CHAPTER XLII (Part 1)

CHAPTER XLII DIAGNOSIS OF DISEASES OF THE ANUS AND RECTUM It is necessary to discuss the diagnostic value of the symptoms of anal and rectal disease ; but, although this is done, it cannot be too clearly stated that a diagnosis should nevfer rest upon such data, for in every case a careful and thorough exploration of the parts is necessary. The symptoms may en- able a surgeon to guess the nature of a patient's malady, but only a careful examination will enable him to arrive at a diagnosis. Pain is perhaps the most frequent of these symptoms. It may be an itching, which if severe is known as frurilus ; this is particularly asso- ciated with external piles, herpes, erythema or eczema of the anus or adjacent skin, external fistula, ascarides, constipation, and sexual irregularities. When ihrobhing in character it is generally due to acute inflammation and abscess, or to strangulation of prolapsed piles or mucous membrane. When colicky in nature and ■preceding and accompanying defcecalion, it is generally caused by ulceration of the bowel. When of a dull gnaiving character with acute exacerbations of severe burning or shooting pain which are caused by and continue for a long period after defsecation, it is due to an irritable ulcer or fissure of the anus. Pain in the region of the sacrum is often due to malignant disease of the 59;i 600 SURGICAL DIAGNOSIS [chap. bowel, and when to it are added pains sliooting down the thighs this indicates that the disease is implicating the sacral nerves. Tenesmus is particularly caused by polypus and foreign bodies in the rectum, prolapse, constipation, dysentery, stone in the bladder, and hypertrophy of the prostate. The motions. — Much may be learnt by an examination of the motions passed, and in many cases the surgeon himself should make a careful examiuation of the stools. The most important points to observe are the size, shape, continuity, and amount of the ftecal matter, and the admixture with it of mucus, blood, or pus. The size of the motion is a measure of the calibre of the rectum and anus ; even the occasional passage of a full- sized motion excludes a stricture of these parts. The breaking-up of the motion into small pieces is a very frequent effect of growths in the bowol as well as of constipation. The motion may be flattened by stricture of the bowel, or by com- pression from without, as in tumom-s of the uterus and prostate. Diarrhoea, in the sense of the passage of the intestinal contents too hurriedly and in too liquid a form, is not a symptom of rectal disease ; but in the sense of a too frequent evacuation of the lower bowel it is a common symptom of rectal ulceration, which induces it either by the active peristalsis excited by the contact of fjeces with the lUceratcd surface, or by the amount of mucus, serum, or blood poured out from the diseased surface. A frequent discharge of mucus, mixed with more or less f?ccal matter, may occur in cases of fs9cal accumulation in the rectum ; it is also an important symptom of acute periproctitis, and occurs in pelvic appendicular abscess. Ind(>ed, this symptom is so commonly XLTi] ANAL DISCHARGE 601 associated with rectal obstructiou tliat it slioukl invariably suggest to the surgeou the necessity of a thorough exploration of the rectum. Constipation is quite as often a cause as a con- sequence of rectal trouble ; it appears to induce pdes, certainly promotes thrombosis in external piles, and increases the hajniorrhage from internal piles, and it is regarded as a cau'se of anal abscess, of fistida, and of fissure. The affections of the rectum which lead to it are painful fissure of the anus (owing to the dread with which the pain of defa3cation is regarded), stricture of tlie anus or rectum, and atotiy of the bowel by which its expelling force is dimin- ished; when this produces impaction of fseces, it may set up a spurious diarrhoea. The association of " spurious diarrhoea " and " constipation "—by which is meant the frequent passage of fluid containing the merest trace of fsecal matter— is frequently met with, and shoidd never be overlooked by the surgeon ; it points to faecal impaction, or to a stricture of the bowel. Dischai-ge. (a) The time of its appearance. — If discharge is constant and independent of the act of deftecation, its cause is extrarectal, either prolapsed piles, mucous patches, eczema, ulcer, or fistula; in tlie last case the discharge may be increased by the pressure of the faeces dm'ing defecation. If, however discharge only attends an expulsive effort of the bowel' It comes from some intrarectal affection, such as poly- pus, piles, internal fistula, fissure, ulcer, or growth 1 ns distinction does not apply in cases of very relaxed patulous anus where the sphincter muscle has so lost Its power that the contents of the bowel can escape freely. (b) The nature of the discharge.-Pure unaltered blood, in the absence of injury, points to internal 602 SURGICAL DIAGNOSIS [chap. piles, to polypus, or to a ruptured varix or iiEevus of the rectum ; hsemorrliage in a child is nearly always due to polypus, occasionally to intussusception ; a streak of blood upon the motion is characteristic of anal fissure. A discharge of altered blood, brown or dark in colour, and having a peculiar penetrating fetor, is met with especially in malignant disease of the bowel and in dysentery ; blood and mucus mixed together may come from the congested mucous cover- ing of an intussusception, or from a growth in the bowel. Mucus is discharged from the bowel in some cases of polypus and of ulcer, and also from internal piles, from coiigested or chronically inflamed mucous membrane, and in cases of periproctitis. In some very soft malignant growths of the bowel there is a profuse discharge of mucus. Pus specially indicates abscess or fistula opening into the boAvel, or anal ulcer ; it is sometimes seen in cases of rectal ulcer. A thin loatenj discharge attends the disintegration of malignant growths, being often mixed with more or less broken-down blood. The escape of gas (not through the anus), felt by the patient as a fine crackling or bubbling, is a sign of a complete fistula, as is also the escape of faeces mixed with pus from a similar sinus. If a fistula discharges much pus, the fact shows that its cavity is extensive. Protrusion from the anus, if constant, points to the presence of external piles or to a malignant growth at the anus ; if it only attends the act of defa3cation or other straining efiort, it is more probably internal piles, polypus, or prolapse. The greater the ease and frequency with which the descent occurs, the greater the probability of the aUectiou being prolapsus, with or without either of the above aiiections superadded. The cxniniuatiou.— Before making a thorough XLii] ANAL EXAMINATION 603 and complete examination of the parts, the rectum should be cleared by an enema carefully given, unless the symptoms point to a stricture ; and where there is any reluctance on the part of the patient to submit to the examination, or a satis- factory examination cannot otherwise be made, an anaesthetic should be administered. This examin- ation may be made in one of five positions : (a) With the patient lying on his left side with the thighs well flexed and the perineum directed towards a good light, (b) With the patient on his back with the hips raised on a pillow above the level of the shoulders, and the thighs well drawn up and separ- ated, (c) In the case of men to Avhom an anass- thetic IS not administered, the patient may be made to stand close against the back of a chair, and then bend down over it to the full extent ; in this way the anus and the parts around it can be very con- veniently explored, and if the patient is tractable the interior of the bowel can be readily examined. {d) A similar position is obtained by getting the patient to kneel on a couch with the head and shoulders low and the thighs vertical, (e) It is occasionally useful to examine the rectum with the patient standing with the right thigh flexed ; in this position a growth high up may be felt when out of reach of the finger in either of the other positions i he parts around the anus should first be ex- plored by gently holding aside the gluteal folds- then the anus itself should be examined by evert- ing^ its edge and getting the patient, if conscious, to bear down as in the act of defalcation ; and lastly, the interior of the bowel should be examined with the finger, a speculum, or both. 1. Examine the parts around the anus, noticing particularly any redness, sweliuig. ulceration, or dis" 604 SUKGICAL DIAGNOSIS [chap. charge. If there is a difiused bright redness of the surface extending all round the anus, and on to the buttock, or forwards to the scrotum, without any swelling, discharge, or pain other than itching, it is ery- thema. If in a young child, this is due either to want of cleanliness or to congenital syphilis, and the sur- geon should look carefully for mucous patches here and elscAvhere, and for other evidences of syphilis. In adults it is mostly seen in stout persons, and the part may be moistened with sweat. If the surface around the anus is of a duller red colour, not swollen, but thinly covered with fine yellowish scales or scabs, or of a sodden appearance, it is eczema. If the ledness is not in the form of a diffused patch, but of an annular eruption, and if it is chronic and attended with much itching, it is para- sitic erythema, or erylhema marginalum. If there is a limited area of bright redness, which is swollen, very painful and acutely tender, it points to acute inflammation of the skin and subcutaneous tissue, and if fluctuation can be detected in it, it is an abscess. It the abscess is quite close to the anus and superficial, it is an anal abscess. If the swelling is deep, attended with much in- duration, and the finger introduced into the bowel feels the ischio-rectal fossa filled up, and fluctuation can be detected between the external swelling and the finger in the bowel, it is an ischio-rectal abscess. This may be either acute or chronic. If acute, its development is attended with great pain and con- siderable fever, and the contained pus has the odour distinctive of B. coli infection. If chronic, it is tuberculous and secondary to tuberculosis elsewhere. 1[ tlioTO are one or more circular or oval flat elevations of tlie surface', of a milky-white or opal- XLii]. SINUS AND FISTULA 605 esceut appearance, with a moist smooth surface into which the probe does not sink, they are mucous patches, and the surgeon will find the Sfironema fallidutn in the discharge. Finely papillated out- growths from the skin, in between the branching divisions of which a probe sinks, are warts. Sebaceous cysts, dermoid cysts, fatty liwiours, melanotic sarcoma, and tumours growing from the coccyx are occasionally found in this situation. Both hard and soft chancres are also met with in this region ; for diagnosis, see p. 622. If a bead of pus or discharge is seen welling from a point of skin, a fine probe should be care- fully pressed against it, and it will probably enter a sinus ; or the opening of a sinus may be at once conspicuous, or may be found beneath a small firm elevation or fold of the skin. Having found a sinus, the surgeon must carefully pass a probe along it and determine its direction and nature ; if fajcal matter or flatus is seen or known to pass along it, or if the probe passes in towards the bowel and its point is felt by the finger in the rectum, it is a com- plete fistula. If, however, the probe passes towards the bowel but cannot be made to enter without forcing its way through the mucous membrane, and the finger in the bowel fails to detect any internal aperture of the sinus, it is an incomplete or blind external fistula. The surgeon may find the probe pass circidarly round the anus, or in more than one direction, showing that it is a horseshoe fistula, or a hranching fistula. It must be remembered that the thin skin quite close to the anus is so loosely fixed to the subjacent parts that the probe can be easily made to pass beneath it round the anus when no sinus previously existed there ; but when the part IS laid open by the knife, an old sinus lined by 606 SUEGICAL DIAGNOSIS [chap. granulations on a base of firm fibrous tissue is at once distinguishable from the track a probe has forced for itself in cellular tissue. It is important to remember that the firm wall of a fistula can always be felt as a cord by the finger ; and the knowledge thus gained will not only enable the surgeon at once to pass the probe in the right direction, but will help him to recognize the presence of lateral diverticula from the main track. Fistulee are often multiple, and their external orifices may be very small, even minute, too small to admit a common probe ; and where there is any constant moisture of the part or other sign of fistula, a most careful examination with the finger to detect a firm cord, and with a fine probe, must be made and even repeated. The neighbourhood of small papular ele- vations must be specially explored, as the orifice of a fistula is often hidden in or under such a nodule. But the sinus may pass quite away from the bowel towards the sacrum or ischium, or up into the cavity of the pelvis, in which case an area of necrosis, or disease of the sacra-iliac joint, or of the Mp-joint, must be sought for. The examination of this region should be completed by the surgeon pressing with his finger on each side of and all round the anus ; if he detects any unusual resistance or induration, and particularly if the skin over it is slightly reddened or livid, he should suspect an incomplete or blind internal fistula. By pressure pus may be made to ooze from the anus, or may be seen flowing into the rectum when a speculum is passed, or the iuternal orifice may be felt and a probe passed into it and made to present under the skin ; any one of these signs will make the diagnosis certain. Ascarides may be seen around the anus. 2. Examine the anus. — If the anus is found re- XLii] ANAL EXAMINATION ' 607 tracted and tightly closed by the sphincter, with deep radial folds around it, the spasm is probably due to an irritable ulcer, and the patient should be en- coiu-aged to force down as in defsecation, and at the same time the surgeon should gently evert the open- ing, when a fissure will probably be seen with a small fleshy nodule of thickened skin— a "sentinel pile" —at its outer end. This fissure is most common at the posterior border of the anus ; there may be more than one. The symptoms of this very important affection are severe gnawing pain during and especi- ally after defsecation, the pain being in the anus and spreading from it down the thighs, a streak- ing of the fajces with pus or blood, and a slight puru- lent discharge. Whenever there is severe pain after deffecation, or the passage of the finger into the anus causes acute pain, suspect fissure. There is another condition liable to be mistaken for spasm, and that is stricture of the anus ; in this the anus is not retracted, aneesthesia in no way lessens the resistance offered to the passage of the finger, and the rectal evacuations are always small i his IS seen in children as a congenital affection, and in adults as the result of badly devised operations in which the cicatrization of the wounds has narrowed the orifice. Epithelioma of the anus may obstruct the outlet. A fatulous anus, offering no resistance to entrance of the finger, or to the escape of flatus, faeces, or discharge, may be due to a lesion of the spinal cord {see Chap VIII.), or it may be the result of the con- stant stretching of the sphincter by prolapse of the bovve , or of an operation, 'particularly a double complete division of the sphincter, or it may be ■ due to the presence of a stricture in the rectum of such a nature as to act the part of a sphincter 608 SURGICAL DIAGNOSIS [chap. Sivellings at the verge of the anus must be care- fully and critically examined. The lining of the orifice may be swollen more or less uniformly, of a somewhat bluish-white colour, with very superficial abrasions, the condition being attended with itching and smarting ; this is known as eczema of the emus. Mucous fcdches may be found at the verge of the anus resembling those seen on the skin around it. Of the remaining swellings, three forms of isolated, distinct little tumours must be distinguished. First and most common is a solid flaccid fold or tab of skin, incompressible, and not tender — anal tabs. Then there are rounded, soft, smooth, compressible swellings of a bluish colour, which are dilated hjemorrhoidal veins covered externally by skin— ex- ternal hemorrhoids. The third form is a tense, firm, globular, very painful and tender swelling, deep blue in colour on the inner surface, with more