CHAPTER IT. (Part 1)

CHAPTER IT. INFLAMMATION" OF THE RECTUM. Cases of Proctitis.— Varieties : Acute, Chronic, Primary, Secondary, Localized, General. — Symp^ms and Course of each Variety. — Causes of Proctitis: Direct Propagation, Foreign Bodies, Drastic Cathartics, Gk)ut, Pederasty, (Gonorrhoea. — ^Treatment. The two cases which follow are not only intei;esting from their rarity, but as being good examples of two differen-t stages of the affection nnder consideration. Case III. — Mrs. G., age thirty-seven, mother of three children. The patient, a delicate and rather anasmic lady, had not been in good health for some time past, but had never had any trouble with the rectum until one month before consulting me. At that time she was surprised to find that she had passed a considerable quantity of blood while at stool, and this hsBmorrhage had been repeated at intervals of about a week up to the day before my visit. There had never been any pain in the rectum or anus, or any signs o£ haemorrhoids, and a careful examination failed to reveal any source of the haemorrhage. The lady complained, however, of a good deal of discomfort in the back and pelvis; had missed her last menstrual period, and was decidedly constipated. An examination showed a uterus enlarged and retroverted, and a considerable mass of faeces in the sigmoid flexure and descending colon, and treatment was begun for these conditions. The bowels were unloaded of many scyba- lous masses by means of frequent enemata; and the uterine condition was so far improved by treatment that the menses soon reappeared, and the pain and discomfort passed away. The bleeding from the rectum never recurred, nor has the patient ever again had her attention called to tha<^ part up to the present time — four years later. The diagnosis in this case was a simple congestion of the rectal mucous membrane, brought about by the retained faeces and by the uterine disorder, relieving itself by a discharge of blood from the over-distended veins. Had the conditions remained, other symptoms would in all prob- ability have soon developed, such as heat and tension at the anus, possi- bly a slight mucous discharge, pruritus ani, and, finally, haemorrhoids. There are various other causes of such a condition, besides impacted faeces or menstrual disorders, such, for example, as excess at table, pro- INFLAMMATION OF THB BEOTUM. 67 longed horse-back exercise or carriage riding, pregnancy, drastic purga- tives, and, in short, anything which tends to produce hypersBmia of the pelvic viscera. In most cases of bleeding from the rectum a diagnosis of congestion alone would be an error; for a congestion sufficiently marked to cause haemorrhage is rare, and bleeding is in most cases a symptom either of hasmorrhoids, polypus, or some more serious affection. But in this case there was no such cause, and the subsequent history of four years with no other rectal symptoms tends to strongly confirm the diagnosis. Note. — ^While speaking of haemorrhage from the rectum, it may be well to re- fer to two cases of bleeding which have recently been reported in the New York Medical Record. The first (N. Y. Med. Record, Sept. 27th, 1879) is by Dr. Manley, of Lawrence, Mass. It occurred in an apparently healthy infant three days old, and ended fatally. A post-mortem examination showed that the blood came f ron;i an opening in one of the rectal veins about three inches from the anus, which ad- mitted of the introduction of a bristle. The second case (N. Y. Med. Record, Jan. 17th, 1880) is reported by Dr. McGuire, of Salem, Ohio, and is very similar, the child being about the same age. Notwithstanding suitable treatment by styptic applications, this also terminated fatally; but no autopsy was obtained, and the precise source of the haemorrhage is unknown. • The second case is one in which congestion had ended in actual in- flammation or proctitis. Case IV. — Woman, married, age twenty-three, mother of two chil- dren: youngest six months old. Patient has always been constipated, and for years has been in the habit of using purgatives whenever she desired an evacuation. For the past six months has noticed occasional discharge of blood and slime from the rectum which is constantly in- creasing. Now suffers great pain on defecation, and the amount of blood and muco-purulent matter is increasing so that while at first it only came away when at stool, it now comes several times a day. With this she has much pain in the rectum at all times, and is in poor general con- dition, having lost her appetite, and being unable to sleep. A careful examination of the rectum showed it to be congested, hot, and painful as far as the eye could see; but nothing else was apparent. The amount of discharge suggested the idea of a gonorrhoea of the rec- tum, but there was no inflammation of the vagina, and careful question- ing of the patient left no room for such a suspicion. The cause of the trouble in this case also was not difficult to find, the patient having been in the habit of taking large doses of patent cathartic remedies two or three times a week for a long time; and as the trouble developed imme- diately after her last confinement, this may not have been without its influence as an exciting cause. This case gives a very good idea of the clinical history of acute inflamma- tion of the rectum. A proctitis may be either acute or chronic, primary or secondary, localized or general. The localized variety is generally 68 DISEASES OF THE BEGTUK AND ANUS. due to the injury inflicted by a foreign body or to ^ome irritation acting upon a small part of the rectal surface. In the acute form the inflamma- tion does not extend deeper than the mucous membrane which is con- gested and hyperaBmic. In the chronic^ the inflammation inyolves the submucous and muscular layers. The acute generally ends in resolution in from eight to fourteen days where the cause can be found and removed. It may^ howeyer^ in severe cases go on to actual gangrene and terminate fatally. The chronic results in infiltration and consequent thickening of the rectal wall, and may end in ulceration^ either superficial and confined to the epithelial layer of the mucous membrane^ or deep and involving the whole thickness of the mucous layer. What is described a follicular ulceration (ulceration affecting the mouths of the tubular follicles) may result from chronic inflammation; and these ulcers, which are very minute at first, may coalesce and gain in depth till they cause perforation of the bowel. When the perforation is above the peritoneal reflection a fatal peritonitis may result; when lower down, an abcess or fistula (see Fistula). A chronic proctitis may in this way be a cause of stricture, and may result in the hypertrophy known as chronic paren- chymatous proctitis.^ The symptoms of this affection have Been partially detailed in the two cases which have been related. They are, in the acute form, a sensation of heat and weight in the part which may amount to actual pai^, and may involve the bladder, uterus, and sacral region, and radiate into the loins and down the thighs. The anus also becomes painful, red and contracted, and in children the mucous membrane may become slightly everted from the swelling and tenesmus. The evacuations soon become painful and increased in number and the faeces are streaked with mucus, blood, and pus. There is apt to be also a train of symptoms referable to the bladder, and to the generative organs, such as painful micturition, cystitis, and leucorrhoea. With these local symptoms there may be, as in the case reported, more or less constitutional disturbance, fever, and loss of appetite. As the discharge from the inflamed surface increases in amount, the desire to empty the rectum produces more frequent evacuations, so that while at first the f sBces only are stained with pus and blood, later the evacua- tions consist entirely of the muco-purulent matter, and the anus may become excoriated by the discharge. In the chronic form the symptoms are all less marked. The diarrhoea may alternate with constipation, and the discharge will occur only at -the time of defecation. This condition may last for years. An examina- tion of the rectum during the acute stage of proctitis will generally cause considerable pain. The rectal mucous membrane will be found intensely congested, and the temperature, as shown by the thermometer 1 Diet. Encyc. des Sci. M^, Art. Rectum. INFLAMMATION OP THE RECTUM. 69 or even by the finger^ will be increased. In the chronic stage^ the solitary glands may occasionally be recognized as small round prominences in (he substance of the mucous membrane. Proctitis is generally found associated with stricture of the rectum and is secondary to it. In these cases the mucous membrane below the stricture will be found congested and coyered with pus or bloody mucus, while above it is eroded and destroyed; sometimes only superficially, at others for its entire depth. In such cases the other layers will be found hypertrophied, especially the circular muscular layer. * The causes which may produce proctitis are numerous. It may re- sult by direct propagation and continuity of surface from inflamed hsBmorrhoids or prolapsus; or from any erosion about the anus such as a mucous patch or eczema. It may be, and often is caused by the presence of foreign bodies or of hardened faeces and indigestible remains of food which act as foreign bodies; and by irritating suppositories, injections, or medicinal applications. As in the case given above, it may be caused by the abuse of drastic purgatives such as aloes, gamboge, or even rhubarb in excess. It has been seen to result from prolonged sitting upon a cold or wet seat, and when found in children it will generally be due to the presence of worms. It may be a symptom of gout (Esmarch, Bushe) alternating with the manifestation of the disease in its usual seat, and there maybe a true diphtheria of the rectum, as there may be of the va- gina, and the formation of a membrane similar to that seen in the throat. Again the disease may result both in men and women from the habit of passive pederasty, and in such cases may be due either to mechanical violence or to the inoculation with gonorrhoeal pus. A true gonorrhoea of the rectum, whether caused in this way or by direct inoculation in women by pus which is passing over the anus from the vagina, is very rare. Tardieu' has never observed a single case. Oosselin* saw only one case at Lourcine in three years. Bollet^ reports a case caused by direct inoculation from the penis to the rectum in a patient who was in the habit of using a finger in the anus to provoke a passage. A. Bon- ni^re' found it ver^ difficult to inoculate the rectal mucous membrane with gonorrhoeal pus placed upon it through a tube, though the anus was easily affected. On the other hand, Bequin* believes it almost sure to follow passive pederasty with a person suffering from gonorrhoea. The diagnosis of gonorrhoeal proctitis will rest upon the amount and puru- lent character of the discharge, and upon the existence of gonorrhoea >Dict. Encyc. des Sci. M6d., Art. Bectum. * Etudes Medico-legales sur les Attentats auz Moeurs, 4th ed., 1862, p. 179. > Aich. 04nL de Med., 1854. ^Dict Elnc des ScL MM., Art. Rectum. R6cherches Nouvelles sur la Blemiorrhagie, Arch. (^nl. de M6d.y Apr^ 1874. * Elements de Path. Med. Rectite, t. i., p. 720. 70 DISEASES OF THE BECTUM AND ANUS. of the vagina in women; or the confession of intercourse with a diseased person, in men. The treatment of proctitis consists first of all in an endeayor to discover and remove the cause of the congestion, be it what it may. In the acute stage, the pain and tenesmus maybe overcome by warm baths, and anodyne injections of starch-water with a few drops of laudanum. The bowels should be kept open by laxatives such as castor oil or preferably the saline cathartics in small doses. The patient should also be confined to the bed, and placed upon a diet chiefly of milk. In the chronic stage, astrin- gents are indicated; such as alum and tannin, and to these may be added suppositories of iodoform (gr. v.), and the same rulop with regard to rest and diet should be observed. * < . ' ABOBSS AND FISTULA. 71 CHAPTER Y. ABSCESS AND FISTULA. Abscess divided into Superficial and Deep. — Superficial Abscesses. — Simple Fu- runcles; Causes; Characters; Results; Treatment. — Suppuration of External Hsemorrhoid. — Suppuration of Internal Hsemorrhoid. — Diffuse Inflammation of Subcutaneous Tissue, Causes; Symptoms; Treatment. — Form of Incision. — ^Deep Abscesses. — Divided into Abscess of the Ischio-Bectal Fossa and of the Superior Pelvi-Bectal Space. — Causes; Symptoms; Diagnosis. — Dangers of Deep Abscess. — Formation of Deep and Extensive Fistulas. — Horse-shoe Abscess. — ^Idiopathic Gangrenous Cellulitis. — Reasons why Abscesses do not Heal Spontaneously. — Prognosis. — Treatment. — Incisions and Subsequent Treatment of Deep Abscesses. — Incontinence of FsBces. — Relief of In- <»ntinence resulting from Operation. — ^Fistula. — Generally due to Abscess. — Divided into Superficial and Deep. — Complete Fistula. — External Fistula. — Internal Fistula. — Description of Superficial Fistulae. — ^How to Detect an Internal Opening. — Location of Internal Opening. — Descrip- tion of Track of Fistula. — Symptoms of Superficial Fistula. — Deep Fis- tula. — Fistula with Numerous External Openings. — Blind Internal Fistula. — ^Ulceration of Rectum Causing Internal Fistula. — Treatment. — Spontaneous Cure. — ^Advisability of Operation. — Fistula in Relation to Phthisis. — Contra- indications to Operation. — ^Treatment by Cauterization. — The Ligature. — ^The Elastic Ligature. — Galvano-Cautery. — How to Pass Ligature. — Incision. — Description of Operation.— Authors Elnife for Fistula. — Division of Deep Tracks.— Treatment of Track running up the Bowel. — Treatment of Blind External Variety; of Horse-shoe Variety; of Fistula with Numerous Exter- nal Openings. — ^Dressing after Incision. — Packing the Incision. — ^Haemorrhage in Operation. — ^Treatment of Blind Internal Variety. — Incurable Fistulas. — Treatment of Deep and Extensive Tracks. — Fistula with Stricture. Abscesses in the region of the anus and rectum are best classified, sccording to their anatomical location into sapeificial and deep. Of each of these there are several different varieties. Considering first the superficial variety, the simplest form will be found to be that which involves the skin of the margin of the anus alone, and which generally originates in one of the minute glands of the part. Such an abscess or furuncle, for it is really only a furuncle, may be due to traumatism, or to any irritation, such as the use of improper paper after defecation, prolonged walking or horse-back riding, a menstrual dis- chai*ge, or a discharge due to diarrhoea or dysentery. This form of disease is always distinctly circumscribed, is generally 72' DISEASES OF THE BEGTUM AND ANUS. about the size of an almond, is found by preference in robust persons^ more often in men than in women, seldom in old people, and almost never in children. It generally goes on rapidly to suppuration, breaks spontaneously on the cutaneous surface, and heals without the formation of fistula, though in cachectic or phthisical patients it may pursue a. contrary course, the skin over it becoming thin and violet colored, and finally rupturing, leaving a permanent subcutaneous fistula. The treatment of such an abscess consists chiefly in the attempt to avoid the formation of a fistula, and the best means for accomplishing- this end is an early incision as soon as suppuration appears inevitable. Eesolution is hardly to be expected, but it may be sought for by the use of laxatives, rest in the horizontal posture, and the application of a blad- der of ice. The incision should be large enough to allow of the free exit of pus, and after it has been made, the part may be poulticed for a day or two, and the abscess cavity then dressed with lint, care being taken to keep the lips of the incision separated. Another frequent cause of superficial abscess is the acute infiamma- tion and suppuration of an external hsBmorrhoid, which generally comes, on after an attack of constipation and straining at stool, or may be due to the same causes as the last. The suffering caused by such a condition, as by the one last described, is out of all proportion to its apparent im- portance, and is sufficient to incapacitate a person of sensitive organi- zation from all accustomed duties. The remains of former external hsemorrhoids are always liable to this accident, and by the proper abor-- tive treatment, the infiammation may sometimes be overcome without suppuration. If, however, suppuration appears to be inevitable, a small sharp-pointed bistoury should be quickly passed through the little tumor. There is also a form of superficiar abscess which lies nearer to the mucous membrane than the skin, and is due to the acute infiammation of an internal haemorrhoid, either just at the verge of the anus or within the sphincter. This is in reality a circumscribed phlebitis in a venous, pouch which is shut off from the general circulation. A circumscribed, tense, exquisitely painf ultumor is formed, varying in size from a grap& to an almond, which, after a few days of suffering, ruptures spontane- ously, and allows the escape of a small quantity of pus. Such an abscess, when within the bowel, is always liable, as will be shown later, to result in the formation of a blind internal fistula if left to its own course, and should, therefore, be treated by early incision. There is still another variety of superficial abscess, more serious in its consequences than those