CHAPTER XXVI THE DIAGNOSIS OF DISEASES OF THE RECTUM (Part 2)

of the rectum, in the case of women who have FISSURE IN ANO 503 had children, by pressure with a finger in the vagina. In virgins, the pelvic floor is too rigid to permit of this procedure. The sphincters are hypertrophiecl except in long-standing cases, when they do not appear to have the normal contractile power. By the use of the short proctoscope, piles may be seen as bluish tumors projecting from the mucous membrane. FISSURE IN ANO Anal fissure, or irritable ulcer, signifies a superficial ulcer situated in one of the sulei between the folds of the mucosa of the anal canal. It is almost always single, it is pear-shaped or triangular in form, is always in the long axis of the canal, and varies in length from three- eighths to seven-eighths of an inch (9 millimeters to 2.1 centi- meters). It is from a quarter of an inch (6 millimeters) to half an inch (1.2 centimeters) broad, the wider part being generally below and in the skin of the anus. At the lower limit of the fissure, or just to one side of it, there is sometimes a small fold of skin called "a sentinel pile." Fissure is most often found on the posterior surface of the anal canal, although it may be on any side. In cases of long standing the ulceration may reach in depth to the sphincter muscle; as a rule it is superficial. The disease occurs in all ages and conditions of life, but is chiefly found in adult life and especially in women during the childbearing period. Constipation is the cause Of fissure; hard, dry, scybalous masses tearing the delicate mucous membrane while being voided. Symptoms. — The symptoms are pain, muscular spasm, and occasional loss of blood. The pain seems to be out of all proportion to the size of the lesion and is described as a burning, aching, and throbbing sensation just within the anus. It begins while the feces are being passed (it may be delayed for half an hour) and lasts from half an hour to six or eight hours, to return when the next motion of the bowels takes place. The patient is induced to put off defecation because of the discomfort and thus the fissure is aggravated. The spasm of the sphincter causes great pain and also interferes with defecation, besides diminishing the diameter of the fecal mass. 504 DISEASES OF THE RECTUM Diagnosis. — Inspection shows a fissure, when the buttocks are widely separated, and the skin of the anus is apt to be redundant and thrown into exaggerated folds in these cases. The external sphincter is palpated to detect abnormal thickening or induration, and when the patient is asked to strain down, the amount of spasm of the sphincter may be estimated, the straining causing pain in the fissure. Discharge from the fissure, small in amount and Fig. 194.— Fissure in Ano. (Tuttle.) non-purulent, is to be looked for. Digital exploration of the rectum should be made, with an anesthetic if the pain is too severe, prep- arations being made at the same time to treat the suspected fissure, so that only one anesthetization may be necessary. The ulcer is felt as a roughened patch in the smooth mucosa of the anal canal. If the situation of a fissure can be determined, the finger should INFLAMMATION OF THE RECTUM 505 be pressed against the opposite wall to cause as little pain as possible. The spasmodic contraction of the sphincters and leva- tores ani is now apparent and feces are apt to be found in the rectum. The rectum should be cleared by enema and further ex- amination made. The complications of anal fissure, such as polypi, piles, and blind internal fistula, are generally situated in the lowest part of the rectum. Unless the patient is anesthetized it is not wise to pass the proctoscope in the case of fissure, because of the great pain caused. Differential Diagnosis. — Simple fissure must be differentiated from Syphilitic Fissure. — The latter are generally multiple and are on the right or left of the anus, not in the middle line; they cause pain that begins during defecation but does not persist so long as in simple fissure and is apt to recur at night. The inguinal or the femoral lymphatic glands will be found to be enlarged individually, and there is a history of syphilis. Blind internal fistula is attended by a history of continuous pain, which is accentuated by defecation but does not cease en- tirely. It is accompanied by a periodic discharge of pus, with the relief of pain, except during defecation. Pus can generally be seen issuing from the bowel in cases of blind internal fistula, and the finger introduced in the rectum will be found to be streaked with pus on its withdrawal, and instead of a roughened patch, as in fistula, the ball of the finger feels induration. Perhaps a depression can be felt and a bent probe can be passed into the fistula. INFLAMMATION OF THE RECTUM— PROCTITIS Inflammation of the rectum may be divided into 1. Simple, those inflammations of unknown bacterial origin, or 2. Specific, those inflammatory processes due to the bacteria of gonorrhea, syphilis, tuberculosis, or dysentery. An inflammation affecting the rectum generally involves the colon as well, because the two are similar structures anatomi- cally and parts of one canal, therefore it is not always possible while considering proctitis to rule out colitis. The absorptive power of the rectal mucosa is considerable, as 506 DISEASES OF THE RECTUM is attested by the rapidity with which fluids injected into the rectum are taken into the circulation. It is here that the fluid contents of the intestine are rendered semisolid or solid by the abstraction of their watery constituents, therefore it is not surpris- ing that the bacteria from the feces, especially if the solid parts cause abrasions, should find lodgment in the walls. As a matter of fact, the rectum, especially in its lower part, seems to be relatively immune to septic infection, just as in the case of the lips and mouth and the other openings of the body. The inflammatory process may be of mild grade, catarrhal proctitis, or it may progress to ulceration, ulcerative proctitis. 1. Simple Proctitis Simple catarrhal inflammation of the rectum is a common disease, especially in women who have uterine disease. It may be (a) acute, or (b) chronic. (a) Acute catarrhal proctitis may be caused by pin-worms, im- pacted feces or foreign bodies, or by prolapse of the rectum. Other causes are: highly seasoned food: sitting on cold stone, wet seats, or the damp ground; irritating cathartics, such as jalap, aloes, gamboge, and podophyllin. Fermentation and putrefaction of the intestinal contents may be direct causes of acute proctitis. Symptoms. — The symptoms are a sense of discomfort and fullness in the region of the rectum, with tenesmus, and the forcible ejection of fluid feces through an anus made small by irritation of the sphincter. There may be pain in the pelvis, radiating into the back and thighs. The patient has less discomfort while lying down than when erect and there may be slight fever. Frequent desire for an evacuation of the bowels is a prominent symptom from the first, and defecation does not remove the desire, the straining even causing prolapse of the rectum sometimes in children. The discharges are fluid and after the first twenty-four hours may be tinged with blood or pus. The process is confined to the mucosa, as a rule, in acute proctitis, though the inflammation may be so severe that portions of the mucous membrane are cast off and the deeper layers affected also. In the latter event, ulceration, abscess, fistula, or stricture may follow. INFLAMMATION OF THE RECTUM 507 Examination shows great tenderness when an attempt is made to introduce the ringer or speculum into the rectum and the sphincter is contracted. The mucous membrane feels hot, dry, and swollen in the very early stages, and later very moist. Through the proc- toscope, at first, it is of a light red color throughout, or deep red in patches and lighter red elsewhere; later, the color is darker red and the surface is covered in places with opaque yellowish mucus. Slight trauma, even from wiping away the secretions, causes bleeding. (b) Chronic catarrhal proctitis may follow acute catarrhal inflamma- tion of the rectum, or, as far as we know, it may be chronic from the beginning. The latter is true of atrophic catarrhal proctitis, the most frequent type of catarrhal proctitis. Hypertrophic catar- rhal proctitis, the other form, although generally chronic in course, may show an acute stage. Atrophic Proctitis. — This consists of an atrophy of the mucous membrane and its glandular elements throughout the rectum. It is limited to the rectum; not, like the hypertrophic variety, affecting the colon also. The disease is found mostly in adult life and is probably due to sedentary occupation, the overeating of highly spiced food, chronic constipation, and the abuse of cathartics and enemata. The affection is not infrequently associated with syphilis, either acquired or hereditary. Sometimes it is associated with chronic pelvic inflammation. J. P. Tuttle has noted the association of this form of rectal catarrh with chronic catarrh of the nose, and C. B. Kelsey calls attention to the frequency with which gynecologists overlook this disease and the possibility, if an ulcer- ative stage has been reached, of its causing subsequent stricture of the rectum. Pathological examination of the tissues of a rectum affected by chronic atrophic proctitis shows the mucosa to be granular, dry, inelastic, and adhering to it small masses of dry feces and perhaps shreds of exfoliated epithelium. Under the microscope the epithe- lium is found wanting in many places on the surface and there are granulations and ulcerated areas. The crypts of Lieberkiahn are atrophied, the solitary follicles are enlarged and distended, and the connective tissue of the submucosa is increased in amount. The symptoms are those of a mild irritation of the rectum. As the disease is apt to be complicated by fissure and hemorrhoids, 508 DISEASES OF THE RECTUM the symptoms are more directly caused by these affections. Long- continued constipation, with hard and lumpy stools and burning and discomfort in the rectum, may be the only symptoms, the latter being often mistaken for chronic disease of the ovaries or tubes. Pruritus ani is a common symptom. Examination shows the skin of the anus relatively normal, and the mucous membrane of the rectum bright red and shiny, with small pieces of dry feces adhering to it in places. It does not bulge into the end of the proctoscope. To the examining finger, the mucosa feels dry and it sticks to the finger. In long-standing cases the rugae seem to be obliterated and the valves of Houston stand out more prominently, while the ampulla is dilated. Erosion and ulceration are not uncommon. In such cases the stools may be smeared with blood or pus, and the eroded or ulcerated areas may be seen through the proctoscope. Hypertrophic Proctitis. — This is a chronic inflammation of the rectal mucous membrane, in which the mucosa and submucosa are thickened. The disease involves the colon as well as the rectum, being a part of an inflammatory process affecting the entire large intestine, and it generally follows an acute attack of proctitis or colitis. The affection is found most often in fat, flabby individuals who are the victims of chronic constipation, and occurs also in cases of chronic catarrhal appendicitis, uterine malpositions, abdominal tumors pressing on the intestine, and in movable kidneys, which slide up and down on the bowel. Pathological examination of the rectal wall shows marked hypertrophy of all the elements of which it is composed, including the glands and the connective tissue of the mucosa and submucosa. The symptoms are apt to be more general than local. Where the disease follows a well-marked acute attack, there will be a lessen- ing in the severity of the symptoms. As chronic hypertrophic proctitis is a part of a colitis and a large area of intestine is involved, the symptoms are of more serious moment than is the case in atro- phic proctitis. They are: diarrhea alternating with constipation, the stools being soft and mixed with pus, or hard and round, like sheep-droppings, and covered with muco-pus. Tenderness on pres- sure over the course of the colon in the abdomen, with swelling of the abdomen and griping pains, may be a feature of the case. In cases of a pronounced character, there may be tenesmus, occurring INFLAMMATION OF THE RECTUM 509 periodically and accompanied by the discharge of a large quantity of thick glairy mucus or muco-pus. Mucus may escape invol- untarily in these cases to such an extent that the patient is forced to wear a napkin. Pruritus is a common and a troublesome symp- tom. Constitutional symptoms are: flatulence, loss of appetite, coated tongue, yellow skin, offensive breath, and loss of weight and strength. Examination shows redness of the skin and hypertrophy of the rugae about the anus due to the irritation caused by abundant mucus coming from the anus. Dermatitis may exist in extreme cases, with much thickening of the skin. Condylomata acuminata, with their characteristic tree-like growth, are not uncommon in the skin about the anus. By digital examination, the mucous membrane of the rectum feels doughy, and the cavity of the gut seems somewhat restricted; quite the opposite to the state of the case in atrophic proctitis. Through the proctoscope, the flabby redundant mucosa bulges into the end of the proctoscope. It is pale red in color and covered with muco-pus. It does not bleed easily and neither ulceration, hemorrhoids, nor fissure is apt to complicate this form of proctitis, although prolapse may. The following table shows the principal points in the differential diagnosis between the atrophic and the hypertrophic forms of proctitis : — Chronic Atrophic Proctitis Chronic Hypertrophic Proctitis 1. Constipation is generally the 1. Constipation alternating with rule. diarrhea. 2. Secretions absent; peri-anal 2. Secretions increased about the skin dry and relatively nor- peri-anal region; acute der- mal, matitis ; moist eczema. Con- dylomata apt to be present. 3. Sphincters usually contracted 3. Sphincters generally relaxed. and hypertrophied. 4. Mucous membrane dry, stools 4. Mucous membrane swollen adhesive, rectum readily dis- and edematous, prolapses tended and easy to examine. over the end of the procto- scope during examination. 510 DISEASES OF THE RECTUM Chronic Hypertrophic Chronic Atrophic Proctitis Proctitis {continued) {continued) 5. Mucous membrane bleeds 5. Bleeding from the mucous readily; light sponging pro- membrane uncommon, duces considerable oozing. 6. Mucous membrane dry and of 6. Mucous membrane moist and a bright red color. of a pale red or pinkish hue. 7. Ulceration common. 7. Ulceration rare. 8. Inflammatory process almost 8. Inflammatory process rarely invariably confined to the limited to the rectum and rectum and sigmoid. sigmoid, the colon being in- volved as well. 9. Hemorrhoids often present. 9. Hemorrhoids an unusual com- Prolapse seldom seen. plication. Prolapse more fre- quent. 2. Specific Proctitis Gonorrheal Proctitis. — This disease is rarely diagnosed, though it probably is not so infrequent as formerly supposed by writers on venereal disease. It is undoubtedly more frequent in women than in men and is due to the extension of the disease from the vulva be- cause of the introduction of the gonococcus on the finger or rectal tube, or it may be due to unnatural intercourse. The symptoms and anatomical appearances are those of simple proctitis and the diagnosis is made by the isolation of the gonococcus from the discharges. Condylomata, fissure, and submucous fistula are found as complications. Syphilis of the Rectum and Anus. — Syphilis manifests itself in the skin about the anus, in the anal canal, and in the rectum proper, in primary, secondary, and tertiary lesions. It may be congenital, or it may be acquired innocently, or by inoculation by unnatural coitus. Congenital syphilis is almost always of the secondary type and occurs in young children, usually during the first two or three months of life. The lesions consist either of cracks in the skin about the anus, radiating from the anus, or smooth, flat, elevated INFLAMMATION OF THE RECTUM 511 patches, from a quarter of an inch to half an inch in diameter, in the same situation. These lesions exude a very contagious discharge. The diagnosis is established by finding the Spirochseta pallida in the discharge or scrapings from the lesions, and in the appearance of syphilitic lesions elsewhere in the body. As indicating the relative frequency of the different syphilitic lesions, the statistics of P. Sick, from the Hamburg General Hospital, may be quoted. Among 11,826 women and children treated there for venereal diseases, there were: mucous patches, 986; chancroids of the anus, 224 ; chancres of the anus, 12 ; strictures of the rectum, 10; rectal gummata, 2; and anal gumma, 1. Chancre, the initial lesion of syphilis, is not uncommonly found about the anus in women. Statistics have been published that go to show that among women who have syphilis chancre is found at the anus in about one in thirteen. The characteristics of the chancre in the skin about the anus are exactly the same as on the vulva. (See page 406.) If the chancre is in the anal canal, or rectum proper, a rare occurrence, it is apt to escape detection. Digital and visual ex- amination will detect a single, non-sensitive lesion, with an indu- rated base, and the individual glands in the groin will be found enlarged. Scrapings from the chancre will show the Spirochseta pallida. Mucous Patches. — The anus is the most frequent seat of mucous patches next to the mouth and throat; they may begin on the vulva and spread to the anal regions. Mucous patches do not occur within the rectum, so far as known. They