CHAPTER XXVI THE DIAGNOSIS OF DISEASES OF THE RECTUM (Part 1)

CHAPTER XXVI THE DIAGNOSIS OF DISEASES OF THE RECTUM Anomalies, p. 494: 1. Arrest or irregular development of the hind gut, p. 496; Imperforate rectum, p. 496; Imperforate rectum with outlet into the urethra or bladder, p. 496; Imperforate rectum with outlet into the vagina, p. 497. 2. Arrest or irregular development of the proctodeum, p. 497; Imperforate anus, p. 497; Imperforate anus with anal canal ending in the vulva, p. 497; Anus well-formed, anal canal ending above in a cul-de- sac, p. 497; Abnormally small anus, p. 498. Hemorrhoids or Piles: Frequency and etiology, p. 498. External hemor- rhoids, p. 500. Internal hemorrhoids, p. 501. Fissure in Ano, p. 503: Symptoms, p. 503. Diagnosis, p. 504. Differ- ential diagnosis, p. 505. Inflammation of the Rectum, Proctitis, p. 505: 1. Simple proctitis, p. 506; Acute catarrhal proctitis, p. 506; Chronic catarrhal proctitis, p. 507; Atrophic proctitis, p. 507; Hypertrophic proctitis, p. 508. 2. Specific proctitis, p. 510; Gonorrheal proctitis, p. 510; Syphilis of the rectum and anus, p. 510; Congenital syphilis, p. 510; Chancre, p. 511; Mucous patches, p. 511; Ulcerations, p. 512; Gummata, p. 512; Syphilitic stricture, p. 512; Chancroids of the anus and rectum, p. 512; Tuberculosis of the anus and rectum, p. 513; Dysenteric proctitis, p. 513. Abscess and Fistula in Ano, p. 514: Abscess, p. 514. Fistula, p. 516: Varieties, p. 516; 1. Complete, p. 516; Horseshoe fistula, p. 516; 2. Incom- plete, p. 517; Blind external fistula, p. 517; Blind internal fistula, p. 517; Symptoms, p. 518; Physical examinations, p. 518. Stricture of the Rectum, p. 518: Congenital strictures, p. 519; Strictures due to pressure on the rectum from without, p. 519. Inflammatory strictures, p. 519; Pathology, p. 519; Symptoms, p. 520; Physical examination, p. 520. Prolapse of the Rectum, p. 521 : Symptoms, p. 521. Physical examination, p. 522. New Growths of the Rectum, p. 522: 1. Benign tumors, p. 522; (a). Tumors about the anus, p. 522, Papilloma, p. 522; Soft fibroma, p. 523; Lipoma, p. 523. (6). Tumors of the rectum, Polypi, p. 523; Adenoma or mucous polyp, p. 523; Fibro-adenoma, p. 523; Lymph-adenoma, p. 523; Glandular polypi, p. 524; Fibroma or fibrous polyp, p. 524; Myoma, p. 524; Villous tumor, p. 524; Myomatous polyp, p. 525. 2. Malignant tumors, p. 525; Cancer of the rectum, p. 525; Cancer of the anus, p. 526, Pathology, p. 526, Symptoms, p. 527, Diagnosis, p. 528, Differential diag- nosis, p. 528; Sarcoma of the rectum, p. 529, Varieties, p. 529, Diagnosis, p. 530. A short sketch of the chief points in the anatomy and physiology of the rectum, as well as a description of the methods of examination, 494 ANOMALIES 495 will be found in Chapter IX., page 121. An analysis of the chief symptoms of rectal disease is given in Chapter X., page 156. ANOMALIES The different stages of the development of the rectum and anus are shown cliagrammatically in the figures from Schroeder on page 395, Figs. 158-162, Chapter XXL As it is not the general custom for obstetricians to examine carefully the anus and rectum of the new-born infant, many minor malformations pass unob- served. Where a careful examination is made some degree of mal- formation will be found not so infrequently. Starr has estimated Fig. 191. — The Anal Canal. A, Columns of Morgagni; B, Semilunar valves or Crypts of Morgagni; C, Dentate Border Marking Upper Limits of Anus and surmounted by Papillae; D, Hilton's White Line. (Tuttle.) that anal and rectal malformation occurs about once in ten thou- sand births. It is more common in girls than in boys, if we include anus vaginalis (see page 393, Chapter XXI.). As shown in the diagrams on page 395 the rectum and the anus are developed from entirely different structures of the blastoderm, the former from the hind-gut, and the latter from the proctodeum, a depression in the epi-blast opposite the lower end of the hind-gut, therefore malformation of the one does not necessarily imply abnormality of the other. As a matter of fact, if the rectum is malformed or displaced the anus is generally normal, and vice versa. Malformation of either of these organs is likely to be associated with malformation in other portions of the body that are derived 496 DISEASES OF THE RECTUM from the same layer of the blastoderm. For instance, children with anomalies of the rectum are apt to surfer with cleft palate. Many of the developmental defects are associated with non- viability and monstrosities. The following anomalies have been described: 1. Arrest or Irregular Development of the Hind-gut Sir Charles Ball ("The Rectum, Its Diseases and Developmental Defects") reports the case of a child three months old, in which the rectum was entirely absent, also the entire colon, the ileum opening in the center of an ex- strophy of the bladder. The external genitals were also wanting. Children born with such defects must necessarily be short lived. Imperforate Rectum. — This is a common malformation, the bowel ending in an open tube on a level with the reflection of the peritoneum on the rectum, presumably due to the failure of the hind-gut to send out a bud, the post-allantoic gut, to meet the proctodeum. The condition may or may not be associated with imperforate anus. If it is, the condition is recognized at once by inspec- tion ; if not, the infant is gener- ally dosed with cathartics, and only when grave symptoms of obstruction supervene, is a thorough examination made. The physician should make it a rule to institute a thorough physical examination if an infant's bowels have not moved within the first twenty-four hours of life. If the anus appears to be normal ex- ternally, introduce the well-anointed tip of the little finger and determine whether the anal canal is patent. Imperforate Rectum with Outlet into the Urethra or Bladder. — In Fig. 192. — Cast of Rectum and Anal Canal. (Tuttle, after Quenu and Hart- mann.) ANOMALIES 497 this anomaly there has been a persistence of the allantoic opening with failure of the rectum to end in the anus. If the opening is into the urethra (a condition usually found in the male) there is an escape of flatus and meconium from the urethra together with the mine; if, on the other hand, the opening is into the bladder the meconium and feces become mixed with the urine and sooner or later the individual succumbs to ascending infective ureteritis and kidney disease, even if the outlet is large enough to obviate intes- tinal obstruction. Imperforate Rectum with Outlet into the Vagina. — This is a per- sistence of the urogenital sinus and is met with not infrequently. The opening may occur at any point in the vagina and is generally large enough to permit the passage of meconium or even solid feces. An imperforate hymen may obstruct the escape of the feces from the vagina, and in this case there is present a bulging, greenish membrane in the situation of the introitus. The rectum has been known to be imperforate and to connect with the uterus, and also to open on the back near a spina bifida; and the rectum may open normally, but have connected with it ureters, uterus, or vagina. Also, diverticula in the lower rectum are sometimes found. 2. Arrest or Irregular Development of the Proctodeum Imperforate Anus. — There may be no trace of the anus, or its situation may be marked by a slight depression, or by a wart-like prominence ; this constitutes entire absence of development of the proctodeum. Imperforate Anus with Anal Canal Ending in the Vulva. — This is a very common anomaly and is confounded with imperforate rectum having a vaginal outlet. Women with this anomaly may have children and live to an advanced age without realizing that they are abnormal, as they may have perfect control over the vulvar anus. Incontinence of feces is common in these cases, however. Anus Well Formed ; Anal Canal Ending above in a Cul-de-sac. — In this malformation the proctodeum develops a normal anus, but the anal canal is imperforate above. The condition may be associated with imperforate rectum, but often the rectum is normal and only 32 498 DISEASES OF THE RECTUM a membranous septum separates its cavity from the anal canal. The child on straining may cause this septum to protrude from the anus. Abnormally Small Anus. — The anus may be abnormally small (see Congenital Stricture of the Rectum, page 519), or it may be divided into two parts by a median longitudinal septum. HEMORRHOIDS OR PILES Hemorrhoids or piles are tumors composed chiefly of dilated blood-vessels or blood-clots, situated beneath the mucous membrane or skin of the anus or lower rectum. They are (a) external, when thejT are on the outside of the anus, either as exaggerations of some of the natural rugae of the skin around the anus, or rounded or elongated venous tumors situated at the margin of the anus; or, they are (b) internal, tumors originating within the anal canal or in the ampulla, capable, perhaps, of being forced outside. Both sorts of piles may exist in the same patient. Histologically a pile is seen to be made up not only of the dilated veins, with thickened walls, but also of a considerable amount of connective tissue, the latter being more in evidence in cases of long duration. The terms hemorrhoids and piles are used interchangeably, but the former (from the Greek alfLoppota, a discharge of blood) ap- pears to have the better authority, perhaps because it appears in the Bible. In 1 Samuel, v. 9, we find: — " the hand of the Lord was against the city with a very great destruction; and he smote the men of the city, both small and great, and they had emerods in their secret parts. " The term pile, signifying a ball (from the Latin, pila), would seem to be fully as descriptive as hemorrhoid, but having been used extensively by the quacks has fallen into disrepute. Frequency and Etiology. — The disease is extremely common and few persons pass middle life without having suffered from it. It appears to be more common among men than women, although authors vary in their estimation of the relative frequency. Perhaps five men to three women is a fair statement. Hemorrhoids are more often found in middle age, although cases are on record as young as six months, one author having reported 1. THROMBOTIC H/EMORRHOiDS 2. INFLAMED H/EMORRHOIDS WITH EROSION 3. INTERNAL H/EMORRHOIDS WITH CEDEMA OF ANAL MARGIN 4. PROLAPSING INTERNAL HAEMORRHOIDS I Fig. 193.— Types of Hemorrhoids. (J. P. Tuttle.) 499 500 DISEASES OF THE RECTUM thirty-nine children under the age of fifteen years who had hemor- rhoids. Heredity seems to play a role in the causation, successive generations of a family suffering with the disease. The upright posture apparently has to do with the causation, for none of the domestic animals have hemorrhoids except, occasionally, very fat, over-fed dogs. It is supposed that the thin- walled, valveless veins of the rectum are unable to stand the constant pressure of a blood column of some fourteen inches in height, which they are subjected to when the human frame is in the upright position. Exciting causes are, overeating, rich food, lack of exercise, and sedentary occupations. Violent straining, as in lifting heavy weights, or straining at stool, may cause a hemorrhoidal condition of the veins of the anus, and thrombotic hemorrhoids are nearly always caused in this way. Heart disease, kidney disease, and cirrhosis of the liver must be classed as exciting causes, but chronic constipation with the passage of solid fecal masses along the rectum, stripping the venous blood away from the heart, is one of the chief direct causes. Uterine diseases are reckoned as causative of piles. Certain it is that the two are frequently associated. External Hemorrhoids. — There are two varieties of external hemorrhoids, (a) redundant folds of the skin about the anal opening, and (6) venous tumors, (a) The normal corrugations of the skin surrounding the anus may be exaggerated and little tabs of skin and connective tissue result. These may be of little significance; on the other hand, they are capable of being inflamed, or even suppurating and of leaving behind more or less induration. Con- stipation is the direct cause. The piles may cause itching and, when inflamed, smarting, rendering sitting uncomfortable. If there is suppuration, the symptoms are those of abscess. Examination shows retained secretion or fecal matter between the rugae and the pile will be found to be red, glistening, and perhaps excoriated. (b) The superficial veins of the margin of the anus become dilated and the condition may involve the entire circumference of the anus. The veins belong to the inferior hemorrhoidal plexus. The swelling may be limited to one, two, or three circumscribed tumors. In any event the swelling is marked during straining efforts and almost completely subsides soon after, leaving the skin loose and redundant when the straining has ended. There is no induration HEMORRHOIDS 501 or excoriation. The chief complaint is difficulty in defecation and also a feeling of fullness at the anus. The patient feels that her bowels should be emptied, but she can not accomplish it even by persistent straining and there is much soreness lasting after stool. In the case of this sort of piles there may be acute attacks of spasm of the sphincter attended by great burning and itching, very commonly just after the patient has gone to bed at night, or after defecation. The patient being on her side and relaxed, examination shows the skin of the anus loose and redundant and the sphincter tightly closed. If the piles are thrombosed there will be small, oval or round tumors, varying in size from a pea to a walnut, situated just beneath the skin, the color being that of the normal skin, or varying from red to dark blue. This is the sort of pile that causes sudden symptoms of sharp, cutting pain when the thrombosis occurs. On straining, the anal orifice forms the apex of a cone-like prom- inence, and flatus or a little rectal mucus may escape. When the finger is passed through the anus, the sphincter grips it tightly and hinders its easy introduction. The sphincters are abnormally strong and the rectum is apt to be dilated and contain flatus, or even feces. Sometimes a chronic condition of this sort is productive of rectocele. Internal piles may complicate the external piles and should be sought for. Many physicians, as well as the laity, assume that all piles origi- nate in the rectum and have come down, and therefore urge their patients to replace them. Of course, replacement should not be attempted unless the piles are internal. External piles should be handled gently, it being a mistake to squeeze the thrombosed hemorrhoids with the object of forcing out the clot, for at any time the tumor may become infected and trauma will assist in gaining entrance for the germs. Internal Hemorrhoids. — Internal piles consist of a varicose con- dition of the veins of the lowest two and a half inches of the rectum. Not all of this region is affected in most cases, and the lower part, the anal canal, is the place where internal hemorrhoids are most often found. The internal pile is apt to be pear-shaped, because the vein (a branch of the superior hemorrhoidal plexus) issuing 502 DISEASES OF THE RECTUM from it, passes upward in the submucous tissue and soon loses its varicosity, the lower end only being bulbous. Generally there are several of these venous tumors placed parallel to one another. On dissection, this variety of hemorrhoid consists of a mass of dilated veins and connective tissue. In thrombosed piles there is a blood clot and more connective tissue. Constipation and heredity seem to play the chief roles in the causation. The symptoms are hemorrhage and the protrusion of the pile through the anus. The amount of blood lost may be slight and occur only at stool, or it may be excessive and come on at irregular periods. It is difficult to judge, from the description of the patient, how much blood is lost, and one must always remember that blood lost per anum is not necessarily from the rectum, but may come from the stomach, duodenum, or ileum. If from the latter situations it will be dark colored and tar-like in consistency, whereas if from the rectum it will be less dark; it may be arterial and more or less mixed with mucus or feces. Generally blood from internal hemor- rhoids is passed after stool. Protrusion of the hemorrhoid does not come on until after the tumor has existed a considerable time and has attained a large size. At first the pile recedes spontaneously, but as it gets down farther, the sphincter contracts firmly and prevents its return. In bad cases, rest in bed, with the hips elevated, may be necessary before reduction can be accomplished, but, as a rule, the pile can be pushed up after it has been anointed.- An excess of mucus is generally associated with internal hemor- rhoids and there may be a sense of weight, or aching in the sacral region, or even pain in the anus, when the pile is prolapsed. Examination shows edema of the skin about the anus in the form of one or more soft elastic folds; this swelling is more marked if the piles are strangulated and is due to the obstruction of the venous return. The patient is asked to strain, and if the piles are well developed they come into view as purplish tumors, the anus being below its natural position. The finger inserted into the rec- tum detects the hemorrhoids as elastic tumors, perhaps pedicled, and hard if thrombosed. Hemorrhoids of the anterior wall of the rectum may be inspected by everting the wall