CHAPTER XXVI THE DIAGNOSIS OF DISEASES OF THE RECTUM (Part 3)

begin as a reddening of the skin between the folds of the buttocks, noticed sometimes before the initial lesion has healed; the chancre, in fact, merging into a mucous patch. As a rule the mucous patch is developed with the secondary lesions, at the same time as the macular eruption upon the skin of the rest of the body. The reddened area of skin is raised a little above the surrounding skin; the epithelium becomes macerated and is shed, leaving a shallow erosion. There is a scanty, thin discharge and there is no itching. Soon the surface of the erosion is covered by a grayish-white membrane slightly elevated above the surface of the skin. The patches vary in size and may be single, multiple, or coalescing, so that the entire circumference of the anus is involved. 512 DISEASES OF THE RECTUM When the papillae of the mucous patches grow upward from the skin they may form flattened warty growths called condylomata lata, or vegetating mucous patches. They are accompanied by more or less discharge and are more commonly found in uncleanly syphilitics. Ulcerations may result from the breaking down of mucous patches. Syphilitic ulcerations within the rectum are common. They present few symptoms and reach the chronic stage before they are recog- nized. They tend to spread, following the course of the blood-vessels and the lymphatics and are destructive in their tendencies, having been known to perforate the peritoneum. The lymphatic glands in the hollow of the sacrum become enlarged and may be palpated, but must not be mistaken for gummata. When the ulcers cicatrize they leave behind them bluish-white, non-elastic tissue that forms a stricture. Gummata. — Gummata of the anus are very rare and only a few cases of gumma of the rectum have been reported. The latter is described as a round, elastic, painless tumor, situated in the sub- mucous tissues. It is single or multiple and from the size of a pea to that of a small orange. The fact that a gumma does not sup- purate, is not tender, and does not occur in chains, serves to dis- tinguish it from enlarged lymphatic glands. Syphilitic stricture of the rectum is considered under Stricture, page 519. Chancroids of the Anus and Rectum. — This affection is rare in America, though not infrequent on the Continent abroad. The chancroidal ulcer, being auto-inoculable, often extends from the vulva (see page 406), therefore we may regard chancroids of the anus as secondary in a vast majority of cases. Chancroids of the rectum are generally due to sodomy. The points of diagnosis and differential diagnosis of chancroids will be found in the chapter on diseases of the vulva, page 415. There is a form of chancroid called phagedenic, characterized by an intense inflammatory process involving the deeper structures, with much destruction of tissue. This sort, if situated in the rectum, may cause stricture. It is rare, and occurs commonly in patients of debilitated constitution. Chancroids and chancre may coexist in the same patient, there- fore the physician must be on the watch for the characteristic appearance of each lesion. INFLAMMATION OF THE RECTUM 513 Tuberculosis of the Anus and Rectum. — Primary tuberculosis of the anus and rectum is extremely rare; the secondary affection, occurring in patients with advanced tuberculosis of the lungs or other organs, is not infrequent. A miliary variety of primary tuberculosis in the skin about the anus has been described. In this form there are minute, shot-like bodies beneath the epidermis, that have developed in the sweat and oil glands of the skin. They are arranged in a crescentic or circular shape and soon break down to form shallow ulcers with ragged, indurated edges and giving forth a thin discharge of sero- pus. An ulcerative variety is the common form in which tuberculosis is seen, both in the skin about the anus and inside the anal canal. The ulcerations are apt to involve both the anal margin and the mucous membrane inside the anal canal. They may be single, or on both sides of the anus; they are round or oval in shape, the borders are irregular in form, but undermined, and of a pale color, shading to the normal pink of the surrounding skin. There is induration around the ulcer, but the base is relatively soft, irregular in its surface, grayish in color, and the granulations do not bleed easily. Yellowish tubercles, the size of a millet seed, are scattered over its surface, and in the older parts of the base of the ulcer cheesy material may be found. The discharge is small in amount, sero-purulent, and mixed with blood. These ulcerations are not especially painful: they do not tend to heal as they progress in all directions and do not, like other ulcers, assume the type of fissure when they invade the anal canal, but involve both the rugae and the sulci. Primary tuberculosis of the rectum proper is practically unknown, but the secondary type occurs. The ulcerations present the same appearance as in the anal canal, ulcerations here producing stricture as their late results. The diagnosis is made by finding tubercle bacilli in scrapings made from the ulcer and by the characteristics of the ulcer itself. Dysenteric Proctitis. — This is an inflammation of the rectum and sigmoid flexure of the colon occurring in sporadic dysentery, and caused by the ameba coli. In endemic and epidemic dysentery the entire colon and rectum are involved, but in this event the constitutional disease overshadows the affection of the rectum. 33 514 DISEASES OF THE RECTUM The inflammation of the rectum is generally of the catarrhal variety, but in chronic cases progresses to an ulcerative stage, the ulcerations being linear, punched-out, and like little grooves in the mucous membrane following the course of the blood-vessels. The purulent discharge is very profuse and the submucosa is destroyed to a greater extent than the mucosa, whence the undermined edges of the ulcers. The symptoms of the acute stages of dysenteric proctitis are pain and heat in the pelvis and anal region, tenesmus, diarrhea, slight elevation of temperature, rapid pulse, and exhaustion. The diarrhea is attended by the frequent painful passage of, at first, partly solid and partly fluid stools, changing to watery stools and finally mucus, tinged with blood and pus. There is burning after stool and the frequency of defecation is very great. In the chronic stages the frequency is not so great and the symptoms are those of ulceration. The ulcers have the characteristic appearances of worm-tracks in wood, following the course of the blood-vessels. They sometimes result in stricture. ABSCESS AND FISTULA IN ANO Abscess. — The tissues immediately surrounding the anus and rectum are especially subject to infection and inflammation, because of the abundant lymphatic and blood supply of the parts, from the ample source of bacteria in the retained contents of the intestine, and from the obstruction to the circulation caused by hardened fecal masses. The bacteria most frequently found in abscesses about the rectum are the tubercle bacillus, and bacterium coli communis, generally associated with staphylococcus or streptococcus. The course of the abscesses is acute or chronic, only the deeper ones, the superior pelvi-rectal abscesses, being of severe grade and immediately dangerous to life. Abscesses in this region burrow in the path of least resistance, passing between the fascial planes and around the blood-vessels which are large enough and vigorous enough to resist thrombosis and gangrene. Superficial abscesses, of the nature of acne pustules or furuncles, open on the skin; subcutaneous abscesses and deeper seated ABSCESS 515 suppurations, generally, besides opening through the skin, make their way between the internal and external sphincters, perforate the mucous membrane, and discharge into the anal canal, forming, in a large majority of cases, a fistula. Those that enter the bowel alone form blind, internal fistula?, while those that open both on the skin and into the gut are complete fistula?. The different sorts of abscesses in this region as enumerated by Goodsall and Miles ( " Diseases of the Rectum," Part I.) are: — (a) subcutaneous, (6) ischio-rectal, (c) submucous, (d) pelvi-rectal, --A?i/cous membra ft c Submucous T/'ssuff ^Circular musclefi'bres ■Long-iTudinal muscle fibres, pelv/'-reclal space. Levator an!. The internal Sphincter. Interval between the internal anof the external sphincters Superficial portion of the _„- external sphincter. " Deep portion of the etlernal Sphincter. — Integument Tendinous inserti'oq of the longitudinal muscle fibres Fig. 195. — Diagrammatic Representation of the Lower part of the Rectum and its Immediate Surroundings. (After Goodsall and Miles.) (e) labial. As has been said, the (b) ischio-rectal abscess opens not only on the skin, but also between the sphincters into the bowel. The (c) submucous abscess originates in the submucous tissue, usually in the lowest three inches of the rectum, and is generally confined to one side of the bowel. It shows a tendency to burrow downward and to empty near the anus. The (d) pelvi-rectal abscess begins in the loose connective tissue between the levatores ani below, and the reflection of the peritoneum above. This space being continuous with the bases of the broad ligaments, septic inflamma- tory processes starting in these structures may spread to the pelvi-rectal space. Infection may come from the rectum, from malignant disease of th(4 bowel, or ulcerations high tip. Rarely, in the acute form of this disease, the pus may rupture through the 516 DISEASES OF THE RECTUM peritoneum into the abdominal cavity; in the chronic forms it is more apt to perforate the levators and form an ischio- rectal abscess. This sort of abscess is the cause of deep horseshoe fistula. The disease is generally attended by extensive cellulitis, (e) Labial abscess is an extension backward to the anal region of a vulvo- vaginal abscess. This is a rare sort of abscess. The symptoms of abscess are pain in the rectum, with aching and throbbing especially on defecation, tenderness in the region of the anus, and constitutional symptoms in the acute stages. Exami- nation shows great heat, tenderness, and induration of the tissues, with fluctuation at the seat of the abscess. The exact situation is determined almost entirely by palpation and the physician will search for the different sorts of abscesses according to the descrip- tions just given. Fistula. — The word fistula is derived from the Latin fistula, something capable of being split, a hollow reed or pipe. Fistula in ano may be defined as an unobliterated abscess track which opens either in the skin near the anus, or into the rectum, or both. Fistula is comparatively rare in women, the average age at which it occurs being thirty-six years. It may be caused by a fissure, by ulceration of the bowel, by stricture, by polypoid growths, or by carcinoma. As implied by the definition, an abscess always precedes a fistula, except in the very rare cases of fistula caused by traumatism. A fistula generally opens by one orifice in the bowel, but by several in the skin. Varieties. — There are three sorts of fistula?, although all three may be combined in the same patient. They are (1) complete, when there is an opening through the skin and also an opening into the bowel, and (2) incomplete, including (a), blind external, when there is an opening into the skin alone, and (6), blind internal, when the only opening is into the rectum. 1. In the complete fistula the main track generally passes between the two sphincters into the rectum, but it may be subcutaneous throughout, and not go round the external sphincter. From the main track branches go off to end in blind passages or to perforate the skin. Rarely the main sinus, after burrowing between the" sphincters toward the mucous membrane of the rectum, may ascend above the internal sphincter before perforating into the FISTULA 517 rectum, but as a rule the internal opening is in the anal canal between the sphincters. Complete fistulse form about seventy per cent of all fistulse. 2. Of incomplete fistulce (a), the blind external fistula is an abscess Complete fistula.- Fig. 196. — Diagram of Complete Fistula in Ano. cavity having an opening in the skin, near the anus. The track may represent a previous existing complete fistula the internal open- ing of which has closed. In the case of (6), the blind internal fistula, there are three courses taken by the abscess track to its opening into the bowel: it may be subcutaneous and pass outside jfth'ncl internal fistula. Fig. 196a.— Diagram of Blind Internal Fistula. the external sphincter into the anus; it may be submuscular, passing through the external sphincter, or between the internal and the external sphincters; or it may be submucous, coursing entirely in the submucous tissue. The last form is often due to a preexisting 518 DISEASES OF THE RECTUM fissure, is apt to be higher in the rectum than the others, and may be felt by a finger in the rectum as a cord, running in the rectal wall. Goodsall and Miles have observed that fistulas which have started posterior to a transverse line drawn through the anus, bur- row more extensively than those that have started in front of this line. Symptoms of Fistula. — The symptoms of fistula are pus from the bowel, together with the history of a preexisting abscess, or fissure, or other rectal disease. Flatus may escape from a complete fistula and also liquid feces and gas may distend a blind fistula so that it is painful. If the swelling due to inflation is of considerable size it is possible to obtain tympany on percussion. The pain of fistula is inconsiderable and bleeding is only an occasional symptom. Physical Examination. — Examination will reveal the presence of an external or an internal opening, or both; the course and ramifications of the track of the fistula, and the presence, or absence, of complicating diseases. If the abscess preceding the fistula has been opened, the opening in the skin is apt to be smaller than when the abscess has opened spontaneously. All the openings should be investigated thor- oughly with a probe. The internal opening is found by proctoscopy and by passing a probe into it through the proctoscope. Palpation and the passage of the probe are the main reliances of diagnosis. Internal piles are the commonest local complication of fistulse; fissure, ulcer, stricture, polypi, or carcinoma may also coexist. If there is suspicion that a fistula is tuberculous, scrapings of tis- sue should be examined for the tubercle bacillus rather than rely on evidences of tuberculosis elsewhere in the body. A tuberculous fistula has generally a discharge that is small in quantity and thin and white, and the fistula is surrounded by much induration. STRICTURE OF THE RECTUM Strictures of the rectum may be classified, according to their causation, as congenital, as due to pressure on the rectum from without, or as inflammatory. Obstruction of the lumen of the rectum by new growths of the rectum or by foreign bodies in the gut may be disregarded in a discussion of stricture, as may the STRICTURE OF THE RECTUM 519 so-called spasmodic stricture, which was formerly thought to be very prevalent, but is now regarded by writers on diseases of the rectum as a rare curiosity and a temporary condition. Strictures may be further classified, according to their form, as annular, or as tubular. Congenital strictures are generally found in the anal canal, either at the margin of the anus or just below the level of the internal sphincter. The condition of stricture is apt to be regarded as simple constipation and the patient does not consult the physician until puberty or after. There is no history of an inflammatory or ul- cerative process of the rectum and a careful sifting of the evidence shows only a gradually increasing constipation. The stricture may consist of a band, or of a circular membrane with an opening in the center, being entirely distinct from the sphincter muscle, which may, or may not, be hypertrophied. Congenital hypertrophy of Houston's valves may constitute a virtual stricture. Strictures due to pressure on the rectum from without are relatively common in women, as in the retroversion of an enlarged or gravid uterus, or a tumor wedged in the pelvis, or a pelvic inflammatory exudate. The rectum is surprisingly tolerant of interference of this sort and, beyond a constipation and a mild proctitis, there may be no evidences that the caliber of the bowel is very nearly shut off. As a rule the symptoms due to the encroaching body overshadow those due to obstruction of the rectum. Inflammatory Strictures. — These constitute a majority of all strictures and are due to tuberculous ulceration, to syphilitic ulcera- tion, and to ulceration of unknown origin. Most of them are situated not higher than two and a half inches (6 centimeters) from the margin of the anus. Occasionally a stricture of this sort is found as high as three and a half inches (9 centimeters) up the bowel. Pathology of Inflammatory Strictures. — Ulceration of the mucous membrane is the macroscopic appearance in the early stages of inflammatory stricture. When the ulceration has healed there is a lack of elasticity of the rectal wall and it has a dry, leathery feel and a dull, non-shining appearance. Often the ulcerative process continues after the stricture has been formed, and in this case the rectum contains muco-purulent discharge. If cicatrization has taken place, the cicatrix appears as a bluish-white, dense, liga- mentous structure. The ulcer is of the type of infection causing it; 520 DISEASES OF THE RECTUM that is, syphilitic, tuberculous, or simple. Syphilitic ulceration is apt to heal below, while, at the same time, it extends upward. Gummata may be found in the course of the arteries and veins, together with endarteritis. In the tuberculous stricture, the entire epithelial surface of the mucous membrane is destroyed and caseous nodules are found in the tissues of the