the neck. These nerves play a very important part in the retiology of irritable ulcer : the exposure of one of their filaments, either in the Chap. VIII.] Spasm of the Sphincter. 129 floor or at the edge of the ulcer, being an essential condition of its existence. As we have before seen, the sensibility of the in- terior of the rectum is but slight, so that ulcers situated inside the anus produce but little actual pain. When, however, the ulcer passes beyoiid " Hilton's white line," it is in the great majority of cases acutely painful, from implication of some of the small nerve filaments ; but, on the other hand, we see occasionally a fissure-like ulcer ex- tending over the anal vei-ge which is not so acutely painful. Accordingly, we find Gosselin dividing these ulcers into two distinct varieties, the tolerant and intolerant ; and Molliere suggesting the more suitable terms, tolerable and intolerable. Associated with painful fissui'e, there is always great spasm of the sphincter muscle : Boyer, indeed, considered that this spasm was antecedent to, and the cause of, the fissure. Yan Buren speaks of this spasm as affecting the muscle in part only, what he terms " fascicular spasm " ; * and he defines this term in a foot-note to be " the alternating coniraction and relaxation of certain of its fasciculi, and not of the whole muscle, as the expression spasm of the sphincter would imply." I have never, however, been able to observe this condition, as it has always ap- peared to me that the muscular contraction involved the whole circumference of the sphincter. Anl in any case the distinction appears to me to involve a frivolous and practically worthless refinement. The explanation of this condition of the muscle is best understood by a reference to the diagram (Fig. 22), taken from Hilton. The sensory nerve filament exposed by the ulcer receives impressions, which are conveyed to that part of the spinal cord from which the lumbar, the ilio- * Loc. cit., p. 221. J— 23 T30 The Rectum and Anus. [Chap. viii. lumbar, sciatic, and pudic nerves, etc., spring, and we find, as a consequence, symptoms referable to reflected influences alons: these trunks : hence, pains in the back, down the leg, and in the genito-urinarj organs are common ac- companiments of irri- table anal ulcer ; and in the same way, reflex irritation of the nerve supplying the external sphincter produces spasmodic contractions of that muscle. A familiar analogous ex- ample of this reflected spasm is to be found in the retention of urine which so frequently follows any of the or- dinary rectal operations. To summarise, there- fore, I may suggest the following sequence of events as tending to pro- duce the fully formed irritable ulcer. First : during the passage of a costive and large motion a rent in the mucous membrane is made; or an excoria- tion the result of syphilis, dirt, etc., exposes one of the delicate nervous twigs. As a result of the Fig. 22. — DiasTram of tbe Nervous l^elations of Irritable Ulcer of the Anus. (Hilton.) a. Ulcer on sphincter ani ; h, fllamrnts of two nerves are exiioseil on the ulcer, the one a nerve of sensation, tlic other of motion, both attached to the spinal cord, thu constituting an excito-motor apparatus; c, levaturani ; d, trausversus permu3i. Chap. viiT.] Symptoms of Fissure. 131 constant motion and distension, and by the lodgment of particles of fa?ces in the rent, continued irritation is set up, which, in turn, occasions sj)asm of the sphincter. The spasm once started, the irritation is increased, and so a vicious circle is established, and the result is that the ulcer is never allowed to heal. We may now approach the study of the symptoms of this disease with a more reasonable hope of our being able to comprehend their significance. The subjective phenomena of irritable anal ulcer present a train of symptoms which are eminently charac- teristic, so that from them alone the diagnosis can be made with almost absolute certainty. The pain is paroxysmal, and always associated with the act of defiecation. During the actual passage of the motion, however, it is not usually severe, but shortly afterwards it comes on with great intensity ; it is a dull, gnawing, and extremely distressing sensation, situated immediately within the anus, and not unfrequently associated with some of the reflected pains before alluded to. It lasts frequently for many hours, completely incapacitating the sufferer from following his occupation, and necessitating the recumbent position while it lasts. It then subsides or entii-ely disappears, to be, how- ever, reproduced in all its intensity when next the bowels move. The act of defecation is therefore post- poned as long as possible, with the result that when the evacuation does take ])lace the pain is greatly in- creased. As a result of the constant pain, the consti- pation, and the frequent resort to narcotics, constitu- tional symptoms of a severe type become developed ; the countenance becomes careworn and sallow, the appetite is bad, and there is considerable emaciation, a train of symptoms which, in many respects, re- sembles the cachexia of malicjnant disease. The fseces are passed in a narrow cylinder, or sometimes they are 132 The Rectum and Anus. [Chap. viii. flattened and tape-like, due to tlie incomplete relaxa- tion of the sphincter during defecation, and not unfrequently a streak of bloody matter is to be seen on them. Serremone * considers that a contracted state of the anus is frequently congenital, and the cause not the result of the fissure, the narrowed outlet being more liable to tears from over-stretching. Amongst the more distant sympathetic affections to which fissure may give rise, Curschmann t has noted the frequent co-existence of spermatorrhoea and rectal disease, and more particularly fissure. If, then, a patient comes to us complaining of severe pain, lasting for some time after defsecation, the presumption is strong that a fissure is present, no other rectal disease producing this characteristic dis- tress. The disease is more common in females, es- pecially those of neurotic tendency ; and although more frequently met with in young adults, no age appears to be exempt ; and it is not unfrequently met with amongst old people. Upon making an examination, the first thing that attracts our notice frequently is a small "sentinel" pile. On passing the linger round the anus, one part of the circumference is found to be tender, and any attem]it to introduce the finger gives a great deal of pain, and is violently resisted. Upon separating the anal folds, the lower termination of the fissure can generally be eeen, the base being red or grey, and the edges some- what indurated. Above the anal margin the fissure is wider, so that it presents a club- or racquet-shaped appearance ; but when the sphincter is fully dilated and a speculum introduced, the stretching of the lower part shows the whole as an elliptical ulcer. The position is in the vast majority of cases dorsal, or nearly so ; although usually solitary, sometimes we * " Inaugural Thesis.'' Strasburg, 1861. f Ziemssen's Cyclopaedia, vol. viii. p. 846. Chap. VIII.] Treatment of Fissure. 133 find them multiple. This is most frequently the case when they are of syphilitic origin. I have occasionally observed, where the symptoms are not very severe, instead of a definite ulcer, with loss of substance, only a line of congestion situated in one of the furrows at the anal marijin, and extending up above the lower edge of the sphincter. This I believe to be the unhealthy cicatrix of a tear, due to the passage of a hard motion : it gives rise to a good deal of irritation, but not the severe pain of the fully developed irritable ulcer, and responds more readily to a milder course of treatment. "When a fissure is fully exposed, and the point of a probe touched over the surface, it will be found that one point is acutely sensitive, while the rest of the surface is not -^qvj tender ; in this respect resembling closely the irritable ulcer of +he leg. Treatment.— In the more recent examples of this disease, and in those in which the origin is un- doubtedly syphilitic, a cure can be generally accom- plished by local applications ; but in those which have existed for several months or longer, these means will, in all probability, prove ineffectual, and operative interference is called for. There is not in the whole range of surgery any operation in which the surgecn can speak so positively as to the certainty of cure and freedom from risk as in the division of the sphincter for irritable ulcer. If the patient refuses to be operated on, or if tlie surgeon considers the case one suitable for the milder measures, he should prescribe a purgative of sufficient strength to ensure one soft and easy evacuation daily. Immediately after the evacuation, the anus should be well washed with soap and water, and, if possible, defsecation should take place at night, immediately before the patient goes to bed. For local treatment. — Touching the surface of the 134 ^^^^ Rectum and Anus. [Chap. viii ulcer with a fine point of nitrate of silver will be found to give considerable relief ; the layer of coagu- lated albumen, which is by this means formed on the surface, eii'ectually for a time protecting the exposed nerve from the irritation of the faices. With a similar object, strong nitric acid has been recom- mended ; but it is more painful, and not so efficient as, the nitrate of silver. Of late, a solution of chloral hydrate has been employed with good results as a local application. If, however, these means prove ineffectual, or if the ulcer is of long standing, with great spasm and hypertrophy of the sphincter, operation should be undertaken. Boyer first pointed out the fact that division of the sphincter was at once followed by a complete sub- sidence of the symptoms."^ He recommends that the incision should extend through the entire thickness of the sphincter. Indeed, he sometimes practised a double division, at ditlerent points, put in a large bougie, and plugged the rectum round this with charpie. Dupuytren further modified this operation by mak- ing the incision only through the superficial fibres of the muscle, and subsequent experience has abundantly proved that this more limited incision is amply suffi- cient. According to Curling, Copeland stated that he considered an incision through the mucous membrane alone sufficient, but, as Curling has pointed out, in the majority of instances the ulcer has already penetrated the mucous membrane, the fibres of the sphincter muscle being frequently visible in the floor of the ulcer. In these cases, of course, Copeland's sugges- tion is futile. The same may be said of the opera- tion of Dumarquay,t which consists in a submucous * Journal Complementaire du Dlctionnaire des Sciences Med.^ Nov., 1818. fArch. Gen. de Med., 1846. Chap. VIII.] Dilatation OF Sphincter. 135 division of the sphincter ; he passes a knife up be- tween the mucous membrane and muscle, and then divides the latter, much in the same way that the sub- cutaneous division of the tendo Achillis is effected. Both of these operations could only be applied to the condition which I have before described, in which there is rather a patch of highly congested mucous membrane than an ulcer with loss of substance, and in these cases no operation is generally necessary. Recamier, in 1829, recommended as a substitute for any cutting operation what he describes as '"'■ massage cadence," and he performed the operation as follows : One or two fingers were introduced into the rectum, and then, with the thumb outside, the sphincter was pinched up and pressed so as to over- come its resistance. This was frequently repeated, and in a regular methodical way, so that no portion of the circumference of the anus was allowed to escape. Although he states that he had considerable success with this plan of treatment, it appears to have fallen into disuse ; and later, Maisonneuve* proposed to effect dilatation in a more rapid and thorough manner b}^ introducing the fingers one by one, till finally his whole hand entered the rectum. When this was accomplished, he closed his hand, and then withdrew it forcibly. This, no doubt, effectually stretched the sjphincter, but as it was performed without anaesthesia, it must have been horribly painful. And although Maisonneuve subsequently modified his operation into a simple stretching of the anus with the two index fingers under chloroform, the method fell into disuse, and it is only comparatively recently that forcible dilatation of the anus has been practised on a large scale. Indeed, now it is used not alone for the cure of anal ulcer, but as a preliminary step to almost all rectal operations and explorations. This revival of * "Clinique Chirurgicale," tome ii. Paris, 1864. 136 The Rectum and Anus. [Chap. viii. the procedure was mainly due to the writings of Van Buren, who, in 1864, reported a number of cases in which this treatment had been successful,* and he, since, has insisted on the certainty with which a cure may be effected by this means. The way in which this operation acts is probably by producing a temporary paralysis, the result of hyper-distension. For this condition Yan Buren uses the term atony, from the obvious analogy there is between the loss of power in the sphincter when over-distended by the pressure of the fingers, and the inability of the bladder to expel its contents when re- tention of urine has passed certain limits. He further suggests that the stretching to which the sensory nerves are subjected so influences their function, that they temporarily cease to convey impressions, the result of irritation, to the exposed fibres ; in the same way that we find forcible stretching of the sciatic and sensory branches of the fifth nerve relieve neuralgia. This theory receives considerable support from the fact which we frequently observe, that the liist time the bowels move after hyper-distension there is complete immunity from the pain, which before was so severe. The best practice, then, is (if operation is decided upon) to stretch completely the sphincter. This is best done by introducing the two thumbs into the anus, and then separating them forcibly, first in the antero- posterior direction, and then laterally. This should be performed quite slowly, under an ancesthetic, and by degrees the muscle will be felt to yield ; the pressure should be well under control, to avoid rui)ture as a re- sidt of any sudden relaxation of the sphincter. After a few minutes it will be found that the muscle is quite flaccid, and has lost its tendency to contract. A * Transactions of the New York Academy of Medicine, vol. ii. p. 180. Chap. VIII.] Methods of Operating. 137 complete view of the lower end of the rectum and the limits of the ulcer can now be obtained ; and if the ulcer is deep, or the edges much indurated, it may be well to draw a blunt-pointed knife over the surface, and divide the superficial fibres of the sphincter. Where, from any cause, forcible dilatation is con- tra-indicated, as when anaesthetics are inadmissible, it is better to resort at once to the knife, and the opera- tion may be performed with or without a speculum : in the former case the left index finger is passed into the rectum, with a straight blunt-pointed bistoury, lying Hat against the pulp, by which means the edge is protected; when both are fully introduced, the edge of the knife is directed against the ulcer, and the necessary division effected. When a speculum is used the ulcer is brought well into view, and its base in- cised with a scalpel, as in the operation practised by Syme ; or a curved sharp-pointed bistoury may be entered at the margin of the anus, passed under the ulcer, and made to protrude into the slit of the specu- lum above the ulcer, the overlying structures being then divided from without inwards. This is the method recommended by Hilton, and is probably the most certain in its result. After any of these operations the patient should keep the recumbent position for a few days, and it is better to confine the bowels with opium, at any rate for the first forty-eight hours : but little local treat- ment is required, except to bathe the parts well with tepid water night and morning. In the great majority of cases healing progresses with great rapidity, but occasionally we see that after the wound has healed to a certain extent healthy action stops, and the ap- pearances of an anal ulcer are again produced. Should this occur, the best treatment is a tolerably free division of the sphincter by Hilton's method. 138 CHAPTER IX. NON-MALIGNANT STRICTURE OF THE RECTUM AND ANUS. Judged from a clinical standpoint, stricture of the rcctiiiii would include all those pathological changes which result in a more or less complete retardation of the passage of the fseces through this tube, but it will facilitate the consideration of the subject if at present we confine the term to those changes in the wall of the bowel and anal outlet which produce a narrowing of the lumen of the gut, reserving for future con- sideration those neoplastic growths which are character- ised by the clinical features of malignancy, and also those instances of obstruction due to the pressure of structures outside the rectum. Of the true strictures, the most important are the cicatricial stenoses, which, of course, necessarily pre-suppose the existence of loss of substance, the result of ulceration, or direct trauma- tism. What the exact nature of this preliminary destruction of tissue was, it may be quite impossible to determine. Even where we have to deal with an open ulcer the diagnosis is beset with difficulty ; and where, as in the present instance, we may have only to deal with "the cicatricial contraction subsequent to this process, it is obvious that the difficulty is much enhanced. Whether spasmodic stricture, due to a spastic contraction of the circular unstriped muscular fibres, ever is present, has been freely discussed by most of the authors on rectal surgery, and consideraVjle differences of opinion are to be found in their works on the subject, but the majority of recent writers Chap. IX.] Spasmodic Stricture. 139 refuse to admit muscular spasm as a cause of tem- porary stricture, much less of permanent stricture. Leiclitenstern,* in his admirable article on constric- tions, occlusions, and displacements of the intes- tines, says : " The existence of such an affection no longer calls for serious discussion." And Van Buren,t after an able criticism of the subject, expresses the opinion that " neither in imaginary nor in actual stricture of the rectum is muscular spasm an elemeut of any practical importance." On the other hand, Dr. J. S. Bristowej states that, "Not very un- frequently spasmodic contraction, with great liypei*- trophy of the muscular tissues, is met with as one of the troublesome sequelae of dysenteric ulceration of the rectum." Mr. Harrison Cripps, also, in his recent work,§ brings forward very strong evidence in favour of muscular spasm being an important factor in the aetiology of rectal stricture. That a permanent con- dition of spastic contraction exists, he does not consider to be possible ; but that long continued irritation, by exciting frequent intermittent spasm, may terminate in shortening of the muscular tibres, with increase of the connective tissue elements, he considers highly probable, and analogy furnishes us with numerous examples of similar changes in striped muscle, the result of long continued irritation. Of these, the most familiar is the condition of the knee joint, to which Mr. Barwell has applied the term " con- tracture," where, as a result of pathological changes in the articulation, spasm of the muscles is first pro- duced. And, finally, such a continued shortening of the hamstring muscles results, that the knee is permanently flexed, and the head of the tibia * Ziemssen's Cyclopaedia, vol. vii. p. 484. f American Journal of Med. Science, October, 1879. t "Obstruction of the Bowels;" Eeynolds' "Syst. of Medicine," vol. iii. p. 72. London, 1871. § "Diseases of Kectum and Anus," p. 205. London, 1884. I40 The Rectum and Anus. [Chap. ix. subluxated backwards. Many other examples could be quoted, if necessary. Quite recently I have seen a case in which aggravated talipes equinus resulted from a patch of lupus extending under the tendo Achillis, causing atroj)hic shortening of the muscles of the calf ; and we have frequent opportunities of witnessing the considerable contraction, with increase of tissue in the external sphincter ani, which will result from the long-continued irritation of a small painful fissure. It may be argued that all these are examples of contraction of voluntary muscular tibre, and that, consequently, no deductions can be with safety drawn from them, justifying the conclusion that like changes can take place in unstriped muscular fibre ; but we know that cesophagismus may last for a very long time from a small ulcer or excoriation of the oeso- phagus ; although it must be admitted that hitherto it has not been demonstrated that spasmodic stricture of this tube has occasioned permanent contraction, recognised after death. In the bladder, however, the presence of a calculus, or of ulceration without direct obstruction, will produce such an amount of thickening and contraction of the wall of that viscus, that after death it may be found impossible to dilate it to its normal proportions. Cripps does not rely upon analogy alone for supporting his argument, but brings forward the following instance of rectal ulceration with some tendency to stricture. He says : " I was puzzled about the case, for upon the first examination I found ulceration in the posterior part of the bowel, with an annular stricture situated two inches from the anus, which would barely admit the tip of the finger. The examination was extremely painful. Upon examining the same patient a few days later under an anaesthetic, the ulcei-ation was present as before, but, to my surprise, there was scarcely any stricture, for the finger would pass readily into the bowel, with only Chap. IX.] Spasmodic Stricture. 141 a sense of being slightly gripped at the spot which previously would not admit the finger-tip. I had this ])atient under observation some time, and soon learnt that by introducing the finger somewhat roughly into the bowel, the sense of stricture was immediately produced, but by keeping the finger gently in contact with the strictured part, a feeling of gradual giving way was experienced, so that the finger would lie comparatively easy in the narrow part, where upon any rough movement it could be felt to be palpably and immediately grasped." Two years afterwards Mr. Cripps saw this patient again ; and on examination, in tlie place of the yielding and comparatively soft stricture encountered previously, there now existed a firm, hard, totally unyielding fibrous contraction, narrowing the bowel to the smallest circumference. Since the publication of Mr. Cripps' views on this subject I have had an opportunity of seeing a case which, to my mind, strongly supports his ingenious theory of the causation of stricture. The case was one of fistula complicated with stricture. Upon makinc: an examination it was found that the fistula communicated with the bowel by a large ulcerated o})ening on the coccygeal aspect of the gut, and immediately above this ulcer, a tight annular stricture was to be felt, which barely admitted the tip of the finger ; it gave the idea of being quite above, and unconnected with the ulcer. What the original cause of the ulcer was in this case I am not prepared to say, as it possessed at the time it first came under my observation no very distinctive features, but viewed in the light of ]Mr. Cripps's theory, I am of opinion that the following sequence of events occurred : first, the ulcer became established, and by the irritation thus set up a frequent peristaltic action of the muscular coat of the rectum was induced, tending to expel the source of irritation, and that in time atrophic 142 The Rectum and Anus. [Chap, ix- sliorteiiing of the overtaxed circular fibres of the mnscuhir coat was produced : finally the ulcer by per- forating the rectum gave origin to a suppurative peri- proctitis, hence the fistula. In support of this view of this interesting case, I may allude to the fact, with which most surgeons are familiar, that a not uncommon symptom complained of by })atients suf- fering from rectal ulceration, is a forcing down and straining, as if there was something to be evacuated immediately after the bowel has been completely emptied, and at other times when it contains no faeces. This is undoubtedly due to the contractions of the tube above the source of irritation in their use- less attempts to expel it. In my opinion, the strongest support is lent to this theory (although this is not alluded to by Mr. Cripps) by the position of the internal opening of fistula when found in connection with stricture. Where a fistula forms in connection with a strictured urethra or other mucous tract, it is in nearly all instances found to open into the tube above the seat of stenosis, but in the rectum this is not invariably the case. In a large number of instances (probably the ma- jority) the internal openings of such fistulse are found below the stricture. That ulceration should occur leading to fistula in the dilated portion of gut above the narrowed part can be readily understood as being a direct result of the stricture ; but how are we to account for the occurrence of fistulse below % This lias been a puzzle to many surgeons ; and when read- ing Mr. Cri|ips's views on the pathology of stricture, it at once occurred to me that in it we had the true explanation of this fact, which may be thus briefly formulated : Ulcer of the rectum, by perforating, may produce a fistula, and at the same time may lead to a permanent contraction of the gut immediately above the seat of ulceration ; so that the only relation Chap. IX.] Syphilitic Stricture. 143 existing between the fistula and the stricture is the fact that they have a common origin in the ulcer. Granting, then, that some cases of stricture origi- nate in long-continued spasm, the result of irritation, there remains a large number in which cicatricial contraction is the sole cause ; and we may take as a type of this class those which originate in direct traumatism. As will be seen in the chapter on syphilis, chan- croids are of common occurrence at the anus, and are occasionally found in the rectum ; and the question, what share they take in the aetiology of stricture, has been warmly discussed. It is quite impossible to come to any accurate conclusion from published statistics as to the relative importance of the various venereal diseases in the aetiology of stricture. Some surgeons, as Gosselin* and Mason, f w^ould have us believe that it almost invariably results from chancroids ; while, on the other hand, we find other authorities, such as Allingham and most English authors, discountenancing the views held by Gosselin and Mason, and not recognising chan- croids at all as a cause of stricture. Again, it would appear that some surgeons, having it impressed upon their minds that the most common cause of stricture is syphilis, are too apt to accept a syphilitic history on insufficient, or even no definite, evidence of this disease. The published statements vary so much, according to the views of the surgeon describinsr them, that the only conclusion we can arrive at, from a study of them, is that in many instances the origin of the disease is rather a matter of conjec- ture than a scientifically ascertained fact ; but suffi- cient evidence is, I think, forthcoming to establish * " Des retrecissements Syphilitiques du Eectum," Arch. Gdn. de Med., tome iv. p. 667. tJ.m. Journ. of Med. Science, p. 22; 1873. 144 The Rectum and Anus. [Chap. ix. the fact that primary soft chancre, phagedsenic ulcera- tion, and the gummatous ulceration and cirrhotic changes of advanced constitutional syphilis, all have a share in the aetiology of stricture. It is quite im- possible, in the great majority of cases, to determine what the starting ])oint was, or even whether it was of a venereal nature at all, or due to some of the other numerous causes of stricture. Dysentery has been credited with being the cause of a considerable number of the examples of stricture which come under our notice, but we must remember that the symptoms of rectal ulcer, from what- ever cause arising, are in many respects similar to the milder cases of true dysentery. If every case in which there is a muco-purulent and sanious discharge is called dysentery, then, indeed, the setiological influence of this disease must be considered great ; but if the term is restricted to true diphtheritic dysentery, we must admit that the number of cases which can be traced to this disease is small indeed. In that exhaustive treatise, " The Medical and Surgical History of the AVar of the Rebellion," * Surgeon Woodward has entered very fully into this subject, and sums up the experience of the American army surgeons as follows : " No case of intestinal stenosis, resulting from the contraction of dysenteric ulcers, has been reported to the surgeon-general's office either during the war or since. The Army Medical Museum does not possess a single specimen, nor have I found in the American journals any case substantiated by post-mortem examination in which this condition is reported to have followed a flux con- tracted during the civil war." In view of the vast numbers of cases of diarrhoea and dysentery that oc- curred during the war, these facts would seem to * Part II. ; med. vol. p. 504. Chap. IX.] Dysenteric Stricture. 145 indicate that in America, at least, this complication is extremely infrequent. The observations of Rokitansky on stricture of the colon have been frequently alluded to by authors on this subject, but the only case of which he gives details was one which terminated fatally thirty years after the attack of dysentery;* so we may reasonably question whether the connection between the two is put beyond doubt. In this country at the present time diphtheritic dysentery is such a rare disease, and the cases which are met with are of such a mild character, that but little evidence can be brought forward upon the subject. In speaking of the stenoses of the intestine re- sulting from dysentery, Leichtenstern. says : " The deep lesions of the mucous membrane and submucosa in the diphtheritic form of epidemic or sporadic diarrhoea lead during the often prolonged process of recovery to marked stenoses not unfrequently at several points. Unaffected islands of mucous membrane often persist between the diphtheritic losses of substance which are made to project into the lumen of the canal in the form of knobs and folds by the contraction of the adjoining cicatrices. By the contraction of unilateral cicatrices the in- testine becomes bent. When the cicatrix is extensive, and on all sides, the intestine is drawn together in the direction of its longitudinal axis, and thus stiff, callous folds, bands, and sickle-shaped projections into the canal, lying one above the other, are produced. Con- strictions of this kind are often increased by tough polypoid, excrescences growing from the edges of the mucous membrane into the canal, and wliich some- times act like valves and increase the stenosis.'^ * "Ueber Stricttiren des Darmkanals, Oest. Jahrb." BJ. xviii. p. 37 ; 1839. K— 23 • 146 The Rectum and Anus. [Chap. ix. Tubercular ulceration is by some stated to be an occasional, though it must be admitted a rare, cause of stricture. Allingham states that he has met with cases of this kind, in which the diagnosis was confirmed by Sir James Paget ; * and Cri[)ps f gives one case as occurring in seventy cases of sti-icture at St. Bartholomew's Hospital ; but until we have the presence of tubercle bacillus demonstrated in case of ulceration with stricture, it can scarcely be posi- tively affirmed that stricture does actually result from tubercular disease. The fact that a considerable proportion of cases of rectal stricture eventually die of pulmonary phthisis would, however, tend to show that in all probability a larger number of cases have really com- menced in rectal tuberculosis than has hitherto been recognised . Where injuries have been inflicted on the rectum, especially those which are attended with considerable loss of substance, or where extensive sloughing or long- continued suppuration have supervened, stricture is liable to occur ; this is peculiarly the case where the entire thickness of the gut is destroyed throughout its entire circumference ; on the contrary, where the mucous membrane alone is destroyed, or where the whole thickness of the bowel is destroyed in |:)ar^ of its circumference only, stricture will be a less pro- bable result. But, on the other hand, in healthy individuals extensive wounds heal frequently without much contraction. This is notably the case in gun- shot wounds. Curling gives a case of stricture follow- ing a wound from an enema pipe ; and Van Buren| records the case of a man who had lacerated the rectum in his efforts to cfet rid of its contents: " He had been t5^ * " Diseases of the Rectum," p. 250. t " Diseases of the Rectum and Anus," p. 209. + Loc. cit. , p. 2G4. Chap. IX.] Traumatic Stricture. 147 left in Texas in charge of cattle during the Civil War, and, cut off from communication, he was compelled to subsist on milk without any vegetable food. As a consequence of the unirritating qualities of this food, and the absence of cathartic medicine, his lower bowel became distended with faeces, to get rid of which he was forced in his extremity to use sticks and such rude means as he could command, and in this manner he caused injuries which led to a bad stricture at the usual seat." Many other examples of stricture following acci- dental wounds could be adduced if necessary. As a result of operations for fistula, prolapse, and haemorr- hoids, occasional instances of stricture are observed. Where the old operation of widely excising a fistula was resorted to, this complication must have frequently supervened ; but where the modern opera- tion is adopted, there is but little risk of such an occur- rence, unless from a debilitated state of the system, or from tuberculosis, extensive ulceration and sup- puration complicate the case. Similarly in the re- moval of piles, unless the submucous tissue is much encroached upon, or too much of the skin at the anal border removed, there need be little fear of stricture supervening. Where the actual cautery has been very freely used, or where nitric acid, or other powerful escharotics, have been extensively applied in the treat- ment of rectal disease, stricture has been known to follow ; but where ordinary caution is used in these useful plans of treatment, but little danger arises. A considerable number of cases of stricture have been met with after parturition, and which are ap- parently due to that process ; in some, no doubt, the direct pressure of the foetal head, by causing sloughing or inflammatory changes in the rectal wall, is the direct exciting cause ; but probably in the majority of these cases the immediate cause is the contraction 148 The Rectum and Anus. fChap. ix. following a pelvic cellulitis, ensuing as a complica- tion of child-birth. In a case recorded by White- head,* the long-continued wearing of a vaginal pessary appeared to be the exciting cause ; and similar cases have been noticed by other obstetric surgeons. It will be seen from the foregoing that a very great variety of injuries may eventuate in stenosis of the lower bowel. From an analysis of 367 cases of non-malignant stricture which I have collected from various reliable sources, it would appear that 276 were females and 91 males, as nearly as jjossible a proportion of 3 to 1 ; whereas, it will be seen in the cha})ter on malignant disease that the male sex in this case is more com- monly attacked. To what can this greater frequency of non-malignant stricture in the female be due % Various explanations have been given ; but, to state the case broadly, the true explanation lies in the ana- tomical relationships of the lower bowel to the organs of generation in the female ; in consequence of which secondary inoculation of the rectum from venereal disease of the genitals is more a[)t to take place than in the other sex, and also in consequence of which various displacements and diseases of the uterus are l)OSsibly competent to jn'oduce injurious effects, which of course are negatived in the male ; the traumatisms common in child-birth, too, no doubt tend to swell the number of cases. In its pathological anatomy, stricture of the rectum must necessarily present numeiXDUs varieties of character, especially when we take into consideration the many diverse setiological sources to which 1 have traced its possible occurrence. It may in the first place present differences in situation, thus : Stric- ture may be situated at the anus, when it owes its origin to congenital narrowing ; to too free a reuioval * Avi. Journ. of Med. Science, July, 1872; p. 114. Chap. IX.] Extent of Stricture. 149 of external ))iles, or a liberal application of the cautery ; and to the cicatricial contraction following the healing of chancroids or other forms of ulceration. In by far the majority of cases, however, the locality ati'ected is the rectal pouch, the lower orifice of the stricture being within three inches of the anus. In rarer in- stances the position is higher up at the junction of the sigmoid flexure with the rectum, and a few cases have been recorded where a double stricture has been pre- sent, one at the upper portion of the rectum and the other in the pouch. The cause of these multiple stenoses is stated in most of the cases to have been dysentery. There is considerable variety to be found in the ex- tent of stricture, the amount of intestine involved in the stenosis varying greatly; in some the contraction is distributed uniformly around the entire circumference of the gut ; but only a very small portion of the length of the tube is implicated. This form constitutes the so-called annular stricture of the rectum, and pro- bably those cases which have arisen from the perma- nent contraction of the circular muscular fibres, as before alluded to, are of this nature. In such cases the intestine is sharply constricted, as if it had been included in a ligature, all the coats of the tube being contracted, and at the same time hypertrophied. In other instances we find that the contraction is due to puckering up, and protrusion into the lumen of the bowel, of one side more particularly of the intestinal tube : such cases are generally the result of cicatricial changes during the healing of an ulcer, and may be so sharply marked as to justify the term valvular stric- tures. We may recognise a third variety where a considerable length of the bowel is involved in the contraction, or where, by the increase in thickness of the rectal wall due to hypertrophic changes in the connective tissue elements, the lumen of the gut 150 The Rectum and Anus. [Chap. ix. becomes narrowed, sometimes for a distance of several inches. These constitute the so-called tubular strictures. Besides the coats of the rectum proper, the fascial structures of the pelvis may cause stenosis of the bowel by their contraction. Cripps "^ attributes to the levatores ani and their sheaths a considerable share in the aetiology of stricture. Speaking of the anterior fibres of these muscles, he says, "These fibres run from the inner surface of the pubis to the sides of the coccyx, crossing the rectum at an obtuse angle, about an inch and a half from the anus. Both the origin and insertion of these fibres being close to the middle line, when the muscles of opposite sides contract they act as constrictors of the rectum as it passes between them, and I believe that not a few cases of rectal stricture at this point are caused by the ])ermanent atrophic shortening of the fibrous element of this muscular tissue." That a permanent contraction of these fibres should constrict the rectum laterally is obvious, but could only do so at the sides, and the resulting stricture would therefore be slit-like, with the long axis in the antero- posterior direction. Mr. Cripps, however, does not bring forward any cases of this nature, and none such have ever come under my observation. In the cases which I have seen where the altered structure was confined to but a portion of the circumference, the anterior aspect of the rectum was that which was most implicated. This probably is to be explained by the very much closer fibrous attach- ments of this portion of the bowel to the vagina in the female, and the prostate and base of the bladder in the male, than are to be found in other parts of the circumference. It is but seldom that the surgeon has an * "Diseases of the Rectum and Anus," p. 201. Chap. IX. Pathology of Stricture. 151 opportunity of seeing the post-mortem appearances of B Fig. 23. — Non-Malignant Stricture of the Eectum.* A, Greatly thickened ■wall of tbe rectum ; b, termination of mncous membrane ; below this jioint the entire thickness of the mucous memlirane has been destroyed; c, bridles of cicatricial tissue ; D, complete rectal fistula. fibi-ous stricture of the rectum in its early stages. In- deed, the same may be said of the clinical phenomena, * Museum of Richmond Hosi^ital. 152 The Rectum and Anus. [Chap. ix. as it is only when some obstructive symptoms become developed that these patients usually seek medical aid. Of the more extensive stenoses, however, the post- mortem appearances have been noted frequently, as this disease, although called non-malignant stricture, is one which frequently terminates fatally. From a review of the jDublished reports of the morbid ana- tomy in such cases, it would appear that there is great thickening, as a rule, of all the coats of the bowel, the new tissue formed being extremely dense and hard (Fig. 23) ; hence the old term, " scirrho- contracted rectum," which was applied very loosely before the characters of fibrous, as contrasted with malignant, stricture became clearly differentiated. In microscopic section it will be seen that there is great hypertrophy of the connective tissue elements in all the coats ; more particularly is this to be noted in the muscular coats, the fibres of which are sepa- rated and compressed by new connective tissue for- mations ; and a considerable amount of hard adipose tissue is always also present. In a case recorded by M. Malassez,* he found that the stricture, at its narrowest part, consisted of a material in all respects identical with granulation tissue, i.e. embryonic con- nective tissue ; it was made up entirely of young elements, and broke down readily. In the lower l^ortion of the stricture, where it was oldest, bundles of newly-formed fibrous tissue were found, sur- rounded by embryonic cells, as in cicatrices, and fasci- culi of the muscular coat were isolated by these cells. According to Cripps,t the muscle fibres undergo marked atrophy, and in some instances disappear altogether, their place being occupied by a hyper- troj)hy of the fibrous trabecules, normally present in the muscular coats. * Cornil : "Lec^ons snr la Syphilis," p. 412. Paris, 1879. t " Diseases of the llectum and Anus," p. 202. Chap. IX.] Relation of Fistula to Stricture. 153 Both above and below the strictured point con- siderable alterations are to be observed in the in- testine. Below, we sometimes find polypoid excres- cences, occasionally of a considerable degree of density. The mucous membrane is, in the majority of cases, ulcerated, or replaced by cicatricial tissue. In other cases, however, the mucous membrane remains unaltered, and, when this is the case, it may be taken as evidence of the extrinsic origin of the stricture. The glandular structure of the lining membrane is atrophic, and the openings of fistulae and internal rectal sinuses are not unfrequently met with. These gross pathological changes so frequently met with, are, in my opinion, a very strong confirmation of the opinion held by Mr. Cripps, as to the aetiology of stricture from spasm, "which has already been dis- cussed. By any other theory they appear to be quite inexplicable. Of the changes which are to be observed in the bowel above the stricture^ generally the most obvious is dilatation, and this may be present to a marked degree. The mucous membrane will frequently be found to have disappeared in patches, as a result of ulceration, and at the seat of these ulcers the wall of the rectum may be so thinned that rupture has taken place. If this should be above the periton?eal re- fiexion, extravasation of fseces and acute peritonitis \\ ill be the result ; but if the perforation takes place into the areolar tissue of the pelvis, then stercoral abscess is the result. This abscess may open in various places, resulting either in a complete muco-cutaneous fistula, which will then present the characters de- scribed under the head of fistula of the superior pelvi- rectal space ; while at other times a fistula bimucosa will result, and of these the most common, in the female, is a communication between the rectum and vagina, the vaginal orifice being situated generally 154 The Rectum and Anus. [Chap. ix. high up, close to the attachment of the vagina to the cervix uteri. In the male the fistulous tract most frequently communicates with the bladder, causing then, in the majority of cases, extreme suftering, owing to the escape of faeces into the cavity of the bladder, a condition which is one of those most urgently demanding the performance of colotomy. In some rare cases, however, the bladder appears to be tolerant of its abnormal contents ; and in one case which came under my notice, and to which I have already made allusion in another connection, the first condition which attracted attention was a peculiar deposit in the urine, the patient making no complaint of pain about the bladder or rectum. Upon microscopical examination, however, of the deposit, some particles of striped muscular fibre were to be seen, which were evidently portions of undigested food which had escaped from the bowel, and a rectal examination revealed the presence of a strictured rectum. Although the greater number of cases of recto- vesical fistula are to be found in the male subject, the female is not exempt, as will be seen by a reference to page 100. One of the most remarkable instances of fistula bi- mucosa is that recorded by Quain"**" as having been found at the post-mortem examination of Talma, the eminent tragedian. The pelvis was filled with an enormous sac, formed by the upper part of the rectum largely dilated. When the sac was raised a circular narrowing of the gut was discovered, situated at a distance of six inches from the anus ; this was proved upon closer examination to be wholly imper- vious. It was, in fact, a solid cord, but on the surface irregular, and having the appearance of a purse drawn tightly, and puckered with the strings tied around it. * " Diseases of Rectum," p. 190. London, 1854. Chap. X.] Symptoms of Stricture. 155 The great dilatation of the bowel at its lower end dipped down below the level of the stricture in the form of a dependent sac, in which was an opening about an inch in diameter, from which fluid had been diffused into the abdominal cavity. The rectum below the stricture was no more than the size of a child's intestine, and upon it, close to the stricture, was an ulcerated surface, with a narrow opening, to which the edges of the aperture above the stricture had been adherent. A new communication, but an imperfect one, had thus been established between the two parts of the gut, severed one from the other by the stricture. But the connection had given way, doubtless in conse- quence of the violence of the expulsive efforts, and thus the contents of the bowel had escaped a short time before death. In this interesting case an effort had evidently been made by nature to overcome the obstruction. In a case recorded by Wagstaffe,* a somewhat similar condition was observed. CHAPTER X. SYMPTOMS OP NON-MALIGNANT STRICTURE OF THE RECTUM. Symptoms of non-malignant stricture are generally in the earlier stages extremely vague. The most fre- quent are attacks of diarrhoea, alternating with con- stipation, and where these have persisted for some time the suspicions of the surgeon shoidd be aroused, and a rectal examination instituted. The diarrhoea is generally slight, and is more noticeable in the morn- ing : it is frequently associated with the discharge of * Trans. Path. Soc. London, vol. xx. p. 176. 156 The Rectum and Anus. [Chap. x. small quantities of bloody mucus, and brown matter resembling coffee-grounds. This diarrhoea is due to catarrhal inflammation, caused by the irritation of retained faeces above the strictured point, the mucous discharge softening down the fsecal accumulation, and so allowing it to pass the stricture. When the bowel has been evacuated, a period of constipation ensues, to be again followed by the fsecal accumulation and catarrhal discharge. As the case progresses the intervals of constipation become fewer, and the local irritation and discharge increase, unless, indeed, the case goes on to complete obstruction, which is not a very frequent occurrence, the patient generally be- coming exhausted before this takes place. Associated with the diarrhoea there is a good deal of tenesmus in most instances ; and pain, which is generally referred to a point above the symphysis pubis, or the middle of the sacrum, is common. Pain after food, and flatulence, are not so frequently complained of as when the con- striction is situated higher up in the intestinal tube ; and the same may be said of vomiting. This last is only to be observed as a very late symptom, and after long-continued obstruction, when it may occasionally become stercoraceous. The symptoms, although at first mainly local, after a variable time produce a general impression on the system. The exhausting muco-purulent dis- charge, which is commonly derived from the altered surface of the dilated bowel above the stricture, more particularly when there is a large amount of ulceration, may produce hectic fever, or amyloid degeneration of internal organs, with which we are familiar as a result of protracted suppuration in other parts of the body ; moreover, the possible occurrence of septic poisoning is always to be remembered. On the whole, the disease is of an essentially chronic character, and it may take many years to run its course. The Chap. X.] Tape-like Fmces. 157 most distressing symptom which a patient with well- developed stricture suffers from, is the constant desire to go to stool, attended with colicky pains, but the attempt to defaecate is frequently without result. This is caused by the accumulation of faeces above the strictured part, and is only temporarily relieved by the spontaneous diarrhoea referred to, or by the action of purgatives. As the constriction becomes narrower meteorism becomes developed ; the greatly dilated and full colon may be felt through the abdominal wall ; the feeling of doughy softness conveyed by ftecal ac- cumulations on palpation of the abdomen may be made out ; or the outline of the large intestine may be indicated by dulness on percussion. Owing to the increased efforts to obtain an evacuation the suffering becomes intensified, till finally death results from exhaustion, unless it is hastened by some of the com- plications, such as peritonitis from perforation, or the supervention of sudden and complete obstruction. Much has been written on the shape of the stools as indicating stricture, but the idea taught in most text-books, that narrow, or tape-like faeces, are indica- tions of the presence of a stricture, requires qualifica- tion. Such an appearance is often produced where no stricture is present, and, on the other hand, a well- formed motion may be passed by a person suffering from marked stenosis. In the case of stricture of the urethra, the twisted or forked stream of urine is not formed by the shape of the stricture, but by the collapsed meatus urinarius ; the flow of urine not being sufficient to dilate fully this orifice. So also in the rectum, the margin of the anus gives the final form to the voided fseces. Where there is a contracted state of the anus, due to fissure or other cause, the fseces are passed in the form of narrow cylinders, or they may be flattened laterally. Where a stricture is situated at some distance from the anus, it is quite possible 158 The Rectum and Anus. [Chap. x. that the mass may be re-formed in that portion of the rectum below the stricture, and so be passed of normal calibre. More frequently, however, the faeces are found in little masses of a spherical or ovoid shape, reminding one of the appearance of sheep or rabbit droppings, and this is to be explained by the relaxed condition of the termination of the bowel and sphincters being unable to compress the mass sufficiently to render it again of uniform con- sistence. There can be no doubt, however, that in some cases the faecal mass is passed in narrow cylinders as a result of stricture, and Van Buren has given the true explanation of this condition.* When a stric- ture is situated low down in the rectum, it is, during the violent efforts accompanying defaecation, extruded through the anus far enough to give its final impress to solid matter passed under this extreme pressure ; and Kelseyt records an interesting case in which he was able to observe the mechanism of an occurrence of this kind, which I give in his own words : " The woman suffered from a stricture one inch above the anus, which was of sufficient calibre to admit the ends of two fingers easily. She had never noticed any defor- mity of the faeces. While under the influence of ether, and after the sphincter had been very thoroughly di- lated, an O'Beirne's tube was passed through the rectum, which was empty, into the sigmoid flexure, which was full. After resting there a few moments it provoked a movement of the bowels. The stricture was instantly crowded down into view, appearing at the anus, and taking the place of the anus, which, owing to the complete dilatation, ceased to have any action, and was merely a patulous ring. Through the stricture there came a long tape-like evacuation, the mould which gave it its peculiar form being the stricture * " Diseases of the Rectum and Anus," p. 279. f Ibid., p. 189. Chap. X.J Complete Obstruction. 159 pressed to the surface of the perinseum, and greatly- lessened in calibre by folds of mucous membrane, which were crowded into it from above. While remarking to those present on the peculiar mechanism of its production, the straining ceased, the stricture rose, the mucous membrane was relaxed, and a passage of natural formation was the result. This alternation was repeated several times. At each effort the stricture was forced down to the anus, the membrane above it was crowded into it, so as greatly to lessen its calibre, and a flat passage was the result. When the efibrt was less violent there was still a passage, but the stricture having risen to its place, and not being so tightly filled with the mucous membrane, the passage was natural. The lesson to my own mind Avas this : that a stricture of large calibre might, as a result of straining, cause a passage of small size, and that, to get this peculiar shape, the sti-icture must be crowded down so as actually to take the 2^1ace of the external sphincter, and be the last contracted orifice through which the soft substance is exj)ressed." A very grave, but rather infrequent termina- tion to stricture is complete obstnietion. After a stricture has continued for a long time, possibly many years, without aff"ecting the general health to any great extent, the bowels being relieved suflS.ciently by the process before alluded to, the symptoms of complete obstruction may supervene, and it is a re- markable fact that the onset of this condition is not micommonly somewhat sudden : this abrupt compli- cation may be due to one of two causes, either the impaction of a foreign body, or even an unusually hard mass of faeces in the narrowed gut ; or, as a result of an inflammatory oedema of the mucosa and submucosa due to the chemical irritation of retained and decomposing faeces. i6o The Rectum and Anus. [Chap. x. Of the former variety the following is a well- marked instance : I was called, in the year 1876, to see a man, aged thirty years, whom I found suffering from well-marked symptoms of obstruction of the rectum ; the belly was tumid and tender, and he had vomiting, not, however, stercoraceous. There were frequent abortive attempts to defsecate, and I was informed that he had obtained no relief from the bowels for the past ten days. He stated that he had small-pox four years previously, which was followed by a discharge of matter from the rectum, and that since then he had suffered from alternating attacks of diarrhoea and constipation. Upon making a rectal examination, a stricture was at once detected within one and a half inches from tlie margin of the anus; projecting through the orifice of the stricture, which was very narrow, a hard substance could be felt, and with considerable difficulty I removed it with a forceps. It proved to be a plum stone. He assured me that it was over a year since he had swallowed it, as he had a distinct recollection of the fact of having done so. I treated the case with a limited incision and dilatation with bougies, and I have recently heard that the patient remains in tolerably good heal til, although he still requires the occasional introduction of a bougie. It is a very remarkable fact, Ijow frequently fruit stones have been found impacted in intestinal strictures, or collected in numbers in the pouch above tliem. A very interesting case of this kind is re- ported by Dr. Wickham Legg : * A woman, aged 28, had frequently before death vomited and voided by the rectum cherry stones, and during life a tumour composed of them could be felt through the parietes, giving to tlie hand a very peculiar sensation as they were rubbed together. At the post-mortem * Tatli. Soc. Trans., vol. xxi. p. 171. Ch.'. p. X . ] Per i toni tis. i 6 1 examination the ileo-csccal valve was found stric- tured, and in the intestine above there was nearly an imperial jnnt of fruit stones. A number of similar instances are to be found recorded. In some cases, possibly, the mechanical irritation set up by the accumulation of stones may be looked upon as the cause not the effect of the stricture. Such, however, was evidently not the case in the instance I have brought forward. Besides cherry stones, many other hai^ and insoluble substances, as pieces of bone, apple core, etc., have been found lodged in a stricture, and so constituting the determining cause of complete obstruction. Inflammatory swelling, as a cause of complete obstruction, is more often met with in cases of malio-- nant disease of the rectum than in cases of the ordinary stricture ; but even in the latter it is sometimes ob- servable, more particularly after the injudicious use of bougies. One of the most serious complications that may arise during the course of stricture of the rectum is peritoiiitiis. In this case we find inflammation of the peritonaeum occurring either as an acute and general manifestation, the result of rupture of the intestine and extravasation of fseces, or as a more chronic and limited disease ; the former not being an infrequent termination to years of sufl"ering from rectal stricture. It may be due to spontaneous rupture, during a violent effort at defaecation, of the attenuated and ulcerated wall of the bowel in the neighbourhood of the stricture ] or, at other times, we have to ad rait that the treatment adopted by the surgeon must be held to be directly responsible for the fatal per- foration. There is, unfortunately, no lack of cases in which the point of a bougie, an enema pijie, or even i\\Q index finger of the surgeon, has penetrated through a diseased intestinal w^all, and permitted L— 23 i62 The Rectum and Anus. [Chap.x. the extravasation of fseces to take place : this accident has occurred to the most accomplished surgeons, who, with a candour highly to be commended, have recorded their misfortunes, and so enabled us to learn a lesson that should ever be present with us when dealing with cases of this kind, to employ the utmost gentleness when examining or conducting the treat- ment of constriction of the rectum. When only the tip of the index finger can be insinuated into the aperture of a stricture, the temptation to force it through, so as to determine the length of the stricture, or to effect dilatation of it, is indeed strong, but it ruust be absolutely resisted, unless we wish to swell the already too long list of mishaps which have occurred. The old saying, " meddlesome surgery is bad," applies with more force to the disease under consideration, probably, than to any other surgical affection. diroiiic and limited peritonitis. — As a result of the inflammation and ulceration of the rectum associated with stricture, the pelvic peritonaeum may become involved, and bands of adhesion be found in consequence, without any perforation having taken place. It is not at all infrequent to find this con- dition on post-mortem examination of old-standing cases of rectal stenosis, thickening of the peritonaeum, limited effusion, and bands of lymph being the most common appearances met with. In some cases the adhesions produce by their contraction an increased narrowing of the lumen of the bowel, the most common seat of which is at the junction of the sigmoid flexure and the rectum, and so that the obstruction thus formed may be considerable. The symptoms of this complica- tion are, however, scarcely recognisable during the life of the patient, so that the treatment of it comes scarcely within the range of practical surgery. Where, however, it is suspected, it furnishes a strong additional argument for the relief of the irritation by colotomy. Chap. X.J Stricture: Appearance of the Anus. 163 Abscess and fistula complicate the case in a very large proportion of cases of rectal stricture, and they may be found in various situations. When oc- curring in the ischio-rectal fossa, the communication between the bowel and the suppurating cavity is generally to be found below the seat of stricture, and when so placed it is, as I have before endeavoured to show, a strong evidence that it has originated in an ulcer, which was also the exciting cause of the stricture ; although it is quite possible that these ischio-rectal abscesses may occasionally form as the result of irritation, without any direct communication being established with the gut, in the same way that we find extra-articular abscesses occurring in the neighbourhood of a diseased joint. "Where, however, they form as the result of perforation of the pouch above the stricture, they are then usually situated above the levator ani and recto-vesical fascia, in the superior pelvi-rectal space. From this position they may penetrate in various directions, as into the vagina or bladder, or into the peritonEeum ; or the first place at which they become superficial may be in the iliac region, as happened in one case under my care. If they come down to the perinseum, their most usual position is posterior to the anus, as the pelvic septum more readily allows the passage of matter there "than at any other part of the circumference. These fistulae have, however, been already considered in connection with the pathological anatomy of this disease, and their symptoms, when fully formed, are sufficiently obvious, so that the subject need not be further discussed. Upon making an examination of a person affected with rectal stricture, it will generally be found that the anus is surrounded by hypertrophied flaps of skin, which no doubt owe their origin to the continued macer- ation and irritation of the parts by the acrid discharge. 164 The Rectum and Anus. [Chap. x. Mr. Colles* considered these appearances as almost pathognoiiionic of stricture. He says : " We often observe at the orifice of the anus the following ap- pearance, which is indeed almost always present when the disease is situated near to the external sphincter ; namely, at each side of the anus, a small projec- tion, which, on its external surface, appears as a mere elongation and tliickening of the skin, but internally j^tresents a moist surface not exactly like the lining membrane of the gut ; nor yet can we say that it is ulcerated. These two projections lie close together below and divaricate above, presenting a resemblance to the mouth of an ewer. Whenever this external appearance exists, I feel almost certain of finding a stricture of the rectum before the finger is ^^ushed as far as the second joint into the gut. In some cases, however, this external mark has not been present." In my experience, however, this condition has not been often present, and I have seen a similar appear- ance when no stricture could be detected. HsBiiiorrlioicSs are of common occurrence as a complication, and this is not to be wondered at when we consider the pressure that must be exercised on the branches of the htemorrhoidal veins in passing through a dense stricture. It is also common to observe the openings of fistulas, and these are frequently multiple ; but of all conditions of the anus great relaxation is the most noticeable, the finger readily passing through without any difficulty. This relaxed condition of the anus permits the involuntary escape of sanious muco-pus, which con- stitutes one of the most unpleasant subjective phenomena of stricture ; and it also sometimes permits the extrusion of the stenosed portion of the bowel which has been already alluded to. True prolapse * Colics' works, by McDonnell, p. 370. New Sydenham Society, 1881. Chap. X.] Stricture : Digital Examination, 165 of the rectum is, however, an extremely rare complication of rectal stricture. Upon introducing the finger into the rectum the stricture, if situated in its usual jiosition in the rectal pouch, will be at once felt, if it has encroached much upon the lumen of the bowel ; but if the amount of contraction is slight, so that two or more fingers can be passed i^eadily into it, it may be more dilticult of detection : in these cases a thickening and hardness, or ulceration of, or outgrowths from, the mucous membrane will excite the suspicions of the surgeon. In this preliminary examination the whole under surface of the stricture should be carefully felt, relative involvement of the various portions of the circumference of the gut made out, and the existence and extent of ulceration or outgrowths determined. Where the entire circumference of the gut is tolerably uniformly contracted, and where the amount of induration of the tissues is considerable, the sensation conveyed to the finger resembles closely tlie feel of the os uteri when the finger is in the vagina : this likeness is occasionally further increased by the fact that the finger can be passed round the stricture, which appears to project down into the bowel, and is due to a very limited intussusception following the violent expulsive efforts. With the finger the lower aspect of the stricture can be completely examined ; but, unless the opening is sufficiently large to admit the passage of the finger through the stricture easily, the surgeon is unable to form an opinion of the length of bowel involved. For this purpose bulb-ended bougies, as recommended by Bushe, are necessary. They are best made of ivory or ebonite bulbs fastened on to a whalebone or readily flexible metal rods; they should be of various sizes (Fig. 4, page 13). Having selected the largest that will easily pass through the stricture, the instrument should be introduced throuijh the contraction until the end is felt 1 66 The Rectum and Anus. [Chap.x. to be free in the bowel above. By gradually withdraw- ing it now the surgeon will be able to recognise the moment it enters the superior opening of the stricture, and thus an estimate of the length of the stenosis can be arrived at. Where the stricture is situated beyond the reach of the finger great difficulties will be ex- perienced in the diagnosis ; indeed, it may be safely asserted that stricture of the upper portion of the rectum has been supposed to exist much more fre- quently than its existence has been demonstrated, even when the greatest care has been taken in the exami- nation by accomplished surgeons. The diagnosis and treatment of non-existing strictures has been a favourite field of practice for charlatans ; persons suffer- ing from ordinary constipation being easily led to believe that their symptoms are due to mechanical obstruction. Kelsey* gives an amusing case of this kind. " A lady went to consult a rectologist, for some reason or other which is not stated, and a sound was introduced into her anus. Her husband, learning this, rushed to the house of the scoundrel in a violent rage, and armed ■with a whip. Half an hour later he returned, disconso- late. He had found out that, like his wife, he had a stricture of the i-ectum, and, like her, he had submitted to catheterisation ! " If the patient has symptoms which would lead us to suspect the presence of a stricture high up, such as diarrhoea alternating with constipation and paroxysmal colicky pain, great straining and pain while at stool, and the discharge of muco-pus or altered blood from the anus, and yet if under such circumstances no indication can be obtained by ordinary digital examination, the patient should be placed under ether, and an examina- tion conducted in the lithotomy position. First of all the anus should be well stretched, and the bi-manual method adopted, with one hand pressing deeply down * Loc. ciL, p. 182. Chap. X.J STRfCTURE HIGH UP. 167 into the pelvis through the aLdominal joarietes, and tlie index finger of the other hand passed as high as possible up the rectum. By this means we may be enabled to make the diagnosis ; failing this, an enema should be administered, and if this is at once returned without our being able to distend the colon, it is strong evidence of obstruction. A careful examination with a bougie should now be instituted, bat the information obtained by its use is open to several fallacies. In the first place, the point may impinge against the promontory of the sacrum, and so its further progress may be arrested ; or, it may be caught in some of the folds of mucous membrane. This may generally be obviated by having the bougie hollow and perforated at the point like an O'Beirne's long tube, and made so that an enema a])paratus can be attached. When, now, the point becomes arrested, some warm water can be thrown up, and so the loose folds of mucous membrane lifted off the end of the instrument. Another source of error is the bending of the bougie upon itself, so that a considerable length may be passed although a mechanical obstruction exists. Whenever the progress of the instrument becomes arrested, the direction of the end of the bougie should be altered and a fresh attempt made. The utmost gentleness should be observed, the surgeon always bearing in mind that the coats of the bowel may easily be perforated. The only un- equivocal indication that the instrument is really in a stricture is the feeling that it is grasped, a sensation with which we are quite familiar in the catheterisa- tion of urethral stricture. Of course it is obvious, how- ever, thai before we can attach any importance to this symptom in rectal stricture, the sphincter ani must have been temporarily rendered pai-alytic by hyper- distension, unless indeed it is so relaxed as a result of the disease as to render this preliminary step un- necessary. The only means left at our disposal for the i68 The Rectum and Anus. [Chap. x. further examination of the ujiper portions of the rectum is by introduction of the whole hand into the rectal pouch, and passing one finger up into the sigmoid flexure, a procedure the details and dangers of which have been elsewhere (page 14) fully entered into ; but it can be but seldom that the requirements for diagnosis necessitate the undertaking of this opera- tion, which has been shown to be attended with a considerable amount of risk. The importance of determining the position of a stricture, situated high up, when the symptoms of obstructioii are urgent, is manifestly of the first importance, as the treatment to be adopted will in a great measure depend upon exact diagnosis ; lumbar colotomy is only suitable to those cases which are situated so low down that they can be easily explored with the finger, and in which linear proctotomy is inadvisable ; or to those cases of stricture higher up in which the position has been accurately localised. Where doubt exists, abdominal section is probably to be preferred, as will be shown in another ])lace. The only points of diagnosis which remain for our consideration are the differentiation of benio-n stricture from malignant neoplasms on the one hand, and extra-rectal disease producing pressure upon the other. It is generally easy to distinguish the ob- struction due to the pressure of tumours, or by bands of adhesion from non-malignant stricture, the sensation conveyed by the finger readily estimating whether the obstruction is situated in the rectal wall or not ; but the diagnosis between malignant and non- malignant disease, although in typical instances easy, is sometimes attended with very considerable diffi- culty, so that it may be impossible to arrive at a definite conclusion until the case has been kept under observation for some time, and its rate of progress carefully noted. Chap. X.] Differ entia l Di a gnosis 169 The following taLle illustrates the more im- portant points of difference : NOX-MALIGXANT STRICTUKE. Generally a disease of adult life. Essentially chronic, and not implicating the system for a long" time. The orifice of the stricture feels as a hard ridge in the tissues of the howel. Poly- poid growths, if present, are felt to be attached to the mucous membrane. Ulceration of mucous mem- brane may be present, but without any great indura- tion of the edges. The entire circumference of the bowel constricted unless the stricture is valvular. Pain thi'oughout the whole course, in direct proportion to the faecal obstruction, and only complained of dur- ing the efforts at defse ca- tion. Glands not involved. ]\Ialigxaxt Obstructiox. Generally a disease of old age. Progress comparatively rapid and general cachexia soon produced. Masses of new growth are to bo felt either as flat plates between the mucous mem- brane and muscular tunic, or as distinct tumours en- croaching on the lumen of the bowel. Ulceration, when present, is evidently the result of the breaking down of the neo- plasm, and the edges are much thickened and infil- trated. One portion of the circumfer- ence generally more ob- viously involved. In the advanced stages pain is frequently referred to the sensory distribution of some of the branches of the sacral plexus, due to direct impli- cation of their trunks. The sacral lymphatic glands can sometimes be felt through the rectum to be enlarged and hard. lyo CHAPTER XI. TREATMENT OF NON-MALIGNANT STRICTURE OF RECTUM. The various plans of treatment which have from time to time been advocated for rectal stenosis may be conveniently classed under the following heads : (1) Dietetic and medicinal; (2) dilatation, (a) gradual, (h) sudden; (3) incision, (a) internal, (6) external; (4) excision ; (5) colotomy. By attention to the diet a considerable amount may be done in the way of making life more endurable, and it is obvious, only such food should be allowed as will leave a small fsecal residue. First in importance stands milk, which should form a large portion of the patient's food ; and strong soup, eggs, and meat, in moderation, also may be allowed. As most vegetables leave a considerable residue, they should be but spar- ingly used, and such articles of food as oatmeal, brown bread, etc., should not be permitted. One objection to giving too unstimulating a dietary is that the faeces which are formed produce such little excitation of peristalsis, that purgative medicines will, at the same time, be required in considerable quantity. As to the medicinal treatment of strictui'e, it is obvious from the very nature of the case, that the use of purgative medicines must constitute an im]iortant element of our practice ; and that some discrimination must be exf)erienced in our employment of such agents. Of all aperients, the sulphates of soda and magnesia, as combined in some of the many mineral Avaters in the market, will be found to answer best. A sufficient dose should be taken early in the morning to ensure a Chap. XI.] Use of Purgatives. 171 free evacuation. Where the calls to stool are frequent, and where considerable straining exists, it is generally an indication of retention of fseces above the stricture, which are best dislodged by a copious enema of soap and water. The compound liquorice powder will often prove an efficient aperient ; or, where patients can take it without nausea, castor oil. Frequently, however, it will be found well to change the medicine employed, care being taken not to use any of the more irjitating drugs, such as aloes, colocynth, etc., as they only tend to increase the tenesmus. Belladonna is highly spoken of by many authorities, and in some cases certainly tends to relieve spasm ; it is best given in the form of a suppository containing a grain of the extract. This may be with advantage combined with five grains of iodoform, especially if there is an open ulcer present. Where the bowel is very irritable, marked benefit will result from the use of small starch and opium enemas, and where the catarrhal discharge is considerable, injections containing liquor of bismuth, or tincture of rhatany, will probably diminish the secretion. Where the disease is of unquestionable syphilitic origin, mercury or iodide of potassium may be tried, but these remedies can only prove useful in those cases of recent origin where syphilitic deposit or ulceration is progressing. It is manifestly useless to expect that where atrophic shortening of the mus- cular fibres, with cicatricial or cirrhotic contractions, have taken place, that any good can possibly result. Indeed, it is probable that under these circumstances a positive injury will be infiicted by so-called specific treatment, further lowering the already debilitated constitution. Medicinal treatment, however, can only at best do little more than relieve symptoms ; and for any permanent benefit we must look to some of the mechanical or surgical operative methods indicated 172 The Rectum and Anus. [Chap. xi. in the above enumeration. Of these the first is dila- tation. Where the obstruction is considerable, as is ahnost always the case when the patient comes under observation, an attempt may be made to dilate by means of the bougie ; but I would have it to be borne in mind that this treatment is only suitable to those cases which are unattended with open ulcera- tion, as where an ulcer exists, rupture through its floor is -^ery likely to follow, so that in this case we should try and heal the ulcer by dietetic and local measures, failing which, I believe the treatment by incision to be decidedly preferable to any attempt at dilatation. In those cases, however, in which there is no open sore, the careful use of bougies is of the greatest service, and although it cannot be said with certainty that a permanent cure can be effected (by Avhich is understood that no further treatment will be rendered necessary) still a considerable amount of good can be done, and the space necessary for a free motion can be maintained by the occasional passage of a bougie. When a stricture of the urethra has been relieved by gradual dilatation, no surgeon will admit that the case has been completely cured, but by subsequent occasional catheterisation the stricture can be prevented from contracting again to such a degree as to occasion serious symptoms. The same is true of a stricture of the rectum. Much will depend on the form of bougie used. The so-called gum elastic instruments, which are made of platted cord covered with varnish, and which have been in general use for many years, are unsuitable, as they are too rigid, and they are made unnecessarily long. Kelsey recommends the use of soft rubber bougies similar to those occasionally used for tlie urethra, and these answer the purpose admirably, as it is almost impossible that any injury could be inflicted by their use : the only drawback to them is. Chap. XI.] H\ 'DRA ULIC DiLA TA TION. I 7 3 that they are so soft that it may be found difficult to pass them into the orifice of the stricture. For general purposes those bougies made with an olive-shaped bulb, mounted on a flexible whalebone stem, answer all })urposes admirably. In some cases it may be found advisable to leave a bougie in the stricture for some hours, thus adopting the principle of vital dilata- tion so authoritatively recommended in the treatment of urethral stricture. For this purpose the instru- ment should be short, about four or five inches only in length, and with a stiing attached, so that it can be passed entirely into the rectum, the string hanging out at the anus, and serving to with- draw the bougie when required ; as where the anus is kept dilated for any considerable time great annoyance is given to the patient, and violent expulsive efforts induced. Cripps speaks favourably of conical bougies, by means of which, if gentle pressure is ke-pt up, a gradual and continuous dilating effect is maintained. A considerable amount of ingenuity has heen ex- pended in the construction of elastic hollow bougies, which can be inflated with air, or distended with w^ater after they have been introduced into the stricture. This is a plan of treatment, however, which requires extreme caution, as the surgeon is unable to satisfactorily estimate the amount of force wdiich he is using, especially if water is injected instead of air. In some cases, where there is a great deal of induration and perirectal thickening, this method may answer tolerably well. None of the special instru- ments which have been invented answer the purpose better than the "Barnes' bags" used by obstetricians for the purpose of dilating the os uteri, the fiddle- shape rendering them less likely to slip out of the vStricture when once they have been introduced, and they can be introduced with the greatest facility while empty. I have treated some cases in this way 174 The Rectum and Anus. [Chap. xi. with decidedly good results. Sudden dilatation by means of Todd's dilator, or other similar instruments, must be looked upon as a very liazardous proceeding, and one which cannot be recommended for any form of stricture. If it be found that dilatation is impossible to any useful extent, or if, as before mentioned, the presence of ulceration render the attempt at dilata- tion inadvisable, recourse may be had to division of the contracted tissue, by either internal or external incision, by which is understood the simple superficial incision of the stricture alone ; or the complete division of the rectal wall from a point above the stenosis through the contracted tissues, and also through the anus, external sphincter, and skin. IiiteriiaB incision is of but limited utility, and is not by any means devoid of danger. It is only applic- able to those cases of very rigid stenosis in which there is a great deposit of indurated tissue, and then only as an aid to gradual dilatation by bougies. For this pur- pose a Cooper's hernia knife, or blunt-pointed bistoury, should be used, and several superficial incisions made round the circumference of the stricture. Gi^eat care should be taken that the division is not carried through the wall of the gut, else fsecal extravasation and stercoral abscess will be the inevitable result. External incision, or linear proctotomy, is un- doubtedly the best operation for those cases attended with ulceration of the mucous membrane below the stricture ; and, indeed, will be generally found to be the best procedure in all those cases where gradual dilatation is ineffectual, or where the continued use of the bougie sets up such an amount of constitutional and local irritation that it is inexpedient to continue the treatment. As it has frequently happened that fistulse in connection with stricture have been operated upon Chap. XI.] Linear Proctotomy, 175 without the stricture being diagnosed, and as the internal openings of these fistulae are occasionally situated above the stricture, it is evident that com- plete division of the contraction has been thus some- times unintentionally performed ; but the first de- liberate attem]3t to cure stricture in this way appears to have been made by Mr. Humphry, of Cambridge,* who proposed this method in consequence of the "good results following longitudinal incisions in urethral stricture." And although he performed the operation on two occasions with excellent results, this method of treatment appears to have fallen into disuse until comparatively recently ; and even still, especially in England, many surgeons prefer colotomy in those cases where gradual dilatation is either in- efficient or inadvisable. To M. Yerneuil is un- doubtedly due the credit of having revived this operation, and of having brought it prominently before the profession. In a paper read at the Surgical Society of Paris,t he enters very fully into the subject, and enumerates ten cases of the operation. He has moreover extended the applica- tion of linear j^roctotomy to malignant disease, as a substitute for colotomy in the treatment of obstruc- tion. Can we anticipate a complete and absolute cure by this treatment in cases of non-malignant stenosis % To this question I am convinced that the answer can be given in the affirmative. If the opera- tion has been completely performed, that is, if the entire thickness of indurated structures has been divided, a permanent cure will result in the majority of instances, and, as compared with colotomy, the re- lative mortality is slight. After the recovery of the patient the power of controlling the evacuations is generally completely regained, so that the occurrence * Association Medical Journal, p. 21 ; 1856 t Bull, de la Soc. Chirurg., October, 1872. 176 The Rectum and Anus. [Chap. xi. of incontinence need scarcely enter into the prac- tical consideration of the subject. The operation may be performed by different methods. Verneuil re- commends the following plan. The bowel having been well cleared out, and the patient placed in the lithotomy position, the finger is introduced through the stricture. If difficulty is experienced in doing this, a probe-pointed bistoury is first passed, and an incision sufficient to allow of the easy introduction of the finger is made in a direction directly backwards. A trocar and cannula is now entered at the tip of the coccyx, and pushed on till it enters the rectum well above the seat of stricture. A flexible bougie, or piece of string, is by means of the cannula passed into the rectum, the end being hooked out at the anus with the finger. By means of this the chain of an ecraseur is now passed, and the tissues thus sur- rounded are gradually divided. More recently Ver- neuil* has recommended the opening into the rectum to be made with a fine point of Paquelin's cautery, instead of the trocar and cannula. Van Buren is of opinion that the entire section is best made with a knife-shaped cautery, the charring of the edges pro- tecting the wound from irritation of the fseces until granulation is established : he also avoids making it directly backwards, as he considers that the wound heals better when made a little to one side. Of all methods the knife is, I am satisfied, the best. With a probe-|)ointed bistoury the division can be more surely, expeditiously, and cleanly made than by any other means ; and if it is confined to the middle line there need be no fear of bleeding. Any vessel which does spring can easily be ligatured ; or, if there is general oozing, the wound may be ])lugged with an aseptic sponge, or, better still, with iodoform gauze, and the whole supported with a T-bandage. At first there * International Medical Congress, Copenhagen, 1884. Chap. XL] COLOTOMY. 1 77 will be a certain amount of incontinence, but as the wound heals the power of retaining faeces will gradually be regained. During the healing, frequent syringing with some antiseptic solution, preferably corrosive sublimate (1 in 2000) should be employed; or, until granulation is established, continuous irrigation with warm solution may be resorted to. £xci«>ioii of the stricture has been performed several times for non-malignant stricture, but where the diagnosis is clear, it appears to me to be a wholly unnecessary operation, as it cannot give more relief than can be obtained by the much less severe pro- cedure of linear proctotomy. In some few cases, where it is impossible to make the diagnosis between malignant and non-malignant stenosis, the operation of extirpation may be entertained j but such cases must be of rare occurrence. In a certain number of cases, however, colotomy must still be looked upon as the proper treatment, and this operation may be required under the following conditions : first, if the stricture is situated hiorh up, it would be dangerous to resort to longitudinal division ; and, if attended with much obstruction, the formation of an artificial anus is unquestionably indi- caced. Again, if the stricture is of the long tubular variety, it might be impossible to carry the incision sufficiently high to overcome the obstruction without considerable danger ; hence it is of the utmost import- ance in every case of stricture to estimate the height to which the contraction extends with the bulb-ended bougie in the way indicated previously (page 13). Lastly, in cases of stricture attended with extensive ulceration, which has proved intractable to ordinary treatment, colotomy is indicated, even though the symptoms of obstruction are not very severe, the operation being mainly undertaken for the purpose of affording physiological rest If the ulceration can, M— 23 178 The Rectum and Anus. [Chap. XI. under the new and more favourable conditions, be made to heal, and the stricture eventually dilated, the artificial anus may be finally closed. Stricture of the aunts is most frequently the re- sult of some operative interference, and can generally be treated by dilatation sulficiently to obviate any in- converiient obstruction, unless there is a great deal of Fig 21. — Diagram illustrating Dieffenbach's Procto-plastic Operation. dense cicatricial structure, in which case the procto- plastic operation of Dieffenbach (Fig. 24) may be had recourse to. Vertical incisions are made through the contracted tissues, one anterior and the other posterior, and from the outer ends of these, two radiating inci- sions are carried through the skin, thus forming an angular flap of integuments. This flap is dissected up, and its apex brought up to the inner extremity of the vertical incision, where it is retained by sutures. The incisions are in the shape of the letter Y, and the resulting cicatrix in the shape of the letter V. Cases requiring this operation are, however, of rare occurrence. 179 CHAPTER XII. SYPHILIS OF THE EECTUiM AND ANUS. From the fact tliat syphilis is credited with causing a larcre number of the cases of stricture met with in practice, considerable attention has been directed to the subject ; and at all stages of this protean disease the anus and rectum may be the locality affected. Considerable looseness of description is, however, to be found in the accounts given by various authors, par- ticularly in reference to the primary lesions met with. There can, how^ever, be no doubt that both the chancroid and true chancre are met with not only at the anus, but in the interior of the rectum. At the anus, especially in the female, the cli aneroid is of common occurrence ; and in this sex it may be the result of auto-inoculation from similar disease in the vulva, the discharge trickling down over the perineeum, and so infecting any excoriations of the part that may be present ; or it is quite possible that the accidental contact of the penis during coition may be the means of conveying infection. In the male, however, primary soft sore in the neighbourhood of the anus is exceed- ingly rare, and when present furnishes strong pre- sumptive evidence of sodomy. According to Pean and Malassez,* nearly one-half of the superficial anal ulcerations observed in females at the Lourcine, in 1868, were due to soft chancre ; and according to Fournier,t one-ninth of the cases of chancroids in the female are situated at the anus ; w^hereas in the male he met with only one case in four hundred and forty-five. * " Etude clinique sur les ulcerations anales." Paris, 1872. f'Dict. de Med. et Chirurg. Pract.," art. Chancre, p. 72. i8o The Rectum and Anus. [Chap. xii. In position these ulcers may be found on tlie skin in the immediate neighbourhood of the anus, or be- tween the fokls of the outlet, and extending over the border of the sphincter. They are mostly multiple, with sharply-cut edges ; in fact, they in no way differ in appearance from the same form of ulcera- tion met with in other parts of the body. When the ulcer extends over the margin, the pain is considerable, especially after defaecation, and bleeding is not uncommon ; in rare instances extensive phage- deena may supervene and occasion considerable destruc- tion of the parts ; when this has been the case, or, indeed, when the chancres have been numerous and large, an anal stricture may be the result, but generally these sores heal without difficulty. That chancroids may extend up into the cavity of the rectum has been put beyond doubt by the ol^serva- tions of Bumstead and Taylor,* Van Buren,t and others ; and there can be but little doubt that the much greater relative frequency of non-malignant stricture in the female is in a great measure due to this fact, although in all probability other causes are concerned in the production of the same result ; for a further consideration of which the reader is referred to the chapter upon stricture. That a primary soft sore may be found in the interior of the rectum without involvement of the anus has been denied by many authorities. The fol- lowing case recorded by Neumann, | from the very full and elaborate way in which it has been investi- gated, apjjears to set tlie matter at rest : " Upon examination, a sharply cut sore, having the characters of a soft chancre, was found on the posterior wall of the rectum, about 4 cm. above the * " Venereal Diseases." Philadelphia, 1879. ■f *' Diseases of the Rectum." London, 1881. X A llgem. Wien. med. Zeitung, No. 49 ; 1881. Chap. XII.] Anal Chancre. i8i sphincter ; the anus and genital organs were healthy. Inoculation of the discharge on the patient's arm produced characteristic soft sores. The patient's husband was then examined, and was found to have a soft sore on the margin of the prepuce. He admitted that he might have infected his wife directly. Sub- sequently two chancres appeared among the anal folds, presumably from secondary inoculation." The first and most important indication in the treatment of soft sore in this region is absolute cleanliness. The bow(ils should be kept somewhat free by means of a saline aperient ; and iodoform, or black-wash, used as a local dressing. Where the ulcer presents a spreading edge, cauterisation with nitric acid is indicated ; and, should the ulcer become chronic and assume the characters of irritable fissure, division of the sphincter or forcible dilatation may be required. True cliancre at the anus is very rarely met with. This fact is accounted for by Pean and Malassez by the very slight disturbance to which the disease gives rise, so that the sufferers do not usually seek advice. True chancres here, as elsewhere, have a hard and raised outline, with indurated base, and might be mistaken for fissure, from which, however, they may be distinguished by the freedom from pain. In doubtful cases the diagnosis should be suspended, pending the appearance of secondary symptoms. Primary hard chancre within the rectum is even rarer still ; and it is scarcely possible that it can occur in this situation except as a result of unnatural connec- tion. Cases of it have, however, been put on record by Picord, Fournier, and others. Of tdl syphilitic diseases in the neighbourhood of the anus, condylomata, mucous patches, or moist papules, are the most frequent. According to the sta- tistics of Bassereau, condylomata were present in this situation in 110 out of 130 cases in the male; and in f82 The Rectum and Anus. [CHap. xii. the feraale, if we except the vulva, the skin im- mediately surrounding the anal outlet is found to be the locality most commonly affected. It is not likely that tyjncal condylomata could he mistaken for anything else, their appearance being so characteristic (Plate III., Fig. 2); the raised flattened surface, pearly-grey colour, and abominably foetid dis- charge, generally rendering the diagnosis easy. They are due to an inflammatory change in the epidermis and corium, especially the papillse, which swell up, owing to the infiltration with exudation cells and fluids ; the epidermal covering becoming macerated and softened. Their growth is ranch fostered by inattention to clean- liness, and they have a great tendency to relapse. They sometimes undergo considerable increase in size by branching, and proliferation of the papillary struc- ture. When this is extensive they present a cauli- flower-like appearance, or even a distinctly peduncu- lated wart may result. On the other hand, ulcera- tion may take place, and irregular ulcers, called by the French writers "rhagades," may be found. These are situated in the anal folds, and may be diagnosed from the ordinary fissures in this locality by being multiple, by having one or both edges elevated, and by being considerably less painful. After these ulcers are healed the elevated edges may persist, as folds of hypertrophied skin, sometimes with a markedly crenated border like a cock's comb. They are of a pale pink colour, soft, glistening, and moist. In speaking of these, 8ir James Paget* says : "I will not venture to assert that these cutaneous growths are never found except in sy})hilitic disease of the rectum, but they are very common in association with it, and so rare without it that I have not seen a ease in which they existed either alone or with any other disease than syphilis." * Med. Times and Gazette, p. 280; 18G5. PLATE III. Fig. 1.— Acquired Eczema from old- standing Pruritus Ani. Eig. 2. — Condylomata of Anus. Chap. XII.] GUMMATA. 183 There is no doubt, however, that growths which are not to be distinguished from these do result from other causes, such as piles, carcinoma, and other internal rectal diseases. Kelsey**" and other American authorities confine the term " condylomata " to the non-syphilitic hypertrophic folds of skin found round the anus resulting from piles. Oiimiiiata.— There is no part of the body, in which connective tissue is present, in which the gum- my deposit so characteristic of the later stages of syphilis may not be found ; and we find that the lower bowel and anus prove to be no exception to this rule. Cases of localised gumma in the rectum have been put on record by Leisol,t Molliere, | Yerneuil, § and Barduzzi. II The most interesting case of this kind is, however, described by Zappula.^ The patient, a man of thirty-six years of age, had gonorrhoea, and an ulcer on the glans penis fifteen years before. Mercurial treatment was at once adopted, and no lesions of syphilis subsequently appeared. Fifteen years later he began to suflfer from pains situated to the right side of the anus, and in the right tuberosity of the ischium ; and afterwards very soon the symptoms of rectal stricture became developed ; and so severe was the obstruction, that a large fsecal accumulation, which could be felt through the abdominal wall, formed. Upon digital examination, smooth, elastic elevations were recognised, which appeared to be enlarged folds of mucous membrane. At a distance of 4 cm. from the anus there was found a painless swelling, the size of a hazel nut, globular, smooth, and elastic ; it was apparently situated under the mucous membrane, to * " Diseases of Rectum and Auiis," p. 146 ; 1883. + Archiv f. Dermatol, u. Syph. Wien, 1876. X Op. cit. § Quoted by Fournier, op. cit. II See Bumstead and Taylor, "Venereal Diseases," p. 607. 11 Arch. f. Dermat. u. Syph. Prag, pp. 62—90; 1871. 184 The Rectum and Anus, [Chap. xii. which it was not attached. The diagnosis lay be- tween syphilis and cancer ; and as a complete cure resulted from the exhibition of iodide of potassium, the former diao-nosis was established. Ano- rectal sypliiloina. — Under this name Fournier has described* a remarkable specific infiltra- tion of the rectal wall, which, as he states, begins in the submucous layers, and that the mucous membrane is only secondarily affected, and being at first free from ulceration. This disease, he has noted, is more common in females in the proportion of eight to one, and its usual situation is the rectal pouch, but the anus may be involved. The tendency of this infiltra- tion is to undergo ulceration, or sometimes to end in cirrhotic contraction without any ulceration. What the exact pathology of this condition is does not appear to be settled. Fournier speaks of it as a hyperplastic proctitis, passing at a later stage into a fibrq-sclerous condition, and it appears that it is more closely related to the difi"used sclerotic changes which take place in the spinal cord, liver, and other organs duriiior the later periods of syphilis, than that it is, as Van Buren describes it, an infiltrated form of gumma. It is to be diagnosed by the stiff, lumpy feel of the intestine, usually free from ulceration. Van Buren states that he has seen it entirely disappear under a mercurial course, but it is obvious that treatment, to be at all effectual, must be undertaken before the stage of cirrhotic contraction has set in. In congenital sypliili!>» the only common mani- festation at the anus is the mucous patch, sometimes associated with radiating fissure-like ulcers. I have, however, met with one case of stricture in a child, aged ten years, who had well-marked " Hutchinson's teeth " and interstitial keratitis ; and, from the great infiltration and firm feel of the coats of the bowel, I • "Lesions Tertiaires de I'Anus et du Kectum." Paris, 1875. Chap. XII.] Extensive Ulceration, 185 have but little doubt that it was the result of a similar cirrhotic change to that described by Fournier, as resulting from the later stages of the acquired disease. Bodenhamer * alludes to inherited syphilis as an occasional cause of congenital stricture. Trelatf speaks of small superficial fistulse, perfo- rating the tabs of skin usually found in syphilitic disease. He saj^s that they are all healed and dry within, like the holes for ear-rings, and are character- istic of syphilis. They have sharply-cut orifices, and are found in cases of ano-rectal syphiloma. During the later stages of syphilis a form of ulceration is not uncommon in the rectum^ which may assume extensive proportions, and finally, by the con- traction which takes place during its cicatrisation, occasion stricture of the bowel. A very instructive case of this kind is given by Sir J. Paget, in a clinical lecture delivered at St. Bartholomew's Hospital. | The following is an abridged account of this interesting case : The patient was twenty-eight years old, and stated that she had suffered from syphilitic sores seven years previously, shortly followed by a cutaneous scaly eruption. About a year subsequently she became subject to an itching about the anus, and a growth of skin appeared reaching a short distance into the rectum. Two years after this a large ulcer formed in the neighbourhood of the anus, and she was received into University College Hospital. The ulcer was destroyed by the application of some corrosive fluid, and the growth before mentioned was removed. Rectal bougies were passed for stricture, which was already in process of formation. At the end of a fortnight, being much relieved^ and her general * "The Congenital Malformations of the Eectum and Anxis," p. 63. New York. t Frogres Medical, p. 473 ; June 22, 1878. + Med. Times and Gaz^, vol. i. p. 279 ; 1865. 1 86 The Rectum and Anus. [Chap. xii. health having much improved, she was made an out- patient, but soon becoming pregnant, she ceased to at- tend. The child she afterwards gave birth to was born dead. A year subsequently she was admitted into St. George's Hospital, having in addition to the previous disease of the rectum a recto- vaginal fistula; the sphinc- ter ani was divided ; bougies smeared with unguentum hydrargyri were frequently passed, and she was placed under the influence of mercury by means of the calomel vapour bath. Under this treatment she improved rapidly, and was soon discharged. After the lapse of another year, having in the interval borne another cliild, she applied at King's College on account of a rela])se of her previous condition, and having receiv^ed relief from the same kind of treatment as that before employed, she soon left the hospital. She subsequently became a patient at St. George's Hospital. The canal of the rectum was so much narrowed that only a catheter could be passed through the stricture. Her general health, which up to this period had been toler- ably good, began to fail, and suffering from sickness and diarrhoea for some days, she lost flesh rapidly. She was finally admitted into St. Bartholomew's. At this time she was in a state of extreme emaciation and misery, and evidently suffering from pulmonary phthisis, so that any expectation of afibrding her per- manent relief seemed hopeless. She shortly afterwards died. At the post-mortem, the points of chief interest were to be found in the rectum and colon. The anus of this patient did not present more than remnants and traces of the cutaneous growths, which are gene- rally significant of syphilis. In the rectum were found the results of widespread ulceration. The whole mucous membrane was destroyed, except one small patch, which was thickened and opaque ; the exposed submucous surface was lowly tuberculated, undulating, and uneven, and was thickened by infiltration. In Chap. XII.] AniVLOID DEGENERATION. 1 87 the early stages the tissue was soft, as if from recent inflammation, effusion^ or oedema ; but as the infiltra- tion organised, it became callous, with fusion of the mucous and submucous coats, and then contracting, thus brought al)Out a state of stricture. On the mucous membrane of all parts of tlie colon there were ulcers of regular (round or oval) shape from a sixth of an inch to about two-thirds of an inch in diameter, with clean, sharp-cut, scarcely thickened edges, surrounded by healthy or only too vascular mucous membrane. Their bases were, for the most part, level, or with low granu- lations resting on the submucous tissue, nowhere pene- trating to the muscular coat, with no marked sub- jacent thickening or hardening. On some of them were ramifying blood-vessels ; on some few there was at the centre of the base a small island of mucous membrane, giving to the ulcer an evident likeness to the annular syphilitic ulcers of the skin. At some plaices two or more of these ulcers coalesced into a large ulcer of irregular shape, and rather deeper than the smaller ones, but in all general characters similar to them. By such coalescence, some of the ulcers in the lower part of the colon were continuous with the ulcerated surface of the rectum, making it ])robable that, at first, similar forms of ulcers may have existed in the rectum, though now superadded thickening and partial scarring had destroyed nearly all traces of any primary shapes of ulcer. The ulcers of the colon were placed without plan or grouping, except that they decreased in number and closeness, and, on the whole, in size also, from the rectum to the c?ecum. In the caecum there were none ; in the ileum only one, very small, and of rather doubtful character. Extensive amyloid deg:eneratioii of the rectum, in common with that of the rest of the intes- tinal tract, is frequent in old-standing cases of ex- tensive syphilis; but this condition is not of much i88 The Rectum and Anus. [Chap.xiii. practical importance, as it gives rise to no symptoms of significance except diarrhoea, which is due to the extensive changes of the whole intestinal tube rather than to any local disease of the lower bowel. The treatment of syphilis of the rectum presents no peculiar features ; the various manifestations de- manding similar treatment to that employed for the corresponding lesions in other parts of the body. CHAPTER XIII. PKOLAPSUS RECTI. By the term prolapsus, or procidentia recti, is under- stood the protrusion of portion of the rectal wall through the anus. The old term " prolapsus ani," which is to be found in many text-books, is so obviously erroneous that it is best discontinued. Of prolapsus, we can recognise three distinct varieties: (1) where the mucous membrane alone protrudes (partial prolapse) ; (2) where the entire thickness of the intestinal wall is included in the protrusion ; and (3) where there is invagination as well as pro- lapse ; or, in other words, the external appearance of an intussusception. (1) Partial prolapse. — When the extruded mass consists of mucous membrane alone, the muscular coats of the intestine remaining in situ, the condition is spoken of as partial prolapse. This is of somewhat conmion occurrence, and is a very much less serious affection than either of the other varieties. A slight protrusion of the mucosa can be produced voluntarily ; and normally occurs during and immedi- ately after defa3cation. In some animals this is more especially noticeable than in the human subject, the horse being a familiar example. Horner has described Chap. XIII.] AETIOLOGY OF PrOLAPSE, 1 89 a special arrangement of muscular fibres tending to produce this physiological prolapse. He states that a portion of the external longitudinal muscular coat of the bowel terminates by passing between the sphincters, and then turning directly upwards is inserted into the mucosa. We may conveniently group the causes of patho- logical prolapse of the mucosa under three heads : (1) that due to the effusion of inflammatory products in the lax tissue of the submucosa ; (2) where the mucous membrane is drao-ged down by piles, polypi, or other neoplasms attached to it ; and (3) where the folds of l^rolapsed membrane have been protruded by peristalsis, the muscular structures of the anus and perinaeum being relaxed. MoUiere* has shown, by a simple experiment, the mechanism of the first of these causes. On the dead body of a young girl he inserted the point of a blow- jiipe beneath the mucous membrane of the lower end of the rectum. Upon injecting air into the submucosa, the mucous membrane bulged out at the anus, and the same procedure at another portion of the circumference was followed by a like result. In this case the anus was not at all unduly relaxed. In the decomposing bodies of animals, the gas generated by the putre- factive changes in the loose submucous tissue frequently produces a like result ; this being more especially liable to occur on account of the gTeat mobility of the mucous coat, and the very loose areolar connec- tions that exist between the middle and internal tunics of the lower boAvel. In cases of catarrhal proctitis and dysentery, inflammatoiy exudations frequently cause the pro- trusion of bright-red folds of mucous membrane from the anus, a condition which has by Hoser not in- aptly been compared to the inflammatory ectropion of * " Maladies clu Rectum," p. 199. 190 The Rectum and Anus, [Chap. xiii. the ocular conjunctiva. Prolapse occasioned in this way is generally, in the first instance, of limited dimensions ; but a prolapse once started has a ten- dency to increase in the same way that intus- susceptions of other portions of the intestine are pro- gressive. So that a prolapsus recti which has attained large dimensions may have been, in the first instance, due to a trivial inflammatory exudation in the rectal submucosa. The protrusion of folds of mucous membrane asso- ciated with the prolapse of internal piles is exceedingly common, but it seldom occurs to any great extent. This is probably due to the fact that the presence of tlie haemorrhoids has produced a certain amount of inflammatory thickening in the submucosa, which renders the extensive separation of the mucosa impro- bable, and the prolapse will certainly disappear en- tirely if the piles are subjected to eflicient surgical treatment. The form of prolapse produced by the adenoid polypus is peculiar, and deserves some notice. In this form, instead of a broad fold of mucous membrane being protruded, a narrow funnel-shaped j)ortion is drawn out, sometimes of upwards of two inches in length, and constituting the pedicle of the polypus. This likewise gives rise to no trouble after the growth has been removed. The most important cause in the production of this variety of prolapse is the occurrence of violent and long-continued expulsive efforts, especially if associated with a relaxed condition of the muscles around the anus ; consequently we find prolapsus recti a commoj? accompaniment of vesical calculus and phimosis ia the ctild ; and of enlarged prostate and urethral stric- ture in the aged and adidt. Other cases are apparently due to the irritation of intestinal parasites, or of diarrhoea ; while the custom, which is common amongst Chap. XIII.] Partial Prolapse. 191 nurses, of leaving young children to sit on the chamber utensil for a long time after defaecation is completed, undoubtedly tends to favour the production of pro- lapsus recti. This is a disease which is very much more common at the extremes of life, by far the majority of cases being met with in young children and old people, its primary occurrence between the ages of fifteen and fifty years being quite unusual. The greater liability of children to be affected is probably due to their much greater susceptibility to reflex irritation, and to the more numerous sources of direct irritation to which they are subject. Most of the authors who have written on rectal disease enumerate as one of the causes of the greater prevalence of prolapse amongst children, the want of support to the lower bowel in consequence of the greater straightness of the sacrum. This, how- ever, I think, can not be considered an important ^etiological factor. In old age the general relaxa- tion and want of tone favours the formation of rectal prolapse. Symptoms of partial prolapse. — The diagnosis of this disease is easy, the protrusions of mucous membrane appearing as bright red folds, arranged witli sulci between them, which radiate from the aperture (Fig. 25) ; whereas the sulci in complete prolapse are prin- cipally parallel to the anal margin of the bowel Fig. 25. -Partial Prolapsus Kecti (Bryant). 192 The Rectum and Anus. [Chap. xiii. (Fig. 26) ; and, again, in partial prolapse the size of the tumour is usually of much more limited dimensions. The principal masses in partial pro- lapse are placed laterally, and on the surface of the prolapsed intestine superficial catarrhal ulcerations are frequentlv to be seen. At first the protrusion ^ ^.^ftas» Fig. 26.— Complete Prolapsus Recti (Van Buren). only occurs after defsecation, and is easily return- able ; in more chronic cases, however, it becomes more difficult to replace, and may reappear independ- ently of defaecation. The mucous membrane also becomes thickened, and the submucosa infiltrated. A muco-purulent discharge is common, and anal bleeding to a slight extent often occurs. As has been elsewhere stated, the protrusion of internal piles is frequently associated with more or less prolapse. of the mucous Chap. XIII.] Complete Prolapse. 193 membrane, but this is a condition Avliich ought always to be readily distinguished from the disease under con- sideration. Prolapsed ha3morrhoids are more isolated tumours, and firmer to the feel than a mere flap of mucous membrane ; and when of the venous variety, the livid colour will serve to establish the diag- nosis. Of the coiiiplications of partial prolapse, tlie most important is iiiflaiiuiiatoiy g-aiigrciie, which is an occasional termination, by means of which nature sometimes effects a spontaneous cure of this disease, the gangrene being due to inflammatory stagnation, and not to the strangulation of the prolapse by the sphincters ; indeed, in these cases relaxation of the s^Dhincters precedes usually the disease, and in cases of gangrene the flnger can be readily passed into the rectum, showing that there is no strangulation by the muscles. Spontaneous recovery may also sometimes result without the actual occurrence of gangrene ; the pro- lapsed mucous membrane being injured either by the passage of a hard fsecal mass or external agencies, to such an extent that inflammation suflicient to effect a permanent cure is set up. Complete prolapse. — After partial prolapse has existed for some time, it is apt to merge into the more serious form wdiere all the tunics of the bowel are involved ; or sometimes the complete prolapse comes on suddenly, the entire thickness of the rectal wall being protruded by one expulsive effort. True com- prehension of the symptoms and diagnosis of complete prolapse readily follows from the understand- ing of its nature and mode of production. When the protrusion reaches any considerable dimensions, it is obvious that the serous coat of the intestine will be involved, and, owing to the fact that the peritonseal pouch descends much lower on the anterior than on other N— 23 194 The Rectum and Anus. [Chap. XIII. asi^ects of the rectum, the first appearance of a sac is to be looked for in front (Fig. 27). If, however, the prolapsus continues to increase in length, so that the upper portion of the rectum and sigmoid flexure Fig. 27. — Complete Prolapsus in a Child. B, Rectum ; b, bladder : s, saornni ; p, piil)ps ; tt, uterus ; v, vagina ; hr, Prolapse ; csp, peritonajal pouch (Uruveilliier). become protruded, a peritonaeal sac will be found surrounding tlie tumour, except where the meso- rectum is attached. As a rule, where the protrusion measures more than three inches in length it is gerter- ally curved, the concavity looking towards the coccyx, and in very extreme cases it may be arranged in a spiral manner. The diagnosis between this variety and Chap. XIII.] Extensive Prolapse. 195 prolai)se with invagination is easily made, as in the latter the outer layer retires again within the anus, leaving a sulcus between the margin of the anus and the tumour ; along the entire circumference of which a probe, or the finger, can be passed ; while in the latter this sulcus does not exist, the outer layer of the pro- lapse being directly continuous with the anus. Com- plete prolapse may assume very great proportions ; in rare instances the greater part, or even the entire, of the colon being protruded. In one case which came under my notice the whole large intestine was thus extruded. The patient was a child, aged four months. The prolapse was arranged in a spiral manner, making two and a half revolutions. The apex was formed by the csecum, the ileo-caecal valve being distinctly discernible, while the other end was continuous with the anus. The mucous membrane was in several places superficially ulcerated. The patient died of peritonitis. From the history I received of this case, I have no doubt that it com- menced as an ordinary prolapsus recti, which gradually increased in dimensions by successive portions of the colon becoming involved, until the whole protruded. A similar result has been known to follow from an ileo-csecal intussusception, the large intestine becoming invaginated from above downwards. In this latter case the first part to appear through the anus will be the ileo-csecal valve, while in the former it will make its appearance last. In cases of colic or rectal intus- susception, which have secondarily invoh^ed the entire lower portion of great intestine down to the anus, it may be impossible to arrive at a conclusion as to whether the disease has originated as an ordinary prolapse, or as an intussusception higher up. The mass may also assume large proportions, even to the extent of hanging down between the thighs. {See Fig. 26.) This may be the case to such a degree that all attempts 196 The Rectum and Anus. [chap. xiii. to return it within the abdominal cavity will prove abortive. Prolapsus recti is generally unattended with any very severe pain, the mucous membrane, from a point immediately within the anal margin, being of low sensibility ; but the constant mucous discharge, and the incontinence of fseces, which in severe cases is always more or less present, renders the patient very miserable. The complications of complete prolapse are both important and serious ; and they owe their chief gravity to the involvement of a peritonseal pouch brought down with the prolapse. In intussusception, the invaginated peritonseum is usually soon the seat of a localised adhesive 2:)eritonitis^ which obliterates the sac ; but this is not the case in prolapsus recti, the protruded portion of peritonaeum retaining its con- tinuity with the general cavity. Into this peritonseal pouch a portion of intestine is apt to fall, constituting a hernia of a peculiar variety, which may be appro- priately described under the term prolapsal hernia. It is usually the small intestine that is thus implicated ; but the ovaries, bladder, and other viscera have occa- sionally been found similarly involved. In the first instance the hernial tumour is to be looked for on the anterior aspect of the prolapse, in consequence of tlie peritonseum descending lower in front than behind. In aggravated cases, however, the small intestine may de- scend behind as well as in front. A hernia thus formed is to be recognised by the same signs that we are familiar with in the more usual seats of this disease : the tumour is usually tympanitic on percussion ; gurgling can be felt when the swelling is manipulated ; and the sac can generally be emptied by pressure, the en- closed portion of intestine being reduced into the ab- dominal cavity. As Allingham has pointed out,"*^ the * "Diseases of the Rectum,'' p. 168. Fourth edition. Chap. XIII.] SpONTA NEO US R UP TUR E. I Q 7 position of the orifice of the prolapse is so altered when a hernia is present as to become a diagnostic sign. Ho says : " Directly the bowel is protruded, you can tell that there is a hernia also present, by the fact that the opening of the gut is turned towards the sacrum. When the hernia is reduced, the orifice is immediately restored to its normal condition." The same changes which are observed in hern:a generally have also been noted in this form. It may become irreducible by the formation of adhesions between the sac and the con- tained viscera ; or strangulation may result from the constriction of the neck by inflammatory swelling. According to Esmarch,* the formation of what he terms an "anus preternaturalis in ano " has been known to occur as a result of this strangulation. A very rare complication of complete prolapse is the spontaneous rupture of the entire rectal tunics, and the protrusion through the rent of a portion of the small intestine. In a very interesting paper by M. QuenUjt the whole subject of spontaneous rupture of the rectum is fully discussed, and the recorded cases of this rare injury collected. In all, nine cases have been noted ; and of these, five are described tolerably completely, and in four of the five an old and extensive prolajosus recti preceded the rupture. The immediate exciting cause in these cases was some violent muscular effort, as defsecation, vomiting, or lifting a heavy weight ; and in all the protrusion of small intestine through the anus was followed by a reduction of the prolapsus recti. All the cases occurred in adults, and but one was noted in the male subject, the others occurring in w^omen. In none of the cases did the structures appear to present any ma- croscopic change, such as ulceration or inflammatory * hoc. cit. t "Des ruptures spontanees du rectiun,'' Revue de Chirurgie, Mar. 10, 1882. 198 The Rectum and Anus. [Chap. xiii. softening preceding tlie accident ; but in the case which came under the personal observation of M. Quenu, there was a considerable amount of inflam- matory exudation to be seen under the microscope, although to the unaided eye the tunics appeared to be absolutely normal. The position at which the rupture occurred varied from one to five inches from the anal margin ; and the direction of the rent was transverse in some and longi- tudinal in others. The diagnosis is readily made, the escape of small intestine at the anus, with its smooth l)eriton?eal covering and attached mesentery, being j)athognomonic of the lesion. The prognosis is very bad, none of the recorded cases having recovered. The treatment adopted by Adelman^ is, however, based on sound surgical principles. Having failed to reduce the hernial protrusion by direct pressure, this surgeon per- formed laparotomy, and drew back the small intestine into the peritonseal cavity ; and then, by pulling down, and so reproducing, the prolapsus recti, he brought the rupture, which was situated at two and a half inches from the anus, into view, and carefully stitched it up. With the improved methods of dealing with peritonseal wounds now at our disposal, should the case be seen early enough, it is possible that success might attend a similar procedure. In forming a prog^iiosis, in any case of prolapse, it is well to bear in mind that, when the mucosa is alone implicated in young children, there is a strong ten- dency to spontaneous cure, and but mild measures will be necessary to assist nature ; but where the disease exists to any extent in the aged, no such result can reasonably be looked for. And h t any age, if the pro- lapse is complete, and attended with much inflam- matory thickening, and if it is of long duration, relief can scarcely be exjjected by any means short of surgical * Journal fur Chirurgie und Augenheilkunde, 1845. Chap. XIII.] Methods of Reduction. 199 operation. In cases of extensive protrusion, with for- mation of a peritonseal sac, the danger to the patient's life is considerable, peritonitis not unfrequently super- vening as a result of sloughing, ulceration, or the inflammation, or strangulation of a hernia. Treatmeiit. — The first step which is usually re- quired in the treatment of this disease is to effect reduction. Indeed, in many cases, it will be found that the unaided efforts of the patient will be sufficient to effect this when the prolapse is recent ; or, in the case of young children, the mother will have returned the protrusion within the anus before the surgeon is called in. But, where the disease has become chronic, or where the submucosa has become distended with inflammatory effusion, considerable difficulty may be experienced in effecting reduction : and in a few very rare cases the hypertrophic changes may be so ex- tensive that it may be quite impracticable to return the mass into the abdominal cavity. In order to effect reduction in the child, the little patient should be laid across the knees, and gentle pressure of the whole mass of the tumour should be for some moments exercised, so as to reduce its bulk by the squeezing out of the contents of the bowel prolapsed, and of any fluid effusion in its tunics. After this reduction should be proceeded with, efforts being made to return the more central parts first, and in the great majority of cases but little difficulty will be experienced. It will often be found that the prolapse immediately reappears after the removal of the finger. In order to obviate this Sir C. Bell has suggested an ingenious manoeu^T^e. He advises a small piece of paper to he twisted into the form of a hollow cone, in the way that paper bags are made. This is to be well greased on the inside, and the apex of the cone placed in the aperture of the prolapse. The index finger is then to be placed in the cone, and steady pressure kept up. As the paper 200 The Rectum and Anus. [Chap. xiii. advances it draws with it tliose portions of the pi-o- lapse which last came down, till finally the whole is reduced. The finger is now withdrawn, and the paper left in situ. In the case of the adult similar means will usually be found sufficient, the most con- venient position being with the patient resting on his hands and knees. Should any difficulty be experienced in effecting reduction, it is better at once to administer an anfesthetic ; and to be prepared, if the case is severe and somewhat chronic, to operate for the radical cure at the same time. Reduction having been effected, it is necessary to apply some retentive ap[)aratus, and the best evidence we can have of the difficulty of effectually keeping the prolapse up is the vast number of appliances which have been invented for the pur- pose. The best temporary means is to apply a pad of tenax, absorbent cotton, or some similar material to the anus, and then to strap the nates together with strips of strong rubber plaister. In order to prevent the recurrence of the prolapse, great attention must be paid to regulation of the action of the bowels, and the usual sitting position during their evacuation should absolutely be inter- dicted, defiecation being effected either on a bed-pan, lying on the side, or in the erect position. It is also a useful plan for the patient to accustom himself to have the bowels moved the last thing before going to bed, so that he may at once lie down after the act. This is a good rule in many other rectal diseases, and with a little practice the habit can readily be acquired without discomfort. The anus should be well washed with cold water, solution of alum, or decoction of oak-bark ; but I am convinced it is a bad practice to use astringent injections, as, if they are strong enough to be of any practical utility, they are apt to produce tenesmus and straining, which will be productive of much more harm than any good they can accomplish. But a Chap. XIII.] Prolapse with Piles. 201 small enema of cold water will often prove of service ; or suppositories containing ergotin, mix vomica, etc., will sometimes be found useful. It is obviously a matter of the greatest importance to arrive at a diagnosis as to the cause of the prolapse, and, when this is practicable, to direct treatment to the removal of that state, whatever it may be ; but, un- fortunately, in a number of cases it is impossible to arrive at any conclusion as to the cause, so that our treatment must be somewhat empirical. In the case of children, however, we should examine carefully for rectal polypus, oxyurides in the rectum, for phimosis, or symptoms of vesical calculus. In certain cases it would appear that the exciting cause is an intestinal catarrh. Should any of these conditions be made out, it will usually be found that efficient treatment for their removal will prove sufficient to effect a cure of the prolapse. Where constipation is present the bowels should be regulated by change of diet, and, if necessary, plain enemata, rather than by the adminis- tration of purgatives, which cannot fail to prove harmful. In the adult, one of the most common causes for prolapse of moderate degree is the presence of internal piles, and the surgeon can promise the patient an absolute cure of the prolapse by efficient surgical treatment of the piles, the cicatrisation fol- lowing the removal of the haemorrhoids by any of the usual methods, detailed in the chapter on that subject, tending to produce an adhesion between the mucosa and the deeper layers of the rectal wall, and so pre- ventinor that free movement of the mucous coat which is essential to the formation of the prolapse in its earlier stages ; and, again, the denser tissue of the cicatrix tends to prop up and stiffen the lower portions of the rectum. Where there are, in addition to the piles, many redundant folds of mucous membrane, they may be subjected to operation at the same time that the 202 The Rectum and Anus. [Chap. xiii. hoemorrhoids are treated, portions being pinched up with a forceps and crushed, or cauterised ; or if the ligature is preferred, the circle of mucous membrane may be divided into four or five segments with a scissors and each portion separately ligatured. Such diseases of the urinary organs as stricture or enlarged prostate should receive appropriate treatment ; and where constipation is present, the bowels should be relieved in such a way as to prevent straining. Sufficient has, however, been said as to the importance of recognising, and as far as possible removing, the cause of prolapsus recti ; and in children these measures, in addition to the mild local treatment already indicated, will usually prove sufficient, the disease having a de- cided tendency to disappear as the patient approaches the age of puberty. In a few cases, however, in childhood, and in the majority of cases in the adult, some- thing more will have to be done. Pes- saries of various kinds may be tried, but are usually of but limited utility. The best form that I am acquainted with is shown in Fig. 28. It was devised by a patient of Dr. R. McDonnell's for his (the patient's) own use. It consists of an oval knob of vulcanite, with a very slender curved shank, which is perforated at the extremity for the reception 3)f a piece of twine, so that if the instrument should happen to slip within the rectum it can readily be withdrawn. Instruments of this kind can be obtained of various sizes, and are used in the following way: the prolapse having been sponged and replaced, the knob is introduced into the rectum, the slender curved shank lying between the nates, and the niechanical stimulus afforded by the foreign body tends to brace up the rectum and anus, and keep the prolapse from Fig. 28.-Pes- sary for Prolapsus Recti. Chap. XIII.] Injections of Ergotin. 203 protruding; the very slender shank allows the sphincter to contract nearly to its full extent, and also affords a healthy stimulus to this muscle. Any instrument which keeps the anus distended only tends to weaken the s})hincter, and so favour the production of prolapse. In several cases, even in adults, I have procured a complete cure by means of this simple pessary. Subcutaneous injection of various fluids into the ischio-rectal fossa have from time to time been re- commended for the relief of prolapse. Amongst the agents employed for this purpose may be enumerated : ergotin, iiux vomica, and carbolic acid. Of these the first alone appears to me likely to be attended with favourable results. Nux vomica has proved dangerous in use, at least one fatal result having been recorded : and although strongly recommended by Kelsey,* I am unable to see how the injec- tion of a strong solution of carbolic acid could possibly be of service. Yidalf records three cases of cure by the subcutaneous injection of ergotin. The first case was that of a man aged thirty-nine years, who had suffered from prolapse for eight years. Injections of a solution of ergotin were practised every two days, and after the fifth injection the mucous membrane scarcely protruded at all. After the eleventh injection it came down only during defsecation, and returned spontaneously. Twenty-two injections in all were used, and the patient was seen and found to be well four years after treatment. The second patient, a female aged sixty-four years, was cured after twenty- four days'" treatment, and remained well two and a half years afterwards. The third patient, a female, aged forty-five, was cured by six injections in a period of twenty-four days. The solution recommended by Yidal was composed of fifteen grains of Bonjean's * "Diseases of the Eectum," p. 116. t Paris Medical, Aug. 28th, 1879. 204 The Rectum and Anus. [Chap. xiii. ergotin, dissolved in seventy-five minims of cheny- laurel water, and of this solution a dose varying from fifteen to twenty-five minims was employed. The injection was made deep into the ischio-rectal fossa at a distance of one-fifth of an inch from the anus. Severe pain usually followed this treatment, but in no case was it followed by local inflammation or abscess. Spasm of the sphincter lasting several hours was induced ; and the local action of the ergotin in causing contraction of the involuntary muscles in the neigh- bourhood was further exemplified by the occurrence of spasm of the neck of the bladder, with retention of urine on several occasions. Dr. Ferrand* has also recorded a case of a lady who had suffered a great deal with a prolapse of considei able size, and who was very much improved by a similar course of treatment. In my own experience, however, I have been dis- appointed with the hypodermic injection of ergotin, in the few cases in which I have tried it. Con- sidering the safety and certainty of linear cauterisa- tion, 1 am inclined strongly to give the preference to this method of treatment, which, moreover, has the advantage of being decidedly less painful than the often repeated hypodermic injection. Various methods of cauterisation have been recommended, especially strong nitric acid ; acid nitrate of mercury ; butter of antimony ; and other chemical agents. The actual cautery has also been advocated in the shape of the hot iron, galvano-caustic, etc., but the benzoline therm o-cautery of Paquelin is now generally preferred by most surgeons. The application of strong nitric acid has been strongly recommended by AUingham.f He directs that the acid should be a])plied on the whole surface of the prolapse after it has been carefully dried, care being * Gaz. Hehdom., Jan. 2nd, 1880. f ''Diseases of the Rectum," p. 165. Chap. X 1 1 1 . ] Use of Caus tics, 205 taken not to touch the verge of the anus or the skirr. The part is to be then well oiled and returned, and the rectum stuffed thoroughly with wool ; a pad must, after this, be applied outside the anus, and kept firmly in position by strapping plaister, the buttocks being kept closely together by the same means. Although " rig. 29. — Paquelin's Thermo-catitery. good results almost invariably follow this treatment in the case of children, it is not by any means so suitable for the treatment of the disease when occur- ring in adults, and is not without danger in old and debilitated persons. Extensive sloughing may be pro- duced, and during the separation of the sloughs, haemorrhage to an alarming extent may be induced. A case of this kind has come under my own obser- vation. An elderly man was treated for extensive 2o6 The Rectum and Anus. [Chap. xiir. prolapse by the application of strong nitric acid. Seven days afterwards hsemorrhage of a very severe character came on, and although the bleeding was arrested by plugging the rectum, he died exhausted shortly afterwards. Inflammation of the rectum of a very severe type sometimes follows the application of the chemical caustics, especially when applied to an extensive surface of prolapsed intestine. Another danger which must not be lost sight of is the occurrence of stricture. Allingham states that he has on several occasions seen this occur. The actual cautery may be applied as recommended by Mr. Smith, with the assistance of his clamp. A por- tion of the mucous membrane is caught in a forceps and tightly clamped. The compressed portion is then burned away with the hot iron, or Paquelin's benzoline cautery. In using either of these instruments the heat should not exceed a dull red, as otherwise the tissues will not be sufficiently deeply charred to arrest haemorrhage ; but in operating in this way the surgeon must ever bear in mind the possibility of a peritonseal pouch being present in the prolapse. And should the tumour from its size and appearance suggest the possibility of this complication, the greatest care should be taken to include only the mucous mem- brane. Mr. Smith has recorded* an interesting case which, although it terminated favourably, should serve as a caution in using the clamp and cautery: "The patient was an elderly man who had a prolapse as big as a cocoa-nut, always coming down and render- ing his life a burden ; he had already been operated on twice by a hospital surgeon, but in vain. The patient was then sent to me, and formidable as the case looked, I determined to undertake it. I applied the clamp deeply in three different directions. There * Lamet, March 15, 1880. ciup. xiir.] Dangers of Cautery. 207 was a great deal of bleedings and I had to apply the cautery over and over again before I could stop it. And then, just as I was finishing the operation a most untoward event occurred, severe vomiting as the result of the ansesthetic took place, the prolapsus was forced still farther down, and before I and my assistants could return the parts, the violent action of the ab- dominal muscles was such that the weakened coat of the bowel gave way, and a knuckle of small intestine actually protruded through the rent thus made. I carefully returned this as soon as the vomiting ceased, and anxiously waited the result. Our house-surgeon, Mr. Newmarch, watched the patient with the greatest care, and treated him with great skill, keeping him constantly under the influence of opium, and locking up his bowels for several days. The result was not a single bad symptom of any kind. On the first action of the bowels there was no protrusion nor afterwards, and as soon as the man was fairly re- covered, I removed three longitudinal folds of skin from the anus, so as further to tighten the parts. The man was completely cured, l^ow, the lesson this case teaches is this : not to employ an agent which could cause vomiting, because, of course, in such a terribly severe case as this, it is absolutely necessary to clamp deeply and thus weaken the bowel. It was a most unlooked-for accident, not likely to occur again ; in fact, it is hardly reasonable to expect to meet with another such case for operation. I have, however, been called to cases as bad or worse, but where no operation could be recommended." It is well to remember in connection with this case that forcible attempts to reduce a large prolapse have been attended with a fatal rupture of the peri- tonseal pouch,* and also, that the peritonseal cavity has been opened in an operation undertaken for the excision * Roche, Reviie Med, Chir., 1853, 2o8 The Rectum and Anus. [Chap. xiii. of a complete prolapse, on the supposition that it consisted of mucous membrane alone,* The galvanic cautery is not at all so suitable for the removal of prolapse as the other forms of cautery, as it does not produce sufficient charring of the struc- tures to completely arrest bleeding. The treatment, first strongly advocated by Van Buren, is that which is now generally adopted by surgeons, and is the one which I believe to be far the best in those cases in which the milder measures before-mentioned have not been successful. It is best described in Van Buren's own words : " Having etherised the patient, elevated the hips as in Sims's position, reduced the prolapse, and introduced a speculum of his pattern of tlie largest size, proceed to draw a line upon the mucous membrane with the cautery at a dull red heat, parallel with the axis of the gut, and repeat this four or more times at equal distances, carrying the cautery each time from a point three inches or more above the anus slowly down through its orifice, and terminating the line of eschar externally, where the delicate integument covering the sphincter joins the true skin ; you will thus have a series of parallel vertical stripes of cauterised tissue, the lower extremities of which will appear as rays diverging from the anus. The lines of eschar may be made more numerous, deeper, and broader, according to the volume and duration of the prolapse. " In a child, or where the protrusion is not voluminous, nor of very long duration, I would use a delicate carutery, perhaps not thicker than an ordinary probe, but for a larger tumour in an adult a more bulky iron ; but in any case it should be bent nearly at a right angle, a short distance from the button at the extremity, so that it may reach all points of the con- cavity of the rectal surface. By operating in this * Van Buren, "Diseases of the Rectum," p. 60. Second edition. Chap. X1U.]CaC/TE/? ISA T/OIV: AfTER-TrEATMENT. 209 manner I believe you would get the full effect of the cautery in producing retractile cicatrices with the least amount of danger of subsequent stricture. Where after cauterisation a cicatrix is left which en- circles the whole circumference of the bowel, constric- tion in some degree must follow. In a very bad case an operation of this kind might be repeated, new lines of eschar being made in the intervals between the old ones. This I did in the case of a young girl of thir- teen with defective intelligence, who had an enormous prolapse, which had existed from infancy. In this case I added to the linear eschars small scattered points made with a slender probe-pointed cautery; the effect of the latter when applied over the sjjhincter was remarkable in arousing its contractility." The after-treatment recommended is to keep the patient confined to the horizontal position for a week, a bed-pan being employed when the bowels act for at least double this period, to diminish the possibility of a relapse ; enemata of tepid water being given when required to assist defsecation. The rationale of this simple operation is easy to comprehend. Any trau- matism sufficient to produce inflammatory adhesion between the mucous and deeper coats of the rectum during the process of repair, would be sufficient to effect the desired result, but by no method can this be so effectually carried out as by the cautery applied in the way described. It will be observed that Van Buren directs that the lines of cautery be carried through the margin of the anus for the purpose of stimulating its sphincter muscle to contract, and also with a view of producing a certain amount of cicatricial narrowing of this abnormally dilated outlet. Great relaxation, frequently associated with fatty atrophy of the external sphincter is a common accompanimant of prolapsus recti. It should, however, be dealt with only in connection with eilicient surgical treatment of the o— 23 2 TO The Rectum and Anus. [Chap. xiii. protruded mucous membrane. That this muscle can be stimulated to contraction by local irritation is abundantly proved by the spasm and hypertroj^hic thickening produced by the presence of an irritable anal fissure ; and it is with a view of, to a certain extent, iuiitating this pathological process that the cauteri- sation of the anus itself is resorted to. Allingham* recommends the following modification of Van Buren's operation. If the prolapse is not already protruded, he draws it down with a vulsellum ; he then makes four or more longitudinal linear eschars from the base to the apex of the protruded mass, taking care to make the cauterisation deeper at the base than at the apex, where peritonaeum may be close. Care should be taken to avoid any large vessels which may be seen. The prolapse is then reduced, the sphincter partly cut through with the cautery on either side, and a little oiled lint placed in the rectum. The recum- bent position is absolutely enjoined for a month or longer if the wounds are not by that time perfectly healed, I do not think that this plan of treatment is an improvement upon that recommended by Van Buren, as if the cauterisation is made through a specu- lum when the parts have been returned to their nor- mal position there will be a close correspondence between the deeper and more superficial portions of the wound, whereas if the cauterisation is effected before reduction of the prolapse, considerable dis- placement of the wound will necessarily take place, and firm adhesion between the mucous coat and deeper structures is less likely to be ensured. Tlie establishment of a traumatic anal stricture for the purpose of keeping up a prolapse has been occasionally recommended. Thus Diefl^'enbach reduces the prolapse and stuffs the rectum with charpie to make the anus bulge ; he, then, with a cautery, * Loc. cit., p. 1G9. Chap. XIII.] Irreducible Prolapse. 211 deeply chars the entire margin of the anus, so that when cicatrisation is complete, a stricture will be formed, which will support the weakened bowel. And although a somewhat similar free use of the cautery receives the sanction of such a distinguished modern surgeon as Esmarch,* it cannot be, in my opinion, compared with the operation of linear cauterisation, for in the first place the protruded portion is only mechanically retained by forming an artificial stric- ture, whereas by the operation of linear cauterisation the coats of the bowel are so strengthened that the tendency to protrude is obviated ; and any surgeon who has witnessed the sufiering and annoyance occa- sioned to the patient by the presence of an anal stricture, will agree with me in thinking that it is very doubtful whether the cure thus produced is not worse than the original disease. Dupuytren has recommended the removal of elliptical folds of skin and mucous membrane from the margin of the anus, and a somewhat similar prac- tice has been sanctioned by Robert, Diefienbach, and Mott ; but with the improvements in the use of the cautery, I do not anticipate that this operation is likely to be again resorted to, except under some very special circumstances. In some rare instances it may be found that the prolapse is so voluminous that its reduction is impracticable, in the same way that we some- times find that the abdominal cavity is incapable of receiving back the contents of a large hernia ; and it becomes a question as to whether any opera- tive measures should be entertained in such a case. Also in those cases in which linear cauterisation has failed, it is obvious that any of the operations which have hitherto been enumerated are unsuitable, and the only procedure that can be contemplated * Loc. cit., p, 152. 212 The Rectum and Anus. [Chap. xiii. is the excision of the mass ; and I believe that this operation is amply justified when we consider the miserable state to which the patient is reduced, and the much greater success with which peritomeal wounds are dealt with now than formerly. Should the surgeon determine to practise this operation, the details, as exemplified in a case recorded by Dr. Kleberg,* leave nothing to be desired in completeness, so I give it in full : " On the previous day a dose of castor-oil was given, and on the morning before the operation an enema of lukewarm water was administered high up the bowel. Immediately before, a glass of wine and one grain of opium were given. After the patient had pressed down the gut as far as he could he was placed in the lateral position, with the pelvis raised and shoulders turned downwards. Chloroform was then administered." (In two cases Kleberg has operated without chloroform, because the patients were in such a miserable condition that he was afraid to narcotise them thoroughly.) " I carefully examined about the rectum at the junction of the skin and mucous membrane, in order to discover the sphincter ani^ a procedure that was more difiicult than one would think, because it had become so stretched and atrophied that I could only make it out by feeling under the fingers the coarser fibres running across the longitudinal axis of the bowel ; of anything like the normal muscle there was nothing to be dis- covered. An assistant at this point surrounded with all the fingers the prolapse from above, the points of the fingers being directed towards the free end of the prolapse, and pressed as hard as possible into the gut at a point perhaps half an inch below the supposed sphincter. Immediately in front of the ends of the assistant's fingers I then placed a good fresh unfene- strated drainage tube of rubber, one and one-half lines * Quoted by Kelsey, p. 123. Chap. XIII.] Operation OF Excision. 213 in diameter, around the prolapsus, and drew it only as tight as seemed necessary to stop circulation. The elastic ligature was kept at the necessary tension by means of an easily untied slip-knot of silk thrown under it. The assistant now had both hands free, and from this time on, the operation was performed under the carbolic spray. A few lines beneath the ligature 1 now made a longitudinal incision, two inches long, through the prolapsed gut, and in this way opened the sac formed by the drawing down of the peritonseum. Then I seized the elastic ligature with the forceps and hxed it firmly. It was thus an easy matter to push back into the peritonpeal cavity a protruding loop of intestine without the slightest bleeding taking place into the wound, or any air entering the peritonaeal cavity, because the elastic pressure follows so rapidly all the movements that no opening can exist anywhere. After I had convinced myself that the peritonseal sac was empty, and that only that part of the gut which was to be removed lay in front of the ligature, I thrust the largest size of Luer's pocket trocars through the prolapsus imme- diately below the elastic ligature from before back- wards, and passed through the cannula two elastic drainage tubes of one and one-half lines in diameter, and after removing the cannula tied them as tightly as possible, one on the right side, the other on the left. These knots were secured against slipping by means of a knot of silk. The first provision against haimorrhage, the elastic ligature applied after Esmarch's plan, was then removed, and the prolapsus cut off with the scissors one inch in front of the permanent ligatures. After a few minutes' time, during Avhich I kneaded the parts which still re- mained and lay above the ligatures thoroughly, and as far as possible removed the fluids from them, I covered the parts around the stump with cotton, and 214 The Rectum and Anus. [Chap. xiii. soaked that part of the prolapse which still remained above the ligature with a solution of chloride of zinc, dried it, squeezed the soft parts once more thoroughly, applied the chloride of zinc again, then covered the whole with dry cotton batting, giving the patient instructions to remove this as soon as it became moist, and to replace it with dry, and to give the air all possible access to the parts. No fever followed the operation, and the pain was bearable with the aid of an occasional opiate. On the next day the parts were so shrunk as to leave a concavity at the anus, where before there had been a bulging. There was no bleeding, no peritoneal irritation, and only slight tenesmus. On the fourth day the first ligature cut out, the second on the fifth. The rectum was irrigated twice a day with water and permanganate of potash ; and on the seventh day a dose of castor oil was followed by a large evacuation while the patient was on his back, without pain or haemorrhage ; the passage was, however, involuntary. On the fourteenth day the wound was healed, the general condition of the patient excellent, and the evacuations regular but still involuntary. The sphincter at this time began to be appreciable, and there was no protrusion of the bowel, the patient going about and wearing a bandage. One month later he had control of solid faices, but there was still a sliglit discharge of mucus, and after another month he was entirely well." In this case the prolapse was about a foot long, and six inches in diameter ; the mucous membrane was excoriated and ulcerated ; the patient had been sick for two years, had been bedridden for two months, and was waxy pale. Another case recorded by the same surgeon and treated by the same method ended fatally ; but can hardly be considered a fair test of the dangers of the operation owing to the bad condition of the patient. Ch..p.xui.] Pkolaps£ ivirii Invagination. 215 It is, of course, a very different matter operating as above, with the full intention of opening up the periton?eal cavity, and with all tlie necessary precau- tions against protrusion of the small intestines through the wound, and operating on a prolapse under the impression that it consists of mucous membrane only, the first indication of involvement of the peritonaeum being the escape of coils of small intestine, some of which may have been injured. The tliird variety of prolapse— This variety, when there appears in the rectum, or through the anus, a portion of the upper sections of the intestinal tract that has become invaginated, can only be briefly alluded to here, and that only so far as the diagnosis is concerned. For further particulars of this interesting subject the reader is referred more particularly to the admirable book in this series on " Intestinal Obstruction," by Mr, Treves, and to the article on the same subject in Ziemssen's Cyclopaedia, by Leichtenstern. The important point in the diagnosis is the presence of a sulcus between the anal margin and the prolapse. If this exists it is obvious that the case must be one of intussusception, and if with a finger or ordinary probe the bottom of the sulcus can be reached, it will indicate that the intussusception has taken place in the rectum. If, on the contrary, the starting point of the invagination cannot be felt in this way, the sase will be one of colic, or the more common form cf ileo-caecal intussusception. Leichtenstern, whose statistics on this subject are the most comprehensive that have been yet published, states that out of a total of 220 cases of intussuscep- tion, in forty-one the tumour projected from the anus, while in thirty-one other cases it was felt in the rectum. These tumours in the rectum have been not unfre- quently the source of errors in diagnosis, and they 2i6 TiJE Rectum and Anus. [Chap. xiii. have in consequence been removed, the intussusception having been mistaken for a polypus or malignant growth ; so that the possibility of a rectal tumour being due to intussusception should be carefully remembered by the surgeon when trying to arrive at a diagnosis. CHAPTER XIV. THE ETIOLOGY OF PILES. It would appear from the earliest historical accounts, and from the most antiquated medical writings, that haemorrhoids, or piles, were recognised as constitu- ting a common disease at a very remote period, and at the present day it may be safely said that the majority of persons who have reached middle life have suffered in some degree from some manifestation of it ; in fact, there is scarcely a disease of more common occurrence. The word haemorrhoids was used in a much broader sense formerly than it is now. It was a term applied to a bleeding from the anus from any cause whatever ; and, indeed, by some of the ancient writers it was applied to any haemor- rhage, whatever its site ^might be. By Hippocrates the term was held to include varices of the extremities of the haemorrboidal veins, as will appear by the following passage, as translated by Bodeiihanier : * " A defluxion of bile, or of pituitous matter, to the veins of the anus inflames the blood which those veins contain. The veins themselves being inflamed attract the blood of the others near them, and being filled with it, raise and swell the internal parts of the rectum. The little heads of the veins are then * " On the Hemorrhoidal Disease," p. 8. New York, 1884. Chap. XIV.] Definition of Piles. 2 1 7 conspicuous, and partly from the pressure of the faeces, and partly from their own fulness, are liable to break and emit blood, particularly at the time of dejections." At the present day the term is so universally applied to vascular tumours of the rectum, that it would be inconvenient to make any change. At the same time the word, as implying a symptom not al- ways present, is objectionable. The word piles (from 'pila^ a ball or swelling) is, as implying no theory or- symptom, perhaps, on the whole, more suitable ; and I would define the term as a tumour originating in a, diseased condition of the hlood-vessels of the lower end of the rectum, the vessels having undergone dila- tation and proliferation. ^tiologyt — When we come to inquire into the aetiology of this disease, we find that the causes of piles which have from time to time been given are indeed numerous ; and that haemorrhoids are met with under almost all conditions of life (in the male and in the female, amongst the opulent and poor, the sedentary and active), so that we must lookj for one common cause as the most essential in the production of the same disease under such diverse circumstances. That common predisposing cause is, I feel sure, an anatomical one ; and ihat the erect position occupied by man is the most essential element is, I think, a plausible theory. There is no similar disease, so far as I am aware, known amongst quadrupeds. In order to estimate fully the importance of this question, it will be necessary for us briefly to review the more imjDortant anatomical facts in connection with the vascular supply of the lower bowel. The arterial supply of the rectum is derived from three sources : the superior hsemorrhoidal branch from the inferior mesenteric, the middle either directly or indirectly from the internal iliac, and the inferior hsemorrhoidal 2i8 The Rectum and Anus. [Chap. xiv. from the pudic. Of these the most important is the superior, which differs from the others by being a single vessel, and not symmetrical. The superior lijemorrhoidal artery passes down between the layers of the meso-rectum, and then divides into two branches, each of which forms a loop at either side of the bowel, the convexity looking downwards. From these two loops a variable number of vessels pass directly downwards, perforating the muscular coat, and then, •lying immediately below the mucous membrane, they descend, one in each of the columnge recti, to the anal verge, inosculating freely with one another, and at the lower end of the rectum communicating by trans- verse branches of some considerable size. Thus it will be seen that the entire mucous membrane, down to the very anal termination, is supplied by branches of the superior Inemorrhoidal artery, the middle and inferior hsemorrhoidal vessels being distributed to the tissues on the outside of the lower end of the bowel and the skin immediately surrounding the anus. Tlie distribution of the veins is somewhat similar : the blood from the lowest j:)ortion of the mucous membrane of the rectum is first collected in a number (generally about twelve) of little dilated pouches, arranged in a circular manner, situated immediately within the anal verge ; from these, small venous radicles ascend, inoscu- lating to form larger branches, and, at a distance of about three inches from the anal margin, the veins, generally about five or six in number, perforate the muscular coats of the rectum by passing through oval slits in the muscular structure. Verneuil has laid great stress on this arrangement in the aetiology of piles, for as these apertures are unprotected by any fibrous canal, the veins must be subjected to consider- able pressure ; and retardation of the flow of blood througli them during the contraction of the muscle must result. The veins having thus emerged from the Chap. XIV.] Predisposing Causes of Piles. 219 rectum become tributary to the inferior mesenteric vein, and finally discharge their blood into the vena portce. Like all the veins going to form the vena portse, these vessels are destitute of valves, con- sequently the walls of the hsemorrhoidal vein have to withstand the pressure of a considerable column of blood, the tension of which is at all times liable to be increased by hepatic obstruction, and intra-abdominal pressure. Veins also accompany the branches of the inferior and middle hsemorrhoidal arteries, but unlike the vessels just described, they discharge their blood into the general or caval circulation, and consequently are unaffected by changes in the portal system. It is ■usually asserted in the anatomical text -books that a very free anastomosis takes place between these two systems of vessels : that, however, as I have several times demonstrated by injection, is proved not to be the case. If a tine size injection be forced through the superior hsemorrhoidal artery, or, preferably, through the accompanying vein (for, as there are no valves, this can readily be accomplished), it will be found that the capillaries of the mucous membrane can be with facility fully injected right down to the point where the mucous membrane joins the skin, but that the skin itself, and the radicles of the middle and inferior hsemorrhoidal veins will not be injected. This is what we might expect from a consideration of the development of the lower bowel. The rectal pouch is at first a cul-de-sac situated at some distance from the perina3um, and as it descends it carries with it its own proper blood supply, which is similar in its source and arrangement to that of the rest of the intestinal tube ; the anal depression, with its cutaneous appendages, which finally unites with the rectum, being supplied with vessels analoo^ous to those of other cutaneous surfaces. I may, while dealing with this point, mention, in passing, that this want of communication 2 20 The Rectum and Anus. [Chap. xiv. between 'these two systems demonstrates the futility of applying leeches around the anus with a view of relieving portal congestion, a method of treatment which, nevertheless, is still frequently had recourse to by physicians. It is obvious that, applied to the skin in the vicinity of the anus, they can be of no more use than if they were applied to any other part of the surface of the body. Another anatomical point which must not be lost sight of is the extreme mobility and dilatability of the structures constituting the termination of the bowel, as favouring the free growth of tumours. To sum up, then : small dilatations occur normally at the com- mencement of the rectal veins ; the blood returning through them has to pass up against gravity while the body is in the erect or sitting posture ; and, as the vessels are unprovided with valves, the whole weight of the column of blood presses continuously upon their radicles ; the veins are subjected to pressure while passing through the muscular wall ; and, again, at the liver obstruction is common. The act of defsecation has much to say to the aeti- ology of piles. During the passage of a solid mass of faeces along the great intestine considerable pressure is exercised on the blood-vessels. In the colon and in the first stage of the rectum this is rather salutary than otherwise, as the vessels are arranged, for the most part, at right angles to the axis of the bowel, so that the con- traction of the tube empties the veins into the larger channels ; but when the lower portion of the rectum is reached, this is not the case. As previously mentioned, the vessels of the lower bowel are arranged parallel to the direction of the intestine, consequently the passage of the fascal bolus forces tlie blood in the opposite direc- tion to that in which it should flow in the veins. An illustration will make this more clear. If an elastic band is passed round the arm, and gradually rolled down Chap. XIV.] Influence of Sex. 221 towards the hand, the superficial veins below the point of constriction are rendered full and prominent. Now, a strictly analogous thing occurs during defseca- tion, with the exception that the veins are to be found in the outer and compressing tunic, and it is the solid mass of faeces in the interior that moves on. The l)assage, therefore, of every hard and constipated motion subjects the veins of the heemorrhoidal plexus to a very considerable dilating strain, and conse- quently furnishes one of the most important, if not the principal, factors in the setiology of piles. When the abdominal muscles are called into forcible action, a considerable amount of pressure ia brought to bear on the entire portal system of veins, and under ordinary circumstances the sphincters and levatores ani, acting simultaneously, equalise the external pressure on the hsemorrhoidal plexus, so that no dilating strain can be experienced ; but when defsecation is taking place, the latter muscles are relaxed, while the abdominal muscles are contracting forcibly ; consequently there must be a strong tendency to regurgitation of blood into the rectal veins. All prolonged efforts of straining at stool are, therefore, to be avoided by persons with any tendency to haemorrhoids ; and at the same time the bowels should not be allowed to become too con- stipated ; and food calculated to leave a hard faecal residue is to be avoided. Sex. — Much has been written on the relative fre- quency of piles in the male and female sex, and very opposite opinions are to be found in the works of different authors on the subject. In my own practice, I find the ratio is about five males to three females, but statistics are at all times apt to be misleading, and especially is this the case in the subject under con- sideration. Females, from natural delicacy, are apt to postpone consulting their medical attendant for a disease which occasions such slight annoyance as 22 2 The Rectum and Anus. [Chap. xiv. ordinary internal piles, unless they are strangulated or inflamed ; and, again, they are so accustomed to observe the mensti-ual flow, that thev attribute but slight importance to a bloody discharge from a neighbouring organ. It very frequently happens that Ave find an?emic women suffering from bleeding piles, who have either not noticed or paid little heed to the bloody discharge from the rectum until their at- tention has been directed to it by their medical atten- dant. In men, on the contrary, the discharge of blood generally at once attracts their attention, and they forthwith consult their doctor. There are several reasons why we should a priori expect piles to be more frequent in women than in men. In the first place, the pressure of a gravid uterus tends to produce dilatation of the veins of the hremorrhoidal plexus in the same way that it produces varicosities of the labial veins, and those of thelower extremity generally ; and, as a matter of fact, piles are extremely common, both during pregnancy and immediately after partu- rition. Another cause which must not be lost sight of is the habit which women undoubtedly have more than men of permitting their bowels to become habitually constipated, although this may be to a certain extent counterbalanced by the greater pelvic capacity which they possess. In women, also, at the menopause, a discharge of blood from the rectum, frequently attended with the presence of hjemorrhoidal tumour, is of extremely common occurrence ; and the pressure of a retroflected uterus, or of tumours connected with the ovaries or other pelvic viscera, may sometimes be admitted as a cause of this disease. On the other hand, men are, as a rule, more exposed to the deleterious influences of excess in eating and drinkinij. Age. — Piles are essentially a disease of the middle period of life; their occurrence under the age of puberty being extremely uncommon ; and whtn thev Chap. XIV.l PlL^S IN EaRLY LiFE. 223 do occur in cliildren they are generally found to be formed of simply dilated veins. I have seen two cases (one in a child aged six years, and another in a child aged eight) in which there were single external piles manifestly due to varix, and similar cases have been noticed by other observers. In a case recorded by Mr. r. Ogston, junior,"^ the disease appeared to be congenital. The earliest age at which an internal pile has been noted, so far as my knowledge goes, is that recorded by Allingham,t in which in a child aged tliree years he found three well-marked venous haemor- rhoids. On the other hand, piles but seldom originate in old people, except as a result of paralysis of the sphincter muscle, either associated with general para- lysis, or from intrinsic relaxation. When this takes place, owing to the pressure on the portal system, from contraction of the abdominal muscles being unopposed by the relaxed sphincter, varicosities in the hsemorr- hoiclal plexus of veins are apt to occur. Heredity. — It is almost impossible to form an opinion as to the influence of heredity in a disease so wide-spread and common as piles. No doubt the habits of life which help to the formation of haemorrhoids are frequently inherited, and to this extent heredity may be admitted as a cause ; but I do not think there is any evidence to justify us in attributing any great importan(;e to this subject. Excessive eating- must be admitted as an important element in the formation of this disease, as, in addition to the general plethora which is induced, Niemeyer.i has in detail pointed out that a general engorgement of the portal system of veins especially takes place during digestion, as evidenced by the temporary enlargement of the spleen during that * LanceU May 12, 1886. . t "Diseases of the Kectum," p. 92, note. Fourth edition. :;: " Pract. Med.," vol. i. p. 586. 1871. 2 24 The Rectum and Anus. [Chap. xv. time. This engorgement, when frequently repeated and carried to an abnormal extent, will produce a more permanent dilatation of the tributaries of the vena portse, and so the formation of haemorrhoids may be originated. The increased bulk and frequently irritating nature of the faecal residue in those who eat inordinately, contributes to this result. A catarrhal condition of the mucous membrane, by the congestion which is produced, tends to the formation of haemorrhoids. This catarrhal condition is frequently, to a great extent at any rate, caused by the habitual use of strong purgative medicines. Many persons are morbidly sensitive about the action of their bowels, and consume enormous quan- tities of medicine, with the result of keeping up a con- stant irritation of the mucous membrane, which is quite uncalled for. If the habit of getting the bowels to move once a day at a certain hour is cul- tivated, it can generally be acquired without the use of cathartics ; and for persons with haemorrhoidal ten- dencies, the best time is immediately before going to bed, as the subsequent rest in the recumbent position tends to relieve the congested mucous mera])rane. CHAPTER XV. EXTERNAL PILES. The classification of piles into external and internal is time-honoured; and as these varieties present many distinct clinical features, the terms are best main- tained, although it is by no means uncommon to find both varieties associated in a given case ; and some- times even difficulty may be found in making out the Chap. XV.] Venous Piles. 225 line of demarcation between them. By external piles we understand those which are covered by skin ; while those which are situated within the anal margin, and consequently have a covering of mucous membrane, are called internal ; and where an external pile is directly continuous with an internal one across " Hilton's white line," without any sulcus existing between the two, it is called intero-external. External piles. — Of external piles several va- rieties have been described, but for practical purposes the division into venous, cutaneous, and compound will suffice. The condition described as cedematous pile by Mr. Cripps can scarcely be classed as a variety, but is more properly considered as one of the compli- cations which may be grafted on the other forms. The essential element in the production of a venous pile is a varicose condition of the external hsemorrhoidal veins, which is predisposed to by any of the causes before enumerated. As long as the vein remains pervious and free from phlebitis, the patient is free from discomfort, and in all probability ignorant of the existence of the disease. When, however, thrombosis takes place, or the swelling be- comes acutely inflamed, the pain is severe, and attended with considerable constitutional disturbance : the tongue becomes furred, the febrile condition being quite out of proportion to the local cause ; the skin in the neighbourhood becomes inflamed and swollen ; spas- modic contractions of the levator ani and sphincters add much to the patient's sufiering, this being peculiarly annoying just when the jtatient is going asleep, the violent contractions and acute pain completely wak- ing him up ; there is a sensation as if there was a foreign body in the rectum, producing tenesmus and painful straining ; the symptoms are all aggravated by walking . or by any sudden contraction of the diaphragm, as in coughing, sneezing, etc. .; constipation p— 23 2 26 The Rectum and Anus. [Chap. xv. is usually present, and when the bowels do move the pain at the time and for some hours subsequently is much increased. Such is the train of symptoms which characterise what is known as an acute *' attack of piles." If an examination be made of a patient in this condition, one or more livid tumours, varying in size from that of a pea to a filbert, will be seen in the neighbourhood of the anus. These are acutely sensi- tive, and have a tense glistening surface; pressure fails to empty the blood out of the tumour ; at least, this has been invariably my experience, and I believe that thrombosis of the varicose veins is the first element in the production of an attack of external piles. At the anus of the majority of adults small varicosities are to be found in the plexus of veins. These can usually be emptied by pressure, but prior to thrombosis they give rise to no annoyance to the patient, and are so common as to be scarcely con- sidered pathological. Many authors describe the presence of a blood clot, surrounded by inflamed tissue, as a consequence of extravasation of blood due to rup- ture of oue of the small veins, and they state that the diao-nosis between this condition and inflammation of a varix is to be made by trynig whether the tumour can be emptied by pressui'e, apparently forgetting that one of the first effects of phlebitis here, as elsewhere, is to produce thrombosis and occlusiou of and con- sequent inability to empty the vein, I have never seen a case of external piles which I believed to be due to extravasation, and in a number of cases I have been able to prove that the tumour was a thrombosed varix. When treated by incision the little clot shells out, leaving a smoothly lined cavity, and if a piece of this lining membrane be stained with nitrate of silver and examined microscopically, it can easily be demon- strated that it has an endothelial lining similar to the veins ; and again, extravasation of blood into tlie Chap. XV.] Compound External Piles. 227 tissue surrounding the anus is extremely common as a result of forcible dilatation, as a preliminary to numerous rectal operations ; yet we do not find ex- ternal piles resulting from this procedure, but rather a diffused extravasation, resembling the familiar "black eye," which disappears painlessly in a few days without the production of any localised tumour. The second variety or cutaneous pile is not unfrequently a sequence of the first, the inflammation surrounding the thrombosed vein producing hyper- plasia of the connective tissue and skin, constituting a tumour, usually of small size and pale colour. These may become somewhat pedunculated, being attached by a narrow neck ; while more commonly they are found with a broad base of support, the hypertrophy of the skin being confined to the radiating folds that nor- mally surround the anus. These little cutaneous ex- crescences are called by some of the American authors "condylomata," and no little confusion has arisen in consequence, the latter term being in this country only applied to the soft mucous patch of unquestionable syphilitic origin. Cutaneous piles are apt from local inflammatory causes to become oedematous ; they then become much increased in size, smooth and shiny on the surface, and acutely painful. Amongst the direct exciting causes of oedematous piles may be enumerated fissures or other breaches of the muco-cutaneous surface, or the eczematous inflammation wdiich is not uncommon in this region. This inflammatory swelling usually subsides in a few days, leaving the pile somewhat per- manently increased in size j or suppuration may result. A form of external pile, to which the term com- pound external pile might suitably be applied, is not uncommon. It is usually of considerable size, about as large as a filbert, with, smooth surface, and very prone to inflammation ; if incised in the usual 2 28 The Rectum and Anus. [Chap. xv. manner, it is found to consist principally of connective tissue, and contains several thrombosed veins of con- siderable size, instead of one central cavity as in the common variety of venous pile. It is found in persons who have suflfered from repeated attacks of inflamed external haemorrhoids ; and is almost always placed laterally, the long axis being antero-posterior. While free from inflammation, external piles give rise but to trivial annoyance, which is caused by the mechanical inconvenience due to their size ; but when inflammation supervenes, the pain becomes extremely severe, so that the strongest man may be thereby quite incapacitated for any active employment. Hsemor- rhage from external piles is an unusual occurrence, and when present is not generally severe. I have, however, several times seen it, and in each case its vsource could readily be determined, the blood being seen to flow from minute orifices in the pile. Keflex pains are commonly complained of, and the bladder participates in this reflex irritability, as evidenced by frequent micturition, or sometimes by retention. Of the more important conditions with which ex- ternal piles are found associated, painful fissure de- serves prominent notice. It is but seldom that fissure has existed for any length of time without external piles being also present, and the character of the pile which exists at the lower termination of the fissure may be quite pathognomonic of this disease. This, which has sometimes received the name of '* sentinel pile," is crescentic in shape, the fissure terminating in the concavity of the crescent. Suppuration is a very common termination to an attack of inflamed external piles, and when it occurs tends to the production of a complete spontaneous cure. In rare cases, however, the abscess cavity opening in a second place, a small marginal fistula forms {see page 68), which may require the intervention of the surgeon before it will heal. Chap. XV.] PHLEBOLITHS. 229 I Lave already (page 1G4) quoted the description of a condition of the anus given by Colles, and con- sidered by hiui to be pathognomonic of stricture of the rectum ; and it appears clear to me that the projections at the anal margin to which he refers are constituted by some form of hsemorrhoidal tumour; but while admitting that a group of small external piles nearly always surrounds the anus in cases of stric- ture, together with a certain amount of relaxation of the sphincter, in my experience these growths have not assumed the characteristic appearance described by Colles; so constant, however, is the association between these two diseases that, in every case of external piles, the rectum should be thoroughly explored with the finger for stricture. A rare complication of piles is caused by the calci- fication of the enclosed thrombus, constituting the so- called phlebolith. Concretions so produced are to be recognised by their hardness to the touch, feeling like grains of shot or peas inside the dilated vein. The occurrence of phleboliths in joiles was first joointed out by Bodenhamer,* who states that he has met with six cases. In structure they correspond with similar concre- tions found more commonly in some of the larger vari- cose veins in other parts of the body. According to Frankland f these are formed of concentric layers, which consist of protein matters, and phosphates : the former, constituting about 20 per cent, of the calculi, are nearly all albuminous or fibrinous ; the latter, though mainly phosphate of lime, are associated with a little sulphate of potash and sulphate of lime : that is to say, the phleboliths consist, as might be expected, of the coagulated protein compounds of the blood to- gether with the less soluble salts. When situated in the hsemorrhoidal veins they may give rise to irritation * " Hasmorrhoiclal Diseases," p. 109. 1884. t Holmes' "System of Surgery," vol. iii. p. 373. Second edition. 230 The Rectum and Axus. [Chap. xv. and the establishment of an anal fistula, as happened in three of the cases recorded by Bodenhamer. The treatiiient of external piles is usually suffi- ciently simple. It may be divided into the palliative and radical ; the latter of these is in nearly all cases preferable. If, however, the patient will not submit to the trivial operation necessary, recourse must be had to local ap]>lications during the period of acute inflam- mation. Of these palliative treatments, the best, in my opinion, is the application of a mixture of ex- tract of belladonna and glycerine smeared over the part, and followed by a warm stupe. At the same time the bowels should be freely cleared, and a light, unstimulating diet, with rest in bed, prescribed. The inflammation will then usually subside in a few days ; but it leaves behind a thickened projection of skin i-eady at any time to again inflame on the slightest provocation ; or, if suppui'ation occurs, the cure may be radical, but only at the cost of much unnecessary suffering. The radical cure may be accomplished either by incision or excision. When the pile consists of a simple thrombosed varix, treatment by incision and Turning out the clot may succeed. The question whether these procedures should be carried out while there is inflammation present has been fre- quently discussed, many surgeons preferring to wait until the acute symptoms have subsided. This I believe to be quite unnecessary, only subjecting the patient to prolonged pain. It is but seldom that the surgeon is consulted about external piles, except when they are inflamed, and the most certain and rapid way of giving relief is imuiediate operation. I have never seen the slightest ill eflect follow operation under these circumstances. Siiii|»le incision may be applied when the pile consists of a single dilated and thrombosed vein. It Chap. XV.] Excision of Piles. 231 is only necessary to incise the tumour freely with a sharp bistoury, and turn out the little contained clot. As the vein has already been occluded by the inflam- mation, bleeding need not be apprehended ; the cavity should be dusted with iodoform, and the patient kept quiet for a day or two. The relief is usually im- mediate and complete ; the sides of the cavity shrivel away, and the cure of the individual pile incised, at any rate, is permanent. As the incising is ex- tremely painful, the parts may be first yjainted with a 4 per cent, solution of cocain, which acts fairly well in a number of cases ; or freezing with ether spray may with advantage be employed. If the pile be of the variety which I have described as compound external hsemorrhoid, simple incision will not give relief. The clots cannot be turned out, and the tumour. will not collapse. For this form, there- fore, and also for the cutaneous piles, excision is the proper remedy. Excision undoubtedly is the form of treatment of most general applicability. If there are several tumours to be removed, it is better to give the patient a general anaesthetic, as the pain is con- siderable; and in performing the operation, the surgeon must be careful not to cut away the folds of skin about the anus too freely, else an anal stric- ture may be the unpleasant result. Only the distinct tumours should be dealt with, and of these only about two-thirds of each should be removed. The bases will then shrink, and all danger of stricture will be obviated. Simple oedematous folds of skin need not be interfered with, as they will quite subside when the source of irritation is removed. For performing this operation, by far the most useful instrument is Richardson's toothed scissors, its chief advantage being that it never slips, but cuts through the tumour exactly where it has been applied by the surgeon. 1 have not, however, 232 The Rectum and Anus. [Chap. xv. found that there was less bleeding after its use than after the common scissors or knife. Hsemorrliage after this operation, however performed, is usually trivial, and readily arrested by the firm pressure of a sponge. Occasionally, however, when a large and fleshy pile has been removed, a small arterial branch may require a ligature. In the treatment of broad-based piles, I have often found it a good plan to bring the cutaneous edges of the wound together with a few points of catgut suture. By doing so, healing will usually be much more rapid than if the surface is left to granulate. After the opera- tion is completed, the surface of the anus should be well dusted with iodoform, and a sanitary towel tolerably firmly applied, which will check any tendency to bleed- ing, and also diminish the painful spasm of the leva- tores ani, so troublesome after many rectal ojDerations. The bowels should be kept confined for three days, when a mild aperient, followed if necessary by an enema, should be prescribed. It is better to conBne the patient to bed until the wounds are closed, as the congestion caused by the erect position tends to inter- fere much with the healing process. Sometimes there is some difficulty in getting the wounds to cicatrise well, unhealthy little ulcers forming, Indeed, I think that there is more difficulty in this way after the operation for external piles than there is after the removal of internal piles, although of greater size. Should the wound become sluggish, it may be painted wit)i balsam of Peru, or the compound tincture of benzoin ; and in other cases lightly toucliing the ulcer with sulphate of co23per will frequently stimulate a healthy actioiL 233 CHAPTER XVI. INTERNAL PILES. Many varieties of internal haemorrhoids have re- ceived special descriptions from various authors, but the most simple, and at the same time practical, classification is that given by Hamilton.* It consists of the venous, the columnar, and the ncevoid. It must not, however, be inferred that the characters which distinguish these varieties are always defiiiitely marked ; but although they merge one into another more or less, the essential characters of typical ex- amples are such as to justify the division. The venous pile, wdien situated within the sphincter, resembles much the external pile already described, with this important difference, that the latter is covered with skin and has not much tendency to bleed ; whereas the former, being covered only by the thin mucous membrane, and more exposed to injury by the passage of hard feces, is exceedingly prone to haemorrhage. If these venous internal haemorrhoids have existed for a long time and been prolapsed, the covering may become much thickened, and paler in colour, so that it more nearly resembles skin ; but even under these circumstances they can be distinguished from external piles by the pre- sence of a more or less deep notch at the position of the muco-cutaneous junction. The coliiHinar pile is thus described by Hamil- ton: "The second variety, for which I would suggest the term ' columnar ' pile, to denote its pathology, * " Clinical Lectures on Diseases of the Lower Bowel," p. 32. Dublin, 1883. 2 34 The Rectum and Anus. [Chap. xvi. consists essentially of hypertrophy of the folds of mucous membrane surrounding the anal opening, the pillars of Glisson. They have a red, almost ver- milion, colour, an elongated form, and contain within them one of the descending parallel branches of the superior hsemorrhoidal artery." This variety is, I believe, much the most common form of internal pile, and at the same time it is the most important, owing to its great vascularity. The arteries leading to piles of this kind become much enlarged, and can frequently be felt pulsating forcibly, and apparently quite as large as a radial artery, at the upper portion of the tumour. If a section of one of these piles be examined microscopically^ it is found to consist of hypertrophied submucous tissue, with numbers of arteries and veins, and, if there has been any inflammation, many of the latter will be found thrombosed. It can therefore be readily understood how, when ulcerated or abraded, these tumours will bleed copiously. The third form, or the iisevoid pile, has also been described under the name of " vascular tumour of the rectum," and very closely resembles capil- lary nsevus. It may be present with the other variety, causing the mucous surface to assume a bright red, spongy, or villous appearance, not inaptly compared by Mr. Houston to a strawberry ; or this change in the mucous membrane may occur without any other manifestation of disease, in patches as big as a sixpenny piece. This is the form of pile in which the bleeding is most constant and continuous, although the amount lost at any one time may not be so copious as in the second variety. Of the syinptoiiis of internal piles, the most im- portant, and frequently the first, symptom to attract attention is bleeding. So constant is this symptom that the terms "bleeding" and "internal" piles are Chap. XVI. J Source of Bleeding. 235 practically synonymous. It is very rarely that the disease has existed for any time without this symptom being marked. It is at first only at stool that this loss of blood is noticed, the tender and highly vascular mucous membrane being bruised and lacerated by the passage of a hard f£ecal mass, the blood continuing to drip from the anus for some time after the rectum has been evacuated. As the disease progresses the bleed- ing becomes more frequent, till it occurs daily after each evacuation of the bowels ; indeed, in extreme cases, it is not confined to the act of defalcation, but comes on at irregular times, without any apparent exciting cause. In this way a condition of the most profound anaemia may be induced, attended with pallid features, dizziness, and palpitation of the heart ; indeed, it often happens, more especially in women, that these symptoms of ansemia have directed the attention of the medical attendant to a daily loss of blood from the rectum, which the patient has either not noticed or not heeded. The amount of blood which may be lost in this way is occasionally very great, and in certain rare cases a fatal syncope has undoubtedly been produced. Bodenhamer has collected a number of cases in which it is recorded that excessive quantities of blood have been lost ; but the majority of them are probably much exaggerated, a little blood making a great show when distributed over a patient's clothing, or mixed with urine and faeces. It is obviously necessary to distinguish between haemorrhage resulting from piles, and bleeding coming from some other part of the intestinal tract, such, for instance, as the stomach or small intestine. When not very excessive the latter is altered in colour by the digestive action of the intestinal con- tents, being of a dark, or sometimes tar-like, appear- ance ; and it is, moreover, intimately mixed with 236 The Rectum and Anus. [Chap. xvi. the fseces. The blood from piles, on the contrary, is not mixed with the faeces, but has evidently escaped subsequently" to the evacuation of the rectum ; and if it has been exposed to the air for any time is of a bright red colour. The fact that it is usually seen by the surgeon some time after it has been passed, has given rise to the belief that it is in- variably of arterial origin ; but venous blood, if exposed to the air, will become bright in colour, even after it has escaped from the body. And again, when a patient is examined with his piles pi'olapsed, the blood may be seen escaping in jets, leading to the belief that it is coming from a lacerated artery. That this, however, is not invariably the case is con- tended for by Cripps.* He says : " It is a matter of some interest to consider the source of this bleeding. The fact of the blood escaping in jets has led many hio^h authorities to reofard it as arisins; from some arterial twisr. With due deference to such eminent authorities as Brodie and Van Buren, I am of opinion that they are mistaken, and I do not believe that it ever comes from the arteries, but that the jet is caused by its being forced as a regurgitant stream through a small rupture in a vein by the powerful pressure of the abdominal muscles. If it really came from an artery, why should the jet only appear when the abdominal muscles act 1 " Cohnheimf considers that intestinal haemorrhage does not necessarily presuppose a breach of mucous surface, but that, when inflammation is present, the discharge may be produced by a diapedesis of red blood corpuscles. Mucous discharge is commonly present, either alternately with bleeding, or replacing it altogether. * "Diseases of the Rectum and Anus," p. 69. t Virchow^s Arcliiv, Band 41, p. 221. Chap. XVII.] Complications of Internal Files. 237 This has been specially described by Richet,* under the name '' hemorrhoides blanches," which, however, I cannot help thinking a singularly inappropriate term to designate what is nothincj more than a catarrhal discharge, resulting from the long-continued irritation of the rectal mucous membrane. Except when strangulated or acutely inflamed, pain is not a prominent symptom of internal piles ; nevertlieless, a certain amount of uneasiness or dis- comfort is generally present, with a sense of fulness and weight in the pelvis ; and reflex pains at a distance from the anus are not uncommonly complained of. These are most frequently situated in the back, groins, or genital organs. In one patient under my care there v/as severe pain located immediately above the symphysis pubis, Avhich was completely removed by crushing some small piles. CHAPTER XYII. THE CLINICAL RELATIONS AND COMPLICATIONS OF INTERNAL PILES. From what has been already said on the aetiology of piles, it will be obvious that they are not unfrequently but symptoms of some remote and more important visceral disease, and the surgeon who looks at these cases with the eye of a specialist, and directs his treatment solely to the rectum^ will be sure to be dis- appointed ; while in some instances positive injury will be inflicted on his patient. Of the more im- portant organic diseases with which piles may be as- sociated, those of the heart and liver occupy the most * Irish Hospital Gazette, July 12, 1874. 238 The Rectum and Anus. [Chap. xvii. prominent position, and it is incumbent on the surgeon to carefully examine every patient with piles for any symptom of these affections. I know of no case in which the surgeon may have greater difficulty, than in deciding on Avhat treatment to adoj^t for rectal hnemorrhage from internal piles when they are associated with grave visceral lesions. As illustrating this, the following case may jjrove instructive : In 1885, I saw in consultation with Dr. James Little, a gentleman who ha.d suffered from aortic patency for several years, and who also, for many months, had lost a very considerable quantity of blood from internal piles, each time the bowels moved. He was markedly anaemic, and it was obvious that his failing heart could not very long contiime to maintain the circula- tion. The daily loss of blood was, by diminishing the arterial tension, still further taxing the weakened heart, and it was obviously imperative to make some attempt to arrest the bleeding, although the under- taking of any operation in the patient's wretched state of health was by no means promising. I liga- tured five large piles, and the bleeding was from that time completely stopi^ed. Although he died six months subsequently from heart failure, the operation unquestionably prolonged his life, and rendered the remainder of it much more endurable. No surgeon would hesitate to operate in a case of strangulated hernia, no matter what condition the patient was in ; yet in some of these cases of combined heart disease and bleed hig piles, the continued loss of blood may be as surely, though perhaps not so rapidly, killing the patient. The connection between disease of the liver and piles is a matter of common observation, so much so that the latter are looked upon as one of the usual symptoms where there is portal obstruction, as is com- monly the case in cirrhosis of the liver; but I think Chap. XVII.] Is Bleeding ever Salutary? 239 it will be within the experience of most physicians that when rectal hgemorrliage from internal piles is coj'tioiis, another joromine.'nt symptom of cirrhosis, namely, ascites, is either entirely absent or very slight ; and I have twice seen persons who had been operated on for bleeding piles rapidly develop ascites after the haemorrhage had been stopped. Conse- quently it becomes a very important matter to decide whether an operation should be undertaken for the relief of bleeding piles when associated with cirrhosis of the liver. If the haemorrhage is not very great in amount and the person well nourished, it may be well to allow the discharge to continue, the slight loss being sufficient to relieve the obstructed portal system, and so prevent the transudation of serum into the 2:)eriton8eal cavity. If, of course, the haemorr- hage should be excessive and the patient much run down, operation is unequivocally called for ; but it is well to bear in mind the fact that Avheii the piles are dependent upon obstructed vena portse, recur- rence is very likely to follow operation, and the wounds are slow in healinof. The discussion of this subject brings us to the oft debated question : Is the bleeding from piles ever salutary, and if so, under what circumstances should it be allowed to continue unchecked 1 If we refer to the ancient writers we find that they considered that a haemorrhoidal flux served as an emunctory, by means of which bile and other acrimonious humours were excreted from the tursjid extremities of haemor* rhoidal veins. Hippocrates plainly teaches that hae- morrhoids perform 'the function of evacuating "the black bile of melancholic humour " ; consequently he recommends, when piles are operated on, that one should be left in order to obviate the danger of dropsy or phthisis. Bleeding from the rectum was thus rather considered as a physiological function than a 240 The Rectum and Anus. [Chap. xvii. pathologicpl condition, and when suppressed, many- methods were resorted to for the purpose of restoring the hsemorrhoidal flux. This teaching of the ancients has been, to a certain extent, continued down until quite recently ; and even still we frequently see patients suffering from bleeding piles, who have been told by their medical attendant that if the bleeding was stopped there would be danger of other more dangerous diseases supervening. Trousseau,"^ writ- ing on this subject, says : " The physicians of past ages have, perhaps, too much exaggerated the import- ance of h?emorrhoids in the scale of pathological phenomena, while those of our own time are fallen into the contrary extreme. It cannot be denied that the suppression of the hsemorrhoidal flux, when habitual, may be productive of general disorders among men almost as serious as the suppression of menses in women. Moreover, it is generally admitted that in certain persons who have not only regularly, but at indeterminate periods, a draining or haemorrhoidal flux, the existence of this pathological condition is attended with a state of general good health, although it may remain for a long time uncertain and variable, provided the haemorrhoids do not manifest themselves as soon as usual. Observation shows also that persons who have had haemorrhoids for a lonsf time suffer generally if this flux entirely ceases, and it often happens that there is a call for its restoration." In the same article. Trousseau recommends the application of cujjping-glasses to the anus, or the use of suppositories containing a quantity of tartarated anti- mony, sufficient to produce a considerable inflammar tion of the lower end of the rectum, with the object of reproducing the suppressed piles; and many of the old writers recommended the attempt to produce * Journal des Connaissances Medico- Chirwgicales, p. 101 ; Sept., 183G, Paris. Chap. XVII.] Piles and Uterine Disease. 241 heemorrhoidal flux, de novo, merely as a therapeutic expedient. It is not to be wondered at that, during an age when the periodical loss of blood was considered essen- tial even for the healthy, this spontaneous bleeding from the rectum was considered not to be in any sense prejudicial, but rather on the contrary a thing to be encouraged, and even, if possi-ble, in some cases, ini- tiated. Now, however, most sensible surgeons will agree thart the loss of blood, such as takes place from internal piles, is a pathological condition which it is well to free the patient from as soon as possible, the only possible exception that I know being some few cases of cirrhosis of the liver such as I have before mentioned, in which an occasional rectal haemorrhage tends to prevent the occurrence of ascites ; and some middle-aged and very plethoric people, who, although they frequently have slight bleeding, appear to remain otherwise in perfect health, and not to suffer in any way from symptoms of ansemia. In these cases the surgeon may well await the onset of indications that the loss of blood is ceasing to be well borne, before recommending any operation for radical cure, unless, indeed, the inconvenience (other than bleeding) is so great that operation may be demanded. Each case, therefore, must be judged on its own merits, and not treated according to any fixed rules. The association of haemorrhoids with uterine disease is not uncommon, and such cases are oc- casionally still further complicated by the presence of irritalale bladder. According to Allingham, these cases are extremely unfavourable for treatment, and he insists on the necessity of curing the uterine flexion, or other disease, before attempting to treat the rectum. In dealing with them we must always bear in mind the fact that uterine disease will fre- quently give rise to reflex pain in the rectum, when Q— 23 242 The Rectum and Anus. [Chap. xvii. no indication of disease is to be found in that organ, and, conversely, we not uncommonly see women who are being treated for supjDosed uterine disease, when the symptoms may be all referable to a small anal fissure or some other rectal disease. Strangulatioo and g^angreiie of internal piles may arise from one of two quite distinct con- ditions. Either the piles may be extruded from the anus, and caught by the sphincter ; or inflammation may be started from some trivial abrasion, and, owing to the extreme vascularity of the part, gangrene may rapidly ensue. Now it becomes a matter of import- ance to determine which of these conditions is present, as in some respects the treatment varies with the cause. The diagnosis is not difficult. If the congestion is produced by constriction of the sj)hincter, the history given will be that the patient had prolapse of the piles after defsecation, which probably occurred on fiequent previous occasions, when he was able to replace them himself. He, however, fails at last, on this occasion, to reduce them, or they descend again immediately after they are replaced. They soon become swollen, and the pain becomes extreme, with considerable fever and other constitutional disturb- ances. Upon inspection (Plate IV., Fig. 1), there Avill be found protruding from the anus one, or more frequently several, livid, tense tumours. Round the margin of the anus there is some slight inflam- matory cedema. Any attempt to touch these piles produces the greatest pain ; in fact, there are but few diseases in which the pain is of such a severe character as in the one under consideration. If the finger be passed into the rectum great resistance is experienced, and the forcibly contracting S2:)hincter can be felt grasping the finger tightly. If left unreduced, these intensely congested piles rapidly pass into a state of gangrene, and are thrown off, PLATE IV. Fig. 1. — Prolapsed and Gangrenous Intcinal Piles. Fig. 2. — Prolapsed Internal Piles. Chap. XVII.] Operation DURING Inflammation. 243 eventually producing a spontaneous cure, which, how- ever, is frequently incomplete, as the entire pile seldom dies, and the ragged portion which remains is likely to give trouble at some future time. Bleeding during the separation of the sloughing pile is not of uncommon occurrence. The treatment to be adopted may be either temporary, or radical. In the first instance re- duction of the piles within the sphincter should be attempted : and if the case is seen early, and is not complicated by much external inflammation, re- duction can usually be readily effected. In order to accomplish this, it is best to try and re])lace the most central portion first by passing the finger into the rectum, and as it is withdrawn to force up the remainder of the prolapsed portion. It is, however, better practice to obtain the permission of the patient to perform the radical operation at once ; and, owing to the very severe pain usually attendant on this condition, there is no difficulty about this. I on one occasion had under care a patient who had previously obstinately refused to have any operation performed on his piles, but who became loud in his entreaties to have them removed once strangulation super- vened. Should piles be operated on during inflamma- tion ? is a question upon which considerable difler- ence of opinion has been expressed. Those surgeons who oppose operation appear to me to base their objections purely upon theoretical grounds : no bad results, as far as I know_, have been recorded ; and, OR the other hand, those surgeons who have made a practice of operating express themselves favourably to it. My own practice, when called to a case of strangulated piles, is to recommend the immediate administration of an anaesthetic, dilatation of the sphincters, and the complete removal of all piles that 2 44 T'he Rectum and Anus. [Chap. xvii. can be seen, just as if the case was one uncomplicated by strangulation. The history of a case of inflammatory strangu- lation of piles differs from that of one of acute strangulation, the result of nipping by the sphincter ; and it is important to make the diagnosis. In the former, the patient may be conscious of having abraded the anus during defsecation, and a day or two afterwards pain and throbbing in the rectum gradually come on ; rigors and febrile disturbance supervene ; and there is great swelling and tumefaction about the anus. Upon examination the internal piles will be seen protruded, together with oedematous folds of mucous membrane ; the external piles, if present, will also be tumid from inflammation, and swollen folds of skin will radiate from the anus. Often, as a result of inflammation, internal and external piles run into one another, the line of junction being only marked by a slight sulcus. If the finger be passed into the rectum, the sphincter will not be felt unduly tense, the contrast with the condition of things in the previous case being most marked. If an attempt is made to reduce these inflamed j^iles within the anus, the most acute suflering will be induced, and the result will be quite futile. I have several times seen cases in which continued attempts had been made to reduce what really were, inflamed external piles and oedematous folds of skin, or internal piles, which from the inflammation of the surrounding structures were quite irreducible, under the impression that the case was one of strangulation by the sphincter. The writings published on rectal disease do not, in my mind, attach sufficient importance to this subject, but I think that the truth of what I have above stated will be evident to any surgeon of extended experience. Inflammation of the structures surrounding the Chap. XVII.] Inflammatory Strangulation. 245 anus of a severe character may sometimes co-exist with strangulation by the sphincter, but this I con- sider unusual ; therefore the following case, which I recently saw with Dr. Roe, may prove of interest, especially so as it illustrates also an unusual, and, in this case, eminently satisfactory plan of treatment. The patient was an officer who had seen a good deal of hard service in the Soudan. While there he com- menced to suffer from bleeding piles, which continued to trouble him at intervals for twelve months. On a certain occasion, after passing a hard motion, which he felt had severely scraped his anus, the piles gradually became swollen and painful. When seen by Dr. E-oe and myself, he had suffered extreme pain for four days, during which time several attempts had been made both with and without the aid of ansesthetics to reduce the swollen mass within the rectum, but without success. Upon examination a mass of internal piles of the size of a hen's egg, was to be seen, obviously gangrenous ; and surrounding these, and continuous with them, were a number of very large and partly gangrenous external haemorrhoids. It was quite evident that the tumours were absolutely irreducible, and also that the gangrene was the result, not of strangu- lation, but of inflammation, probably of septic origin. Upon introducing the finger into the rectum, how- ever, it was very tightly grasped by the sphincter, and the continued spasm of this muscle was causing the patient very great pain. As the gangrene had done its work so completely, no operation for the removal of the piles was required, it being quite apparent that they would, in this case, entirely slough away, but as the continued spasm was keeping up irritation, and causing very great pain, we determined to set it at rest. Owing to the gangrenous condition of the surrounding structures, we deemed forcible dilatation 246 The Rectum and Anus. [Chap. xvii. inadmissible, so I introduced a tenotome beneath the mucous membrane, and divided the sphincter muscle freely. The operation was followed by imme- diate relief to pain. The anus and its surrounding skin were saturated with a solution of iodoform in ether, and charcoal poultices applied till tLe sloughs separated. The patient made a rapid and good recovery, and although there was destruction of the entire circumference of mucous membrane and anal skin, no stricture resulted, and he has been able to 2:0 on foreign service acrain. Fissure of the anus is not an uncommon complication of internal piles, and when a patient complains of pain during defaecation, this may always be suspected, as internal piles produce only a sense of discomfort rather than real pain, except when inflamed. Since the introduction of preliminary forcible dila- tation of the sphincter when operating for internal piles, the practical importance of diagnosing the presence of tissure has been much diminished, as the dilatation will generally effect a complete cure; indeed, I have sometimes first been made aware of the presence of a small fissure, situated far in, when dilatation had been accomplished. In cases of old-standing piles small polypi are sometimes met with ; they are usually of the fibrous, and not of the adenomatous variety. They can with ease be removed at the same time that the piles are being dealt with. Simple stricture and mali^iant neo- plasms are sometimes met with co-existing with piles, and it is necessary, of course, to determine whether this is the case by careful digital examination. Indeed, the complete rectal examination of every case of piles that presents itself should be the invariable rule. The oidy other local afiection likely to complicate cha^. ^wiu.^ Files : Palliative Treatment. 247 piles is fistula, and usually there will not be much trouble about the diagnosis of this. The principles of diagnosis laid down in chapter v. apply equally here. CHAPTER XVIII. PALLIATIVE TREATMENT OF INTERNAL PILES. The treatment of internal piles may be classi- fied into the palliative and radical. Unquestion- ably, in some cases, the palliative treatment will be followed by complete immunity from further trouble ; yet these cases are quite the exception, and where the piles are large, and attended with the formation of much new tissue, it can hardly be expected that any- thing short of some surgical operative procedure will effect a cure. There are, then, two classes of cases in which the surgeon will confine himself to the medical treatment of the case : one that in which he considers there is a fair chance of cure by such measures ; and the other in which operation is declined by the patient, or is considered inexpedient on account of some complication, and in which, there- fore, the surgeon has to confine himself to mere palliation. I think the recommendations of a surgeon to have the trivial operation necessary for complete cure, are more often neglected by the patient suffering from internal piles than any other surgical malady. This is partly due to the fact that the public are still imbued with the teaching of former clays, that piles are beneficial, and believe that many ills and disabilities follow this trivial operation. Again, the pain suffered is not very considerable unless in- flammation has supervened. Yet there is no class of 248 The Rectum and Anus. [Chap, xviii. cases in which, with such slight risk to life, so much good can be done by operation; and patients who have suffered years of trouble and annoyance with piles are most grateful for the relief afforded by surgical treat- ment. What, then, are the indications or contra- indications for resorting to or not resorting to opera- tion % I can point out some of them. If the case is an uncomplicated one of long standing, with large piles pro- lapsing after def?ecation and with considerable haemor- rhage, radical treatment is clearly indicated ; and, on the other hand, if the piles are associated with grave visceral disease^ more especially disease of the kidneys, with albuminuria, operation should not be undertaken, unless the bleeding is so copious as to immediately threaten life, as in the case before recorded. Should piles be operated on during pregnancy "? is a question that often arises, in consequence of the very common connection between the two ; many pregnant women suffering great inconvenience and copious bleeding from this cause. Now, in order to answer this ques- tion, we must remember that the cause of the piles in this case is frequently due to the mechanical pressure of the gravid uterus, and that they will subside as soon as deliver}^ takes place, and that owing to the close ner- vous relationship which exists between the uterus and rectum, any operation must occasion some risk of pre- mature delivery. In this, as in many other cases, the indication for operation rests with the answer to the question, whether the loss of blood is making itself constitutionally felt to any great extent, or not : if it is, the piles should certainly be operated on. I have on one or two occasions operated under these circumstances with the best results, and without cur- tailing the duration of pregnancy. The most important indication to be fulfilled in the treatment by medical measures is the regulation of the bowels. If allowed to become costive, tl\e piles Chap. XVIII.] Selection OF Purgatives. 249 are liable to be excoriated during defsecation, and in- crease of bleeding and possible subsequent inflam- mation, is the necessary result ; whereas, if an easy and soft evacuation is secured each morning, a state of comparative comfort can be maintained. Numerous purgative medicines have been especially recommended for persons suSfering from haemorrhoids. In a work of the present kind of course it would be impossible to enter upon a discussion of the compara- tive merits of all the numerous purgative drugs which have been advised in cases of the kind of which I am treating. Such disquisitions are suitable to, and should be left to, special works on therapeutics. I can only [refer to, and indicate, those practices and principles in medicinal treatment which strike me as being of more especial practical importance ; or which demand notice from their habitual and customary employment. Of purgative medicines which it has become the fashion to recommend, the most recent appears to be the cascara sagrada. I have tried the fluid extract frequently, and think it is decidedly in- ferior to many of the older and well-established medi- cmes. It is unpleasant to taste, it frequently causes pain, and its action is inconstant. The use of aloes is by many ^viiters supposed to be contra-indicated in rectal disease ; for what reason I do not know : on the contrary I think a pill composed as follows the best for ordinary purposes : Ext. aloes socotrinse . . . . gr, 1^ Ext. nucis vomicae . . . . ,, -j Ext. belladonnse . . . • 5> a One or two for a dose as required. If these pills are taken occasionally, and a dose of some of the well-known ordinary purgative mineral waters in the morning, motions of the proper consis- tency will be ensured. If the pills alone are used^ the 250 The Rectum and Anus. [Chap, xviii. dose will have to be augmented ; and if the mineral water only is employed, it is apt to produce only a small fluid motion, after a time leaving some larger masses in the great intestine. When this occurs, it is, I think, the indication for the employment of pills containing aloes. Far better, however, than any pur- gative medicine is the use of an enema, the employ- ment of which is too much neglected in this country, most people, especially ladies, preferring to take any quantity of medicine to the use of this simple expe- dient. I cannot do better than quote the plain terms in which Mr. Mitchell Banks speaks of the disinclination of English peo^Dle to use enemata.* "Why do not English lecturers and text-books tell students more about the value of enemata % A Frenchman looks upon his enema very much in the light in which an Englishman regards his tub ; and a most excellent and cleanly thing it is. But our silly false modesty has in- duced us to attach something almost of indecency to this very innocent operation. I find some eminently respectable persons who are quite shocked at being asked to employ so un-English a remedy. And, again, the public have got an idea in their heads (fostered chiefly by medical men) that the frequent use of enemata produces distension and subsequent paralysis of the gut, and is consequently a veiy dangerous thing. I suppose if a man were to throw a quart of water into his rectum, and try to walk about with it there all day, that he would do himself mischief, but that the occasional use of six or eight ounces of tepid water can do anybody any harm, however long the habit may be kept up, 1 do not believe. A large number of persons are always purging themselves for constipation, in whom, I believe, the fseculent mass is lying in the rectum quite ready to move on if only the bowels could * Liverpool Medico-Chirurgical Journal, p. 293 ; July, 1886. Chap. XVIII.] Bathing with Cold Water, 251 effect its expuJsion. The introduction of a little water at once lubricates the canal, and gives the gut the stimulus to a smart contraction, which is all it wants." After the bowels have been moved, the anus should be carefully washed with cold water. This is one of the most important conditions to fulfil in order to make the hsemorrhoidal patient comfortable ; and it is one of the most powerful means of checking the tendency to hseinorrhage that we possess. Banks tells us* of a method which a patient of his found out for himself, and it appears to be at once the most effectual, and has the advantage of being simple and always a^Dplicable. " So soon as the bowel was evacuated, he remained perfectly still, emptied the pan of the water closet, and, keeping the rush of water on with his right hand, he threw it up with his left on to the everted mucous membrane. By this means he thoroughly cleansed his piles, and, by the direct application of cold water to them, ensured contraction of their blood- vessels, and their complete retraction. Carefully drying the parts with a soft towel (and not using paper), he then washed his hands, and was comfortable for the rest of the day." The diet should be regulated. All food tendincf to leave large fsecal residue should be avoided ; but the error most common is eating too gi^eat a quantity of food rather than the quality, and all persons suffering from piles who are great eaters will derive great benefit from restricting their diet. Stimulants are better avoided, except under special conditions. The internal administration of glycerine has been recommended, and when taken in large quantities it acts as a mild laxative, and so far is beneficial ; but beyond this it does not appear to have any decided action. Another remedy which has for many years had a reputation when administered internally is * Loc. cit. 252 The Rectum and Anus. [Chap, xviii. " Ward's paste," or confection of black pepper. What it was supposed to do I never was able to find out, and I certainly have not been able to see any good results from its use. Numerous topical applications have been from time to time recommended. Amongst these, the compound gall and opium ointment of the British Pharmacopoeia is a general ftivourite, and it certainly, in many cases, succeeds well both as a local astringent and means of relieving pain. The following ointment has, however, the advantage of being more cleanly and of more definite strensfth : o' R INIorphiae hydrochlor. Ext. belladonnse Acid, tannici Vaselin. . Lanolin. . Misce ; ft. unguent. gr. X. 3 j. 3 j- A small piece to be rubbed over the piles when pro- lapsed. Many of the American writers speak in the highest teruis of the use of ferrous sulphate in powder, to be applied either dry or in the form of ointment or suppository ; and where there is much bleeding it is a most admirable astringent, but it has the disadvantage of sometimes causing very con- siderable j)ain. The application which I prefer for ordinary cases is a dry powder composed of equal parts of oxide of zinc and subnitrate of bismuth ; tliis should be dusted over the tumours after they are washed subsequent to defsecation, and will be found very comfortable and quite sufficiently astringent for most cases. Where there is much mucoid discharge, this powder will be found eminently suitable. We find sometimes with piles an eczematous ex- coriation of the skin surrounding the anus. When Chap. XVIII.] Local Applications. 253 this is the case, the following application acts veiy well : R Liq. carbonis detergentis . . . ^ J- Liniment, calcis .... ad. 3 vj. Misce. To be applied to the piles with a piece of soft sponge. When the piles are inflamed, the aiDplication of a piece of absorbent cotton moistened with dilute lead lotion warmed, will prove very comfortable, especially if it alternates with light poultices. The application of an ice-bag is sometimes very comforting, but its use requires careful watching, as, if too long continued, the tendency to gangrene will be fostered. A patient labouring under piles should always take as much exercise as possible, riding being especially good. A gymnastic movement for the cure of heemor- rhoids is practised at the Bellevue Hospital,* and, it is stated, with considerable success. '• It consists simply in trying to touch the toes with the fingers without bending the knees. This movement, though difficult at first, soon becomes easy. It not only strengthens and develops the muscles of the abdomen, but also those of the legs and thighs ; it assists the action of other remedies, and thus aids in the cure." In conclusion, I would sum up the most impor- tant points in the medical treatment of piles as follows : Keep the bowels scrupulously regular ; adopt thorough ablution with cold water after de- fsecation ; use moderation in quantity of food and drink taken ; regular exercise ; and the occasional use of some of the astringents mentioned. If this plan is followed out, tolerable comfort will be ensured, and in a few cases which are not very severe a complete cure may be looked for. * New Ywli Medical Record, p. 599 ; 1877. 254 CHAPTER XIX. operativp: treatment of internal piles. To detail the numerous operations wliich have from time to time been recommended for the cure of internal piles would prove a laborious and useless task ; but, on the other hand, we cannot subscribe to the doctrine of Verneuil, that the treatment may be sunmied up in two methods : cold enemata and laxatives for mild cases, and forced dilatation for severe. The more important operations may be usefully enumerated under tlie following heads : 1. The application of chemical caustics to the surface of the tumours. 2. The injection of fluids of various kinds into the interior of the growths. 3. The gradual or forced dilatation of the anal sphincters. 4. Electrolysis. 5. Ligature. 6. Crushing. 7. Excision. 8. The actual cautery. 1. The application of chemical caustics. — Nitric acid was originally employed by Cusack, and strongly recommended by Houston,'* since which time it has met with very wides})read support ; and for a certain class of cases it undoubtedly answers admirably, viz. the small bright-red nsevoid pile, the object being to destroy the spongy and highly vascular mucous membrane covering this pile, and to tlnis substitute for it a cicatrix. As its action is only quite super- ficial, it is manifestly unsuitable for use in cases where there is a very extensive new formation of tissue ; and the attempt to treat such cases by means of nitric acid has occasionally brought the method * Dnh. Jour, of Med. Science, p. 95 ; 1843. Chap. XIX.] Chemical Caustics. 255 into undeserved disrepute. In order to use it with success, tlie rectum should be well cleared out by an enema, and the pile, if possible, protruded. If this cannot be done, a small speculum, preferably of silvered glass with a small aperture, should be intro- duced. The pile is now made to protrude into the aperture of the speculum, and fuming nitric acid spread over the surface with a glass rod or piece of stick. The little brushes made of spun glass for use with nitric acid are not suitable for this purpose, as small fragments are likely to break oif and irritate the mucous membrane. In doing this care should be taken to protect the skin of the anus from contact with the acidj or it may be protected by smearing with oil or vaseline. When sufficient acid has been applied, the surplus is neutralised by the application of chalk and water or solution of carbonate soda. If con- lined to the mucous membrane, the application of nitric acid is almost absolutely painless ; but if any is allow^ed to escape over the delicate skin surround- ing the anus, a very considerable amount of burning pain will result. The acid application usually requires to be repeated two or three times, at in- tervals of a week, Vjefore the cure is complete. Other chemical caustics have been employed for a like purpose, such as acid nitrate of mercury, Vienna paste, and butter of antimony ; but none of them answer the purpose better than fuming nitric acid, which has stood the test of such a long experi- ence. Amussat devised a s^Decial form of forceps by means of which a stick of caustic potash could be kept applied to the base of a pile for some time until sloughing was induced ; and Hamilton recommends the passage of needles covered with melted nitrate of silver through the substance of the pile for a like purpose. The injection of fluids of various kinds, by means 2c;6 The Rectum and Anus. [Chap. xix. of a hypodermic syringe, into the interior of a pile, is a method of treatment which has recently been re- vived, more especially in America. The fluids used vary considerably. Tincture of perchloride of iron has been used by Colles ; * solution of ferrous sulphate by Yan Buren ; f and liquid extract of ergot, etc. ; but the only injection which is now used to any extent is carbolic acid, either in simple solution or combined with tannic acid,| or combined with liquid extract of ergot.§ This method of treatment has been much more popular with American surgeons than with others ; amongst those who have especially written upon the subject, the names of Kelsey, Wash- burn, and Andrews must be mentioned. Kelsey, more particularly, is high in its praise, and states that he has now operated by this means two hundred times. II He tells us that for many years it had been a common practice amongst quacks and itinerant pile- doctors, and owing to the undoubted success which they sometimes obtained, he was induced to try it scientifically, so as to determine its limits of applica- tion. It a})p6ars to act in one of two ways : either sloughing is produced if the solution used is too strong, or even sometimes with weak solutions if the patient is much debilitated ; or a certain amount of inflammatory consolidation and thrombosis of the vessels is produced, which eventuates in a subsequent shrinking and subsidence of the pile. This latter condition is to be aimed at, except in some special cases in which sloughing is especially required. Care should be taken in performing this operation that the point of the syringe is passed to as nearly as possible the centre of the tumour, and the fluid slowly injected. * Dublin Journal Medical Science, p. 505 ; 1874. + Loc. cit. , p. 48. I Givard, British Medical Journal, Sept. 5, 1885. 5 Dr. Fenn, Medical Record, June 15, 1883. II Braithwaite's " Retrospect of Medicine," vol. ii. p. 45. 1885. Chap. XIX.] Injection of Piles. 257 The point of the syringe should be kept in place for a minute or two, so as to allow the fluid to become dispersed amongst the tissues, and the needle gently withdrawn. If the injection is merely passed V)eneath the mucous membrane, it is very liaVjle to cause sloughing of this membrane, leaving an ulcer slow in healing, and without curing the pile. Only one pile is to be dealt with at a time. The injections are best performed at intervals of a week, and several applications may be required for the cure of large piles. Kelsey gives the duration of treatment for severe cases as from ten to fourteen weeks, the patient being able to follow his usual occupation during that time. With regard to the solutions used, Kelsey employs carbolic acid in fifteen, thirty-three, and fifty per cent, solutions, and in some cases even pure acid. The larger and severer the piles, the stronger the solu- tion employed. Dr. Fenn's solution consists of equal parts of liquid extract of ergot, and of a ninety-five per cent, solution of carbolic acid, and of this he injects five to ten drops into each tumour. Washburn uses solution of carbolic acid in sperm oil, of the strength one to two if he wishes to produce sloughing, and one to four if he desires to produce absorption with- out sloughing ; * while Givard uses a solution consist- ing of tannic acid one part, carbolic acid two parts, alcohol four parts, and glycerine eight parts ; but he states that sloughing is a usual result.! The advantages claimed by the supporters of this operation are safety, freedom from pain, and no neces- sity for confinement. But even in America it has not met with by any means universal approbation. Dr. Matthews, of Louisville, declares it to be painful, in- sufficient, and liable to cause death by peritonitis, embolism, and py£emia. Amongst British surgeons * Philadrobably originate, like warts on the penis, from the irritation of gonorrhoea or other acrid discharge, Fig. 41.— Anal Papilloma. A, Surface of aual papilluma . b, section of anal rapi'loma, while at other times they certainly appear to form without any such apparent cause. T have removed a mass of this kind (Fig. 41), which weighed nearly lialf a ])Ound, from the anus of a young woman, in whom there was not the slightest suspicion of venereal contamination. They are easily removed with scissors, and as the attachment is external, bleed- ing points can be taken up without difficulty, and pressure applied to stop general oozing. Care, how- ever, must be taken not to remove too much skin from the anal margin, as otherwise stricture may result. * Loc. cit., p. 317. Chap. XX.] Dermoid Cysts. 295 Upon microscopical examination, anal papillomata present similar characters to those met with in otlier regions of tlie body, wliere the covering is of scaly epithelium (Fig. 42). The " cauliflower- like" ap- pearance is due to the ninne^rous sulci which exist between tlie papillae ; the epithelial covering extends rig. 42, — Section of Anal Papilloma (x 50). A, Scaly epithelium ; B, enlarged papillie. to the dee|)est ramifications of these snlci, so that in cross section it sometimes appears as apparently isolated spots. Teratoma, or dermoid cyst.— Although toler- ably commonly met with in the sacro-coccygeal region, and. in the pelvis in Connection with the genital organs, growths of this kind originating in the rectum proper are of extreme rarity. The most remarkable case recorded is that by Dr. Port.* A girl, aged * Transactions of the Pathological Society, vol. xxxi. p. 307 ; 1880. 296 The Rectum and Anus. [Chap. xx. sixteen, had suffered for three months from painful straining and difficulty in obtaining an evacuation. A polypoid tumour of large size came partly out at the anus when the patient wanted to pass a motion, and a lock of long liair repeatedly made its appear- ance, and could only with difficulty be replaced. It was found that the tumour was attached to the rectal wall by two pedicles about three inches above the anal orifice. The tumour subsequently became completely extruded, when the pedicles were ligatured and the growth removed. It measured 2^ inches by 2 inches, by 1|^ inches, and the bulk of it was found to be made up of fibrous tissue, with numerous fat cells, and embedded in it were two masses of bone, one hard and the other spongy. The coverings of the tumour showed all the characteristics of ordinary skin ; i.e. epidermis, papillae, hair follicles, and seba- ceous glands. The microscopical examination proved also the existence of numerous bundles of muscular fibres below the cutis. A canine tooth was observed growing from the tumour, near the pedicles. A somewhat similar case is described by Dr. Danzel.* A woman, aged twenty-five, complained of hairs protruding from the anus, which she pulled out when they became too long. They were found to spring from a polypoid growth about the size of a small apple, which was situated in the front of the rectum, about 1\ inches from the anal margin. The tumour was removed ; and, besides the lock of hair, a tooth was found on the outside, and microscopical examination demonstrated a bony capsule containing brain substance in the interior ! Molliere records a case of small tumour, of aboiit the size of an almond, the surface of which was covered with normal skin. The tumours of the sacrococcygeal region, although * Langenbeck, Archiv f. kliii. Ckirurg., p. 442 ; 1874. Chap. XX.] Fatty Tumours. 297 occasionally obstructing the rectum by pressure, are beyond the scope of this work to consider in detail. 5, JLipoma occurs in the interior of the rectum, as a more or less pedunculated growth, and a consider- a})le number of cases have been put on record. Un- less of a size suflicient to give rise to obstruction or prolapse, they do not appear to be characterised by any definite symptoms. Claude Bernard records a case * of a woman, aged eighty-three years, who suffered from constipation. Upon passing her finger up she felt the growth, and detached it, with complete relief of her symptoms. The growth was of about the size of a pigeon's ^gg., and composed of pure fat. Esmarch t mentions a case as occurring in the Clinic at Prague, in which an extensive invagination and prolapse were produced by a small lipoma. The growth having been removed, the prolapse was cured. Virchow| quotes a similar case from the practice of Sangalle, in which two submucous polypi, which were pedunculated, and about the size of hen's eggs, pro- duced an invagination of the colon, and finally a prolapse. And a third case of like nature is reported from Langenbeck's Clinic by Bose ; § and cases are on record in which the tumours have been expelled by unaided efforts of the patient to defsecate.j] This, in all probability, is due to the fact that rotation of the l)edicle has taken place, which causes rupture or strangulation. Virchow has shown H that a similar rotation, and final separation, sometimes takes j)lace on the outside of the gut in the pedicles of fatty tumours occurring in the appendices epiploicse, and he thus attempts to account for the occurrence of free * Quoted by MoUifere, p. 525. t Loc. cit., p. 154. X " Pathologic desTumeurs," vol. i. p. 379. Paris. § Esmarch, loc. cit. , p. 154:. II Castilaiu, Molliere, loc, cit. t Loc. cit. , p. 380. 298 The Rectum and Anus. [Chap. xx. lipomata in the peritonseal cavity. In some of the recorded cases, the pedicles of rectal lipomata have Leen noticed to contain a tolerably large funnel-shaped process of peritonaeum. This, taken with the fact that all the recorded cases appear to have descended from the sigmoid flexure, or upper part of the rectum, would possibly tend to show that these growths had originated in one of the appendices epiploicse which had become inverted : against this theory, how- ever, is the fact that similar tumours are sometimes found in the small intestine. In colour they are described as being redder than the ordinary lipomata, but otherwise they present no characters difterent from the same growth occurring in other parts of the body. The removal of these growths can be carried out in the same way as that of other pedunculated tumours : namely, by ligature and snipping off of the tumour. It is essential to remember how frequently there is a prolongation of peritonfeum into the pedicle of these growths. This would become a real source of extreme danger if simple excision were practised, or if the ecraseur was used. Broca records * a very instructive and warning case, in which he removed a polypus from the rectum by means of an ecraseur. The patient died in forty-eight hours, and an autopsy revealed the fact that a circular opening had been made communicating with the peritona^al cavity, which had permitted the escape of faeces, and so induced a fatal peritonitis. Voss reports a case f in which he successfully removed a lipoma from the rectum of a woman, aged forty-seven years. It was as large as a goose's Q^^^^ and attached by a pedicle, the origin of which could not be felt. He made an incision over the equator of the tumour, and without difficulty shelled it out of its capsule. * "Trait(^ des Tumeurs," vol. ii. p. 536. Paris, 18G9. f London Medical Record, p. 200 ; 1881. Chap. XX. 1 Fatty Tumours.' 299 Ligature, therefore, may be i-elied on as the most satisfactory and safe way of dealing with this pedun- culated growth, as it obviates all danger of htemorr hage, and should the pedicle contain a peritonseal pouch, it is not at all likely that any serious con- sequences would follow, as adhesion of the opposed serous surfaces would soon follow the application of a liijature. In the neighbourhood of the anus, fatty tumours have been noticed, some of which have gradually encroached upon the lumen of the bowel. They are sometimes pedunculated ; while at others they are more diffused in the subcutaneous tissue. One of the most interesting cases of this kind is re- corded by Robert,* in which the tumour sprang from, the ischio-rectal fossa and was removed, and was at lirst mistaken for a perinseal hernia. It occurred in a riding-master, aged forty-five years, and measured ten centimetres by seven. The operation at first consisted in cutting down upon the tumour layer by layer, as in the case of a hernia, but as soon as its true nature was evident it w^as followed into the ischio- rectal fossa and extirpated. 6. Cystoma. — Serous cysts have occasionally been spoken of as occurring in the rectal wall, but I have been unable to find any such case in which the pathology was made out with exactness. Sometimes, however, small cysts, filled with viscid fluid, are met with in infiltrating adenomata, and possibly larger ones, having a glandular origin, may occur. Atheromatous cysts are sometimes met with in the region of the anus. Those recorded have been of small size, and surgically unimportant. They could of course, if necessary, be easily removed by the same means had recourse to elsewhere. The fact that hydatid tumours have occasionally * " Annales de Th^rapeutique," October, 1884, quoted by Kelsey. 300 The Rectum and Anus. [Chap. xx. been met with in the pelvis should be borne in mind when investifi^atinoj the causes of obstruction due to ptessure on the rectum from within the pelvis. Eiictioiidroina. — A case of cartilaginous tumour of the rectum has been put on record by M. Dolbeau. D ^\--:r.zji Fig. 43. — Angioma of Rectum (Barker). A, Mucous membrane; b, section of miicous membrane: c, nrevoid structure; D, ulcers from which the fatal h'jemorrhage took place. It was removed from a youni^ man, aged twenty-seven years. It was of the size of a small nut, freely mov- able, and situated at the entrance of the anus, where it gave rise to little trouble : the mucous membrane in the neighbourhood was eroded. Microscopic exami- nation showed that it was in part composed of fibro- cartilaginous structure, but the greater part was Chap, XX.] N/EVUS OF ReCTUM. 3OI adenomatous.* Van Buren gives a case which he con- sidered was one of chondromatous tumour, but the case was not verified by minute examination. Ang'ioma. — The most remarkable example of this extremely rare condition is that described by Mr. A. E. Barker t (Fig. 43). A healthy man, aged forty-five years, stated that since boyhood he had difficulty in obtaining a motion when he was at all constipated, and that at these times there was bleeding from the bowel. Sometimes he remained free from these symptoms for several years at a time, his bowels as a rule being regular. A careful examination of the wall of the bowel showed three shallow ulcers on the rectal mucous membrane : they were seated on some smooth longi- tudinal folds in the wall of the gut, of a yellowish colour, and suggesting a quantity of fat in the sub- mucous tissue. The ulcers, though shallow, exuded continuously a considerable quantity of blood. Their base, however, presented a peculiar mottling of a purplish colour, as also did the surface of the irregnlar folds alluded to, the whole picture giving rise to the suspicion of a nsevoid mass in the wall of the boweh The statement of the patient that similar bleeding- had occurred on and off since boj^hood seemed to lend support to this view. The patient was subsequently admitted into University College Hospital ; the bleed- ing became of daily occurrence, and very copious ; and, in spite of all treatment, he died of haemorrhage. At the post-mortem examination the wall of the rectum in its lower four and a half inches was found much thickened by a n?evoid growth in its walls, which gave a purple colour to the mucous membrane. There were three or four prominent longitudinal folds, each three-quarters of an inch or more in width ; the two largest were on the left side of the bowel. * " Bull, de la Soc. Anatomiqiie," vol. v. p. 6, second series. t Medico-Cliiriirgical Transactions, vol. Ixvi. 302 The Rectum and Anus, rchap. xxi. These were the folds felt during life, one of them just to the left of the middle line in front. Two ulcers, one of them about the size of a threepenny- piece, the other larger and somewhat irregular, were situated about two inches from the anus. The tumour everywhere presented the character of cavernous naevoid tissue (Fig. 44). At the same meeting of the Medico-Chirurgical Society, Mr. H. Marsh related the case of a girl, aged ten years, who had suffered repeat- ^'AuRiom?o*f 'Sec^ ^^^^7 ^^^^ ^®^*^^ hsemorrhage. With turn, showing ca- the aid of a speculum, the patient (Barker)! ^^^ ^^ being Under chloroform, a nsevoid growth was seen in the lower part of the rectum, completely surrounding the bowel, Several applications of Paquelin's cautery relieved the symptoms considerably, but did not cure the growth. In the case already referred to as recorded by Dr. Barnes also,* the large polypoid tumour removed is stated to have been in part cavernous. CHAPTER XXI. MALIGNANT NEOPLASMS OF THE RECTUM AND ANUS. Of the various new growths which are found in the rectum, and which are clinically malignant, cylinder- celled epithelioma, or, as it is sometimes called, " malignant infiltrating adenoma," is unquestionably the most common. In a subsequent chapter we will discuss, as far as is at present possible, the pathological differences between * Sm page 292. Chap. XXL] Statistics of Cancer. 303 the various forms of rectal tumour exliibitino: malioj- nancy ; but as it is sometimes quite impossible to differentiate these varieties clinically, it will be con- venient to retain the term " cancer," using it in its broadest sense, as synonymous with all the forms of malignant tumour, whether histologically of epithelial or connective tissue origin. It is not necessary here to discuss the vague and speculative theories which have from time to time been put forward to explain the aetiology of cancer. Much has been written and said upon this subject, but nothing definite has been arrived at ; and it still remains an inscrutable mystery why it is that tissue in all respects apparently identical with normal epithelial structure should overstep its natural limits of gTowth and development ; extend widely into neighbouring regions ; appear as metastatic growths in other situations ; breakdown and suppurate as a result of excessive and exuberant grovrth ; recur after wide removal ; and, lastly, produce that constitutional dis- turbance and rapidly-progressing marasmus known as the cancerous cachexia. In order to arrive at some idea as to the frequency of rectal cancer, both relatively to the examples of tlie same disease in other parts of the body, and more particularly in other parts of the intestinal tract, it becomes necessary to refer to large statistics. It is, however, quite useless to collect for this purpose a simple record of cases published in periodical literature, the returns of large hospitals alone affording reliable information. Leich- tenstern"^ has carefully collated the following figures from the returns of the K.K. Allgem. Krankenhaus at Vienna. Out of 34,523 deaths at the hospital be- tween the years 1858 and 1870 were 1,874 cancers of different kinds, equal to 5 '4 per cent. ; and of 4,567 cancers ab the same hospital, 143 were of the * Ziemssen's "Cyclopaedia of Medicine," vol. vii. p. 635. 3^4 The Rectum and Anus. [Chap. xxi. rectum, and 35 of other parts of the intestines ; tho former were therefore 3 per cent., the latter 0'76 per cent, of the whole, and the former 80 per cent., the latter 20 per cent, of all cancers of the intestines. Mr. W. R. Williams* has collected a large series of equally reliable statistics from the Middlesex Hospital, St. Bartholomew's Hospital, St. Thomas's Hospital, and University College Hospital. Out of 5,556 cases, he gives the following table, showing the frequency in some of the more important organs : Male. Female. Total. Breast . 13 1,310 1,323 Uterus — 1,160 1,160 Tongue . 384 64 448 Rectum . 130 127 257 Skin of face including ro( and neck, ( i^^i lent ulcer . \ 89 250 External genitals . . 126 102 228 Lip . . 221 2 223 Intestines, etc . 23 26 49 It will be seen from this table that the results obtained at the London General Hospitals are prac- tically the same as those observed at Vienna. Re- ferring to the records of the Brompton Cancer Hospital, as given by Jessett, f we find that out of a total of 1,908 cases of cancer admitted, 58 were suffering from cancer of the rectum, or slightly more than 3 per cent. One would expect that a slightly smaller proportion of rectal cases would present themselves at this special hospital ; because persons suffering from cancer of tho rectum would be more likely to apply to a general hospital, under the impression tliat it was some other form of disease that they were suffering from ; whereas, persons suffering from some of the other and more easily recognisable forms of cutaneous cancer would •Lancet, May 24, 1884. t "Cancer of the Alimentary Tract," p. 238. London, 1886. Chap. XXI.] Statistics of Cancer. 305 gravitate to the Brompton Hospital. It may, there- fore, be taken as sufficiently accurate that in 3*5 per cent, of all cases of cancer the disease is situated in the rectum ; and in 80 per cent, of cases of intestinal cancer the disease is located in the lower bowel. In the records of St. INIark's Hospital, as given by Ailing- ham,"^ out of 4,000 cases of rectal disease, 105 were examples of cancer. The degree in which apparently sinilar forms of carcinoma exhibit the clinical features of malignancy varies notoiiously with the situation in which the disease develops. Thus, for instance, epithelioma of the tongue is extremely malignant ; whereas, the same disease situated upon the lip is, at any rate in the early stages, one of the most benign of the unequivocal epitheliomata ; similarly, epithelioma on the scrotum is very much more satisfactory to deal with than the same disease when occurring on the penis. Compared with other regions of the body, it would ap^Dear that the rectum is one in which the average intensity of the malignancy is not very great, the disease for a long time not passing the limits of the intestinal wall. Allingham, whose experience on this subject is so extensive, puts the average duration down at two years, the most rapid terminating fatally within four months of the earliest symptom of its invasion ; while the longest duration noticed by him was four years and a half. It is, however, quite impossible to estimate accurately the duration of this disease, as the symptoms during the early stages are so slight that they may be scarcely sufficient to attract the attention of the patient. This will be a matter of familiar observation to all surgeons. It not unfrequently happens that a patient comes to us complaining of some slight diarrhoea or other mild rectal trouble, and an examination unexpectedly re- veals the fact that he is the victim of cancer so very * Loc. cit., p. 3. u— 23 3c6 The Rectum and Anus. [Chap.xxi. extensive that it must have obviously existed for a very considerable period. And, again, the life of the patient is not unfrequently sacrificed by the accidental complications of the disease, such as intestinal ob- struction, or involvement of the bladder, rather than by the progressive marasmus, which is the usual mode of termination of cancer of other regions. Some authors state that as the result of their experience a greater number of males suffer from rectal carcinoma, while others assert that the opposite is the case. The large statistics of Williams, however, show that there is extremely little difference in the relative frequency. Out of 257 cases, there were 130 males and 127 females. Although essentially a disease of middle life and old age, rectal cancer has been met with several times under the age of 20 years. The earliest age that I have seen recorded is that noticed by Allingham* as having occurred in the practice of Mr. Gowlland at St. Mark's Hospital, in which a boy not 13 years of age suffered from cancer of the rectum ; while Allingham gives a case of his own in which a boy of 17 years died of what is described as encephaloid of the rectum. Con- sidering the vagueness of the terra encephaloid and the frequency with which it is applied to rapidly growing tumours of the sarcoma type, it appears possible in the absence of detailed microscopic examination that this tumour was sarcomatous, and it is well known that tumours of that type are not very uncommon in early life. A case of cancer is recorded by Godinf at 15 years, Quain one at 16 years, and Cripps one at 1 7 years. Schoening;}: describes two cases as occur- ring at the Eostock clinic. In the first, a girl, aged 17, presented typical symptoms of rectal cancer. She was stated to have suffered from rectal prolapse at the * Loc. cAt. , p. 270. t Quoted by Mollifere. J Deutsch. Zeitschrift f. Chirurg., Bd. 22, Hft. 1 and 2 ; 1885. Chap. XXII.] Pathology OF Cancer. 307 age of seven, and the more severe symptoms began to manifest themselves at the age of 16 years. The tumour was excised, and presented the microscojnc characters of undoubted carcinoma. The disease re- curred, and proved fatal in two months. The writer concludes that she suffered from adenoma at the age of seven years, which subsequently began to infiltrate and become malignant. In the second case, a girl, of 17, presented herself with a tumour the size of a fist, very hard, and encroaching on the pelvic organs, and affecting the inguinal glands. As the tumour could not be removed, the constricting tissues were divided. A portion removed proved the tumour to be an alveolar, cylinder-celled carcinoma partly undergoing cystic degeneration. CHAPTER XXII. THE PATHOLOGY OF MALIGNANT NEOPLASMS OF THE RECTUM AND ANUS. The older method of classification of tumours into be- nign and malignant, although of great practical utility, was soon found to be insufficient ; for although the difference between typical varieties was sufficiently obvious, cases were met with on the border land between the two which it was impossible to refer to either with certainty, and for these the class of semi- malignant tumours was introduced. Since the clinical classification has given place to the histological, it does nob appear that the exact limitation of the groups is thereby rendered, in some instances, more definite, and this is notably the case in cancer of the rectum. The clinical differences between the simple adenoma, or mucous polypus, of the rectum, and cancer of that 3o8 The Rectum and Anus. [Chap. xxii. organ, are sufficiently obvious : the simple adenoma generally occurring in young persons ; being attached by a long pedicle ; not tending to recur after removal ; or to affect the constitution : the cancer, on the other hand, is sessile ; tends to infiltrate deeper parts ; to break down and ulcerate ; to profoundly affect the constitution ; to recur after removal, and produce metastatic growths of similar character at a distance from the original site. Now when these growths are examined under the microscope, they both consist essentially of the same tissue, namely, the glandular structure of the mucous membrane, such as is normally found lining the Lieberkiihn follicles of the intestine ; the only difi'erence being that in the benign form there is a tendency to project into the lumen of the bowel, and to draw down a pedicle of normal mucous membrane, while in the cancer the wall of the intestine is from the very first infiltrated with the new forma- tion. First the muscularis mucosae becomes perforated, then the submucosa invaded, and subsequently the muscular coat itself is infiltrated {see Fig. 45, page 314), so that the only histological difference between these growths is really one of situation, and of relation to surrounding tissues, not of structure. As might be expected, cases are occasionally seen in which it is impossible to say to which class, whether adenoma or adeno-carcinoma, the growth should be referred ; so that histologically as well as clinically the limits of classification are not very distinct. As the carcinomata originating in any structure are principally composed of the epithelial elements similar to those normally present in the immediate vicinity, it follows that those com- mencing in the intestinal mucous membrane should consist principally of adenoid tissue, and such has been found to be the case. Mr. Harrison Cripps, whose investigations of the histology of rectal cancer Chap. XXII.] Varieties of Cancer. 309 have been extremely extensive, embracing a careful investigation of sixty separate examples of the disease, says : "In the rectum I have failed to dis- cover any growths or tumours which pathologists designate as scirrhous or medullary cancers, or as belonging to the different varieties of sarcoma. Con- sidering the eminence of many careful observers who have applied such names to these growths, it would be quite unjustifiable to assume that such distinctive structures never form the entire bulk of the tumour ; but I feel bound to state that, with j^erhaps a more than average opportunity of examining such growths from the rectum, I have been myself unable to dis- cover tumours composed entirely of the distinctive features appertaining to these diseases."* Mr. Treves f expresses a somewhat similar opinion, that the form of cancer found throughout the entire intestinal tract is cylinder-celled epithelium, and he quotes from a monograph by M. Haussmann,| who says: "We will give, then, cancer of the intestine the following definition : cancer of the intestine is cylindrical epithe- lioma of that organ." Putting aside for the present the question of sarcoma, the occurrence of which in the rectum is undoubted (and of which I have had an instance in my own practice), let us consider what is meant by the terms scirrhous and medullary cancers at the present day. If the former is taken only to indicate that in which, with the epithelial de- velopment, there is a very considerable hyperplasia of the connec^'ive tissue, forming firm and hard masses of tissue, the so-called stroma, which frequently manifest a tendency to contract and pucker the invaded tissue, then, without question, scirrhous cancer does occur in the rectum. Similarly, if medullary cancer or * "Diseases of the Rectum and Anus, "p. 317. 1884. t *' Intestinal Obstruction," p. 268. X " These de Paris," No. 228. 1882. 3IO The Rectum and Anus. [Chap.xxii. encephaloicl is taken to mean that the tumour is of rapid growth, soft structure, and that the epithelial cells are more or less embryonic in character, and the connective tissue ill developed, then this form of tumour is also present in the rectum. But if, on the contrary, tliese terms are taken to represent distinct types of carcinoma, the epithelial elements of which essentially differ from those found in the organ or tissue in which the carcinoma originates, then not only are these forms not to be found in the intestine, but they cease to have an existence in any other part of the body. As, however, these terms have been used with much vagueness, it is better to dispense with them altogether. All observers, however, appear to be agreed that at any rate by far the most common form of intestinal cancer is the columnar-celled epithe- lioma, or adeno-carcinoma, or infiltrating adenoma, as it is variously termed. The term cylindroma, which has been frequently used as a synonym for this disease, is misleading in the extreme, having been introduced by Billroth for a special form of tumour quite unconnected with this form of cancer. When cancer primarily attacks the anus, as might be expected, the bulk of the tumour is composed of scaly epithelium, and the growth resembles that met with in the lip. {See Plate I. ) Cripps has, however, stated that when a cancer, originating in the interior of the rectum, and of the adeno-carcinomatous variety, invades the anus, the character of the epithelial cells varies, and comes to resemble the ordinary scaly type. Tliis is remarkable, as the metastatic repro- ductions of intestinal cancer in other organs corre- spond very accurately to the original histological character of the growth ; as, for instance, the multiple tubercles in the liver, which are such a common sequela to rectal cancer, when examined under the microscope present the same follicular structure so Chap. XXII.] Varieties of Cancer. 311 characteristic of adeno-carcinoma. My colleague, Dr. Purser, has given me a section of a tumour in the lung, secondary to a carcinoma of the sigmoid flexure, and in it the reproduction of the oi'iginal character of the tumour was most marked, little masses of ejnthelial cells closely resembling Lieberkiihn crypts being sur- rounded by normal lung tissue. There is some considerable variation in tlie macro- scopic characters presented by adeno-carcinoma when present in the rectum ; these differences being chiefly influenced by the rate of growth, and the direction in which the tumour principally extends. These varieties may be distinguished as the "tuberous," "laminar," and " annular." The tuberous adeno-carcinoma presents itself as a considerable-sized mass projecting into the lumen of the bowel, obviously implicating the mucosa, which can be traced into it, but not moved freely over it. Associated with it may be other smaller masses. It is not necessarily very hard to the touch, and, in the early stages, does not extend beyond the limit of the rectal wall, as is demonstrated clinically by the free mobility of that organ in the pelvis. This form tends to ulcerate very rapidly; first the mucous membrane on the surface necroses ; then the centre of the mass breaks down, exposing the muscular laj^er of the intestine, and leaving a crater-like cavity surrounded by the infiltrated mucosa and submucosa ; at last the intestinal wall is perforated, and the pelvis becomes invaded, the bladder or urethra may be opened, the vagina ulcerated into, or the nerves of the sacral plexus involved in the neoplasm, or even the bony wall of the pelvis may become implicated. This variety may be taken as the type of the more rapidly growing adeno-carcinoma. It is the form most frequently met with in younger subjects. It may produce obstruction by the bulk of the growth, but does not usually do so by 312 The Rectum and Anus. [Chap. xxti. producing contraction of the intestinal wall, as the other and more chronic forms do. This no doubt is the variety alluded to l)y most of the older writers under the head of medullary or encephaloid cancer ; though in all probability the same term was applied to some of the sarcomata, which from rapid growth and large tumour formation resemble closely the tuberous adeno- carcinomata in their clinical aspects. The laminar form. — This, according to the investigations of Mr. Harrison Cripps, is the commonest variety. It occurs as a layer of adenoid groAvth spreading laterally in the submucosa, of a thickness of about a quarter of an inch or less, while the area over which it extends may be considerable. It has a tendency rather to extend laterally than vertically, so that in time the entire circumference of the gut'may be involved. Although principally situated in the sub- mucosa, it is obvious tliat the mucous membrane is attached to, and incorporated with, the growth ; and in the same way, the muscular tunic of the intestine is adherent to the tumour deeply. As the tumour advances in growth there is a considerable develop- ment of connective tissue in the outer walls of the intestinal tube, which subsequently undei-go con- traction, producing the puckering and cicatricial con- strictions which have given origin to the use of tlie word scirrhous in connection with this disease. As in the former variety, ulceration of the mucosa soon occurs ; which may be followed by perforation of the rectal wall into any j^ortion of the gen ito urinary system ; or at other times the new formation will be more rapid than the ulcerative action, and the result will be the spreading of a fungating mass into the rectum. The aniiiilai* form is that in which the neo- plasm surrounds the rectal tube without extending vertically to any great degree. It would appear to be one of the most chronic forms, and naturally attended Chap. XXII.] Histology OF Cancer. 313 with iDucli contraction, forming the true " malignant stricture." Besides the infiltration of surrounding structures, rectal adeno-carcinoma tends to reproduce itself in other parts of the body ; and like all the grou]) of the carcinomata, the lymphatic glands become implicated with extreme frequency. When, as is usually the case, the disease is situated entirely within the rectum, leaving the anus free, the first to be involved will be the pelvic and lumbar glands ; and sometimes these are seen to be of very large size, the glands along the iliac vessels being sometimes quite as large as hen's eggs, and capable of recognition during life by ab- dominal palpation. Next in order, the lumbar glands are enlarged ; but the lymphatics of the groin only become implicated as a consequence of involve- ment of the external skin of the anus, or when in an advanced stage of the disease a very widespread lymphatic implication follows the primary enlargement of the pelvic glands in cases of adeno-carcinoma. Next in frequency to the lymphatic system, the new growths are liable to be found in the liver, probably the most frequent cause of disseminated hepatic cancer being the form of disease under con- sideration. As is usual with metastatic tumours, the secondary growths re])roduce with singular exactness the histological characters of the original tumour. Involvement of the peritonaeum also is not unfrequent, the metastatic growths aj)pearing like grains of boiled sago over the surface, and matting together, when extensive, the coils of small intestine. Secondary deposits have also been found in the j^ancreas, lungs, etc. The essential histological characteristic of adeno- carcinoma is the fact that in this disease the adenoid tissue perforates the muscularis mucosae, and develops in the submucosa and muscular coat (Fig. 45). It is 3^4 The Rectum and Anus. [Chap. xxii. this characteristic alone which serves to establish the accurate diagnosis between the malignant and ^' B C A.' Fig. 45.— Cyliuder-celled Epithelioma of Rectum. A, External muscular coat of bowel ; b. internal muscular coit of bowel ; c, masses of adenoid tissue separating the bundles of muscular fibre of tbe internal muscular coat. non-malignant forms of adenoma, and in this respect the case is exactly analogous to difference between a wart and an epithelioma on tlie skin proper. In fact, Chap. XXII.] Histology of Cancer. 315 the essential element in the production of a carcinoma is the development of epithelium beyond its natural superficial limits. For fuller detail of the histology of rectal cancer the reader must be referred to the work of Mr. Cripps.* It is, of course, seldom that the very earliest stage of rectal carcinoma can be investigated, as no important symptoms are usually produced until the disease has made considerable progress, so that it* is impossible to state Avhat the initial change is. Cohnheim has propounded a very ingenious theory, by which he attributes an embryonic origin to all tumours, and considers that an embryonic rudiment is left during development, and that at some later period thie may undergo proliferation. He bases one of his ar- guments in support of this theory, on the frequency with which cancer occurs at the places where, during development, diverse epithelial formations pass one into another, as the lips, rectum, stomach, cervix uteri. Certainly the fact that, in a large majority of cases, rectal cancer commences at a place corre- sponding closely to the site of junction of the procto- dseum and mesenteron would appear to favour this view. In order to investigate the method of growth, it is necessary to examine the spreading margin of the tumour ; that which projects into the rectal lumen being the most suitable for demonstrating the mode of growth, the deeper parts being altered by the way in which the neoplasm is disseminated between the normal structures, and mixed with the debris of atrophic tissues. The central parts are also unsuited for minute examination, as fatty degeneration and breaking down of the tissues is usually taking place there. If the spreading margin be examined, it will be found that it is raised above the level of the adja- cent membrane, and sometimes overhangs it to some * Loc. cit., p. 308. 3i6 The Rectum and Anus. [Chap. xxii. extent, but it will always be found to be attached by a broad base, and incorporated with the structures form- ing the rectal wall ; it is, however, never distinctly pe- dunculated as in the case of the simple adenoid growth. It is quite true that we sometimes find small pe- dunculated adenomata in^ the rectum in conjunction with adeno-carcinoma, but they usually appear as if they were due simply to the irritation of the dis- charge from the cancer. And althouo[h a few cases are recorded in which a malignant form of disease has followed the removal of a simple adenoma, yet they are so rare that the rule may be adopted, that pedun- culation is a very strong argument against malignancy. According to Cripps, if the surface of a growing margin be examined with a low microscopic power, it will appear like " an ant-hill thickly studded with fungi. Upon closer inspection these bodies are seen to be projections from the surface of the tumour." Upon making sections, the Lieberkiihn follicles are found much increased in size, being three to four times lonfjer than normal, while the individual cells are also much increased in length, sometimes being ten times longer; i.e. one-hundredth of an inch. The follicles may be lined by a single layer of columnar epithelium, only leaving a central cavity. In other instances the central cavity is absent either by approximation of its walls, or by a growth of offshoots from the epithe- lial walls. These offshoots consist of a central stroma of retiform tissue, upon which a bi])inniform arrange- ment of cylinder-cells is seen to fill up completely the cavity. The question arises whether these cavities are shut sacs, or only cross-sections of convoluted tubes of dilated Lieberkiihn crypts. Cripps appears now to take the latter view. Where the sections are taken from very rapidly growing and soft tumours, it will be found that the tyi)ical cylinder cells will not be formed, the whole aspect being more embryonic in Chap. XXII.] Colloid Cancer. 317 character ; the cells being rounder and less defined, the way in which they are disposed, and the tendency to follicular formation, however, leave no doubt of their connection with the adeno-carcinomata. Colloid or g^elatJnous cancer. — The writings of Cruveilbier* have been frequently quoted as show- ing that this form is the most frequently met with in the intestinal tract. As Cripps, however, justly remarks, an examination of museum specimens does not tend to show that this disease was more common formerly than at present, and certainly an examina- tion of recent specimens tends to indicate that colloid must be considered one of the rarer forms of intestinal cancer. In the reports of cases read before the various pathological societies formerly, the terms were used with much vagueness, and probably applied to very different forms of growth. In the rectum it may occur as a definite tumour or as a diffuse infiltration, and is characterised by the translucency of its substance. The stroma contains, instead of closely packed masses of epithelial cells, a more or less clear jelly. Accord- ing to Ziegler,! "the colloid or gelatinous texture of the tumour is due to mucoid or colloid change affecting the cancer cells. It begins with the formation of clear globules in their interior ; the cells then perish, and the globules coalesce with each other and with the larger gelatinous lumps already formed. In this way a large homogeneous mass is ultimately built up. It is not uncommon for all the cells over a wide area to perish in this manner, so that the stroma is the only formed constituent remaining ; in other spots cell groups may still be found encircled by colloid masses ; in others there is no colloid substance at all." Some, no doubt, of the gelatinous rectal cancers * Traite d'Anatomie Pathologique Generale, p. 64 et seq. + Macalister ; "General Pathological Anatomy," p. 242. London, 1883. 3i8 The Rectum and Anus. [Chap. xxii. might be with greater precision designated as carci- noma myxomatodes. Professor Purser has kindly given me a very beautiful microscopic section of a colloid cancer of the upper part of the rectum, which Fig. 46.— Colloid of Rectun (x 50), showing perforation of Muscularis Mucosae, by new growth. shows the new growth perforating the muscularis mucosae, its development in the submucosa, and infil- tration and separation of the bundles of the muscular coat. In the greater part of the section nothing but the stroma is left, while in a few places cells con- taining globules of colloid matter still remain (Fig. 46). The second great class of malignant neoplasms, Chap. XXII,] Sarcomata. 319 coming, in order of frequency, after the carcinomata, are those tumours, the bulk of which is composed entirely of embryonic connective tissue, but sarcomata are rare in the intestinal tract. Mr. Cripps states* that he has been unable to find, in his extended ex- aminations of rectal growths, any of the charac- teristic structure belonging to the different varieties of sarcoma. In the Museum of the Royal College of Surgeons ^■^^wSSs^ r. f^'M Fig. 47. — Large Sarcomatous Tumour of Anus and lower part yt Rectum, -with Secondary Tumours on the inside of the Thigh. t of Ireland are two very remarkable examples of sar- comatous growths : In the first (Fig. 47) there is projecting from the anus an enormous mass which measures five inches by four ; it is much lobulated on the surface, presenting somewhat the appearance of an ordinary papilloma of this region. It differs however, in this, that the individual lobules are much larger, and the intervening depressions much shal- lower ; a small group of secondary growths appears near the scrotum, in the skin of the thigh, and the disease extends up into the rectum for a distance of about two inches. There does not appear, however, to have been any obstruction, as the tube was quite pervious behind the growth. There is, unfortunately, *Xoc. c(Y., p. 318. t Museum, Eoyal College of Surgeons in Ireland. 320 The Rectum and Anus. [Chap. xxii. no very reliable history with this specimen. Dr. P. S. Abraham, the late curator of the museum, kindly under- took a detailed examination, and he made microscopic sections from the mass inside the rectum, from the external growth, and from the secondary formations. In all of them the appear- ances were practi- cally identical : there was no trace of pro- liferating mucous membrane ; almost the entire of the sec- tions consisting of small spindle cells, with but little fully developed connective tissue. The second speci- men (Fig. 48) is one in which a long tubu- lar rectal stricture exists, commencing about one inch inside the anus, and ex- tending upwards for a distance of five inches. All the coats of the bowel ajipear to be lost in the growth which surrounds the intestine evenly, and which measures one inch in thickness at the middle portion. Above the neoplasm, the intestine is widely dilated, showing very clearly that during life the degree of obstruction must have been considerable. * Museum of Royal College of Surgeons in Ireland. Fig. 4>?.— Sarcomatous lufiltrafion of Rec turn, producing loug tubular stricture.* Chap. XXII.] LvMPHO-SaRCOMA. 32 1 Dr. Abraham has made a careful examination of this specimen also, and the structure appears to be almost identical with the former, and undoubtedly is an example of spindle-celled sarcoma. These two specimens illustrate remarkably the very different macroscopic appearances which may be pro- duced by tumours of the connective tissue type. A well marked case of alveolar sarcoma of the rectum is reported by Billroth.* The patient was aged fifty-six, and there was a three years' history of difficult defsecation, the growth prolapsing when the bowels moved : it increased so much in size that it could not be replaced. It extended into the rectum for a distance of 6 cm., and there was a well-marked constriction where it was embraced by the sphincter. There were no enlarged glands or evidence of secondary tumours. The growth was excised, and microscopic examination showed it to be a well-marked example of small-celled alveolar sarcoma. In connection with Hodgkin's disease, several ex- amples of lymplio-sarcoma of the intestines have been recorded. In these instances it appears that the tumour oriocinated in the adenoid tissue of the mucosa and in Peyer's patches, and they do not hitherto appear to have produced obstruction or other impor- tant symptoms. Dr. CarringtonI has detailed a case in which a tumour of this kind weighing one-and-a- half pounds, occupied the CEecum without producing symptoms. I have had personal experience of one case in which a tumour, apparently of this nature, was situated lower down in the intestinal canal, and gave rise to rectal obstruction, I have already alluded to this case in another connection (page 56), The patient, an old man of sixty, came under Tnj care in * Quoted by Esmarch, "Hanrlbucli der allgemeinen und. speciellen Chirurgie," Pitha u. Billroth, Band iii. p. 183. 1882. t British Medical Journal, vol, xi. p, 773 ; 1883. v— 23 32 2 The Rectum and Anus. [Chap. xxii. June, 1884, at Sir Patrick Dun's Hospital. He complained of piles and difficulty in getting the bowels to move. U])on making an examination a tumour was felt in the hollow of the sacrum, obstructing the rectum. The raucous membrane was freely mov- able over it, and the tumour itself was movable in the pelvis. As I thought, from the movability of the mucous membrane over it, that it was out- side the intestine, I attempted its removal by linear proctotomy. When reached it was found to be very soft, and it broke down under the linger. As much as possible of it was removed. The patient, however, died of septic periproctitis. At the post- mortem, it was found that the neoplasm infiltrated and thickened considerably the posterior portion of the muscular wall of the rectum, the new growth in parts above where it was removed being one and a half inches thick. The mucous coat was en- tirely unaffected, and freely movable over the growth, which appeared to have originated in the muscular coat of the bowel. The pelvic and lumbar glands were all very much enlarged, but with this exception there did not appear to be any general disease of the lymphatic system. Microscopic examination was kindly made by Dr. Abraham, who states that it was in all respects similar to the descriptions given of lympho-sarcoma.. Melanotic sarcoma. — Primary melanotic can- cer of the rectum is extremely rare ; and according to Yirchow this is the only portion of the intes- tinal tract in which it has been found. Mr. Treves, however, states that there is a specimen of appa- rently primary melanotic gi'owth arising from the ileum at the London Hospital Museum ; and there is an example of melanotic growth in the colon in the Museum of Trinity College, Dublin, but as there were apparently (from the history) similar growths in Chap. XXII.] Melanotic Sarcoma. 323 other parts of the body, it is improbable that the in- testinal growth was the primary one. In November, 1884, I brought before the surgical section of the Academy of Medicine in Ireland, the following typi- cal case of melanotic sarcoma of the rectum. The patient, who was sent to me by Dr. J. K. Barton, was admitted into Sir Patrick Dan's Hos- pital Sejjt. 16, 1884, She was a tolerably healthy looking woman, aged sixty years. Eleven months before admission into hospital she first felt a lump coming down when she was at stool, and difficulty in obtaining an evacuation, with occasional haemorr- hage. A month later she was in a Dublin hospital, where, she stated, a pile which appeared externally was removed. From that time she remained free from bleeding and pain for six months. Towards the end of May, 1884, she suffered from flatulence and indi- gestion, and the bowels, which had for a long time been costive, became more so, relief being only obtained after the use of strong purgative medicines, and then with considerable straii)ing and pain. There was some slight discharge of bloody mucus occasionally, but not to any great extent. A month later she became conscious of a growth in the rectum, which partly protruded when the bowels moved ; lately this had increased much in size. The pain during defseca- tion was considerable, and was referred to a point immediately above the symphysis pubis, and she was much troubled with pruritus ani. Upon making an examination the anus appeared normal, and the sphincter was not unduly relaxed. About an inch from the anal verge, on the anterior aspect of the rectum, two distinct and tolerably hard tumours could be felt. By passing the finger well up, the superior limits of both could easily be made out, and below them a smaller mass was to be felt. With one ihiger in the rectum and the other in the 324 The Rectum and Anus. [Chap. xxir. vagina, it was easily determined that there was no abnormal adhesion between the two canals. The rest of the rectum, as far as it could be examined M'ith the finger, apjDeared normal ; and no enlarged glands could be felt in the hollow of the sacrum ; nor was any evidence to be found of engorgement of the liver or other abdominal viscera. I removed the growth by the usual method, Clover's crutch being employed to keep the patient in the lithotomy position. The anus was first stretched, and an incision carried from its margin back to the coccyx, dividing the posterior wall of the bowel to the extent of about \\ inches. The angles of the incision were held asunder, and a good view obtained of the interior of the rectum and the origin of the tumours. An incision was next carried round the anterior two-thirds of the wall of the gut, about half an inch below the attachments of the ccrowths, and well above the external sphincter. The wall of the intestine was now carefully dissected from the vagina, until it was evident that the healthy bowel could be felt between the finger and thumb above the highest limits of the disease. A curved incision was made with a scissors well free of the mass, and the whole removed. Hsemorrhage was not as severe as might have been anticipated, only two ligatures being re- quired. There was a little oozing from a point deep in the incision between the vagina and bowel, to which the benzoline cautery was applied, and, finally, a deep suture was passed to arrest it. No attempt was made to suture the divided portions completely. The wound was thoroughly well washed with a solution of corrosive sublimate, 1 in 2,000, and a sanitary towel wet in the same solution was applied. The progress of the case was quite satisfactory. The temperature never reached 1(J0°; indeed, for a few days it was subnormal, during which time she Chap. XXII.] Melanotic Sarcoma. 325 was mucli depressed. The bowels moved on the fourth day, and again on the eleventh ; each time she had complete control of the motion, and has not since suffered from incontinence, except when she has diarrhoea. I have lately seen her (two years after the operation) : there is not the slightest evidence of Pig. 49.— Melanotic Sarcoma of Eectum. A, Surface view ; b, section. recurrence ; the bowels move naturally every day ; and she is earning her living as a cook. Upon examination of the structures removed it was found that a good margin of healthy tissue sur- rounded the disease. The piece measured about 3 inches in breadth and 2^ inches in length, and consisted of the anterior two-thirds of the rectal tube (Fig. 49). A section carried through both of the prin- cipal growths shows that the greater portion of the 326 The Rectum and Anus. [Chap. xxii. smaller one is of a sooty black colour, while the larger one is quite white. The third and smallest one is also melanotic. Microscopic examination, kindly made by Dr. Abraham, shows that the growth is a typical sarcoma, much pigmented. In no part of it was there to be found any evidence of prolifera- tion of the gland tissue of the mucosa, and, as far as could be made out, the disease originated in the sub- mucosa. At a meeting of the Society de Chirurgie, January 28,* 1880, M. Nepveu delivered a lecture on the subject of rectal melanosis, and gave statistics of the cases which have previously been recorded, from which it appears that but ten instances had been noted. In only five of these was there any microscopic examina- tion detailed, and all of these were instances of sarcoma. In two the position was immediately within the anus, once at the sigmoid flexure, and the rest were situate at the anus. In all the cases recorded the disease ran a rapidly malignant course ; and in four which were submitted to operation, recurrence was not long delayed. Virchowhas pointed out the remarkable factf that intestinal melanosis, which is such an extremely rare disease in the human subject, is met with frequently in the horse. Ossifying: cancer of rectum. — As far as I am aware, the case put on record by Mr. Wagstaffe of this form of neoplasm is nnique. \ The following is a condensed summary of the case as recorded : The history pointed to disease of the rectum for about twenty years, when symptoms of obstruction came on. This was followed by pelvic suppuration and death. * "Memoires de Chirurgie " (quoted by Kelsey). Paris, 1880. t " Pathologic des Tumeurs," vol. ii. p. 281. Paris, 1807. X Transactions of the Pathological Society of London, vol. xx. p. 176. Chap. XXII.] Ossifying Cancer. 327 At no time could any tumour be distinguished by examination with the finger in the rectum, nor by manipulation above the pelvis, but the history pointed distinctly to obstruction of the bowel in this region. Upon examination of the pelvic viscera, post-mortem, a tumour was found in the back of the rectum, of about the size of a walnut. It occupied nearly the whole calibre of the rectum, but the disease involved more or less the entire circumference of the intestine, upon a level rather above the larger mass. A small opening large enough to admit a goose-quill was found in the sigmoid flexure, about twelve inches above the cancerous growth, and communicating with a circum- scribed abscess cavity within the periton83um, and this again communicated with the rectum below the obstruction. When first laid open the surface of the cancer presented a nodulated red appearance, but the larger or posterior mass was roughened in its lower half by numerous sharp spicules of bone which pro- jected from its surface. Section shoAved the growth involving the thickened muscular coat, as a hard con- tracting mass ; and from its base firm fibrous bands ramified into the neighbouring fat, just as from the base of an ordinary scirrhous tumour. That portion which projected into the cavity of the rectum was softer, and its lower part was occupied throughout by numerous spicules of true bone. On the surface, the softer structures having sloughed away, the bony constituents were exposed. The growth did not extend to involvement of the sacrum, which was perfectly healthy, and the other bones of the pelvis were also free from disease. The other viscera were examined and found healthy. The ulceration in the sigmoid flexure appeared simple in character. The solid portion of the growth was composed of cellular and nuclear structures embedded in granular matrix. Bands and fibres, composed almost altogether 328 The Rectum and Anus. [Chap. xxiit. of nuclei, ramified in the growth, and could be traced as continuous with the osseous portions. It appeared that the nuclei became darker, more granular, and harder in outline as the examination was carried towards the ossified parts ; the intervening matrix became more fibrous, and the processes of bone branched out into this. The bony spicules contained numerous lacunae, whose size was about that of the ordinary nuclei of the growth. They were of various forms, generally branching, and were arranged with no regularity, but in the manner usually found in adventitious bony deposits in tumours. Cancer of tlie aous is not very commonly met with ; if it originates at that aperture, it is of the usual squamous type of carcinoma, and does not present any characteristics to distinguish it from the same disease in other parts of the body (Plate I.). Secondary cancer of the rectum, most commonly following cancer of the uterus, does not require here any separate consideration. CHAPTER XXIII. SYMPTOMS OF RECTAL CANCER. As in cancer of other parts of the body, pain is a j)rominent symptom at a certain period of the disease ; but in the early stages it is in many instances ex- ceedingly slight ; this is so as long as the disease is confined to the interior of the rectum, and before the anus or the pelvic contents have been encroached upon. So slight is the pain, that in some instances patients consult a surgeon on account of some slight discharge from the anus or sense of uneasiness in the rectum, and an examination reveals the fact that a very Chap. XXIII.] Rectal Cancer : Pain: 329 extensive neoplasm is present which must have existed for months previously. This is no doubt due, as Hilton has pointed out, to the cliaracteristics of the upper part of the normal rectum ; i.e. its great dis- tensibility and little sensibility, conditions the phy- siolosfical reason of which is obvious. In the im- mediate neighbourhood of the anus these conditions are reversed, and, as might be expected when this region is involved in the disease, the pain experienced is extreme. It will be within the experience of most surgeons to have met with cases of malignant disease of the rectum in whicli for months or even years trivial pain alone is complained of. Sooner or later, however, pain becomes a prominent symptom, and is frequently very intense. In no locality, not even excepting the tongue, is the suffering sometimes more severe. The pain may be due to four distinct causes ; and the character of the suffering in each case is quite distinct : 1. The disease may involve the anus, where, owing to the abundance of cutaneous nerves and contmued motion of the part, the pain will be severe. 2. As the cancer extends beyond the limits of the intestinal tube, the nerves of the sacral plexus may be encroached upon, which may result iii violent neuralgia, or in painful cramps of the muscles of the lower extremity. It is well to bear this always in mind, as not unfrequently an attack of (so-called) " sciatica " has been the first indication of a cancerous rectum. 3. Obstruction, when situated in the rectum or lower part of the sigmoid flexure, is followed by a considerable amount of pain ; which is always that of a paroxysmal character, and associated with frequent efforts to defsecate. 4. Implication of the bladder will be, of course, associated with consider- able pain, especially if the disease has progressed so as to form a fistula, and permit the flow of faeces into the bladder, or of urine into the rectum. 330 The Rectum and Anus. [Chap. xxiii. Bleeding is a symptom which is seldom altogether absent ; and on the other hand is not often severe. It commonly follows the passage of hardened faeces, and may be taken as an indication that ulceration has commenced. A certain amount of discharge also is a common result, frequently blood-stained and abominably foetid. At a later stage this discharge, mixed with thin faeces, comes away through the patulous anus, the relaxed sphincters having lost all power of control. The skin about the neighbour- hood becomes excoriated, constituting by no means the least of the miseries to be endured by the suflterer. Diarrhoea may alternate with constipation, or be continuously present, and is often the earliest symp- tom which attracts attention. Every case of diar- rhoea, or so-called dysentery, which has become at all chronic, should be examined by the rectum, and in not a few the cause will be found to be a malignant growth. I have several times seen cases which had been treated for diarrhoea for considerable periods which owed their origin to this cause, and the im- portance of making an early examination in these cases cannot be over-estimated. Early diagnosis is of greater importance here probably than elsewhere, the great majority of cases not coming under the notice of the surgeon until the disease is so far advanced that the hope of successful operative interference is passed. As has been before pointed out, narrowing of the intestinal tube, sufficient to retard the passage of faeces, may be due to two distinct causes in cancer : either the neoplasm may by its exuberant growth obstruct the calibre of the bowel ; or in the more chronic form the cicatricial contraction may form a true stricture of the gut. In either case, the symptoms will be similar. Stricture of the rectum produces symptoms in some resjiects differing from Chap. XXIII.] Cancerous Fistul/e, 331 those met with in obstruction of the intestine higher up. The continuous straining and tenesmus which is so marked in the former is absent in the latter ; while vomiting of faecal matter, which comes on tolerably soon when the small intestine is completely stenosed, may not appear for a very long time when the rectum is occluded. In some of the recorded cases complete obstruction was continuous for many weeks or even months before continuous and fsecal vomiting super- vened. Cancerous obstruction, which may have existed for some time, may eventually give way, and an exit be established for faeces through the rectum again, or by an alternative route. In the first instance, the neoplasm may slough to such an extent that the bowel will become pervious again, or, as in the case recorded by Wagstaffe,! ulceration of the bowel above the obstruction may lead to perforation and the formation of stercoral abscess, which may again open into the bowel below the cancer, thus aflfording a new, though not very efficient, route for the faeces. In the case of the celebrated Talma, as recorded by Quain, this also appears to have been the case. Where an opening of sufficient size forms into the vagina, the more urgent symptoms of obstruc- tion may be relieved, but the patient is left in a truly miserable state ; but where the opening takes place into the bladder, no sufficient exit for faeces will be by this means provided, and tlie urgency of the obstruction will continue ; while at the same time the other symptoms will be much aggravated. Opening into some of the pelvic viscera by ulceration in this way may be due to breaking down of the neoplasm itself, or it may be due to the distension and irritation of faeces above the obstruction; the ulceration then being of a X See page 326. 332 The Rectum and Anus. [Chap, xxiii. simple character. This form of stercoral ulceration may take place at a long distance above the seat of obstruction, several cases being recorded where the csecum has given way and produced a fatal peritonitis, in consequence of the dilatation due to rectal cancer. At other times nature has attempted to overcome the obstruction by the formation of an artificial anus at some pait of the cutaneous surface, but such cases are of extreme rarity, and likely only to give a very inefficient relief to the obstructed gut. Dieffenbach records a case* in which it was necessary to evacuate, by means of free incision in the buttock, an enormous quantity of faeces extravasated from a cancerous rectum ; and Smith f gives a case in which an extravasation in this way found its way into the hip joint. As has been elsewhere stated, the glands first affected, if the disease does not implicate the anus, will be the pelvic and lumbar systems. The former may be felt through the walls of the rectum, and the latter occasionally by deep abdominal palpation. When secondary tumours have formed in the liver, there may be indication of its increase in size ; and possibly, if the abdominal wall be thin, the surface may feel irregular and knobby. The duration of symptoms may, in difficult cases, materially assist the diagnosis. If there is a history of rectal trouble slowdy increasing for years, it is highly probable that the disease is not malignant. CEdema of either leg is a symptom not uncommonly present in the later stages, and is usually of grave import as indicating an involvement of the iliac vein in the disease. In common with all forms of cancer, the peculiar cachexia soon becomes obvious, and if hajmorrhage has been at all abundant it comes on * Quoted by Leube, Zieinssen's Cyclopaedia, vol. vii. p. 437. + " Sui-gery of the Rectum." 1872. Chap, xxiii.j Cancer : Diagnosis. 333 more rapidly. I think the sallow skin which is so characteristic is more marked in this form of cancer than in others. The onset of bladder implication is indicated by frequent and painful micturition ; and fistula is of course soon rendered obvious after it has occurred. In a case to which I have already alluded (page 100), which I saw under the care of the late Mr. B. W. Kichardson, the first symptom which aroused suspicion was turbid urine, from which a sediment settled. Upon examination by the microscope particles of striped muscular fibre and other fsecal debris were to be seen, and a digital examination demonstrated a rectal stricture high up. Leube* notes a case in Avhich the secondary involvement of the ureter in rectal cancer produced a large hydro -nephrosis. I^ig'ital examiiiiatioii. — Whenever the symp- toms of rectal cancer exist at all, a complete digital examination should be made. In the majority of cases, within a short distance of the anus the surgeon will feel a hard nodular and irregular surface, which may surround the entire circumference of the bowel, or be more particularly confined to one side of it. When stricture exists, the tumour frequently is felt pro- jecting into the lumen of the bowel, and conveying to the finger a sensation almost exactly resembling that of the os uteri. Should the finger not en- counter anything abnormal, the patient should be made to stand up, and the digital examination should then be repeated, the patient at the same time being told to bear down. In this way a tumour which was not within reach by the ordinary method may occa- sionally be explored. Should nothing still be felt, and the symptoms clearly point to rectal disease, the patient should be etherised, and a careful bi- manual examination instituted, with the patient in the * Ziemssen's Cyclopaedia, vol. vii. 334 '^^^ Rectum aad Anus. [Chap. xxiii. lithotomy position. This method is also of use in de- termining the height to which neoplasms, that are easily recognisable below, extend upwards. The existence of malignant disease having been determined, it is essential, with a view to treatment, to determine the following points : First, the distance to which the disease extends upwards ; this may be done with the finger alone, by the bi-manual method, or by a ball- ended probang. Secondly, the movability of the rectum upon the other pelvic structures is of use in estimating whether or not the disease has spread past the limits of the intestinal tube. And thirdly, a careful examination should be made to feel, if possible, any enlarged glands, which may sometimes be felt in the hollow of the sacrum through the rectal wall. In examining a case of this kind the greatest care should be employed, as in several recorded cases the attempt to pass a probang, or even a roughly made digital examination, has been followed by ru2:)ture into the peritonseal cavity. I>Jag°nosi8. — There are but two conditions with which rectal cancer is likely to be confounded : viz. tumours external to the intestinal tube ; and non- malignant stricture. In the case of the former the diagnosis is easy if the disease is within reach of the finger. The fact that the mucous membrane is freely movable, and that the neoplasm is unquestionably outside the bowel, will render the matter clear. Hilton records a case * in which the presence of enlarged glands, which could be felt through the rectum, in a case of chronic ulceration, had given rise to the opinion that the case was one of cancer ; when the ulcers healed the swelled glands disappeared, showing that they were simply due to irritation. In the same way uterine * "Lectures on Rest and Pain," p. 294. 3rd edition, edited by Jacobson. Chap. XXIV.] Cancer: Treatment, 335 tumours, or even the fundus of a retroflexed uterus, by pressing on the rectum and causing obstruction, have given rise to an erroneous diagnosis of rectal cancer. To distinguish between the malignant and non- malignant strictures is a matter of greater difficulty. In this the duration of symptoms will prove of much service, the onset and progress of the non-malignant being extremely slow. The sensation conveyed to the linger will also be different. The ordinary stricture is smoother, and more regular, and there is generally an absence of the nodular and protruding masses so characteristic of cancer. Cripps has also drawn atten- tion to the fact that in the malignant form there is usually a portion of tolerably healthy mucous membrane between the cancer and the anus, where- as in the non-malignant stricture this portion is generally more or less infiltrated. The diagnosis between squamous epithelioma of the anus and papillomata is sufficiently easy ; as in the latter the skin surrounding the tumour is not in- volved, the neoplasm being in some instances even pedunculated, whereas in the epithelioma there will be considerable infiltration of the true skin. CHAPTER XXIV. TREATMENT OF RECTAL CANCER. The medical treatment of cancer of the rectum presents two chief points which must be borne in mind by the surgeon : first, to ensure that the bowels are kept sufficiently free to obviate the occurrence of faecal accumulation above the disease; and, secondly, to supervise the use of morphia and other narcotics. 336 The Rectum and Anus. [Chap. xxiv. In order to relieve pain, morphia, either hypoder- niically in the form of suppositories, or internally, is frequently used somewhat recklessly, with the result that there is superadded to the miseries of the rectal cancer the mental suffering and total inability to bear physical pain of the morphia habit, so that, unless used with a very sparing hand, opium, instead of rendering the remainder of life more comfortable, adds to its suffering. The use of bougies, or any dilating instrument, is attended with extreme danger, several cases of fatal rupture having been induced by this means. The operative treatment of cancer of the rectum may, with advantage, be classed under two heads : the one necessarily palliative, as directed only to the relief of the prominent symptoms of intestinal ob- struction and pain ; the other having for its object the complete removal of the disease. Of the former, three operations are at present practised where extirpation is inadmissible, and of these colotomy must still be ranked in the first place, although there seems to be a tendency amongst operating surgeons to make use, as far as possible, of other plans of treatment, even where the symp- toms of severe obstruction are manifest. Of these procedures the most important is linear procto- tomy, or external rectisection, which has, chiefly owing to the writings of Verneuil,* Panas,t and Kelsev, obtained a recognised place in surgery as a treatment for malignant stricture, and at the Copen- hagen Congress % Verneuil speaks strongly in favour of this procedure as replacing both colotomy and excision. In many cases he considers it preferable to * Gaz. des n^>p., October and November, 1872 ; and Gaz. Hchdom., March 27, 1874. t Gaz. des Hfip., December, 1872. X " Compte Rendu," par C Lange, Secretaire G^n^ral, tome ii., Section de Chirurgie, p. 21. Chap. XXIV.] Cancer: Excisioy. 337 tlie former as being less dangerous, equally efficient, and more convenient ; and he considers complete removal by excision impossible. Those surgeons who practise excision confine colotomy to those cases in which it is impossible to extirpate the whole mass, consequently the cases in which opening of the colon is now practised would be incapable, in consequence of their extension, of relief by the linear proctotomy of Verneuil. The operation, therefore, must be com- pared with extirpation alone, and I think that the results now gained by the latter procedure will decide most surgeons in selecting it. Eor the treatment of non-malignant stricture linear proctotomy is an admirable method, and for a description of the operation the reader is referred to the chapter on that subject. The suggestion of Kelsey to make two vertical incisions posteriorly, and remove the mass of neoplasm from between them, gives more room certainly, but it is open to the same criticism as the more simple operation. The third form of palliative operation is the removal, with a scoop or the fingers, of as much as possible of the cancerous mass. Such cases are described by Allingham, Cripps, and Yolkmann ; and the result was a removal of the obstruction. From the recorded cases, it appears that when the mass was thoroughly broken down and removed haemorrhage was not excessive, and sometimes even partial cicatrisation has been known to follow. Sir Joseph Lister states* that he has seen in the practice of Simon of Heidel- berg great advantage follow the scraping of epi- thelioma of the rectum with the sharp spoon. The radical cure of cancer of the rectum may be attemj)ted by a free excision from the perinseum, and where the disease is situated high up, the operation, to which Marshall has applied the term colectomy, may * Lancet, May 20, 1882. w— 23 338 The Rectum and Anus. [Chap. xxiv. be performed. This subject is, however, rather be- yond the scope of this work ; but it will be found fully dealt with by Mr. Treves in his book on in- testinal obstruction. Excision of the rectum is now a thoroughly- established operation, and although at first it met with a great deal of opposition in this country, it is now pretty generally adopted as the best treatment in selected cases. Originally performed by Faget in 1763, it does not appear to have attracted much attention till 1833, when Lisfranc again brought it into notice ; but its establishment, as at present prac- tised, is due to the German surgeons. In order to arrive at a just conclusion as to the advantages of extirpation of the rectum, it is necessary to review the course which rectal cancer runs when not subjected to operation. It would appear, from a consideration of a large number of statistics, that the average duration of life is about two years from the appearance of the first symptoms, and during that time the condition of the patient is truly miserable. Where obstruction is present, the constant straining is a source of perpetual pain and annoyance to the patient, and even when this symptom is not present the continued mucous and bloody discharge, the ex- treme pain suffered when the disease encroaches on the bladder, the anus, or the nerves of the sacral plexus, combine to render this disease one of the most distressing that can possibly come under the observation of the surgeon ; and it is little to be wondered at that any operation which can hold out a chance of remedying this condition should readily be gras[)ed at by both surgeon and patient. We must, however, consider the question from more than one point of view : first, as to the immediate risk to life ; second, as to the probability of complete cure, and, if so, the condition in which the patient will be left ; and, Chap. XXIV.] Excision: Statistics. 339 lastly, supposing recurrence to take place, how long will it be delayed, and what will be the course of the secondary disease. I am convinced that a careful and unbiassed consideration of the facts bearing on these questions will serve to convince the impartial observer that they are not only sufficient to justify the operation in suitable cases, but that it is the duty of the surgeon to strongly recommend it. Let us proceed to consider these questions in detail. First, as to the immediate risks of the opera- tion. In trying to estimate the mortality of any operation, more particularly one which has only of recent years been extensively practised (as is the case with the operation under consideration, in this country at any rate), it is manifestly useless to collect all the cases published in the journals and from these deduce statistics, as there is a strong tendency amongst surgeons to publish isolated successful cases, while their fatalities are not so accurately recorded. Consequently, we must only place reliance upon the experience of those surgeons who give the results of the total number of operations which they have performed. I have collected 175 cases in which, I think, we may be satisfied that the conditions necessary for faithful statistics have been carried out, so that we may take the result as fairly reliable. These give a death-rate of 16*5 per cent.; and, when we take into consideration the nature of the operation and the disease for which it is performed, we may consider this a fairly good result. Upon looking to the cause of death in these cases, we find that in upwards of 80 per cent, diffuse cellu- litis, or peritonitis, is stated to have been the chief factor in producing the mortality. Although the full details of Listerian dressings are inapplicable to these operations, a great deal can be done in the way of antiseptic treatment to obviate the 340 The Rectum and Anus. [Chap. xxiv. above preventable complications ; and the more fully we appreciate the advantages of thorough drainage and continuous iiiigation, frequent washings with anti- septic solutions, or dusting with iodoform, the more likely are we to still further reduce the death-rate. Yolkmann states that amongst his early cases he lost a great number from se])tic inflammation, but since he has adopted better methods of wound treatment his results laave been very much better. He advocates continuous irrigation of the wound with an antiseptic fluid, such as solution of salicylic acid, or carbolic acid, until granulation is established. Billroth, between the years 1860 and 1876, lost 13 out of 33 cases, and all the cases died of septic periproctitis and peritonitis.* Crippsf gives twenty-three cases within his own experi- ence, of which four died. The statistics given by Heuck | of the 2)ractice of Professor Czerny for a period of six years appear to be the best hitherto recorded. Of twenty-five patients operated on, only one died as a direct result of operation. In many respects the history of rectal extirpation resembles the early history of ovariotomy ; and it is highly probable that with increased care in wound treatment and operative detail the rate of mortality will be matei-ially lessened. It is, therefore, at present premature to be guided too much by statistics. Let us now consider what are the probabilities of complete cure ; or, if recurrence takes place, how long will it be delayed? Billroth, in 1881, had only two CRses in whicli the patients lived two years after the operation ; and Allingham speaks with great caution, apparently not considering that life is even })rolonged by the operation ; on the other hand, C'ripps found, that out of twenty-three cases, in nine * "Clinical Surgery," New Sydenham Society, 1881. i Loc. cit.,\^.'6\)l. X Archiv fin- kJinische Chiriirgie, Banil xxix. Heft 3. Chap. XXIV.] Excision : Prognosis. 341 the disease recurred after periods varying from four months to two years, and he was able to trace six that remained well at periods varying from two to four years. Curling* had one case in which there was no return after six years ; Velpeau records two cases which were well after ten years ; and Chas- saignac has had similar experience ; but, probably, the best results obtained by any one are those of Yolk- mann.f He states that three times he has had com- plete cures, and several cases of very late recurrence : once after six years, once after five years, and once after three. One died of carcinoma of the liver eight years after operation without local recurrence, and one case remained well eleven years after the removal of a very voluminous and high-reaching mass ; in this case local recurrences in the shape of hard nodules in the cicatrix occurred twice, and were re- moved. In Czerny's experience, according to Heuck, nine were alive at the time of publication of the paper, and free from relapse. Of these, two had survived the operation longer than four years, one had been operated on three years and nine months before, three were well after intervals of at least two years, one at the end of twelve months, and two at the end of six months ; while in fifteen cases (60 per cent.) there was a local recurrence within one year. Dietfenbach records thirty cases in which tlie patients lived many years after operation, but this statement is usually looked upon with suspicion. Although the total number of cases is as yet small, and the opportunity of judging whether many of the apparent cures will be permanent is insufficient, the results hitherto recorded will compare most favour- ably with the records of operation for cancer in other parts of the body, notably the tongue and breast, * " Diseases of Rectum," p. 164. 187G. f Sammlung klinischer Vorlrage, May 13, 1878. 342 The Rectum and Anus. [Chap, xxiv, botli as regards the prolongation of life, and the possibility of complete cure. As to the condition of the patient after recovery from operation, we must remember the horrible disease for which that operation was performed, and compare the condition before and after its removal. When the sphincter has not been removed, the amount of incon- tinence is usually trivial, and it is only when there is diarrhoea that any trouble arises. This is generally easily met by the use of an antiseptic pad. When the entire lower end of the rectum has been removed a considerable amount of control often is maintained, but even in the worst cases of incontinence met with after ablation of the rectum the result compares favourably with the usual artificial anus following colotomy, and is vastly preferable to the state of a patient sufifiering from advanced rectal cancer. A more troublesome sequela of operation than incontinence is stricture, which in many of the re- corded cases appears to have given a very great deal of trouble in those cases where it has been found im- possible to draw down the gut and suture it to the skin. As the extensive surface heals by granulation the orifice gradually becomes constricted, and in the hands of some of the most skilful surgeons treat- ment by means of tubes, incision, or even colotomy has been required. If, however, a small strip of mucous membrane can be retained down to the anus, or the mucous membrane brought down and sutured to the skin, as in the procto-plastic operation of Amus- sat for imperforate rectum, this trouble is not likely to arise. The freedom from incontinence which some of these ]:)atients enjoy is very remarkal)le. In a case of my own there is a slight prolapse of mucous membrane which occludes the anus, and prevents escape of fa?ces, except during defsecation. As O'Beirne pointed out long ago, the rectum in health Chap. XXIV.] Excision: Details of Operation, t^xt^ is empty, except immediately before the act of defie- cation. Recurrence of the disease usually takes place as nodular masses in the cicatrix ; or in the deep lumbar glands, livei-, or other internal organs. When oc- curring in the cicatrix, a secondary operation is often attended with good results. And even where not suitable for removal, these secondary growths arc usually much less painful than the primary disease, owing to the destruction of the sensory nerves of the region at the time of operation. Death from internal cancer is also considerably less painful than that from unchecked cancer of the rectum. The most complete and accurate directions as to the selection and the details of operations for excision of rectal cancer are those given by Volkmann.* He classifies the cases met with under three heads : 1. Where there is a localised nodule of disease which can be removed by dilatation of the anus, and the wound closed by suture ; this is not attended with difficulty unless situated high up. 2. Where the greater pro- portion of the rectal circumference, including the anus, is diseased ; in this case the anus must be sur- rounded by an incision extending into the ischio-rectal fossa, the rectum dissected up, and amputated above the seat of disease. Yolkmann, in the paper alluded to, recommends the brino-ins: down and suturincf of the divided rectal tube to the skin, drainage tubes being inserted between the stitches. 3. Where the disease is altogether above the anus, involving the entire circumference of the bowel. A deep posterior incision to the coccyx is the first essential procedure in this instance ; the rectum is then incised round its circumference above the external sphincter, the bowel dissected up and amputated. This operation is open to an objection not applicable to the other two, * Sammlung klinischer Vortrdge, May 13, 1878. 344 The Rectum and Anus. [Chap, xxiv namely, that as the blood-vessels supplying the lower portion of the rectum are of necessity divided, gan- grene of this portion is apt to occur. The following description of the operation ot excision includes the principal points to be borne in mind. In order to prepare a patient for operation, a dose of purgative medicine should be given for a couple of nights before, and the bowel well emptied by a copious enema on the morning of the operation. The patient should be retained in the lithotomy position by means of Clover's crutch, and an incision carried deeply from the back of the anus to the coccyx. This is an exceedingly important part of the operation, as it gives full room for further manipulations ; and has been called, not inaptly, by AUingham, the "key" of the operation. If the entire circumference of the bowel, including the anus, is diseased, incisions should be now carried well clear of the disease round the anus, and deeply into the ischio-rectal fossa, the attachments of the levatores ani divided, and the dissection carried upwards posteriorly and at the sides. This can be readily accomplished, but in front there is always considerable difficulty, owing to the close attachments of the rectum to the bladder and urethra in the male, and the vaijina and uterus in the female. In the former the presence of a full-sized sound in the urethra will prove of much assistance, and in the latter the occasional introduction of the finger into the vagina will serve a like purpose. For dissecting the intestine free, a pair of blunt-pointed scissors will be found the most convenient instrument ; and assist- ance may be gained by the use of a blunt hook, using it in the same way that a strabismus hook is used to hook up the ocular muscles in an enucleation of the eyeball. If the disease has not implicated the anus, or if a vertical strip of mucous membrane be unaffected, the preceding operation should be so far modified as Chap. XXIV.] Excision: Use of Sutures, 345 to leave as much normal tissue as possible, care being always taken that at least one quarter of an inch of healthy tissues surrounds the disease upon all sides. The dissection having been carried up to healthy tissue above the disease, the rectum is to be amputated. For fear of haemorrhage this has frequently been done with the ecraseur, the Paquelin cautery, or even the ligature ; but as the part is so well under control bleeding need not be feared, and the section can be made much more cleanly with a pair of curved scissors. A number of catch forceps should be at hand to secui^e vessels as they are divided, but there is not likely to be any free bleeding until the last section is made, and then the arteries can be picked up, and tied generally without difficulty. An important question now to decide is whether any attempt should be made to brinof down the gut and suture it to the skin wound. Cripps strongly advocates leaving the wound to granulate without the application of any sutures, his objection to the stitches being that they cut out before union takes place, and that Avhile in place they produce little pouches outside the gut in which fluids will collect, and become septic ; while leaving the wound entirely open, with the patient in the recum- bent position^ ensures absolutely free drainage. Other operators give similar advice ; while Yolkmann and Czerny recommend stitching, so as to diminish wound surface as much as possible, and by joining mucous membrane to skin to obviate the tendency to stricture. It appears to me that a great deal depends upon the way the sutures are put in. If they are simply put through skin, and then through the gut, they will, when closed, make a cavity outside the rectum ; but if they are passed deejoly through the surrounding pelvic structures as well, these cavities can not be formed, and as the strain will be then divided over a larger surface^ the tension will be taken 346 The Rectum and Anus. [Chap.xxiv. off tlie gut so irmcli that they will be much more likely to hold (Fig. 50). If two such sutures are passed on each side they will bring the gut well down if it has not been divided very high up, and a number of superficial sutures should then be put in to complete c ' r D Fig. 50. — Diagram showing the method of passing Sutures. A, Suture passed (li'eply ; c, the sarae suture closed; b, suture passed throut-'h bowel and skin only ; D, the same suture closed. the adjustment of the skin and mucous membrane. After the operation an attempt may be made to keep back the faeces by plugging the gut with iodoform gauze or other similar antiseptic material, a catheter passed through the plug being left in the bowel to permit of the escai)e of flatus. If the gut will tolerate this plug, and it can be left in situ for a week or ten days, it will prove of enormous advantage, by permitting a complete adhesion of the gut to the perinaeal wound Chap. XXIV.] Excision: Wound of Peritonmum. 347 to take place. The diet for the first fortnight after the operation should be carefully regulated, so as to leave as little solid residue as possible. Compljcatioiis of the operation. — Wound of the peritonaeum is of frequent occurrence, and care- ful anatomical measurements have been made to determine the distance of the peritonseal pouch from the anus, so as to define the limits within which the rectum can with safety be removed. Such measure- ments are, however, comparatively useless. In the first place the measurements must vary with the dif- ferent positions of the anus, and the amount of fluid in the bladder; and the relation of the serous covering to the bowel in health is no criterion whatever as to its state when the rectum is diseased, as the constant straining, if there is obstruction, and the dragging due to con- traction of the cancer, will materially alter the normal relations. The only important anatomical point to remember in this connection is the fact that, in the female, the peritonseal pouch descends about an inch farther than it does in the male. Allingham states * that he has met with peritonseum within two inches of the anus in a female, and removed five inches of gut in a man without ever having seen it. In order to render wound of the peritonseum less likely to take place, T have tried fully distending the bladder before operation, which I find has a much greater effect in lifting the peritonseum away from the bowel than the converse proceeding of dis- tending the rectum has of clearing it away from the suprapubic region for lithotomy. This is manifestly of greater use in the male than in the female, and the distended bladder is more easily recognised and pro- tected during operation than the empty one. Wound of the peritonseum does not, however, appear to be such a serious complication as some surgeons have * Loc. cit., I). 281. 34^ The Eectum and Anus. [Chap. xxiv. thought. According to Heuck * this accident occurred in eleven of Czerny's cases ; in six of these the wound was sutured, while in the remainder the rent was left open, care being taken to join accurately the margin of the divided bowel to the skin, thus preventing extravasation. As Cripps, however, has pointed out, direct involvement of the peritonaeum in the cancerous growth is a very serious complication, as it indicates such an implication of the lymph paths that recur- rence of the disease cannot long be delayed. Implication of the other pelvic structures is a very serious complication ; and, when extensive, must be held to contra-indicate operation. A slight involve- ment of the recto-vaginal septum, however, can easily be dealt with, the vaginal opening being either closed at the time of operation, or by a subsequent plastic procedure. Where, however, the bladder, prostate gland, and urethra are much involved, the prospect of useful interference is small indeed ; althouirh a case is recorded by Nussbaum in which a man was reported well three years after the removal of rectum, prostate, and neck of bladder ;* but such extensive operations have not since been frequently imitated. Amongst the modifications of excision, the combina- tion of colotomy with it is one of the most important. In a paper read at the Societe de Medecine of Lyons, in May, 1884,* M. Maurice PoUosson advocates the combination of laparo-colotomy with extirpation of rectal cancer. He selects the left iliac region as the site for the operation, because there more readily than in the lumbar region can he close up the lower segment of the bowel, which closure he regards as a point of essential importance in the operation. This * LoQ. cit. t "Bayr.jjirtz. Intelligenzblatt," November, 1868; quoted by Van Buren. I St. Louis Courier of Medicine, July, 1884. Chnp. XXIV.] Excision with Colotomy. 349 he does by invaginating some millimetres of the lower free end after dividing the bowel clean across, and closing up the opening completely by means of five or six catgut sutures, which thus bring into close apposition the serous surfaces. The artificial anus is completed by suturing the upper extremity of the bowel carefully into the wound. After the patient has recovered from this operation, he proposes to ex- tirpate the cancerous mass, which, by virtue of the pre- liminary operation, is practically removed from its relations as a part of the digestive tract, and converted into a pelvic tumour. Operating under the conditions so brought about, it is possible to apply the principles of antiseptic surgery much more thoroughly and efficiently than in the conditions existing Avithout such a preliminary operation. In most cases he believes that it would be advisable to allow the patient to re- cover from the effects of the fii'st operation before performing the second ; though in certain cases he thinks that circumstances might be such as to make it better to go on and extirpate the cancerous mass at once after establishing the artificial anus. Mr. James E. Adams has recommended* the per- formance of lumbar colotomy as a preliminary measure in all but the very slightest cases, and as soon as the patient had recovered from this to excise the rectal cancer from the perinseum. The advantages of divert- ing the faeces from the wound during healing, and from the recurrent growth, should it take place, are sufficient in his opinion to quite justify the additional operation. In a case in which he performed the double operation, and in which the patient was under observation for two years subsequently, he states that the advantages were very obvious. Although a re- currence took place six months afterwards, the patient was quite unaware of its existence. The annoyance * BHtish Medical Journal, Aug. 15, 1884. 350 The Rectum and Ax us. [Chap. xxiv. was so trivial, he contends, that by adopting the course indicated, any patient might pass through all the phases of this horrible and fatal malady with scarcely any pain at all. I should not be disposed to adopt either of the above modifications except under very special cir- cumstances, as the advantages of retaining the faecal outlet in the perin?eum are very great. The removal of cancers situated hig:h up. — There is a class of cases which, as Volkmann has well described, are too high for removal from the perinseum, and too low for removal by laparo- tomy. Excision of the coccyx has been tried ; and also a partial removal of the lower end of the sacrum for these cases, without any good results. Dr. P. Kraske of Freiburg* communicated to the German Surgical Congress a method which he had worked out on the cadaver. According to him access to the upper jiart of the rectum is made far easier by splitting the soft parts in the middle line from the second sacral vertebra to the anus, dividing the muscular attach- ments to the sacrum as far as the edge of the bone on the left side ; excising the coccyx, and then dividing fi-om the sacrum the attachments of the two sacro- sciatic ligaments, and drawing away the left edge of the wound. Still further access to the upper portion of the rectum is gained by chiselling away a bit of the lower left side of the sacrum. If the bone be divided in a line beginning on the left edge at the level of the third posterior sacral foramen, and run- ninsf in a curve concave to the left througrh the lower border of the third posterior sacral foramen, and throuo^h the fourth to the left lower corner of the sacrum, the more important parts, especially nerves, are not injured ; and the sacral canal is not opened. The upper portions of the rectum thus become so * " Annals of Surgery," vol. ii. p. 415. 1885. Chap. XXV.] CoLOrOMY. 351 accessible that the rectum can be broiiglit into full view and amputated without difficulty up to where it passes into the sigmoid flexure. Further, this procedure admits resection of the upper rectum with preservation of its lower end. Kraske tried this method on the dead body in a case of high rectal cancer ; and then twice on the living subject. Once in a debilitated woman, set. forty-seven years, the cancer commenced a short distance above the anus, while its upper end could not be felt. The rectum was amputated (with avoidance of the sphincter) where it was wholly surrounded by peritonaeum. The patient made a good recovery. His second case was in a man, set. thirty-seven years, the lower extremity of the disease could just be reached with the finger. A portion of the lower bowel was spared, though divided posteriorly. The gut was pulled down, and the anterior two-thirds united by suture. The lower (posteriorly open) portion was closed later by a plastic operation. CHAPTER XXV. COLOTOMY. The history of this operation is in many respects one of interest. Although it is upwards of a century and a half since it was first proposed, it is only within the last twenty-five years that it has been practised upon at all a large scale, as a means of obviating death in one of its most painful forms, viz. by intestinal obstruction ; and its present position as a recognised operation is mainly due to the eflforts of English surgeons, notably Curlings Bryant, and AUingham. 352 The Rectum and Anus. [Chap. xxv. Apparently the first suggestion of the operation was made by Littre in the year 1710^ but it does not appear that he performed colotomy ; and it was not till sixty years afterwards that the operation was actually performed on tlie living subject by Pillore of Rouen, who opened the cjecum in the right inguinal region. The dread of wounding the peritonaeum, which, with our ancestors, was so great, suggested to Callisen the possibility of opening the descending colon, where it was uncovered by peritonreum in the left loin ; but failing in this intention on the dead body, he does not seem to have attempted it on the living. In 1797 Fine of Geneva opened the trans- verse colon by an incision in the umbilical region. Subsequently Amussat published six cases, in which he was able to open the colon without wounding the peritonceum, five of these cases terminating suc- cessfully ; and since then the operation of lumbar colotomy has borne the name of this distinguished surgeon, and is universally recognised as " Amussat's operation." As the object of this procedure is to provide an alternative outlet for the intestinal contents, through which more or less incontinence of fseces is a necessary result, it follows that the condition of the patient afterwards is by no means pleasant to himself or those about him : it is, therefore, only to be undertaken in cases in which the indication is very clear, and after the patient has been fully told of the inevitable result of the operation. In the case of imperforate infants, where perinatal incision has failed, it is the duty of tlie surgeon to lay the case fully before the parents, telling them that life may be possibly saved by means of colotomy, whereas without it death is certain. The onus of deciding for or against colotomy should be thrown on the parents in cases of imperforate rectum ; but where the patient is an adult, suffering Chap. XXV.] Cases requiring Colotomv. 353 from obstruction, he alone must decide. In the latter case the pain and distress is usually so ex- treme that the sufferers generally gladly accept the conditions, and when the case is successful in relieving urgent symptoms, are loud in their thanks for the relief obtained. The surgeon has no right in these cases of his own motion to act as the arbiter between life and death ; and, if he fail to recommend colotomy in urgent cases, is, in my mind, as guilty of dereliction of duty as if he refused to sanction tracheotomy for the relief of a patient suffering from obstructed glottis. It is necessary to clearly indicate the condi- tions calling for this operation, and they may be conveniently grouped under the following heads : 1. Congenital malformations which cannot be relieved by perinseal incision. 2. For the relief of distress attend- ing recto-vesical fistula. 3. For obstruction, the result of {a) pressure of tumours ; (5) cancer of the bowel ; (c) non-malignant strictures, which are of such an extent as to preclude perinjeal operation. 4. As a means of treating extensive ulceration, by providing physiological rest to the part. Operation of lumbar colotomy, Amiissat's operation. — This operation, which is the one most frequently recommended, and has been generally adopted in all cases of obstructive disease of the rectum in the adult, is one of some little difficulty to the inex- perienced operator; and it is therefore essential to bear in mind the anatomical landmarks which indicate the position of the descending colon, in order to avoid the accidents which have not unfrequently happened durirg its performance. Allingham has directed special atten- tion to this subject."^ He says : " The anatomical guide to the position of the ascending or descending colon is the free edge of the quadratus lumborum * " Diseases of the Eectum," p. 302. Fo\irth edition. X— 23 354 The Rectum and Anus. [Chap. xxv. muscle, but this is by no means always easily found, and consequently it is better to substitute a more certain and unmistakable guide ; and this may be obtained by marking a spot on the crest of the ilium fully half an inch posterior to a point midway between the two superior spinous processes. From more than fifty dissections and the experience of over eighty operations of my own and others, I can confidently assert that the colon is always normally situated oppo- site this point. Before operating I mark this spot with ink or iodine paint, and I have always found it, when the superficial structures are divided, a most useful landmark and guide to the exact position of the intestine." The vertical incision of Callisen, and the trans- verse incision of Amussat, have now generally given place to the oblique incision as recommended by Bryant, and for it the following advantages are claimed : More room is afforded for manipulation ; the incision taking the course of the vessels and nerves lessens the liability to their injury ; that following the ordinary integumentary fold when the patient is recumbent, it facilitates repair and tends to prevent prolapse of the bowel. Before operating the bowel should be as completely emptied as possible by means of laxatives, and an enema, if the obstruction is not complete. The patient should lie in the semiprone position, with a small, hard pillow under the opposite loin. An in- cision should now be made parallel to the last rib on the left side, midway between this bone and the crest of the ilium ; the centre of this incision, which should be about four inches in length, should correspond with Allingham's point. The incisions are now carried deeply, some fibres of the latissimus dorsi and pos- tei-ior edge of external oblique muscles being divided ; and the edge of the quadratus lumborum muscle and Chap. XXV.J CCLOTOMV : DETAILS OF OtERATION. 355 lumbar fascia next looked for. The fascia when found should be freely divided, and probably also a little of the outer edge of the quadratus lumborum. The fascia transversalis is now met wdth and div^ided, and the subperiton?eal fat exposed. If the gut does not now present in the incision, two pairs of dissecting forceps should be taken, and with them the little masses of fat pulled asunder, and the search prose- cuted, the most usual mistake being that of looking for the bowel too far forward. If any difficulty still be experienced, the body should be rolled a little forward ; and at the same time air may be injected into the rectum by means of Lund's insufflator. This will usually have the effect of rolling the bowel into the wound. The colon thus reached and havinor been identified, deep sutures may now be passed through the entire thickness of the abdominal wall, and through the posterior wall of the colon. A longi- tudinal incision is now made in the gut, the loops of the sutures hooked out, cut, and tied, and as many more sutures as may be necessary to completely adjust the skin and mucous membrane put in. Immediately after opening there is often a free discharge of fseces ; while at other times, especially if the bowel has been first well cleared, no faeces may pass for several days. In one of my cases nothing passed till the sixth day ; and my friend, Mr. Thomson, tells me that in a case upon which he operated nothing passed for seventeen days. It is a considerable advantage when this is the case, as it permits of healing of the wound to take place quietly without disturbance. A pad of tenax, or other absorbent antiseptic material, should be kept applied, and changed whenever the bowels move ; and it will much conduce to the comfort of the patient and those around him if large doses of charcoal are administered internally, which, in addition to making the motion harder, tend to remove the 356 The Rectum and Anus. [Chap. xxv. odour. I have recently tried for this latter purpose naphthaline in two grain doses, given wrapped up in wafer paper, and found it answer admirably as a deodoriser. At first there is no control whatever over the motions, and the patient is very miserable if there is any tendency to diarrhoea ; but, later on, if the bowels are kept moderately costive, there is usually but one motion in the twenty-four hours, and, although the patient has no power to restrain it, he knows when it is coming sufficiently long beforehand to make the necessary preparation, and with an absorbent pad comfortably adjusted he is then tolerably comfortable. At any rate, the freedom from pain, and frequent straining, contrast now most favourably with the antecedent miseries of rectal obstruction. Acci<1eiit8 diuing^ and consequent on operation. — Wound of the peritonseuin is of fre- quent occurrence ; and when there is a meso-colon present, its injury is inevitable. 3^ the opening is at all free, prolapse of small intestine is likely to take place, and considerably complicate the operation. In such a case the proper course would be, having re- duced the prolapse, an aseptic sponge should be plugged into the wound, and the search for the colon prosecuted, and as soon as it is found the peritonseal wound must be carefully closed before attempting to open the bowel. In some cases the operator has failed entirely in finding the colon, some portion of the small intestine being opened in its place. It is hard to imagine liow this accident has occurred on the left side, because the small intestine could only be reached after the peritonaeum has been opened, and under these circumstances the appearance of the longi- tudinal bands and appendices epiploicse are so char- acteristic of the large intestine, tiiat with ordinary Chap. XXV.] Closing Lower Opening. 357 caution the distinction should easily be made. On the right side the mistake of opening the duodenum instead of the colon appears to me to be a much more real danger. One of the most experienced colo- tomists at present living has candidly admitted that this accident has occurred in his practice. Durinof the after treatment one of the erreatest dangers is the occurrence of diffuse inflammation and suppuration along the areolar spaces of the abdominal wall. I have seen very extensive sloughing of the skin of the loin follow an operation of this kind. Although it is impossible, from the nature of the wound, to follow strictly the rules of antiseptic surgery, much may be done in this direction with corrosive sublimate solution and iodoform ; but the most important of all measures, I believe, is the accurate suturing of the mucous membrane to the skin, and thus preventing extravasation of faeces. During the after treatment also, a collection of faeces in the lower segment of the gut is a trouble- some complication. When occurring to any extent it may produce, as Bryant has pointed out, symp- toms of intestinal obstruction, notwithstanding the fact that an outlet for faeces exists higher uj) ; and even where this is not the case the irritation in cases of malignant ulceration defeats to a great extent the object of the operation, while in cases of vesico-in- testinal fistula the trouble is even more exaggerated. In order to remedy this, several suggestions have been made : (1) to pass the sutures deeply, so as to include the entire thickness of the bowel instead of its posterior aspect only. As this, however, necessitates the passage of the sutures across the peritonseal cavity it does away with the sole advan- tage claimed for lumbar colotomy. (2) It has also been attempted to bring out a knuckle of intestine at a very acute angle, in the hope that in this way a 358 The Rectum and Anus. [Chap. xxv. spur might be formed similar to that which is found in artificial anus following hernia. (3) The only proceed- ing, however, by which the advantages of lumbar colotomy can be combined with absolute closure of the lower segment is by means of the operation recom- mended by Mr. P. Jones.* He detached the mucous membrane from a prolapsed portion of gut, and from the lower margin of the colotomy opening, turning it on itself, and attaching the raw surfaces by means of the catgut, and afterwards brought together the surfaces denuded of mucous membrane. No faecal matter passed beyond the opening after this procedure had been carried out. Of course it is obvious that no attempt to close the lower opening should be con- templated when there is a possibility of establishing at some future date the normal exit for fseces. Another troublesome after complication is prolapse of the bowel through the artificial anus. This is frequently due to the continued expulsive efifort trying to get rid of the accumulation of faeces in the lower })ortion of the bowel. It is to be treated by the ad- justment of a well-fitting pad, and, if possible, by the closure of the lower orifice. In common with all other extensive wounds of the abdommal parietes, hernia may occasionally occur. Of this accident Mr. Simpson records an instructive example.! Upwards of four years after the operation of colotomy, the patient felt something suddenly give way while coughing, and a tumour appeared imme- diately below the artificial anus, and he died in two days. At the post-mortem the tumour was found to contain a large loop of ileum in part gangrenous. Operation of ingxiinal colotomy (Liittre^s operation).— Under this head is usually described the operation of opening the csecura, or sigmoid * British Medical Journal, April 24, 1886 ; p. 782. f British Medical Journal, May 23, 1885 ; p. 1039. Chap. XXV.] COLOTOMY : STATISTICS. 359 flexure, by an incision in tlie right or left groin. It is witli the latter alone that we are at present con- cerned in considering the treatment of rectal disease. It is, of course, obvious that in this procedure the peritonseum is necessarily injured. It is performed by inakinor an incision throuojh the muscular coats of the abdomen parallel to Poupart's ligament, and then drawing forward a loop of large intestine, securing it to the wound, and opening the bowel between the points of suture ; the subsequent treatment being similar to that of lumbar colotomy. The operation has been pretty generally selected in preference to the retro-peritonseal procedure in cases of imperforate rectum, because in these cases the colon is very hard to find from behind, and is frequently attached by a meso-colon, which would necessitate peritonseal wound. Statistics of colotomy. — The most compre- hensive record of cases of colotomy hitherto published is that by Dr. W. K. Batt ;* and the following is his analysis of cases, slightly condensed : Of a total of 351 opei'ations, 154 were performed for malignant disease, 20 for fistula, 62 for imperforate anus, 40 for obstruction, 72 for stricture, 4 for ulceration, and 9 for miscellaneous causes. The recoveries were 215, deaths 132, equal to a mortality of 38 per cent., the result of 4 cases being unrecorded. Of these, the number of operations performed by Amussat's method was 244: 165, or 68-2 per cent., recovered; 31*8 per cent, were fatal ; and the result in 2 cases is unrecorded. After Littre's method 82 operations were performed : of these, 38, or 46*9 per cent., re- covered, and 43, or 53-1, proved fatal, the result in 1 case beinof unrecorded. After Callisen's method 10 were operated upon, 2 of which recovered, 7 were fatal, and in 1 the result is not stated. Four cases * American Journal of Medical Sciences, Oct., 1884 ; p. 423. 360 The Rectum and Anus. [Chap. xxv. were performed by Fine's method, all of which are recorded as having been successful. In one fatal case a T-shaped incision was adopted, while in 10 the method of operating was not stated. Of these, 6 re- covered and 4 proved fatal. Of the total number, 160 were males, 147 females, and in 44 the sex was not given. Of the 154 cases operated on for malignant disease, 105, or 68'4 per cent., recovered ; 48, or 31 '6 percent., were fatal ; and in one case the result is not stated. The patients in 72 instances were males, in 74 females, and in 8 the sex was not mentioned. Following Amussat's method were 124 cases, of which 91, or 73-5 per cent. , recovered, and 33, or 26*5 percent., were fatal. According to Littre's method there were 23 cases, with 12, or 52*2 per cent., recovering, and 11, or 47*8 per cent., proving fatal ; of the 4 cases fol- lowing Callisen's method all proved fatal, and Fine's case recovered. Of the 2 in which the method was not stated, 1 recovered and 1 died. The ages of the patients were as follows : 20 to 30 years, 22 ; 30 to 40 years, 22 ; 40 to 50 years, 30 ; 50 to 60 years, 29 ; 60 to 70 years, 18 ; over 70 years, 2 ; while in 31 cases the acje was not given. With regard to the duration of life after operation in malignant cases, Dr. Batt has published the following details of cases in which the patients recovered from the immediate effects of operation : 13 died within six months, 15 between six months and one year, 10 died between one and two years, 8 died between two and three years, and one died four and a half years after operation. Of 20 cases operated on for fistula, 18, or 90 per cent., recovered, 2 alone proving fatal. Following Amussat's method were 17 cases, with 15 recoveries, and 2 deaths; and by Littrt^'s method one case, which terminated favourably. The method of operating is not mentioned in two cases which re- covered. Of the 52 cases operated on for imperforate Chap. XXV.] COLOTOMY : STATISTICS. 36 1 anus, 24, or 4:7"1 per cent., recovered; and 27, or 52*9 per cent., were fatal; and the result in 1 case is not stated. Following Amussat's method were 12 cases, 6 recovering and 6 ending fatally ; and following Littre's method were 34 cases, 17, or 51*5 per cent., of which recovered ; ] 6, or 48 "5 per cent., ended fatally ; and there is one case in which the result was not given. Five cases were operated on after Callisen's method, 1 of which recovered and 4 died. In 1 fatal case the method is not mentioned. Of 40 operations for obstruction, 1 9, or 50 per cent., recovered ; 19 died; and in 2 the result was not mentioned ; 24 were performed by Amussat's method, of which 13, or 59 per cent., recovered, 9 terminated fatally, and in two the result is not men- tioned. Eleven cases were performed after Littre's method, of which 3 recovered and 8 proved fatal ; and 3 are recorded by Fine's method, all of which recovered ; in one case in which the method is not stated, and in one case in which aT-shaped incision was made, a fatal re- sult followed. Of the 72 cases operated on for stricture, 41, or 57 per cent., recovered, and 31, or 43 per cent., ended fatally. Following Amussat's method were 59 operations with 35 recoveries, 59 per cent., and 24 deaths. After Littre's method were 10 cases, with 4 recoveries and 6 deaths. Callisen's method was performed in one case which recovered, and two cases are given in which the method is not mentioned, one terminating in recovery, the other fatally. Of the 4 operations performed for ulceration, 3 terminated in recovery and 1 in death. All were performed after Amussat's method. And of 9 patients operated on for miscellaneous causes, 5 recovered and 4 died. Amussat's operation was performed in 4 cases, Littre's in 2, and in 2 the method is not mentioned. Arranged in a tabular form showing the various forms of operating, we find the following convenient summary condensed from Batt : [62 The Rectum and Anus. [Chap. xxv. Form of operatiou. Cases. Eesult not ascertained. Recovered. Died. Mortality per ceut. of terminated cases. Amussat . . Littre . . . Callisen . . Fine . . . Not stated . 244 82 10 4 11 2 1 1 165 38 2 4 6 77 43 7 5 31-8 53-1 77-7 0-0 45-4 Total . . . 351 4 215 132 38-0 According to these statistics, tlie mortality of inguinal colotomy is 20 per cent, greater than that of the retro-peritonseal operation. According to Erckelen's statistics,* the mortality shows a difi'erence of 10 per cent, in favour of Amussat's operation. I think, however, that it will be admitted that statistics of this kind, which are collected from published cases, are at all times misleading ; but especially is this the case in the instance at present under con- sideration, for in the first place the inguinal operation Las been selected in a large proportion of the total number as a treatment for imperforate rectum, and frequently not adopted until after an extensive ex- ploration from the perin?eum, when the patient was nearly exhausted. And, again, as these statistics contain the records for many years back, they embrace a period when peritonseal surgery of all kinds was in a very different condition from that in which it is at the present day, so that I think the time has come when the relative merits of both operations may be fully discussed without our being too much influenced by the results obtained under the older methods of wound-treatment. The unquestionable advantages of laparo-colotomy are these : 1. It permits a thorough exploration of the abdominal cavity, which may enable * " Aichiv f. klin. Chir. Langenbeck," p. 41 ; 1879. Chap. XXV.] COLOTOMY A DeUX TeMPS. 363 the surgeon in some instances to j)erform a more radical operation for the complete removal of the disease, and if removal is impracticable it ensures that the opening is made above the seat of obstruction instead of below, as has happened with the lumbar operation. 2. The large intestine is found with ease and certainty. 3. A complete operation for closure of the lower lumen when considered necessary can be much more readily and completely carried out, thus making the artificial anus a terminus^ and not a lateral outlet to the intestine. 4. A shorter distance of in- testine intervenes between the opening and seat of disease. 5. The abdominal wall being thinner in front, the extent of wound surface is less, and the finer skin in the front abdominal wall permits a much more accurate coaptation of skin and mncous membrane. 6. The position of the wound is much more convenient for the patient, and it is interfered with less by the clothing. So then the sole disadvantage of laparo-colotomy is the necessary wounding of the peritonjeura ; and it must be remembered that even in the hands of skilled colotomists wound of the peritonaeum in the lumbar operation has not unfrequently taken place. It is manifestly easier to deal with a peritonaeal wound, advisedly and carefully made, than with an accidental opening at the bottom of a rather deep incision. Delayed opeiiing^ of tlie intestine. " Ope- ration k deux temps." — The unequivocal advantage which has been found to follow the division of the operation of gastrostomy into two stages has naturally suggested a similar manner of proceeding in colo- tomy ; and cases have recently appeared in which both laparo-colotomy and lumbar colotomy have thus been performed. In a communication made to the Clinical Society of London by Mr. Davies Colley,* three cases are recorded in which the lumbar operation * Lancet, March 21, 1885. 364 The Rectum and Anus. [Chap. xxv. was performed in two stages, the intervals being one, four, and six days respectively. It would appear from these cases that the procedure necessary to retain the loop of bowel in the wound was attended more or less with symptoms of intestinal strangulation, and in order to minimise this result as much as possible Mr. Davies Colley has devised a form of clamp, in which two pairs of ivory studs placed on steel bars are made to grasp the bowel at two places ; and by this means the loop of intestine is held without being strangulated, until sufficient healing of the wound has taken place to obviate any risk of extravasation. In two out of the three cases this instrument was used, and the resulting constitutional symptoms are described as beinof trivial. The analogy between gastrostomy and colotomy, however, scarcely holds, because the mere fact of retaining a small portion of the stomach wall in the abdominal wound can have no direct influence one way or the other on the oesophageal disease for which tlie operation has been undertaken ; while in the case of the colotomy a certain amount of obstruction will probably have existed before the operation, which will be rendered absolute by the drawing out the loop of intestine, and to the symptoms of obstruction will be added more or less those of strangulation. Indeed, it is a very common result of colotomy to have some vomiting and depression for the first two or three days, which may in all probability be ascribed to the strangulation of a small portion of the intestinal wall by the sutures. And it is obviously a prolongation of this trouble if after three or four days the bowel is opened, and a fresh set of sutures put in. I operated on a case of rectal cancer in November, 1884, by laparo-colotomy, having chosen this operation, as I thought that possibly I might be able to do the more radical operation of excision. As the disease was so Chap. XXV.] LaPARO-CoLOTOMY. 365 extensive that excision was deemed impracticable, a loop of the sigmoid flexure was drawn out, emptied by pressure upwards from the seat of obstruction, and caught between two clamps : it was now divided between the clamps, the wall of the lower segment was inverted so as to bring the peritonaeal surfaces into apposition, and carefully sutured up, and the upper orifice was stitched to the wound. This patient lived for two years and a fortnight after the operation. Until a short time before her death she was able to go about and attend to the artificial anus without help ; the bowels moved but once a day, and she was conscious that the motion was coming sufficiently long beforehand to make all the necessary prepara- tions. In a more recent instance I again selected laparo-colotomy in a case of rectal cancer, and I adopted a method which so absolutely prevented extravasation, that I venture to think it will prove more useful than the method of performing the operation in two stages. An incision about four inches long was made in the left linea semilunaris, this position being selected for the following reasons : it freely exposes the sigmoid flexure ; it is made with- out cutting muscle ; the parietes are thinner here than elsewhere; and no vessels of importance are wounded. The deep epigastric artery is quite safe from injury if the lowest limit of the incision does not pass below a line drawn from the umbilicus to the middle of Poupart's ligament. The upper limit of the cancer having been determined, the gut was emptied upwards by careful pressure, and a loop of bowel drawn out ; a narrow- bladed clamp was now applied to the intestine so as to prevent any faeces coming down, and a similar one ap- plied to the distal extremity of the loop. In the pre- sent case, Ricord's phimosis forceps, covered with rubber tubing, and closed by means of elastic umbrella-rings, were used for clamps. (I have since had the clamp 3^6 The Rectum and Anus. [Chap. xxv. illustrated in Fig. 51 made, which has the ad- vantage of allowing the blades to move quite parallel. By means of the screw the exact amount of pressure necessary to retain the loop of intestine in the gras[) can be ap[)lied, and the double angle permits of the blade portion lying easily within the peritonaeal cavity.) The clamps being applied, a number of sutures were passed through the abdominal wall, including peri- tonaeum, on one side, through the intestine in front of the clamp, and through the peritonseum and abdominal wall on the opposite side. Eleven sutures were in Fig. 51.— Colotoniy Clamp (scale one-third). this way passed, five perforating each portion of intestine, and one passing through the meso-colon. The bowel was now opened between two aseptic sponges, and the interior CiirefuUy cleansed of mucus and fseces. The loops of the sutures were hooked out from within the lumen of the bowel, cut, and the central ones tied on each side ; the suture through the meso-colon was also tied, the sutures through the ano;les of the abdominal wound and outer borders of the bowel alone remaining unclosed. A number of superficial sutures were now put in so as to render the application of the mucous membrane to the skin extremely accurate all round, except at the angles where the handles of the clamps lay. The clamps were now withdrawn one by one, and the remaining sutures at either angle simultaneously Chap. XXV.] Colo to my : Pr ognosis. 367 closed, thus shutting off the opening into the peri- tonseal cavity at the moment that the clamps released the bowel. The single suture through the meso-colon is, I think, of use in ensuiing a larger surface of peritonaeum being in apposition to the abdominal wound, and the second clamp on the distal extremity of the bowel, although not as essential as the other, facili- tates the operation considerably (Fig. 52). In this case I did not close the lower lumen, as there was very ■•■":i!>»,„„„^/53^/ffi^^,,l^_^__^ '"%. ''%»-. '^^i m. # Fig. 52.— Mode of applying Colotomy Clamp. considerable discharge from the cancer, and I wished to be enabled to wash the lower segment out occasionally ; but it could have been done, if considered advisable, with the greatest facility. This patient recovered well, and was much relieved by the operation. Prog-nosis. — In estimating the probable result of colotomy, it is necessary to carefully classify the cases. Where the operation has l)een performed for malignant disease, the duration of life can only be prolonged to a certain extent, the disease progressing, and ultimately proving fatal. According to Batt, in 32 per cent, of the cases operated on, death was apparently directly due to the operation when 368 The Rectum and Anus. [Chap. xxv. performed for malignant disease; and of 105 that recovered, and whose subsequent history was traced, it was fouiid that six died within two months of the operation, seven died between three and six months after operation, fifteen died between six months and one year, ten died between one and two years, eight died between two and three years, and one died four and a half years after operation. Of thirty-two patients recorded as being well after the operation, only one had survived two years ; and one, one year. It is of course obviously impossible to form any estimate of how long these patients could have lived if colotomy had not been performed. In my own practice I have performed colotomy five times. For rectal cancer in three cases the lumbar operation was selected : one of these patients lived six months, another three years, and one is alive at present ; and in two in which lapavo-colotomy was selected, one lived two years and a fortnight, and the other is alive at present. It has, however, been suggested that this operation has a direct influence in checking the growth of disease. There is in the Hunterian Museum a very beautiful specimen (Fig. 53), No. 2591, taken from a case of colotomy of thirty years' standing, in wliich the mucosa of the rectum below the opening has undergone atrophy and become villous, these changes being apparently the result of disuse. It is claimed that, as the form of cancer usually found in the rectum is so completely formed of glandular tissue, the abro- gation of function of the rectum induced by the colotomy will be followed by atrophy of the morbid growth as well as of the normal structures. I do not think, however, it is safe to draw conclusions as to the result of a certain procedure on a pathological formation from the changes induced in normal structure, as the conditions of growth under the two Chap. XXV.] COLOTOMV : MlLTEORlSM. 369 circumstances are so essentially dissimilar ; and the dreary record of early death after operation shows conclusively that the progress of disease in these cases is not to any great extent arrested. That life can be pro- longed when death is threatened by obstruc- tion is of course certain, and probably the diver- sion of faeces from the surface of the mali tenant growth, and absolute rest ensured for the part, tend somewhat to retard the growth ; and any one who has wit- nessed the relief af- forded to a person, suf- fering from obstruction, by this operation wdll at once admit the com- plete justification of the procedure. The imme- diate result is much in- fluenced by the stage of the disease atw^hich the operation is performed ; most of the fatal results being due to what Mr. Bryant has truly called "too late" cases. I believe that the most important evidence that the case is too late for operation is the presence of extensive meteorism. Where the bowel has been hyper-distended it has become in such an atonic condition that it may be unable to recover itself after Y— 23 Fig. 53. — Villnns condition of Mucous Membrane from a case of Colotomy of thirty years' duration. 370 The Rectum and Anus. [Chap. xxv. an outlet has been provided, and if such should prove to be the case, a rapidly fatal result must follow. Extensive meteorisra is in itself also a very serious complication to the manipulative details of laparo- colotomy. I recently witnessed an operation under such conditions. The moment the abdominal incision ■was made, a very extensive prolapse of small intestine took place, which could not be restrained. The re- commendation of Mr. Greig Smith was followed, and an incision made in the small intestine, which was then as far as possible evacuated ; the incision sutured, and the intestine returned to the abdominal cavity ; the colon was now drawn out, and the operation com- pleted ; but the patient never recovered power over the intestine, and died in two days. In a case of rectal obstruction with extensive meteorism, I have recently adopted the lumbar operation, instead of laparo-colotomy, with a satisfactory result, and I am strongly of opinion that the sole reason for selecting the former operation should be the existence of this symptom. Of colotomy for imperforate anus, according to Batt's statistics, 47*1 per cent, of the cases were successful. Of course when once the patient has lecovered from the operation there is practically no limit to the duration of life, as there is in the case of malignant disease already discussed, but the chil- dren are frequently ill-developed, and die eaiiy from other causes, comparatively few having reached adult life. In the twenty cases opei-ated on for fistula 18 (90 per cent.) recovered. This would aj)- pear to point out clearly that the dangers of the operation itself are comparatively trivial, and that the greater degree of mortality of the other classes is mainly due to the damage done by intestinal obstruc- tion. Of the four cases in which the operation was performed for the relief of ulceration three recovered. Chap. XXVI.] Pruritus Ami. 371 In these cases the operation shoukl be so performed that when the ulceration healed the artificial anus could be closed. In the few cases in which it was attempted to close an artificial anus the result of colotomy, considerable dilhculty was experienced, and although " Dupuytren's spur " is not so marked as in the artificial anus folloAving hernia, it is sufficient to give some trouble. Mr. Barker* has suggested an ingenious addition to the means at our disposal for the cure of artificial anus. He introduces into the bowel a piece of flexible rubber sheeting one and a half inches long by five-eighths of an inch broad ; this is secured on the internal aspect of the orifice by means of two Avire sutures, one at either end ; the anus is then closed by paring the edges, and inserting sutures in the usual way, the object of the rubber being to protect the wound from faeces. As soon as the wound is closed the wire sutures can be i^emoved, so allowing the rubber to pass aAvay with the faecal contents of the intestine. Although in the case given by Mr. Barker this plan did not com- pletely answer the purpose intended, it appears to be well worthy of more extended trial. CHAPTER XXVI. PRURITUS ANI, Or, as it has been not inaptly termed, painful itching of the anus, is a most distressing complaint when met with in an aggravated form ; patients frequently stating that it is much more difficult to bear than acute pain, and that their lives are rendered absolutely miserable by it. As it may arise from a multiplicity * Lancet, Dec. 18, 1880. 372 The Rectum and Anus. [Chap. xxvi. of causes, it may tax considerably tlie powers of the surgeon to cure. It will, therefore, assist in the con- sideration of the subject, if we discuss in detail the various diseases of which pruritus ani is a symptom. Eczema, as one of the not unfrequent causes of pruritus ani, occurring in the neighbourhood of the anus, may be of two forms, viz. the moist, and the dry. In the first, the skin surrounding the anus is red, and exudes a rather copious gummy discharge. AVhen severe, there may be some subcutaneous ttdema, and it is attended with smarting pain, in addition to the severe itching. This form demands treatment by soothing applications, such as the liiii- mentum calcis, unguentum zinci, etc. ; or, in some cases, it will be found more comfortable to apply boracic acid in fine powder dry, wliicli, mixing with the discharge, forms an antiseptic crust, protecting the raw and sensitive surface. In the dry form of eczema the skin round the anal margin is dry and cracked ; the surface is covered with dry scales, which, if re- moved, disclose a red and sensitive surface. This is the form met with in connection with the lithic acid diathesis, and the itching produced by it is very severe. It must, however, be distinguished from a somewhat similar appearance produced by scratching to relieve pruritus arising from other causes. This form of eczema requires an essentially different plan of treat- ment. Here some of the tar preparations will be found more suitable, such as the compound soap liniment, which consists of equal parts of soft soap, oil of cade, and rectified spirit ; or the part may be bathed with a solution of simple tar water. Van Buren recommends the wearing of a pad of prepared oakum in contact with the affected integument. Tliis substance keeps well in place by its adhesive quality, and moulds itself to the parts with which it is in contact ; it prevents the morbidly altered surfaces from touching each other Chap. XXVI.] Eczema Marginatum. 373 (a most essential point), and at the same time keeps them constantly moistened by the tarry exudation it ajQTords. If these means fail, recourse may be had to painting with a solution of nitrate of silver or other powerful irritant, which, by making the eczema more acute, renders the cure more probable. It is well to remember that sometimes, when the skin around the anus is not much affected, there may be an excoriation of the muco-cutaneous margin similar to what is seen on the lips and eyelids sometimes. Eczema marg^iuatum. — Under this headHebra has described a disease, which is now proved to be due to the same parasite (trichophyton), which pro- duces ringworm in other parts of the body, the some- what distinctive characters being only due to the locality of growth. Commencing usually where the scrotum and thigh touch, it spreads along the inguinal fold and backwards over the perinseum, thus in- volving the anus secondarily. The spreading margin is raised like a wall, and sometimes small vesicles are to be seen ; but they are not so frequent as in other parts of the body, owing to the moisture of the invaded parts. Ill consequence of the intense itching, the appearances are soon modified by scratching, so that the case comes to resemble one of ordinary chronic eczema. It is stated to be much more frequently met with in tropical countries ; and that the disease is rare in women. Although seldom originating at the anus, it spreads to it, and owing to the great sensitiveness of the part, produces there an extreme amount of pruritus. The diagnosis can be readily made by observing the raised, spreading margin, and confirmed by making a microscopical examina- tion. If a few of the scales are scraped from the spreading edge, and moistened with glycerine on a slide^ the characteristic mycelia and coniclia w^ill easily be recognised. The treatment consists in the 374 The Rectum and Anus. [Chap. x)^vi. application of various parasiticides, such as solution of sulphurous acid, perchloride of mercury, or iodine, or ointment of pyrogallic acid (5 per cent.), will some- times prove eflectual. The disease is exceedingly hard to cure, and liable to relapse. Oxyuris verniicularis.— The presence of thread- worms are universally admitted as a cause of pruritus in children ; and in adults they likewise give rise to considerable irritation, and should always be looked for in cases of pruritus ani. Contrary to what is usually taught. Heller has shown * that these worms live principally in the csecum and lower part of the ileum, and that it is principally the females, when about to deposit eggs, that descend into the rectum. The diagnosis can be made sometimes by seeing the worms in the motion just passed, or in the anal folds of skin, and if an injection of cold water is given while the itching is present, a nmiiber will probably be expelled. Heller's observation has most impor- tant bearing on our treatment in these cases of a very common and a very obstinate disease ; as, if the crecum is the principal habitat of the parasite, it is manifestly useless to treat the rectum by small injections of lime-water, infusion of quassia, etc. The great difficulty in treatment is humorously alluded to by Bremser : t " Just as these parasites are, on the one hand, to be counted among the most troublesome of all those that live at the expense of our bodies, so on the other do they, at the same time, belong to those which are the very hardest to exterminate. Their number is legion. And if, after we have slaughtered thousands, we lay our weapons aside for one moment, imagining ourselves safe from a fresh attack, new cohorts again advance with increased reinforcements. The faeces and intestinal mucus * Ziemssen's Cj'clopfedia, vol. vii. p. 752. t Quoted by Heller, loc. cit. Chap. XXVI.] Rectal Neuroses. 375 contained in the large intestine behind which they hide themselves, serve them for a breastwork and parapet. If one attacks them from the front with anthelmintic?, these become so weakened by the long march through the small intestine that the worms only laugh at them. If we attack them in the rear with heavy artillery the foreposts stationed in the rectum must certainly succumb, but the heaviest enema bombard- ment cannot reach those encamped in the c£ecum, and so long as ever so few remain behind in some hidinsr place, they, from the amazing rapidity with which they are reproduced, soon again become a large army." According to Heller no direct reproduction of these worms takes place in the intestine, but the eggs which pass out with the faeces must pass through the stomach, the action of the gastric juice being necessary to allow the worm to escape from the %^;g by soften- ing the outer coat, and he supposes that the eggs are conveyed to the mouth by the fingers after scratching, having frequently found the ^gg?'> under the nails of persons suffering from oxyurides. This shows what an important item in both treatment and proiDhylaxis absolute cleanliness is. He considers free purgation the best form of treatment, and in aggravated cases the washing out of the entire large intestine by means of Hegar's monster clysters, Pediculi and scabies may possibly be the cause of pruritus ani, and if so their presence should be easily determined. Similarly other diseases of the rectum, such as internal piles, fistula, or fissure, may be the only apparent local cause to which the itching can be assigned. A certain number of cases, mostly very in- veterate ones, remain, in explanation of which it is impossible to find any local cause, and which must be, in the want of accurate pathological knowledge, described as neuroses of the rectum. Usually found in elderly 376 The Rectum and Anus. [Chap. xxvi. men, but not by any means confined to the male sex, it appears to attack the plethoric and the spare, the rich and poor alike. The patient usually is not much dis- turbed during the day, but when he goes to bed his misery begins. The itching is so intense that it is impossible to avoid scratching, which, instead of giving relief, only adds to the trouble. Sleep at first is impossible, but when at last it comes it is frequently but of short duration, the patient being awakened by the intolerable itching. If an examination be made, the skin around the anus will usually be found devoid of its normal elasticity, and parchment-like. Imme- diately in the neighbourhood of the anus the normal pigmentation will be absent in patches, the skin here being of a dead white. This is considered by Molliere to be a pathognomonic symptom of the more severe forms. I have seen it very character- istically exhibited in several cases. From the multitude of remedies which have from time to time been recommended, the difficulty of cure may be inferred. Local measures which will relieve one case will be found absolutely futile in another. In the first place, oleate of mercury with morphia may be tried, and has often proved successful in my hands ; bathing with very hot or very cold water, either plain or containing carbonate of soda ; the application of tincture of iodine ; painting with solution of nitrate of silver, or even the light application of the actual cautery have been recommended. Yan Buren says that he thinks most relief is given by the constant application of chloroform ointment, and he recommends patients to go to bed with a large bottle of this beside them, and when the itching comes on to smear the ])arts well with the ointment instead of scratching. Allinghani recommends the wearing of a small pessary in the bowel at night. He says this was suggested to him by the fact that some patients are able to go asleep Chnp. XXVI.] Pr ur itus : Tr ea tment. 377 when they keep the tip of the finger in the amis, but not otherwise. In one case I recently forcibly dilated the sphincter in a very inveterate case of pruritus for the purpose of making a more complete diagnosis, and the o})eration was followed by complete relief of the itching, although nothing abnormal could be found in the rectum. In a second case, however, there was no marked improvement. Painting the part with a 4 per cent, solution of cocain hydrochlorate has, in some cases, given marked relief, but its action appears to be rather uncertain. While attending to the local treatment, the consti- tutional must not be overlooked. Constipation is fre- quently more or less present, and must be appro- priately dealt with. If the patient is very plethoric, a course of saline aperients should be ordered ; and if the reverse, iron, quinine, and cod liver oil may be indicated. If nervous and excitable, a combination of chloral and bromide of potassium wi!l usually prove preferable to the internal use of opium or morphia in any form. These are cases in which patience is required both in the surgeon and patient, treatment at times being anything but satisfactory. 1'he regulation of the diet should be attended to, cases having been known in which special articles of food, such as salmon or shell-fish, have brought on an attack of pruritus. 378 CHAPTER XXVII. ATONY OF THE RECTUM. Rectal constipation. — During health the lower portion of the rectum is empty, except im- mediately preceding the act of defsecation, and the impulse to expel the faeces is caused by the descent of a mass of excrement into the rectal pouch. This fact, which was pointed out by O'Beirne * more than fifty years ago, although frequently doubted, is substantially true. If the call to empty the bowel is not responded to at the time, the desire to a certain extent passes off, and when next the bowels move it will be found that what first passes is a hard mass, the more fluid parts having been absorbed by the rectum. Many of the cases of habitual constijDation met with in practice owe their orio^in to a habit of neglectinoj the calls of nature. In this way the rectal pouch soon becomes tolerant of the presence of fseces, tbe intervals between defsecation become longer and longer, and the habit of costiveness becomes more and more established. In adults who are capable of taking a sufhcient amount of exercise, and those in whom the general health is good, the faecal mass is, sooner or later, expelled, but habits of irregularity in this respect once started are difficult to overcome. In some people the bowels are evacuated more than once daily, while in others there is only one stool in two or three days ; and yet neither of these can be said to deviate from a condition of normal health. It is the irregularity in responding to the call that is a principal factor in the production of this form of constipation in * "New Views on the Process of Defrecation," 1833. Chap. X XV 1 1 . ] ReC TA L CoNS TIPA TION. 379 elderly and debilitated people, and occasionally in children there may be habitually incomplete defseca- tion, resulting in a gradually increasing accumulation in the rectal pouch, the true condition not being suspected, as the bowels occasionally act. After a time a catarrhal dysentery is produced by the irrita- tion of the mass, and the patient is supposed fre- quently to be sufi'ering from diarrhoea. This catarrhal discharge, which is not inaptly compared by Cruveilhier to the overflow of an atonic bladder, may be sufEcient to soften and break down the mass, thus permitting its expulsion ; but at other times symptoms resembling acute obstruction of the bowel supervene ; active peri- staltic motions take place, frequently started by taking a purgative internally, but which are unable to expel the accumulation of f?ecal matter in the rectum ; violent colic is often induced, ^vdth frequent straining and exhausting efforts to procure an evacuation ; pro- fuse sweats break out, the patient becomes cold; the pulse is small and weak ; and not unfrequently vomit- ing occurs ; in fact, the degree of collapse produced may be considerable. If an attempt is made to give an injection, it will be found that there is resistance to the introduction of the tube, and that it is almost im- possible to force any fluid in. A digital examination will now reveal the fact that the bowel is blocked by a hardened mass of clay-like faeces, which must be broken up mechanically before the rectum can be emptied. For this purpose a lithotomy scoop, or the handle of a spoon, may be used to aid the finger ; and as soon as a tube can be introduced copious injections of hot soap-and-water may be with advantage used to assist in the dislodgment. This operation is frequently a tedious, and at all times an un- pleasant proceeding, but the relief given is great, the amount of fseces got rid of being sometimes amaziner. 380 The Rectum and Anus. [Chap, xxvii. Besides the symptoms detailed, rectal constipation may give rise to other serious complications. Ulcera- tion of the bowel, leading to a future perforation, may result at any part of the large intestine.* Again, extensive sloughing of the rectum may super- vene, as in a very remarkable case that I saw in con- sultation with Dr. Wright, of Dalkey, in 1884. A widow, aged sixty-five, had what appeared to be an attack of inflamed piles, from which she had suffered before. She stated positively that the bowels had been quite regularly moved. She suffered from reten- tion of urine, and swelling of the vulva came on, followed by diarrhoea. The skin of the. buttocks became red, glazed, and erysipelatous-looking, and felt very tense, the inflammation being much more marked on the right side. The skin gave way finally, per- mitting the escape of a considerable quantity of faeces. Rectal examination now revealed the fact that the entire lower bowel was blocked with f£eces. By care- ful breaking up of the mass, and copious enemas. Dr. Wright succeeded in evacuating what the nurse de- scribed as a " bucketful " of faeces. When I saw the patient, at the right side of the bowel, about one and a half inches from the anus, the wall of the rectum had sloughed, leaving an opening as large as a half-crown piece. There was a considerable quantity of faeces in the areolar space external to the bowel, and pressure with the finger extruded lumps of hard faeces as big as walnuts througli the large fistulous opening in the right buttock, through which, indeed, almost all the faeces appeared to pass. Notwithstanding the age of the patient, and the gravity of the local manifestations, the constitutional symptoms were slight, and she made a good recovery. I have been since informed by Dr. * See Lecture by Dr. Bristowe on the consequences of \oxv%- continued constipation. — British Medical Journal^ vol. i. p. 1085; 1885. Chap. XXVII.] Regulation of the Bowels. 381 Wright that the fistulous track completely closed without any active surgical interference ; the bowels act normally every day ; and she has no stricture or other inconvenience. This case shows very forcibly how insidious may be the onset of a grave rectal con- stipation. Except during the paroxysmal efforts at expul- sion, pain is not a prominent symptom, and when pre sent is due rather to the pressure on the branches of the sacral plexus than to the nerves of the rectum itself ; thus we sometimes meet with cases of sciatica due solely to the pressure of an over-distended rectum. Havinof once aot rid of the accumulation, care must be taken to prevent its recurrence. This is best done by alterations in diet, by the use of purga- tives, and enemata, and care to at once defsecate when faeces are felt to go down into the lower bowel. Variety in the way of food is of great importance, as if there is too great uniformity diminished sen- sibility of the intestinal canal will be induced. The habitual use of coarse vegetable food, such as much bread, oatmeal, and potatoes, induces chronic constipa- tion ; while these articles of diet will relieve the con- stipation which comes on in persons who habitually use too much animal food. Similarly, milk used as a principal article of diet may produce constipation, while with others it acts as a purgative. In the same way aperients must be used with the greatest dis- cretion : if one form ceases to act it is better to change it for another than to increase the dose. But the best treatment of all, as it more nearly simulates the normal stimulus, is the daily use of a small enema. It has been frequently stated that the constant use of enemata leads to the production of rectal atony, but this objection, I feel sure, is chimerical. Probably the best way of all is to constantly change the kind of 382 The Rectum and Anus. [Chap. xxvii. stimulus applied to the intestinal mucous membrane. Dr. Lee has suggested,* that when a patient is trying to get rid of a rectal accumulation much assistance may be derived from firmly pressing up with the fingers into each ischio-rectal fossa, by this means making the presenting mass more wedge-like and easy to pass. Tliere is a form of rectal atony met with in hysterical females and hypocliondriacal nuen, whose attention is morbidly fixed upon the evacuation of their bowels, and whose sole interest appears to be directed to the subject of defsecation. In illustration of this subject I cannot do better than quote from the graphic pen of Dr. Weir Mitchell :t "If it happens to you in an evil hour to have one of these cases to treat, with the additional need to treat also the difiiculties with which some tender mother surrounds such a case, you are much to be pitied. 1 recall such an example which I saw in consultation some years ago. It began with a spot of abdominal tenderness over the spleen. Pressure on this caused nausea and vertigo. Then we had convulsions, hysterics, coma, enormous polyuria, and at last constijmtion. The physician in charge gave this list of the drugs given in four days : night and morning on each day an ounce of castor oil, at midday and bed-time one drop of croton oil ; three drops had been used in one day. The more drugs she took the more she demanded, and yet it was impossible to see that it gave her ])ain. Meanwhile for the nurse and mother the arransfement for each evacuation was the event of the day. A long stomach tube was carried six or seven inches up the bowel, and half a pint of olive oil injected, then followed one quart to three of flaxseed tea. During the use of the enema one person was occupied compressing the * British Medical Journal, Feb. 10. 1883. t "Diseases of the Nervous System." London, 1881. Chap. XXVII.] Atony of the SpiiiNcrER. 383 anal opening, so as to prevent the escape of fluid. This help was made necessary on account of the great relaxation of the sphincter, into which a thumb could be passed without any resistance which could be felt to arise from a muscular act. Meanwhile the patient, while insisting on the use of more water, was shrieking with pain. The whole affair took two to four hours, and the patient was, I thought, the least exhausted of those concerned. Sometimes their efforts gave rise to a stool, sometimes there was none for a week, and sometimes under the wild entreaties of the patient tliese trying scenes were repeated in the night, nurse and mother beincr aroused to assist. I endeavoured to get this girl out of the control of the family, but I did not succeed, and I believe that her hysteria is now firmly established." There is a form, of atony of the sphincter w4iich gives rise sometimes to a good deal of annoyance, in which it is impossible to expel just the last little portion of faeces, so that there is a difficulty in cleansing the parts after defgecation, and a tendency to have a slight escape of f<3eces during the day. This condition is not unfrequently associated with piles, but is some- times independent of them. It is to be treated by copious ablutions with cold water after defsecation. The paralysis of the rectum following spinal or cerebral diseases and diphtheria presents no points of special interest for consideration here. 384 CHAPTER XXVIII. IRRITABLE RECTUM AND NEURALGIA. In addition to pruritus and atony of tlie rectum, there remain some neuroses which require brief notice. Curling has divided tliese more purely nervous diseases of the rectum into three classes, and the distinctive characters of each appear sufficient to justify the classification: (1) Irritability of the rectum, with frequent desire to expel the contents. (2) Neuralgia of the lower bowel, without any tenderness. (3) Morbid sensibility, where no gross local pathological change is discoverable. Frequently the last two are associated in the same individual, and may exist with a considerable amount of spasm of the sphincter. (1) Irritability of the rectum is sometimes due to a catarrhal condition of the mucous membrane, while at others no such definite cause can be assigned, frequent desire to go to stool, usually at inconvenient times, being noticed. Of this condition many familiar examples will suggest themselves, indicating that when the mind is intensely occupied, chiefly by anxiety, the rectal reflexes may be abnormally high. It is common to hear of students going in for an examination having diarrhoea in the morning before it ; and of persons having a desire to deftecate before a train starts, or when it stops at station ; and I know a surgeon who has always to retire to the water-closet immediately before undertaking any severe operation. This minor degree of irritable rectum is common enough, but in rare cases it may be so marked that it may materially affect a person's enjoyment of life, or even interfere with business, as in the case of a Chap, xxviii.] Neuralgia of Rectum. 385 clergyman, recorded by Curling, in whom the desire usually came on just before commencing divine service. Cases of this kind are best treated by urging the patient to try and overcome the inclina- tion, in which, with the exercise of a little moral control, they will usually ])rove successful. (2) Neuralgia. — As in other parts of the body, pain of a more or less severe character may exist at the lower end of the bowel, without any discoverable cause. It is usually found in rather weak and hypo- chondriacal males, and hysterical females. At other times pain referred to the anus and interior of the rectum may have its origin in an injury to the coccyx, constituting one of the symptoms of the so- called " coccygodynia." These cases are to be treated in the same way that vague neuralgias of other parts of the body are, but it must be admitted that for the most part they are exceedingly unsatisfactory cases to deal with. (3) Morbid sensibility. — The third class is when there is a true hypersesthesia of some par- ticular spot, Avhich frequently is associated with more or less spasm of the sphincters and levatores ani. These symptoms are usually all much aggravated by passing a motion, the pain afterwards being very severe. In the great majority of patients suffering from these symptoms, a definite cause will be found in the presence of a small irritable ulcer or painful fissure ; but in a few, no such obvious pathological condition is to be seen. If, however, the symptoms are really severe, the best treatment to adopt is that which would be applied to fissure, namely, forcible dilatation. z-23 386 CHAPTER XXIX. INJURIES OF RECTUM AND AXUS. Wounds of the rectum may be tlie result : Of foreign bodies being forcibly thrust into or through the bowel; of injury inflicted during parturition ; of per- foration by fragments of bone or other hard sub- stance which have passed through the alimentary tract; of gunshot injury; and of penetration by a fragment of broken pelvis ; all of which would be classed under the head of lacerated and contused wounds. Cleanly incised wounds in this region are extremely unlikely to occur, except as the result of surgical oj^eration, either intentionally done, as in the operation for fistula and other similar procetonis of, 328 trtatni' ut, 335 , abuse of morphia, , colectomy, 337 , colotomy, 33G, 351 , excision, ;i38 Cancer of rectum, treatment, ex- cision, Causes of mortality after, 339 , , combined with colotomy, 318 • , , , details of ope ration, 344 , -, , Incontinence of faeces after, 342 , , , prognosis, 349 • , , , Kecurrence after, 343 , , , statistics, 339 , Stricture after, 342 use of su- tures, 315 , , when situated high up, 3i;0 , , , wound of pe- ritonaeum, 3i7 , Tuberous, 311 , varieties, 309 Carcinoma myxomatodes, 318 Cardiac disease, Relation of, to piles, 237 Oarrington, Dr., lymphosarcoma, 321 Cartilaginous tumours, 300 Catarrhal proctitis, 48 , Chrouic, 50 , Sequelae of, 49 Chancre at anus, 181 Cheselden, Mr., operation for fistula, 81 Claude Bernard, case of lii)oma, 297 Closmadeuc, case of box of in- struments introduced into the rectum, 392 Clover's crutch, 9 Coates, Dr., excision of piles, 266 Coccygeal eminence, 19 Coccyx, Removal of, 29 Cohnheim, embryonic origin of cancer, 315 , intestinal haemorrhage, 49 Colles, Dr., ewer-shaped anus, 164 , injection of perchloride of iron into piles, 256 Colley, Mr. Davies, delayed open- ing of bowel in colotomy, 3ti3 Colloid cancer, 317 Colectomy, 337 Colonoscope, 14 Colotomy, 351 , Amussat's operation, 353 clami>, 366 , Closure of opening after, 371 Index, 403 Uolotomy, Delayed action of bowel after, 355 • , delayed opening of bowel, 363 , Hernia after, 357 in coii genital malformation, 30 in malignant disease, 336 in simple stricture, 177 , Indicatvous for, 353 , laparo-colotomy, 365 , Littre's operation, 358 , Lumbar, 353 , meteorism a serious symp- tom, 370 -, methods of closiig lower opening, 357 , i>rognosi9, 367 , Statistics of, 359 , Wound of peritonsevira in, 356 Comjlete obstruction from im- paction of plum-stone, 160 Complex fistulse, 73 , treatment, 84 Concretions in intestine, 391 Condylomata, 181 Congenita' malformations, 13 , absence of rectum, 25 , classificaiiou, 20 , narrowing of anus, 22 , occlusion of auus, 24 • , rectum opening tlirougli sacrum, 36 , opening under pre- puce, 36 — ~- , E.emoval of coccyx for, 29 , Statistics of, 23 , treatment, 23 , by perinseal in- cision, 23 , trocar and cannula, Use of, in, 27 , varieties, 21 syphdis, 184 Cripps, Mr. Harrison, congenital malformations, 24 , pathology of cancer, 303 , pol3'adeuomata, 283 , source of bleeding in piles, 236 , spismodic stricture, 139 , siricture produced by leva- tores ani, 150 Crushing piles, 264 Cruveiluier, colloid cancer, 317 Curling, congenital malforma- tiou~. 32 Cylindroma, 310 Cystoma of rectum, 299 Czerny, excision of rectum, 343 Danzel, teratoma, 296 Dermoid cysts, 295 Development of rectum, 18 Diagnosis of rectal disease, 1 Dietfenbar-h, procto-plastic ope- ration, 178 , operation for vaginal anus, 45 , operation for prola])se, 210 Digital examination, 4 Dilatation of sphincter. History of, 9 , Results of, 11 Dipbtlieria of the anus, 52 Discharge, an evidence of rectul disease, 3 Disuse, Effects of, on rectum, 369 Dittel, elastic ligature, 92 , operation for recto-vesical fistu a, 102 Diverticula of rectum, 396 , False, ;^9? , True. 393 Dolbeau, M, case of enchon- droma, 300 Dowue-, Mr. , pile clamp, 265 Dumarquay, submucous division of spbincter, 134 Dupuytren, limited incision of si^bincter. 134 , operation for prolapse, 211 Dy senteric proctitis, 50 stricture, 144 Ectropion recti, 49 Eczema ani, 372 marginatum, 373 Elastic ligature, 92 Electrolysis of piles, 260 Encboudroma, 30J Encysted rectum, 400 Endoscope, 14 Enemata, IJse of, for piles, 250 Euterotome, 87 Erysipelatous periprocti'is, 64 Esniarch, anus preteruaturulis in ► ano, 103 , case of very large polypus, 290 , lipoma, 297 EstliiomC-ne, 121 Ewen, Dr., thrombosis from pile operations, 277 404 The Rectum and Anus. Examination of rectum. Methods of, 3 Exner, arrangement of vessels in cioati-ict'S, 279 External piles. (See Piles.) • rectal sinus, 71 rectisection in cancer, 33S Faeces, Varieties of, in rectal dis- ease, 3 Faget, Dr., excision of rectum, 338 Ferrand, Dr., injections of ergo- tin in prolapse, 204 Fine, M., colotomy, 352 Fissure, 127 , a compl-cation of piles, 246 - — , a result of fistulee opera- tions, 90 , clnracter of pain, 131 , Eeflex pains from, 130 , Re'atiou of nerves to. 128 , relation of pain to defalca- tion, 131 , tape-like fsece^, 131 , treatment, 133 , , dilatation, 135 . , incision of sphincter, 134 , , limited incision of sphincter. 134 , , Medicinal, 133 , , submucous incision, 134 Fistula, m , a compl' cation of piles, 247 — — , Analogy between urethral and rectal, 81 , a result of tubercular in- oculation, 105 between rectum and other parts of the intestine, 103 bi-mucosa, 99 ■ , Blind external, 71 , Blind internal, 71 , cau- es, 67 , classification, 68 , Complex, 73 , Diagnosis of, 75 , Examination of, 75 , Horte-shoc', 73 , .treatment, 86 , immediate ligature, 96 in ano, 68 , Incision of; delayed healing of wound, 89 , Incomi)lete, 67 • . incontinence following ope- ration, 91 Fistula, internal opening, Me- thods of finding, 77 , Eelations of, to phthisis, 104 , secondary sui^puratioii, 91 , statistics, 66 , structure, 73 , treatment, 79 — — , by elastic ligature, 92 , by incision, 80 , by ligature, 92 , without operation, 79 Fibroma of rectum, 291 F^bro-niyoma of rectum, 292 Foreign bodies in rectum, 390 formed in rectum, 390 introduced through anus, 391 ■ • , rectal calculus, 393 ■ , Removal of, 393 , by introduction of hand, 394 , by laparotomy, 395 , , use of forceps.etc, 394 ■ , size of substances, 392 , variety of substances, 392 Friedberg, multiple membranous occlusion of rectum, 31 Galvanic ecraseiir, 98 GangrenoiTS Tierii)roctitis, 64 ■ piles, 242 Gerdy, treatment of deep fistulse, 87 Givard, injection of tannic acid and carbolic acid into piles, 257 Glandular polypus, 281 Godard, congenital malformation, 32 Goeschler, multiple obstructions of rectum, 32 Gonorrhoeal proctitis, 51 Granular papilloma of rectiim, 292 Gross, Dr., concretions of cal- cined magnesia, 391 , sacciform disease of rectum, 400 Gummata, 183 Hasmorrhage after incision of fistula, 88 after pile operations, 275 , Concealed, 275 from piles, 235 from iDiles ever salutai'y ? 239 Haemorrhoids, 216. (See Pies.) Haimoi-rhoidal arteries, 217 Index. 405 Harailtou, Captain, clay plugs in- troduced into rectum, :i91 , Dr., classification of internal piles, 2.3:3 • , treatment of ijil- sby needles covered with caustic. 2^5 Hand, Introduction of, into rec- tum, 14 Hard polypus, 291. (See Fibromi.) Haussmanu, cancer of intestine, 3J9 H gar's retractor, 7 Hepatic dsease, Eelations of, to piles, 237 Hernia with prolapse, 196 Heuck, Dr., excision of rectum, 340 Hewett, Mr, P., injury of rectum, 387 Horse-shoe fistula, 73 •, treatment, £6 Houston, M., naevoid pile, 234 HulUe, Ml-. J. W., diverticulum of rectum, 397 HumpLry, Mr., linear procto- tomy, 175 Immed'ate I'gation of fistula, 96 Impaction of fasces, 378 Imperforate anus, 24 Incontinence of feeces after exci- sion of rectum, 342 after fistula operations, 91 Inflammation of rectum, 47 Inguinal colotoniy, 358 Injuries of rectum, 386 ■ by substances swal- lowed, 388 , Direct, 386 , Gunshot, 389 in parturition, 388 Internal piles. (.See Piles.; rectal sinus, 71 Intussusception of rectum, 215 Invagination of intestine, 215 Irreaucible prolapse, 211 Irritable rectum, 384 ulcer, 127 Ischio-rectal absctss, 61 -, treatment, 61, Itching of anus, 371 Jessett, Dr., statistics of cancer, 304 Jessop, Dr;, torsion of piles, 268 Jones, Mr. P., method of closing lower colutomy opening, 358 Jordan, Mr. Furneaux, gangre- nous periproctitis, ^ii Kelsey, Dr. C. B., linear jjrocto- tomy in cancer, .336 , subcutaneous injection of carbolic acid in ijiles, 256 Klebertf, excision of i:»rolapse, 212 Koch, intt-stinal tubercvdo&is, 105 Kraske, Dr., removal of cancers situated bigh up, .350 Lapai'o-colotomy, 365 Laparotomy for foreign bodies, 395 Lebert, M., gonorrhcBaof rectum, 51 Lee, Mr., cautery for piles, 270 Legg, Dr. Wickham, collect'on of fruit-stones in intestine, 160 Leichtenstern, dysenteric stric- tu-e, 145 , spasmodic stricture, 139 , statistics of cancer, .303 Leube, iuvolvement of ureter iu cancer, 333 Leutai^Tie, Dr., cnse of false di- verticula of rectum, 399 Levator nni, Spasm of, a cause of stricture, I'^O Lieberkuhn, follicles in cancer, 288 Ligature of piles, 261 of rectal tstula, 92 Linear proctotomy, 174 • in cancer, 3-jJ Lii)oma, 297 , varieties, 298 , treatment, 298 Lisfranc, excision of rectum, 3.33 Lister, Sir Joseph, treatment of cancer by scoop, 337 Littre, colotomy, 352 Luke, Mr., ligature of rectal fis- tula, 92 Lumbar colotomy, 353 Lupoid ulceration, 121 Luschka, polyadenomata, 283 LymiDho-sarcoma, 321 McCarthy, Mr. J., case of com- munication between vfermif urm appendix and rectum, 104 McDonnell, Dr. Eobert, I'ectal pessary, 202 McLeod, Dr., congenital malfor- mation, 30 Maisouneuve, ciilatation of sphinc- ter, 135 4o6 2 HE Rectum and Anus. M It'ormations of rectum, 18 Malii;naut neoplasms, 302. (See Cancer.) , statistics, 303 Manual examination of rectnm, 15 Marchettis, c^se of pig s tail in rectum, 395 TVIargiua' abscess, 63 Marsh, Mr. H., angioma of rec- tum, 302 Martm, Mr. M., operation for atresia aui vesicalis, 41 Measurements of foetul i^elvis, 27 Melanotic sarcoma, 3i2 Mesenteron, 18 Mitchell, Dr. Weir, neurosis of rectum, 382 Molliere, congenital malforma- tions, LO , method of examining for polj'pus, 291 • , method of producing pro- lapse, 189 , teratoma, 295 Morbid sensibility of rectum, 385 Moigagui, sinuses of, ulceration, 114 Morgan, case^ of congenital mal- formation, 23 Mucous membrane, Prolapse of, 188 Myoma, 292 Nepvew, M., rectal melanosis, 328 Neuralgia of rectum, 385 Nitric add, Use of, in piles, 251 , in prolapse. 2 4 Non-mal gnant stricture. {See Stiicture.) Nussbaum, excision of rectum with portion of bladder, 348 Ogston, Mr. F., congenital i^iles, 223 Ossifying cancer, 326 Oxyuris vermicularis, 374 P;)get, Sir James, extensive sy- l^hiUtic disease of rectum, 186 Pa n an evidence of rectal dis- ease, 2 Panas, linear proctotomy in can. cer, 316 Papeudorf, congenital malforina- tums, 20 Papilloma of anus, 294 , Causes of, 291- , Microscopic appearance of. 293 Papilloma of rectum, 29 , symptoms, 2it3 Paquelin cautery, 97, 205 Pars-caudalis iutestini, 37 Pelvi-rectal fistuli*, 70 space, Abscess of, 55 Perinseal incision in congenital malformation, 26 Septum, Formation of, 20 Perinseum, Appearance of, iu con- genital malformation, 24 Periproctitis, 54 , Circumscribed, 60 Pbleboliths, 229 Phlegmonous abscess, 61 Phthisis, Relation of, to fistula, 104 Physick, encysted rectum, 4')0 Piles abase of purgatives, 221 , etiology of, 216 , age, 222 , Anatom'cal in'edisposing causes of. 217 , Congenital, 223 , Constipation a cause of, 220 , Erect posture a cause of, 217 , exce.<^sive eating, 223 ■, External, 224 , , Compound, 2"7 , ■ — -, Cutaneous, 225 -, , Haemorrhage from, 223 , , Inflammation of, 228 , , (Edematous, 227 , , Phleboliths in, 229 , , Suppuration of, 228 , , tx'eatment, 230 , , , palliative, 230 , , , radical, 2;J0 , , , , excision, 2 !1 , , , , iuc.sion, 2:i0 , , , , use of su- tures, 232 , , Venous, 225 , Internal, 233 , , abscess after operation, 278 , , Bleeding from, 235 , , Columnar, 233 , , connection with ute- rine disease, 241 , , Effect of rectal cicatrix ou, 279 , — , Fissure a complication of. 216 , , Fistula a complication of. 246 , , Gangrene of, 242 , , Haemorrhage from, 233 Index. 407 Piles, Int runl, ligemorrhoides blanches, 237 , , Inflammatory strangu- lation of, 244 , , in relation to cardiac disease, 237 , , in relation to liepatic disease, 237 , , is bleeding ever salu- tary? 239 . , , Nsevoid, 233 , , operation dui'ing in- flammation, 243 , , Polypi a complication of, 246 , , retention of urine after operation, 277 , , septic complications after operation, 277 • , , Simple strictui'e a com- plication of, 246 ■ , , sloughing after opera- tion, 278 • , , Source of bleeding from, 236 , -, Strangiilation of, 242 , , stricture after opera- tion, 278 , , Symptoms of, 234 ■ , , tetanus after operation, 276 ■ , , thrombosis after ope» ration, 277 • , , treatment, Palliative, 247 ■ , , , , cold bath- ing, 251 , ; , , diet, 251 ■ , , , -, ferrous sul- phate, 252 , , , , internal treat- ment, 251 , , , , selection of purgatives, 249 ■ , , , , use of ene- mata, 250 ■ , , , Operative, 254 , , , , actual cau- tery, 270 ■ , , , , , JgQi- puncture, 273 , , , , , Lee's clamp for, 271 , , , , , Smith's clamp for, 270 , , , , , Woille- mier linear cauterisation, 272 , : , , , chemical caustics, 254 Piles, Internal, treatment, opera- tive, chemical caustics, acid ni- trate of mercury, 255 , , , — , , butter of antimony, 255 acid, 254 , , , , , Vienna paste, 255 , , , , crushing, 2f 4 , , , , , lien ham's clamp, 265 , , , , , Pol lock's clamp, 26 1 — -, , , , dilatation 253 , , , , , forci ble, 258 , , , , . gradual 258 , , , , electrolysis 260 , -, , , excision, 266 , ■, , , , Coate's operation, 266 , , , , , White- head's operation, 236 , , , , injection, 255 , , , , , carbolic ac d, 256 — — , , , , , ex ti-act of ergot, 256 — — , , , , , perchlo- ride of iron, 256 , , , , ligature, 261 , , , , , Salmon's operation, 262 , , , , torsion, 268 , , ulceration after opeia- tion, 278 . , , Venous, 233 , heredity, 223 , sex, 221 Piatt, Dr., case of false diverticu- lum, 399 Polypi a complication of piles, 246 Polypus, 280. (See Benign neo- plasms.) Pollock, Mr. G., pile crushing, 264 Pollosson, M., excision of rectum with colotomy, 318 Port, Dr., teratoma, 295 Post-anal gut, 37 Pott, varieties of periproctitis, eo Ponlet, foreign bodies in rectum, 391 4o8 The Rectum and Anus. Proctitis, 47 , Catarrhal, 4R ■ , Dj'senterio, 48 , Gonorrlioeal, 48 , treatment, 6i ProctodjBum, 19 Prolapsal hernia, 196 Prolapsus recti, 188 , Complete, 193 , extensive, 195 , irreducible, 211 • , , peritonseal pouch. 194 • , , Spontaneous rup- ture of, 197 , Partial, 188 , , age of patients, 191 • , , associated with piles, 190 ■ , , associated witli polypus, 190 • , , Gangi-eue of, 193 • , , mode of produc- tion, ls9 ■ , treatment, 199 , , acid nitrate of mercury, 204 , , actual cautery, 206 , , Dieffenbacli's ope- ration, 210 , , Dupuytren's opera- tion, 211 • , , excision. 212 , , galvanic cautery, 203 , , iujections, 200 • , , linear cauterisa- tion, 203 , , miethods of reduc- tion, 199 , , niti'ic acid, 204 , , 4 aqueliu cautery, 205 , , pessaries, 202 , , subcutaneous in- jection, 203 , , use of supj)osito- ries, 201 ■ with invagination, 215 Pruritus ani, 371 , a symptom of eczema, 372 ■ , of eczema margina- tum, 373 ■ of oxynrides, 374 of pediculi, 375 of scabies, 375 , Neurotic, 375 , treatment, 376 Purgatives, Selection of, for piles, 24i9 Quenu, M., spontaneous rupture of rectum, 197 Eecamier, massage cadence, 135 Rectal constipation, 378 intussvisception, 215 sinus, 60 Eecto-urethral fistula, 99 vesical fistula, 69 Reeves, Mr., igniijuucture for piles, 273 , immediate ligation of fistula, 96 Reflex pains in irritable ulcer, 130 Rhagades, 182 Kibes, M., p-^sition of internal opening in fistula, 69 Richardson, Mr., toothed scissors, 231 Richet, hsemorrhoides blanches, 237 , polyadenomata, 283 Rizzoli, operation lor vulvar anus, 45 Robert, lipoma of anus, 299 Rollet, gonorrhoea of rectum, 51 Roser, ectroi^ion recti, 49 Rupture of rectum, Spontaneous, 197 Sacciform disease of anus, 403 Salmon, Mr., ligaturing piles, 262 Sangalle, case of lipoma, 297 Sarcoma of rectum, 319 , Alveolar, 321 , Melanotic, 322 Schenck, multiple obstruction of rectum, 31 Schroeder, formation of direct cunimunicatiou between rectum and small intestine fi>r cure of vaginal artificial anus, 103 Scirrhous cancer, 30;) Septic periproctitis, 54 , prophylaxis, 58 , treatment, 57 Serremone, congenital narrowing of auus a cause of fissure, 13i Simpson, Mr., heruia after co'o- tomj', 358 Sims, J. Marion, gunshot wound of rectum, 3S9 Sinus, Rsctal, 71 Saiith, Henry, Mr., cautery for piles, 270 , cautery for prolapse, 203 Index. 409 Smitli, Stephen, Mi'., treatment of fistula by sutnres, 9G Sormani, Professor G., digestion of tubercle bacilli, lOQ Spasm of sphincter, 129 Spasmodic stricture, 138 Specula, Rectal, 8 Spontaneous rupture, 197 Stercoral abscess, 60 Stokes, Sir Wm., injury of rec- tum, 387 Stricture, Anal, 178 , Annular, 149 , C.'Uises of, 178 , Colotomy in, 177 , Complete olistruction in, 159 , Congenital, 21 , Dieffenbach's proctoplastic operation, 178 ■ , Diet in, 170 , Differential diagnosis of, 169 , Digital examination of, 165 , Dilatiition of, 172 , Dysentery a cause of, 144 , estimation of length, 165 , Excision of, 177 from contraction of levatores ani. 150 • from tubercular ulceration, 146 , Haemorrhoids in connection with. 164 , Hydraulic dilatation of, 173 , linear proctotomy, 174 ■ , Manual examination of, 168 of rectum, 138 , Pathology of, 148 , Peritonitis a result of, 161 , Eelation of, to fistula, 163 , Section of external, 174 , of internal, 174 , selection of purgatives, 170 , sex, Influence of, in, 148 situated high up, 167 , Spasmodic, 138 • , Sudden dilatation of, 172 , Symptoms of, 155 , Sj^jhilitic. 14:3 , Traumatic, 146 , treatment, 178 , Tubular, 149 , Valvular, 149 Subcutaneous injection for cure of piles, 255 of prolapse, 203 SjTne, fistula in ano, 70 Syphilis of rectum, 179 , amyloid degeneration, 187 — — , ano-rectal syphiloma, 184 BB_23 Syphilis, chancre at anus, 181 , Chancroid, 179 , condylomata, 181 , Congenital, 184 , Extensive ulceration from, 185 , gummata, 183 , rhagades, 182 , Stricture from, 184 Talma, Case of, 331 Tape-like fseces, 157 Teratoma, 295 Thermo-cautery, 97, 205 Thomson. Dr. W., delayed action of bowel after colotomy, 355 Todd's dilator, 174 Traumatic stricture, 146 Treves, Mr., cancer of intestine, 309 Trichiasis recti, 91 Trousseau, diphtheria of anus, 52 Tubercle bacilli in rectal disease, 105 Tubercular iilceration causing stricture, 143 Tuberculosis a complication of fistula operation, 91 of intestine, 105 Tuberculous fistulae, 105 Tufnell, Dr., case of injury to rec- tum, 387 Tumours of rectum. (See Benign neoplasms and Cancer. ) Ulceration of rectum, 109 • , Albuminuric, 117 , causes, 110 , classification, 112 commencing in lacunae. lid , Dysenteric, 125 , Follicular, 117 — ■ , Hsemorrhoidal, 112 , , symptoms, 113 , , treatment, 113 , Irritable, 127 , Lupoid, 121 , Perforation of intestine by, 112 ■ , Eodent, 123 , Syphilitic, 185 , Tubercular-, 119 Ureters, Involvement of , in cancer of rectum, 333 opening into rectum, 46 Uterine disease, Eelation of, to piles, 241 Uterus opening into rectum, 46 4IO The Rectum and Anus. Vagina opening into rectum, 46 Vau Buren, Dr., linear cauterisa- tion for prolapsus recti, 208 Vascular tumour of rectum, 234 Velpeau, operation for vaginal anus, 45 , position of internal opening in fistula, 69 Verneuil, linear proctotomy, 175, 336 Vicq d'Azyr, operation for vagi- nal anus, 44 Vidal, subcutaneous injection of ergotiu for prolapse, 203 Villous, tumour of rectum, 293. (See Papilloma.) Vircliow, lipoma of rectiim, 297 , melanotic sarcoma, 322 Voillemier, multiple obstruction of rectum, 32 Volkmaun, excision of rectum, 341 Voss, lipoma, 298 Vulvar anus, 44 Wagstaffe, case of ossifying can- cer, 326 "Warts at anus, 294. (See Papil- loma.) Washburn, injection of carbolic acid in piles, 256 Wliitebead, excision of piles, 267 Williams, Mr. "W. R., statistics of caucer, 304 Woillemier, linear cauterisation for piles, 272 Wounds of rectum, 386 , Complications of, 387 , Gunshot, 389 , Treatment of, 390 Wright, Dr. W. M. A., rectal con- stipation, 380 Ziegler, colloid cnucer, 317 rniNTKr) BY Cassell & Company, Limited, LaBkllk Sauvaqk, London, E.O. 1 COLUMBIA UNIVERSITY LIBRARIES This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the library rules or by special arrangement with the Librarian in charge. , ■ 1 OATE BORROWED DATE DUE DATE BORROWED DATE DUE ' C28(ll40)lOOM £p RC864 ^^^rectun, .^d a £21 1837 ^^^- their di s eases -7?(: ^6 ^ m: