CHAPTER XXVI THE DIAGNOSIS OF DISEASES OF THE RECTUM (Part 4)

submucosa. Symptoms of Inflammatory Strictures. — The symptoms of stricture during the ulcerative stage are dull, constant pain in the region of the rectum, diarrhea, tenesmus, and the discharge of mucus, pus, and blood; during the obstructive stage they are, increased fre- quency in a desire for an action of the bowels, the passing of small quantities of feces with incomplete relief, and, after an interval of a few minutes, the repetition of the desire for defecation. As the stricture becomes smaller in caliber the feces are passed in small-sized, round, or flattened pieces, and, if ulceration is still present, pus or blood may streak the stools. In the case of strictures of long standing the large intestine becomes chronically distended because of insufficient emptying, and, as a result, the abdomen is distended. The patient complains of distention and of flatulence, more particularly during the first two hours after taking food. Another symptom in these cases is swelling of the feet and legs, particularly on the left side, and, in extreme cases, emaciation, with cachexia from autointoxication, result. Physical Examination. — Physical examination shows the anus to be normal in appearance, except that there may be present several folds of redundant skin, or scars, if the patient has suffered with complicating fistula. If the stricture happens to be at the anal orifice, the natural rugae are absent and there is no redundancy, while cicatricial tissue takes the place of some of the skin at the anal margin. Straining on the part of the patient produces bulging, but no relaxation of the anus, and the finger feels a rigid ring about the opening. In the case of stricture within the rectum, the finger introduced into the rectum notes deficient contractile power of both sphincter muscles. The stricture, as has been said, is generally in the lowest two and a half inches of the gut. If the finger tip will pass through the stricture, the caliber and the shape and length of the stricture may be estimated; if not, the finger in the vagina will estimate the length of the inflammatory or cicatricial PROLAPSE OF THE RECTUM 521 mass. The short proctoscope passed through the anus permits a view of the stricture, and its size and length may be determined by passing through it olive-pointed bougies. Sometimes a smaller proctoscope, or a large Kelly cystoscope, may be passed through the stricture and a view of the rectum beyond the stricture thus obtained. The presence of much thickening about the rectum, with the escape of pus on digital examination, generally indicates the coexistence of an ischio-rectal or pelvi-rectal abscess. In making the diagnosis, the history should be inquired into minutely and search made for the stigmata of syphilis or tubercu- losis, the two most common causes of stricture. PROLAPSE OF THE RECTUM By prolapse of the rectum is meant the eversion of a part or the whole of the rectum through the anal orifice. It is partial when the mucous membrane alone is everted, and complete when all the coats of the rectum are involved. The disease is found most fre- quently in young children and in old women, especially in the women who have suffered from weakening of the sphincter ani muscle from childbearing. Laxity of the connections of the mucosa with its underlying structures and weakening of the tone of the sphincter muscle are predisposing causes. Exciting causes are obstinate constipation and chronic diarrhea, causing prolonged and repeated straining at stool, also extruded rectal polypi, or other rental tumors, causing overstretching and relaxation of the sphincters. Symptoms. — The symptoms are (a) loss of control over the bowels with the involuntary escape of rectal mucus as well as flatus and feces; (b) protrusion of the bowel, at first at stool only, followed by spontaneous reposition, then protrusion on coughing, or any sort of straining, and, finally, permanent prolapse unless reduced manually; (c) increased frequency in the action of the bowels; (d) pain of moderate or small amount as a result of long- continued irritation — pain is of an aching or throbbing character and persists as long as the part is protruded; (e) hemorrhage when the prolapsed mucous membrane is excoriated or ulcerated, not of large amount in any case. 522 DISEASES OF THE RECTUM Physical Examination. — The prolapse may involve the entire circumference of the rectum or only a part of it. There is no redundant skin about the anus in these cases and palpation deter- mines that the mucosa moves freely on the muscular coat: the sphincters are relaxed and deficient in contractile power. The determination of the thickness of the wall of the prolapsed mass shows whether only the mucous membrane or the entire rectal wall is down. If the mucosa alone is extruded — incomplete prolapse — • the mass is seldom more than two inches long, and one side is gen- erally longer than the other. In complete prolapse the protrusion is generally equal on all sides and the mass measures some three or four inches in length. In incomplete prolapse, the opening into the lumen of the gut is circular, or oval, and centrally situated, whereas in complete prolapse the opening is slit-like and points backward because of the traction of the meso-rectum. In incom- plete prolapse these are generally sulci anteriorly and posteriorly and the mucous membrane is smooth, whereas in complete prolapse there are no sulci and the mucous membrane is marked by several concentric furrows. NEW GROWTHS OF THE RECTUM New growths of the rectum are:* — (1) benign, or (2) malignant. 1. Benign Tumors of the Rectum and Anus Benign tumors are of infrequent occurrence, are of slow growth, they do not infiltrate the surrounding structures, and, when re- moved, do not show a tendency to recur. They may be divided into : (a) tumors about the anus, and (b) tumors of the rectum. a. Benign Tumors about the Anus These are papilloma, soft fibroma, and lipoma. They arise from the skin and subcutaneous tissue. Papilloma. — Papilloma is due to hypertrophy of the papillary layer of the true skin. It occurs in young adults and appears to be due to want of cleanliness. The tumor consists of an enlarged papilla in the form of a bulb-shaped tumor about half an inch or three- quarters of an inch long, at the margin of the anus. Several tumors NEW GROWTHS OF THE RECTUM 523 are generally present in the same case and the pedicle of each is separated from its fellow by a strip of normal skin. Each tumor is made up of a central artery and vein in a connective-tissue stroma, which is covered by stratified epithelium. The surface of the papilloma is the same color as the surrounding skin, though it may become eroded and ulcerated. These simple tumors must be differentiated from carcinoma. In the latter there is no normal skin between the different parts of the tumor, and there is much infiltration of the surrounding skin and subcutaneous tissues. Condylomata lata have the appearances described on page 512 and condylomata acuminata those to be found on page 407. Hem- orrhoids are of a deep purple color, and are soft and compressible, or, if thrombosed, very hard. Soft Fibroma. — Soft fibroma is a pedunculated tumor of rare occurrence arising from the connective tissue of the submucosa. It contains besides connective tissue, muscular and glandular tissue, and is similar in structure to molluscum fibrosum. The tumor may attain great size and may weigh as much as a pound or more. Lipoma. — Lipoma is a fatty tumor caused by hypertrophy of one or more lobules of fat. It is situated under the skin surrounding the anus, is soft, and is freely movable, in this respect being dis- tinguishable from an inflammatory exudate or abscess. Occasionally a lipoma is pedunculated. b. Benign Tumors of the Rectum — Polypi These tumors originating in the rectum are generally pedunculated growths and therefore are classed as polypi. They are of the following pathological varieties: adenoma, fibroma, myoma, villous tumor, myxoma, and lipoma. Adenoma. — Adenoma or mucous polyp is the most common form and is met with almost entirely in children under ten years of age. It consists of a hypertrophy of the crypts of Lieberktihn, and shows on section the tubules lined with columnar epithelium and surrounded by areolar tissue. If the connective-tissue elements predominate the tumor becomes a fibro-adenonia. Lymphoid tissue may form the basis of a tumor of this sort, due to hyper- trophy of one of the solitary follicles of the rectum, and in this case the tumor is a lymphadenoma. 524 DISEASES OF THE RECTUM Glandular polypi are usually single, vary in size from a quarter of an inch to one inch in diameter, are round, and attached to the rectal wall by a long and slender pedicle. They generally arise in the lowest two inches of the rectum and may exist for a long time before the pedicle becomes enough elongated so that the tumor is passed through the anus at defecation. When it is, the diagnosis may be made. The probability is that many of these growths are torn from their pedicles and extruded during a movement of the bowels. The symptoms are hemorrhage from the anus after the growth has gotten within the grasp of the sphincters, and straining. The passage of blood from the rectum, in children, should always lead the physician to make a rectal examination. The examining finger is swept around the rectum and search made for the pedicle of the tumor. A view of the rectum and the tumor may be obtained through a Kelly proctoscope, No. 12. To make an accurate diag- nosis an anesthetic will generally be necessary. Fibroma or Fibrous Polyp. — A fibrous polyp is generally situated in the lowest two inches of the rectum ; it is from a quarter of an inch to an inch in diameter, and is attached to the rectal wall by a short, thick pedicle. It occurs in adults and is usually single. It is made up of fibrous tissue and is covered with stratified epithe- lium when it springs from the anal canal, but has a complete mucous membrane over its surface if it originates higher up in the rectum. The tumor originates from the submucous connective tissue, a thrombosed internal pile, or from the nodules on the free edges of the valves of Morgagni, and is at first sessile. There may be no symptoms until the growth becomes pedun- culated, and then there will be rectal irritation or loss of blood. Digital examination will detect the polyp and its situation. If the pedicle has been torn by the violent action of the sphincter, there may be so much pain that an anesthetic may be necessary before a satisfactory diagnosis can be made. Myomatous Polyp. — Myomatous polyp, a very rare sort of tumor, has the same characteristics as fibrous polyp, except that the tumor is made up of muscular tissue in excess of fibrous tissue. Villous Tumor. — This rare sort of tumor in the rectum is de- scribed by Allingham ("Diseases of the Rectum") as "a lobulated, spongy mass, with long, villus-like groups studding its surface." Goodsall and Miles had collected thirty-five cases of villous tumors, NEW GROWTHS OF THE RECTUM 525 twelve in their own experience. The tumors appear to originate en- tirely from the mucous membrane of the upper rectum in patients who are beyond middle life. The growth is at first sessile and as it increases in size becomes pedunculated, the pedicle being band-like or poorly developed. If it is well developed the tumor has the appearance of being slung to the rectal wall as by a mesentery, attached obliquely. These tumors do not infiltrate the rectal wall, but may be the seat of carcinomatous degeneration. The symptoms consist of the escape from the anus of a thin, watery fluid. The frequent defecation caused by the tumor is described as diarrhea. There may be present dull pains in the region of the rectum and hemorrhage, also constipation alternating with diarrhea, and cachexia from loss of blood. The growth itself does not appear to bleed unless it is prolapsed through the anus. Internal piles are apt to complicate the disease. Anesthesia and the rectal specu- lum will be necessary in order to map out the situation, size, and character of the pedicle of a villous growth. Myxomatous Polyp. — Myxomatous polyp is very rare in the rectum. A tumor made up of a combination of fibrous tissue and mucoid tissue, a fibro myxoma, is occasionally seen. Here, there are loose areolar-tissue spaces filled with a thick viscid fluid. The diagnosis is made as in the other forms of benign rectal tumors. There are no characteristic symptoms beyond an increasing diffi- culty in emptying the bowel satisfactorily. 2. Malignant Tumors Malignant tumors of the rectum are cancer and sarcoma, the former being frequent, and the latter rare. Cancer of the Rectum Cancer of the rectum forms about five per cent of cancers of all parts of the body (combined statistics of 45,906 cancers by Heimann, Zeman, Kronlein, and De Bovis, "Diseases of the Rectum," J. P. Tuttle) and about fifty per cent of all cancers of the intestine (same statistics). The disease is more frequent in men than in women and is found most often between the forty- fifth and fifty-fifth years in both sexes, although it may occur at any age. The etiology is entirely unknown, except that it is found 526 DISEASES OF THE RECTUM more often in patients who have suffered previously with hemor- rhoids, ulceration, or benign tumors of the rectum. The most frequent situation of the disease is the upper rectum between the sigmoid flexure of the colon and the internal sphincter. The lower down in the rectum the disease is situated the greater the discomfort to the patient and the greater the likelihood, there- fore, of an early diagnosis. Cancer of the Anus Cancer of the anus is infrequent. It may originate in the skin about the anus, in this case being a squamous-celled carcinoma, or in the anal canal with downward extension, an adeno-carcinoma. Squamous-celled carcinoma is rare and is most often met with in women over fifty years of age. An ulcer having an indurated base, bleeding easily, and extending into the margin of the anus is the appearance generally seen. The lymphatic glands in the groin are the ones that are enlarged in cases of cancer about the anus. A piece of the ulcer and its base should be removed for microscopic examination. Pathology and Course. — Pathologically, cancer of the rectum belongs to the class of adeno-carcinomata, the disease showing an atypical growth of glandular elements. If the connective- tissue elements predominate and the stroma is large in amount and dense, the tumor is called scirrhus; if, on the contrary, the glandular elements predominate and the tumor is soft in consist- ency it is called medullary. Colloid degeneration may affect the growth; then it is known as colloid cancer. In the early stages adeno-carcinoma of the rectum is a sessile, rounded tumor, flattened on top, situated in the mucous and sub- mucous tissues and freely movable. As the tumor increases in size the cancerous outgrowths invade the muscular wall below, and the mucous membrane above, so that within a few months the tumor is ulcerated on top, fixed in the rectal wall, and of irregular outline. This is the condition usually found when cancer of the rectum in an early stage is first seen by the physician, although the less fully developed growth is occasionally detected during a routine examination. Involvement of the lymphatic glands in the hollow of the sacrum appears to be a relatively early event. CANCER OF THE RECTUM 527 The cancerous ulcer is excavated, with irregular, everted, and indurated edges, lying on a base that is of a porky hardness. When it has extended nearly round the circumference of the bowel stricture occurs, and by this time infiltration of the tissues sur- rounding the rectum takes place and the rectum is fixed. The ulceration may open into the vagina, bladder, or peritoneum in the late stages of the disease, and at this time the abdominal lymph glands are affected, and metastatic deposits occur in the liver and other organs. Symptoms. — Goodsall and Miles have analyzed with great care the histories of their cases of cancer of the rectum, with a view to detecting any symptoms, however slight, that may excite the attention of the physician and suggest a probable diagnosis of this dreadful disease. The patient's condition is so uniformly hopeless in the later stages that any facts that may lead to early diagnosis must be sought with painstaking assiduity. In the earliest stages before ulceration has taken place, the patient is apt to complain of a well-marked attack of constipation, having previously had regular movements without the use of laxatives; also there may be slight loss of weight, and after the attack of constipation is over there is frequency in the action of the bowels excited especially by the ingestion of hot fluids. The bowels at this time may act four or five times during the day and not at all at night. Goodsall and Miles insist that such a train of symptoms, occurring in women who have passed forty years of age, should lead to a thorough rectal examination, and I can not but agree with them, for any tyro can make a diagnosis in the advanced stages when it is too late for treatment to be of avail, and the patient's only hope lies in early detection. When the ulcerative stage has been reached the symptoms are, increased frequency of defecation with difficulty of procuring a satisfactory evacuation of the rectum, the appearance of blood and mucus in the stools, pain in the rectum from constant straining, and