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Full text of "A treatise on diseases of the anus, rectum, and pelvic colon"

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Ik^l^lK© 







Dr. S.0.}3easley 



A TREATISE ON 

DISEASES OF THE ANUS 
RECTUM, AND PELVIC COLON 



BY 
JAMES P. lUTTLE, A. M., M. D. 

PROFESSOR OF RECTAL SURGERY [N THE NEW YORK POLVCLINIC MEDICAL SCHOOL 

AND HOSPITAL, VISITING SURGEON TO THE ALMSHOUSE 

AND WORKHOUSE HOSPITALS 



fVITH EIGHT COLORED PLATES MND 

THREE HUNDRED AND THIRTY-EIGHT ILLUSTRATIONS 

IN THE TEXT 



SECOND EDITION, REVISED 



NEW YORK AND LONDON 

D. APPLETON AND COMPANY 

1906 



copthioht, 1m2. 1005 
bt d. appleton and company 






FUNTIID AT THK Am#BTON PR> 
NEW YOBX, CT. ■■ A. 






PREFACE TO SECOND EDITION 



Three imprints of this work having been exhausted, it is deemed 
odvisablc by the publishers to issue a sccoml edition. Since its pubU- 
cation no radical clianges have taken place in my opinions or practice 
of rectal surgery such as would call for a complete revision, but advan- 
tage is taken of this opportunity to correct whatever errors have been 
found in the tH)ok. 

The sections on Ana?sthcj^ia in Hectal Diseases and Dysenteric 
Proctitis have Ix'en entirely rewritten; and numerous practical points 
gained from experience have iK-en introduced into the text throughout 
tlie work. While I have end('avore<l to keep the book abreast with the 
times, its general plan and scope remain unaltered. To tlie profession 
who have so generously accepted the work, and to the critics who have 
been so kind to its sliortcominga and flattering in its praise, I hereby 
extend my sincere thanks. 

James P. Tuttle. 



50184 



PREFACE 



Within the past decade the field of rectal surgery has been greatly 
broadened and its methods changed tlirough improved instruments, asep- 
tic technique, and a wider knowledge of pathology. The lively interest 
taken by the profession in this branch of medicine and the little atten- 
tion paid to it in the undergraduate schools Jiave resulted in the estab- 
lishment of special clinics for teaching and treating rectal diseases. 

This book is practically the outcome of twelve years' conduct of one 
of the first and largest clinics of this kind. The opinions expressed 
herein are therefore based upon a clinical experience derived from a 
large number of actual cases. Such an experience teaches that no one 
method succeeds always, and that the practitioner should be conversant 
with many in order that he may have resources in reserve for all emer- 
gencies. Therefore, while relating my own practices and opinions, I 
have also given those of other operators, so that the reader may have as 
complete a knowledge of the subject as possible. 

Much space has been devoted to examination, diagnosis, and local 
treatment, because these are the subjects which the general practitioner 
needs most to know. The non-operative treatment of each disease is 
first described, together with the class of cases in which it will prob- 
ably be useful; but when such measures are likely to prove futile I have 
not hesitated to say so. 

The book has been written during an active practice, and almost 
every opinion expressed therein has been put to the test. I am sensible 
of its imperfectioDs, but should it prove useful to the many physi- 
cians who have honored me by attendance upon my clinics or assist in 
the dissemination of knowledge upon these important subjects, I shall 
be amply repaid for the nights of labor it has cost. 

I take this opportunity to express my appreciation of the generous 
assistance afforded me in the work by Drs. S. T. Armstrong, George H. 
Wellbrock, P. M. Jeffries, Mr. H. J. Hopkins, and the publishers, who 
have been patient, kind, and courteous. To them and all the friends 
who have aided me by suggestions and encouragement I extend my sin- 
cere thanks. 

JA1IE8 p. TOTTLE. 
42 West Fiftieth STREn*, New Yoke. 



CONTENTS 



cnAPTER I 

KHRRVOt/MIT. AHaTDMT. XttO PBVSIOL06T 

'DaRnlUons of the purta — JCmbryolosy—Analmrttf — The j.erinft-imi — Ischio-rMUl 

fiMoi- Tli« anftl caiinl — The rHrtiini— Ttic iniit-ifU:) nienit'fatic— Siit)mucaiii 

|iij«r — Mii««viUr wall— Serous ooal — Vasriilsr siip|i!y— Xervc supply— 
Ijjniptintira — Retro-n^cUl nml lujicrior ijclvi-recliil sjiHtt* — [t>>lnti>;>as of 
Uu rectuiii^^igiiioli] fluxure or pelvic colon — Phgeialogs . • . . , 1-4(1 

CHAi'TKR II 

KALPOBMATIOM« OK TUB AStJS ASR RECTUM 

Jffil/ormntiona of tKt anw-t— Kiitim uliEcni^u— Abnormal niirrowi lip— Partial 
nr in)) rutin 11.1 nci'lit-iluti — <\)m[?1i.'l<; <)b«t[ucti'>n L>f u (iii:ml>runou9 diuplintfin 
— Ann! opoiiiniCBl hhihi nliiKtriiiHl |iciiiit in the jwriiin-uiu or sutTuI rtpiun— 
f«l/oninition' of (A< ivWum— tCnliro nbwnci.' — Uri'Tuiii iirri'JUwI iti iia 
cnl, ihc ttnii!> Itcini: normal — IWiuiu tiiieiiing intw soino uthcr vJKas — 
Oilier or£an»,moh as Iho iirelcrs, VH^itiH, r>r uti'ni«, qwn Into iJiO rtotum 
— TroaUncut— R&culuuf ofMiiMitMiiaforiuiporforatA nmis .... i'-fH 

CHAPTKR !II 

KXAM ISjtTlOM AND PUOXOHIS 

HtntnricRl psaminnlion — Dicilal rinniiimtjon — Instrumunlnl pxn ml nation at tlifl 
nvtiim— KiaiDtD&tioii of toces— Anwslbeaia m rectal dluiasai . . S4-13S 

CHAPTRR IV 

MTARBIIAl Siaunx OP TBI BBCTm AMI BtUNVID: nUMTTTia AXI> einuoiDrTiit 

[Simple PAlarrbal inltamniatiAn — Aoitlit ^AlArrhuI proolitiB — Ctironii^ jirnvtitiv udU 

sigin<>itlUii> — H7perlro|>liic cntiiiTh — AIro|ihic c»i«rrh — Spwifltj ^.^Bl«^^haI 

InflaauiiaUiiB* — DyHMilvHe proviiiM and iii|[muidili»— |}ii>lillieritjc pnx^fiin. 

CHAPTER V 



•"KIloXIV IflLITIS. xrmil!* ('(tl.iriS, HBWnKJtKOirS COLITIS 

lary tBotntmiXfits oulltia—U lev rati vo culitis— Fullicular uolili» . 



ie7-lU3 



CHAPTKR VI 

TitnuitrrLOflia or tiix Avvn, kkctum, jum pelvio roum 

■tmuJ f«^rru/mn'«~Mili«rT rdriotr— I'lrfralirc Tiiricty — Anal ttibtrftihmt— 

[.(ipiiiil iilceTalian ot llie anas — Vurruootis nli>vraliuiiB of the anu« — Tiibi'ren- 

Itniiof iIk- tdHuin and *it!'""'>l— ^lifpcrplaitic lul>«rculoti« — Acnt« tuburciilitr 

iiiAanimaiion 1V8-S13 



\id TUB AKUS^ RECTUM, AMD PELVIC COLON 

CUAPTEU VU 

ITBHKKKAL I>I8C18EB OK THE X}Hf AXD XECTVM 

P*UK 

OouorThccal proclitU — (.'hnncroiil of Iho anu^ — (.'haiii.-r<ii<i<Ll ulceruUon of the 
rei-tiim — Phug*denii; chaiicruiil — C^mplicalimtti — Ryiitillis—Aiial chancre*— 
Rectiil c'liiiii4-n« — Sct'txi'lnrv inntiirMLatidiis— TiTtiHry lesiona — UorMlitary or 
OOngAiiiUtl »7]>liiliso( LUu unuH tii)(l r«otum 218-257 

CHAPTKR vrn 

SOK-BPEririr ITLCKUTlUm 

VUtraiiOH* of the ptrianal region — TruuiiiuLic tilceration—llerpetii! nlcenflion — 
Bcsetua of tlio anus— K->dtiil ulcere — Vltfratioiig »/ Hir anal rdnci/— Siiii|)le 
til«ra— TraiiiimliL' ulicr!.— t7efrn/ion» of fht rtr/uiii and utijmoiii — SjH-i-iiU 
uk>cnitimi>i — Sjiceiflo uk'crs — C'aia.rrtinl iilci'riiCion— Varjcn-c w let- ml ion — 
Un-'iDorrliutdiU ulcers— Follii'iilur liloTBtion— 8lrirliirnl iiliL-nitiuu — I'ltrci- 
nomntoiis ulceraliuii—rifi'ml.iim from Bripht's diwasr — DiiitH'tk' ttiuerHlion 
^ — Ucfiktlc uleamtiotk— Tro|ihi(^ ulccrBljon— Mnmsmio iilwrat-wii . . SGS-SW 

CBAITKR IX 

nsSUKE IN IXO — IKRITABLK < LC^ER— IXTOLERlBLiE ITLCCt 

^apo xnA loontijin of iilcors — Elinlogy— l'ivili»i<igy — Synipt"ins — Kefloi symp- 
toinit — N(i]|-r>porAlive Ircftlinctit — Oprmlivv Trt-atiiiwit — RraiilU cif ililaliilion 
— Methods of iucUion— Bloisjon — ^^ubmucous Huuro— CoiuplicKtii:']!* of 
fi«ur« 291-318 

CUAPTER X 

FEKIAXAL AMI) fEKIKKiL'TAL AD60MB 

Sup«rfielbl ftbwess — Tegninentjirj- abuCMK— Suhtv;um'<iiUiry nbeccM— Isohio-rptrtiJ 
abMwas — I'roffUiiii nlisces*— Rvtro-rtK-tnl ab^c^sa— SinitTiur fwhi-iiieliil ob- 
MXM— DIlTuHe septic poriprocrtitis — Idiopfttliic- ^ngmioiis periproctitis . 3ItMI53 

CUAPTER XI 

Deflnilioii— niftmtfieatfon— Froquwiuj' — Etiology — DiBtfuoeis — Aiiatomit^al charoc- 
tor— Origin — 'ruUTwi lar fistula— Oixriitioiis in tiilwituUr UbIiiIii— ProguoniB 
— PiitlioluBT— Ti*ntinpnl~Mi>i»-c.per»liv* nielhoiis— TJic lipatiiri^— FiKMilol- 
omy— Opcrailirr miithtiilM — tftstnimcnw Docei^an— I iici si uii—Esi-isi on— Ex- 
cision wilh imiTiwIiatP sutiim— <'nm]>lfx QstiilA — Primary, sreondary, and ialic 
couipli(«(i»its — Iiivoutinvnoe of fiK<«« — TT«atn:i«nt of Incontinence . . 363-430 

CHAPTER XII 

ooKPLiCAiTD ntmnj, 

Flitnlu ori^ivating in bono dii>ow« — FiMulas ponnwling rectnm with oth#r 
onmn*— Urinary fistul*— R«jt«-vw.ic»I fl-tuta— RiHto-iirulhral ftsltiln— Reo- 
lo-getiil*i ristula «MM 




CONTENTS 



vU 



CnAPTEB XllI 



STStCTtlBK or TUB BSCTUX 



Strktuns of largo caliber — Congenital stricture— NooplMtio stricture — Siwuinotliu 
atrioture— InflnmniatorT Blridlure — Diffuse inflamnialorf alrictiire — t'icatri- 
cial stricture— Peri rcuLai slrictur*— rathtilogy of strict ur«— Tubercular strto- 
tur»— Syphilitto inricture— £"/i'«fofl.v— Sj/nip'uni»— LnHint period — L'lceralivo 
or inllAmmhtory stage — Obstructive period — DioffnofiA — KiBiuitmtirtu— Rec- 
tomet«r« — Laparotomy in— Maligiutul elricliire — 2V*«( met/— Dietary and. 
RKxlitrinaJ: loutL and operatirc^Gradual dilatation — Rnpiil (Jilalatiou or 
divuleitxi — Kli-olrolysis, oauleriititlon, and ra<^Iag« — Proelolorry— Eieisioii — 
Proctoitlasty — LaUial eutero-anattotaocia — (.'olotomy— /(/tfwmi . . 4&&-514 



OUAPTElt XIV 



OOItSnPATION, DUSTIl'ATIOH 

O^ffniVion— Pefwat ion — R« verse porislalai 



IKD r.SCU. IMPJtCTIOK 



Exciting causes— I <o<'*l and mnlianiinl enusiy»--The iiiHufiiL-e ot llouolori's 
Talve»— Malformations — Rnteroptoais — Arut« tlcxiircx — Spmiin of tlie sphincv 
t«r— Bxlm-inteetiral obstruction- />»ayiK«ti«—^(ii(« c<ni*tipal it/nSy tap- 
loiii^— Oiaglioaiit — Trealnieiit — Chmnic conitipalion — Syinploms — Keflex and 
fiouatitiitiotial eflo^Is— Mi^Rtal and neriroiiit lympConis — Trealnifnl — Mc^lic- 
InaL local, and operotjre — Valvotomj — Facai impaction — Sjmptami — Diag- 
nocit — Tnutlnieut Q 1 7-0a7 



CHAPTEn XV 

fKURlTUS AH I 

KuwiiCial pruritus— Cbar«cWri«ticj^I/o«il raitiuTji— Knflei r«ii»e»— Conatltutional 
causos — TreatminI — Constitutional, local, and operative .... S03-S81 

CHAPTER XVI 

R^EUOKltUOlU!) — PILK8 

Prcdiiposing ca uses— Esd ting oau3«a — Nomenclatnre — C taitn Heat ion —fxr^raoZ 
AtwtffrrAvi'do — Symptoms — Trvatmcnt — InUrnai hamorrhi/iiia — I'sthologj — 
Sjmptoma— I'rerenliFe Iniacnicjil — Palliativt Ln»lmnit-~-Ojtfmlire trtol- 
mtiU — Dilalnliun — (*aiilo fixation — Klwtnil/Bis — Inji>c(ion mt'i hod— Ligature 
—Submucous ligaturt^Clanjp atid cautery — CriiBlmii:— Kxciwuti— IJirit«d 
aioiaton ^ Acciilcntit aiitl l'Oiii plica liona following o|)eration — Recapitulo- 
lUco Wi-WS 



CHAPTER XVn 

raoum or tdk xxctuk. pRoctDKima ixTBiiTno krcti 

iMOmpltif p r d a f W Etiology— Symptoms— Trgatmcnt — CompUtt pmhpte — 
First (li-KTce — Scwinil ilogrco — Tbltd degree— Syraptoras—Etiiiliijry— Path o!- 
cR7^7^(^'"'^'i'~'Km1uc1 ion— -Rod action in Rangrenoui t'otidJUonn — Cnutvri- 
■Uoo— Sipnoidopeijr— K«cto{>oxy — AmpiiUtirin— Complieatinn* of pniltipnc 
— Raptnn of hernial tte iu prola)»e 067-710 



VUl 



THE AKUS, UECTUM, AND PELVIC COLON 



CHAPTER XVlir 

BEjrrOX TtUOBS OP TUB RKCTl'M 

ConnectiTc-tiwue type— Muscular typ<> — H^piihelial t^pa — Fblyjnt» — Seat >iid 
manniT of develop intnt—HiatoItigy — Cotirw! wid nymptims — Dinffnosis — 
T ireiit mciil — Fittrv ma — Knckondro ma — htpo m a — Jf y o win — Lii mphade noma— 
Xyzoma — Adtnomn — Simple adenouift— Symiilimis— Treulrnent — MnhipU 
adtnomala — Etiology — 1) list ribut ion of — Conformalinn — Cclor — Coiieiptenoe — 
Condition of the imic&uB membraiit hi — Syin]iloms— l)i4»gnoM!i— Ili^tulogj-^ 
IHaligiMdt 1 raiiitfontialiiiii in— Treai rnenl — VUloiu tumor : PupiHoma — Ktiol- 
ogy ftRil (ievplopiiiutit — SyinploniB— niignusis — Trout men t—t'j"' cm '» — .Simple 
Cfsla— Diirmoiil rvsl»— Kxlm-nectal demKiids — Pottamit dimplts — Sucro-coc- 
oygeal lumoK—Angeiuaia — r^rriMtt^Fuugus ol tliti recltitiii — Hj/dalida — 
MyptrtrvpKitd anai papilla 711-769 



CHAPTER XIX 

■AtlOHlirr HEOFUSUS — ChKCISOKJl tKD eABOOMJ 

CarefnomaSeat of Ihe di^Mi«e — Etiolo^i/ — Ilcrwiity— Age— Sex— OcmpttioiH— 
Previous discuses— //iWu/u/Vrr^i/ t^pf* — K|>itlii>liAiiia — Adtnoid eanct^r — Modul- 
Iiiry cancer — Scirrhous cantur — Ccilloid cancer — SvnijitoQis — Lines of cilcn- 
giori — DiHgniKii.i — Tfi'Mfrin'iil. in gPiuTiil — Hi-siiUs — SlatlsI.teal t Abies— Cat isos 
of dcftth following dxlirpation — lfnJic»liotn snrf f^nlraindicnlifiTii to dif- 
fereiiC iuuIIiimIh fif mntiiKTiil — I^ilHalitt /ren^ineni— Irrigation — Viva^?— 
Q 1 n't iMgn— t'niil*Tiwitir>r— f'olwlnici y — E ri tr ro-*iii ju torn ocid — Sartmnu — Form 
— Nuiulier— ClmmftMJslics— Sile — Course — llistology- Eliologj' — Symptoma 
— Diiguosia — TrcatiiiciiL— Progniiais 780^09 



CHAPTER XX 

EmxpJtTIOK or THE RECTCll 

I'MpfttnUfiti of the |iA(ienl — Perineal m«tliods — Sacrnl methrtis — Abdominal 
iturtliodft— Combiued methods — Vaginal mot bod— Prolapse nftcr — (nooiiti- 
iimioii — Slru'tiim— KiiriflloDiil mmplicH-Ciuiis— ('unci usions— Choice of meilhod 
— St«U»ti(Mi! Ubl« 810-838 

CHAPTER XXI 

COLOIWMIT COLOTOHT— iRTtFICIAL ANITS 

Uortality from colcakntiy — HlfttiHticnl tabl« — LiiinbuT colostomy — Inguinal or 
abdominal i'o1o»il»my — TprTi[H>niry coloiilamy— MnUxid* of dxaljoii of Ibti gul 
— Ctoiure o( nriitlcial anus — Permanent oolostomj — Author's mpthod — 
Coloatomy an tho riglit .^tdo 8J!0-803 

CHAPTER XXII 

rOUCIGK HOIIIR IK THE KECTUM AMD SIGMOID ri.KXUKK 

Bodies whioh har» b«pn Kwaliowwl — KnlrrolfthK: coproliihc fircal ■tones- 
Bodies Intrwtliieed for the reiipf of oortain nymptjimB — For purposes of eon- 
cealment— By aciridcnt — Syfiiploms — Diftgiiow-i- Complications— Prognosis 
— Tnsatiiieut 8tH-0U 




CONTENTS iX 

CHAPTER XXIII 

WOUSHe, DIJDRIES, AKD RVPTUBS OF THB BBCTtlM 

PlOB 

Chanctera of — Csuses of— Prognosis — Symptoms — Mortality from — Treat- 
ment 915-921 

CHAPTER XXIV 

HEBTOCS OR BTSTEKICAL RBCTOH 

iDsane rectum— Neuralgia of the rectum — Irritable rectum — Morbid sensibility 
of the rectum — ReHex irritation— Nerve affections — HbeumatiBin and gout in 
— Insensitive rectum— Treatment 923-929 

CHAPTER XXV 

KECTO-COLO.VIC ALIMEKTATION 

History of — Indications for — Principles and methods — Selection of materials in — 
Methods of administering— Forma In 930-937 

IRDD 939-961 



LIST OF ILLrSTRATIONS 



Moru vjoK 

I. I>ev«In[immil. nf iiit«Klina1 tntfl (Sth&fler) 3 

5. Ptfvelojitnt-nt orreclniii (SL-lluffl^r) ......... 8 

8. DiviHiDiin ur nixil cjninl iStnnicI) 4 

4. Divisions a( tho [mMc uiillot S 

6. Diaveolion thuwiiiKinusculur urmti;:i'mcnt nt pelvic outlet, iKTrincul t ritn^- 

Urspsiws. and iscliio-rectsl (ossic 

8. XAFiniil HI1II.1 in rL-poiw . 8 

7. Tho anal cunat fl 

8l l*niKitiiriirjitl wi'licm of anaE wall*. i>liijwiiig nrrmigr'nii-iil of tiiiiM'ular flbori 10 

9. Fifni*lp fieri ri 11-11 in {K*illy) II 

lOl l.«vat»r aiii iiiuM^le .•.*■.■(. ...13 

II. IrfTBlor Biii iiiiiiwlif (t'ripp*) la 

IX, Cast uf n'cuim (CJu^iiii uml Huriinnnn) -....,.. 16 

13. Cart of rectum <Cju^-iiii niid Hartninnn) IS 

14. rust vf recluii) ami Hiialj'niial (iJiK^iii) Kiiil Ilurtiiiniin) IS 

15. Canlof rcituin mill l<>w*r lonp of digmoiiUMnrliii) 18 

16. Cut af rectum iQiirriH anil llArttiianii) 17 

17. (^t of rpdnm iitiil unjLl cuiinl ((jiii^iiii HMii llartmaiin} 17 

18. Armnt^'ni(?nt of circular iiiuHculHr liliTs of rL-i-lijin 19 

10. DiacmminAtic illtistnilioD of chief nggrcgatioDtt of circuUr muscular (lliers 

111 ni-liil wiJI lO 

SO. PiMvction bj Martin, showing fan-tihapcd nrrangriDtiiit of circular uiuscuUr 

fltn^m 21 

31. ArrBiif!onii>nt of longihidinal mtifUMilnr Inrrr of Ihir rrcliiin (E.nmipT) . . B9 

9S, Sbowinj; rvllcction of (>vrituiiicur[i fr«ii> nvtuco on lo thv pulviv walb . . 8S 

S8. llliistrHling luual loc-alion of Hoiintoii'a valv«« 20 

pL Inferior and inlddli' viiItm ftf HoUBlon 37 

IB, Abnormal (lcvvlo[>mL'iit of Talvcs of QdukIvu S8 

tt. Inferior iiic.ii>iiit>rii- arli-ry giving off sigtnoida) bmnch and lonninatlnfc In 

mpnrior hN>iniMThiviilnl S9 

W. Gxtcriinl Mid iiiidil!i' linfmi>nhoiiIftl vsina nrimg from Ihe anal canitl mid 

lowi>r ptiil nf llip nrliiMi : ntwi limnctieti miiriiiig iijivrard In foi'iii Nii|)t>ri<ir 

livmurrlKijilid vciiia 91 

M. Vanciilariiiipply of Inwi'rrnd of recLiiin (partly MJieiuaUo) . . , , 8S 

VK Spinal nvrves of Ihr rectum ami niiiiN 84 

80l Lyniphaliiniof anal fliid prrinnid ro^rioti . , S5 

81. Shoving cnnnwtion Itotwr^n iHTinnrtl and inj^Hnnl lymphatics • . , 36 

SB. Kiagiio nil I'll rvtro-rrolnJ i<p||ii1ar s|uioe 87 

83. Liriii III ittlMthiittMit of lli« iiii-viiiigmniil 41 

in. Tntrnnemoid fioua. >)i(iwiii)c li-fi ftigmoiilal artery 48 

8ft. ConiplHe abwnco ol tho anus SO 

si 




Xii THE ANUS, EECTUM, AND PKLVIC COLON 

rtnou MM 

86. Membranous ocolnsion of the anas 58 

87. Partial membraQOUS occluaiaD of the anna Hi 

88. Anus opening at tip of coccyx SS 

89. Complete absence of the rectum, the colon ending in a lai;ge dilatation and 

tbe anus being normal S7 

40. Case in which rectum failed to reach the anus 68 

41. Cose in which the rectum descended posterior to anal canal .... 58 

42. Fibrous cord leading from the anus to the arrested rectum .... 59 

43. Rectum descending posterior to tbe anns and tbe latter opening into the 

vagina (Amussat) 60 

44. Atresia ani vesical is 63 

46. Atresia ani urethralis 54 

46. Atresia ani preputialis 65 

47. Atresia ani vaginalis 66 

48. Malformation in which tbe peritoneal eitt-de-Kie extends between the blind 

ends of the rectum and anus 76 

49. Commode for offlce use 90 

60. Left lateral or Sims's posture 100 

51. Bzoggersted lithotomy position ......... 101 

62. Incorrect knee-chest posture 102 

63. Correct knee-cheat posture 102 

54. Patient held in knee-chest posture by straps and bands 103 

55. Patient held in knee-chest pasture on Martin chair 104 

66. The Little ofBce-lounge closed lOS 

57. Electric head-light 118 

58. Kelsey's rectal speculum Ill 

69. Conical bivalve rectal speculum , , 114 

60. Gant's operating rectal speculum 115 

61. Sims's rectal speculum 116 

63. O'Neill's rectal speculum 115 

63. Author's conical fenestrated speculum 115 

64. Van Buren's rectal speculum 116 

65. Pratt's rectal retractor 116 

66. Mathews's rectal speculum .......... 117 

67. Kelly's proctoscope 117 

68. Kelly's set of instruments for examining the rectum and sigmoid . .119 

69. Kelly's rectal curette 120 

70. Kelly's rectal scoop 120 

71. Kelly's sphincter dilator 120 

72. Tuttle's modification of Kelly's sigmoidoscope 121 

73. Laws's pneumatic proctoscope 122 

74. Laws's proctoscope with aperture in window for therapeutic applications . 122 
76. Tuttle's pneumatic proctoscope 138 

76. Tuttle's long sigmoidoscope with flexible obturator giving tbe instrument 

tbe Mercier curve 124 

77. Tuttle's silver probe 136 

78. Tuttle's rectal spoon 126 

79. Tuttle's dressing-forceps 127 

80. Alligator forceps for ase through proctoscope 127 

81. Wales's soft-rubber rectal bougie 128 

82. Rectal bougie & boule 129 

83. Tuttle's recUl irrigator 144 



LIST OP ILLUiiTUATIONS 



xui 



M Hypertrophic oAt AH- hft1 priM^titi^i: E|M(?imi^n shnwins increiiM in iScpth of 

tiiliiili-> Hiiil iiiiciiulxitnr ^iilmtAm't 147 

85. Attti['hie faliirrhnl prm*!)!!*; «|vi-ini''>i Hhnnin^' ;ktrii]itiy and eifoliatjon of 

qiitb<li«I i-ell» niiJ (Iwrpiwo ill iuturlulmlarsnbeUneo .... 159 

8Sa. Typical ulceiTi of flmtrbic ilywnUiry 183 

86. Linwir »ml Mi'tlni* iilcerAtioiis on Hotuton's Talvos a?t<n in n iMitiont with 

aiiMBbic dyvnlrry 168 

Traiisterie t<wttoti of InRanied folliclo 168 

GroR: ApiHiamiicu iit iiitii'nuii mviii bruriu iit rolllcular i^dUlut (Dolaiteltl mid 

rnidvii) 168 

88 A. First tkr of MiitiiTiw til vnlruUr udltjiitoiii)' (Gilraon) ISI 

88 B. Last tiifTuf suiuros ill Oibiion'g BiellKKl . .' IBS 

8B C Lou^ptudiiHl Kclioii sliuwini; n.'»ults «t i»(pl4in^ by GibnonV method . IBS 

n. Perianal tubercular ulcer aUTToiindliig external openiDg ura flAula . . 165 

90. TulwK-ultr iiloentlion ot lliu Tcelum wilh Mibmuoniix HbIuU . . W7 

91, Tmna'cn* HKtion ot tubercular uUerof the re«luni, Uiowiiip oloToleJ eea- 

Cnr ami ntidt^niiiiieil o(Lk<!!i 207 

93. T«ilwr.«lar nionr at tho i-ectum 908 

93. Tiilwn'iilur ti leu ration of tliu rectum 908 

M. Tulwrc'uliir tilcur viicircling the sigiDoid 908 

K. TuUtrciilar ntrlcturc and ukrrRtion of tbo tigiuoid 900 

06. rholomirrograph of tuberL-ulur ukiT of Uie n'cluro 810 

07. Tulici«ular ulivr with kjiucI ititnidiKNtil l)«n<Atli tliu tiiidermiuiMl edge . 210 
Rt MuitipU pcriaiiJtl cUHriiTnids .......... SSI 

9S. PliuLuniitrnit^'ph of (linngikii from the nKtum 945 

100. Impui-teH fftf'es ill cavity cf foUiouUr Dicer 981 

101. PiMun ill Olio 9D8 

10& Invgular flwure or irritable ulcer of anus 988 

108. PiMure with wnilnrl pilu tri JiyphilillactiJtd 9M 

101 Fiteare produced by rent in a crA-pt of Morgagni 9BS 

IOCS. Ferinnurtll* in ctinndi- Ii«>ure{(jn^im and Elartiiianii) .... 2BT 

106. InlrafasriniUr itdinli* ill chroiiif I!Binn'((Jur'iiii and Ilartiiianii) . 2B7 

107. Ereralini of anliTJur flwiiri-- liy flciKt-r ill lliv vugina 801 

lOft V-8ha|ieii iiiriBJoii for UMiirr nl tlic iioitirior i-niiiMitMiim of thi' anii» . . 81 1 

lOO. Inlraitiura) ur iiiibiiiu<y>ue abK'PiK of ihf rvptum 3S9 

110. J. ischio-rcctfll »bsM'w; //, mipprior jn-lvi-nxital abBCwa .... 381 

111. Bilateral lKolilo>n'oial abK-BK* iijieniiijic into rrcliiin po6teriorl]r . . 889 
119. l«ch)o-re<itiil and tvt ro-ivctul abai>es6es (>oinniuni(wting with cju'h other. 

Tli« m-tum in dissected off and drawn forward 8.13 

lis, iBchio-reclal and mbmiu-DUx nbmt^iM tutiiinuiiioikliiii; .... 884 

114. lachio-rcctnl and vtibmuoous alj«c«E8e« connected by tract through U)« 

niiuolei 1)35 

lt.1. fUlRvrenral fthB<v>K S40 

115. Blind FXiumal fl-ifiiliui 8S8 

117. Rlind inU-mul flctula*!. A. mbldiftiniitiilarT: B. subnpoueurotic . . 854 

118. Complele subaponvurotic fisinlas. showing irrcfcular tract:! .... 894 

119. Subtrffumculary (Istulait. >i, blindcsUrnal; A complBto. ... 805 

150. Eitetnal opening of snbtefninientarir fliltiU 868 

191. Sub(/^gum«nt«r5 ftflulAalmMt iinrronndlnf^ the anus 868 

1C9. Straight tnbular flHtiiU imaging dirpctly Llirougii cxtomal sphincter. 

Drawn fmm imM'tnorlcni dlMcoliim 889 

151. Tract of iiHnary fiituln whiirli timnUrod the ano-nectat variety . . . 8M 
191i OaUIne tit lurtuoua anu-revbil llstiila 870 




X17 THB ANUS, BECTUH, AKD PELVIC COLON 

PMCRa MM 

I3& TraiiHrena Mctton of tiiWrniUr flstniA (photomicro^mpfi) .... t7S 

ISd. Allinxhain's ligMLurv -currier SSQ 

127. Uj^turv panwil through llMuU U)d Mcund 381 

186. Piiliiln in whk-h tho inlonul oiienlnc (A) ialaa iltfferrat qiuulnuii from 
thai ill whiL'li tlie alwcMa caritf (5) is n^sTMt the rectal wall, and show. 
ing h«w ptrlnniing the wall ftt lli« UtClcr fwint and incLnng tiic gut 
down to the anus brll^tutvur knife will ImwaiRirt of thefathalogical 

tract utitoiicluvl 9S3 

ISO. Malbcwa's flstulotome 384 

180. ClorcrNcniiv'h 8W 

131. Brodio'g pn>lw-poiDt«) grooved dirooter J»7 

ISi, Artcr)- ftirccpfl. . ' 387 

1S3. T-*li«|)eic) hsDioatatic forcei>i 387 

IM. N'(«ill(i« for metal inirg«rj'(a«liul nxo} 888 

Wx«iIi'h iiecJle-lralder S8S 

()riHiri-il dimclor fNUWd LJimiLiih tiittilnuK Inu^t and »tiowine linw |ia«siiii; 
a biHtourr along Iha groove and cutting outwanl will divide the spliinc< 

tcr obliittii-l^ 3^ 

U?. FiRtula laid open ouUide of sphincler ao Lb&t the latter can Iw cut squarelj' 

jwiwa* 3IKI 

138. I'irst step in exciqinii of Osiula . 9&i 

)S9. 1{ciii'>vul<>r a fliliilit tlimitdi^l u|K>iia imilM* 303 

140. M^tlifl of inlnvhicing the HiitiLres aft«r oscision otfl«tala I , ■ . 8M 

141, Filial ntsp in (ilnNini: finliila ASS 

14S. Iteotal portion of liiilulit cloMxl bf flap of muoouB memUrtkUo . , . 306 

148. V-vliain-tl blind iiilpnml Mula 3D6 

144. Director patting througli internal aod oitt^irtial openings at ftslulu and 

loariny part nf tmol uiiltiiiduHl 400 

140. FifrtuLoiu trucl pawing through «stcrnal ephlnctcr 401 

148. SiibltTguini-'iitarv tl-iliiU tiivulvliig iM-'hld-ri'dal and n-tro-reclal spaces . AVi 

147. Long fliliilniiii Triu't upotiiiig n<VLr thi^ ^inTitiT triM'liiiiilar .... 40!! 

H8. Tnu'l iif litir»-9)iiit> li-tlula ti)mral«tl on ill ScpUinUir, IWl .... 400 

14SI. I)umh<lii<il n^liili> 406 

100. R«aiill8 of operatitn in preceding pa«e 406 

161. 1, Ul)lt(|uc ictvLvion of vphinctcr. wtikOi is frctjutiiUy iiillowcJ hy iucoiili- 

itence. 3. Tranitveriie incision not liliely to result in iiaiue . . . 413 
IDS. On lh« left U ulinwn I1>4> ai^pHratluii aiiii leufrtlioniing of the miiecle (1 to S), 

duo la oblique inmion. On (lie rijjiit if Mvn llic vicioui union of Lho 

lIlMtr* mill ibe liiiM of liiclhioii for repairing the niiiscle .... 414 

188. OM nii>thfHl r>f iwpairing uphinclcr 41S 

lB-1. Olmtwood'HOiierntii'ii for fmcal incontinence— first step .... 417 

IS.*). (Til i>|. wood 'h it|wmli<>ii— ^•M'oiid olep 418 

188. Uwlo-iiTL'thrjil !l«tiilii. 1. Tract running .lowiiu-nr'l ai»I lifn'kwiird. proli- 

ably nriginntiiig in iin-Lhrii. 2. Tract, ninnitii; tlownvrnrd and fDi^ard, 

jirobabl}' originating in rwlnii 436 

1S7. II«ctum, |>eriitii>(im, and urethra inoiaed to expous rve to- urethral flstiila . 484 
168. Ilccto-urctliral flttuin nnd woiiiiil tn tha rectum clowd. The inci»ion in 

the iiretbra aoterinr to the HsiIiiIa is left open 4SS 

160. Final dtep in o|)eralion for n'Ho-iirellirnl Hxtiiln 486 

180, Rirteet.Eou of the urotlirn fomTrto-iirsilind (iHiiila 487 

181. HeuUi-vcsien-vaginMl nviiiln. Tbn flstnltiiH t.Mu-l indicated by the dotted 

]I»e passed amund the <«rrli and uot through it . . . . . 440 



nncu TAOK 

lie. Iiitueiwtoiii'* opcralloii for i-ec to- vaginal ftslulfi 4ft3 

163. C'loeurp of rct'to-vn^fiiiii) li^liiln, sliuwiiig hiiichuk I1ii{> brougLt ouUciili' or 

rai'tiiiiiaiid autuu'd to the itkin 4^ 

104. LoDgiliiiliiiul mi-li'iii <>r>(rk-tiircof Ihi! mr-Iiiiii 4lVl 

185, Slrieturc of the reoHim duo ti> jiroilatic inflnmmfitioii. J. |>ert(}r«liuii of 

Uic rectum: B, cuYJly iu wliicti Iciik^ii-si'mIs were found; C, luBmuniu- 

tor; hyjierplasia; U. )<(>ritoitiruni MT 

IM. Strictiirit coin[tlica,t«d by recto-va(^nnI flitulA 474 

lAT. Stricture of the nrctiim causing prociiloiiliu 4dl 

1C8. Itoiigjviirn'iiti'inii (llvc^niiriilum HurromidiiiiT iiklrlrtuiii .... 4H9 

tW, Bodmliiuuor's I>ii1ti»n)i rfcUA h<Fiif[ii? 4i>0 

174. Credo's rfi-Eal biiiiL'io 400 

171. Sinis's rvcinl iliUlnr 499 

17«. Duilinm'o i^clnl .liktoc 500 

liA. Multi[>lo firleliin? of tticTORliiin ^. 50S 

174. TWx--Br for iiiscrl ion e( fi'tiiiile se^etlt of Murptiy biiltuii In Bacoii'^ 

■>)iftrati(>n (or stritturo «( llip nxrhiin TdO 

170. liatttral *'nt«n>-ai»ft*loiiif)sis liliiMXi), ^. mesoroctiim 511 

176. CIftnii> iiitrulii'Ut.il Uiriiu){li Hliu-Iuru ami nrtiLiloriiutlo oiutiing in unlcr lu 

witlon tiio i-ulilii>r ..f lli<i gut in l{jt{.'»ii'» ojH'mticiii ..... S13 
17?. DittKramnimid illiii'tnitioii of Kcut« (loxiire bctwuen tht- Mijpiiniil Ahd nv 

turn S23 

178. .Mkllonnttlioii vt tliu si|;niot<l flMiire , 598 

170. Acute flcxine of tlic sigmoid on 1 1)0 n-rtuin 537 

IHO. Adhesion of sj^f iioltl to tlio routuin. oaiulu); nL-utc flcxuro iil thoir jimi'tinn 539 
ISI. InHKraaiatory ikilhm-.>n of Itic npiiumlix. triiitliug llii.' »i||[inot<J to tlic ftiite- 

rloFBurfnte ot Dlk wi-c-uiu itri<l iiriviiiiiiiK in HNfiiji nut of tlii; |wWio 

tj 839 

[ akctrixlD aa 

188. Twins n-»i*ljinc(! of mlvo mfitli Mnrtiri Iloiik {npininctpr) . . . . ftS8 

IM. Fixation nn.l jn^Mun of raivd fitter Mnrtin'i method (Iloinm«t«r} . . 450 

lf5, Miiitin'n krlivl^ti MO 

IM. IVinnincLan c'lii> for eutiint; rcwtal rnlvo ntid tho Inatmorant for Apply* 

Ingit 5S0 

187. Pennington clip ai'i'lii-tl * 5ftl 

188. flant** «-IIp fur <?iitlln{{ nK^tnl viilvn 561 

Ract«l v*lra Afl<r iiu-iaioii l>y MhtHii's tiiothotl (Hu[uiiit.'t«r) , . , {MfV 

Rc<:lal ralve nfti^r iijH^nilioii liy Priiuiiig((inNE.[ip ..... 5S8 

IIH. K^lwy's tvcUl dcoop SA5 

IIK. PnirituH nni $70 

IIM. Pmliififnl rntcrriFit tufniorrhoid with condyloma attiv-li^l ■ . . ■ flOB 

IM. Mixiil lia-miJirhoid All 

Its. lUrd-nibbor pilc-jtipo SIO 

IM. Mallirw*') roclxl dirulsar (IIU 

1»7. tiant's srringe for injcdin/r hD>inorrboi(U 638 

IDK Tnii»fixion wkI li^ntiirr of tiirniorrhnid ..,,... MS 

IW. legation of hiBiiiorrliftId (ifirr ADiriBliBio's method COS 

900. SuticutaTi^nii* 1iplt>l^l^ I'f a hifiiinrrlioid 9M 

SOI. TutUe't lin-morr1i<.iilnl f«rc<e|i»i 038 

90S. Itln w)n-d with liii-mnrrhoidnl r'ir«i>|K OSA 

90S, MAthrat .if npplyiiij; thp rlnmp ufl*T Ihc 1i&-i)iorrhuM is dr«|n^ down . WW 

tWH. Gsiil'a iMrmorrlioidnt rUniji 040 




m 



THE ANCS. HKCrCM, AND PJSLVIC COLON 



ruiriui ruja 

305. IlKtnorrhnitlAl oln-mp $4U 

Mft. Moilfllri] Faqutliii CAiitcT)' (Kennedy's) 641 

907. Groove cul iiit-n niiivn-cuiniii'niiK tisKUf into which the cliUiip fits . . tVi 

2081 Stump vf excUi'd litt-iuLTrbui'l bH<l by cituup 043 

80ft. Allinghain's lin-niorrboiil cruslior Mfl 

210. AUin/^liam'j furoops for use in cnuhidf* opeiHtion 647 

211. Smith's hiGiuorrhoid criulier 647 

212. Pfr»l iilBp in modiflo'l WhitchBad openiCion forhwcnorrhoiiia . . . 630 
SIS. Knonitil tti'fi in innilifltMl Wliil^livwl c>|Jc-rnlion 631 

514. ThirJ aUiJ iti iiiiHltBvd Wliilclieail operation 6.^2 

315. Mo<lifiMl Whiti'limii! opfniliori com [ilyleil 833 

211 Kar)e'<i lorc^rH 6S5 

217. Burlc'a operation CS& 

218. Liultod exdclon of lismorrhaidi CIO 

515. KxstKiphy <tl miiomi* nx^inbruno follovln; tuahj Whitchcju) operation 657 

220. SirsuKi'tiilo'l Ill-Ill urrliotila CRS 

221. IncomiilHt' |>r<>tu|i«o of chi> n'cfum €08 

22!. Ooiii|ilelt? [Twiileiitiu rwti — lii>t decrre 672 

228. Complete proctilciil in n-cli — sfcunil ilr)OW> 672 

224. Complete prociderilin recii— tbirJ lU-jjnf (178 

223. Complete pnilapM of the rectum, showiog circular iLmii^ment of tbc ngn.: 674 

236. RvciAllii^miA urarcliui.'ek' fti6 

22". IJelormp'i" nix'tftiiin ff>r prnri<lptiiiB recti 688 

929, Pclonne'a operaliuii cuinplctc<l, almwintr reduplication «f rcct«l wall . , QtiS 

339. InroldiDgof the gut ill PeterB'5oiH>rallu[i for priK-iilenl-iH nvti . . . 090 

23U. .tttiwhmotit of tha Rtit t« tho abdominal wall ill Peters'a opemiion . . BOO 

281. Ret'Cifpesj fur priwldentia ruott— ilie juciifon 6fil 

332. Kfctitpnxy — thi< pit riivorlfi) Htid hroii^ilit Chrmigli tlis iiu;i»ion; the EU- 

tiin>!i pu^^i) lliroii};1i ilM rmiaciilur wiills 699 

MS. Rt.'i;topcKr^tlie siitutr^ out lliroii^h (he tiasuee on okcIi milo of iho sacrani flS3 

S34. Beotopexj'— the opora-tion completed nfl4 

S3<>. ttr^t^lAt hcriiJA protniiling through (be anus 70S 

2M. Ructal hernia, fiarue case u Fig. 2S0, protruding through T&^ina . . 707 

S3T. Mjxiiinii.rcclJiI [mtvp 718 

288. Lodinitki'd ivulul snun , 7IS 

290. Pihroids of the »nus and rectum. Drann from p]icita[,'nip1i taken Iwfore 

opcTatioii, 1*94. KiiK^ dlstitiet tnniors were removed .... 716 

S4fl. Myxoma <Slcnpil) 722 

241. Multiple siluiioinata of lh« r«'luin 728 

242, lty|u-rl.riiphi(' f'llilniljlie nf rertnm and eolon (Lflii^nthiirf com) . . . 729 

248, Iiyinpho-i^lcnniiia . rat 

844. Papillnitia with cjlindncatcpilhetlomaCQiiiSiiii and Hartniann) . . . 7»!l 

249. SehematJc illustmllon of r<«tAl pnpillomft 740 

946, 1^lpiII^tma of rectum 741 

247. VilloiMpoSypotthe ri«liira(BalH 74* 

247 A. ('ongenilal postanal Hfeiiiv. 247 B. Coiip^nilat iiortnnal dinnple. <Mar- 

kue and Ruhli-t. Am. Jour, of Med. Sci.. May. 1802) . . . . 7S2 

S48. Mypeni^iliied nnal papilla* TfiO 

942. Epiilielioina 707 

800. Adenoid eanrer 768 

351. Medullary eanoer TOO 

S9S. Soirrbiiaof iolMtiae 770 



LIST OP ILLUSTRATIONS 



XVIl 



vioi'u naw 

S3S. CnlluicI onnoerof liirgo inlHlJne 771 

Hi, Itoulal tipvciiufU toKKf>» Tut 

MSi Modullitrjr inreint)in»o( itifl nratum 77S 

SM. SuisBore »in|)laypi] for oblafnin); ipeoimeiia at rectiiL f^wihH , 781 

237. LaU-rul ciitciv-niiBBtniiiiiaiit 7$7 

S88, Bi]lrn>-uia«totiii<»i> with coinjilptc olitni nation of the [»ckJ mmnL tropi 

the (Ijiieubd ari-'ii 798 

35)1. AnMtuiRLwir of the ikuni witli the raclLim Tor carcinoma of the aiicmoiil 

and ilenm TVS 

SfiO. [Cuuiiil- BTiil »p]mll'i-cclli!il Mircnnm MS 

86t. MeLuiolicAlviLigUr Mrx'iiuu MM 

S62. Line of liuUiLin in |K<riiirnl iirtivtnctoiny liy Allinglitim's mi^od . Hlfl 

S68 Sfcontl ttt^p in AlHiighHrnV iriethoil (Mathevi) .... BI9 

904. PitrineBl utir[Mtinn uf f.hr n-iiiun (Qiifiiu's meLhod) Hit 

963. P»ritie«l pitirpalion— Ifxiseniiig TwLani frora anterior |)»rliicnl rhApho . 817 

966, Perlnwvl fxtirpuiiun 818 

367. tWincftI rxtirpuliou — lh« peritoneal pouch Uld opru 819 

968. Perineal uxilr|iN)ic>it 8S0 

969. Peritiosl oxiirpAtinti cotiiplotcd 8St 

970. KroAhr'a 823 

S7I. Iloolwnnggi'a fISS 

S73. B&rd»nheu«r'8 8£S 

£73. Row's 828 

3«. Von n«ineoke"8 823 

973. \jtyj'» iSi 

97fl. Rjrdygicr's 833 

977. lli!tgar"« 893 

818. Kxtirjialion of the rectum by the H&cml roule— Urat stvn in the boiic-fl»t> 

n[NiriiLici[i ...... . ... 894 

STSi Sarrum rvniiived to MpoH reotuin anO nih«r pelvic orgsnn (iMilly 

KlicmaLk) 835 

ISO. Hecotid «to|) Ipi bone-Hap operation 896 

SBt. Third »t«-p in bone-flnp-^f^mlinn 837 

9B&. Fourth Mfp ill tiotii'-flop »|H^i-»ti<in 898 

SSR. Flfchati!|t In bai)e.fla|rniwntiioii. The frtiwth lia« bran receded and thi> 

ends uf tlir iiiUMinc lllt^<' Ih-hii Kiitiirvil to|;cther 839 

284. Sacral jinii^ mink' In l>on<-t!Q|i niitiriilinn when it whs imposN'lilc lo estab- 
lish (bpnrliiri' in liDriniil jin^llinn 880 

9fVL Finnl Mvp in lioiii'-Rivp ogwration 881 

980. Racial carcinomn inralvinft Tiiirinni wnll 699 

9R7. Incitinn in vajiinal extirpation (Miirfhy) 883 

868. Sepaniion of roL-iiini fmm rarinn) trulls (Mnrphy) 934 

98ft. Rivltiin laid fl|H'n and cul ai!ruM tM.*l()«r Fionpltuni (Miiriihj) 835 

90(1. ni^M-tinn nt inroIvoH mwa in vnffinitl <>itirpalion of the Pectnm (Murfihy) . Ifil6 

Sni. Itftttnral Ion »f k*iI I» •ak''>oI <'xLlrptttit>ii uf the rectum (Uurpb)-> , . 8S7 
9U. t1o«an of peril ini'ii in ami vaginal wound after va^nal extirpation nf the 

rsctiiin (Miiq>hy) 888 

SM, Cn1om-t»stnni.v {Krlly) m invncinatinn of cnlon thronirh a slit in llin 

Ulterior wnll of tho rcolitm . 889 

?M. Hrthod of widr tiiniC the cmIih»T of the gnt nfl^r folorrpUmlomy . . WO 
Sfl3. Reauh o( colorricl ostomy for (carcinoma la aeen tJirough proctascope tire 

yean after opentlion 841 



xviii 



THE ANUS. RBCTUM, AND PKI.VIC OOI-OX 



n 
* 



I 



SM. Alxloinino-Mutl oitirpalion of high reotal cancer— enuvlnti iuii nt ilimitMd 

portion tlirough sbduiulnal ruulu 848 

2»T. AtKt^mlliO-snAl cxlirpHti«ii, SigcuoiU ■» bruiiclit iliiirn throiiKh rverlnl 

rectum ant] wlurvil afiiir mntlitMl of W«ir 844 

298. Fltwl «»|w ill iiliiliiiiiiiKbttnal fxtirpt.ti«n. Peritoneal tiavitj cloicil, inlec- 

titml tnu'l rwlotwl, itnd drniuftj[c-tubi' fixfJ in rrtro-rcrtal (pare . . &tG 

299. Ri|)(u>iiro of livniriTrhoiiinl uid signioiOul Biit>ri' In utiiliiiiilnal exUrjDit.ioti 

of thi> rectum 94lti 

8O0. Linoof inci»iQn in lumb&r colMtociiy S84 

SOI. Lumbar culotUfiii)- SM 

S03. I.umbiinolnstoiny nomplotM 69k 

S03. Iiicimon in iiiK»iniil txiliwluiuv 8i0 

80-t. Ini^uinji] fiolinttuiny 811 

30.V Ingiiihfti col(Mti>m]r, Cripija'a ni«tb(xl 8JS 

SW. liiKiiinjU ucilost»iii7, Crippa's niirtliCKl. FltJftl sulunti in pltu-c . . . HTl 

SOT- CroKs-sectickti iifter culoetomy bj AlUiighain** mcltiocl H74 

308. frosa-isetiftn aflur eolostoiny by Kcl» y'j" mclhiMl .,.,.. Srt 

S(t&. Inguinal colostomy. BodJiM>'ii nictliut] HTS 

310. Eiitorutiiriiy after uoluKloriiir by II<Hlini''K iiii<11iin1 8?t 

Sn. InfTuiiml coloatoiiiy {MhUiowh')) iiK-tliLHl) 679 

313. Crus'i-'M-L'liiiii Hfli-r rnlnstoiiiy by Mayill>RiTlii« niHliiRl .... 877 

318. 'IVnipomrj* jngiiitial t'olonlomy 877 

814 reiiipumry iiiguiiiul coliMtotiiy. Otit »i]pp»rtr<l on roU and sntuiiM in 

IHoritioii 87S 

818, Incision Tor ufwniiig the gut In lempornry fiiptilnal CAlrvtlomy . . . 878 

316. niitiuytri:'ti'> cntemloinci 8Tti 

817. Wlatoii"» InLeHttnul diiin|> 871* 

818. CcilliTiK'i Iniig L-litinp for<,*r>ju> 87D 

810. .Murpby buttnii t)|H!ii 880 

Siilti. Murpliy bnCtuii rliHril 880 

830. .Sonii'd (lM?Ji1ciifi»i boiie-pUte 880 

SSI. Iiit|ilAii'r\ f()n'i7|i.i for iiilenlinal reacclion >•■.•■. 880 

Vi^. O'lUrti's cimiiii* 881 

823. Isolation of JiwfWtfd porlion of gut by U'llara'* nicll»»l . . . .881 

Si!4. ])l»caaeil poiiton DXciMitl aod hI^gs of pcritoniiHim liniiif;lit tngctlicr 

(D'HaiBl 881 

S25, SuHiTtT* inlmiluretl otht fnrcrpii (O'llani) KMS 

826. SiiUi.tr--' tbril mill forvL'lJh rt-jwly t(j bi? williilrawii lO'llui;») . . . . 8!*8 

;!127. Iliil w^ixisl r»r fiilvniL viiti'r»-Hiiiuit>jmimia. by ll'IIikrji'ii iiii-[tii)J . . . fKi 

828. liali^riiL etitori>Jiiiii!'li>in(H'w (■foi^inl «l*|i ill O'Hitra's m^llK-J) . . *W 

1)29. Lnlt^nU rciioni-aiiAstoniimU I'oiiipli-liil iC'lliira's inHhutl) .... 884 

330. Closure of nrltllciiil Hnus by plastic RiPllia*! 880 

ilill. L'litsurcof artilluinlaiiuf by pl&»Li« mctlivil conipluli^d . .... BS& 

832. fn«i»-iccLloii after extra-ierllmieal clwure of itrtiflciui anua . . . 9»fi 

833. Liptliire thrown nrouiid proximnl loop uf gut ill culcutomy In nnlcr l» 

Mvurtt fwoni (.vutn>l , . , . . 867 

334. WilMl's niethmi of cobwtomy 888 

333. A&iluy's m«rh<Hl ot pernifHienl t^fllostoni}' ^Ml 

HIJC. Urnuii's mothntl uf pcnniincnt c-oliiBluiny (ttryunl) SIH) 

:)37. Wi-ir'« niethmlflf permanent coliislomy(llryiiht) WO 

.'[■"W. IVrraiincnt colMKimy <author*i* mothixl) 881 

3!% Permftnent cwlovtomy <^«mplpt«d by aiilhor's mctliwl . «. ■ ■ . 809 



LIST OF COLORED PLATES 



TACItia 
PAQt 

PLATE I.— IsFLAMMATORY Diseases 140 

1. Normal Mucous MciiibrBiie, 

3. Aciile f'litBrrhnl I'n>clitip. 

:i. Airofihii: Cntiirrhiil Proctilia. 

4. Ilyperlropliie Catarrhal Proctitis. 

5. FolliiiilHr Proctitis. 

6. Ulceriilive Proctitis. 

PIjATE ir.— Anal TriiKR. ilosis 199 

1. TnlHTciilar Uk-eriition with Fislula, 

3. Iiupoiil Uli'cr. 

3. Superficial Tuberoulur Ulceration. 

PLATR III — SvpiiTLiTic AKKErTKiNs of the Rkctum 252 

1. Mucous Patch on Ilmisloii's F<il<l, 

2. .Syphilitic Stricture (seen through proctoscope). 

3. Hereditary Syphilitic Fissure 

PLATF IV. — n.«jioRRiioins 594 

1. Tlironilmtic nn?raorrhoi(is. 

2. Irillaincil Iln'morrhoiils with Erosion. 

:i, Intfmal Hn'inorrhoids with (Ericma of Anal Margin. 

4. Prolapsing Internal Hapmorrhoids. 

PLATPj v.— C'oNiiVLiiMA, Fibroid, and Papilloxa 738 

1. Cnniiylomflia Ijata. 

3. Fihroid Polypus. 
H. Papilloma. 

PIj.\TE VI.— Malignant Neoplasms 802 

1. Melario-sarcoma. 

2. Epithelioma of Anus and Vulva. 

PLATE VI!.— Proctoscopic Appearance and Specimen of Medullart Car- 
cinoma 804 

PLATE VIIL— Maliuxant Neoplasms 806 

1. Ulcerative Medullary Carcinoma, 

3. Epithelioma of Sigmoid. 

3. Epithelioma of Sigmoid (proctoscopic). 

4. Epithelioma with Ulceration (proctoscopic). 



DISEASES OF THE 
ANUS, RECTUM, AND PELVIC COLON 



CHAPTER I 
EMBRYOLOQY. AA'ATOMY. AXli PTTTSIOhOOV 

Foil the imrpoHcs of our diecussioa tUw lollawing anatomical divi- 
Bion« will be observed: 

Th« anus is that jinrtion of the intwtinal tract wliicU extends from 
the margin of the true akiu to the fret; bordcnt of the ccmiluimr valves 
of KurgH^nt. 

Thi- rvxtum is that portion of the intestinal tract which extends from 
tbc free boTdcfii of the semilunar valves to u point about o{){>uBito the 
thinl Nscral virt^lim, wlu^re tho gut becomes entirely surrounded by 
peritnufpum find the loww ("iid of the mesentery is attarhed. 

Tin- f)tlvit colon or signwid firrurr h that portion of the intestinal 
trart which extenda from the (hiH sacral vcrtehra to the lower end of 
Ific difvcniliog colon at the external bonlL-r of llic left p9oaa miisicle. 

This division differs from thut urdinari];v gircn in works on anatomy 
and tfxl-boolie on rlisoasca of the reftiini, hut it ^ivc? definite limits to 
alt three purtionii, and confines the term rectum to the immnbilc por^ 
tioQ of the cnnni comprised between the points where the mCH^nlcry 

|se« filirive and Iht* mucotts mpmhrniie cpHse-; Iiplnw. 

Embrjolo^. — The i^ignioid mid rertuni, like the upper portion of 
the nlimentan,- cnna!. nro dereloped from the ht'prthlast and mc^oblaat 
of the o'i'nm; the anus is developed from the epihlast. In (he develop- 
ment of the embryo, after the formulion of the neural canal and tho 
foldinjc in of tho three layer* of the blastoderm, which forms the head 
and prodncng a cavity known ap the " forejut." there appears a pro- 
tnuion at the posterior blind end oT the enteric groove, creating, tha 
KM^IIed "hlndpot," or rudimentary recitim. 

Soon aft«^r the fonnation of the neural otnal, the me«ohlast is 
divided by r-learagc into two layvrv, one of wtiich follows the hypoblast 




THK AJIUy, RECTtM, AND PELVIC COLON 



d' 



^P 



nnd the oihcr the cpiblast, umi \\iv s|)iUi; Ik-im-ccd tlu-m gradually en- 
larges to form the ca'lum or plcuro-peritoiicjil cavity. 

From the liypoblat^t the niiicou^ iticnibrnDe, Hnii probably the eub- 
muoouK tissue develop, while ihe inner layur of the itiot^obla^t forms the 
miifieuUr, |>t?riton(^iil, and glandiikr portioQg of the gul (Schiiller). 

To the sixth week of gestation the ldr;;e and small inte»tine»( are 
one ctttity, and nf nearly an uniform t-aliWr. with llu; exL-L-pliou of the 

lower portion of the hiiids"'- ^>*liit;h 
even at this early period is more C4- 
pncioiis than nny other portion of 
the intestiDfll trael except the 6tom- 
ooh. About the sixth week the 
veniiifonn a|>jjeiu1I.\ U developed ; 
from Ibis time the euloii, sigmoid, 
and rectum grow more rapidly in 
circumference than the " foregut," 
or small intestine, and, extending 
downu-ftrdj more and mopo nearly 
apjjrofteli llie OMter layer of the 
menoblarit and the epibla^t at the 
lower portion of the embryo 
(FiK. 1). 

Tin; blind end of tlic hindgiit, 
in elosc appoj^itioQ with the lower 
end of ihe rtpinfll eoluinn arnl orig- 
inally eonneeted wilii tlie neurt'iili'r- 
ie c-anal, forms what has been ealled 
l!ie chiaeu, in iJiat it receives at tliia 
period ihroti^h Ike allunl^*i^ the se- 
ereiiuiia of the urinary and genital 
or(;aiis a^ well as thoec of the in- 
testinal canal. 

About the eighth week of jcesta- 
tion Ihe etoaea is divided, how- we 
do not elearly miderf^luiul, iirtu two 
parts: the anterior fomis the uro-geuilal organs and the posterior the 
entemn or nnUnientary reelum. iTiijH-rl'iTiioii in thi* division causes 
uiauy uf the ahnarmalitiefi of Ihe rertmii. 

The urinary and generntivo organs develop from the inner layer of 
tho.mcsoblnst, some of the cells from which differentiate into a cord 
in nliieh a linnen is formed, the so-ealli'd Wolflmn duet, which haa its 
posterior opening in the eloara or hindfrut, and thue eonneets the two 
By«teni9. In normal development this duet closeii, and the connection 



[W 



i 



J 



Tractt (Schatferi. 

a, nutitL'lt'irJ ; ft. liypojiIiyaU; r. WIimIucI; d. 
tongiia; f, ptrnmnent kidnap'; /, irlcw-'ii; 
g, uiiis: h, ■(■xiiul pronilnoiim : i, tail; J, 
cmcnin «ali : Ir. tndtta ; I, lurynx ; «, paiv- 
emm; n, wc^lnn of ninnJibuluT iiri'li; o, 
commcuainfi lun<; p, ttoiaoeli. 



EMBRYOLOGY, ANAT'OMY. AXD PaVSlOLOGT 



« 



between tlie urinary and alimcnUiry tracts becomes obliterated abont 
the twelftli week of gestation, it will be noted later that this <rominii- 
nicatiou sometimes periii-ts and forms one oE the tvpes of malfonna- 
tioaa of the rectum. With suoh intimate relationship in development, 
one is not ituq)ri3e(l to find theee or- 
gnnit closply related in dymptoitiatology 
and diiit>a»>. 

IHiring^ the development of the rec- 
tum from the liy|Mjbla<>t and mpsohlaat 
there is goin^ on an inva^nation of 
the cpibtoitt or i-ctoderm. which ia 
called the proctodrcum (Fig. 2). This 
invaginAiion increaiM'e until the outer 
and inner layers of the mesoblast are 
pressed together and ab^orbt-d, and the 
epiblarit of ilie proelodafum and the 
hyiwhlaal of the hindgiit approach 
each othiT. and form a duuble sieptum 
bslwccn the rL'climi and the proeto- 
danm or embn'onio nniu. Testnt and 
Waldeyer state thai the layrs of the 
mesoblost an.* not present at this 
point: that the hindgut or euteron and 
proftodi'um are 8f|>araled by two 
epithelial layers, tlie one belonging to 
the hypoblast, the olht-r to the epi- 
blart. The existence of fibrous tissue 
in this ftffpium, in cases in which the 
Latter has not been absorbed, would 
indit-ate thai the ab^noe of the mo*o- 
bl&«t at ihis point is nul at all uni- 
form. The absorption oF the iM-ptuni 
render* tIiL> eonjnuition of Itit- rectum 
and anu« complete, and leaves a Qar- 
ron* lonc that indicates thi- transition 
from mtieovu to mnco-eulnneoue tis- 
sue, whieh hag been termed by Stroud 
the "pecten" (Fig. S). This zone 
marks the lower limits of the rectum and the upper margin of the anus. 

The conjunction lakes place gcneralh at a point slightly in front 
of tl>e poeterior end of tlie put, and thus leaves a cul-de-sac which, as 
has been eaid, is comicctcd with the neureoteric eanal. Thie cul-de- 



tae and connecting canal are largely nbi-orbed during foetal life, leaving 



VK: 



>)^' 



f 



Ui 



"X 



Ftw, 3.— DevBiflrMBjfT ur BBk-ri-n 

a, noctioii of mundihutkr trch : ft. Iini- 
vyXiftXt, L>«hli]il !l ills r«tuidnii q( tlio 
pliai}'llV^' Mcliliiiii; e. coiuincliulllg 
Iudk; d. iiiimucti; c. U«er; /, yutk 
■talk: tt. WuliHan liuvi; h. Uloil por 
lltiu bf liiiulaui. 




THE ANUS, BECTUM. AND PELVIC COLON 



tWVA- 



I 



n 



the coccYgcftl glsnd or gland of Lu^clika, wliJch is eituated just in frost 
of the coccyx and mRiHJn.'t in adult life. Sometimes tinperfc<!t absnrp' 
tion leaves n eongenitnl [Hi-^terior rectoTOle. It is from the remnins of 
this posterior ev(-4ie'Sac and coitiinimioiiting canal that dermoid cjnts 
and other loratoicl tumors of the recto-coccygeal space develop. 

It will be 8Ci?n from this brii'f niid inpomplelp nccnunt of histo- 
genesis that the rectum proper is a ilL'velopiiient of the hypoblast and 
mc-f^oblaet in common with the rest of the coIod; that iU uiusclvA and 

submucous layer are from the inner layer 
of the raessoblost, and that it lo^caHy and 
practienlly ends with the scrratod margin 
of the pecten or free borders of the semi- 
lunar valves. It i^ al^ apparent that the 
anus, with all its surrounding muscles, 
cells, and fascia-, is a development of the 
cpiblasl and outer layt-r of the mesoblast, 
and histolofflcally inclndcs all that por* 
tion of the intestinal tract below the upper 
margin of the pecten. 

As will be gcen farther on, the mem- 
braiies. the glands, the blood and nerve 
supply all undergo a more or less abruiit 
chnn^ at this point, and the diseases 
which M'c encounter in the two portions 
are almost as distinct. It is necessary, 
therefore, to understand exactly the lim- 
itaiioDB of the auiis, rectum, and sigmoid, 
and also to deBcribe them iseparaltily. 
They are diacussed consecutively from belon- upward, because this m the 
order in which they ai-e met in examination ami treatment. 

The bony outlet of the ijcItis eompriMcs a somewhat dtamond-shape 
spaoo, which bd imaginary line extending from the anterior border of 
ono tuberosity of the ischium to the other divides into two triangular 
tpBC««. The anterior one is known as the uro-penital trianglL-. and the 
posterior as the rectal triangle (Fig. 4). For convenience of descrip- 
tion these triangles are fiirtlu-r divided by a line dniwn from Hip sym- 
physis pubis to the tip of the coccyx into the right and left anterior 
and pofitcrior quadrants. 

The uro-g<'uital triangle is in c!o*o relation with the anus and 
rectum, and conlain)i important genitn-urimiry nrgims. The recta! 
triangle contains the anus, tectum, and surrounding tisKuen. The 
anatomy of the parts included in these two spiici^s must be thoroughly 
understood in order to practise n-elal surgery Kueccssfully. 



Pio. a.— PtviRinvi Of Aval 
t'AHAt (Strouil). 
a, rkto; b, lUtwu^ wLiit line; o, 
pn4ou : d. utol pHpnU : «, atial 
pockcEi /. ftlllad mucoMi ; 9. tiuiu 
dinilaU; fc. reoUl (Inod*. 



EMBRYOLOOV, ANATOMY, AND PnTSlOLOOT 



The PeriBKum. — The pffriiKtum ie th« space comprised in tbe upo- 
genital Inanglc. It is boundM b; tbe anus behind, the scrotum in 
front, and the rami of the iscliii upon the sides, and is occupied by vari- 
ous iinijorlani structiirc-s. SuperCnally it in covered by the Kkin, iv 
the central tine of 
which there runs a 
rbtphe continuuiis 
with the eentml 
rhaphe of the «cro- 
tum, and endiTi;;; at 
the max^n of the 
anus. Tlierc ie iiotli- 
ing peculiar in tiits 
cutaneous layer, ex- 
cept that in the cen- 
tral rhiiphe thci-c are 
few j;lftndular constit- 
uents and vei^' few 
hair follicli'ii. Im- 
mediately beneath tbe 
xkin itf found th« »u- 



/ 



Fio. 4. — DiviOTftxi ar Yim Pi.-t.nir Optlkw. 
B.A.. right auHiririr quwlmnt: I,.A,. I«fl wnietiiit auulmiit ; 
S.P., rfBlit p«il*rlr.ri|iiii<!rnnl; J,./*.l*fl |)oiii«rlriri|iiBilr«ut: 
R.A. ami f^A-vtv-xvuiud trfnuitU'; R.F. onii L.F., itaiel 



perficia] fascia uf the perinaeum, vhich ie continuous with the superficial 
fascia all over the body. It is not attached to th<> biincfi or muscles, but 
coalef*e<^ with the deep fascia, u( tin- nt ilui -, Ih-ih miIi ihiM is (omid the 
«up4>rliotal perinpjil foiicia, caJleii ai,-i^ l ^'lli'^ '^ I'a-i i.l. \»]iieli ia conlinu- 
OU9 with the dartoK of the scrotum in frunt, attached on each side to the 
rami of the piibeti and ischii, and Mretchrd across the potstcrior bonier of 
the perineal epace in a line slightly anterior to the tuber ischit. In front 
of the anna this fascia dipa down around the posterior border of th« 
tninBvereuB perinipi muscles, to be attached to tlu' free border of the 
triangular ligament (deep perineal fa-teia). The latter structure is a 
dense, fibrou* memhmne etretched aeroBs the anterior portion of the 
pelvie floor. It h divided by anatmnistt. into nuperficial and deep layers. 
Anteriorly it arises from the superior pubic ligament, i« attaehed later- 
illy to tlie rami of the pubes and inchii s little deeper than the cms 
peni». Poslerioily it in stretched acrcifi* the perineal fpnce, just above 
the tnini>Tcr»UB perinwi niHi^cles, and is continuous with the posterior 
border of the superficial fai^cift ; while its attaehnient anteriorly in above 
that of the HHperiieiiil fRHcifl, their posterior bonlers are conjoined, and 
tbe two thus enclose a wi^lge-shaped space anterior to the anuH. In 
this spacD are situated the aixvlerotor urinic, Iran^versus perinei, and 
the erector jH'nifi niuijclcfl. the (urpus spongioBum, the iH;rineal arteries 
and oervee, and the bulbous urethra cODtaining Cowpcr'e glanda. Tliia 





e 



TUB ANL'S. KKfTUai. ASD I'EL\nC COLOS 



Wfldgo-8ha|)ed space is divided imo two triangular ^mw^ hy ibt' allach- 
ment of the two walls in the whIlt to the rhaphe of the [wrirn-'ul body 
and the accelerator urin* muscle (Fig. 5). Tliefie spaci's coiiimuui- 
cate anteriorly through n Lrai;t of trllular tisane at thr jimctign 
of tlie scroluni and the ptTina-um. Tht-y are filled with ceUalar 
tieaut', in wliich the blood-vessela and norvcs of the jfenerative organs 
ramify. 

The trnnivcrsus pcrina!! muscle crones the posterior border of the 
pcrina-uiu from one tuberosity of Ihe iscliiuiii lu tbu otlier; the accel- 



y\;' 



Flo. ■' IJi»-ii'Tii.!« ■iinvivii MmwnuB AniiitvastmBT at pKr.vin OrTLrr, Pekixkal 

emtor urJDSB niu^elc runs through the center of th« i^pace, being covered 
b}' the sii|K'rlli?iaI fnsriH, and these, together with (he extornal sphincter 
ami the pphircter vagin* in wonipn, iinite in a eonnimii fibrou* eenter 
called the perineal body, just in front of the ami*. The deep and super- 
fii'ial faseite tbii!* enclose important organ* coimecttil with the uro- 
geniliit tract, and form a barrier between thinn and tliL' rectum. 

Isohio-rectail Fossb. — Back of tlicac perineal spaces, and separated 
from Ihein liy (lie w^'ilpe-^haped border of the perineal fasciie and the 
tmiiiversua pprina'i nuiseles, are situated Ihe iseliio- rectal spaces whicOi 
praeticftlly snrround the lateral and posterior portion* of the anus and 
rectnm. They measure from before backward 5 to 8 centimeters (2 to 3i 



EMBKYOLUOV, ANATOSIY, AND PHYSIOLOGY 



» 



inche?). from 9id« tn side 3^ to 3^ ccntimctorfi (1 to 1^ inch), and in 
d<>pth fnini 4 to 10 ei'iilimelers (1^^ id 3^1 Iiu^lies), aecordiug lo the 
size of th»? siihjeet (Fig. 5). 

Eadi fnssa forms nn irrt'f^ular. wedgp-sbaped or ciiiieiform space. 
il8 l>aw being directed diwiiwiirii. Each space is eiiL-Iosed by the pL-ri- 
neal fascia? and (lie Irausvi'raiii? pi-riiia>i tiuii^clc in front, tlie k-vator 
ani mugclo above, the obtiirntor fasciae, the obturator intemis imisck, llie 
ischium find the sacro-iHchiatic lignnients oxtornnlly, the rectum nnd 
the iiniiH interna lly, tlin glutL'Uii ninximu.'i niuRele, the SAcrn-J^rintic 
ligaments and the oneeyx posteriorly, nnd the skin and siiporfioini fas- 
cia bclov. The fofj^ie are cnnnected pnwteriorly by a zone of cellu- 
lar tUsue between the filjer? of the levator ani muscle and the ano- 
coccygeal ligament. Tlieee spaces are filled by fat and cellular tissue, 
iu wliicli ramify the btood- vessels and nerves of the lower eud uC tlio 
rectum and the perineal branch of the fourth sacral norvc. The fat 
in tlH'»e upaei's is Riippnrted by a network of eoiineclivc-tiwue bands 
which divides I hem into numerous com|)artment8 that coniiiiuniealo 
irith each other through the lymphatics and thu blood-veesels. It U 
owing to these divisions that one often finds in openiting upon ab- 
B0C3SC* hero that he bus to dL-iil wUb muliiplc cavities iosteud of one largo 
eicnratiou. The deciK*st portion of the sjmccs lies close to the rectum. 
This explains the fact that in large abHcesj«« in this region the higluHt 
point is always nearest the rectal wall. Although these fossa; arc 
crciMed by mimerou* blood -vessels and nerves, none of them ie vitally 
important Mirgically, fur the entire cellular tissue may be dpstruyed 
without any perimis dnniage to llii; nerve or blood i^upply of tlio adja- 
cent organs. 

Above the levator ani muscle are situated llic superior jH'lvi-rcdal 
anil retro-rectal :rpace.-. but thew can be U-tter utiderstood uft«-r (he iiniis 
and rectum have l>eeii de>erilx>d. 

The Anns or Anal Canal. — The nnu* is nenally desoribod bs^ a simple 
oriRiv at the lower iMid iif the iiitei-tinal tract, but practically it embraces 
all that portion of the tract lielow the true nmcou$ membrane. It is 
situated in the middle of the |»elvic outlet just back of the imaginary 
line drawn between the tuberosities. In women it is sliglitly farther 
forwanl than In men, the distance from the coccyx measuring in the 
former 35 to 30 millim^Jters (1 to \-^ inches), and in the latter 20 to ?5 
millimi'tcrs (^ to I inch). In n condition of repose it appears oe an 
antoro-posterior clit fKig. fi>. The eltin around it is slightly pigmented 
anil drawn into folds by ihe contraction of the sphincter muscle. Em- 
beildnl in this *ikin, chiefly posteriorly, aif sudoriparous glands callei! 
circnmnnal glands, Kome aebaceone glands, and a few hair follicles, from 
which ie8nc6 a nhort stumpy growth of liair. All of these decreAse as 




8 



THE ANUS, RKCTrM. AND PELVIC COLON 



^ 



the central portion of th^e anus is approacheii, an(J rliaappour altogellier 
wheru the skin cliaugca into iiiuco-ciitaneous tisane. 

Behind the unus iherL- is a suiuotli. dvafi: ridsu of skin extending 
to tlic poeti'i'ioi: Eurfucc of the coocyz, called the anal rhai>h(.-; in fnint 

of it is tlic perineal rhapho 
proper, wliicli hag bci-u 
already dcscriliod. ;\8 the 
center of the anus is ap- 
prwiched the skin luscs 
it« corneous cliarautcT, 
gradually clmnfiiiiji iutf> 
niucD-cutaneous tissue, 
whi«h 18 finally trans- 
formed into mucous niora- 
brano at the upper end of 
the anal canal. 

DiriieiisiifHS. — The anal 
raniil ia limited by the 
true ekiu below and the 
free borders of the semi- 
lunar valves or the aro- 
reetal line of Testut 
(Traits d'anatomie hu- 
niaine. vol. iv, p. 234). 
It meaiiures from 16 to 
24 millimeters (I to 1 
inch) in length. Its cir- 
cumference variai from 
3 centimeters (1-^ inch) in normal condition to 15 centimclrrs (.J/, 
inches) in disease, following injury or vicious practices. Tlie average 
amis will admit a cylinder of 05 millimetcT8 ja circumference without 
rupturing the mucous memhraae. 

The walls of the anal caual are composed of muco-cutaneoiis. fihro- 
cellular, and nuiscular layers. The muco-cutaneoue layer ie smooth, 
shiny, and j^lossy. It contains few glands and blood-vessels, hut it is 
richly endowed with terminal nervivends. It is covered in its lower 
portion by stratified, squamous epithelium, which undergoes a gradual 
transformation until it ends in the typical columnar epithelium of the 
mucous memhranc at ^]w upper margin of the linea dentata or ano- 
rectal line. This irregular Lonlt'r limits the upper end of the anus, 
and forms the central flour of the rectal ampulla. Tlie dentations are 
slightly elevated above the surface o£ the adjoining mucosa, and form 
an irregular ridge between the pcetuni proper and the aual canal. They 




Fiii. t.—HanuAi. Anvt IK KKKiaB. 



1 



EMBRVOLOGY, ANATOMY. AND PHYSIOLOGY 



» 



vary in number fmm fire 1o eiglit, arcl ajisumc tho form of papilla at 
their sumniils. Andrews (Uiseai(«s of the Itectum, 1895, p. 303) con- 
i aiders these papilla? the nonniil tactile Argans of thp rectnm endowed 
with a Bpeciiil rectal srasc. Stroud, howRver, fitAt«8 that thfy are al>- 
normal structures growing from the tips or face* of the in dentations. 
He found in Iheui epitiennal, dermal, and aniycliiiic nerve-fifcers. Tiiey 
are ahatmt, or al U-asi nut noticealjle in the lar^'e majoritj' of caaesi; but 
when they are well di^veloped they produce many reflex disturbances 
which an* arcounieil for W their abundant nerve supply (Tig. *). 

In the upiM-r portion of ilie niuco-cutancous tissue ono finds a few 

'irregular, tuhulnr gliinds antilogous to tho^ scl-u in tla- rtiHum. Stroud 

calls them accidcntnl trlaiidr', but Ilenimim cunfidors them as simple 

mucous crypts. About 4 to 5 millimeters (^j of an inch) below the 

uio-rectal line there 

iit a poorly defined lim? 

I or depression which 

I mark!! the lower end 

l-of the internal s|diiiic- 

ter, and i& known ag 

Hillou's white line. 

lu many cafes thii^ is 

almost imperceptible 

i to the eye, but it can 

ittwaTA be mjidf oul by 

touch, as it markn the 

juncture between the 

internal and external 

sphincter muecloe. 

Th* yibro-e*nu\ar 
Latfer. — Bt-neath the 

muco-cutaneous timtio, and separating it from the muscular layer, is a 
thin fibro-cellular hiyor of the anal canal. Above Hilton's wliite line 
|th» layer xa chiefly ctdlular, below tlii» [)oiijt it develops into a thin 
(layer o( connective tissue continuous with the supcrliciul fascia cover- 
ling the i*chio-rcctal fossec. It is closely attached to the nmoo-cutaneous 
and mtucular layers, thus uniting the two and preventing any great 
movenwut of one upuu the oth^r. 

Tht Miucular Lajfcr. — Tlio anal canal is surrounded hy the external 
sphincter, come tilwni of the levator aiii. the longitudinal inu»cuUr Sbem 
of the rectum, and a few of the circular Jibcrs comprising the lower por- 
tion of tl» internal Bphinrter. The citcnial sphincter forms the chief 
ninitailar wall nf the anal cunal. A few iuterlflcing fibers of the le^-ator 
pni and Iho longitudinal muscles of the rectal wall pass down between 




A, (olumii* of MriTKKKiiI; B, Miiiiliuiar vnlri* or C'lTp'* '>f 
iloFfmail; C, dcDLalc U>rder nurkiuK uppor lituIU of niiii* 
aiiO tormoimu^ t-y pbdIIIil' ; Z>, lllUou't wlilu Hue. 



n 




1 




TUK ANl'S. BBCrrM. AND fKLVK' OOUJN 



and amuDd its Ittwrr niar;nn to be attached to the deeper Uy- 
of ibe skin, and thus «»iiipri«> a portion «f the muKiilar wall. The 
in)Mnent of these fibers will be wen in the illustration (Kig. 8). 
The Kxtcnutl t^[iJitncler Mu.icU.—*T\k estLTtml sphincter i& enm- 
kI tif voluntan.' or i;tmtcd mUMiiiIar fibers, and from a surgical point 
riew U the most important mu«cle of the nrtum. It arUes from the 




fin. L— LumiirrDniAi. Scimnir or AK«t Willi). MiAirna ARB&vsnntitT or 

Ul'*C0LAK FtMUa. 

liviiUr iMUMiilar flbtn of Inttatlne cndlnc in Inwrnal •iihincHT bcliw : A. InnsliuillnBl 
LkikiMlkT Oban of cm t>on<!*'>'l<il exi«in*l sphlneutr: r. QIwts af iBvaiur atii, nuine ml 
WHiMMir 1)1 uppar {■■nioii. >ii<l oUicn iDiiKiiuUiiutlr vlicm I)>Br an united lo fui wail 
ihI itfMOMt tin* nwmnl . D, cttamd otihlDflcr. 

Ivrior eurfacc of the coccyx nnd the fibrous lavfr of the slcin over 
I tvgioti, ])A<i*ee forward to iIk- ]irtiterior oonimiflx\ir<> r,t the anus, 
'W its parallel fibere divide to surround this ajwrture, and reuniting 
ht* anterior conimi»«urc. p8»« forward to lie in^L-rtt-d into the p(>rinea) 
y. It i* composed of a superficial ami deep layer. The fibers of 

sH|K'rficial layer are cireular and cnlirely siirmiind the anus (Fig. 

The fibers of the deep layer are imralUd. and simply separate and 
ly theii)6elT«« to llic anal |iurtii<u of the rectum to the height of 1 to 




Viii. 0. — Fwt.iui PanfcAVN <KeUr>, 



Levator 4"t }(uj^f. — Tho \fivMnT ttm is a broad sheet of muscular 
dht'K wliit'li torms tho eupportinir flrtor nf tin? }ui\v\c cavity (Fij;. 10). It 
aridVR in. front upon each 8i<le at tlio nvmphy^iis j'lihis, latorallr from the 
pnlric fascia fthtiig the line of its alUchment with the obliinitnr fascia, 
aod posteriorly from the spine of the ischium on each side of the pelvis. 




l:A 



THE ANUS. RBCTL'M. AND PELVIC COMN 



lis antrrtor Hhon pu^ downward ajid backward aroiiod the prostate 
yUutl in uiiitc with tlu- fibers ot the opposite aide beneath ibc m-ck «f the 
U««tdrr ; ihv middle tilM^nt |)a»a downward and iuwand aruuod tlie rectum, 
wuMe [ving dttaeht-d to tlu- fridvs uf this orgna, and intirlacin;; at llteir 
Wwvr fude with the fibers of the external sphincter, while others iinitfi 
poittt^riorlY and "pass backward to be inserted on the ontorinr surfsoe of 
thi' iMiws. Tin* [Kwtfpi'T fibers pass downBiirc] nni! baekward, and are 
Ituvrtfil upon the sidei ot the cocrvx and lower part of the sacnini. 



Tin. to.— I.kvatiir Ajn .Mitkci^b. 
Dniwii from <Ji>»Mtt»[i t>X lliu uutbor. 

t'ripp9 {Diseases of ihe Rectum, p. fl) states that this muscle crosses 
i\\o rectum at right anfjlw, and ttius eneloses this opjran in the narrow 
ongb> of a V-sbupud niUfculyT forniHlion. in consequence nf which its 
only action is to constrict the rectum (Fig. 11). Upon this anatoini* 
ca.1 construction he hmt hnsvi\ bis injrfnious thcnn,- of t»pa?inodic stric- 
twro, XnmcniuB disf^cctionn have failed to show any olhor arrangi- 
meiits than illustrated in Fig. 10. Viewed from lielow, the muscle ap* 
peara ne an inverted dome, and the contraction of its fibers not only 
lifts but ako constricts the pt'ptum nnd anu>. Its fibers are not nniformlv 
spread out, but are colleeted in smHlI bunilles, the apnrcs between those 
being occupied by fibrous tissue. 



EMUItYOLOBV, AXAToMV, AND PHYSIOLOGY 



13 



l3€hio-eo€eygeu.t ilusclr. — AnuloinixlK :leacribe the postorior libera 
of the lerstor &m a a dUtinct niiucle under the above naniu. Tli<: por- 
tion 60 described Ahive from tlie rami and spine of the ischium and 
from the border of ilie saLTii-iycbiatit.' liffanu-iit, and imssca ilnwnwnrd, 
inward, and backward, tw Ix? itistTU'd liy aponoumtic fibers upon tlio 
:tidM of the coccyx and last sacral rcrtebrfl. Tbis portion of the musclo 
Iwt more fibrous than the nnterinr ]tnrtion; its frniction seems 
'fllit of ptilling the eocryx forwani. It forms the floor of the 
i'peWu posterior to the 
t Tectum. 

Tlie author sees no 
kreaeon for describiug it 
ait a Ht'panilft musi;U', 
awl thuruforL- wliL-n ref- 
f^tmcc is made to the 
levator atii in 1hi» Imok 
tbc oQtire muscular 
pUoe OT floor of the 
jiclvia will bo meant. 

rlr. — Under thin name, 

and al^n under the 

Dames tensor fa^tcia' ppl- 
\\i» (Kohlrauech) and re- 

tnictorcs recti (TreitK), 

Itro flat hands of un- 

Rtriped ma«ruUr HluTn 
^ hnvw heen dpwribi'il, 
■which are said to arise 

from the coccygeal liga- 

nirnt near the tip of the 

coccyx, autl paad forward 

and downn-ard, finally 

blending with the loiigitadiuHl niUBCular fibers of the rectum and tlie 
Lpelvie faxcin around (he auuii. 

Belations of the Anai Canal. — Aeeording to tbe foregoing descrip- 
tion*, ihe re1i)tion» of the anal ranal are &» follows: Anteriorly it is in 

relation with the perineal body, the deep layer of the superficial peri- 
\tx»\ fascia, the |>o*(erior bonier of the triangular ligament, and the 
rior fibcn of the levator aui iiiuBcle; lalrmlly with the perianal 
B, which scparolc it from the ischio-rectal fosete, and with the ex- 
[t4*mul t>phinelcr mnu'Io: {wstoriorly it ie in relation with the external 

aphinctcr, tlio levator ani, and the ano-coccygeal ligament. 



Fm. 11— I.KVATOR AJti MirwLt (Crippii). 

A, auui 1 B, bUnUer ; C, cooori ; tt, ivnuin ; S, r.yati]iyti» 

pnbla; LA, iwnviT «nl iiiubcIcl 



14 



THE aKCS. rectum. ANTi PELHC COIiON 



Tht! MooiI-vessfU, nervi**, imJ Uuiphatics of ilie aoiis are eo inti- 
mate!/ coniieck'd wfilh ihuse of llie rct-tum pnijier that it is dvciucd 
advisable to describe them all tuguthcr. 



THE RECTUM 

The reelura, »s defined, compnees that portion of tlic intestinal 
caiuil between thu si-miluiiar vitlvrs nf Mtirgngni nnd thr nttadiitiL-iil. »f 
tlie mesentery apposite tlie ihinl jiiunil viTtclfra. Trr-ves fin*t iidvixau^d 
this divieioD, It gives to Ihe orgon definite limits; it eepurate^ the 
mobile from tho immobile portion of the gut; it marks the line where 
the cuurse of Ihe bluinl supply chatiges; it iiu)iL-nli>^ llw point where 
the three longitudinal muscular bunds of the culun spreiid uut and be> 
come more or leas ef|»nljly distrilmled around the gut; and, finallv, it 
marks a point at which there is alwavs & det-ided narrowing in ealiber, 
indieating the juncture of the rectum with the pelvic colon. 

According to this division, (linl j)ortion of the rectum which it- nrdi- 
nnrily called tlie superior or fiwt portion it Jntluded in tlie eigiuoid flex- 
ure under the term pelvic colon, and joitly «o, a« it correspond* in every 
anatomicnl detail with ihe other lonpg of this organ. 

Course and DirecUon. — The nam<.> reetuiii wotdd imply that the 
orgnn is iitraighl, but such is not tlie case. BE-gimiug in the hollow of 
the wicrum, it follows the siirrn-rnccygfal cun'e downwiird, bciuji first 
directed backward, then fnrwiinl, and finFiIly backwani ngnin at the anal 
canal. It thus form? a lUmhle antern-poslerior curve, the concavity of 
which is directed forward in the superior portion and backward in the 
lower or proetatic portion. It begins ordinnrily opposite the center 
of lb<» saiTum, passes outward to the right beyond the central line, and 
Ihon ngnin to the left, thus making two lateral ciin-es as it descends. 
These eurvatiire.-' are not mnrki'd, and they are of no great prnetioal 
importance. The antero-posferinr curvatures are w^ll marlicd. how- 
ever, and indicate the direction in which the finger or instrutnent* 
fthould be directed in introdiicinf^ them into (he orpiin, Tht-y arc more 
marked in 9ome individuals than in others, uml may he; greatly in- 
creased by tumors, displaced uteri, or pelvic adhesion*. 

Above the third sacral vertebra the >:ignioid I)egin5: the canal may 
(urn to either the right or left; the angle may be sharp or obtu^^e, 
and there is no way of aocoirately detennining this except by ocular 
ins|>ection. 

Divmons. — The rectum may i)v rlividrd into two portions — the in- 
ferior or prostatic portion, nnd the superior or saoro-roccygcal portion. 
The inferior portion is very short, and extends from the ano-redal line 



EMBItVOLOOy, ANATOMY. AND PHYSIOliOOY 



15 



or upper border of the crypt-* of Mnrgngni to the summit nf the prostate. 
The superior portion extends from the summit of the prostate to the 
middle of the lliird sacral vortebra. 

Soniv writers bubdividt? the ui>i>er portion yf the rectum into peri- 
toneal dud infraperitnm'iil portions. 'J'hi* division, however, u im- 
prHclienl. inRt^murh as it is inipoHsible lo determine the lower limit* of 
tlK> pvrituneul rovericg. Numerous dlviiiion^ and ^ubdivisioDH 6K COD- 
fu^iiii;, and i\\v 3\illiiir prefeis to study thu organ as a whole. 

Diiiicn«ioriK. — The length of the rectum is 10 to 15 cculimeters <3fJ 
to SJS iiiLht'K) ill Hien, and y to 13 ceniinielcTn (33 to 5J inches) in 
woiueti. This va^e^ according to the kIk- of tht- individual, iiiul is some- 
rhat (jrcatcr in old people than in young. Thc*e mcasurcmeutiS arc Icn 
than thogo ordinarily givon, on account of the fact that thoj- do not 
include the first or superior portion of the rettum in th<? old divisiona. 

ThL- diameter is very diflic-ult to obtain in tlit' living' suhjct't. It 
measures when <!mpty 10 to Hi millimeters from biffore Lackward, and 
SO to 40 millimetcpi from side to sidp. When distended, or removed 
from tlic body and ^pn■«d open, its measurements vary gn-atly, and 
soDKtinics assume enormous proportions. S'ap{>eY has reported a case 
in which the gut meapured 34 centimeters (13^ inches) in circumfer- 
ence at iltJ widest point. From the chapter on Foreign Bodies ju the 
Rectum one Ttill gain some idea of the extent to which the organ may 
bo dilated. 

The circumference varies in the dilTiTont pnrtinns of the organ, 
being on an average 6 to 10 ocnlimeters in the prostatic portion, 18 to 
SO centimcterB in the widest portion of the ampulla, and 10 to 14 centi- 
metors in its upper or narrow portion. Numerows instances have leon 
recorded in which these figures were greatly e.\ceeded. Quenu and 
Hnrtmann, after having excised and mplit open a large number of recti, 
give the following average circiiniferenee : .Anus, 5 lo 9 c(mlinielere; 
rectal anipiiMii, 13 to Ifi centimeters below and 8 to 10 centimeten* 
obore; the tubular portion, or the la»t loop of the Higmoid act^ordiug 
to onr division, 10 to 12 centimeters. 

Cnnformation. — When the rectum is empty, the anterior walls ara 
prcMi«d backward by the pelvic contents, and thus come in clo*e ap- 
poiition with the posterior wulU. Tlina there is formed a lateral elit 
or flattened <4nal, much u-iiler fmm Hide to side than from before 
bnekwnrd. When distended with gns, li(]uid$, or solid sulistannes, the 
organ assumes an irregular ey)indrio«I shape. It is often wider from 
tide to flide than from before Ijackward on account of pressure by the 
pelvic organs, or through adhesive bands which prevent its being dis- 
tended as much in tlie antcro- posterior direction as in the lateral. The 
irregular shape of the organ will W appreciated by referring to several 




Kim. is. — L'Ait or Khi^iu miii 1m*km 
Ltot i,w SiAVoitj (Martin). 




I 



Fi«. 11).— «.»iiT or Kbi-tcii. 

6li«irti)| iihIiImi futitrM.-il(>ri iti oliU'raC ]uiil-- 

tun wltli •iitnioli. tQuOnii anil Ilanmnonj 



Flo, 17, — I'aw it Kenrn asd A»*i, 
L'nTiAL iQui^nu anil IlBitnuuinl. 



IQtlly to occur once in every six adults. This proportion, however, 
<pp<?un» to the author to Iw liir|i;<'ly overeHtiimitod. 
Tlie (■xli'rnal Burfacv iti iri"t!(;iilarly convolulvJ. but less bo lliaa the 
kigmoid lt(>xun>. Thp groovt-H wliicli mark its uonioiir L-orresjioiid with 
pile Nile of Um mui.Miis UAih nr KuustimV vatvett intenially. 
' Anolomifal atniciure. — The walls ot ihe ivctuni arc composed of 
(oar layei-s or coats. Proni witJiin outward they comprise the Tmii-ous, 
IP piiljtiiucou:*, thi- iiiiHiiiliir. and the eerous layers. 

The Kaooiu Kembrane. — The mucoue mcmhranc of the rectum 

Uffen* from tlial of Ihe ujipcr «>I«n in tlmt it is thicker, darker in ih»1»p. 

lorp viiseular, and nn^re iiiobile, l)oing attnched to ihe museular wall 

Miroufsh a looee, Iss. eubmueou^ li^uo. which allow? it to Klidc in all 

lirwtion*. It is clianicTprized liy a preal tVvelnpnient of tuhular and 

iu('i{urou8 filaudc, togelhur with many cIobgiI follicle* nnd an es- 

IfHuivc vascular a|i{irtrntue. Thitfii^hout its extent it iii tlirowu into 

kum: horizonlHl UAiit, wnou u£ which eorR*[joiid with tlic valves of 

[oui^ton, In its lower porlion it is )fallH-n.-d into longitudinal foldd, 

Onlilutinff tliQ coluninit of Morgagni, Mwwn (h<^ ba^ti of wliiiib are 



18 THE ASUS. RBCTCM, AND PELVIC COLON 

fouDil ibe semilunar vaivos or crj'pts of llorgagni, the free borders of 
wSiich tuurk tlie Hmitatiou uf tbi* rcotuiu abovi> and Iht.* anu« b<>lovr. 

Structure of the Mucuiut Mtmbraim. — Tlic lueuilranL* is comijoscd ol 
thrws layers: ihv epitlielial, t;!awUi!ar. and muscular. The fpiihelial 
/ojfrr cfinsisti^ of a layer €)f i.'oluinmir tx-lls tliroiit;hnul tlif n!cl«m ]ir«|)«r. 
Thifi cimiigfs, liow*!vpr, inlo stnilificd p«lyhGilral and prismatic; Inyers in 
the transitional zone at tlie lower end of the orgnu. IWow tlic epitheli- 
um there are numeniuB closed CulUilos; betwooa iheno folHclos arc Ihc 
glands of Lieijwkiihii, which praetioally fompose th« siiWance of tli« 
mun)UH mernltram?. 

The glands in the rectum, chiefly Lit-lx-Tkiilin's fnlUcIos, differ *ome- 
wliat from thntie in the npper portion of the colon in cimtuining more 
goblet or miitUB-BCcreting ctdls. The gland]) &iv tubulur and aiv very 
close together, the intervening tissue measuring about one-sixth the 
diameter of the tiilK;?, 

TliP oellH linin;^ the tubult-B are arranged at nghl anjjk'g to the 
cavity, ajid are eonliiiuoufi with those wivering the iiiuooub membrane 
between the tubiilet;. The nrrangemeiit of these lubuIeB \» simitar to 
that of a honeynomb, the division between any two forming u common 
wall for each of them. 

The intertubiilar tissues are compooed of a fine traU^fular network, 
the long meshes of which run parallel to the tubules, forming, accord- 
ing to Cripps and Testut, lymph-palha. PraetieaUy, the Lieberkiihii 
fuliicleii are nothing more than inverted villi. Tliey art" aaid to tie 
inverted on account of the -*olid condition nf the material with whii'h 
they come in nmlact, hut their function remains the siime as that of the 
villi — vii., the ahsnrption of the fluid contents of the bowel. The ab- 
sorption taken place through the epithelium or through the intervening 
epacea, more probably through the former. 

At the lower end of the rectum are found numerous compound 
raecmoae glands, called hy Seliiiffer anal glandii. Here and there Ih>- 
tween the Lielierkiihn glands are found small nndulea nf lymphoid 
tiHitue, which are said to possess a very feeble ritality. These have no 
moutliH or openings connecting them with the cavity of the rectum, and 
no connection with the lymphatics, so far &.* has Iwen discovered. 

Ths mmfitlar latjrr of the mucous membrane, called the mmcn- 
Utris muona, is somewhat more developed in the rectum than in the 
other portions of the colon. Kohlrauseh (Aunt. u. Phv^iol. der Beck- 
enorgane, Leipzig, 1854) desonlwd these fibers under the name of 
su^t^ntator lunine mucos*. Treiti states that the filMTs are specially 
developed in the columns of Morgagni, hut other anatomijits hnvp failed 
to establish this faet. The exact functions of these minute fibers are 
not known. 




EMBEifOLOOY, ASATOMY. AND PHYSIOLOGY 



19 



Babmncoiis Layer. — The submucoas tissue o£ the rectum consists in 
a tootsc, alveolar netvork of elastic ti^eue and cooaective-tissue cells. 
It is ihicker arnl niope clnstic than at «iiy other portion of the intestinal 
canal, ami thu^ allnw» n greater niol]ihty uf thu mucouH membmne 
above it. In this tissue ramify the Wo<mJ- vessels, nerves, and lymphatics. 
lu certain iliii^oasee it becomes greatly hypertrophies, and may become 
entiri'ly iraiti^fonnoj into librous tissue. 

Miuculw Wall. — The muscular coat of the rectum is compoaed of 
circular and lon^'itudiiial fibers. The circular fibers coinjiose the inter- 



I 



Pm). 18.— AuAsamjrr of Cmittua 



Via. 1>.— 1>U4in«¥iiATifl TiLcnvATTOX of 
Ciutr AeoBEOATiox* or ('in<:i lab Mi**. 
cclab Finnu tK Rkctai. W^u- 



nal laytT. Thi* layor ib irrcpular in iU distribution, the fibers being 
apRregated at differcnl Icvele ii))on cm: |>art at the circHnifcrcnro and 
Bprmd out at tli« other (Fig«>. IS, 19), The chief aggTeju^tion of libers 
i* ai the lower oiid. u-hi>rc thov go to make up the internal sphincter. 
The miiiteiiUr fibers throughout ihe reetnm are jteparatwd by conuective- 
tixaiie libi-nt arranK^l pamlld la tliem. This arrangrment upparcutlr 
accouittA for the rapid dcrolopment of the connect ive-tii«ue stricturea 
in inflanie<l conilitiona. 

iiflfrnal SphiitcUr. — This muecle, composed of an aggregation of 
eir<-«bir fibt-r*, liegin* about 4 eentimeterfl above the anal margin, and 
gradually incrcaeeM in Ihickness until it reaches the ano-recial line, after 



TIIK ASliS. RK4rrCM, AND I'ELVIC COLON 

v\xM\ ii iltin^ (Mil Hirain urn) dUap|vHt« about the middle of the anal 
I'Hdiil iVi$(. Kt. Ila wMili tnnu alKwi' dnvnward averages 1 to 3 cen- 
tltiwh'r* (I !<■ 1) in.'lO. ll« tliiokni'M i» so variable tliat no accurate 

""«■' "til '-'"i !"• (ihim. [IM lower fibers aru bolow and within thtt 

N(«*|t ii( llttt Ptlrhtut «|iltinclPr, fiwm uhitli it it Beparalod by u narrow 

(iiiio til t-.i.. , t,,,. iiwiv^riit. H). 

'^ ''•'! ' •"♦'. ">"» «l»*.v« |>^>rv'v|tt)lllc to thp ere but appruciable 

|.V tlltfltitl loMKit, Mtai-K* llw lhti> or iltvMon brtwwn tbc*e two luuscli-n. 

TltM \uumiii ■|iltliti<li<r l> iitiiviv an liu,»iunt«rv imistW. but it ik l.«.k.-d 

|||>*>lllit litaiM •iirtivoii-toillHMii.ul liii)u.ruiii f:i.'i.*r in fawnl continent, 

llltti III IImi |lh<(IUI>llltn tir ffitMM)MtliMI 

fh' TkUi* l*fkiHii<tf. Amir,.4n(i„i„ .,( viniilar fll-'r* »t difTerent 

|.«Vl*U i.f lli» ivntuiii t(«v.' I^'on iht' ,^, ,f ,„m.|j wmrx.\o?>v. Vehieati 

^»|V«tl4 it'nuol, iiliir., IHlir. |i. mi) Nvy.; " NiUioii diwrib^d a n,u«.l« 

^ji*»''' >"' '"•ll"'! itt" ■iitHtrii.r •|ttilm>ii.r, luut wliicli i« sitiiatp.! about 4 

jj„i|.Mi alM>vi< III.. ,11111.. .ilmiit III... .,,oi «|,.,r.- »lriclun-6 «f th,. ivutum 

J, ,.,' «"n'*''ill.v nliM-nml. It la Umiivd of fibont whicli nrt- both aKPTugatwi 

jj,|il ri«i-"li«|"»l. lt<i il.4>tli In from i* iibom six in eoven lint-s, while 

, ,!#»*<*''■'"'' *'"' "" "'*' "''''"^ '^ 'f* »|>rc«a out to about 1 inch." Vel|icau, 

^,|ll|tf iJuHylnjt iMinw of the functions attributed to the muscle, cnnftmiod 

j^/.liil""'" 'Ii-»<Ti|.tioii. and (Joedt-Iin (Aivli. g.-n. f].> iti^tl., Ifir.l, p. mn) di?- 

^j-i-ibi"! ll>'« a«j(n'«ftliwn as dividirig iW- ujiper and middle portions of 

^1,L' nftiini. 

Hyrll (Tiij)ojr. Anat.. p. 168) dc^'crilx-d this iiggrrgntinn. He 
frankly confoH^'d that hif dissections faiktl ttt confirm it? uniform prw- 
enc*. i"t. reasoning from physiological phenomena, claimed that tliun- 
was fl tfio circular i^phinctor entirely jiirroundinp tlio rectum at this 
THiint. His t'laims have not boon vfrified hy Sappcy {Traitc d'anawniio 
liumaino, p. 273). Chadwick (Tmiisaetions of thp American (Jvna'co- 
lojrical Society, irol. ii, 1877). Ijimier and Twmt (ti/i. rit., vol. iv. p. 211) 
have all practically verifn-d N^lat<in'a statL-ment. Then; art also «imiUr 
aggregations aljiivit nud below thin point (Kig. 30). It is generally con- 
ceded that these aggregations of circular libers occur at the Iiaso of IIi.nis- 
lon's valves, and that the muscular fiksrs extend into the layers of these 
valTcs, O'Beimo {Xew Views of the Process of Defecation, Publir, 
]ft33) described the aggregntinn found at the juncture of the sigruoid 
and rectum a^ the third Rpliinclcr, and attributed to it a mast important 
role in the aet of defecation. DiBsectinn has dorn.)nstrateil the existence 
of an aggregation of circular fibers on the concave surface of the gut at 
this point, the fibers of which spread out upon the sides and convexity 
(Fig. 19). It ia claimed that the action of such a muscle will constrict 
the gut at the point where the fitjeis are concenlrnlcd, and this muscular 
conelrictiou can be easily demonstrated through the mt'dem ptoctoitcvpc. 



EHBRVOLOOy. ANATOMY, AND PHYSIULOOy 



SI 



From (])« casts made of tlio rectum and uucTOdcoiiic cxaiiiiiuition of the 
iatestinal walls, it liuB bcvn shown thnt there exist nt everv flexure af 
tiic rootmii iirid mlon nil iipgri'j^atioii of eirciilur fibois jimportionate to 
the fleiilfiie!i«. of tiio lli'sure; ttia: iii ttic roetuiii Ihteo aggiL'^utioiis are 
wtuated opposite the insertion of the valves of Houston, and, finally, 
tlic fhiff ug^nrgfiltons oi-eur about 3 inches aliovc the margin of the 
anus and ut tlio junction of the rec- 
tuiQ Rjid xi};iiioid. A^umiQg that 
n perfect riiij; of ajitrivpated circu- 
lar libers i* neei-ssjiry to the fonua- 
tion of sphinclor, it iiiu^t be ad> 
iiiilleil that tlicrv is no analomical 
cunforirmiiou abovL' (Iil- iiilcriial 
spliiiicter to v!)ich lhi» temi can 
Ik? a|>]>li(f1. On the other hand, it 
we tonsider the ^'inicirrular ajCKre- 
galioDfl aa sphinctent. one mu»t ad- 
rail aot only u third but u frinrth, 
flfUi, and even tnort< s{)hiiiclt>rs. 
Such a ric>nienelatiin> would be con* 
fiiDinji. and thcrrfore tht'si* aj;>;iv- 
gatJon.s should he called the »emi' 
circular muscles of the rectum, 
and the term thiitl ^jihiDctcr 
flbould be dtseanlcd. 

tjntyUiiilinal Mufcular l.aytr.- — 
Outaide of the circular fiberg is the 
totigitudinal iniiseulur layer of the 
rectum. Tliia layer is a continua- 
tion of tlic tlircc lonptudiniit iiius>- 
cular bundd of the colon wliicb coalesce at the Juncture of the rei:lum 
and sigmoid, aud Kpn-ud out. funiiiiij; a dislinet euut around the rectum, 
somewhat thicker in frfmt and behind than iipon the sides. This layer 
iii divided h_vniiat'>rniii;l8 iiitoexii>rnnl, middle, and internal portiouii. 

Tho external lihtrv paes dovrnwanl and are inserted into the snperiAr 
ptdvie fascia ctivi^rinjr ll"? upp<?r t^urfaec of the levator nni iniisdc. The 
middle fibers niiiiult- with lb«s« of thv li?vator aui. and arc attached with 
them to tltr rpctal wall. The internal fiijcr^ pasts ilowiiward. together 
with some filx-rs fnim Ihc levator ani brtwccii Ihc two sphincters, and 
are ioi^cricd in the fiupcrficial faecia surronndin^ the &x\\\^. Goodsall 
ond Miles 8tate that thcfe fi)K>r^ can be ftoon to pass betu'cen the deep 
and superficial layere of the external s|>hincter muscle. The arranRe- 
iDOnt of \\»m IiIk'k iu the upper portion of thi- i-eetuui is very irregular. 



Ftn. }!>,—[) I Mien ox BT Uartis. 



S2 



THE ANUS, RBCTITM. AND PELVIC COLON 



11 



■'^^■jS- 



Up 



M will be eoen from the illustration (Fig. ii) taken from Lamier. 

Sometimes Iht-y dip into the flexurc-s of ihe giit, and nt others they pMB 

over the »aiui.v 

Oulsiilc uf the longitiidiaal muscular layer 
ia the luwcr ]>ortioD ot the rectum the walls 
arc rL'eufurot-d hjr liie libera of the levator ani 

Sereiu Coat.— Begiuninff at the lower 
point uf the jielvio jieritrtnenl enl-ik'saty the 
pL-nluiiu-iim cuvL'i's thuauti-rior surfaee of ilie 
rectum, and, ]>ass)ng iipu-srd and hackward 
in jin obliquf iiiii-, (inully iiivcsts the entire 
circiiiiifercnri' of the nrjfiiii nt Hhoul the levt-l 
of the ihird ancnil vcrtvbra. As this coat 
\nt\^K-9 upward it is reflfcted externally upon 
the sides vi the peivie, tims forming the Ul- 
cnU ^upportB of the r&etum (Fig. SS). At 
the level nf Ihp third Kai-ral verleluia llit- two 
folds of peritoiLTiim imito jHKlt^riorly to 
fonii the pelvic menocolon or iiienorectmn. 
Anteriorly the srrrnis etmt in refleL-lcd u]m»u 
the bladder in males and the uterus in fe- 
malea.thas forminju; the recto-vesical or Doug- 
las's nd-dr-?ac. These euh-*lf-»(U' cnrilain tha 
sigmoid flexure, lonpa of small intestine, and 
sometimes the etReum, vermiform appendix, 
and ihe ovaries. The depth tn which they 
extend u|>on tlie anterior surface of the rec- 
tum raries in indiritUiale and under different 
cireiimstiineea. With the Wudder and rectum emiity, they extend to 
within 6 centimeters of the murjtin of tlic^ anus; but when these organs 
are distended this distance niny he increased to 9 or even IS centimctcra 
{A'\ inehcs). They are about 1 to 2 eentinieters neftrer the anal mar- 
gin in uomen thnn in men. In eases of proeldentia with reeta! iiemia, 
or where the perinjeiim hain been injured during eliilJbirth. the cuU'At' 
Mjt sometimes approach very near ibe perineal wiirfaee. In one case 
the cul-iit-mc vBA separated from the perinieum by imly ila- thickuciw 
of the e.\ternal sphincter muscle. These variations are rendered im- 
portant by Ihe fact that the cuh-dr-sae, when extending abnormally low. 
may be easily penetrate<i in operations upon the nntcriAr wall of the 
rectum. 

Cclumng of Vorgnijni, Pilhra of GHsunn, Columns uf the Rfctum. 
— The mueouK mtmhraiie at the lower end of the rectum is gathered 



iin"' 



AKiu»otiit?rT or I^soirrm- 

NKLUtM'LLJfl LaVKROV THE 

Brti-m (Lunlvr). 
«, (, c^ (L KToovva •■f rvctnl vtMn- 
drr; Uf. loiurliiiillniil flbcn 
fbroilug wovtn tntiidli^ : «. loo- 
iltiidliul Inud nriiltiic In p«it 
fVnm rlrciikr fllmti ; fp. fAn. 
kliiilK'kt IiuikIh urUiiie frfiD 
botli iiiuai'uliir Ufiin ; ji, tar- 
daulua BpUltiuK 'jIT frJDi Ivn- 
gUuiliMl bundle (, t'. 




EMBKTULOGY, ANATOMT, AXD PUYSIOLOGY 



-^3 



together inio longitiidinnl folds deiigimted by the above names. They 
are rtutlered more [iroinineni liv the contraction, of the sphincter, and 
ohlittrHiei! by dilalaiiou of the canal. The base of each coiuran joins 
with the dt-nttile iiiar<^iii, forming the upper limit of the anus, uad is 
continuoufi til lU duUt ungle with the adjacent semilunar valve. The 
top of the column gradually epreiuU &nd loses ita-lf in the smooth mu- 



\^ 



^ 



■pA 



Fi... .. 



iu RRTumoM or PmiioKJitTit raoii lixirtii on to tiib ritTic Waua 
A. O, aupiirinr palvt-n-tui kpw**; (^ I>, >-«hto-roclBl fow*. 



coDit membrane of the n?ctnl wall. They vary in number from five to 
twelve, and measure from base to ape.\ IIJ to 12 iniilimoter* (about J 
u ineh) (Fig. 7). Tliey are composed of mucous and submucous tiai^ue, 
and contain, a^n^tnlioji to Treitz, eoine muscular fibers which act in 
owrt'OHiing the evcTBinn which takes place at the time of defecation. 

The grooves betwet'ii thej^e wluiiins gradually deepen froiu above 
downwartl. and end in the (semilunar TiiilveM. Teiitut (op. cit.. vol. it. p. 
1W4) states iliat iu these (•p)ov»-s are found irregular elevations caused 
by dilatation of tlic auhjacent veins. 

SetniluiKir Valven, Crypts nf Murgatjni, Aiuil Pockeh. — The rvctal 

nncous membrane cndi- U-invr in Rn irrecular fentooDed border com- 

^fotd of email foId« «trctclM>d acroiis from the iMse of one rectal column 



hS* THE ANUS, RECTUM, ASD PELVIC COLON 

to anoliier, their concavity being directwl upward. The upper border 
oi tbe^ folds comprises the ».o-ralled ano-rectal liiii'. Ili-liind these folds 
(he mL-rnbniQe dips down nnd formH little poiidie» of variable depths, 
wliieli arc called the crypte of .Morpagni or anal pocket*. The folds 
Iheinsc'lvtw ure U-nited the !*oniiIiiuar valves of the rectum. The epi- 
thelium eoveriag ihc^e Coida jn^dtmlk changes from the 5tratitied poly- 
hedral fonn to the typical columnar epithelium of the n-clal mucoiu 
'inembraDe. Tht frt-o borders of ihe valves are conca^p, and their ex- 
tremitiut) are c^'uiUiiiiiuiM with the angles of the rerUl colmnns. They 
van' in nyinlKT from fivu to iwotre, as do Ihe reetal columns, and meai^* 
ua* in width from G to 12 millimeters. In depth they measure upon an 
average 3 to 5 millimeters. la sipme leases thei-e i-s ,-ciircely any dopres- 
Bion, while in others a veritable sinus exists behind the valvt-s iVig. 7. B). 
Q'bey are said to be deeiK-r and more appan-nt in early life than in old 
sgc, btil they are often quite marked in nitidis. They are almost in- 
variably absent at Ihe anterior and poslenor L-omiai««urej; of tlif reetuin, 
but there is generally a well-develojH>d erjpi upon oaL-h side of tlu-se 
points. ThoM iu the anturior eirtnmferenee are less aeccntualed than 
tbone -situated posteriorly. This fact has l>et'n utilized by Ball to fx- 
plaia why liiwurea occur po much mon- fn'(|m-nlly juet to one side 
of Ihe i>osterior anal commi.'wure than at any other [joint. Oecajiion- 
slly stiiall massee of fa'cal matter or foreign hmliet- are arrested in thi-*c 

(little poekeu and produee nmeh loeal and rellcv irrilaliou; suili acei- 
denl£ are comparatively rare, although certain irrei;iilar pranlitioners 
have made great capital out nf them, and ascribe almost evt-n- di»- 
ease of the intcKlinHl lanal to thi'se jHickels. The function of thi-se 
valves is praelicully unkniivrn. They have been ennsidered as reservoirs 
for the mucus or lubricating material of the rprtwm, but frequent ex- 
aminations at periods rcniote from defecation have failed to demon- 
strate any accumulation of nnicus in them. Moreover, their epithelial 
lining contains uu inueus-proiluoing colls, whieb indicati'K fhcy do nnt 
secrete Ibo material. Tlmy arp best ^een in tho living sult j .n'f Itv iIk' use 
of a eonical ft Mn-stralt'd •.pi-t.'iduni. into which !> intmdiici'd a nmnll bir- 
y nyeiil iiiirnir^ l)n tin- niaririii of these valves are s^erti ttie small papitlffi 
wbieh liiive been dcscrilM-d iu rounection with the annl eanal, 

Thn Valves of Unitnfan or Hie lierlnl Valves. — The mucous mem- 
brane of the rectum above the crvpts of Morgagni is thrown into irregn- 
lur horisontnl folds, nio-Jt of which entirely rli^appenr when the organ is 
difli'uded. At tliR'e or four point;* in the organ, however, these folds 
become more proniinont when the gut is distended, nnd extend out into 
its cavity in a rreseenlir form. 

Houston (Publin Hospital fieports, 1830. vol. v, p. lS!=t> first di>- 
Fcribcd these fold? a.s vahe^s of the rectum. They vary in number froiq^ 



EMRRVOLOOV. AXATOMT. AND PUYSlOLOOY 



2S 



one to five . Oixlinarily iliere are ;hree, lornied tilt superior, the middle, 1 
and uil'i'fior valves of ilie rectum. The middle out U tlie must tuustuiit. 
Il nri!*i;s fr^jiii tin- riylit aiitLTi-ir nuiuirui it of llu: rfctul wall hIohI C to 9 
centimclcre (S3 uiclivs tu 3ili iutlios) above the mai-giii of the anus. 
Kohlrauscb <le»erilK-<i this fnid a* ihc " plica trttuivorsalis recti,'" but 
tht-reiB no occasion toconfu^f the reader by iulroidueiiig unv new nomen- 
clature. Afl Teslut says, ibe nam*' oriyinally a|iplied to them by Hotis- 
ton "is renilen-d sflcrod by hiug usa^L'." As descrilipd hy Kohlrniisdi, 
Ti'.itut, Otis, and others. t Uia iiiidJle vatve varips in lipigbt nrrordiiig fa 
the iiepth fif the ]» TiHim'Hl nil-dr-siu\ being alwnys just helfw the laije r. 
The "inferior vhIvi- it* IdcjiIciI ii|>nn tin- left pnsti'rior Quiidranl 2S to 
30 milliitict4^r» (1 to 1^ inchog) abovv the margin of the anus, and the su- 
perior valve il* locatpii 
in the mtaa qnadrmil, 
Bliglitiy more to tlie 
Bide, al 9 to II centi- 
luoters {^\ to 4| ineli- 
esjabovf the aoii*! Fig. 
?3). At the iiinftiirc 
iif llie m-liiiit n illi (lit- 



Ml 



Nioiij, oiit'osite tin' 



t hiril t^trai venehrj i. 
theiv is always a wrll- 
di>v('l(i|ied (nld or viilve 
wliicli mi>re imirly oe- 
dudes ihe caliber nf 
the orKan than either 
of the fltlien*. Thi* 
valve waa orisinally 
(described by O'lleime. 
whn alTribiitt-d to it 
the fiiiiclion of main- 
taining Ihe fa-eal inniM 
in tJic sigmoid llexiire 
until jii»t bitfore Xh« 
end* of dofecftlion. 
It i" ■itiinl'vl gfiT""- 



' 



Xi.A -lo!. . 



Fi*. ■a. 

uti.tl juiloriiir. ;nn 

t jie riglt 'i "■■ '"ft ""t^ 

Bcconlinc to the di- 

reetion of the flesurt! of the sijrmoid upon the rectam. It is more 

m«rke4l in those casec in whieh this liexuro i» acute, and in such ca5«a 

ObKurr6 any view of Iho sigmoid througli the rectum. 



Wliita ckrtUO lino •hown heiitlil To which Uic pcrltaneal nt 
Jtttne t> nSf-trA trh'ti liliuUlcr U distended. 



TBK ANUS, UBUTUM. AND PKLVIC COLON 

TliO rt'Ctal valves prolnidf into tlic cavity of Ibe orgiui lu variou* 
extents. They ore nttaclied to the wnli of the gut from oue-third to 
■half of its circumference; they are crcKonlic in shnpe, and present 
►roonsideration two eurfaces, a free border, a ba«e, luid a central body. 
Th4> superior surface of each valve appeal's as a uuootli, ineUued plane, 
kli].'htly dL'{)]'i'^!^t.'d in iu L-eiiLer. in iilttiorinal enildiliuu*; thiri depi'e^ioil 
, may beeoiwe tjuile martced and capable uf relsiuing fwt-al or foreign 
siibstancHS. The inferior surfnee of the valve corrusponda to (he supc- 
rinr, being more or less convex, nrcording to the cuiuHvity of llu; hitter, 
and if. separated from it by the niucoiii; membrane and tiK^ues which com- 
pose the body of the valve. The free borden; of the valves are creM^ntic 
ill ^hapCf olearly defined, and direutcd toward the (.avity of the riHtuin. 
In the normal enndition they are ii-mally lliiii, (iHxible, and easily pushed 
^!de. Owing to the nrranpemimt of the valves at different levels, these 
^Ugea overlapping give lo the ivotiiin, when dilated and viewi^l through 
^Bie proctoscope, an appearance somewliat like a turbine wheel (Fig. 21). 
The bases of the valves where they join tlie rectal wall are convex, and 
Conpiderably thicker than the free border: they are ordinarily opposite 
one of the grooves in the external rectal wall, as ^bown in the casts, but 
this arTflngement is nni invarinble. Their Bttnehiiient to the rectal wall 
is not upon n horizontal plane, but slightly higher nn one side tbnn on 
the other, thus furnishing n sort of inclined plane, which contriiiutes to 
the e»^y passage of the faecal material over them. As Howslon stated 
in his original paper, the valves consist of two folds of mucous mem- 
brane separatL-d by cellular lis.*ue and muscular fjliers. The mucouB 
membrane covering tlicni differs in no wii-e from that covering the rest 
of the rectum in normal conditions. The structtires composing the 
body of the vnlvps between the layers of inueotis membrnne have l»een 
minutely dPBcribed by Martin {Philadelphia Modieai Jounial, lHHi)), 
Pennington (Journal of the Anieriean Medical Association , Decem- 
ber, 1900), and more recently by Teatnt (Trait»i d'auatotiiie hnmaiue, 
1901}. 

Martin claims to be the first to hove diseovered fibrous tissue 
in the valves, and has based an elaborate theory of eonstipntion upon 
their almonnalities. Pennington removed a large namber of recta from 
childnm and adults indiscriminately, and submitted (hem to Prof. Wil- 
liam A. Evans for examination. The latter demonstrated the pn-scnce 
of these valves in each individual case; he located the most prominent 
one just Ih?Iow the level of (he peritonnal ntl-ih-»ar, and the next most 
prominent, "that which conlrac-trd Ihr caliber of the gut chiefly" at 
the juncture of the nctum and th«> sigmoid, just as we have described 
above. The nniseularis mucosa was found to !«• more prominent in the 
talvL'B than elsewhere; the submucoea was composed of loosely arranged 




28 



THE ANUS, RECTUM. AKD PELVIC COLON 



over llie depresnions formeti Uy llie entrance of the circular fiber* into the 
TalveSf and sometimes dijiping into Ihesc groores. This Is in harmony 
with thi* obtiervhliona of [^ttmiiT referred to ia describing tlie longi- 
tiidimil rou&culiir oat of the rectum, 

Evatia dpscrilw-s numerous iitiuuual conditions and iihnormal develoj 
mnnts in the valves. While tlient; minute studies of tiie nnnlnmienl slruo- 
ttireare inletestinp, l?iev have iio jiraclinil value for the Hurgcon beyond 
confinning the statemenw of Ilonslon thnt t!ie structures are not simplu 
miicou* inhh, but true valves eoiii|ii»sed nf nnienus membrane, cellular 
And fibrous tissue, aud poaees^ed of circular mnscnliir fibere. It is a 

ein^liir fact that m none o£ tlie 
examinations thus far made has it 
been shown that tli« ]>eriloUtt'iim 
dippe'd into the j^oovn at the base 
of the Vftlve. The illiislrarion (Fig. 
25) shows the extent to which llieso 
valves may develop, togethir with 
their oblique attachment to tlie rec- 
tal i«-all. 

The function of theiie valves is 
to support the fa'cai inaas in its 
passage through the rectal canal, 
aaii, being so urratigL'd n$ to jiresent 
to the mass nu inclined plane paAs- 
iiiir cinruliirly around tlic rLx'Ium, 
tiiey imparl to it a rotary or cork- 
screw motion by which it is depos- 
ited from one valve upon tht- upper 
BUrfaee of the valve below until 
it reaches the iinus. ^lartin and 
Pennington have experimenleil by 
introducing lubricated cot 1 on-lialls 
into the sigmoid flex:»re, and have 
olisen'erl their passage downward 
through the rectum liy tin; aid of 
the proctoscope. They state that 
the bolls ilip from the sigmoid into the reelum and lodge ngiiinst 
the first valve; tliey are then carried by a rotary motion downivaril 
and forward to the middle valve, and then by the same motion they 
arc depoifiled postorinrly upon the lower valve, aud finally from iltij! 
valve upon the internal ephincter or into the mouth of the instrument 
through which they were observed during the procc**. Thus, uppar- 
«iitly, i;ro«M &ud microocopical anatomy and clinical obscrrations all tend 



Valvei o» llornTiiSi, 

DnvD ftnin •perinicn nl(al^Ilal the «iitlinr 

by Dr. J. It. i'trntwitifM. 






KMBRYOLOGT, ASaTOMT. AND PIIYSIOLOGT 



29 



to confirm more and more nuUBtoH's original clnini!* as to the existence 
nml fiinoiions of (lu'ee vhIvub, 

Vascular Supply. — Arlerirp. — Tiic rectum ren-ivcs its blootl supply 
fpoiii four iiourtvs : tite tujicrior, initMIr, Jin<l infirior hitmorrhoiilnl, and 
the middle eacral arteries. 

Thv superior hirmovrhniiiul artery is tlie terminal division of tin? in- 
ferior tnoHt-ntPrie wliith has its origin in the aorta jiii^t below the nephrilic 
arteiT. It dewcmiK in front and slightly outside of the right internal 
iliac, and \» emlHrddi-il in ihe two fohls of the inescnlerj'. At nhont the 
level of thp jironiontory of the sm-runi it gives off tbr sijrinoidal urterv 
(Fig. 2<i) vrbich supplies the lowvr portion of the BiginoiJ; it piu^es 




m >i.i-t.j.i'^ii II J uvniiimitijiL. 
iJUlrlbution of Inluir tatbo nKiiiiit >n<l lu arutcrniiinsla wlib iiilJillo hMuorriiokljtl anrry- 

downward lit-tweeu the folds of the luesorectum, and dividoB about the 
■level of tlie second piece of thv sacrum into two, sometimes three divi- 
»ioiis. which pas!!. one np<in the risbt nnd ime upon (he left side of the 
RCtuui; the left Lraneh ih distributed to thnt fide and to tht! anterior 
ftUrface of the gi''. the right branrh is difitrihnted to the right eidc and 
[loAHTiiif fiiirfacc of the gut. About A\ infhes above the nmr^in of the 
anuis these vewels penetrate the muscular wall of the gut, after whicli 
their divide itito namerous hranches, nnd descend to the lover limits of 
tlie rectum, wht-n- they terminate. The Iruuka of the veiiseU run more 
or lofs parallel with the long axis of the gut, aod their capillary diTi- 



30 



TUE AKUS, RECTUM, AND PELVIC COLON 



sions pOAS around the inttwtiae, froclir anaMtninoetin^ with nne another. 
They abo aaastonioge with branc-lies from the mid'dle h^iuorrhoidal and 
middle sacral arteries. 

Tkt middle hamorrhoidai artery is extremely variable in its origin. 
It generally arises from Ihe hypugastric artery, but may nrUe from tho 
intemal iliac or (he [irnstJitic. li is situati'i! jiliovc the levator aiii nm*- 
de, and [)asse8 through the superior pelvi-rectal space*, distributing some 
braiirhL>s to the anterior 6UTfacc of the rectum, to the seminal vt'siclea 
and jiruslate in men, and to the vagina m women. It supplies the leva- 
tor nni muscle, and furnishes o dir*linct anastomotic einulution with tlio 
superior hftmorrhoidal artery, which in ease* of injury to the latter rea- 
(iel would afford an adefjiiute circtilstion to the lower end of the rectum. 

The inferior hiFmorrko'nla! arteri/ arises from the inlernnl pudic and 
erosaea the iscbio-rectal tosssi obliquely from the posterior portion of 
its outer wall; it dividen into a nuiiibi^r of braucliL')! nhicli supply the 
lower portion of the Ifvulur ani, the external and luternal sphiocterts, 
the ttkin, tiod ttupcrficial fa»cia around the aiiUK. Tlie lirnnchcs of one 
side anaEtomose with tho^e of tlic other, and witli branches of the mid- 
dle hseniorrhoidal arteri,-. They also anaptoniosc in a very mild degr«e 
with tho lowest branches of the superior hemorrhoidal artery. 

The middle sacral iirfcri/ arises fmni the poslirior portion of the 
aorta at ils bifurcation, and deacends along tht* middle line in front 
of the Mirnim, terminating in a minute branch which supplies the gland 
of Lufichka; it gives ofT branches which pads through the cellular tiesue 
to supply the poeterior surface of the rectum. Its branches anastomose 
with (he brauehet^ of the superior ha-niorrhoidal and the lateral sacral 
arteries. 

Veitis.- — The veins of the rectum correspond in name and course to 
the arteries, but they return the blood through two entirely different 
channels — viz., the portal vein and the inferior vena cava. The internal 
or tu]»erior lia^uiorrhoidal veins collect the blood from the rectum proper 
ami empty it thmugh the mesenteric vein into the jiortal cireiilatioa. 
Th« middle and external ha^morrhoidal w'mt (Fig. SI") and the middle 
Meral veina collect the blood from the cttcrual Burfaces of Ihf rectum 
and anus and empty it into the ^ncrol circulation through the vena 
cavii. The interna! Iwemorrhoidal ple-XUrf forms the venous supply of the 
r«ctuni proijer. The ano-n-etal line marks the beginning of tlioi^e veins 
above and the external vt>ins Wlow. Thict line, as Otis has happily said, 
provides a sort uf watershed between the two cimilatlons of such low 
altitude that under »-ertnin conditions it does not interpose a sufficient 
barrier to prevent an intermingling of the two etrcams. The two sys- 
tems are conneeted at this point thivugh anastomotic brancheji which 
are so narrow in early life as to be alraoet imperceptible. 



EMBltVOLOOV. AKATOMV. AND PnySIOLOflY 



31 



Cripjis {(/p. cil. 



261 



he ii 



Ipinonstratod that liio iiiturnul 
hiBfiiorrlioidnl pirxus can not It' iujt'rted ihmiigli the iliac veins, but 
it can be injected through tlit- iofitrinr niesimteric vein, and llic lilood 
will not pass on into the vxk-riial veins, po thai if any (^uminunirdtion 
eiiBtfl lielweeu ihe two sysitems it must be protected by valves. Qiii'mi 
and Ti'slut havu liotli 
demoniitnittid ihe ex- 
istence of valves in 
these anantomolic 
reins in llie ailult, ninl 
lliiu in |mrt corrolti 
rate the views vi 
Cripps, Imt thny stale 
that the inferior luvin- 
orrhoidal ph^vus ran 
be injected tlirmiKli 
the inferior meaenkTic 
veins. Tlie author lias 
deiuonstrated the fai.1 
that the cxtomnt plex- 
UKcan he inji'dcfl fn>iu 
the inferior moson- 
teric vein* in old siih- 
jecla who have suffered 
from e«Datipation und 
ha.-niorrhoidal diseusc. 
Indeed, the coninuini- 
cation between llii'i<i' 
tvo sTutvina in often 
appan<ul to tho nakfd 
eje in operations upon 
mixed haemorrlmidfi. and it U no longer necessary in the light of such 
poeilive facts to further discuss this question of anastomosis. 

Jupl atxue the ano-ivctal line in the subrnueous ti.-'sue there are 
DumerouR small Tenon^a nics or pool." (Fig. SH), hiilhou? or elliptieal in 
ahnpp. and enrh nl>out the fixe of a ^rain of whent. The-<(* little pnnh 
Bumiund the rectum, sonie at a higlior nnd some nt n lower level, and 
practically form the lieginnin;; of the internal hieiiiorrhnidal plexus. 
Durct (.\r(hir. p^-n. de mi>d.. December. 18;9 und 1885t states that 
thew little pools are arranged like clusters of grapes in the columns 
of Morgagut. The dissection made by the writer, luiwevcr, shows that 
they enlip'ly surround the rectum, and are not particularly asKrejraled 
in the columns. From the<e ])ooU the ^iiiall veins proceed in all direc- 



. 



Km. T,. — KvtgrkaIj ami Mii>i>i.k II IiUhkiiiioidil Viim* 
AKinixu fKiiK riiE A»»L CmtAi. >»!> LowKn K»i> or 
THE Rurrin; aijo ItRi,xniit> ntRiriMa CPitAaDTo runu 

8t['KH[0II ll.HUuflMtlOIKAL VkIM*. 



THE ASVS, RECTUM. AXD PELVIC COLON 

tions to form an iniricalc network of vc^^els eumnindiiig the rectum. 
Above the ]nai;gm of tlie intomal gptiinolcr thi^y unite to form lai^et 
tronki), which approach the nrteries, and with thom itonelrntc the mu*- 
Ciilnr wnll of the put; the vonrm? trunks unite nbove this point to form 




Via, 2s. — V&KiiLAH ScrrLv or Liikbr Em) of RBirri'B tl'^iTu S..iiMir%Tii 
Showing vcnnu* iiooU In wtiLch iQiariMl Winortliolilal plcxu* oTiglnuirs. 

the inferior meseutvric veiu whjcli einptit'8 into the portal circiilntion. 
These veins are without valves. 

Verneuil liiiis udvancftl the injieniou* thcor>- that the contraction 
of the lonpitudtnal muscular fibers, at thi- points wht-re the vessels per- 
forate the roctot wall, Benree to supply the placi> of the valves, and inci- 



EMBRTOLOQY, ANATOMY. AND PUYSIOLOOY 



33 



dentally hf- riuims lliat IHk »padin« of these musclt-s, musing obstruction 
in th« veins, liavc a jioteiit iiillucEicc in the produvtioii o{ inlcrnal lifeinor- 
rboids. It is impossible to cooiinu or deny tbie theory, as the f«cU are 
not demoD^triiblc, 

The midJIe hemorrhoidal veins arise from the anterior surface of 
the reetutn above the k'valor iini niuncle, the itetiiiiuit I'esirles and the 
priMitatt! in men, am) the vag^iual wall in wtinieii. Tlie cftpillarias unite 
into iargur trunks am! follow the course of the arteries tlirough the 
pelri-rcctiil s[iitei», iind empty sometimpfl into the tiypogaatric and eome- 
times into the Jschiatii^ veins, but always finally into the genera) circula- 
tion through tlie reua cava. 

The externa] ha;niorrhoid&l veins originate in the small aDa^toiiiotic 
capillHneii in the ana! ennal; they liecomo more or loss dilated as tlioy 
pasK outward over the Iwrder of the external sphincter, but immediately 
narrow down and unite with the subeutamiou^ L'apillHrie:< of thi» region 
to form trunk* which empty into the exiernal pudic vein, througJi whi(--li 
they are connecti-d with the gi-ncral circulaliun. 

The Nerve Supply of tie Anas and Hectum. — The anus and rectum 
rc«ivc their ucrvp eupply both frnm the gn^at sympathetic and cprebro- 
<pisal systems. Tiie rectum proper is largely supplied by the sympa- 
thetic syatem; it receives? branches [mm the me.ienteric, Bneral, and 
byiKigUBtric plexiiMes. It also reeoivos HUments from the thini, fcmrlh, 
and fifth sacral nerves. The mueoiis membrane of the rectum Ix'tMiiies 
letiB and less sensitive from belnw upward, thas indicating the absence 
of s«n?itive fibers in this portiun of the put. a fact which has been cor- 
roborated by mieroscopic and anatomical research. 

TJie nerv«! supply of the muM-uUr apparatus of the anus nnd rectum 
arifr« fmrn the intricate plexuspK formed by tlic ei.cond, third, fourth, 
ftod fifth eacral nerves (Fig. 39). The filaments from these nerves 
unite, separate, and reunite so often that it ia impossible to determine 
the «.iael origin of any of the final truuks of dietribntion. According 
to Hwn'Stin, [jingley, .\nderson. and Tt-stut, the levator ani receive* its 
thre<> filamcntfi from ihe third and fourth sacral nerves. The fir*t two 
fltanienti* are distributer], one to the posterior or i«chiu-eoccygefll por- 
tion, and the other to the anterior or tcrator ani pro|)t'r; tlic third fila- 
ment fv^sea beneatli the muscle and gives off brunches to its lower eur- 
faw. and parses onward to supply some sma)! filaments to the gnperficial 
mrface of the external aphinoter. 

The external sphincter muscle roeeives ita nerve supply from three 
■onrres; two filament*^ from ihc hmnrho-t formed by l)ie third, fourth, 
and fiftli sflcral nerves extend transversely across the. ischio-rcctal fossa. 
and disiribiite theniBclves to the middle portion of the muscle and 
tu the poriiuuil cutaneoua surfaces; a Blameiit which conu-e off from the 



84 



THE ANUS, RECTUM, AKD PELVIC COLON 



intenul pudic, just before its division into terminal branches, §np- 
plies the anterior portion of the muscle, and is called tlie anlorior 
sp/iitirtfrinn n«rvp; while n lilamt>nl roiniiig off from tliw fifth awl 
gUth SHcral nerves passes iJown into llie hollow of the siicrum l>etwppn 
the levator am muscle and the recto-coecjgeus ligament, and finiilly 

reaches the poeterior 
euperficia.1 siirfacfi of 
the external sphincter. 
Morcwtin rails tliis tlie 
lesBer sphmetcrinn 
nerve. All these fila- 
ments possess hiilh 
seusilive ard nmtor 
fibci-s. and with them 
are tlislrihiitud fila* 
ments of the eyiupa- 
thetic nerve. The cen- 
tral nrifiin of the nerve 
i<ii[)l>l3' of the anu^ and 
rectum i« said to be 
lopated nlioul tJjL- K-vel 
of the fii"st himbur ver- 
tebra. This center is 
practically the same as 
that of the gcnito-iiri- 
nary apparatus, which 
faet a*'<'f>un1s in a large 
measure for the vari- 
ous reflexes between 
the tvro systems. The 
inhibitory center of 
this uerve supply is 
sinialed in the brain, hut the e.\nct location is unknown. 

LjrmphaticB of the Anus and Bectnm.. — ^The lytuphaticii of the iinns 
and rectum are very difficnit to demonstrate by disscetion. Occasionally 
ea0e.s have been found in which the vei^sels and ghind^ have become in- 
flamed and thickened, and \\m» the r>eu( and c-uur»e of iIichc particular 
vessels have been traced. Qm^nu (Bull, dc la Soeit-tt* auatomie. Paris, 
1893. p. 31*9) lias shown tliat tbcic ur^ans arc supplied with three sets of 
lymphatics practieaily corrcapfmdiuy to the inlcrial supply. The sacral 
or superior plexus of the lymphatics originates in the submucous and mu- 
cous portions nf the middle tind upper rpctum posteriftrlv- They follow 
the couree of the vessels, the lympliatie ganglia lying in close apposition 




Flo. 39,~Srrs*i. Ntitviu ur rim KtiTnii ajio Axo». 



KMBRYOLOOT, ANATOMY, ASH PHYSIOL,OOy 




i'tti. 90.— LritriiATiua «> Anu. *»v I'tmAtnt. Rutov. 



with thfl hirmorrboidnl veins. Betwopn tho rectum and the anterior 

surfaei'^i of Iho siipnun anil eoeeyx is found n eliain ot lymphatics wlucb 

exiende upwan! in ilie 

cellular ti^^ue between 

the folds of tite mes- 

CDtery, «od ia t)ui!< 

connected with the 

|>revi>nobril lymphot- 

ic system. 

Tlio middle hiem- 

orrtmidal vl'Sm.>Ix are 

also accotiipiuiicd b_v a 

chain of lytnpliuUcs 

which fiplloBs tht'ir 

couracand end« in the 

hypogu^trio lyntphalic 

plexus. These Iviii- 

phulics origioato iu 

the anterior portion 

of thv recltirn, and, 

p«a«ing outwiinl above the li-mtor aiii muscle bctwoca tht rectum and 

the prostate in the male uud iilun;; the cjreular vajiiual veius iu the 

female, they tiuaU.v roach their di^tinolion in tho hypogastric plexus. 

^ Quenu **}•« it appeiir* 

^^^HT 1 from his dissections 

^^^B 1 that the middle por- 

K / I tion of the rectuiu U 

I / J coiini'ited with the 

" \t'%^ * m lymiiliiiticM »f buth 

the sacral and hypo- 
gaetrie plexusee. 

The Ivmplialiea ot 
the anal and perianal 
rejiion are very nn- 
nipmns. They ai*o 
coiiniMrted by amudo- 
niot i e branches wi th 
the lower lyiiiphatie* 
of the rectum. Thcydo 
not follow the course 
of the vxtcmni lisenior- 

rhoidiil veins very closely, but ramify Iteneath the okin, thi> chief brnnchea 

patting forward and upvurd between the scrotum and the thigh, and 




lnvviKAb LntniATK*. 



3fi THE ANUS. EECTUM. AND PELVIC COLOX 

finally unite with the Inguinal lyiiipliaties (-Figs. 30, 31). It has not been 
dt'iiiiiitKtralfd whelUer or not this uhain is diryi-lly coimL-eU'd with the 
inferior chain of tht? hmpliulicit btluw !*oupurt'a liganiL-nt. Tbe im- 
{lortance of thp lymjiliatic sjulirin about the anus mid rt-ctum will l« 
appreciated whtn wc omr to ftudy thr sulijcrt of iafcftjous and luuUg- 
nuut diseases of these orgwns. C'lininil (;x|>frii'nif lorroljoratcs the ana- 
tomical studies of Dtavcr, QuMu, and Mortau (Bull, dc la Soeiite de 
biolo^io, JSII], ]i. f>12) witb pegard to the orij;iu and Jislriljulion ivl the 
lymphatic systoni. 

Hetro-reotal and Superior Pelvi-reotal Spaces. — To cninpreliend the 
R'laiious of th*? n-L'tiim oiU' imist lh<)rou^hly undcrstmul the ci>llubir 
^[lares ^urrouiidiDg it. That portion of the organ lielow ihf |»rritoneal 
attacluiieut-and above the k-vator ani is siirroiindcd in its entire rourse 
bv a t'tillulw-tibruuM layt-r, in whitti minify ibe blood- vcsooU, ntrves, and 
lympliatica before they penetrate the walls of the orpao. This layer 
forms a complete sheath to the rectum, and p.itends from thn perito- 
neal (old down to the »iuporior surface of the levator ani nuisclo. It 18 
lunger behind than in front. The fibroue portion uf this sheath is out- 
side of the et'llular. and origiiiat«s in thi> faseiip Huiug Ihe true pelvis; 
it pluses oif fniiij Lbf pLlvi.-* in n doultW layer at the jHiiiils wliere the 
latcnil eacral artrries diverge, and the inner layer attac:h«'» itself more 
or Ksas firmly In the sidefl of the rectum at about the middle uf its cir- 
tuniference. These foldo represent the lateral ligaments of tbe pelvic 
rectum, as described by .Jonnesco and Ombredanne, and arc the chief 
8Up[)tirl8 of t.lii« portion of the organ. The cuter layer of this fascia 
proei't-ds along tbe b»nlc?r of the sacrum and is attached to this bono. 
Between these layers posteriorly, separating the rectum from the sacniin, 
is a eompuratively thick eellulo-vascular area whirli extendd tn tbe su- 
perior fascia of tbe levntor ani below, and upward between the layers 
of the mcaorectum. thus becoming continuous with the prevertebral 
cellular layer of the abdominal cavity (Fig. 32). Tins cellular space is 
termed the retro-reetal spacp, and has been en^mpared by Ombredanne to 
the prevesical apaee of Iletzius. 

Anteriorly the rectum is also svirrounded l>v a celluUr space above 
the levator ani muscles, which Ik sepaiatt'd from the retro-rectal space 
by the latero-rectal ligaments which wr have just described. This space 
separates the a-ctum fnim Um bladd(?r. prostate, and seminal vesicle* in 
mCD, and from lln; bruad li^iuiiieiits and uterus in, women. It is bounded 
in front by the prostate-peritoneal apoiieurosis, which contain* a cer- 
tain number of muscular fibers. This aponeurosie is closely attached to 
the prostate, passes loosely over the seminal vesicles backward, and is 
attadied to the side.i of the rectum along with the tati>ro-reetaI liga* 
nientit. It is also attached to the anterior wall of the rectum, thus divid- 



I 



EMBUVOLOOy, ANATOMY. AND I'UVSIOLOOV 



87 



ing this anterior cellular epacc iutu ivro [mrtionx. The spans thas 
formed are more closely connected with the gcnito- urinary apparatus 
thau wilh the rectum, iillliough they form the anterior houndary to the 
latter OT;gau. They 



:f^ A 



r/. '-4 



ll 



i\ 



■re known &s the su- 
perior pi'Ivi - rectal 
spaces (Tig. i'i). It is 
in them that abscesses 
origiuatinj; in the 
prostate, seminal vesi- 
cles, iitenitt, fln<l broad 
lignnient ofU'ti rii'vel- 
0[>. Il is not pretend- 
ed that the division 
belwoi'ii the retro- 
n-ctal uu<l polvi-recla! 
flpacfs V6 so tirm llial 
it can not hv brokon 
down, or that abscess- 
es developing iu oul* 
may not penetrate the 
otlier. As u rule, how- 
ever, those developing 
in the retro-n^ital 
^Mce will buret into 
the iechio-rectal fossa 
or burrow out through 
the obluratur foramen 
before they invade 
the anterinr spncett; and those developing in the superior pelvi-rectal 
»))econ will burrow upward and forwnnl, often npenJng iu the inguinal 
rt^ion or through the abdominal wall before they invade the relro-n-ctal 
space. Tlieee epaces are separated from the Jachio-rectal fossa? by the 
levator ani muscle and its limiting faaciie. The ischio-rectal fossse 
which surround the anus and lower portion of the reetum have been 
descritMil in ihp preeedinj* page.^. 

The Belationi of tlie Beotam. — The rectum h iu relation at its dif- 
ferent levelii with the various organ* and tiwnes of the |)elTic cavity. 
The lower or prostatic portion is in relation anterioriy with the prostate 
and membranous urethra in men, and in women with the vaginal wall. 
As the rectutn turns backwaitl at il« lower end, and the uro-gemtal or- 
gans forward, the space left between the two comprises the uro-genital 
triangle* or porincol body. Ijitcrally this lower portion of the rectiun 



Vio. 82. — ExiooKKAnio KkTieo-KWTrt.1, Cklmliir SrAirx. 




U In relation with the pxtcmal ephinctcr, the levator ani muscle, and thd 
HluitiuK fascJK of the iachio-rfctal fosew. Posteriorly it is in relation 
Willi the It'^Titor ani, the oxlcnial sphincter, nml Ihif recto-croTOVgeus 
jiiiisot(>3, iind with Ilif (ibro-fcliular tiwiit' ^('iwraung it from the coccjx 
aiid Ihc glHnt) of huM:lika. 

The iiiipiT nr [KTitciiiL'al pDrtLoii nf the rectum is in relation ante- 
rii»rl^ with the hltidtler and upiJtT porliou ol iht* pru^tai^.' and i^emiiial 
Vbsick-s in men. anil with thu vH^iuu in women. Ahorc these points U 
tfie peritoneal cul-de-sac oalloi! the proittnto-vwioal rul-df-fnr in men, 
and Duiiglas's pouch in woinon. Those fw/s-i/f-*flr contain the Big- 
moid Dexiirc, loopa of the eninll intestine, and varion^ nbdominni organs^ 
as hus IwiTi alreadv dL-tcribt'd. Tht- anterior surfuee of tlie rectum above 
this point is therefore in Telutluii with lliL-se organs. 

laterally, below the reflection of the peritonmim upon the sides of 
the pelvii*. the rctfuni i^ surrounded hy a ccMuIjir layer rontninrn}; the 
hypogastric nerveti and thif lalcrul sacml iirterte^, ivhich pa^i^ uut^^ide of 
it in the filroua sheath. Posteriorly this portion of the rectum is sepa- 
rated from ihe suenun and eoecvx by the cidhilnr ti<«i^ue. ocfiipying the 
retro-ruclal spate. On eau'h side posteriorly it is in cuutuct up above 
with the siicral ple.vuA and itynipathctic ganglia, and also with the fascial 
origin "if t\u' pynniddnl nniscles. At its lower end it conies in ronlact 
with the gliind of Liischka. It is important to observe that the orgnn, 
while relatei! to the pelvic contents, is not so closely attarhed to any of 
them that it ean imt Iw removed without injury to vita! parte. 

The ty'upports vf the Iteclum. — According to the division which we 
linve adopted tlio rectum is prnetienliy a fixed organ. Tt may vary in 
ciiliWr itnd fthapo aeeivrrting to vnnoUM eirnumstiinro-i. but unless dis- 
plaeed liy pathnlogieal conditions, it renifiins always in one position. It 
ia liehl in this position hy active and passive mipports. The active sup' 
porta are fimnd in the nui^eiilar libel's of the gut itself, in the external 
sphincter, Ifvator ani, and rccto-eoecygeiis muscles. The paj««ivL' sup- 
port* coniti»t of connective-tissue fibers, which bind the rectum to the 
surrounding organs or tissues, in tdastic-t issue b\indlet! formed by the 
peritoneal fold, and finally by the blood -vceseils which supply the organ. 

The chief support of tli« lower portion of the rectum cornea from 
the levator nni nnd externa! »iiphiiieter muscles, togethnr with its fibrous 
attttchments to the coccyx. pru!«tate. or vagina. The middle portion is 
held in position by the lateral fIbrouH sheaths, which puss off from 
the sacrum and ihum along the course of Ibn ijilrral sarml nrtprirn. The 
superior portion is held iu position by flic perilonciil folds which pass 
from the organ and are reflected upon the bladder or uterus in front, 
upon the pelvic wall.* latenilly, and iinilc poBtcriorlv to form the meso- 
rectani and attach the organ to iho autoiior surface of the sacrum. This 



r 



EMBRYOL<K)T. ANATOMY, AJTD PHtSIOLOOT 



39 



pirt of the orgau also n'ceives a CL-rtaiii niiiuiint uf suj)jt(irl from the infe- 
rior iiie«L*Dtt;ric arterieii aud Iha litiruiis slinitlis ttiiich surround Ihom. 

The Sigmoid Flexure or Pelyio Calon. — Tins luu]) of tlic Inrge inles- 
tiue, [(.riiKii lilttj tlif ouitnii iuup. uuil bj frt-ndi writem the pelvic 
colon, btigic* ttb<tvc at the termination of the defceiidiiig colon near the 
tfUter hordtT <>( tliv k-ft jinoaj* luubcK", and wmpriMis nil that portion 
of the intvstiuitt l-uuuI betut^eu thU point aud the upper teriiiiiiatiun of 
the rectum npposit*? the third siu-nil vcvtehra. 

As ordiiiarilv inca!iurc(I in fitu, it is ahout 19 inches in length, but 
when removed froni the hndy ond *trelchfd out upon hs nie^enterj' tliis 
length is considerably increased. 

It originates in the k-ft iline fossa, pusses downward (or 2 jnehes 
parallel to the external border of the psoas muscle; it then crosjsea 
transvcrs'cly to pnss into the pelvic cavity, which it occupies for th« 
greater portion of its extent; passing aero>.i^ Ihis cavity from left to 
right, and slightly upward, it reaeht'S tin- lower iiiarjrin of the rigiit iliac 
foeea ; from Ibis point it passes duunwurd. bnclfU'iii'd. and inwaid along 
the antorior surface of the sarnun to its junction with the rectum. It is 
attached to the poslorior wall of llic abdoiticn aud pelvis by a periloneal 
fold culled th(; lucsoai^jrnoid. which is conl inuous with the tuesocolon. but 
is much longer than Ihe latter, thus giving the sigmoid ^eatcr mobility 
than any other portion of the large intet^tine. Thi^ mobility esplains Iho 
great variation in its situation, direction, and rylationa, as described by 
dilTenMit authors. 

The Higinoid is divided into four portions: The firbt portion is verti- 
cbI; the second is transverse; the thinl forms a long loop with its con- 
CBvity directed upward when the sigmoid occupies the pelris, and down- 
ward when it is lifted «p into the abdomen ; the fourth is irregularly 
curvfd. and descends into the hollow of the fHcrmn, downward, backward, 
and inward. 

From this dpBoription it will appear that the sigmoid joins the reo- 
lurn from the right side of the pelvis insiteaf! nf the left, as is held by 
mon authors. For a long lime the author has taught nnd demonstrated 
the fact that \hfi intestine at the juucture of the reclnm and sigmoid 
tvTtu to tlie rinhl quilf us frctjuenily a.s to the left. The anatomical and 
clinical studies of Tcslut, SchifTerdeckcr, JoDnesco, Trcvee, and others 
prove that this it in reality the most fi-e(|uent disposition. 

The walls of the sigmoid ore composed of four layers, the mucous, 
pnbinucou)", muscular, and ferow». 

Thf Afurous anil Submrieous Lnytrf. — The mueoiis and submucous 
layem differ in no wise from those of th<? rectum, except thnt th« soli I a ry 
fnllirlea are lens frer|iipnt. and the membrane in its entirety is not tjuite 
BO thick us in the lower organ. 



40 THE AXfS, KKCTUai. AND PELVIC COLON 

The Muscular Layer. — TUl- uiuacular layer consists of circular and 
longitudinal libers. Tlit- i-irculur fibers are distribute*! arouud the sig- 
moid niucli mure e4uably than around the rectum. While tKere are cer- 
tain poiDts or flexnive iu tlie gut where aggregations nf these ]iberi> take 
place upon one oi<lc, these aggregationj^ nevor <^<>m|>lc't«lv surround the 
gilt, nor are Xhvy ever «o marked a to prodwce anv idea of a Hjihincter 
muscle. 

The Ifingitudinal fibers, arranged at firat in three bands aa in the de> 
scending colon, gnMJimllv UK^uim- tin* form »f an anterior and u pa^terior 
band, which spread out ae thi^ approach llie reetu-ttKuiuidal juncture, 
and form a more or Less compleic layer around the gut. 

Serous Lcifer. — The peritoneal lay^r of the sigmoid flosm-e surrounds 
the gut siuitlarly Lo that of the nmall intestine, and its (ulds, coining in 
contact with eaeh other iiostoriorly, ffirm the mejiortignmid nr ilio-jHiIvic 
mesocolon. This iiieseiitery is quite short in its iliac portion, hut rapidly 
bccome-s longer, peaching its maximum about ttie middle porlion of the 
pelvic loop, where it again grows shorter, and linally terminates at the 
jvinetiire of Ihe sigmoid with the rectum. The lower portion of thia 
mcseatcry, as already stated, is called the meeorectum. 

The line of insertion of the mcsoBiginnid into the pelvie and alidom- 
inai wnll.'i may Ih' ile^crilwd as folUiws: Beginning abnvf Ht tlip pxter- 
nal border of the psoas (Fig. :iri), it follows this line downward to a 
point about 2 to 3 cenhimeteni (} to li^ inch) abore the crural arch: 
here it crosses the psoas niusde from left to right, mid turning upon 
itself follows the intemnl bonier of the muscle upward and inward as 
high ai3 the fifth or fourth lumbar vcrlebra;. where it again Ijends down- 
ward and inward, crossing the right common iliac artery, and reaches the 
median line on a levul with the aacro-vertohral jnneture. From this 
point it descends in the median line as far as the third sacral vertebra, 
where il ends. Sometimes the aitachnient of the mesoeignioid extends 
across the middle line, passing over the fiflh lumbar vertebra almost to 
the infernal border of the right psoas muKcle, and Ihcti turns downward 
and inward, followinjc the anterior stirfacp of the KaLruin to the begin- 
ning of the rectum. Butwecii the two layers of this fold there is a thin, 
eelltilar layer, through which the blood -vessels, nerves, and lymphatics 
of the iatestinc ]>a»s. 

In a certain nurnhor of caseB the niesosig timid, after turning down- 
ward at the lumbosacral junelure,. parses Coward the left until it reaches 
the sncro-ischintic fvinphysi*, and tlien turns backward toward tbe 
median line of the eaerum. It li thia dii-tribution which led to the tirat 
descriptions of the ructum as beginning at thi^ point. Such an ar- 
rangement, however, is Ear frum k'iug the most frequent one, 

Inif.rsigmoid Fossa. — When the sigmoid is turned upward one sees 



IRYOLOGV, ANATOMY. AND PUVSIULOOY 



41 



at the point where tho mesoeigmoid crcsws the iliac artory a circular 
orlfiep, 10 lo 15 milIiiiiott?r!* in diameter, which leada into a funnel-shaped 
ev\-df-sac called the interBiginoid fossa (Fig. 31). 

This ful-dr-mc was fircl pointed nut Itv ITi^nsing and Ilosftr. It iB 
situated iit the ]>arictal iuMertiun of the mejiusigmoid mid a little to the 






Pis. 33.— I.m or ATTtcimiiT at thk Mt^Hxiuvviii. 

left of the median line. Its direction is obliquely upward, and from left 
to right in the line nf the iliac artrrv. Its depth varies from 3 to tj cen- 
limeters {X-f^ to 'i^ inchesl, but occasionally it extends much deeper. 
Arr>und this orifiw are Hitunted the iliae artery below, and the mesen* 
Ivric ur lhn>(! signioidal arleria^) aho%'R and at (he biAhs. It ia an impor- 
tant fTuid^i therefore, to pelvic opRrationR to indicate the toeation of 
thcae recaelfl. 

The nignioid whi-n empty orilinarilv Mh down in the recto-resical 
space or Dougla^'a cul-de-mc% and occupies the pelvic cavity for tlie 



greater |)orlioii of its extent. I'nder tnch circumstances il forms an 
acute tk-xurv at its juncture with tlif rectum. 

Wlicn distuuilej willi gas or fiwal material it rises up in the abdom- 
inal cavity as )itfi\i as the umbilicus, sometimes t<i the tiaa^verstt colon, 
or evtn to (he diaphragm ; its distal end Ueinff carried across into the 
right iliae fossa, ulraighteiis out thi"? anyie Ih-iwocii it and the rectum, 
and productK a euiuparativuly 6trai};ht chaiiuf^l through the tno organs. 

WhenpviT hy iKlhesiv*? La nils, liiuturc or any other eonditiouB the sig- 
moid is preventpd from rising up in the aWoiiiiiifll cavity, and thus 
straijihtening out this flexure, a mechanical diRkulty in the pusHigu of 
fa^rnl materinl will be presented ; as will be seen later on in tlie chapter 
upon Constipation, this condition of alfaire ia not at nil rare. 

Blood Supply, — The sigmoid flexure receives its hlood supply from 
the sigmoid arteries, branches of the inferior mesGaterie artery; they 
run cin-ularly arniinfl the gut and nnasloiiin»ie with the colonic arteries 
ahove snd I he suptrior liieniorrhnidal arteries beldw (Fig. 34). 

Il8 veins follow jiractically the same course as the arteries, and empty 
their blood into ihe portal circiilatinn through the inferior mesenteric 
vein. 

The arteries enter the mesocolon at the aidea of the inter?igmoid 
fo8i-a, and any injur*' at this point during operative procedures or 
through prnlr.nged pressure frimi uterine tumnrs may be followod hy 
gangrene of the sigmoid. 

Thf AVrrpK of the .St'^fiKtiV?.— The nerves nf the sigmoid are of the 
synipathelic variety, with the exception of n few fibers of the sensory 
type, which are derived from the lumbar and sacral plexuses and dis- 
tributed upon the posterior wall of the gut. 

Jtelationa of the Sigmoid. — Owing to Ihe srcnl mobility of the sig- 
moid flexure its relnlinns are very variws. In its uppcT or iliac portion 
it is in relation anteriorly with the abdominal wall, or separated from 
the same by loops of small inlei^tine. Pottteriorly it liew upon the iliac 
muscle and fascia, then upon the pKoas muscle and left iliac vesi^els, 
then upon the last lumbar vertebra, and finally upon the right pcoas 
muscle and the anterior surface of the sacrum. In its course across the 
pelvis it is in relation nnlrriorly with loops nf small intefitine, with the 
bladder in men, and with the uterus, pvaries, nnd fimbriated estremities 
of the tuljcs in women. Adhenions between the latter organs and the 
sigmoid are hy no means uncommon, and noemint for a great deal of the 
pain wliieh women suffer from con.'itipaLion and intestinal aeeumulation 
of ganes. 

When empty the sigmoid lies almn»t entirely in the pelvic cavity, 
ajid is therefore called the pehtc colon. Under such circiim-stancea 
it w in relation anteriorlr nnd below with the bladder in itteii, and 




of (iniall inlestint^ nnd tlie utxlomiual wall ( Engle, McdiciQischc Wochen- 
■cUrirt, Viernia, 18i»?, p. fi4" ; Jacobv. Ameriean Journal of Medicnl Sci- 
ODCL'P, ISM: mid IJoui-liui-d. Tlii^se. I^ris. I8*!3). 

ThyMloigy. — Tlic uhh», rt'ctuin. and sifjinoid, while forming a por- 
tion f'f IIk* ftlimentBry (mot, ti»ko no pnrt in the procesies of dijtestion. 
The picuioid mul rectum aw etort-hoiuee f"r tlii^ ftroal itmtprial after the 
prooe^^ uf digofition is campletc. They nrc proTided with r svslem of 




a 



•mm A.NUSJ, ItBCTL'M. AND PELVIC TOLON 



glands or tubules which absorb (toiii tiii; mass whatever fluid or nour* 
Ubing subetaDccs aie left in it. 

The functions of the anus consist in fwrni*!bing nn e:^it fir tho fircol 
material and in coiilrolliug it* discharge uscept al opponuiic iin-nuvnts. 
To normal conditiontii this exit is wide enough to admit of the passage 
of wpll-fnniipil masses, and capable at dosing sufTaiuntly to n-'iniii abso- 
lutely fluid materials. It is governed by both voluntary and involuntary 
musclea. Normally the aperture is clofied, but this cloeure may be ren- 
dered ninch more firm and recisting hy Toluntary ac-tion when exigeucien 
require it. The organ relaxc.* nnd opens through the inhibition of spbinc- 
teric contraction ordinarily governed by will-power. It 8««Tuti to be eou- 
trollcd by two centers: one in the r^pinnl conl ami tlip otliiT in tin? brain. 

Physical and anatomical experiments and a study of lesions of the 
cord show that tlie reflex center of the anus and rectum is located 
in the cord nearly opposite the bfl-se of the first lumbar verl-ebra in the 
xery tip of the cord or cnnus med\dlari8. 

The inhibitory center is situated ia the brain. Injury to the chorda 
and more part icularly to the conu? is therefore followed by incontinence, 
while injury or disease above this region result* in constipation. 
" Vrocos or air in the reetura excite the lumbar center and cause two 
effect*— cont Taction in the wall anr! relaxanViii of the sphinct^^r. Tliia 
process can be controlled by the will to a cousidicraljle extent, although 
we are still ignorant of (lie precise modi- in which the voUiiitftry iuflu- 
bDcc ia excited. Hut if Ihc volitional path in the cord is intcrruptwl 
above the lumbar wntcrs, the will can no longer coutrul the reflex pro- 
CC£«C6; aa soon &a the fa;ces irritate the rectum they will be expelled by 
the reflex meehaniwm. If tlie damage to the cord involves ihe sensory 
tract. Ihe putieut is unconscious of tlm action of the bladder or bowel. 
If the sensun- tract U unaffected, the patient is aware of the process, 
but tan not control it. It is often said that there is perraanent relaxa- 
tion of ibc sphinctcns but this in true only nhen the lundiar centers are 
inartive or destroyed. In this condition evacuation occurs as soon as the 
nrine or frcccs enter the bladder or rectum. The urine escapes continu- 
ously instead of being expelled at intervals. The condition is le69 
obvious in Ihe ease of the rectum, becauae there is no .iiteh continuous 
passage of fiuces into the rectum n« ibere is of urine into the blnditer. 
Vie may, however, distinguiRh between The two states of the rectum hy 
tlic introduction of the linger. If the lumbar center is inactive, there 
is a momentary contraction due to local stimulation nf the Bphincter, 
and then permanent relaxation. If, however, the reflex center and 
motor nerves from it are intact, the introduction of the finger is fol- 
lowed firsl by relaxation and (hen hy gentle, tirm, tonic contraction" 
(ttowerSf Diseases of the N'ervous System, vol. i, p. 3-16). 



I 



The functions uf lUv rc-ctum and sigmuid are practically tUe sumo. 
They arc both n-'CojitaileB or restTvoirs for the fieeal maU-ria] aJtcr it 
has pnssod through the intc*iina! cnnal. The nmterinl is softer and more 
fluid in the si^nid tlmn in the rectiiin; it i^ also mom- conslnntly pres- 
oDt in the former. It is not true, however, as is frequently stated, that 
the rectum i*; always empty exet-pl JH*I before the period of defecation. 
It nearly always itintaius tuore or less faecal luatter. The writer haa 
made mauj exaniinatioiis with regard lo iliis t»Li, bhJ, uxcept in cases of 
itufjacliuu, la- lias nt-vt-r fduuj u mi«' in whiHi 1.lw rectum wb:" empty 
and the sigmoid well filled with fa-etil muterial. They both act as reter- 
Toire, and a certain amount of faecal material is always present in them. 

The tlieory and proeeiwefi ol defeeutioii, toj^etticr with O'Boirne'a 
doctrine of relro-peristiiltie aeliou by which the fa-eal mafes ik lifted hack 
into the siftiiioid after it h»6 ouee entered the ret-tura, will all be dis- 
ciwsftd in the chapter upnn ■constipation, hs ihcy Uur directly ujion this 
Bubjett. It is Huflii'ient to stale hi-re llial after a >;reat imiiiy ouular es- 
BminationB of the reetuni and sigmnid, the authur has never sccu a cuae 
in which The fipial nuiiier, havitig once entered the rectum, has been 
lifted back into the sigmoid Hoxure. 

Owing to their giandulHr appuralus, both the rectum and eigmoid 
act as ahsorptive and si-t-retivi' or;,'Jiiih. The lunger the fa'eal mfljifi re- 
muius in them, the drier will it Ifficorne through the absorption uf its 
fluid inaterinls by the Ijieherkiihn follieles. This nbsnrplive aetion of 
the rerliini is made use nf by physirians for the stimulntion or nmir- 
ishnient of patients when feeding by the 6tom«ch is impnictirnblc. t'er- 
tain medieitwl substances eeem lo enter the eirculation much more rap- 
idly through this route than through the stomach. Ab example*?, we may 
nu-niion eoiaine, belladonna, hyoscyamus, aud opium. \Vhi?ther ahsorp- 
tion tikes pbiee through the blond -vencels, or through the i>pillii>lial eellt;, 
or (liron^h the intereellulnr suiwtnnec between the individual eell*. is 
not rjear. Cripps (op.cit., p. 16) doubti* the rsistence of llie intrreel- 
Inlnr stibtjlaiiee, an<l mivh that "it in highly prnhable abt^orptioii takes 
ptaec through the epitliehat cells themsehef. Poscibly the nurloi of 
the columnar epilhelinm may be the meana of taking nourishment into 
the body by escaping into the retiform tissue between the glandvt, and 
thu« becoming lymphoid erdls. Aeeonling to this view, the i-ohiiunar 
epittiolial celU lining the n'clal follicles have a far higher function than 
that generally asidgned to them by physiologifits, and instead of being 
employed in n simple secretion ef miirtis, they arc in reality the paivntfl 
of IcucoeytcH of Ihe body." Tbie theory is intcn*ting, au<l iu author 
Iiat> produced eoine microscopic eridenee in ile fflTor, but the neecwnrily 
t\oie proceftjeg of such absorption are not in keeping wit h the rapid entry 
into the circulation of certain substances wlien introduced into the rec- 



46 THE ANUS, RECTUM, AND PELVIC COLON 

turn. Considering the large capillary and vascular supply of the rectum, 
it seems more probable that absorption takes place through these, and 
that the absorbed fluid enters directly into the circulation. The secre- 
tory functions of the rectum and sigmoid consist in secreting mucus in 
greater or less quantity, which lubricates the faecal mass when dry, and 
thus facilitates its passage with the least possible friction. The amount 
of nuicus secreted depends upon the dryness and irritating qualities of 
the faecal material. In normal conditions it is barely perceptible, but 
in cascK of chronic coniJtipation or acute catarrhal inflammation, it be- 
comes greatly exaggerated, and sometimes exhausting to the patient, 
even where it is not accompanied hv discharge of blood or pus. 



CUAPTEU II 



ilALFoHHAnOSS OF THE ANVS A^D RECTUM 



W1111.K the proj>orltnii nf lllill^o|-lIliltil)ll^ uf tlu^ umi!i iiiid roi-tuiii iQ 
the total number of rhildiL-ii Inru i^ vifry niiiatl. IIk' hl-IuuI miinljer is 
far from incoiii'iilfi'jiljii'. Murciiii ^lult-d In tlic I'uris Aiiicli-mv iiT Mi-ili- 
cine tlial lie haxi obaervfJ iluria^; u [inicticf i»f forty years in ilif Mulvr- 
nitv Jiut>pitul only four l-usls of iiiiixrrrixriile aniii'. C'lnity, of Jiuvre, in 
AD es|t.>rk>rice of 3,500 eonlinomeiitsi mw :1 cnsee. Collins, in Ihc MnltT- 
nil)' Hoi^pity] of Dublin, siiw uiilv ! tii»-t> in ](),OiJ)J L-hildrcn, wliile Zulire, 
of the Vionnu Mut^riiilv ITu^pital, iL'iinrtMl only 'i iinpurfDnitions in 
fid.OOO i-liiliin-ti liorii ui tlial iii»tiliition. In 11il> rari-'i MutiTiiity Ilu^iiiUl 
from J871 to ]SSr> tliere wpre .1 rii,'*<!s of Hiio-rccliil niiilf<)riiia<iuii<i in 
80,fiOti births, nml in the (Jochin lying-in Ho^pitnl iJuring Ihr siatiu? [HTitwi 
(hcrp WHS only 1 irafle in Tli.'i'J"^ birtlis. These fiicts iipn-H in the nmin 
with tlie cslimatc of Starr, who i^tatoil thai tlK't«e iiialfunnationD occiirrcMJ 
about Olio; in iU.DOU births. 

AHllinfB ililTiT as til tlipir ri'liilivc fn'(|iicik'y in Ihi' two snxes. Thus, 
wliih> SMilh)t Ktatf'ii that ;;irU alwavH furnii^h tlm grcateet nitmhtT of 
cnq-rpctnl andiiinlips, Curlin^t fniiml in HH) siir-h rnsps .18 boys and +8 
giiU: Bouii«8on in t!tf sfliiie mnnlMT of chililrpii found 5:1 g^lrU and \1 
boys. In onr own collection of 14C) tnses t*o far as the scs was known 
llieri' wt'i* 52 boys uiid 70 girls. II the enscs of atrnsia iini vagiiinlift 
arc )ii('1u<lc(l. the preponderance frill be in favor of the fernate sex. but 
omitting thc«e cndos, Ibeiv i* no appreciable ditlcremx in the frequency 
with whioh nialformntions ownr in the two S4'xes. Thwsi; utatii^tii'S all 
refer to protts nialfnrimitione, and are no( entirely aecurate, tniisnmeh as 
many of tht'*e abn»rnialilio» are of a partial nature and present no phys- 
ical syniptoriw calling' attention to tlu'nj iu early life. As a enn.'ie([iicnce 
the viclinid oftcu so to old ujre without knowing that any deformity 
exisl«. 

The uegl«ct of systematic examination of the rectum iu now-hom 
children by accoucheur* and midwivoe allows many of theso minor mal- 
formation* to go unolwt'rvwl. Thus one sees (\\x\\f fTe(|Hentfy instances 
of couguuital stricture, valvuhir otclusioa, and rectal umIfornintion.i in 

4 « 



iS TUB ANUS. KEOTUM, AND PELVIC COLON 

perKoiis who Iiave n'litlit'd Ihc age of imlcrtj, sui)posing th^y wt^rc aiui- 
tomically perfprt. Mcirpijnii records a riiKe of tliitt kind jn wliJch ■ 
woman who lived lo be one liundred years of age, was married, bore chil- 
dren, and performed all tlie duties of life without knowing she hod any 
nialfortniition until »borlly before her death. 

Tho impnrtaiK'O «f sueh c^iiiiniiiation iirul the early reengiiilion of 
initlfnrinntioiiK eati not Ih' overi'stiriMted, fur it is oiity in the earliest 
stages that we can hope to remedy the rase.* of complete occlusion, and 
it is at this stage al->o that we may do most to prevent the minor malfor- 
mations proving serious in Inter life. 

Welch, of Baltimore, hat^ shown ttiat the meconium ut thi: time of 
birth and for some houi-s thereafter is a sterile Hiiid, but that oftcr 
the digestive ppoei?»ries linvc token pinoe in the intoi^tinitl canal it be- 
come!* infeetions and is no longer frtu? from danger to siirf^tejil wounds. 
This fnet would indicate the advanlageK of t-arly operation from an anep- 
tic point of vifw, for it is the rule in »udi operationi* that the mecnnium 
escapes into the wound and thus exposes ibc latter to whatever infec- 
tious >rcrnis it may contain. The lnr;if niujority of duiitlis from opera- 
tions of this kind are due to peritoiiitis or sepsis which follow tht; i.-£va|ie 
of the intestinal coutcnte into the peritoneal cavity or wound. The 
earlier, therefore, that remedial mensur<?8 are undertaken, the less dan- 
ger will there be of septie infection. 

In tht! st'cliim on eudji-jolo^'y it was ishown that the reelum and 
anus are developed from two enlirely ililTerftit layers of llu* blasto- 
derm, that the hlooil supply of these two orgaiw come fmni ililTerent 
Bources and return by different roiitcfi lo the general rircuhition. Arrest 
in the development of one, therefore, if not npcirtrwnrily nfifooialed with 
that in the other; in the majority of ca?es where there is ma 1 format ion 
or displacomont of the roetHm, the nnu.i i» ordinarily nonnnl, and vic» 
Virsa. On the nlher hnnd, malformation of eitluT one of theBO orj^iiH is 
very likely to be assoeinted with mntformation in olher pnrts of the body 
derivi'd from Ihe same layer of the bla.'ilodfrm. Thus, children with mal- 
formations of the rectum are very likely to suffer with cleft palate, nasal 
and pharyngeal obstnictions, or other abnormalities of the alimentary 
tract. Thojie with malformationa of the anus iire likely to be a^t^ocialed 
with malformations of the uro-genitaL organs, such a^ hypospadias, cx- 
Btropliy of the bladder, atresia ani vaginnlis, etc. : Other malfnrmfitions, 
eiieh as deformities! of the pelvis, nbsenec or twisting of (he coccyx, close 
apposition of the tuber ischii. and absenco or iuiperfeet formalion of the 
perinjeum,may be associated with malformations of the rectum and anua. 
It is not within the scopi- of lhi> book, luiwi-vcr, to consider iimnstrosities, 
80 the text will be restricted to those ma I forma lions affecting the rectum 
and anus only. 



IL 




MALFORMATIONS OF THE ANUS AND RECTUM 



49 



The claBsipnl divisinn of tlw^c niiilfnrmatinns v.m first laid down 
[by Piipppmiorf in ITHJ, and iias hwn elnsolv fdllowoil bv uioiit Wp'ritt'rs 
^inre his 6ay. In tliis cla^sificntion the rectum and anus are congiJered 
'^Bs one and the same organ, and no distinction i» made belwwn inalfor- 
mationa re.sulting from arrest of develoiJiitcut in the jmrts originating in 
tlie epil>la»t and lliuse ori^'iuBting Ju tin- hypublast und mesolilast. As 
the writer has always observed this distinction, Paiipcndorf's division is 
Diodili»d an M]ovn: 

Malformat'wm of the Anu» 

fl. Entire aberttce of the anue. 

b. Abnttrmal narrowiug of the anuf,. 

c Partial ocdmion of the anus. 

d. Absolute ucvhision of the anm. 

e. Anal ojienimj nt some abnormnt point in the penneal, scrotal, 
or teuTtil region. 

Ma!formatio7tg of the Rectum 

a. Heclutn entirely absent. 

•b, tteclum arrealed in its descent at a point mor$ or less removed 
the anuf, the anus being normal. 

c BectufH opening into some other viscus, with anas present in its 
normal paaition or absent. 

d. hectum and anus normal, with the erception that thff -urtter, 
bladiifir, vaffina. urethra, or uterux opens into the rurliim. 

iWith this division we an* able tn clearljf follnw nu( the iiialforma- 
lion» dne t« the urrc&t of develupmcDt in the different ta,ven> ot the 
blast odemi. 



MALFORMATIONS OF THE ANUS 



a. Entire AbMnec of the Anas. 

Ca^es in which the unut* i;^ ^Mitirelv absent are comparatively ran. 
The nurse or medical attendant when exnmintng the child for sex 
*ill imim-'diately rpcuynizc iIh- entire absenw of llii* iinuri, wheresH i( 
it is only partially funiu'd llie dcfnrnntv is gc-rienilly (.iveiliioked. In 
lh(«e eaMiH there may be n dppr«HKion in the skin at tliu point wlierv the 
inuH f>)inu1d lx>, but sometinieii there is n Nmnll mrm^nted biiltnii nf 
»kin or protniiiion at ihis jioint. At other tinicB there is t^imply n slight 
(liMxdoration, with more or less rugte of the ttkin tistiue rentcrinj; around 
Ibe rutrmnl point. Again, the skin or central rhaphc of the poHiiiPura 
My e!ct*nd in in unhrolcen line from tha scrotum to the coeeyx (Fig. 35). 
n *nrh caned the rectum may reach down almost to the Bkin, it may open 
tosonw other viscus, or it may Iw arrested in its dei!cent at a grpaf.er or 




so 



THE ANUa RKCTUM. AND PEIAIC COLON 



;t 



;l^' 



,», 



less distance from Uie point of ll»^ auriiml uuiis. The Lwistenec or ab- 
scDL'e of a tleprvssion at the piiinl wlicrt? tlir aurmni niius sitould be is iio 
imlk-aliou wliatt-vtr of the distance at which the rectum will be found. 
Ill some aisvs wUerc there is a marked depression, or even a well-formed 

aaue, (h« rectum will 

_^ be found hi;|;li up, 

'BB whereas in otliyr cases 

iti which tticrc is not 

iL\ ^Li ^ t ■ the »li;;hlest indiriitioit 

of an anuii the rectum 

will be fuuiid close to 

tilt" surface of the skin. 

Tliiti fuel in of impor- 

laiiec from a pmclieal 

. I point of view, showing 

^ ' *^ I that the abwnce or 

Tery slight devflop- 

jiieut of the anus 

would be iio iudieativn 

for doing nn nltilom- 

ilittl (ipi.'nitii>ii for iin- 

perfurntioit iinlil a 

careful g«ireh through 

the perina'iim had 

been iimde. 

AsKocinti^d with thin 
form of nifllformation 
we are likely to have 
other d(>foriiiilLC8 in 
the exterim.) genital or^'iuis, such as alropliy of the vaftimi, hypo- 
Hjiailias, exstrujihy of the bladder, and (leforiiiities uf thi' jvi^lvis. The 
tuberi iHt'hii are likely to he iiniisiially close loyether, and the iH-Wia 
itself iriiiy he so narrow and generally pniallcr than tmrimil that 
the defomiities will be obpcrvalde from a simple inspeetion of the 
parti. The genital organs aho may ho set further liaek toward the coc- 
cyx, and the space between the bladder and the sneruui niav bo so narrow 
that it would be almost impossible to insert the finjier between tinini. 
These malformalinns it will be seen arise in tissneu nil having their 
oripin, as the anus, in the upihln^t, and m»y be independent of any de- 
formities or arrests of development in the tissues arising from the other 
layers of the blast uderm. 

Diagnosis. — Where the nnua is ahsent there is no ditriculty in rerog- 
niuDg the fact by »ight. Where such oijscrvatioa is not made at tlic time 



■in, s.'ii.— Cow riKTK AnoicxcK ot tub \vxf. 



t 



MALI'"OUMATI0NS OF THE ANUS AND RECTUM 



61 



of birth it will sonn he noticed thai there i» no pa^^agv of moL'oiiium or 
fiecal mutter; tlijit the child is restless, aud soou begius to Etruiu ; the 
nlidomeTi becomes tenee and ewoDen. and after a fuw du v» the child ejects 
its food, digested or Tindigeated, accordioj? to tbc slule of tho ttonuirh. 
With thotir.1t appearance of such symptoms, ocular and digitnl examiua- 
tiooii ore called For, and when these arc made there is no difliciiltv to 
dingnoi>e the malfnrinntinn. As this is one uf the tvpe^ uf itiijierfonitc 
anus, (he consideration of treatment will he postponed uutil ulL have 
been described. 

b. Abnormal JTarrowiEg of the Anus. 

Jn llii-'se caste the anus is present, and may appear perfectly normal 
lo the superficial okiHTver, but upon csaminntinn it will be showu that 
it ia unusually narrow at some portion. This narrowinj; may take place 
at any {Hjjnl from the margin to its junction with the rectum, nr it may 
extend throughout the whole lenj^th nf the anm. Ah the length of the 
iiorinal anus [.■; fntm 1 to SJ centimeters (J to ! inrli), the narrowing 
wliicii win lie jiropfrh- tittiibuted to it will he limited to this extent. 

The n»rrowi:ig may be annular and very short, being foniied by 
band? vt uienihruneH extending,' from one sidt^ of the anwH to the other, 
or it may extend fron) the margin to the upper limits of the anus, 
consisting in a general incapacity of the entire anal eanul. This eomJi- 
tioif dilTiTs from the narrowing of later life produced liy pathologieal 
caueeR in that there \^ no hypertrophy of connective ti*r!He, no eicatrieial 
liSHUo, and no hardening of the parl)^; the anus is soft and Hexihle, and 
its walls coDlinue so upward to the rectum. The eondijtous atlribulablc 
to intlammalion iiiu.v develop later od in life, owing to tin: passage of 
faval matter thnnigh this nbni»rmally narrow channel, and the conse- 
quent irritation llnTcfrom, but in thow chmis which liave been observed 
at the time of birth there h&e not yet been reported any evidence of 
pathological proecsj^es having taken place. 

Tile que>ilion of tlit> dize of a iioriiiiil anus at the time of birth is 
mihiT ditTieult to decide; it depends upon the size of the child, but in 
general une may say that the anal canal at birth ought to admit with coin* 
partitive ease the little finger of a msu'c hand, m Ihe iiidcv iiiigcr of a 
Woman's. If the sphincters are normally dcvdoiM'd they will Ik- found 
to graep the finger gently, and yet easiity enough to admit its pa»i»agc 
well into the rectum; whci-e there is abnonnal narrowing this sphiiic- 
teric atiion i» generally defirient, and one finds it diilkult or impossible 
to introduce the finger through the contracted canal. These eases are 
the oiH-'s in wliieh children are reported to have U'cu ennstipaled all their 
liven, ami who fn'^piently develop strictures or fisstires in early life. 

Pntlhes, in a thesi* before the me<1ic«l faeulty of Paris, discusses thia 
sabject at length from the point of view of congenital strictures. Ho 




I 



62 TOE AXUS, RBCTUH, AKD PELVIC COIXJS 

that nuui; of thes« cum reach adult and «t«o old a^? vithoat 
rcring the trne tutare of thoir condition, and r^t their hifitoriM 
■od lifptong fspcriooees would g» (o prove that the narruTing had ex- 
isted at the lime of hirth. We mart differ with Trelat, Rinmier, and 
Pfltlbn JD calling thu) rondition etricture at the time of birth, U-cause 
thut lerm de«igiiale« a pathological narrowing of a canal whi<-h has been 
of nuntial pruportiomt, and the; all declaim any cmch procesA in ita 
production. Tlic patholt^ical condition in these cases comes on after 
birth through obstnictioti and cou«ci]UCQt irritation from the fiFcal pa£- 
Bagca. It is Inio when thcee cases arc treated in adult and latL-r lite 
that the condition ta then one of sirivtun- with all \t» pntholo^pca) ac- 
eoin|janiiuunti>, and niay be (.-laBsed (as Puilhes lias done) under the head- 
ing of congenital ulrii-ture, referring, of tounte, to it^ origin and not 
to its pathology; but the congenital feature con»iiil» in an abnormally 
anutl anal canal incapable of lieing dilated by the fa.*eat muss, 

DiagnoKU. — The dlajfnofiiK of this condition iit not so ca^y as that of 
total absence of the anus. There is generally more or le^ room for the 
paamge of the mc^'onium, and a^ ga? escapes through ven' fnml] pas- 
Bagw, the child in early life is not much disturbed by it« accaunuliition. 
As loti^ as the fieeul piDiKogptt are seniifluid, ati thi>y should be in infant 
life, these abnormal narrowing!! of the nnus will pn)duce no subjective 
synipLuniit; hut as iwon as the fiecal Tualeriat heginn to be itolid, obstruc- 
tion and irritation will take place, and the patient will have lo strain 
and suffer piiin whenever a movement of the bowels occurs. Such chil- 
dren soon Icam to dread the hour for being sent to the commode, and 
the result is a marked constipation with all its evil i>flects. The only 
absolute diagnoKig of thettc mnlfnnnntion? i:* that miidc' by the eye and 
finger. 

Serrcmone han callpd attention to cnngenitnl narrowing as a fre(|uent 
cause of fissures, both in children and in adults. When these fissurca 
are found in infancy, however, they must be clearly distinguished from 
those due tu the dry. lirittlc mucous nieiiibranc found in hereditary 
erphtlis. Digital examination in these cases will elicit a narrowing at 
one point orthronghout the entire length of the ami?. When the canal ia 
large 4-nuugb to admit the tip of tlie iinper, the extent of the nialforma- 
linn and the density of the surrounding ti««uo* can Ik? easily told. When 
it is too small for such examination, tho uterine probe or some such 
instrument can be passed through, and. being bent upon itself, one 
may bf able to iletennine the nature and extent of llie narrowing. 
The older the pjilioiit is, the more dense and inelastic will be the 
conelrictim'fi; and the more imviclding they are, the more distress will 
lliey occasion. 

The child may pass through infnDcy and childhood with no other 



MALPOEMATIOKS OF TUB ASUS AND RECTUit 



53 



uiiiiy 
■ Sxan 



I 



nns llinii those of constipnrion. Tills, however, may aUemate 
with 8 pBeinin-diarrhtPB — thai i?. the ehild may have impaction, and yet 
at the same time suffer from the frequent passage of lluiil fttTca around 
th« fsecal TTtacs. The author saw an interesting case of thi^ kind some 
years ?incc In a boy four ycnrs of iige, who wns brought to the cUmc on 
account of the dinrrhn-a. He vem having twenty to thirty pasgagos 
dnilv. was eiimeititKl, pale, and seplie in nppcamnee, his nbdomen was 
grvatly dinfeinlfd. and his iiliysiognoiiiy suggested lubtreiikr ifntehtis. 
Examinaliou iindcT cidon^form revealed a narrow tubular anas not 
I'noujili t<i ndmit tin- littk- Jin{;»rr, niid innipiibk' of bi-liij; dthitifl 

lOut tearing. It was therefore iiiciftd ])oi«ttTiorly. Within the fol- 
lowing hour hir pnitacd more than six pound* of iiurd, lumpy ficcea. An 
oxamination of tho child's Tectum at hirth would hnvD *lif>wn this dc- 
lormity, and perwielent diliiiiitioii at llial lime wuiild have prevGUled 
tliv auffering and necessily of operation. 

Tho*« eaxoR in which the narrowing is not oh«fi-v«l until in adult 
life can only l»e KHi>pni):ed as rongcnltnl from the subjective history. 
Kelsey (Disensei* of the Reetnm and Amw, p. T4) ha.1 related a case in 
which the c«ndi(ion wjis tlieiovered at the age of thirty-eight. Trelat 
fittw one al riftv-tno, toid. the author 
has accD one at twenty-seven. Xone 
of theii«o jtQlieiilii had any idi'H thuy 
were malformed. In genonil tenrm 
one may nay an amis that wilt not 
admit a N'o, Ti Wales* hnugic in in- 
fuDts. or a Xi>. • in adiilti^, may be 
called ■bnommlty narrow. 

r. Partial Membranous Occlu- 
non of the Anus. 

This viirietv of malformation of 
the anus is not rnrc. It fonsistn 
in a partial occlusion at Kome level 
of th(> anal canal by a membrane 
or fold of tissue. If Ihe fohl i« 
situated at the margin or outside- 
of the anal canal it ia composed of 
»kin. Sometime.^ it (irciirfi In Ihe 
shape of a central rluiphe exLeud- 
iog from the itcmtum to the coccyx, 

with a umall opening on one sidt- or holb. at the point where tlic amis 
should be, thus allowing the passiige of llnid fieeee or meconimn 
(Fig. 36). 

Wben tlie occlusion is higher up, the membrane is composed of maoo- 




■ 




54 



THE ANUS, UECTITM, AND PKLVIC COLON 



cutsneoii}! tii^ur. and has a crescentic nr circular shape with a small 
opeoiug either in the middle or upon one side. These opening may be 
of cuu^tderaLle size, or barvlv large enough to admit a probe. The 
Bnmller the opeiiinjf, llic more Ukcly it i* to produce coustitutiomil itud 
iubjcctive syinptouis oarly in life, When the mombrone U &ituatx?d as 
high as IJ lo 'i eeiitinietors (| to } of an ineh) from the margin of tho 
aiiU!;. it will be* diiv prottiibly tu iiiiperft^eL ab^urptiuu of tlie uuo-reetal 
u».>nifariiTie. Sudi ciisuii, however, imist lie ilistingTiishwl from those in 
which thiTt! is B» iibiuiniial fold lower down. Thesi- <'ases have bt-en 
tlescrilx'd as rnnjfeiiitiil strirlurei^, but should be elaftsilied under the head 
of enngenital iiial rorniiitions. As in the previous class, they have neither 
the pnthoh>gieal nor physical characteriiitiei* of stricture. Tliey are gen- 
erally oU-erred earlier in life than the preceding cla»ii, and arc much 
more caBily dealt with, in tlitit they do not involve the (Iee|>er layers of 
th« nnal wnl). When attention has been oneo called to them the ding- 

nosi.f is ea!»y, liecaiwe 
iill of the nialfonaation 
is within reach of the 
tinker or the ppiibe, aa 
well as wit hi I) oeuLar 
obacrvation. Tla-y fti'o 
frerinendy si>en in adult 
life, and produce 80 
little diHturhauco that 
tliey are oC lui surgical 
iin]K»rl!in(c (Fig. (i"!). 

d. Complete Obstruc- 
tion «f the Anus b; 
a Membranous Dia- 
phragm. 

'I'lif ilislinetinn be- 
tuern this iirnl the lost 
vnriety of niiilforuiation 
of the anus is simply 
one of degree. The 
former represented a 
partial oreIii«ion not irnmodiately dangerous to life, while this rcprescnta 
a complete oeeUiiiion,whieli iiiunl be overcome in order tlint the child may 
live. Siieh eases are extremely rare, and are among the en^icst to rem- 
edy. In these the anus is simply elnsed by a thin menilrniioue diaphragm 
resembling very much thp hymen, which is composed of fibrous or luueo- 
eiitaneoua tis-ue, very thin and flexible, that extends in erescentic layers 
from one wall of Ihe ami.-? to the other. I f the rectum is properly tlevel- 




Fm. S7< — rAwriAi. Mr.uutiAM.i- <i'>i.i6ui> or turn .\»i'h. 
ObMrvod III u inuii Tiinr two r«x>v otnen. 



1 



MAIiPOBMATlOXS OF THE ANDS AND BECTUM 



55 



opod in th<>90 cases one cjin ensih- sec or feci tlie bulging of tho meconium 
sgaiD«l thiii« thin rlJnphanoue uiouibraQo. 

It has been aftsumcd that this form of niall'oriiiatioii is simpl}' »n 
arrest in the absorption of thi- ineiiibruiie dividing tlw proflod.Tutn nnd 
the I'liliTun. Iln lotalioii in smue casi-s la too luw down to justify any 
Auch genvral conclusion. T)ie riica.'^iiri^nicnt laid down by Trelat, and 
H^ain by Bodcnhnmiir, pivirs Ihi^ length of the anus as IJ centimeter (J 
of uu iiU'h) mi the time of birth. Now. if this diaphraKiii were Ihc 
uiiabworlied nHMnbranc tetwi-'cn tlicse two purtionB of the intostinc, it 
would 1)0 located lit the h^vcl at whifh Ihi' partition is found, Writew 
who hiivfi dcscrilK'd thvi-v lascs t^pi'iik of (hoiri ixs Ijcin^ faiinU at J a 
centimeter, ^ of n centimeter, nnd at 1 centimoler from the anal mar^'in. 
The author lias seen three such cjim's. In niic lliu nienibrane wan situ- 
ated just i a ci-n 1 itnotL-r (fV of an iiitli) from Ihe niarjfin of thu amia; 
in auoUier it was mtuiilL-d a little k-t« timn 1 cuntiinuter (S of un inch) ; 
an«I in thp third at ulmi>st exm-tly 1 wnlimehrr. They wen? nil covrrod 
bclon- Willi ii muco-ciitancoiie nienibriinc. Tlic incnihranu in ono case was 
eo thin that it was punctured with the fiat end of an ordinary probe, 
nnd then diiuUed by the fin^'crs. Four Vfiirw iiflerwanl lliis chitcl was 
nuun, mid tlierv was no i-vid4'rife of llii- n>riiiiins of thi? nu'inlnme, but tho 
i.QIglttal line of tht> peeten war* clearly marked and well ahm'c the point 
nt whivh the mendiriine was allnchml. judging by meiisiireim'Tit. In the 
ftthiT IvTii cases later oliservntions were not nhtHiiiahle. One should not 
infer from this that, occlusions from arrest in absorption of the sa'pliim 
betvreen the proctoda-uui .ind enteron do not oconr, for they do; but they 
■re not the only meTiilininnus oeehisions of the anita. Ljifer on we will 
wc that in some ensen the anuH in oeelud(>d by one and the rectum by 
another separate and distinct nternlirane. 

Diiiifnims. — The diajjnojiis of ihcHp cases is based u|M)n the absence 
of diiichargcs of meconium, inability to introduce the finger into the 
rectum, the ubMtnu-tt'in hein^ tow down, and the thin fluctuating feel of 
the onrhidiii}^ Tiii'inbram*. 

r. AnKi Opening at tome Abnormal Point in tlie Perinseam or Saonl 
Eegion. 

Thiit variety of inAlfurniation i» descrilxtd ordinarily as a malforma- 
tion nf the rectum itself, and in some ini^tfinees it is such, for we have 
cnwti in whieh the aiiu« is more or less dex'L'lofied in its proper site, and 
yet the n-clum opciu* at some ntliir point of the perineal or saeriil region. 
In the toajority of catico, however, where the rectum opens at one of 
thew abnormal imsitions then- is no otlu-r nnus jirf^ent, and a careful 
examination v( the abnormal opening will show that there is o inon? or 
IcM deTclo[)ed ephincter around (he aperture. Where sueh a sphinetop 
exists, it #vcm«i quite natur.il to call this opening the auus, especially 



S6 



THE ASL'S. RBXrrCM. ASD PELVIC COLON 



if vecan ehow that the pawiiit'nt t-iiitlit'lium which covers the skin and 
lines the lowi-r purtion of tin- ink'dlinal t-auul L-.\tvnd» for aoy distaD'ce 
upward in the abnormnl openinfr. Where this pavement epithelium 
ci*»»c« nhni|it!_v upon the odfje, niid i^ trfflosforniciJ into eoluiiintir i>pi- 
thcliuin, witliout i-iidt^'nco of tiiL- ^rndual tran^iticm bolvpon Iho two 
won in the norroul auiw and rectum, then we may properly classify tliem 
under nialfonim1iou<! tif the n-ctuin. 

There in no (ixi-d positimi, nor evi>n a general one in which sutli 
openings may he fmind; in fiirt. sometimes there is more than one orifice. 
The openings may be in the anterior or posterior part of the periua-um 

(Fig. 38), to one side 
or the other of th« 
sacrum, or oulHide of 
ihi' gluteal fold. In- 
deed, the rectum or 
ihe Bman intestine liaa 
bivn known to open 
on the thigh, the ab- 
domen, and the shoid- 
dor. The anus is usu- 
ally developed in the 
iionnal site in the lat> 
ler cases. 

It is not intended 
tn <lii»sify under thia 
head tiiui«e canes in 
which the rectum' 
opens at siich remote 
points, or into other 
origans. We refer hero 
tn thotie in wliicli the 
anus opdis at au ab* 
nominl position in the 
perinietim or Kaenil r*- 
gion. They have been 
described by some as 
Hstulous ojH'ningv, but 
they liave ntmo of thfl 
pathological chaimeteristics of fistula. There is no pus aswiciated with 
them, th'-n* is oo ricatricial conlraelion at the time of birth, and there 
ia every evidenee that the foUlin^r in of the epibla*t simply (Hrcurred 
at an abnortnal position. 

Piagnosis. — Tlic diagnosis of such cases consiate simply in seeing 



Tut. W,— AMua orUfiN* at Tip ur C<wcvx. 




MALFORMATIONS OP THE ASUS AND KKrTl'51 



5T 



tTiem. It 19 iiiiprtrluiit, linwevcr, to di't ermine wholhor 1Iw>rp is sphine- 
teri»; control ovtr the passages. If tJierp is, interference will not bo 
jiwtified; Iiiil if there is not, it should lie undcrtakpn as soon as the 
child's condition will admit of it with safetjr. 



V 



MALFORMATIONS OF THE RECTUM 

a. Entire Abtence of the Rectum. 

Tliii* vnrioty of ninlfnnnntinn i." one which it is impossible to liiag- 
nose wilhnnt explnrnlnry incinion. The eondiliun of tliu oxtc>riial jjiirts 
in no vr'mo indicates the pnibable abscDce of the rectum, lu Lhn^L- eit^es 
in which the imperfo- 
rate anus inw(.'ll formed 
the n*rtum muy be 
clo«c at liond, tiiinj^inji; 
•loowly in the pelvic 
eavityj atlaelied to 
some other porilon of 
the atiduniiiial null, cir 
it may he fnliivly ab- 
sent {Fiff. 39). In cases 
where tliiTf 18 no ex- 
ternal evidence of an 
anns or twtiim, the 
latttT may be eloAely 
attached tollu' piTitit-al 
skin. No defecli! of 
Hurf ace con f o rma i ion 
■re tfuflicicrit to predi- 
cate the entire absence 
of the rectum. ISoden- 
ham«r and Verneiiil 
hav« guRgfsteil the vine 
of thr Ktethoiioope ap- 
plied to (Jic perineal 
repion to (U-tcrminc 
I he existence of gn» 
in imperforate anu*. 

The information obtnined fmm tliis is 60 far from reUnblp that one 
can onlv call it a negative process. 'Die alwieiiee of the n>i*tHiu can 
be deti-rminvd only by a eearrh through botli the perineal and abdom- 
inal routci^ 

Tbc entire absence of the large intestine farms one variety of mal- 



>■■ 



^ 



Fio, 3!».— C'lKi-LTTB Amikce or IWir RrrtiM, »ni. tJaiMK 



• 

a 




fornifltion in Iho rcvigod clai^ification of Piippeiidnrf nml Btnlenhamer. 

In such eubt's tbt' fcUtiiU intastino o|)L'n* ol some iil)nornial (lositinTi, ns, 

for example, the sliouldtT, the 
neck, ihe chest, the (psophagus, 
the etoniHch, or, as in amne in- 
!.1aiice8, through Ihe umbilicus. 
Such cases, however, are beyond 
the <]oniiiin of rectnl surjjcry unly 
in aa fjir that if the tJiild slicvuhl 
rpiich thfl nge nt which it would 
hear surgical interfL'iein'fl well, 
an artificial nnus, cither in the 
pcriiia'iini or at some convenient 
|ioaition of t3ie abdominal wall, 
might be made to taki' the place 
of ihc'sc ahnorninl opening*. 

!>. The Rectum arrested in its 
Descent more or less remoTed 
from the Anus, the Anns lieing 
Normal. 

In this variety of malfornia- 
tion the enteron is cither nrrcst- 
ed in devclopmont and fails to 
come in apposition with the proc- 

toda'iiiii (Kifi- 10), or it may pass downwani in tlie wrong direction and 

parallel with (he rwWp-sttr of the proetodrcuni (Fig- +1). The distance 

at which the rectiim is arri:sted 

above the amis ia very variable. 

Sonii'times it is only n few lines 

removed, whilo at others it is 

found entirely abovu tht- pelvic 

cavity. Aj^ain it may be apjmr- 

ently in apprmilion ivilli the anal 

nil-ilf-sftc, and yet, when the iuvm- 

brann dividing fh<' two in incised, 

no mer.Dniiim will appear. In 

FMch cases there exist multiple 

obslniclions. Friedherg, quoted 

hy Ball, irientiunB a ram of Ihiw 

kind in which the walls of the 

intestine were foimil adhering to 

each other in two pUccfi, and ., ,, „ „ 

• ' _ tltl. -il.— ( 1« W Wllll'll THE K£fTll* l>I> 

Sclicnck records a aimilar case in KTiHpiin I'iiw-kkiur to ti.k Asiij, c*ii*t. 



PlO. W. — C*»B IN WHIRII TIIK lUiTI'U 




MALFORMATIONS OF THE ANrS AN'D RECTUM 



59 



which hi' stjitt>9 that the reelimi wa!! ilividt'd at two U-vt'ls by uiiiiulHr, 
thin, iiiembi-auous septa. BodfiihniinT. ISuslii-, {'urlin^, MoIIiitl-, iukI 
Matiia III! Loiilinit llioae reports, ami Willi-tuitr ri'conls a rjise in which 
the rt'ctum wa* UiviJtd into four dititiiut eomiiai'tniKnlp by tliree septa. 
Occasionally there will 



Ji 



\\ 



"¥ 



A 



S 



\ 



be foiinri n distinct 
fibrous corx) lliat ex- 
tends froni llie ch)«erl 
eul-tle-MC of llie hdvis to 
tlu- uudcsc-ended rL-ctiim 
(FifT. 12). Wlioa tilt! 
rectum (IcscoikIs imrnl- 
lol with the anal niUdt' 
aae, lUii) yi-t fails to 
conio in np|)ogilion with 
it, the furiiier gent-rully 
assunifs a posit iou par- 
alhl with the t-otc-yx 
and Kacruii), while- the 
lat1«r pasiBos upward 
nlon^rsiidc nf the pros- 
tate gland or vagina. 
In these caseit Llii* peri- 
toneal cavity may t*x- 
leud downward and 
»ard belivftn tlie 
two occluded ends and 
renik'p it impoRsihle to 
{WW rpom one to the 
olhc-r without entering 
this c-arity. In the intorcsting owe described by .\miissal (Tn)isiime 
lotinoire, Paris, \M3>) not only did the two nilg-ilf-ntir fail lo meet 
one another, hut the jinal cul-de-sac opened inti> the vajrina (t''i}i. 43), 
whilv the rectal mi-de-atf ended a short distance from the skin jurt 
anterior to thw eoecyx. 

It has Iknt nininied tlint thene multiple Bcptn nnd the Qbrouu corri 
leadinfi from the nnnl cul-de-sac to the cnteniti Hri? indicative of tlie 
put having W-en patiilons in f«?fal life and heeome ccrliided through 
inflaniiualory op palliolofiieal processes. No betl«r answer to this Ihcory 
can be gifen than that of Ball, who saya: 

•* Unquestionably this cord is very frcquenlly present, but it by no 
moans follows that its presence prt-swpposcs a pervious inlcptine. On 
Uw contrary, itj* iinnw-nee can be ghown with much greater probability 




Flu. 43.— Fi Bums Cnmi i.K.tniira riMii rut Arv» to 
Tim Ai(jttnt.u K*:(.iLii. 




i 



CO 



TEIE A.VUS, RECTtlH, AND PKLVIC COrX)X 



to Ijavc deTclopniental origin; the mesenteron which originatps from 
tha bypoblsst, as befnrG mcntiuii<>J, fornit) tb'e upper ]Kir1ioii u[ the rec- 
tum, htil fnnii it tlio mucous nipiiitinini' tiloiu' is ilfvolojJL'il, a layyr of 
uiosobhD^t sulifieijiiL-nily tiurrmniilinii ttii' liihi' to form lh«! niuMmlar and 

iithrr (-xti'rnal purtions 
nf ilip intcfttiniil w«U; 
(■onac<iurntly, whpn thu 
(ievelopment of the cul- 
df-sar of nieHftilemn 
boeoiiies, from auy 
('«ii8c, arreetetl, it does 
not fallow thai the 
grotrth of Ww other 
tunics orlgiiiatiny from 
Ihi; infaubliift should 
be arrested uIm; and 
when there u no mu- 
co«B coat to be s»r- 
roiindt-'d, it cau bo read- 
ily tinilerstood how thig 
portion of iiiL'soliUst 
can form itself iiilu the 
roumleil cord. Again, 
wc must rpiiu'inbcr how 
exceedingly rare it is 
for fl miieoUH cauftl to 
bp oljtitemtoil by in- 
llainnDilioii, uulesg at- 
temled with a very 
considcrnhle siipfrfitial 
lofts of fiubstoiiCT. Tiie 
only instance that 1 Vimw of in which a imtcutis canal is obliterated 
(iuriri!; Iho process of development in the human 3iit)ject is that of 
the uradius, but (>V(>u in this cuiie evidence of the inui'ouii nieiubrane, 
and even small miioous cavities, are »till found in the cord which 
foriiid Ihw runiaiiis of this ftnfiil slriietiire. I have recently had 
on opportunity of carefnUy examining a case of thie kind from a 
ptLlii-nt under Profpfsor Bennett's care in Sir Patrick Dun's Hos- 
pitul. in which, after fjiihire to meet ttie rectum l»y perimtal incision, 
« eolotomy was performed, but the result waa fatal. In this instance 
there was a very firm and strong cnrd extending fruni the cul-de-aae to 
the iiiial purtioii : n iiiiproBr»pical rxaminntiim of this eiird showed it to 
be cuuipuited entirely of muscular and connective tissue, without a truce 




FlU. 43. — B»i--Tl-« liJ.a(I.M>IMi l'^iaT»|llg« (o Till! A»V'B AJtD 

Tiik IiATTJEii onaiiva iirro niit Vaoiha. (Amamtii). 



MALFORMATIONS OF THE ANUS AND RELTUM 



Gl 



f mucous membrane. 1 w«* giso abk' to dotenniac another important 
tot in this cusp. If the nrtnl depression is compus^d alone of procto- 
deum, it is obvioTis that, a* IL ori^ritiatL-M cutirely from tin- (■[nbliiRtic layer 
of the emfarj'o, it ulioiild \m\e ila •turfuie <?m-erL'd Willi snily mid not 
'jcoluinuar epilholium. 1 (.-onKwiut-ntly olitaineiJ a sniflll piei.-e from the 
fundus iif till- amil drjin'.*si<iii, jind made prrtiiins nf it. There was not 
a trace vi glandular c-plthi^liuiii Id In hn'II in it. ho that, in this ca»e at 
ny rati-*, the comtuifioD wag uuHvoidablo tliat the malfommtion vr&s due 
to the fnot that Oio tiiesentcmn did not dt'swnd low nmii^h for thr prce- 
t(Mla?uni to iiiL'fl it; aod thai, I iRdif've, is the i'.vpliinjiti<>n nf the major- 
Ij, if not all uf these eases.'* 

In additiiiii In ihiis il shtiiiM bp ri'nmrk4'd that ihnrf is no other evi- 

idrnci- of jirt-viutis inlliimmiitinn in the intestinal ranals nf such children. 

I}ia</noata. — Thn diagnosis of these ca.ies is not made frequently 

until Komc days after birth. The normal aitjwarance of the anus does 

not 6Hj:gest the necessity nf digital esaminalion, and it is not until sub- 

tive symptoms, Ruch as mcteorism, nausea, and freral roniiting, hegia 

that tin- real conditiim of jiffnir^ is n>efignized. The anal cuI-'If-mc 

under such circuinsfaneis nieasm-es from 1 to IJ cenlimpter (g to | nt 

an inch) in depth, and frpfjuently less. The finger is arrested at once 

upon attempts to intrnilnre it into the rrctnm. 

If the euleron ie close down to the vul-desac of the amis, with the 
finger in tlie latter, when the tliild criea ur its abdomen is pressed upon, 
an impulse can be felt. If, however, it i-s at wme considerable dislanee, 
or if it dei<cends alongside of the iinni ennni, snch an impiiU(> will be 
■lucDt. It ia impossible to tell aectirately by any method the dislanre at 
which the rectum will he fonnd from (he anal fvl-df-stir, and the fad that 
tlie perilone-al cavity may intervene between the two renders the introduc- 
tion of trocars or aspirating needles for diagnnsi-s very dnngernus. Tlic 
only method to determine the distance i^ by artiial diKiecLion, and this 
hould bo done innnediately iipan recognition of the condition of nfTairs. 
e. Hectmn opening into aome Other ViacnB, the Anus being Present 
P ». Its Normal Fosition, or Absent. 
^^ This variety i.« by far the most freipient of all malfoniiaCtuns of the 
^^brctura and anus. It comprises almiit AO per i.'ent of all the caiH-a, and 
^^nbe large majority nf Ihem are of the ndvd-vaginal type. 
^H l.ei<;htert?tem (Zieinsaen's Encyclo]t«'di«, vol. vii, p. -185) Mya that 
in 375 casee of rectal malformation. 40 per cent were of thia vorictyj 
Boflenhnnier Mva that H-^ out of 2>*7 cases lielonged to this class. AVhf-n 
it I* recalled how eompletely thi? anterior is shut off from iho posterior 
part of the perinieum by the perineal fascia', it is dilTieuIt to understand 
ow this malformation ran oeeur so fn'<]HHntIy in male subjects ; on the 
ther liand, when the fact is reeallrd that the a-riiim and gun ito- urinary 



UK 

tio 

It 




69 



THK ANirS, RKCTUM, ASD PELVIC COl^S 



apparaluf^ are at lir^t camiirtt^dl in oue gt'ocrol clouvn, tlic mulforma- 
tion seems likely enough. The divUion or the pnrts not having been 
]wrfi?ct, sonu! smiill ctminmnicaliou i;" htt. and Ihron^h thin (In- wt-re- 
tiung of tht> intc'HtiiLL' eBciifw, kvi']) it ]>aliilun»i, and al the sutiie time 
prcrcat thnt woi^ht in thi> iatattin« iUolf which would iiuturellj ckumc 
it to sink (Ifjwnwnrd «nd come in contact with the twcv-mling cuUdr-mc 
of the proctddanim. 

The vnrinns types »f these inalfnrniBtinnfl are (lesignated aefopiling 
to the orgitti with wbicli the rectum communicnte'', ii.-> follow:*; 

Atre>ia ftiii Yi'*ica- 
li«: Where the rccTHm 
<)|i;'riK iiitii tlic Itlad- 
dep. 

AtreKia an! um- 
thrali,*: When.' the riv- 
tuiii ii|)L-iis iiilii the 
ui'cllira. 

Alri^i^ia aiii vn^fiiia- 

lis: WlicTc iIk' ri'ctura 

openn inro the %-agiiia. 

Alri^'sia ani uleri- 

n;i': \V1hm'« lhi> rfi^tiim 



4^^ 



-A 



\ 



'^ 



()pi>n!i iiitd thi? ulL-ni);. 
,-l/rr»i''i Alii Tpsi- 
caii^. — -When tlic rec- 
tum eoinmunicates 
with the blaiMcr, 
whether in the male 
or fnniale, it in usually 
by a very narrow cJinal 
lined throughout witli 
mucous membrane 
(Fi^'. '1-1). In Feiunlca 
thir( comuiunicatiuo; 
very rarely takes place. 
In rnilcn, however, it 
is not «o rnre. The 
opening is Hkely to be at the trigone or higher up in the fundus. 
Where the opening is down btlow between the orifice* of the ureters, 
the communicfttioa is ficneruHy Imt an elongated, narrow canal, rnii- 
ning diagonally or obliquely through the walU of the bladder, and 
fumiyhinfj; only ii very restricted outlet f.«p the contents uf the tn- 
toron. Where the opening is in tiae (uudus of the bladder it is usually 



Fm. 44.— ATBitn* Aki VBaiiiAi.t«. 



MALPOHMATIUNS UF THE ASUS AND UECTUM 



63 



ider^ and there is an exit far lliu iiiU'stJnal oontciilR. Tlii-rc hnre 
en no ca^e* rfpoik'd wlicre LhusL' t)[j«?niii^>i liavt' invdlvi'il tho ukWth 
>r Iht'tr exits. 

Diagnosis. — 'I'lu- Jiiigriu5i.< of tlicsc casr-R will vary iii dilliciilty ao 

Icortliufi 1(1 lliK linif wticii llic i-hil<l is neen. Urtunllj it ie simple enough j 
ihe aUento ttt any iiasi^igt^s froni the anus will suggest an examination, 
*nd iniperforation will thus be detenninetl. 
Tile a|)pouranc« of \\w dark jfrt'ciiitih stain of lucconium in the urine 
is Bufik'ii'ntly (■hiinu-li'ristic to indirate coinmiinicfition Iwlween thy rec- 
tum and urinary tract. The amount of this iiiattor soen in tliy urine will 
indicaic to a greater or less Gogrw tlu' ^iz^f of tliL' tiitcning iiilo tin- Mad- 
der. Sometimes the quantity ie so miibII &e tn barely ^tain the urin«j 
and ?oii)etinie» it '\» so uhundniit timt the urine nmr ii|)|K'ar lo l>c pure 
tntx'oniuiii. In tin? latter t:Iiis« i»f eases it will rvquiri' closer wdti-hiiit; lo 
dctomiino whether the o]>ening is in the hlnddt-r itself or in the arethra. 
]^m Kail «nys, " The fact that the meeonium is intimately mixed with 
^ftlii* urine, and it only iijipean^ during uriniitiuti, would nl uiice distin- 
guish lhi» variety from atresiit aui un'thralis." This in very lugieal and 
clear if we eould obsGrve tlip child during tlio urinary [las-iage, liul. un- 
fortuimt*.'Iy, this a{'t generally takes jilaw during llie absi-nw i)f the 
pby!>ieian, wliilo the child is asleep, or at such times nn it is almost im- 
j>i>Aiiil>If to oliflerve it, and ciinfiinjiienlly we have to draw our eonelnsions 
/rom the staiiiiiig «f tin- diapers and ilothing. Conotunt oozing of mc- 
cvnium from the urethra would indicate that the opening was not in the 
blaildt>r, l)ut it does not prove it. The rapidly fatal rour^ie of wurh cases 
renders dilatory proeeedings in Iho diapnosiw nf this eondition very dan- 
geroiu. Unlewi the condition i« rapidly relieved, and the contentB of 
the bowvle are turned away fmm the bladder. ey.«titis will result, with 

IrnhMqneni infection of the ureters an<I kidney», and the child will die. 
On the otlier hand, if tlio opening be anialK as it usually is when the 
loWu-r portion of the bladdvr u invaded, the ehilil will likely sueeunib to 
tile oljgtniction of the inU-iitine. The progno.<ii!i in sueh cases is uni- 
formly; bod. The operation neeett«ary to alter the enndition 18 of such 
fnaj^itude that most ohildren are unalde 1o »tand the shock; on the 
I other hand, delay ^ubjeet^ the* vietinn lo Ihe double risk of intestinal 
obstniction and septie infection of the bladder and genito*urtnarjr 
^organ^. 

Atreeia Ani Vrelhralu. — In a certain number of eascii the rectum 
ftpere into the urethra {Fig. 15). This condition may occur in the male 
>r female, hut it 1^ mueh more frequent in the male, The o]M'ning may 
[•UT ut any point along the whole tra(>t of the urellirs, but in the major- 
ity of eaei's it oceuw in the membrannus portion. The eomiuunieation 
lUy by a long, narrow, luLidike chuniiLd, ]>a!.iiing from the un- 




64 



THE AHOS, RECTUM, AND PELVIC COLuN 



■'\ 



\ 



1 . 



doseeiKlcd rpctuni down in froiil of tlie ptTiDPal fascia, and opening into 
the pQnterior swrfaoe of the urL-thra. Tliiit comlition 'a not so serioiis as 
the iiR'i-ciIinp. Unwati rciinrt-i ii c«sc- iri wliiili tlie child di-rmited 
tiimiigii tlie pfui* for two niojiths withnut rnusiiif; any )siKn» itf iiilUiii- 
^__^^^_^^^^__^^_ umtion. BoJcnIiaJMr 

in u'liich the victims 
have livGd to the age 
of twouly- riiit- and 
thirty jears rwnpect- 
ively, always defeca- 
ting 1hn)ii;:h thi; ure- 
thra. Thf o|funing 
insy &l6o occur at the 
j>rL'[>u{-e or froiiura, u 
in tlie vain* ut Coley 
<Ki^r. 4<i). 

Diaiftiniiix. — Tlie 
iliftgiio.si.s of this con- 
dition ifl 6omewhat 
luori- -■'iinplc lliHn that 
of atresia am veftica^ 
li*. The meconium 
or ftrcal matter piuiueti, 
either ciinfetantly or 
111 stated periods, un- 
mixed with urine, and 
indi-peudent of tlie 
iiriiiii.ry act The in- 
testinal contents may 
bi' fonnd e»capiag 
from the mentua at any timo, and no cvideni'e of cystitis or nephrttia 
seom» to develop. If ihe eotnniuiiic-iitiun li-hvccn tlie ret-tiMii and ure- 
thra 1m* very i-iiiall, as it geiienilly is, the pttlicmt uiay itiiiTer from ob- 
struction and distention of (he luwels and all lh« consequent conipli- 
eatioui^ : but if tht? npcniiift he fnirly large there may hr- no subjective 
Kymploms whatever anil no indiration for immediate action. Under 
stich circumstances it con be easily understood that the pro^iosie in such 
cai'eB ie nmeh more favonihle than in Ihe preceding tiasa. Moreover, 
the faet mat the recluni iw usually htw dnwn in the perina>um in these 
cases uiulccs the probable autenme of an npcration to restore the anus to 
its normal pn^Uiitn tiiiieh more encduniping. 

Aircxia Ani Viiyitmlis. — This variety furnishes about 50 per cent of 




Flo. 43k — AnutiA Asi Uhktiihau*. 




MALFORMATIOKS OP TflE ANUS ANTl RECTrXI 



C5 



*- 



>tl the casrs nf iiialforJiiiition of tin? rerliim. TiiL- frwjuency wilU wfiirh 
it occurs H-ill never be known, iiiasinm-h as it proOiiecs so litlle sub- 
jecU'v« incoaveuience that putk-nls go tliroiigU life, perfwnn nil their du- 
ties, marry, bear chil- 
dren, conduct thuir 
housvholrlti, and yc-t 
f\a not know that any 
Oeformity exUts. 

Buckmaflter rejiorts 
a case of a vrom»n 
thirty-two yeurs of apt' 
wliostf rectum opened 
into the viiginn netir 
ihe Tulva, eml who 
never knew ihat slie 
was deforiiied iintil ex- 
aminatitiii for a itler- v 

int! complaint revetilcd 
the condition. The 
author obfM?rved in the 
l*bihtdel|)h in I !os|iilii1 
a prosLitute whow rcir- 
lum opened by a sort 
of valmlar orifice into 
the vagina, and irho 
liad lived to the a^c 
of twenty-eight years 
wiliidul ktiowiiig xho 
ma in any nay de- 

funiied(F*iir-,I')- The 
irdiiimtinicntion be- 
tir^<en lliv recturn and the vagina in this rariet^' of nialfonnatious inay 
be located at any portion uf the vaginal tract, fmin the posterior eul- 
itt'Mf down to the vei-y margin of the vulva. It may also bu between 
llie anus and vs^na, thuR involving practically neither organ. 

TW' o])oning niny lie very Kmrtll, hut it in gnnprnlly tif tmtlicient pro- 
portions to allow the free and rogidnr escape of inoconiimi nnd aUo of 
f»oa1 inarier, unless the tnltor beeomci!i very hard. The opening may be 
Ui (be center of the lower e:id of the recliini, or upon the »ide, in whicli 
cane the organ iikuaIIv emls in a larf;e, dilated cut-dr-sac. Sonietiiiics llic 
opening ie by a Mimowhut clon^iitcd, tubular canal, and in theKo cases 
iht- pasragt: of faecal matter will be obstructed as soon as tlic condilioD 
of tb« bowoU becomes the least solid. 



\ t:-l -1 I A St T' 



THE A^•tIs, itEcrrM. and pelvic colon 



Vmll ri>|>(>rU a ninv o( a woiiihi). (tii^ uiotlitT of »i:t diildrvn. wlio hud 
tliis Fnrtn of inHlfoniiiitUin iiU htr \ih- without tlie alightcst incoiive- 
rience. Up hivs; "The anus t)|M.'iu'(l into thf lower portion vf the va- 
^na, and was fn far iimvidcit with a sphinfttT tluit wtiou tht- tip of tho 

finypp was introducctl 



VI 



^» 



into the i-pctiim it wna 
tifihtlj'jiiiisix'il. Thore 
viBx not tho loast in- 
continence, imil the 
buwclH nctcd rcguhirly 
ererjr day." Hicord 
and Modliii have re- 
ported eimilar cases. 

liiK'kinastor haa 
rollwlpd 27 cases of 
thiR niaironnatioii, the 
ages running all tlic 
r .. g way from six months 
to forly years. He 
iLL'liidca iili^o in tliifi 
collection ilorgagiii's 
ca«o at on<? hiiibdr<Hl 
years of ago. 

t'arftdec (dazeltc 
d'ho|)ilaiix. lSr,3) has 
ri'iiorlod the case of 
a wuiiuiii. (hirly-two 
years of ago. in whvm 
tlic anus and vaj^inn 
were norinnl. cxcnpt 
that from the margin 
of the vulva, between tihe orifices, there was an opening. «lii,'htly oval 
and largi' enough in «ilmit two fingers, with its longest diameter an* 
tero-])03tKrior. This opening led into a cul-de-mc lined with mucoua 
membrane, which at its entrani.-e olfered u eertuiii rw'istaiue like that 
of the ephincter. The aiileiior wall between it and the viigimi was 
thiekor ahovi- than hclow. 'Ilio posterior wall, oil tho contrary, was 
thicker below, and presented a liBluloui! opening largo enough to admit 
the tip of tho finger at ahout S eentiiiieters ('i inelies) ahove the anus. 
The woman siifTered no incunvenienee until after niarriage, when fa?ca! 
matter hegan to pass by thia median opening. Caradec ternuil this 
malformation a sotoml vagina, but it appears that it would have been 
more appropriately termed a fictoad anus. 



l-'i... it-— Arnoi* Asi V*n)HiMs. 



! 



MALFORMATIOXS OP TIJK ANUS AND RECTUM 



67 



In this vurii-tv i)f mniruriimtion tho anus may be perfectly formed, or 
it may be entirely absent. In eomc cases thcro is an opening into tite 
vagina as wu\] as a iR'rfei-tly forniL'd Loauectiou bctwot>n tho ftntis and 
rectum. lu Iheev caiCH the upLMiitig!; iiitu l\vi vagina may never bo sua- 
peeled during virginity. I liave hc>anl of nne ease in which it watt olaiined 
timt iiic jiSKSHgc: of facial mailer through thn vagina van due to trauma- 
tism during (he sexual act. Closer examiniition proved that Iherc was, 
and had always been, a sort of valvular communication between the 
vagina and rt'ctutn. lini-d tlii'uugliout by mucous i]iL-nil>rutie, und that 
tbfi parage of fjtutl matter tliruugh tli<j vagina hud uuly beuu prcvi-nted 
by the Mistcncc of a close hymen, 

Out of 36 oases of malformations not included in the statistica so 
far colleeted by others the autliOL- finda la cases of this variety. The 
ojieningH into Ihi- vagina are uiiually large enough to admit of the pas- 
sage of nnlliiHriiy formed fieral nuiswes, they rniise little incmivenience 
in early life esjK'cinlly, iind happily do nnt dprnaiid ajiy iriimeiliiile opera- 
live interference. The child will grow and thrive, and if the opening is 
a«t large enough to admit of the paftsage of fiecal ruat^se*. it can be 
dilated lo a gulhcit-nt cxk-nt to serve all practieal purposes, until the 
child attains an age nt ■which surgical operations can l>e aafely per- 
fonneil. The prognosis, therefore, in mieh cnses is nlwiiys gond. 'riienj 
is no exonee, hnweverj for the malformation bein^ overlooked, ;md tho 
child aDuu-ed to reach the age of puberty or even older years wilh such 
a defoniiily, Tliese casca eiupha^izo the iieeeasity of cxanuning the 
rectum at birth. They are [iraetieally hunuleas if recognised antl treated 
proiierly, but if neglected, they niny be diseovered at a time when such 
a defomiity would wreck the life of the woman. 

Atresia Ant t'Ceriij(r. — (.'ommunication between the uteni* and rec- 
tum ia of the rarest oeeurrenee. Only two caseH of th\» condition tiavo 
been reportwl. The o|)eniug in one of thewe eases was in the posterior 
lip of the cervix, in the other the site wa« not mentioned. No case Iiaa 
iM-t-n reported in which the intenlinc communicated with the fuudua of 
the uteru^i. The tracts of communication in the eases repnrlerl have 
iH-en small and contracted, only allowing a feeble escape of nieeoniuin 
through the vaginal orifice. In each case the gut had been supposed 
to open into the vagina, but upon dissecting tho rectum away it n-as 
fonnd to enter the uterus itself. Such ejiHe,s are too rare to merit any 
lengthy digeussion. They are simply inntnnees of the frealts of nature 
which are i^een and exhibilW as monstrosities in museums or patbo- 
Ingiciil laboratories. 

tl. Where the Rectum and Anus are Kornial, but have opening into 
tkem Other Organs, sach as the Ureters, Vagina, or UteniB. 

Kuiuuruua oueea uf Uiih form of malformation liave been reported. 



f«8 THE ANUS. RECTUM. AND PELVIC COLON 

Bodenhamer has collected 7 caaes in which the uretrrs opened into the 
reclutii at the peritoneal reflection, and 11 cases in wliicli the vagina 
tvnuinat'Cd in the rectum. Thv uuthur hn^ seen i ca»e in wiiich tlic 
vagina opened into tlic reetuui at about I indi above Ibc oiial orifice. 
The litem* in this ca«c oponvd Ix-twcen two little pillar? or mdinientnry 
Tiilvse, Then? was absolutoly no vaginal formation npon the oxtonial 
surface. Tht? two lilt[(^ pillant eauic tufji'ther aud foriix^d a tiiuiliau 
rliaphe which ran lijidcwiird lo the rcetum. The utenis iHJuld hv easily 
felt through llie opening intn the vagina from ihe n-clmii, ami llien- wi\* 
no cul-tlr-sar in tile vagina hclow this opening. The woman snffrrnl no 
inconvenience whate%'er from the malformation, anil rleclineil lo have 
■toy operation done to reiiiedy it. Most of these caeos occur in females, 
tni the dia;:iio^i:< is not made until puberty. In the ca^c which the 
author .ia\Vj ihc jualfomiation waa discovered thrmigh ineffei;tual at- 
teinptii at soxnal intercourse. When opportunity for examination is 
afFonlcd there is no ditliculty in diagnosing sucli nialformationR. 

Treatment. — While the method of o]K'ratiiin in malforinationti of the 
anus ia of great tiionient. t)i(> lime at wtiith it should be done Is of para- 
mount iiiijiortaiice. Wlicn there is complete atresia, what is to be ac- 
^OMplifilied iiiuf^l Ik' done «< mice in nnler tn afTonI tlic child any ehitncca 
of lif«. On the other hand, in those cases iu which there is an exit f-^r 
the meconium and fluid f«?cc8j a more conservative course mny he 
adopted until the child ha-t grown 1« such an age that its stn>nglh will 
admit i»f whatever surgieal maiii|)ulation umy he necessary. If the 
ex.it for the mi-cnnium he very small, but within reach, it may be 
gi-ntly dilatc'd. even though it lie in bud position, until the child's age 
will juHtify nulii-al surgical interfiTcnL-e, 

When we rcalijic how much at times depends upon the life of a 
single infant, liow abeoluloly lives may depend upon the altering of 
*uch R deformity as this, and how dear the life of overj- child is tn ila 
mother, we can comprehend how neeessary it is for every pliysieian to 
he prepared to act — act promptly and wisely in such an emergency. 
The prime object in all operations for mnl formations of the amis and 
rectum is to give an exit to the intestinal eonteiitfi. Such an exit 
should be made convenient, permanent, and effective, if it can be done 
without jeopardizing the child's life. We nuut therefore consider first 
in what position the outlet ean be placed with the greatest safety to 
the child. .After this our effort." should be direcled toward obtaining 
all the funetional activity of the normal organ; tlierefoi-e, if possible, 
(he opening .shonld be made at the proper time iu the normal site and 
aa far as poBflible niirroimded by the nonnal iiiuack's and tissues. 

Opemtions for imperforate anus are eompttiativcly modern. The 
Greeks and Romans seem to have looked upon this malformation as 



1 



JlALI--OltMA'riONS OP THE ANC'S AND RECTUM 



69 



I 



be;oDil Ihf fiur;jkttl urt. Tlie first instancrs given of an uiit-ration for 
IbU conditiou ia that «E Kgineta (Mariiis Durand, Gaz. iles hopilBux, 
Paris, December 1, 181H, p. laOl). who in the sevL-nth centuiv n-ljL-viMl 
ui imperforate aous by incising the sieptnin. Tliia iiu-lhod van (he 
one goiierally adopted from that tim« on, llip itioisiion being diUti-d b^ 
wax Ijougies or by thu fingor. II is n-nuirkiiblp that nt this ewrly period 
the line of WMentific siirgienl Iccliniqiie should have been no ek-arly 
forL'tohl. The dp-scriplinn given by Durand does not indicate any blind 
plunging with Hie knife, hut a careful intision into a bnlging sue. Tlie 
operator knew and (taiv what he was ineieing, and this is the whole 
aocret of lite modern n|K-ruliou. 

Later on the u?e of the tiooar as an instrument for searching after 
the reelnl poueh wiw intrndiieod, imd for a long time tlie method of 
incision was little used. Ohililren falling into the hanrU of general 
practitionern wei-e eiihjeeted to the iroear operation, and most of lliem 
were left to die if this uielhod failed. In 1834, Bre-schat reported he 
had obtained twelve successful results by the method of perineal inci- 
sion. This populuriKcd tlie method in Kriince. In 1787. .Sir Ucnjamin 
Belt, says Bodenhamer, advututej a direction through the periaieum, 
dilating the wnxind by the use of his finger, and searching for the roetal 
nmpulln in the hollow of the wierniii ivilh the trocar, if it wen* not 
found lower down. Shortly after this Dr. .John Canipliell, quoted also 
by Bodenhanier, Bucce**(ully performed this o|jeration in Flemings- 
burg, Ky. This What the th'st successful operation for imperforate 
rt'vtum ill the United Ktatcrt. IlutehiiLson advueutcd dissection for 
1^ to 2 incticK, and uflL-r this tnist't^d to the trocar only. DielTenbach 
made a cruciiil incision in llic perineum, cxeiBcd the triangular fhips?, cur- 
ried hiadiseection to the height of 1 ineh, and then mihutitiitwl the trocar 
for tlio knify to penetrate upward and hnekward into the hollow of the 
ncruni until the rectal pout-h was tapped, when the path of thr- trocar 
wan dilated and the nwconiuni al!owi?d to ewape. " If this procedure 
failnl, the cannulii was allowed to reniniu in xitu, and a piece of sponge 
wan fnrcpd through It and left to dilate the space beyond. If after thia 
dilatation the pouch could not be reaclicil, colotomy was performed " 
(Malan, Surgical Treatment of Imperforate Anne, p. 1). 

For a long time no Attention whatever wa* paid to the preservation 
of the aniu, nor was any altfinpt made to do anything more than to 
give the contents of the bowel a free outlet through the incisions made. 
The ijuestion of retraction and eloRiiro of tin* incisions was firet brought 
up and discUBsed by Dionit- (lloHenhanier) in I?Jft. and aftcrwnnl by 
Malyn in IS-tO, who both niatntaini'il that the retraction of the perineal 
muM'lea would efficiently prevent the reconlractinn of the wound. This 
auerlioD hm not been coDHmiod by surgical experienec. 




70 



THE AXUS. RECTUM. AND PELVIC COLON 



Houx ((!az. ties [iftpilanx, 1851, vol. vi, p. 434) first, luiil spccinl 
t^Lrc^ ui'Ttu the iiit[)<ortance of proserving the sphincter fibers wIuIq 
(lissocliDg the [K'rmiL'Uui. He miulc a ck-an surgical Oiesection by tho 
UBC ot the knife, prescrviiiR oe for a« pcjssible whatcivor mdiiiitfiitary 
r]vvelu|>i)ii<ot» of thu (>xl<>i-nal t^jihinctcr oxiKted Jn the perimcum. lie 
still fulIowcJ. !i(jwfVL-p. tilt' faulty twiiniqiic of allowing; tlic niocti- 
uium to t'sc'upt- tliniu^li iho open [K-iinuftl wound re^nlles* of its 
depth, thus exposed tho uhild to inftction, and if the peritona-'tun had 
been opened. Allowed the contents of the inlcHtiuc to cxtravaaatc into 
this cavity. 

Id 1835, that great and original thitiker, Amussat, published in 
the Gazette de Paris an article entitled "The History of Operation 
for Artificial Aims, IVactiwd with Succtiss by a New Proeedure in a 
Cftso of Congeniljil .Mtienpe of tho Anus, with Sorne Refieetioiw upon 
the Obliteration n{ the Hwttiiii." Frum this operation and report 
befriii!^ the ^ciciitiru- and rudiL-al treatment of ii ml format ions of the 
anu8 and rt'ctuin. lu this piijier hIso wm fiwt thrown out the sugges- 
tion thnt rr>i>m for oix-nitivi; proc'fduri'j! about tlic EVL-tiiui and pelvis 
nii);ht be tiblainiil by iIil- n-iiioviit of the voctyx, thus for tlit- lirst time 
poiiitin^T out the possibility of the sdcrul or Kraskc operation and all 
i\s nivdiiu'uli<'>n)4. 

It scenis that the French and CemiaiiB have utterly furgulteii tha 
8iip>rci»tion of Aniiisaat in nil their writing's on, nnd developments of, 
the i>aeral route. Vemeuil. writing in 18T3, stated that the possibility 
and usefulne)** of i'ei*ection i>f the coccyx had occurred to him as far 
back as 1S53. hut he had not put it into practise, on'in>; to wiint u( 
opporl unity, until 1870. Jn this viduablr paper, so ofttMi nifurrt'd to, 
we can reeoenijie the siigRestion of Aiimsssat, who wajt, no doubt, ori^imd 
in his work and thought, if not the pioncor in this lino. Thi.* chief 
feature, however, of Amus^al'ii reconimendution was not the removal 
of the t'oeeyx to ;.'ain space for oponitton; it wfla iha fact ihat he dis- 
siK'tod tlie reeluiii Itxis*.' ami brought it down, liuturinff the nnicoiis 
membrane of (he gilt to the skin at the margin of tlip anus, if sn aniig 
exit>le<), or al the ncarc«l point tn the normal position of the latter 
to which 111' could bring the undcAPcndi'd rectum. This furnished an 
exit to the intestinal contents upon the oKt(iid«. which war- sealed off 
from the wound by a close apposition of tlie parts. IK- advoiulL-d that 
the rectum should be freely detached fmni all its j-urro«nding8 bo as 
t« bring it down to its normal position, if possible, without nny tcn- 
aion; and that it shonld be drawn out of the wound and emptied of 
ita meconium hefore snturing. He advised Ihc free and wide dissec- 
tion of the perina'uni. as well as the removal of l!ie coccyx, if necea- 
Bary, to accomplish this. He aUo advised, where it vas requisite, to 




3 



Ann 
^B I>oen 



I 



open tho peritontpum, as this cfluM be done with as little danger 
through ihe iifhie route hk through the abdominal. From liis day to 
the presieot limt' all meLhodH of opemtioii upon imperforate ani und m&l- 
formuliom of ihe recluin have bwn haseil upon ihose pnipn.*;tiniis of 
AnniKwit, and barring ihe introilnclion of aseptic Hurgcry, there has 
I>een no radical improvement in the method which he pro]>osed. It 
id by some authors that Aiiiuftsal's proposition to remove the coccjfx 
not to train t*pace, but in order to affoi-d a position higher up and 
nearer the undcgcended rcctiun, to n-hich the latter could be attached 
in case of diflicuUy in bringing it down to the normal anus. 

What he saj-s is: " After having resected the eoceyx, in order to gain 
nutn room far reaching the rtctum, the space thus left riti afford a 
convenient position to attaeh the latter in case it can nol be brought 
douTi m ihe nitrinal position." To those interested in the devulojiment 
of modem technique for njn'rations upon mfllformatinng of the rectum 
and tmiis. the reailiiitr of Ooyraiid's article* publirilied in iH-ICt (fJan. 
«iM. de Paris, pp. oO», oH, 538, GUI, and 63:)}. ujid MatosV bi-oclmro, 
]8ir7, is ^ugKVKted. 

A ilij«pi3A«ion I'f fn-atment under the individual types of mnlfornia- 
tion has been avoided fur the reatwn that such di!U.-ui4iiiun would neee«- 
Bitato numerous repetitions with regard to tecliniquc. We shall there- 
fore consider the Irt-atiiient in general, and point out it* application 
to each particular forjii of iiuiifonimliuii imiiliiiiiivl in tlie text. In the 
fint pUcc, then, let ua study those roalforrimltous of the anus and 
rectum in wliicli there is obiiolutc oeclusi'm. In such cases it is nccea- 
sjirj that immediati- and radical operative interference should be under- 
taken. The policy o( waiting for a day or two to see if spontaneous 
opening nill not niviir. or willi the vit^w of allowing the elijld to gain 
Btrangth, is most fallacious. Where there is no aperture at the time 
of birth there ia little or no probability that it will show itself after- 
wnril. The chilil at birlh is quile iis nlilc to withstand surgical shock 
aa it is two or three dayn later afl^r NulTcring from iutcetinal obatruo 
:tioiu Stotifltica of the operotions performed within the first twenty- 
four honrs show a decided advantage oTcr tho*e done at later period*. 
tn gftieral, we may siiy the earlitT the ojieration in all ea^es of complete 
oceluaiun, the more faTornble will be the progooaie. Every hour's 
delny. thi'refore. U a wanle of valuable time. Tlie complete absence 
of the anus is no indlt-alion wlmti-Yer of thr di.»tiinee at which the 
Tectum will lie found; indeed, it« distance is generally in inverse pro- 
porlidH to Ihe devi-lopmrnt of the anus. Therefore, the amount of mal- 
formation found in the anus, or its entire abeonce, will not indicole 
JD any manner Ibe diflicnlty of the operalion. 

The prognusiH iu a caae depends largely upon the facility with wluch 



ra 



THK AXUS, ItECrUM, AND PELVIC COLON 



the rectum is found and brauglit iuto position, but thi« can not he 
BtfiU'd wiih any ccTtainly ext-qH iil'lfr uptMstiuu. It jii the duty of 
the HurgcoQ to explain iik-arly io tlie family tJiat lif« ie impuiiaible 
without giifh an operutifm, and tliat no possible advantage can accrue 
rrmii ili'Uiv. Till' opi-ralioti itsi'lT !.lu)uld l>f uuLitTtakcu with tlie gri-at- 
est awpttc precautions. Nd ana'stltirtic shnidd be j^Wva to children of 
this age. They liear pain woll, niiil tfu' danger nt ulioik frnni Ihis 
IB Le^ than tbat "f lineal or t'tni-Tal un^eiithveia. 

Before bcKiunin^' the incision, it is well to nee every method at 
onr viiriiuiand to riet^miine if possible tlw position of the rcctiiin. The 
ekin at ilu' normal position of thr anus, or nt Boni« portion of tho 
porina'uni, may be uf a grvenish tinge, due to the transmiegion of tho 
green color of the t-untained nit^conium through the attenuated tissuo. 
'riii-ii- may U- bul^in^ at suuil* point in llii' ]ii'riua-uin. indiciiliug the 
near approat-Ii of Uil- rectum. With a hand upon Ihc perina'um and 
pivHi^un; on tJif ubdomcti, one nny Hoiiioiiiiir« f«i'l an imimlftc from 
tlie rectal pouch wht-n the child is tauBod to cry or strain; percussion, 
while the stethoscope is applied to the perinivum, may also aid u« to 
deteniiine the proximity and site of ihw rectum. 

Oilier mcttiudK, siirh nn intnidurinj; n sound into the vagina, the 
blnddtr, or thv urethra, havt? Iwen advisi'd; but the connensiiii of opinion, 
among thosp who have seen the most of this sort of surgt-ry, is that 
tlit-y arc nvitliout nny niutciial benefit. Finally, and that which has 
been the ino^t frequently aged and advised, the introdiictioD of an 
ae]>imtiug needle, or a trocar, inlo the pcrina'um. and backward into the 
hollow of the sacnnn, nwy b« n«e'l to (lptenoini> the poiiilion of tho 
Tcottiin. So far aa thia operation is coneenied, exploratory net^lcg 
are dnn>.'ePoug inslnimi-ntn. In their inlroduction through tin? p«r- 
ina^'iim into the rectal pouch, even if the latter can hv found, out- can 
never be assurt-d that they do not pasa through a diverticulum of the 
peritoneal cavity, and upon being withdiawii will allow the nii'toniura 
to wcnpc into llii» cavity, f.xposiiig tin- child tf) ail the diingcrs of 
«eptic peritoniti*. The aspirating noddle ia slightly less dangerous than 
lh« trocar. A fine one miiy bo intri)duced into a bulging point, or at 
^^ a place whore impulse i-ui bo ft'lt, and inecuniuiu witlidrawn; then, 
^B without withdrawing it. one may diswct down along its track and open 
^^ the gilt, fnfortunali-dy. howcvt-r. ihc iHision in all these blind re(-tal 

^^ jMuicheg id »o gn-atjbat cvrn the i^iicking of a needlr into ihcin may 

^B cduai? rupture and «.-\tniTHKation of mpconinm into the peritonaeum or 
^H trairk of the aspirating needle, ttpyond tliene cafles, in which the bulg- 
^H ing or impulse arc perceptible, no i<evirch with the trocar or ai^pirating 
^H needle should ever tie maile; and, indeed, in these very eases, the advan- 
^H tagee are altogether with the plan of careful, patient diaseetiuii. 

^ I 



HALFOOMATIONS Q» TUE ANDS AND UKCTUU 



73 



After having tlctcrmincd ne far as posBtble Ihe iiosition of {lift n-xU] 
pouch, till' iipeniliim pan be iiiMcrtftlccn tt once. In caaes in wliich 
■there U no anus, one should endeavor to Ruik(! one. A straiglit mcit^ioit 
ghoiiM W mmln fmiii the point nt which the anU?riur luargiii oC the 
anus would natumllj apppar (Fig. 4). hack ihrough Ihu i^kiu uud huh- 
cutaneous tissues to the tip of the coccyx. It there be a rudimen- 
larv onus the irtci?:i<m t^huuld be^in at Ha poistcrior margin. Htiviiig 
cut through lilt! skill and MubcuLum-oUrt tieauc, wc comf do\rn upun Lht; 
cxtonut ephinctcr muscle, or the fibrous bond which take^ Hn placo 
vrhea ■Ijsent. In the majority of canes in which the anus is altogofher 
absont, the sphincler is absent also. At any mtu, whelhor fibrous iir 
muscular tissues exist at this puint they should he divided by a blunt 
pi^rioHleal elevator insti-ad of by tnrtsion, and pullrd ;r('ntly apart. Aftpr 
thi» the diiwpction caii he carried upwanl as far a.* ii> necessary in search 
for ihp undescended rectum. This median incision should be invari- 
able; whether the impulse from the rectum ie felt to one side, anterior 
or posterior to the aiiut*, the incision and the divit^ion of Hit; :«phiuc- 
ter should always be the same. The direction in searching for the 
rprlum shmild be eiirricd upn-nrd iiml bnrkwnnl in tlie hfillnw- of tlic 
Mieruiii ill order to avniil woniidlng the tilndder or ntlier pelvic organs. 
When the rectum ha» been found, an effort should be made to loosen 
the pouch from all its attachments, and hring it out through the o[}cn- 
ing which haa been niadt-, with a view of preserving the funilidiml 
activity of the aniin. This should be done, if poHsible, without open- 
ing the pouch. SomotirueM. however, it will be found imp<i»iible to 
bring it down into the wound until its distention has been reduced. 
Ju«t hare we have the one useful indication for the trocar. When 
the gilt has been freed from its attaehinents. and it is found ini^ujfi- 
cientty long to ho brought down into tiif wound, tlic tn)ear may be 
in*crt«i and the ineconimn drawn off entirely outside of the wound, 
tiini* reducing the di'tenliuu and iengtli tiling tlie gut. After this it 
will generally be found that the latter can be i>r<>iight down into the 
wound without diflicully. Stcrilixed gaiute nhouhl be piickt'il around 
the troear and well into the wound during this procctw, and the gut 
held firndy by pressure fowvjiH. It i^ a better plan, however, if tho 
fpit can be brought outside of the wound, to do so, and having packed 
the etlgcx of (he wiuiud with gaiiu>, incise it as freely as necessary to 
alTonI un exit for the t-oulained nieeonium. 

The suggi-stiiiii of Miitiis that a running stream of s&tine or other 

plic solution be carried over the parts during this process of ciiipty- 

tbc rwtal pouch #oenis to be contrary to the opinion of most 

■urgeoM, It t« better to uao gimple, dry sponge*, thus keeping tlie 

parts free from the discharge. 




74 THE ANUS. RECTCM, AND PELVIC COLON 

Bsvisg emptied Ibe rectal poiich uf its contents, the next atep 
in the operation is lo Rji it in its normul «ite ii possible. This is done 
by suturing the mucous menibrane to the fut wiges of the skin nt the 
site of the normul anus. It i» neeejann,' to enipliasixe lieru that the 
sutures arc not ptuced in the peritoneal or inui^cular waih, but in the 
mucous meitihrane uf the ;iut. The intention i? to seal off the perineal 
wound from contact with tlie fa-caJ discharges, to bring the inner layer 
of the ^ut upou the outer surfaee of the skin so tlial the alvine dis- 
charge will U- airriw! entirely outside of the wound. If there he BUper- 
fluous mucoui) nicinbnuie, acting sonicvluit att a prolapse uf the rectum, 
it would be all the better, fio for as this intent ie concerned. 

Vincent has advised that when the anus mus! be made at »oiiio other 
than the normal position, it would be well lo di!ifieet two elliptical 
flaps of skin from either side of ihe wound and carry the mucous uiem- 
branc outward over Iho edges of the woutid, uniting it to tlic skiu at 
the points from which these ilai>s have been tlissecteil, thus alTurding 
fl larger urea of ilenuded ti&siic for the flttarhnient of the gut, and at 
the same time cnrrvirg' the dieeharge from the intestinal <anal more 
thoroughly away from the deeper section of the wound. This ie a moat 
oxeellent euggeslion. When the gut has Ijeen brought down and sewed 
in its norniul position nt Ihi- anus, the rinsing of ihe posterior part 
of the perineal wound i^hould he mnde with sulmvs pa*ied deep enough 
to take in tlip fibers of the external sphinrter and hold them in position. 
until reunited. Silkwoim sutures or ehromicized eatgiit arc most suita- 
bie for this purpose. AVith regard to the sutures to be used in fasten- 
ing the gut to the margin of the skin, authorities differ; a good 8\it& 
sterilized catgut ie preferred: first, beoauM it has less tendency to cut 
through the tender iiii?nd>ranes than does any other form of suture: stec- 
ond, it dne.'i not have to be removed; and third, after it is introduced 
it swells and slops up tlie holes through which it pnases more or Icsa 
effeelually until it has become pnictically absorbed. Silkworm gut and 
silver wire are BtiiT and too unpliahle to bring the points inlo eluse 
flpposilion. 

The author prefer* a broken, contiuuouH eulure. ]ly this is ine^ant 
R continuous suture carried half-way aroimd the rectum and tied, and 
then a Kecuud oiie carried nround the other half. The advantage of 
this 8uture is that it more coniplelelv sosXa off the wound from the 
rectal discharges than do the interrupted sutures. ltd being broken 
in two pliiccs gives the anus more o))portiinity for dilating, and pre- 
venta the eulure acting b« h purac-striug to contract the oritlce. Where 
there is any difficulty or tension nec-ewiirj- to bring the gut down to 
the margin of the unna, this may be relieved by passiug an aiiHioring 
suture through the external wall of the gut or the mcsorcctum, if it 



MALFOEMATIOSS OP THE ANUS AND KECTUM T5 

can be found, anrl out tlirongh the ekin, tying it oyer a wad of cnuze, 
and tlius tiikiug thi? traction ofT the autiiroi) in the iiiucour membrane. 

Tlie <i rciwin^r* shoiiM lie nf soft ahscirlicnt tpjuze tmnstoiu^tl wiUi 
bonc-iu-id »)liiii»u, and holil in plnco by a diiiper. The nbdmneu 
ghould be incased in a snug roller- bam iagu to avoid stpwiniiiff. 

Casfx in it-fiirh the Rutum i.* firmtleit Ifijh Vp fu the i^fU-is. — The 
incision anil methods of suturing the gul, when found, ait; aijplicabU' 
to All forms of imperforate anus. We come now to the etudy of those 
fomm in wltiL-h the rectum is removed, or arrested, in its descent at 
a greater or less distance from the eul-tle-sac of the imua. In such 
ca<c« the anus may be dbsont, op it mnj be perfectly developed, ending 
in « rvl-Jf-aur ahniil I In 1 J centimeter (nliout j incli) in clcplli. The 
method nf deahng with this cul-de-taf. will be deKcribcd Inter, ns fto de- 
sire at this time to devote out attention to the nndescendeil rectum. 

In ordt-T to tliorouKhly eomprchend the diHicidties of searehing for 

• the n*clal pouch, it is ni-L-essary to understand (he epace in wliieb the 
Operation must bu performed. This space is outUneil by the tuber 
iBchii upon each «idc. the soiiptum in front, and the coeeyx behind. 
^_^ The distance in infants between the lubcr isehii is normally about IJ 
^B Xb 2 centimeters (g to j of an inch), and docs not differ mnlerially 
^H in the sexes. That from the scrotum to the coccyx average* from -t 
^™ to 41 ctfutiineters (1^ to IJ inch), and from the posterior commis- 
aurc of the vagina to the coccyi in girl* about 3 to 4 centimeters 
(liV •'» ' i*« int^h). Till- disluMce from the anus, when devehiped. to 
the tip of tlic Coccyx woujil average about li centimeter (3 t'f ft» 
inch). With these measurvmcnli; in view, wc con understand that the 
operative field or space would be embrnee<] in an elliptienl figure 

Ewith a miLximum length uf -i cenliinutcrs (1 ^ ineh) and a ninximum 
breadlb of 2 eentimeters (J of an inch). The depth of the pelvis, or 
rather the distance rnmi the tip of the coeeyx to the promonton,- of 
the (iBCTum, is about (i teutimctcrs (Sij inches). The distance from 
the perinu-um, at which Ihc peritoneal ctil-dt-ftie is found, varies con- 
didiTahly, but it may he staled thai in nonf-rat this pouch in females 
t£ aboui 2 centimeters {\ of an inch), and in ninlee it is 2} to 3 eenti- 
meiera (1 inch to Ij^ inch). It sliould be home in mind tlia! these 
are normal ineiuurempnts. and tbut in ea»^es of mHlfornmtion of the 
anus and rectum there is also likely to he some malformation of the 
pelvic frame. This malformation getieratly lakes the form of abnormal 
eontraetinn. antl the .space for npenitive pmeedurc is thus reduced. It 
IB well to mention here alao the fact, shoirn by Oripps. that where tliere 
ia malformatton of the anus and rectum there is likely to be itome 
tbnortna] distribution of the peritoneal eaUdt-me. Thi« may pa*! 
downward and backward almoiit to the ulun near the tip of the coccyx. 





7e 



THE ASUS, RECTDM. AND PELVIC COLOH 



I 



VtiMi separating the ends of Ilie proctodeum and the eateron hy a true 
peritutHui] cavitj (Pig. 48). Sudi ou armtigeiiieat of the peritonirum 
wniilil rcmlt'r it iTii|>tJs>ii)ilL> tu iiitnidueo un aiipiniLinff nt>M)lt> nr Irnrnr 
from ihe anus into tht- roctiini withmil pimeing directly throwfth it. and 
vould necessitate the subsequent irifeclion of tliaC cuvity wh^a the 

instniment was with- 
drawn. As it is im- 
possible to predicate 
siU'ii a condition or its 
ubsvace before opera- 
tiun, one should abdii- 
luti'ly limit tlic use of 
the trocar to carrjtng 
Ihe fluid contents of 
the rectum hej-ond and 
outside of the wouud, 
after the nrtj^tm has 
bwn found, and it it 
impossible to bring it 
oulsiflc of the wound 
bfforp implying it. It 
cnn be readily seen 
from the mmi-iirfl- 
ments above given 
that spttL-o for opera- 
tive maiiipulutiuEi is 
wry limited, and with 
the bladder, itt^'rus, 
and other pelvic ar- 
^ns in pnflition, the 
operator will have to 
be very careful iu 
working in so small a 
8IMCC lost he inj\irB 
them. The chief space of the pelvis thus k-ft for opL-rative manipula- 
tion is in the hollow of the jMicruni, uiid in order to reach this, one has 
to dissect backward and upward around tlio poinl of the coccyx, work- 
ing largely by fcpling nnd not bv wight. 

Tlie inelhods which have bwn deviHed tu incrt^flse this space have 
been numerous and ingenious. The first wa* that of .Vmussal, which con- 
sistt^l in removal of the coccyx. This operation, sinipli- in itstdf ami very 
easy to pcrfonii iii children, is objectinnablc beciiusc it takes away the 
Dortoal attachment of the anal iind rectal muHclcsi it also removes the 




Flo. ift,— M*i.ri>T[<itrii)w tu wBinii tiik PitKnnii«At. Cvl- 

TUH AXO Axil*. 



^ 



* 



support to Ihe lover end uf the rectum, and ttiu^ invites prolup»e imd 
posterior rectocele. Currying tliis operation one step farther, we have 
the various nioditit-ntionii of ilie Kra^ke or sacral operation. It U not 
ncceHiary to dot't^'ribu tlivm liore. furtlier llian to si^&y lltal v-biitcvtr 
portioQ of the raonim it is tliouj^ht wi.sc to reTciove cau be done by a 
etmng pnirof stissors without Iho »m of n rliisel or bone-cutting^ instru- 
ment. Tlic danger of injury u> ihe nerves, ahoek, anil the removal of 
rectal suppurl^ and mui^-ular attarhnicnta are the abject ioiiahle [matures. 

If une could say pusitively nhen he bc^fins that the rcctuiii wits high 
up, and Ihc Hpavo would liave to be lUL-ii-aHfd, there is no doubt but 
that the Itydygicr ojienition, dueorihod in the chapter ou excision of 
the rectum, would be a pritctical and saSe procedure. Such n radical 
operation, however, would not be jutttifed unleas we had some tibsohite 
assurance that the rectum was high up in the pelvis. 

A more conservative plan in that of Vineent, who takes advantage 
of the HofI, carlilaginoiiK condition of the l)nnf„-% at thi« period, and 
splits the coccyx and the lower part of the wtcruni through their center 
with a large ]iair of scissors: then the oilgrs of the wound niii re- 
tracted and ample ttpaco for operative inanipulntiHii, and a good, free 
Tiuw of the whole pelvic cavity are afforded. Aft&r the rectum has 
bctn found and brought into its normal position, deep Kuuires are 
vwed to bring the bones and tissue* togiuhcr, and Hiub the peWic frame 
is absolutely postored. This operntion, as described by Matas, Vincent, 
and othens ha»i provwl entirely (■licccssfiil. and the ultinmte results 
have been most sal isfaci ory. Theorcl i cal ly then* is one objection to 
it, ind that is in cases in which (he rectum can not be brought dom-n 
to its normal poBitior, and must be attached to the upper end nt the 
wound, it will necci^ariiy biiug (he gut out between two (lap of bone. 
In such instanced the bone flap or Kraske operation wonhl !«-■ more 
s*ti8faetor>". Neverthelesf, in ihi' Viiiet-nt ojn-rntion there would be 
little dillieully in ptt'ling out tliL- cartilaginous section of the sacrum 
or coccyx m as to make the flap Boft upon one side in such an emer- 
gency, and the ultimate r.>sult» would be the same as by the other meth- 
ods. The space for ojurnitive rnauipuhition htivinK ihua been materially 
enlarged, the succeeding stops of the operation will be in full view and 
com)«r«tively flimple. Piiwction should be cinriid upwanl into the 
hollow of the eacnmi to the de|itli of .*» or « coiiliiiien'i's (2 or 23 inehcH). 
At the namt lime careful palpalion should be made with the linger in 
Ihe round In elicit, if p<is«iVde. any impulse from the child'^i crying 
or fnmi pn*«ture upon the abdomen by tui luwistant. Where euch 
impulse is felt il ariws from the rectal pouch oe from some loop of 
aigmoid. and diwa-ction should be made in this direction. At this stage 
of tiie operation it is best to introduce a sound into the bladder of 




7« 



THE ASUS, RECTUJI. AND PELVIC OOI-OIT 



tiie nuile or the to^qii of the feinalo, in oHor to d«tonninc the exact 
location of theiw organs, and thus avoid wounding tlietn. The (ihrous 
con) wliic}i HoiiK-tiiniM liaids (nmi t)i(^ iiiiporfuratL- aiiii« up to Iho nvtal 
poncli (Fig. 4".i), «*Iii'n found, tilujuld alira^K bo ki'pl in vk-w and f()l- 
loved ctoeelj^, as it is a certain guidv to Xhc rectal jmuctu Wlioro chiit 
cord does not exist vc must depend upon ran-ful dinsi-ctiun in ordi-r 
to find the gut. When it is not found in the hollow of tht- Bacniin 
after having: dissected upward for the space of 5 or 6 c(!ntimct«re (3 
or 31 inthc*) from the iiiorjriu of the anus, dissection in this line i* 
no longer advisable; but the operator ahoukl carr>- iii3 ini;i*ion through 
tbe soft cellular tissues funrurd and upward, entering th« peritoneal 
eavity at oni-e, if the rectal jiouch is n«l roaclit'd befoi-e doing no. The 
dangers in this operation are not fmrn o|)eniug ihc periioneal cavity, 
but from alloa-ing the intestinal contents to escape into it. The author 
wwuld Hot advise ofM^ning the peritoneal cavity unneix-ssarilj under any 
conditions, and much lees &o in a feeble child; Imt tlie old dread of 
invading this cavity has caused the wa^te of much valuable time, and 
has been the eauw of death in many coses. Therefore, when the reetal 
pouch has not Iweu found, after a reasonable ditweelion in the hollow 
of the Bacrum, the immediate and free opening of the peritonieuni !& 
advim-d. When thin has heen done the soardi for the rectal pouch is 
simple enough. If it is diittended and teUMe. and Iti the pelvic cavi^ 
at all, it will be eiwily fell. It may \v attached to the pmmomory of 
the Mcrum oJT to one side of thia bone, or it may he tloating loose 
in the |»eritoneal cavity. In the latter inntance il ie generally easily 
bronght dorni, and can be attached to some ])urtion of the wound with- 
out imieh teuBion. UHien, howewr, it is nltnehed to the pminontory 
of the sacrum, or to it« side higli up, the proecses of bringing it down 
ia much more diflieult. The diflicully lies in the fact that the reeWl 
pouch is covL-ri'd over and bound dowTi to the bone by a y>eritoneal fold 
which entirely envelops the lower end. and 1m really the caii^ of it» 
non-descent. 

The splitting of this peritoneal eoverinK. and the cnin-leation of Iho 
rectal pomh so aa to bring it down Iq Ihe margin of the wound, has 
been attempted with some succests. Tliie. however, is a most dillieuU 
procedure, and the «uth«ir ijuestions very much if iI would not be wiser 
to do an inguinal colotomy as soon an sueh a (•(nidilimi of alTnini is 
found to exist, or, if possible, bring a loop of the Higmoid flexure down 
and attach it to some point of the perineal wound. When the rectum 
ia found, tlie grealest care muBl hv t-xerciscd lo loosen ils attnchmenta 
and drag it down eo as not to rupture the inferior mesentcrir artery, 
and llniB obliterate the blood supply to the parts. When it has been 
brought down in the perineal wound at tlie normal position of the onus, 



A 



MALPORMATIOXS OP TRK AIJl'S AXtl llECTtJM 



79 



or hipher up. if nrcPissary, tlie p*ritona'Miii should b« vIobkiI by >;auxe 
packing heforn the put is opened to allw* the t'scai)^ ot the iiiuconiun). 
If lEie (levelopiiU'Ul vf tlie rectal poucli iet i<u ^liui-l that it ciiu not l>e 
brought outside of the peritoiicni cavity, thcu tlibt aivily slioiiltl he 
clodedi the perineal wouml packed oil', and inpunal colutomy done at 
once. Sometimes, whrro I he pectiim oan not be fuurid by perineal inci* 
Mon and disKcction, and inguinal colutom)> hiiK bt>en duiit^, it will 
descend at a later period, and llie opi-tulor will In? abli' finally to 
appritximale the amis and iTL'tiicii at their itormnl pasitioiis. 

'Die llxation uf the rectinn in lliis form at nialforniHtinn js prac- 
tically tht- suine as tlint in Binipk' iin]u'rfiiriiti; niiiiB. The mi»(;ou9 mem- 
braue should be sutured to the wkiti at the norninl anus if posnihle, and 
if not posjiible, it »;ht.iikl be sutured at the lowest point of the perineal 
wound to whieli it eun be brought without too preat tension. 

An interesting ease illustrative of tlio cnndiliniiK just mentioned is 
reported by Kronleiu (Berlin, klin. Wih-Ii., 1H7P, p. V2G). Ub opened 
the peritoneal cavity after a dissicetion nf .1 inrhe.<i without finding the 
n-L'tal |ioiiih. The (inger end intmdured in tlie eavity fniled to (hid 
the m'juiing rtil-dr->iac, and he immediately attempted ingiiinal cohitomy. 
Hero again he met willi a dillieuHy in the close attaclinient of the colon 
to the lumbar region, which iibsoliitely prevented his bringing the colon 
up into ihf iilidnminal winuid. He was therefore eompelled lo bring 
ap iind open the m*\t and most distended loop of Intestine. He dues 
not .itflte tt'hetlirr this was the snuill intestine, sigmoid, or tr.iiisverse 
colon. Nevertheless the clnld recovered, and .wven months lattT, 
"when the finger was iiitrodured into the iirtiftcial anus," a reaieting 
h<idy was fell in the pelvis, whirh he supposed to be the distended 
reetum. The perineal inoinion was reopened, and he found that the 
dititondcd reotnl pouch had since the operalion descended low enough 
into tlie pclviH lo he brought down and sutured iit the pite of the noniud 
inns. This caeo ii« (|Uoted in illuiitrHlion, lirst, of the wisdom of early 
incision into the peritonea! cavity; wcrond, of the difliculty which may 
ftrif* in inj^iinal colotoniy in children; third, as illustrative of tlie fact 
thut the rectal pouch may continue to prow and di^scend, ami evciititally 
rearh a position from whicli it nuiy be attached to tlu' normal anus 
long after birth. In Kronlein's caee the inguinal anus closed in thrcfl 
week)) after the rectal pouch was attached to the anuis. 

Trtaimrnt of the Anat Cul-df-nnf. — We ccune now to connidur thfl 
niatiiiigi-meDt of thostc eases in which llie anus Is fully develo|M.>d and 
th« rectum more or less removeil or ha.s descended alongside of the 
anal cul-dt-me, as illustrated in Fig. 41. 

In these ca»e« the external ttphinctera are normal and the anal nii- 
d«-*ac, for Uw space of 1 to 1J centimeter (g to j of an inch), n per- 



tflB ANUS. HKCTtTM. AND VFAA'tC COLON 

fectly formed. The trpalineiit of this (nl'dg-sac nnd the qui?stioD of 
onion botweeu it and tli« rectum {wlien the l&tt^r has be^n fuiiiid) hiui 
crentfil i-DiiKidcTable diaeuxuiou. The oijcratiun of t'lid-tu-t'iid uiiiun 
between Ihe Iwo cuU-dc'Sac i« a very dltlicult one to pfrfonii, aud most 
uncurtain in ita resulte. Kcccttt surgical opinion and the results of 
operations upon this class of coses have convinced nic that it h beet 
to dissect away the lining meinhrane of the annl ctil'iie-sar unci bring 
the rectal mucous membrane down to the nmrgin of the skin thus 
frtwhrned and suture it ihorc. The iuuision in sueh cases would dejjcnd 
upt)n whether ihe reelat puuch can be uuide out without diiweclion or 
not In case thii: was poMiible, the incision tliruugh the tinus shuuLd 
undouhteilly be made in the dirrctinn in vihirh the n'ctal pouch is 
felt; but if the position of the rectal pouch cjin Dot be nmdn out witli- 
out direction, then it should he made from the poetorior niarpn of the 
anal riil-df-sar back t(^ tht> ctitcyx, just as in the pruvioHu operations. 

Jfutan, in a case in which the rectal pouch deacended in front of 
the anal ruUdt-mc, sutured the end of the rectal pouch to the perineal 
margin, left in xUu the anal ciil-de-nar and incised the Bfpptum hetween 
the two. lie says: "The objection lo lalcrfll ano-[no€torrhaphy (as we 
might distinguish the suture of the bowel to the niLJitiientary anus as 
practised in my case) is, thai it k'avcs a lar^jer anal orilicc thiui is 
required, and that the interpositiun or new mucosa in the t^sterior 
eegmcnt will act as a wedge and will interfere with the perfect grasp 
of the sphinelers." He ihercforo adviws as a bettor procedure tho 
total cxciriion of ibc anal rttl-df-mr, leuFiiig the luarginnl aniil iiiUL'oea 
intact, and suturing to this the mucous membrane of the rectal pouch. 
Aside froiH the diineiiHy of cnd-to-eiid siiliire of the rccliil and anal 
pouches (Ihe eircUuifLTcnce of the rectal poueli bi?in^ always much 
greater ttian that of the anal) there will bo iiupf^rfcct coaidatitm and 
danger of valvular fitrichirc eventually succeeding. 

Vidfifomif in Vatfs of Imperforate -Itiwa. — Thus far we have only 
referred to the operation of eolotoiuy m a last resorl in cases where 
the rectum could not be fuund. or where it wan iinpossil dc, owing to 
other complicaliuEiti, to eslablinh tlte anus at its norma) position. Tlie 
operation, however, Bucrita a closer consideration. Some surgennH hold 
that an in;;tutial anus should be mailc as a preliminary operation to 
perineal search for the undcscrnded rcctiijii in all rnsrs in wliirb the 
Iatt<?r can not positively be felt through the anal tul-de-sac or perinieura. 
They hold that it is more certain and less fatal than prtntoplai^ty, and 
that it does not interfere with the ultimate establishment of the anus 
at its proper site after the child has grown stronger. The arguments 
in favor of such a procedure are not without weight. The rapidity with 
which such an operation can be performed 13 urged in its favor, end 




MALFORMATTOVS OP THE ANUS AND HUCTl'M 



81 



'can ant W igiir>rc(l. Tliu Tart that the. Higtiioid Ikxun; U snmotimes 
diffirtilt to find in 4-hililn-n. nr thnt iL gL-nmilly rrstB iipnn (lie n^ht 
side ini^t^acl t^t the left in enrly iiifaucj, does not militate o^uiitM it. 
To one familiar with Ihes* conditions it la not difficiiU, if the ubdyiiicn 
is ii|»oii, to Hwwp the tinger i-lear acrtisa thu pelvia in thenv little onca 
nni! find the loop of iiitL-stiiu^ iu whiuh it is do^irRble to iiuikr th*' nrli- 
dem) iinun. A^iii, it in iir^ed that in Lhin u])(>r»tion iiii opporlunity 
will be «ffordpd to sftarrh the surnil rurvatiire and deeper peliin, and 
thus acciimtidy cluteniiiiie the alwrnre or jireeenee nnil tlio location 
of Uie undescended rettum. Mon-over, it i» claimed tliat llie amount 
uf truunialiitm and mutilation uf llic tii^uc» necL-i^siiry lo ])criiieul Ki-urdi 
for the rectal pouch will be ;,'reail}' lessened by a preliminary colot- 
omy, and that if, after the abdomen is opened, the opunitoi" iliecoverB 
the rectal pouch within eat^y reach of the pcrinanim, tho ahdoiiiiiml 
wound cnn be promptly elosei:! and tho porini'al operation perftirriic-d 
with Diucli greater certainty, and with «zimller ineisionii than where 

I it i* attempted ab itiitio. Furlhcnuore, the Hdvoi-ates of prtHiiiinnry 
culoloiny claim that after the nrtificiiLl ingiiimil aituH m established 
and the patient has rernvered fmm the same, it will lie (jiiite fetu^ible 
to p48)? a blunt probe or ttdund through the lower aeginent of the gut 
iuto the rectal cxd-tk-sac and thus determine the exact location of 
tliiu [wuch. With the probe in thiR poiiilinn one ean dinsret ihnvn 
upon it with compamtive ea»e tmd eslnhlii^h the nnun in it» noniml 
position at a time when the child is well able to withstand Burgieal 
uilt'^rreroncc. These advantages are imdeniable, and shonid be g-ivc-n 
due consideration. 

The argutnente a^in^t 8uch an operation have been hnsed cliiefly 
upon the fiuDj^r of invading the peritoneal cavity, and the hixh inor- 
tfllily which has folloiFod the operation. Since Lnwuon Tftit ha? prac- 
tically dissipated the fear of invading this cavity, nnd since it has been 
ahowii that under proper aaeptio precautions and vrith due celerily the 
pvritoneal cavity of a child can bt> opfned aliiinst as safi-ly as in tho«n 

I of greater y^ars, this argument ha» Ini^t much of lU weight. No one 
would controvert Uic proposiliim that if Itn.- fffoal exit could be ea- 

|tabliahed at the norrmil Fit« without invading the )K*ritoneal cavity, 
or BuVjecliiig the cihilil to too great and protracted surgical procedures, 
Buch a method would be preferable to inguinal eolotomy. But when 
th* child ia esinMticly weak, when immediate relief is urgently de- 
nuofled. and when the conililion will not justify even the delay of a 
prolonged eeareh for the rectal pouch, inguinal colotomy undonhtedly 
ha» ita wlvntilage*. 

Another argument against the performance of thi.4 opemtion in 
childiva u boacd upon the thiu and fragile texture of the inteetine 




IS THK ANUS, KBCTUM, AND PSl.VIC COLON 

(litrinif infiinny. It Imi lwi>n lii>1<l, mid juittly eo, Uiat it» ilRsues will 
not Imir NiitiirinK wp)l, Ihnt Ilicy bfc luil nlnrng eiiau>;h to hold th« 
({■It Itniily ill 111" iilMloiiiiiiiil uouihI. iintl tlirn-run' tlnmr i* grv&t <)iingi-r 
Iff llu'lr Itri-iiktriff liioM' iiDil iillimill); iIk' lon]i nf |)k' iltU'iililie tn ilroji 

lifli'k liilii till' nlHlDinitml I'lwHy afU-r it lias oiict' btt-ii opened, tluin 
|fifm'llit(t III" |itTltiitiH<iiiii niid pnuliit-inK it fttlnl termiDation. 

If i(. WNH iiri'i'Miir; W< iIi'ih-ikI Ttpuii Kuiiiiv^ lo hold the gut in posi- 
tlftrii IhvM) fAClil wniili] lit) Miillli-imit tu mndenm the operation, except 
N* H ilffniff I'fimiirt. liul tliU iir|^iimi>iil [unt^s Us tunv whi'ii h-r consider 
til" tai-i llltil tllii Ik^kI oixTntiirti no luDgiu' use siiLureFt ti] Htippoi't the 
tnlMliim 111 niUiiomy. Maydl nnd Hoc-liut have establinhed the fiirt that 
few If nfi^ ■iitiiii'ii iiro m'fCft.«Jir>- in the performance of this operaiion. 
mill IIimI a ^[»it» n>d jiartfted thrnii^rl) the mesriitery frnm »Dr gide to the 
ttdinr of thff M-oiind fi>rm» a safer, a more permanent, and better Aupport 
Id (lilt iiiiefdjno than any number of iititcheR c»n potu<iblr do. lliiii- 
ilrfdii nf operaliniim rione aftiT IhiK inntiner uilh perfect succvea Imve 
nmllniu-d their opinions that the daiigera nf infection, tearing Inuite, 
anil punetiite from gtitchea ami »titch-liole ahso'sseit have lje**n entirely 
(ibliteraU'd by tlieir method. Not only is this livu'. but ilie time of the 
oporaliun lias been ^eatly shortened and the dangers of surgical sliock 
proporLiuniiti-ly dcLTL-ai^ed. Time, where (.■ir('iiiii»tuiR'C-i< seem lo demand 
it, an iuKiiinul culotomy may be Mifely and quiikly made- in clilldnu 
with imperforate ani, and by it vahiablc livce may bo saved which would 
almost eortainly be lost if any nther method were ai1o]ile<I. Tlie ques- 
tion of elo&iiro of the artificial inguinal anue will be discussed later on; 
Imt it may be stated hero that in children such apertures will generally 
close spontuneously if a nomml exit for the intestinal contents has been 
well I'slubliahcd. 

The clioice of operations, therefore, tictwcen the pcrineul dissec-liuu 
in ficarch of the recital |)oiieli and Inguinal colotomy will depend first 
upon the knowledge which wc hftve of the proximity of this poitch and 
the child's ability to withstand surgical operation. Where there is no 
evidence that the reelal poiieli can be emtily reached, and where the 
child is in an enfceblud lundiiioii, with dinteiuled abdomen, fieiral vomit- 
ing, and nausea in progreaa, one Nhonlil not hesitate to chnone the 
obduniinal route, perforin an in^iinal mhitnniy at onre, and tliiis afford 
un iuimedialc exit lu tin: intestinal contents, mid an escape fur the ganca 
which are earning the distention and the constitutional dii^turbaucea. 

Friirtnplaslij Versvfi Vvhtnmi/. — The term [ircH-tophiHty hae heen 
adopted by retent ^Titers to deserihe llio viirious perint^al inelbods for 
operations npon imperforate ani. There has been a long and animated 
disciii^sion concerning the coniparalive morljilily from prnetopliuity and 
colotomy in these cases. Able and vigorous writers have been engaged 




MALFORMATIONS OV THE AKUS AND KKCTDM 



83 



apon fitlier aide. Jleceiilly the wngc ol battk eeciiis to favor the 
perineal moLliud. 

Id the total Diunbcr of operations done, there is do doubt that the 
pppc'ciit«KP of ffltalitios is less in prottoplaety than in colotomv. It 
must not he forgoll*»n, however, tlmt a large- miniber of the ca^cn clone 
by the former method have been of the simpleet type, and have reipiired 
operations of no iiia-itiifuele. In many of ihene t-ases tin? vec.uii pouch 
has hetu in apposiliou with, or veiy cluae to, the periiia*UTii, ^n that 
id eoitld be reached by a very ahuUow incision and without involving 
any iniiwrlaiit urjrans. The liet of tiit'sr opcnjtions also iiiHiidfe many 
cases of malformation, such as atresia ani vaginalie, which would not 
have proved fatal had nothing been done for them. On the other 
Itand, tlip coses in which priniaiy colotoniv has bei^ii purformcd liave 
been ihose of the most d^Mporale charat'tL'r. many of them havinj; 
already undei'gouB prolonged perineal search previous to the colotoriiy 
openiliiui. 

In sluilyin^ the comparative fig^upes, therefore, we must not ail^ich 
too great iin{)ortaiiC0 to the percentage column. In the old statistica 
Iho oivoration of puncture by the trocar was always included, an<! a 
very high mortality rMnlted. Thus, Aiidere gives for il 50 per tont, 
Curling T6.4 per cent, and Cripps Ha.3 per eent. Tliia operation is 
now pRictieally ahnndonwl, and np(-d nnt be considered here. 

The following brief table represents the comjiarative refidts of 
colototny and proctoplasty in the collections of cases by Andei-s, Curl- 
ing, and Cripps: 

Vortaliiy from Differmi OpfmHonn for Imperforate An'tB 



Aaien. 



^.'4A^A^>ll\v, priinnry,, 
— i. I-., »fif>r iin*- 



5S.8 per ot. 



llA(l 



lotiliuty 

nIti-iiiiiUil 

I'roctopltwrt.y 

?riMi»|itnsi;, omit- 

liiiK alrrala aiii 

vairin«lh 

TrtUI rasM 



30.5 per cU 



88.9 iwr Bt. 
87 



Oirllu^ 



47.ftiwr Pt. 



B9.8 |wr ct. 



100 



CripfH 



68.4 [»r el. 



M.7 |>er et 
40.4 jjer ct. 



A 11 (bar. 



43.7 per et, (33 mmc), 



4.V3 pvTct. (42casca)i 



140 



From Ihe (able one will see at a glnnce that the perineal mellmd 
is less fatal than colotomy. We must not forget, however, Ihe varia- 
tioDs in gravity between the class of coeea in which the one and the 
other operation is adopted. 

In a study of the niodeni journal literature upon Ihia subject, 110 
oascA in which opcnitious have been done for taalfonnattons of the 
rectum have been collected. Of these, 66 cawa were performed by the 




84 



THE ASUS, RECTUM, AND PELVIC COLON 



perineal and eacra] route with 2G dcallis. n mortality of SUM per cent. 
In 4S iiiB«8 i!ulotoiiiy vaa doiiu eecondan' to pcriimal and BQcral opera- 
tions with 19 dontlis, a mortnlity of 15.8 per cent. Thirty-two primary 
colotoniiog were done witli M deaths, o mortality of 43.7 per cent. The 
till rod net tun of ihcsp tal>k>« would «oiMUine too much space. But almntit 
without exooption primary L-oIotomy was done in the most grave comli- 
lioiut. Thia is empliaaizeil by the fact that the mortality in iimuediale 
CdlotiHiiii'S is very uliphtly Icsa than in ttinse whicli were done secondary 
to rxtfusivp pcriarHl upcralioris. Thccc; fiuta an- bonu; out by thow; of 
MataH ( Transact ioiiii of the Amt-ricaii Suryical .Wociatiuu, 1897). The 
higli mortality given by Andera for colotomy in these fa*08 is explained 
by the fact thai in 21 operations done, 13 of the patit-nt* liad previounly 
been subjected lu prolonpMl perineal operations, luid than their eoutUtioQ 
was not what it shnuhl have been in order to beg'in the cnlotomy. More- 
over, Ibc low mortality in bin table for proctoplasty iai general is made up 
fnim a number of exceedingly simple case* in wliich there were only 
membranous divisions between the rectum and amis, and others of atre- 
eia ani vaginalis. If these eases are left out of his fables the mortality 
from colotrtmies will be largely decreased, and that from proctoplasty 
will be eonsiderably increased. Hut, after nil aMoivanees are made, proc- 
toplasty, or tlir perineal openition, still bag the ndvniitaS" '" a smiiller 
mortality. Xeveiihelesx. it i« the coitditioti of the child ami the urgency 
of the case, and not the statistical mortality which should determine us to 
choose proctoplasty or colotomy in any individual instance. In ex- 
hausted cEiildrcQ with tympaJiites and ayniptunis uf iutestinat sepi^is, the 
most expeditious lucthoda of rt^licf arc; denuindi'd. ami, iia Mata« well 
eaj-s: " Under stich adverse conditions it can not be denied that inguinal 
colotomy is the quiekest and aifest operation." 

Tn>atmenl of Abnormal ^'arrowitiij of Hip .-1«h*. — In cases of abnor- 
mal narrowing of the anus no operative procedure is called for in the 
early period of life, provided a renaonable exit exists for the fluid con- 
tents of the bowel. Gradual and gentle dilatation with bougies, or 
with an oitlinary uterine dilator, will geiieralty Lriuj^ the part^ up to a 
comparatively nonual size. Thi« conscrvulivc method of treatuic-ut will 
afford the neeeasary exit for firrnl matter, and in this condition the 
child may wait until it has developed suflieient strength to stand eurgi- 
ra.1 proeedures. IE the contraction should prove to bo of a libroua 
nature, which condition is exceedingly rare, posterior proctotomy, or, 
which is better still, the excision of the fibrous tube, bringing down of 
the mucous membrane and suturing it to the skin may be pcrfonned at 
a later date ( Lannelonguc, Bull, et ini'm. soc. de cbtr. de Turis, 188i, 
p. ?t>i>: Degouy's Tb^sc*. Lyons. 1894; Couty, Theses, Paris, 1889; and 
Vanclaire, MM. infant, I'aris, 1895, p. 86). 




MALPORMATIOSS OP TDE ANCS AND RECTl'M 85 

Trealment of Pariiat OcfJtisionJi. — Wlit-ii llie obslructioQ coiuiists of 
n fold or band of skiu rumiing from tlif Mci-otuiii or |»ostcrior comniis- 
sure of the vulva hunk to the rnccyx, there is no ULlvaiiUigu in delay 
even though there tic a mo<li>rnte exit for the meeoiiiuni. Stich a band 
can be sDipped o0 at its ende with ecissorfi and dU«cctod away. Tlio 
autis should thtu be period icully diluted until it am<uri\o» it« nortnat 
shape and nize. When, Itowevvr, this partial oeelusioQ ueeurs at a 
higher level, and the exit for tlie iiieeoii iu m is very limitod, the qunH- 
tion as to mnnH^>ment is somi>wlmt nion- 'liHicult. 

Matns (op. cU.) states thnt simple incision of these rrescentic 
diaphragms has not been entisfactory. The proc«hire, he says, is fol- 
lowed by recurring strictures and conaeriiK-nt obstruction to the fiecal 
pouages. lie therefore advises the total excision of the mcmbranee 
and eataring the oHj^es of the wound tojfethor. Most authors, however, 
do not appear to have seen any »«eh resiiUi; from simple ineisiinn in 
these cages. In fact they vtote that if such membranous obstnictionB 
are thorotij^hly incised, ttiey will atrophy and entirely disappear. The 
author's ex^jerieoee has been Uiiiitocl to 4 cases of this kind, and lie 
lias not been able to follow thuni to any late period of life; but two 
of them he haH a-en at the nscs of four and six years respectively, 
and no such strictures had occurrc<l. tic is of the opiaion that Matae's 
TJeva ar* larpely theoretical upon this point, and that inasmuch as the 
simple incision is almust eiitirt-ly without danger and involves no uhoelc 
it ought to be employed ill all these caHea. If a stricture should oecur, 
it may be resected later on in life. The iKiiuibility of lia-niorrhage in 
incising these obstructions Hhouhl always be boriK- in miud. One caae 
has bfcn reported in which the child died from this cause. 

Trtalment of CovipUlr (Udusion hfi a Membrane vr Piaphragm. — 
TbcM caacs arc among the simplest as well as the rarest of rectal iiial- 
fonnations. Usually this membrane is so thin and diaphanous that 
the color of l!ie meeouium is transmitted through it, the bulging ol 
the rectal pouch is easily felt when the child cries or when pressure 
in made on the ahdonieii, and there is little doubt about the close prox- 
imity of the pouch. 

Honietimes these mcmhranee are so thin and fragile that vrcn 
examination with the finger, especially if the nail be liharp, will rup- 
ture them, and there will be a spurt of meconium from the anus. At 
other times, however, the membranes arc more dense and fibrous, and 
while the impulse can bo fell, onlinary pressure fails to rupture them. 
The impression to the touch in mjch cases is very similar to that pro- 
duced by the hag of waters in the early .-itages of labor. In such simple 
casM a cmciat incJHion through the membrane, carried from one side 
to the other of the anus, will be all that is Deceseary. The little tri- 



THB ANIS, RBCTUM, AND PELVIC COUIN 

angaliT fold« left hy euch Incision atrophj and disappear, and do 
nsuins of them can be seen in after life. 

tjBfortiinaleK',. howt?vcrj there is sometiiji«i tnore than one sut^h 
■cnbrane. When thin is the ca-ie the fluiil which escapes through the 
flnt incukin m only a thick serum nr mucus and not meconium. Great 
care miut be exercised in drtprmining the natttre of tiiis fluid, eUe 
in tbcwe cases the operation will be of do avail. The fin^r should he 
introduced well up ioto the rectal pouch after the incision ie made, 
the ptrta wll dlUtod, and thp operator should awure hirmieU that no 
•ttcondary menibrnne <>xi8te at a higher level. Voillemier's cat*, in M-liicrh 
there were three siieh distinct merabranM, forcibly illustrates the 
nfcessilj' of «iich precaution. One point must he taken into considera- 
tion in thcAC cMea, and that in tliu.t the iiiipuUe imparted to the linger 
may be due to fluid in the peritoneal cavity. Incisions through sucli 
nenibrancg should Ik- made with the ^eatext aseptic prccaiitiuit?' in 
order to prevent any diitaetrouH resulle following. When n second luom- 
brane ia found to exist, a tubular spectilum should be inserted and the 
partA carefully ohs(>rvcd to see lliat the cavity from which llie first 
fluid escapes is lined with niiieuim membi-auu and i^ cntiroLy shut ofT 
from the peritoneal cavity. Through this speculum, under aseptic pre- 
eautioni*. a long nspirutitig needle may he introducL-d througli the sfctjiid 
Dieinbronc if lluetuatiuu utid impidst! can be felt. If ineeouiuni is 
drawn through tliis needle, then, vilh the needle still in puaition, an 
incision may be niade through the second membrane and the wound 
gently dilated. 

At these higher levels wide crucial incisions are to be avoided, as 
they may accidentally involve the periloiu^al cavity. The makiii-j; of an 
exit sufficient for funcliuna] purposes is as much as can be safely iimler- 
taken in audi casc«, and if, at a later period, the lateral fokls lh\is left 
produce any obslruetion or inconvenience thoy may be excised by 
Mieeora or F«nningtou clips. 

Tftatmer.t of Casti in u-ki(}t the Iledum apena al some Abnormal 
Pofilion on the. .STfrr.— Interfereniio in Buc-Ii cased i« not generally 
urgently demanded, es])eeially if the opening be in the perineal, sacral, 
Tulvar, or abdominal regions. The exit is generally sufficient for 
functional purposes during early lifi'. and the time at wliieh o|)erative 
interference ia undtTtnken can bi- Beleeted with refi-reucc to the i:on- 
Teniencc of the family and the condition of tho child. Happily in 
these cases there is no necessity for prolonged, blind dissection in search 
of the missing gut. 

The abnonnal opening, if it be not too far removed from the natural 
onus, should be dissctted out, togeihLM- with the reetal pouch, and 
sutured to the »kin at the site of the uurnial anua. Where the abnormal 



UALFOKUATIONS OF TEE iSUS ASD UECnM 



8', 



opening is too far removed from the pcrinffiim io be brought down uml 
sutured tn this position, the rectum should be senrclied far by permoal 
djswec-lion, ami if found diould bt' brought (iown and ju mucous luem- 
bruiie sulurt'd to ihe skin at the site of the anue. Tho fajeol eurrent 
will thiiK be turned in Ibe naltiral direction. Tho abnormal opeuinge 
will grradiiully atrophy and t'lnse iindtr siit-h ciriuiiitilaiicc'a. If they 
do not, however, at b sccoud silling Ihey may be diasected out, luvagi- 
nnled, and closed by Lerobt-rt sutures. 

Whore the abnormal opening is conneetod with the reetiini by a 
long tiiJ^tuloiie tract, as in those cast's where it ojicna at the prepiiec, 
the lower end of the gerotum, or iu the glans penift, obetruetion will 
be likely to ocear. Siieb caeeg demand an parly interference. The 
nblileratioa of tbe^e long nmcus-lined tracts, willimit a too elaborate 
diaii^etion, a a question of eon»iderable diffictdty. The anthor'g opinion 
its althuiij^h he ha» bad no experience in sueh eat«eit, that the opening 
iiiiv the rectal poiieh at the normal eJtc of the anus should be estab- 
lished jart as 90011 ae the (child's condition will perniif. W'hcn thin 
has Iwi'n done, the tmft leading to the ahnorma! opening slimild be 
tilt across at a point el«sc Io its pnlrmice into llie nnrtal pouch, and a 
ligature hhimid he applied to the proximal end. Thii* end iihnuld then 
I)p invaginatcd into the nTliita and reitiincd there wilh I,cmbert snlures. 
The cat end of the remainiiig portion of the tract t-hould be closed in 
the same manner and left to alrnphy after it has been thoroughly 
cleansed. It is a well-known fact that niitenniB tracts thus ubandmted^ 
BO far UB funclitinal activity is eonecnied, do atnipliy and beeom« noth- 
'mg more than fibron« cords whitth are not detrimental to the individual. 

Wbrre thu ubnorniully placed aiiii't is iit some such rnnole position, 
aK on Uif alidnnirn, llii? chest, the shiiuUler, or in thi; jieck, ihe iiigi'iiuity 
fif Ihe fipcrator will W put tn the ficifercBt teat to devise some means of 
establishing a convenient outlet for the fsrciil niatcriol. It ia improba- 
ble ill such casee that the rectal pouch is or can be brought near to 
the perinmum. If a loop of (he Bigraoid or colon can bo brought down 
ad »utured at the anal site it will prnlwibly serve all necensary pur- 
sen. Otherwise an arliticial anus sbnnid hi? made in ihe left inguinal 
region after the niuimer of Witzel or Bailey. Certainly no interfer- 
ence beyond dilalin<; the ahuornirtl opening to facilitate the escapf of 
the inti'i^tinal oonlentrt shimid be iiinlprlakm in such a disc until iho 
child han arrived at an age to justify a prolonged and dil^cnlt ^ur^caL 
operation, 

Trmlmmi of Cases in vhich Ihe RtrUim opens into Sonu Othr 
Vtxrua. — This elfl«g of caws embraces about 40 per cent of all enaes 
of nialforinatiiin of the reetuui. and the large majorily of them are 
those in which ibe rectum opcn« at sonic point in the vagina or vulrai 



* 




The tfeclum eomniunitnirs wilh Hladtler. — AVlierc the rectum opens 
into the hlfldder it i« a qnestioa of immediate operation or death in a 
short time from infection. 

The iXzQ of the u{)eDing Into the bUddcr haa little to do with the 
prut^wnis. 'i'lie IrL-er the discburgc of the intestinal contents into the 
liliiiider thi' iiiori- nipiJ will be llic pripfrri*.'^ of inftrctiyii, Tlie prog- 
nosis iu ihis L-unditioti is alwujs mifavuiuWv, oud yvt uiifiiiliuu oUera 
the only hope of life. 

All teathin^ with R'gapd to shcIi nial format ions are largely theo- 
retical. Suine Jl'W c-aat-s liavc bet-n optTatt-d upon, but si'meely two by 
the saiiiP mt'lhod. Martin (Diet, des Ses. mM., toI. xxiv, p. 127) sug- 
gested as a mfaii« of rrlii^f in tlifsi? eiisps ihut a perineal amis should 
be c»labli»lH'd and the rccto-vcsical Hppimn incised down tn the nwk 
of the blarldiT, thuit furnishing a free exit for the combined (;ont<?nt« 
of the two organs. This appears to be a yerr blind operation, and it« 
erentua! benefit to the child would be of a most doubtful character. 

From a rational point of view there are two methods of procedure 
in such casps, bnlh of which involve abdnTnirial Footioii. The author 
beltevpH such cases ghoiild he operated iipnii at the earliest poiwible 
moment by a full, free incision into the abdominal cavity. After this 
the cimditinn of the parts and the location of the opening into the 
bladder will determine the future steps of operation. Where the com- 
munication is high up and can be reached, it is perfectly feasible to 
separatt' the two organs at Ihe point of comiiiunicBtion, invaginate the 
openings into each, iind suture them, pnnided thcrp in an external ori- 
Hoe for the escape of the fipcal matter from the rectum. If, however, 
there in an imperforate anus this condition should be remedied first 
by proctoplasty or coloioiny. 

Where the opening into the bladder is low down, in the neighbor- 
hood of the trigone, and bcyortd the reach of the operator to wiiture 
■with any degree of certainty, it will be better to make a permanent 
inguinal anus, and clofw up the lower end of the colon entirely. There 
is littk' danger in such ra'^es that the uritic will eseape upward intn 
the gut. and if the ffecal eiirnmt is shut otT from Ihfi Idaddir the diutid 
end of the divided intemtine will atrophy, and eventuidly the communi- 
cation will ihisr. 

The fui't that this operation condemns the child to an artificial 
ftnu8 all it« life must be considered by the parents and surgeon. These 
arlilieinl «ni are no longer the nightmare wliieh thoy were in former 
days. Even in adults they are so made at the present day an to pittLieaa 
almost absuluto control, and in a position in which thev are iwmpara- 
tively rnnvenlHittL Knw, when sueh an amingfmeiit, is inadi? in infancy, 
the child 'iA tau{;ht from birth to utiliiie it, and it bccumes just as con- 




MAl.FOUMATIONS OF THE ANUS AND BKCTl'M 



89 



. 



Tcnicnt a* if it were in i(s u«niial jioditiou. Such an aim* maJL' m child- 
hooil develops everitufllly almust as perfect Bphincteric control as has 
the normal nmis. Certainly there is no question of choice between the 
two procedures, if it U possible to can-y out iJie first with any deji^ec 
of safety; but where the opening is so low down that oue ean nut ruach 
and safely suture it, eolotomy is Ibe more conaervativw operation, aud 
offers a better progiioiiiit. 

The lleclum annmuuicates vHh the Urethra. — In this type of cases the 
dangers of infcclioii an- less (ban in (he prereding variety, and while 
tlic cscsjif of meconium is limited the condition is generally not ati 
urgent one. The conditional for mn'gical intcfference are also uiucli 
more favorable, the bowel is always lowi-r down and nearer the pelvic 
floor, anil the point at whieh the reetum npi'tin into the urethra ean 
be made out by touch or hy thp ugn of n line probe. When it is in the 
memhmnoiis or bxilhmis portion it will he easy to di8i*ect down upon 
tiic rt^c-tal pouch, disconnect it from the i.iretlii'a. and bring the fresh- 
oied edges of the orifice by which it emptied into the urellira back 
to the normal position of the anus after eHlarj^iiij,' it lo wliatevi-r extent 
is necessary to produce a good aperture. When the opi-ning is nca^r 
the meatuit the ease should be treated as ndvised for prepulinl ca^'ee. 

The time at which this operation should be done depenth largely 
upon the condition of the ehilrl. When there is a free escape at 
meconium and no distention of the abdomen, the operation may be 
deferred until the child's strength justifies surgical inlorferencc. If, 
however, the escape of the iiieeuiiiuui ie obstructed, the iibduiucc 
ewoUcD. the clutd fixitrul and peevJHli, the operation should be done 
at once. 

Aj" to what becomes of the ojR'ning in the urethra after Mieb an 
operation as this, one has only to consult bis experiences with perinesJ 
section for strieturL>s tind Hhtida in adult life. If the uivthra is split 
and the redundant nnicous membrane cut away, the^e fistulous tracts 
cluMc spauteneouKlr and without diiliculty. So also in the child. After 
tlie rc'(i.uTn is detiirhi'd fmm ils counection with the urethra n simjile 
perineal fistula is left, which evi-uluully heals of it* own accord. The 
prognosis in such ease* is comparatively gftod. 

Tfif Itfltttri tijitn* initi the Vcjjinfl. — In these easen the nppning may 
occur at any point from the nuirgin of the vulva up to tlie junction 
of the A-agina with the iiterin» eei-vix; it is generally free enough to 
allow thi' [lassage of nu'conium, aud even solid matter, without great 
difliculty; it may be <-nmpnrBtiTfly large, and yet the diMiharge of 
mwtoniiim be otwtnicd'fl hy &u imprrfopatc hymen. In such cases the 
diagnosis i* made from the bulging, greenish nu-mbi-ancs between the 
vulva*, and incision of the hynocn ishould Ixt the first step in treatment. 




TUE ANUS. KECTUM, AND PELVIC COLON 

If tlic opening bctwoeu the vu^iiiu uud Ihi- rectum is not sufliciently 
free it should be dilnlr-rl by buu^ie« or ft uterine dilator. Further 
interference should be governed by tli* condition of the cliild. 

At what age should the operation for vaginal auue be uodirr- 
taken? In the nuthor's experieuce, children at the age of (liree to 
fire yonrs stand surgical optratimis very well. He has opL-rati'd upon 
a large number of pluldren at thin age for various (.roiiditiauB of the 
rertuni and anuB, and has never yet neen one suffer jiarticulurly fnaii 
surjiical shiK-k or lueniorrhage. Frnm this and ponie €S|)('nL'ntv villi 
the nialfonnation under consideration, it would appear wi»e to select 
lliis period of life for its correction. If, however, the condition is dis- 
covori'd in infancy, and the aperture is toy stiuill to admit of tho 
funelional aetivity of Ihe intestine, one may be ealled upon lo dwide 
whether it \n not blotter to operate then than to dilate the upcuing and 
wait until later years. The author has no hr'sitancy in saying ciilatu 
it and wait. In general the opening will be found suffieient, for func- 
tional purposes, and the time most siiitahle and convenient may bo 
elected for operative interference. Many methods hiive been devised 
lor carryiDg out this procedure. One of the tirst operations consisted 
in making an incision through the pertna-iim ami anu.« up to the ab- 
nonnnl opening in the vagina, Ihiia giving an exit to the fa'eal nialter 
through Ihe perina'iim at the site of the normnl anu«. A tu'te or eiinnula 
18 paired into tiie reeUim and kept there until the anterior portion of 
the wound liaii healed. Such 0|)eratiun8 are far from succesxful. Later 
on the operation n'<l^ inodllied by making tliiis ^ame incision, cutting 
and dissecting Llie mucous nieiubrane from around the iiutrgin of the 
flbnomifll opening, and suturing the onterior cdgoa of tho gut together 
from Ihic point down to the level of the perina?um; the miieous mem- 
brane of the gut wm then i^ulurod to the skin at the eito o( the normal 
anu!^. and the pvrina'um and vagaua uoru closed hv deep guluret; as in 
tlie ordinary operalioms for eonipltle rupture of the periiianirn- Such 
operations were fairly suecL-ssful, but; it was a long lime before the 
patient obtained any sphincteric control over the movements of the 
bowel. 

Another operation consisted in dissecting upward in tho porintcum 
until Ihe roetal pouch waj- foniid; the mucous niembnine of this ponch 
waji ihen sutured to tho skin at Ihe margin of the anus, thus leaving 
two exits lo the rectum^ one in Ihe vagina and one in the anus. The 
opcrator.1 Inisted Ihal, owing to disuite. Hie opening in the vagina 
would close spontanetnisly. Such hopes. Imwcver. were fciUaeiuuB. 
Later on they weiv led lo attempt to close the nlmorirml opeainga by 
cauterizing theiii, wliieit procedure led lo a number of !iuece»*c«, but 
was not altogether RatiBfaetory. Knpeeially wa* this operation unsuc- 



<?eaaru) in uam'n in vhich the condition had bo«n allowed to roach atluH 
life, owing to tlie fact that tlie gphinot«r muscles having never been 
drought into action had atrophied and practically disappeared, coo^te- 
qucntly the patients upon whom th« opL-ratiou nas done suffered from 
persistent inconlineufc of fsecai umiter. After this the problem of 
correcting the itutlforiuatiuti was ]>nu:lteally M}lved hy Kiicfoli ((tniH^'e 
System of Surirery, vol. ii, p. 205, sixth edition(. who »ayg tlint inas- 
much as these vaginal ani aln-aye possess a certain amoiuit of Tt>tui)tary 
control there niii^l exUl around them a Hplmieter iuii^(.'le, and that 
the preservHtiuu of such an organism w-tmld be of the utmust impor- 
tance to th« child. IIIk tiiethod of occomplBlitng thte is as follows: 
An Incision is tiiude from the piwlerlor marpin of the vagina hackwanl 
to the i«iint at which the nnnnal aniisi should end; the pcrini'id ii-sstics 
are carefully dissected to reach the rectal pouch; this is then carefully 
]o«9«ncd from itH attachment all around, and the vaginal anus ia dia- 
Btcted out intact, dragged down to llic position of the noniial anus, 
and carefully traiiHplanted therp. The perineal ti»?ne* in front of tlie 
gut are then brought togellicr by buried catgut or deep silver Mitnres, 
and the murniis membrane of the vagina is carefully sutured, thus restor- 
ing complelvly the recto-vaginal 8»>ptuni. and closing all commimiration 
between the two organs. By this prmi'iUire the iintuml upciiing in 
the intenline is perfectly preserved with all its apliincteric power, and 
the danger from non-union or retraction of the parts is practically 
obliterated. It also has the great advantage of restoring the perina-uin 
and rerto-viiginal sa'ptum, a matter of the utmost im[)nrt«nee to the 
woman. Another advaotugo in this ojieratioD is that it pmcticalty 
obliier>itP8 any diverticulum in the rectum at the point of communica- 
tion with the vagina, such as is very likely to occur in operations by 
other methods; and, Uj;uiQ. it obviates the necessity of repeated opera- 
tions Mich as KL'tf nceessury in the ctises of AvL'Ung (Ijiineet, December 
80. mai), and Buckmuater {Trunin. Amer. Gymtc. Ass'n, 1891, vol. xix, 
p. S7&). Cases sometimes occur in which this opcrttion is not fcaaible, 
owing to the fact that there arc two or more openingi! into the viigina, 
u has been reported b^' Ainsworth (Bodenhamer, np. cil., p. 32(). In 
such instances much ingenuity must he exercised in performing « planlic 
operation which will cover the nec^eiwities of the case. If two openings 
are close together lliey may be coDvcrled into one by a eimple inoitiion, 
the margins of which may be puckerttd with u purse-string suture and 
attached by the mucous membrane to the margin of the ekin »t the 
site of the normal anus. When, however, thew openings are separated 
by Bomc considerable space, it would be better to dissect out the lower 
o]H>ning. eomplelely detach the rectum from all its attachments \ii> to 
the upper opening, and close this by inrersionand the Ijcmlwrt sutures. 




TUB ANUS. RECTl'M. ANT) PKLVIC COMN 

Tti« low^r abnurmal anus tihoulil Uiun be tnuutpliuited tu the pooition 
of the iiorniiil unus. 

The- Itfdutn. tunuaumeaif* with ihe Uterus. — Sjch cases are practically 
so rare tliat f)ti<: can K'arcely Rpeak with any tlvJiuiti^ness concerning 
their trcatmeut. As slated before, the author koowe of but ODC case, 
and no opiH-aLioa was [tGrfornied to roniedv it. It Be«>tna, however, 
tliat Ihi- pmpLT proceL'ding iu such vbspb would be to i>8tablish lui anus 
at ihe nomia) site, if pusHible, and to follov thin by laparotomy, divi»ioii 
nf the ranal connecting the (wo orgaiiN, and invcrsinn and stiture of 
the apprliirt's in cacli, after the !!-ainc manner as lias been advised in 
those caeen in which the rectum communicates with the bladder. If, 
however, the rectal cttl-de-»ae ends at its conimnuicatioQ with tli« uterus, 
the establishment of the anus at the noniial position would bo practi- 
cally imposdibU'. The only recourse left to us under such circum- 
RtnnceR wniiK) he the esttiblishnicnt of an inguinal aniiK nnd tlio closure 
of the lower end of the gut. If. however, iipou opening the abdomen 
for this procedure the eigmoid flexure and rectal pouch are found 
8iiff!cieiillv l'>ng to reach the perineal floor, one iiii^ht dissect the 
rectum fi'oin it8 atiachriicnt to the uteruet. close the opening in that 
orpin, and finally briug the openinp into tJie intestine dow-n and aulure 
its mucous membrane to the skin at the site *>f the normal antie. Such 
a proceedinfi, however, has never been atleiPipted, ae far m can be 
loanu'd, and the above remarks ai-e simply suggestivo. 

Tiif I't'ftutti and Anvs are Normal, btil have oprniug inlo Ihrm Gu 
Urvltrn, the I'lernn, iir Vntjina. — Some 'ZH caseti of such tualfomu- 
tionit have been deiirribed by various authors. Bodeniiunier hiix co\' 
lected 7 in which the ureters terminated in the rectum, and 9 in 
which ihe vagina or litems ended in this organ. In those cascH in 
which the ureters terminated in the rectum the bladder was found 
aWnt, and the rectum performed all the functions* of both organs. 
Any openilion intended to remedy such n deformity would be irrational, 
inasmuch na there would be no reiiervoir into which to trannplant the 
ureler.s. The danpere of infection traveling from tlie rectinii up the 
ureters and into the kidney will always exist: although Nature .seems 
able to protect herself in such eases, and persons with these abnonnali- 
ties have lived to a eomparatively good age without sutTering from 
such complications. 

In thoKc cases in which the uterus or vagina opons into the reetum, 
operative interference mav be safely nndprtjiken if a proper period 
and state of the patient hv solected. irnfortuiialely the victim.'* of this 
nuilformation rarely realize their condition, and cases have been known 
to grow 1*1 womanhood, marrj-, and bear children successfully, even 
allliungh ullhcted with this deformity. 



MALFORMATIONS OP THE ANUS AND RECTUM 93 

Ball says: " It does not appear that there would be greater difficulty 
in operating upon thege cases than in those of a converse condition 
already described, where the rectum opens into the vagina." Tliis 
might be so or not, from the fact that where the vagina or the uterus 
opens into the rectum the communication is not by a small, narrow 
opening, such as is the case in the inverse condition, but by a large 
patulous communication which it would require an extensive operation 
to close. Only one operation, so far as 1 am aware, has been under- 
taken for this condition, and that was succes^^fnl (Bodenhamer). 



CHAPTER in 

EXAitlNATlON AJ</D DIAGNOSIS 

Tub importance of loca.1 cxaniinalions ia digcasce of the anus and 
recliini tun not bo avfruBtimatCHl. Hero muro than in any oilier jior- 
tiou of Ihe liodj ari> tlif (JJsyilHL'a Uably to [imyifss |-a|u<ily, find earo- 
lesancss tinA urvors in diHgntisLi often allow tht' 8impk>»it afTfction lo 
assume (trr«t nuignituile. In cimBtiliitumnl iiml Moir-limilfil tliseaBes 
dv\ny of H. (3iiy or two in inflking tin- ihaicnosis sulilutii rL-sullji iu any 
injury to the patitnt; but in progrrjwivE; tiififfisr.s, KUi^h as tlioso (jener- 
fllly founH in Iln' n-rUitii, a duUy of even ii lUy may b(> followed by the 
most disastrous results, to say nothing of the dinconifort anJ siiHuring 
which the patient is iin necessarily forced to bear. Tho aulhop bos re- 
ported elsi'H'bpn? (Traiisiii'tinnK (((-tir^ia Slate Mcdieal Assoeiation. lS;»9)i 
a case nf oitlinnr v tliroinliotlc lia-^ni nnho ids in w hich the family ptiyMtL-ian 
faihxl to recognizf tin' cuiidilion. Aftpr two or three days the ihniin- 
Inis bccninc infeete<t. ami an ahscess devclopi'd whirh hnrst into the 
reetum, tliiis conetilitting a blind internal Jistida, necesftilalingan opera- 
tion anil more than two months of ironvalcscente. In the abstess waa 
a hroken-down clot, showing clearly that the trouble had originated ia 
a siniplf. tliroiiilintrc bivniorrlioid. Undpr proper diagnosis and man- 
sgpmifint, tliin pntiont would have been cured in tlirco or four cJayB, 
anil ho wnidil have been spared not only the lo>;8 of niiieli time nnd a 
great deal of sutrering, but also an actual danger to hia life from sepsis. 
In (he large tiiajorily of reetal diseases an early diagnusis and proper 
treatment will result in a, rapid cure, mul in iniiligmuit diseases uf the 
rcetuiu it is only in the early stagt-s that there is hope to eradicate 
them. In such eaaes, therefore, positive and immediate diagnosis upon 
the first appearance of the symptoms is of paramount importance. 

The subjective symptoms in rectal disea.wa are always referable to 
more than one pathologieal cause. They are of great value, but no 
dingnosis should ever bi- made of any rectal condition until the patients 
have been thonmiriily examini-d, both by rligilal and instrumental meth- 
ods. The endiarra.'isment of the patient and the disagrocabk' task for 
the doctor will never be an excuse for the omiaHion of such cxamiiu- 
H 



b 




KXAMIXATIOX AND DIAGNOSIS 



95 



tiwna. niagmnsia of ri'irlal ilisQasi's in tlioip cjirly Btajfcs is somptimM 
wry (lifliruU, io«smu(!li iiH tlie suKjci'tivc sympttmis are often rc'Fon'i> d 
flat' wilt; re. Surh rciWx sjuiiMoTii.-i htirmhl bi* kiiown ainl a|)|treciatoil by 
every [iliyirian, imd slimilii eiiiplia^ixi' \}w. iiecessity of local oxainiuatiou. 
The mrtlioilfl i-niplnyetl in the exaiiiiniuion and ilui^^nusU of rt'crtftl di»- 
eas«« may W daMiiti<»l at^ liin^toriml, digital, nntl iiidti*iiint:n(ul. 

Historical Examination.— W lien tUe |)aiic-nt i-ou^ulu tlu; doctor for 
any fonn of disriisc^ wlu^thcr ivctnl oi' otliorwidc, a eorefu! review of 
hi.i faniiiy ami |>i-rsoiiHl hiRlopy ik imiKTalive. It is goiiiotimeB tedious 
and rimiinlnnoiis lo listen to n patient 1*11 his own story in his own way, 
and often miicli that is iiTclevanl is inlroiluwJ; but afu-r all il haa its 
advantages. It calms hi« nervous sonailiilitie^ aiid makes him feel at 
home with the pliysician, to whom he ie. pt'rhupH. a straugt-r. There 
is nolhing so conducive to ciiiitidenie in u ptiliinit as tlie iiiiprerisiuu 
that his physicifin is patiently ajid thoroughly interested in hie ca«o. 
Th«-r<'fnrfl. wh^n sncli pntifnli' inlcr the consul ting-room, n fitelnry of 
tlipir persona! and family life should bo patiently heard. Heredity may 
or may not have any great influonco in diseases ot th<> reetum, but 
many pntientx have a very positive impression that it does, and to these 
)b<* fiict that the doctor is luuktu^ into it is very eonstdiii^. A man's 
occupation, his enviromncntjt and his liabita may or may not have auy- 
tlunjf to do with the symptoms from wUich be is suireriuK; but il is 
Tery important in ndvising individuals as to regimen that one should 
be sure they are not already following this very course, even to cxcow. 
As »n example of this, the tinthnr bad a patient consult bim sonic years 
ago u'lio wax initcb disjileaited with a consultation ivbicb lie had bad 
only 8 few hours prfviously. The c-aust? of his disconteiil was that 
the doctor had tolil him be needed more jilivBienl and uuldcior exer- 
cise. The young luuu wiis iin uthleti; wlio Imd gone elalcr fi-om over- 
training, and was well aware of the faut that any increase of exercise 
had persistently made bim feel worse. A man's environments may not 
have anything to do with his disease, and yet when one is unacquaiutud 
with these, he may Bomelimtti carelessily allribule sytuptoinH to them 
or give advice ctineerning them that make hiiu appear ridiculouB. A 
calm hearing, lluTcfore, of Ibe patient's history will he udvantag^eoua 
in more waya than one. After Ibis h&s all been told, one may Iwgin 
a direct examination with regard to Ihe symptoms which have been 
dotailed. The melho^l of the physiciaii'i* exaiainutioti often imprebe«4 
a patient favorably or unfavorably, and has nmch to do n*ith gaining 
or losing hi« confidence. If our inr]iiirie* are nt random and onr ques- 
tions art- aiiibigunus, and if we ondt to iiif|iiire into what Ibi^ )mtient 
iK>nsi'cten( liijt important s^mploms, ho is voi^ likely to suppow that 
we know little about Ibcm. Whereas, if our inquiries are concise, direct, 
7 




dG TIIK ANUS, RKCTCM. AND PELVIC COLON 

And to Ihe point with regard to the gymptoms nf vh'wh lie com|>Iaiii», 
and if we by a knowledge of ri'flex effects call liU attention to sj-mp- 
tiHiid which hir Iiiis iiiatlvLTteiilly ulserved. or wliich he liaa ncyledcd 
ti> obscrvt^ he will al oiicu be uoiiviuL-eil tlial ihe examiner knows wliat 
he in talking about, and will submit with conlidencc to his direclions. 
In recording the hietoi'^' of a patient, his name. flg«. honiu adilreas, voca- 
tion, and domcslie station ehoiilil all lie noted, Hig family liislon,- hIiouM 
be briefiy but carefully put ilowa. His personal history from infancy 
ought to bL< inquired into, mid all iIr- iiiaterinl fael8 with regard to early 
liubitM and dint^ane* should be elicited as fur a» posiiihle. These early 
habits and discmtes cfli^n Iiuvl' u uiaterial bearing upon reclnl d!-ieasi'». 
Many jmtieiilK aro awart- of t!u; fia-l that \\\vy Imvu been con^ttipuU-d from 
infancy, and kooh: will dttnil indistincl n-colk-ftioiuf of reelu.1 diKuaHcv 
in early life. The knowledge of these fact* h of the utniogt iniporiancc 
to the examiner. v\fler such general facts hiive been taken cognizance 
of, the direct and local exa mi nation wf llie patient ehoiild be taken up. 
The gymptoma siiggysting loeal examination of Ike rectum luay be enu- 
meralctl as ftiHows: 

First, indigestion, flatulence, loss of uppi^titc, irregularity of tho 
bow«l8, or constipation. 

Second, TOgiic aching paine about the pelvis or sacral region and 
dkooting do\t-n th& loft leg. 

Third, a sense of constriction or wLnght about the pelvia. This is 
especially important in inalpK. 

Fourth, spasmodic or jieriodical dytturia, without adequate cause, in 
Uio gcnito-urinary apparatus. 

Fifth, n tcndcnry tn dinrrhcra, esperially in the morning. 

Sixth, the presence of nnimis, j>nn, HhritdH, or blood in the fiL'cul 
discharges. 

Seventh, irregular menHtniation or dyeraeDOrrhifa in young women. 

Eighth, restlL'SHUtew at night, picking the hobo, senitdiing of the 
ahdumeu or anus, and vitiated appetite in young children. 

All or mont of these Kynipioms nuiy arise from diseases of the rcc- 
iuni, and at the same time nmny of them may he due to other nfTi-c-tinns. 
Tho fact that they are very frequently due to rertAl Hisordors renders 
a local examination imperative. These facts, should be known to the 
family practitioner more thoroughly even than to the rectal specialiat, 
for h« is the one fimt consulted in regard to these eonditions. and it is 
nearly alwnys thru iigli hit; advice that the rectal surgeon iscnnsultud. The 
patient generally knows there is something wrong with his rwetuin when 
he consults the Hpccialist, and therefore these reflex symptoms are not 
of »o much importance in his examination as in that of the family 
practitioner. The latter should be prepared to examine the rectum 



L 



quite as well as Ihn rlicst, anil lip kIiouM nut !iogilaU» U> Ho so in anr 
rafie presenting ftyniiitoinH ivfi.*rable to it. Wlien Ltii-ougli delii^acy aJiJ 
bjiHlifulncsrt tin' imlii'nt. refuses to allow such an I'varninutioii. ttu; physi- 
cian sKmild pfiually mt firmly rt'fuf<e io pRwcribi; for tlit- iiyin|>l"iii». 
After the gt-ni>ial fauls ami liii^lory have bi'un rei;urtli^(l, niu! their brar- 
inps duly weighed, one should thon inquire into the existing conJi lions, 
ns fiiUiiwii: 

l^tfjfe of file Romeh. — One slimiltl vxaniino aa to the habitual state 
of the Wwe!«: wlielber it is normal, eouBtipatf-'d. or diarrlm-al. If the 
patient in constijtated, to uliat i^xtent di>^» this cunrlitinn exint. l» 
there a stool ovL-ry day. or doL-s it only oeuiir wlnu laxaLivt;!i hiivi? been 
taken? Whi-n tliu stool dops oct-nr, i» the fitt-al material soft, mn- 
»etcnt. and of normal Rimpc, or ii^ it t^inall, tape-like, or lianl and in 
little l)aiU? It is important to know when the stool has been paii»ed 
whether it is of swtTieient r|iiftiitily and clean, op eovered with iniieua 
and Unjjifd u-i!h Mood. If tho eondilion of the bowels is diurrhtenl, 
one shoiihl inqiiirt* whollier the paiitiageH are watery or Beiiiittiiid, 
whether large (|u>intities are |)a»**d and paiiili'Wfly. or whether the 
pHMsagtv! an; st-aiily. nueoiis, and alti-iidLil with pniu, tcnetitrius, and 
cub«eqm-nt L'xlmus'i«in. 

Pain. — If the patient gives a history of piiin, one should intjiiire as 
to the exact jioint at which it is felt; whetlur at the anus, within tho 
Peetuin, in tlio sneral region, about the j>eivis. in the inf;uinal rej^on, 
or, as often ha|ipenH. in ibe nleruc. neek uf Ihe bladder, or urethra. It 
is aI*o iniportuiit to know whether it extends to other region*. Pain 
ahiiotin;? down the h-jr. f<'r iustani-i-, liajs been dfneribed by Hdton a* 
coOHlnntly nasntiuied with ruetal dinL-aso. The time at whieh the pain 
ocenrs chould abo be in«iuirctl into; whrllier it is Ijcfore or after kIooIs, 
and how long It lasts; wiR'thor it is persistent, occurs ■with every stool, 
or only occasionally. Ajrain, one ought to know the nature of this piiin; 
whether it is aeiile. cutting, burning, or of a dull aehing oharaeter. All 
of lliese syiJiplonifi are of material importanee, for they point with morHa 
or less Beearaey to the pmiH-r diagnosis of the ease, 

itching and iS/wfuwi uf Oie Sphifiiier. — I^ntit-ntK, wlu-n fwkcd about 
jMiin in thi* rertnm. often say they have no real pain, but rather dis- 
comfort, iini'ai«ineMi, and itching, or aonietinieK a f^pai^m of the anuH. 
The time and circumstances of nuch ejmptoms should be earefnlly 
noted. 

Protrtiniiin. — The patient ahould be aslied if he auffera from any 
iinuHiial protnision about the anus; if so, we should inquire as to when 
it occnra and how it. is brought, ubout; whether by straining or upon 
alight exertion. One should also know whether it disappears spon- 
taneously or if it ia ncceeeary to restore the part^ to their nurmiU po«i- 



B8 THE ANUS, KECTUM. AKD PELVIC COLON 

tion; if »o, is tlic rostoration difficult nr easy. It is necessary aleo to 
know whether such prftlrusiona arc hard or soft, smooth an<l regular, 
or localizt'ft and nodular. One *hoiilfl furth«'nnorp inqnire if the 
patient can produce the protnision nt will, or whftthpr it only aiipciira 
when he goes to etool. He should also know whether them U any pain 
prnduci'il l)V handling iho protnigion, Jf it is prpsi'nt at ihp time of 
examinBtiiin, one should exnmiuf carefully the nigip, whether they are 
circnlar or run «|> and down, and he should also observe any abrasion, 
ulci'ratirm. or iiUht ahnornuLlitica ujjoii llie pui'tx. 

Habile. — Tlie habits and history of tht patient should be most oare- 
fully inquired into. Is he accuBlomed to the use of cneiuos? Is he 
in the habit of sitting long at the shrint.^ of t'lo uciiB with hiii pipe and 
paptT as cHnipunions-' Is there an untmtiKlitiil feeling uC tjoiiietliing 
TRovf- to coiiH' iLwtiv W'hon tliR bowels havL- moved? Is he the vielim 
of pederasty? TT;is he a history of venereal disease? Ilafi he an heredi- 
tary tendcTicy to tuberculosis or to iiialignunt growths? 

All these point* should be carefully tiotrd, and by the time one 
has obtained a salisfadory account of them, he will gi'tierally have 
information such as will aid and direct him materially ia the local 
exaniiimtioii. 

I'reparaHnn of Ihe I'atipnt for KTaviitmtirm.- — In order lo make a 
proper and careful examination of the rectum, all ctmstricting clntbing 
should be removed or loosened: corsets, tight waistbands, or anything 
which has a tendency to crowd the small intestines down into the 
pelvie, or prevent their rising upvvui'd touai'd the diaphragm, should 
be removed. The rectum should always be empty in order to make 
a final and satisfactory OMmination of this organ; but sometimes where 
an iTn|verfe<^t or unaat i y factory history of the habitual st-nte of the 
bowels has been obtained, it ie better to examine the patient as to this 
condition first, then move the bowels with an enema, and proceed with 
the complete examination later on. Tli<^ author has time and again 
had patients couie to him who had previously taken encmiifu, and yet 
found their rectum* full of luird, inspissated firoil niaterial, Wlielher 
this material had come down into the rectum after the raovemeut of 
_ the l>owcl, or whether the injection had failed to remove it. it was 
' inipossihle to say. As a mio, therefore, if it is prfietieablo, the first 
j examination of a patient's rectum should be made before an enema 
'is given. By such an examination, if pus, blood, mueus, or inspissated 
ftecal material are present, they can he seen; whereas, if an injection 
has been taken and the recluni ilioroughly cleaned out before the 
physician examines it, these Hiibstances may he entirely removal, and 
the condition cautiing Ihem may he overlooked. It rcqnires a, little 
more time to make the double txamination in this way, but in tho 




EXAMINATIOK AND DIAGNOSIS 



d9 



I 

I 



I 



author's experient* it has betii more satisfactory. If upmi Hie |ire- 
limiiiary ejtanudatiou tlio rt;etiuii is rouml full of fcecal matter, or Rub- 
stances interfuriiif; willi a thi>roii};1i diagnositt, an enema aliuuld lie 
giv«ii and the paticut allowed to retire until these have bLx-ii pHsspd. 
Where the phj-sicittn's office is not so arranged that llie l(iili;t-iooin is 
Hiljoiniii^ it, ho shoiihl always iitive at hand a cominodo, so that in 
ease of an cmergeney after giving the enpma the pationt may reliey© 
hiinBelf at once without the danger of an 
accident in iwssing fmni nnv. room or floor 
to another in order to reach the toilet. The 
cut here givL-n (Fig. 4S) illuslrates a very 
practical and efficient commode for the physi- 
cian'd office. It is so arranged that tliore ie 
wry littk escape of fn^cal oilor from it, and 
at t)iv same time one uould hardly t^uspeet 
tliat it wan anythinfT hut an ordinary slool. 
For ihn spprialisl's nlTifo certain double fau- 
cets and slopeorkg have been arranged by 
which a patient can be given an enema or 
iiTigatcd dirvctly from the water-pipe. Sueli 
an arrange ineut ia described by Dr. KcUcy 
a& futtuwii: 

It consists " of a g\ass jar holding one 
gallon, which stan^U upon a shelf 1 feel above 
the floor, and is filled by a rubber tube con- 
necting with what i.s popularly known ait a 

barbers* faucet, by which cither hot or cold water eaii he drawn from 
the eanie tnbe at pleasure." The apparatus may also be uBt-d for irri- 
gating the rectum, Iho temperature being regulated by & theniionietcr 
in the jar, and the How may be kept up indelinitely. 

This is an excellent arrangement, but the jar should not be set 
more tlinn 3 feet above tlie level of the ]ialient, for too great force is 
objectionable for either irrigation or vnemaU. It is not indispeu^ble, 
however. The onlinary fountain syringe Berves every purpose for giv- 
ing rectal eneinata. H ciin he sterilized, and the tips, al lea«l., «liould be, 
after each uj^e of them. The question of what eort of a tip i» best for 
giving a reetal enema will he often asked of a physician, A hiird-nibher , 
tin Willi on olive-shaped cmj . smooth, polished, and well lubrieated. or a' 
mediimi-Rised soft-nibber catheter, are the only in>;trument!i with which 
a |iatienl ought ever to administer an enema to himitelf. When the phy- 
Hieian or a trained nurse i>4 called upon to give the enema, the tip ^\v 
acribi'd. or a fmall-iijterl Wales biHigie. are the instruments of eboiee. 
The ordittiry Davidsun bulb syringe in preferable to the fountain syringe 



Kio. 4I>.— CaiiMODii T«n 




IttU 



THK ANUS. RKCTUM. AND PEL'nC COLON 



wlipo the itijeetion is given thiinifjh a loiig tube liku the Wales bougie, 
inasmuch a» the imjiulse lifts up llie folili* of mueou* nieiiibnme from 
in fmut uf the bougie anJ fatililatcn the pausugc of the iustniinent up- 
wai-d into llie fiiji^iiioid flexure. 

Immediately itftcr the enema has passed, the patient should be kid 
vpoD a lounge or tabic before any protru&ionB or prolapse, whicli niay 
have oeciirred during the action of the bowel, have disappeared. Some- 
times it IB well to feol or exaniine the parte before the patieul leaves 



Flo, 6*\ — Ltrt LATKHiVt. t.'ii SrU'-'' I'i'nTciu; 

Tho Iwd nf ihu iciuuKc btliiir niNiNi w) ii't to 1'unii ii tnlilo. 

the eoiiniiode, as motion, especially walking or clinibiiig up on a table, 
may eauee their retraction, and the opportunity of viewing them will 
be lliiis lost. In order to avoid this. It ia well to instruet the patient 
before he retiroM to the toilet-room or eeats himaelf upon the roramcde, 
that he altall not replace any prolapse, and shall simply use a little 
m&ist cotton or gauze in cleansing himself. One should always have 
pR'senl in his office, if possible, a tmiofd feiiinle niirse or an attendant 
to wait upon ladies and prepare them for examination, to adjust their 
clolhiiig, ami assist in the adininisti-afion of enemata. She should 
not be pi-osent. however, during Ihe questioning of the patient, ils thia 
pnrt of the examimition should 1h- confidential. All unnecessary e-tposuro 
nf llw patient's persim hhoulil be avoided ; Indies should k' properly 
postured and covered with a ifliw-t by the nurse before the uxiiminatiun 



patients 
before the nurse U culled in. 

Poxilion for ETatui finiiau.—Thprc arp fotir posiltona in which a 
patient nmy \w exHiiiinctl for i]is«iscs of the rectiiuij and each uf tlmm 
has its special use. The first and moat generally useful is the left 
lateral, so-calleil Sima's jKisition (Fig. 5(1). This is odljiiiied l>y laying 
the patient upon the left side, the cheat upuu Itie tublc, with the left 
arm behind the back, the thighe well ilexcd upon, the body, and tlie 
hips olevated upon a hnrd pillow. In llie Inrgc ninjority of cases this i 
position is ^iitlictcut for all examinations, whether digital, oeuUr, by 
specula, or through th« signioido^ope. In very stout peopio, however, 
the rectum is mo rftnict^'d and covered in by the birgo folds of Iho but- 
tock Utat it is dilTiL'uU to oblaiu a good view of the parts in this posi- 
tion, and almost impojwihlo to introducu uii ordinary spi^culum witli 
Ktttiiiractiim. In fiirh caseH other positions arc found imiru euti»factory. 

Nragijeratcd Lilkahmi/ Poailinn (Fig. 51). — Tliis fwaition is ordinarily 
tho most cotivenient for operations u])cn the rectum, Eind it $.\tQ has 




Vn. M.— EiAuaciuTMi LmoroxT Puamov. (Brruit.) 

\U flcM of uM'fnlne»i in examination. Tlie aiitlior has wveral times 
•Itrnipled to intnuhirv the 8igni»idn«coi>e in Ihc Siiiu'it and also ia 
llic knce-t-hwt [Kwlun- williout avail, and lia* 9nceoe<Ied wilh oom- 
p«ratlvc case aftt-r having pljiei-d thv patient in (he lilhotimiy poai- 
.jUoD. In stout [Hilieutd IhU position affords an excellent view of 





Flo. M, — (^tiJiniuT K.M I. ■ Mi,-i Pomiub 



lOS 




104 



THK ANL'S, RE<:TUM, ASD PKLVIC COLON 



Upon the thi^s. In this position the weight of the abdoniiual or- 
gans is tak«n onlircl^ oil the rectum, and the dilating efTeot of atiuug- 
phf^rii.' ]ir('!;«;ure caQ be easily nbtnined. It ig almost iiiipo^ible tu iiiaiii- 
tain tliia posture under anH'«tke*ia wilhuut a spwially pru|3iii-L'd ap- 
paratus for hulJiug the jHitiful, such us that employed by Dr. Howard 
Kelly (Fig. 51). Such aii apparalus cxmld, of toarsr. In- uwed wilheiit 
an anaesthetic, hut it wnukt l»f vtry uui^iirnfnrtjihtc to the patient. More- 
over, this positioD, although a most useful one, is an exceediagly uni- 
barrassing one, especially to ladiea; it is difficult to induce tlieiii to 

ansumo it in the fli-st 
}ilan(>, and very diffi- 
cult ioT them to maiu- 
lain it m llie seeond. 
Martin, of Cleveland, 
liLW doviBi'd a rompli-| 
culed but exceedingly ' 
useful chair (Fig. 55) 
by ivhitli ihu patient 
eau be placed in this 
pofiition and held there 
for an iiidi>finile period 
without iiiiicli djificoni- 
fort or (.'iriljarrassHieui. 
Tlir Sriiiatlititf nr 
Sh<jl n»/Hre. — This 
position is not gener- 
ally pivcn aB oiip in 
which Id make exum- 
inaiions. 'Plii^ autlinr 
has found it very iige- 
ful, howerer, in a number of conditions. .V patient sonirtimes finds 
it very diffieult when lying \ipon the side, or when in the knee-chest 
posture, to strain and briug into tiiglit protrusions or prolapses which, 
habitually occur when at the stool; but when in this position he C8tt 

(easily produce them. When a patient is in other positioiig, cspoeially 
the knec-ebe.it posture, prolapse of the third (iej:,'rpe is likely to rt'cedo, 
and the dingnosia may he iinpofisible: wherea.'i in the' squatting poslura 
8ueh a prolapse in ea*ily brought down by the patient's Blraining, so 
that it inipinpet; upon (he end of the finger iiitrodured into the anus, 
and the diajjinwiw in ciisilv iiiiide. The ponition is aUo «»eful in rn.se» 
of Ktrieiure and Iiuiiors of IIil- i-eetum which are hIiovc the reacli of the 

i finger, ftlu-n Ihey are only removed a short distance above the reach 
of the index finger, if the patient i« placed in ttiu position and cauued 



C'luu. 




EXAMINATION AND DIAGNOSIS 



lOS 



to bear down, they may frpqucntly ho brought within rejich, and thus 
tnforitmtion may he elicited which could not be otherwise ubtniiivd 
except by the ftilniinifltration of an anirstlietic. 

Apfianitu». — There is great difference of opinion among the medical 
men and »|ii:ciHlie>t« as to tlie adranta^'e^ <i( loangm, chnir^ or tables 
for the cxaminntion of patients. Ordinarily a ifood gyiiiecolo^ail table 
will serve every pin-podc. A lounge is gi'nerally tw) low for eicamimi- 
ttons, but it is Romelimefi of (he greatest conreiiienpc in the doctor** 
office. Chairs also have ailvantajres, in that the patient i« seated tlienron 
and by sjiecial mcchnnism plsrcd in any [losition desired by the operator. 
The Hiiti]i>r uses a lounge devised by the late Dr. J^ittle (Fig. fit!)- The 



b'li.. ■"■. — TriK 1 .1 j-J I K < In n K..r 111 MM i i ii»f ri. 



bed of the lounge is Ti fwt Ii»ii;i and ^J ffct wide, and its ini'chuniam 
is simple. When it 'i» liTti-d up it furni? a table S^ feet bt(;b (Fi^. 50), 
and is abundantly lar^'c for any o]>oration or position which may be re- 
quired in a pbyeician's oflieo. 

Kfreently, however, in order to obtain the advaQtagea of the knee- 
cbcst posture, and to inaiulaiu it without inconvenience and exiiau&tioa 
to a patient, the ingeuioiis chair of Martin baa been used. Tlita chair is 
a mwlifiratinn of the well-known Yale |ry lupcolo^fica I chair, which by 
a erank p1iu:es the jtatient fn>m a Sims'n jioifition into a perfect knee- 
chest posture tritboiit his movinp or Iwini; ineonvenieaeed. A patient 
IB Sicated in the tipri^'ht {tosition, \\h rigM \<:n en>«ged over the b'ft, en<I 
the left arm rt-sls upon the baek of the chair. The pillow i^; held with 
thu right arm uuderuuatli the bead, aud the eliatr is tlirown back- 



106 TBE ANUS, RECTUM, AND PELVIC COLON 

ward into a horizontal position. The retaining shoulder-strap i") placed 
over the fight arm and attached to the snap which holds it. With the 
Iflver ill the riglit hand, the viimk which controls tin* screw is ihun 
rapidly n'volv^d and I he [wtient la turned slowly ami gradLially into 
the posture indicated in the cut. The head of the patient rexts upon 
a dcvicp whirh is arranged bo as to support it, and in tliis way every 
advantage of thp knee-chest |)n,stur<? is oblnined. For spccrialistrt in 
rectal diecnsee this chair is of jfrcat aissistauce, and for one who is ia 
the hahit of using a ohair for ^yna?eolofrical and olhor wnrlc. tlie com- 
bination in no wise detracU from its ordinary iiaagea. Pennington, of 
Chicago, has devised a table in which Martin's principle is carried out. 
It is light and can be easily trHnsported from place to place. .Ml such 
appliances are convenient and of assistance, but they are not absolutely 
necessary. 

In all examinations of tlie rectum it is belter to Iwgin with the 
Sims's position. It is the least eiiibarra^stng to the patient, and la ^ncr- 
ally the only one which will 1i« neccssaiy- 

Eiti'Tiiiil Apprtirnnrfs. — Tlnving pltieed the pntipnt in position, a 
careful iibscrvation of all external appearances should bn maile. The 
shape of the anus should be noted; wliellier it is normal, protruding, 
or retracted and funnel shaped, and whether the pigment about it is 
noniiai, increased, or reduceil. The epidermis should be examined 
carefully for parasites and pediculi. and ita condition noted; whether 
it ie normal, white and sodden, or red and excoriated; whether it 
ia moist or dry and brittle, .smoolh or nodular and swollun at paints, 
and whether there arc any gears, ulcerations, or fistulous openings 
about the anal ru'ifice. Palpation of the parts is of itiiportaui'e, for by 
this (ire elieiled any tfnsc or painful points that indicnte abscesses or 
]>en-rectal inflammation ajnl induration. TJy palpation it is'poesible 
to follow up a fistulous tract through its induiated line, anil thus to 
maJte a diagnosis without the use of a probe. M-hich ie always psiinful 
and often unsatisfactory. If tliere are any external growths, Fueh aa 
eonilylomnta, fibroids, polypi, or connective-tissue hfemorrhoids, these 
should be carefully examined, and Iheir cnnditinn. whether painful, 
inflamed, con.stricted, or thrombotic, should be noted. Little thrombi 
about the anus are very frequent, and sometimes cause a distress entirely 
out of pRtportion to their appearance. If there is & protrusion present, 
one should cart-fulty observe all its characteristics, especially the direc- 
tion (if the riigii', and whether or not it is excoriated or ulcerated. 
Epilhclionia of the iinus is often apparent upon the external surfaces, 
ajid where it is so one may clip otT a small section for mierodcopic 
examinalinn wilboiit much pain to the patient bv the nppliention nf 
cocaine or orthoform. Assiuning th&t no sucli external abnormalities 



EXAMINATIOK AND WAONOSIS 



107 



exist, tho examiiiiT ^liniiUI proceptl In look higher up. Witli tlie bul- 
luckfi pulled iv-(^ll iipiirt. anil ihn patient straitiitig slightly, one can st-c 
pretty well all uf the anal canal. If there be a fiesurc or hit-iimrrliuiilB 
they can gcnernlly be brought into view hy this lucaiis, and ^jtiWi)i luw 
down may also bo Been tliiriiig this part of tliR exnniinnlion. Unc shoiild 
be carefnl to note the conililion of thn niiien-eutaneoiitt Ijnnlcr of tho 
anus, ft»r fn'<]in'iiliy the dragging of the buttocks npiirt strett-hes tliig 
membrane, nnd if it in in an unliealthj condition siioli as the dry, 
brittle state in whieh it is found in atrophic caUirrh of Ihf r^^-L-tuiii and 
in fionie forms of t^yphiiia. it will crack in mirnerous Utile point;i. ftoine- 
times bleeding, but more often appearing like little hut(un-iu)le» — not 
deep enough to cause actual pain, but sensitive to the toucli Jind to 
irrilanti). At this point one should ohservc the condition of the nuliat- 
ing folds of the anus. Tf one or more of them is inflamed or swollen, 
it would imlirate some ulceration or irritation in that aren of the rectum 
»lii*eetly above it. If, however. iLey are all congested and hypertrophic, 
some general inHnmniation or affection of the rectum will be indicated. 
Valvular constriction of Llio anus may eometiines be detenniued by such 
an ocular examination. 

I>ig;ital Examination. — Knving proceeded thua far, the physician 
will tiii%'e obtnined wliataver informntion i» pot^^ible without digital nr 
ocular rxiiminniion of the rectum itself. Here the cdueate^l finger 
becomes our most important agent, at least so far as the first four 
inches of the organ are concerned. This should be well lubricatisl 
before any atleiiipl to introduce it into the rectum. The author has 
tried majiy substnnet>!t ua lubricants for inr'triinienls and the finger in 
rectal dieeascK, and has finally settled upon vaseline aa the nmst siitis- 
faetory, except in enncB where some iitinnilnting or cauterizing subxlanee 
ie to be applied. In bucIi cnsce one should Ufie some sort nf hibrieant 
which can be nadied off, and which will not interfere with the nelion 
of the drug. Onlimiry non -irritating or Castitc soap ii» probably aa 
gotid ws any other dubstanee under such circu Distances, hut there are a 
number of vcgetiiblc prepamtioiiN upon the market which :'erve thifl pur- 
pfiiw wry well. Such lubrtCAnt^ ehould be kept in collapeable tubes. 
Tlio old pot of oil or jar of grease into which the finger and in.stninienta 
are dipped day after day, infeeting one patient from nnnther, \» e relic 
of niedieal liarbarism, and should be discarded from every physieian'fl 
ofRce. The vaseline or lubricant in tubes can be sterilized, it is clean 
and convenient, and the slight increase in expense is inconsiderable. 

In intniducing the finger into the rectum, one should remember 
that the aiiuit i^ eluded by a very sensitive, irritable muscle, and that 
■ny roughnetw or undue hatrtc will cause spasm and increase the diffi- 
culty and pain of an examination. It should bo introduced slowly 



f^ 



108 



THE ANUS, UECTVM, AND PELVIC COLON 




uiJ ivitli a. boring motion, firat npwaril and furward tiwanl llic \-agiiia 
or prif^tate until the intertuil nphiQcter mu&cle is pawtil, aud then 
biiokward into the ampulla of the rectum. A itiistake in dircctiiif; the 
tiiif^iT, »r ron^hnesR in itji iLic, ^ill rause piiin and .tpa^m iucU as will 
diHcoiii'ni^e the patient, nnd Etomoti ineit prevent a thorouji[K (-xniiti nation. 
Ae tht' fin>jer is i)ajwetl through the anus one shtnild study the condi- 
tion of the sphincter muecle. A twitching, tender, spasnKMlic sphincter 
indicatvs srjitie acute disease near the nmrg^in; a hard, (irm, resisiing 
ap]iiiiL-ier iniiii:iitcf< a uhronie cundilion which lias caii&cd liyperlropliy 
tif the iiiui^'lc: luid a i-ehixcd, llaccid. hfelees one [»ads Ma to aii^pcct 
eomo cxhniislinjf, malignflnt, or constitutional diaooso. As the finger 
pAi'^eii beyond ilie wnr^rin of tlio externa! ephiiii'toi- it Khniild hv swept 
artiiind thv nrtal eannl t o exaiiiine the crypts of HloiaiiKtii a nd ih c pil- 
laiTj (if (iliijjsonj lo elicit, if pi>»«ible^ tlie existence of any ulcenitiwn or 
other pathuhj^ical i-uuditiou. Hyp4.*rtTopliicd pH]jili;i> iiiiiy )w d La{i;iiO!i{>d 
liy this procedurL'. It in just at this [loiiil, hulwcfu the cxli-riia! and 
internal Bpliinctur, tliat the educated lin^i-r most often rpcojjnizca the 
internal opening of a fistula, Huctuatiun of perirtvtfll flbsctfiBtv. a.nd the 
proik'ncc of sninli foreign hodii^ which liavf lodged in tho orvpts or 
been caught in the grasp of the muscles. The eduoalion of the lln>;er 
to reco;.'niice abnorirudJIict^ in this i>urtiun of the rectum is the iir>tt and 
nil ».t iiii]jiirt;iiU stcji ill lla- dL-vclHnrufnl of a rectal specialist. T ^jjjiuut 
tlu^ laclile iTiidilion one can tifViT iiiiike a success in the treatment of 



H'H' disi-jises. There is no one thing that will irive more sntisfartion 



n prariifM! than the ahility to diagnose the internal opening of a fistula 
V l"iich. The comfort to the patient, tlie certainly of the operator 
when he feela the opening, and the greiit assistanei^ it afTnrd* him in 
operating upon tortuous fistuloUK lru(?t», render thin aceonipli aliment 
of ineRtiniahle value to one who prnctises in this line. An uneven 
ppot. elpFiited or depre.'Wed. with an inrhiraled htise, and more sensitive 
to touch than the rest of the circumference, reveals to the ex|>crienccd 
examiner more than any probe can tell, and he who has experienced it 
a few times recognizes the condition as unerringly aa the KktUul miui- 
ciau vrill a string out of tunc. 

After the examinution of thitt portion of the organ, the finger should 
he carried througli the internal sphincter and swept gently around its 
upper tturface. The impression that internal ]ia.>morrlioids can be felt 
in this way is a mistake. Unless there is true hypertrophy of the con- 
nertii'e ti-isue one can not feel thcni at all. He may, however, reiiognize 
ulccrationa whether eimplc, tubercular, or speuifie. Ae the linger is 
swept around the rectum the levator aui muscle can be felt and its 
condition determined. One can also dotemiine whether the mucous 
mcnibmne is smooth and without tlic normal folds, lhun iudieaiing 




EXAMINATION AXD DIAGNOSIS 



109 



I 



ttony; or wlifLliL-i- il is iiarwJi uutl dry, tliue iiidic-utiiije atrophy of its 
[» iind iiiduHteicnt sccrctioas. Koi-eigD bttdiL'H Imlju'inl in the am- 
piillii of th<* ri'otiini ofti-n jiiisiinic a position jii!it above the internal 
ephinctcT, and can he felt hy the fingor when Ihcy ai-o in tliie posi- 
tion. Polypi and otlior noopltt^iiiij^, «trielurfs, prncideutia, and inllam* 
matory con^litions, may alttti Ijl* diagnoiiud \>y this niuaus. A knowl- 
edge t)t the st-nsalion iinpartt-d to tlie fingfr by ihtJ various pathologi- 
cal conditions is iii(li^pi-nsa)>li' to the proper diaji^riosis of reclJil dis- 
e&ecB. T lu? auft, ii-n-^idar irtltri-a of a liil»rnilnr nr simiilc iiNiratioD, 
and the lianl. jiid iiiiili-ti fr<-l >.( Hi.. .ipi..-iiV i-yi<i^, Tr^^^\itTc fxpt-i-i- 
ani-o to <|ieti»giiish llii'in. The smooth, aoTl, tiliiiiv f«cl of a polypoid 
{growth is cuiiruly iliirt'roiit frotn the hard, nodnliir one of caromoiiia. 
'ITie Inic tibroiig and the Huft milaiuinutory Hlricture j^ive ontirt'Jy differ- 
ent si?usatio[iB to tilt! toucli, but it roquirHR (•durulioii of tliiR st>ns:i> nJid 
expcrit-nct' to distinguish them. The romlilioii of the prostate and the 
uterus and its iippwidaxf^s should nlsn be carnfnlly noted in digital 
ttxsniination of llip rectum. FrrcjiipntlY wc arc able to foe! thi' nodular 
aurfacft of an inlliirnvd eervix pivs,siiiir d<j\vii iiiion and irritatint; this 



organ. A prolapsed ovary or relroverted uterus, a fibroid or cystic 
• tumor, a hii-niatoma, or even on extra-utprine prcjrnaney, may be made 

»out by digital exaniiiiatinn nf thn rootnm. Frcijucntly symptoms re- 
ferred to this orgjin arc due to discanos clspwlipre. A ston« in the 
bladdu* or urethral tilricture may cause rertHl symptoms only. The 
sprt-ialist in rectal disipases must therefore pmcticiilly be an accom- 
plished gynwcologiftt and gtmito-nrinnry eurgcon. He may not do the 
I Operative work of such, hut eo far as the diagnostic knowledge ia con- 
*oriii'd hi' should posspw it in both branches. 

While the linger iii still in the rectum the ecu^oyx should bi^ gi'aiipi:id 
I bctwi'cn it and the thumb externally, and moved backward and forward 
, to delcmiine whether then' is any inlljininiatorj- or lender r<inditIoQ 
I about it. Kentnceles, both anterior and podtmor, should be thoroughty 
I eicplnrffll for foreign bodiea or liardened f;p(-al ma^nci-. As the finger ia 
■ withdrawn, if the patient in requested to bear down, internal Iia-iuor- 
rtioids, if present, will frequently follow it out through the anu«. II 
there is blood, muemi, or pus in the rectum, it will also follow the finger 
upon withdrawal. 

^_ The o<lor h a\tn important. That imparted by carcinoma in the 
^Hiectitm, once smelled, can never he forgotten: that of ulceration, whether 
1^ simph'. Hpccific. or tubercular. i» entirely different. There is a feculent, 
sickening, dead flmell to the discharge from a carcinoma which is pro- 
I duce<) by no other disease. 

I Exannnation by the linger is practically limited to the lirst 4 

indies of the rectum. With the patient bearing down and the surgeon 




110 



THE AKCS, REdTTM, AND PELVIC COLON 



pressing upwartl upon thp pi?nna>niii, the tbiinib being ctirricd bock 
over the coccjs and the ftngeia over the pcnmeum, or vice vtrsa^ 
aiiulhi-r ) inch ciiti pusslbly bv ^iiiL-d; but 4} iiidies is the limit of 
tli;{itul 1oiii-)i. WhtTu tlic clUi^iM; ia higlit-r up eviiie other method 

pmuet be adopted. 

^ Introdvclion of iht Hand into Ihe Kf^lum—Manual Examinalion. — 
Extending tlie principle of tactile oxaniinnlion, Siniou, of Ht'idelberg, 
deiJioiititraled in 1872 the feasibility of introducing the whole hand 
into tlif rL'L'luiii for the purposes of examination. In order to accom- 
jilitfli lhi», lliL- jfuliciit ijiiisl be an».'Stheti%ed. and Ihe hand should be 
tliuruujfhiv lubricated. The flngt^ra are introduced into the anus one 
ufier unutlK'r. and Ihi- tipluiiuler iriuseles gradually stretched until the 
puliu uikI liuaLIy the whole huud is introduced. The dilatativo must 
be very glow and with a boring motion. After tlic hand passes through 
the gi-nsp of the sphincter niiisele it will slip into (he widest portion 
of the rectum, where the space is ample. This portion of Ihe rectum 
is not coTered by the peritona?uni, and ther* is little danger of injury, 
as It is very distenaildc. From this point upwanl. however, the gut 
grows narrower, and if Houston's valvus are much dcvctuped, there will 
be points at which there ie a partial constriction. After the hand liaB 
beon carried from 4 to 5 inchc? upward gonornl constriction will begin 
to be felt, whether the gut is normal or diseased, iind from here on 
tlic greatei;! gentleness and care are necessary to avoid traumatism to 
the put. In lIiL' first portion, above the great ampulla of the reetuui, the 
peril oiiipum covers ih f front surface of t!i»? gut. and as we asct-ud it 

until it limiUv entirelv siirruiiuds 



poJiSi'S more uud iimnL' to the sides, ^ 

t he inU'^liiic on u level with the third piece of the riiifru ni. At (bis 
point, whcru IIil' rcctujii joins the sigmoid, tine will ulwiiyi- liiid a iriarkyJ 
contraction in the caliber of the gut; and the introduction o£ the haikd 
through this is fraught with dnngcr, unless the liaiul bi' verv uniull. 
Whatever cxaiiiinalion enn not be cuade by the iutruduetiou uj two 
fingers through this contracture had better be left undone until an 
exploratory laparotomy sliall clear up the question. The dangers of 
the latter are le;*? than the intmduction of the whole hand through 
the recto-eignioidal juncture. Simon states that with half of the hand 
parsed through this contraeturc, the abdominal cavity may be exam- 
ined to the cjclent of several centimeters above the umbilicus; one 
rarely has occasion to pass hie iiaod higher up than this. According 
to Simon's directions, a hand measuring 25 eeutinietere (9.J inchps) in 
circumference may be liius iutroiliiced without dauger. The author 
believes, however, ttiat a hand that requires & kid glove larger than 
No. ^i should never hi.' intnidueed into Ihe rertum except in a life 
or <l«ath emergency. The danger of this procedure hm been diecuased 



BXAMlNATlOy AND DIAGNOSIS 



in 



by iiuiny writers. Four cases have been repmicd in which ilwith fnl- 
lowcd the operation. They are a» follows: 11. B. Sands (New York 
Medical Hccorcl, Jitno, 1H7-I, p. .'!01) iiit,pi»iIuft-4! » haml int'ftsiirin^ I!) 
centimclcrtt (T,*, inches) in eireiiiiiU'rcnee 12 iiu-hes up into the gut 
(the arm being loo large to allow it ti> pas's any farther), but <)ii^ 
covered nolhiiig by this exaniiiiatinn. One week later lie made a sec- 
uad L'xuiiiiuatiuii, this time iulruduL'iDg his riglil haiid L3 iul-Ul'* nhuro 
the nuu*. The eipeuiiiferL*nce of this haiid is uot stated, liut it wtut 
presuiiiiihly UrRer Ihuu liis h-fl. Ky thif cxmninaiinn hir diii^o^'t-ti it 
strictut'c of till) ascend iug c<jlon. He llicii did a right lumbar colnt- 
omy. The patient died froiu shuek on the fiillowiug day. In liie speci- 
men I'ciiiovL'd, 111.' " (-ii]iijl (.■itii " nbov'i'il Hrjiiirofuiu of fiii' mtinrnUir fihtrs 
and mphire of Uif jierilunetii cunt iit ,V iiirfif-a ahiire tlir unua. Siiint' of 
the luiigitiulinal HiuBuular fibern iii tht- itLgrnoid wt-rt* s«jmni(ed, but thure 
was no riiplun; through llie gyt wall. WV c-sll attPiilioTi to ihr- fact ihat 
the pt-ritoneal injurj- was not nt the rcclnin hiH in ihn caput coli, and 
the sopnrntion of the nmacular fibem wns apparecitly 119 uiueh al this 
portion ns in the rectum ilM'lf. FurtlitTinorL*, atletitiuu is invited to 
the fact that it was impossible for the hand to have Wi^n introduced 
up to the caput coli, and therefore those irjurios iiiiist hapc been the 
result of the np('mli<iTi fitr c^jlotoniy iind itiit of t)ie exiiTuinnlion. 

Weir (New York Meilieal Journal of ISTj, p. J I i) rL-jJurlcd the 
case of a woman, aged lifty. ulio t^'oinplained uf syiiiptoins of ubxtruc 
tion, and upon whom iimiiual <.'\iiintuiiliou \\m pcrrornted. ]{e was 
onablc to make iiny diiignosis, olthuugh he (tuucccdcd in touching the 
kidney with \\\» hand. A lumbar cololoiny was pi^rrnrrned. and the 
patient died the nf'Xt day. The aiitopfiy revealed no peritonitis, but 
about two teojipoun fti l« of free blood in the Douglas ettl-iUsac. There 
was a rent in Iho inuseular and [)erituneal eoaU of the bowel on its 
anterior UKpect. just where the peritonifiiiii is retleeleJ from l]ie blailder 
upon thu ri'ttuin. Thu irnicous membrane was not rupluieJ, and there 
was nu evidence of pfrilouitia. A close strictuw of the tronaverae 
colon via» found with a large accumulation of fa^™! matter above it. 
'Vhv patient rallied fn>ni the operulion, it \(. said, and the vawit ol 
<I«ith seemed very obscure. If it had been from rupturo of the bowel 
there wotild have been peritonitis and olher evTiiijfoms nsunciate:! there- 
with. If from shock, it may aa w»'ll be attributed to the opcrnlion of 
colotouiy as to the manual examination. The tliird case i-eferred to 
by Weir (Medical Ri-cord. 1875, p. 201) ocruriwl in St. Fluke's Hospital 
under the ean; of Sibinc. Thi« patient <iicd at the end of four days, 
and the imst-nwrtcm csaniination showed a laceration ol the mucoua 
cost of the rectum with eerhymosis. but no niplure of the gut. There 
stem« to liOTe been no perforntion in any of lhe>i« cases. Diudridge 
9 



114 THE ANUS. RECTDM, AND PELVIC COLON 

(C'iticiniiati Laucot and Observer for 1876) reported the case ol a man 
with A [iHoaH ttlittcesti, who nas m ihv hospital vrith a cuo<]ilii>H of iiup- 
puratinti appan-nt, but na diujiruoKis had liit.-it mmk-. On March 2Sd the 
doctor exptored the rectum with his hand, |)asrtiitg it tiirou^h what 
Beemed to be a constriction of the bowel, ba though it were hound don-n 
by a false menibrane just above the rectum. Before roaehing tlie prom- 
ontory of the Mcruni, a large ewelling posterior to the rt'clum was ob- 
uei'voi. The examiner proeeeded with due care, exploring the surfaeea 
of the vprtebrip, the pwias miiscle on both Rides of the common iliac, 
and upward to Die hifiireation of the aorUi. His atvuiciate, \)t. Connor, 
then repeated the examination. The circumferenc* of the hand in not 
givr-n in fillier ease. Tliis man suffered from surgical shock a:id tem- 
perulure for lliri'e day», some evidt-iiees of peritonitis develo[)e(l which 
practieally subsiiled upon the third day, after which time the patient 
developed pneumonia niid died on the tenth day. The autnpirj- revealed 
Bcptic pneuntoiiiii wilh j>nH in the pleural envitie>i, and pk'urni adhesions 
showing evidences of an nid IntlammAtion. Thciv were flecks of recent 
lymph th]-oup!iout the peritoneal cavity bindinp the hiops of intestines 
together. There was no fluid found in the aluloniinai cavity. The 
mucnufi membrane of the intestine was normal. On the anterior surface 
of the rectum there was a slit-like tear in the peritona'um nboiit 5 
inches from the anus. There was no special evidence of intlammation 
in its immediate vieinity. The mucous membrane corresponding to 
this nipture wa.s ncirmal. At the same level, on tlie latfrnl and poa- 
terior aspect, there werp two al>sceK»e8 in the wall of tlie lnnvel. .Just 
above the sphincter there was a tear through the mucous and muscular 
eoat, but there seemed to be no infection or inflammatory coiujdieation 
from tlii'MC. Pfioas aheceaece and necrosis of tlie Iinitbar vertebl^l; were 
also found. Dandrid^^e eunctudei< that the peritonitiB woa cluu to the 
rupture of the peritonnum 5 inches above the anus, and to the mucous 
membrane torn ihrougli just above tlie sphincter; and y»'t he distinctly 
says in his report that there was nn evidenet of aeult inflammation around 
tUJier our itr the oilier of Ihse points. It seems that wilh all the patho- 
lojrlcal complications in this case, it is rather straining » point to at- 
tribute the fatality to the manual examination of Ihc rectum. Thus, 
taking the four cases, one may say thai while they simw deaths fol- 
lowing Ihiit procedure, only oitc uf them (that of Subiiie) i^eeius to 
be clearly due to it. These coses have been somewhat extensively 
rcviewcfl, beenuse fhey are so often quoted to show (he fntu! j-esults of 
such esnnirnations. They do not appear to be conclusive. At the same 
time one should not underestimate the dangers of this method. In 
malignant diseases, in uleeratlnns, and in cases in whic-h atheroma ot 
thu arterial syatem ciiiEte, il ^ll■mlll not he underluken. But iD cases 



I 

M 



EXAMINATION AHD DIAGNOSES 



118 



til 

g 

ti< 



■^> 



m 



foreign bodips aiitl of fa-L-al iinpartinn in tlio eigtiioid flexure, the 
cout* of the bowel boilig olbtTMisp licalthv, oc for purposes of esploring 
the pelvic eavitv, umler lEiu snmi* t-onditions it iimy be nafclv eamt-d 
out, provided the Jiaild oX Ih*.- oprmLnr does not tiiuisiire nver ?0 t-fiili- 

oters (?5 inches) in circumference. Tht; uuVhor hns done it more 
tban a biiiidrpd times, mid ba^ not yet hud any unffirlimatt- msults 
^iurllier tlian. a Ifnijiorarj' iiLuomim-nct- of fsrcc*. which lasted for about 

D liaj-s in one case and loss in othei*. Whilt.- this method i^ iieoful 

d Klill has ils place iu nttal Kiirgerv, it Iuim been larjfelj guperspded 
in tiic lust few yearn by the advances made in instninirnin! <;.vaniina- 
tions of the recttnu. 

Instniniental Examination of the Reotam.— /.lyt/.— In all meibods 
if iustriimcntnl exnniination of tiii; roL-tuni. Ibe qiie.stion of lijrlu is a 

ry importfliil ono. It ean hanlly be gaieiiiaid tliat rellected daylight 
In gi-nfrally the most 
uuiafacCory for rectal 
examination. When 
this ean nut be ob- 
tained, the electric 
light is the bwt sub- 
slihile. In larpe cities 
lown« lighted by 

ectricity the street 
current can be ujied 
for this purpune. An 
ordinary bund • lamp 
with a reflector around 
il «in be used lo throw the light directly into the re-etnm, or it may ba 
refleeted from a bead-mirror. The IMuetratLtm [Viff. 57) shows an electric 
hes'l-li;;lit uhieh ie more gatisfaclory than any other, and whieb for gen- 
eral ill u mi nation of ibe lower rectum and operative work i^all that can bo 
deaire*!. For deeji examinutionB U does not fotu8 as perfectly us the rc- 
fleetcd liKht, and is (brreforc not so (food. In smaller plates, where there 
ia no street curn-ni, or in tlic coimli^, some form of «toni^c or dry-cctl 
battery will be found useful. Small electric batteries ore in the market 
hich fnmieh n lijrht of »boiit H candle-pnn-er. They are easily portable, 

t some of thi'Hi liave ingenious attaebmenls wliieh make them very 
uftofiil in nther instrumental examiualions. A little care in the manage- 
ment of these batteries and renewing the oelU occasionally is all that 

necotwaiy <o aupply a most eilieicnl ami rcliublc light for the treat- 
lent of rectal dincose*. The name bottcrica arc aliio used for illumi- 
nating purposes in the pneumatie pn)rtosrope», which will be described 

ler oQ. The couipUcatod gaslight brackets and lamps with condensing 



Fiji, tt.— ELscmio Tlcut-tianr. 




Hi 



TBH AS OS, RECTUM, AND PELVIC COLON 



lenaeB are traublc^nme and no longer noccftsary since the electric light 
CAil be 60 L-iisil^ obt&iitod. 

AltacliofI 111 the Martin chair is an nupurattifl with many compli- 
patL'il M-n-ws arid joint« for iliri'rliii^ tlu' liglil iiiu> tlic retlum. The 
invontor iiscs it with gnM lU-xturitj, but others have bt-uii unable to 
do ao .^aliufnclorily. 

A wry usi-fiil lijrht for nighl aiid i-ouutr>' practice is that known 
U the acctj-loni- iiicycli'-lflmi>. Tiiis burns for a lon^ while after it haa 
OBfiv 'iii'ti clinr^'i'd. ami ^'ivue rt vory bright and onccntrnted li^'lit, 
whlt'li nm be iim-d vithcr dirvclly or by roltfctioii. One of these lamps 
of »iimli imltonj \» a very convenient adjunct to a gpui^ral opraling hag. 

Ivelni'v lulviBi's earrying in such a iMig a quanlily of magnet<iiiui 
•trill" whicJi, being biiriieil, produce a very bright light for exumiiia- 
tiim* ut Iho jintienl's houHc. To nne in the habit of using the pneu- 
mntiv )>n«-loHeopc, such aids will be imnpressary. inasmuch as he will 
always curry nloiig with him the Htllc buttery belonging lo this instru- 
ment, and this will supply abundant light. One of the best of these 
briHerii's ih nmd* by the Anxerjcan Endoscopic Company. 

Spfcula. — Formerly, that portion of the inlestine above S itichps 
W08 praetieally a terra incognita. Within the pact few yenrs, however, 
tliHiiks lo Tlnwai-d Kelly, we have beeome as fanilinr with the appear- 
ance of the iipptjr purtinriB of the rectum as we are with thai of the 
vagina or any oilier open cavity of the body. 

The old-fuishiDiied npfcula oniy i;avc u» a partial view of llie first 
4 or 5 inches. They Hcrvcd their purposes very well, and as instru- 
menta for treatment some of thom are even now superior to many 
of the modem inslPiiincnta, but their field is very limited. The intent 




Via. iS.— Kblmt'b 




Y\o. 60. — CoKiOAL Bivalve 



of every ."ipeeulun is tn afToril a good view of as much of thr rectum 
as po8;?iblc. .\s will be seen at a frlance. the instruments illiiHlraled 
(Figs. 58. 59, GO) aiTord only a partial view of tiic circumference of 
the intestine, and a very ]imite<l view of itji length. The .^ims'i? rectal 
speculum (Fig. (51) would give a very fair view of the anua and rectum 




?i«. no.— Oaiti^ OruMnmi IUctal. Si-iuvLim. 

bp UB(?il csci'pt iinilfr ftfiicral aniL-stliPsia. The s«inc objecUon may lie 
offerpcl. only in ii Itss degree, to the KelnL-y speculimi. 

The O'Nt'ill specu- 
lum (Fip- fiii). whicli 
utiilvrtakes to cnmbint' 
in oDc the bivalve and 
fi'Ubfltrntcd conical 
*pecula, » sonictiiiics 
ft very ii*cful infitru- 
iiieot. The blades nrc 
likely, however, to 
pineh tli« folds of the 
inuroun iTieinbrane or 
lurmorrlioidiil Joteloii- 
nic-uts Aittl vnutv eon- 
jiilcrable|i«iii. It only 
(■tvcsan imperfect viov 
of about 4 inches of 
tbe rectujD. 

The spcciiluni ithi«- 
tmUnl iu Fig. 63, ck-vised by Ibo author, is a moidiflcation of the Brindt* 
nrholT Bpeculiim. with two feticHtrtt. Uy a turn of ooe-quartcr of a circle 



TSATzu SncviVM. 



116 



THE ANUS, RECTUM, AND PELVIC COLON 




it gins a view of the «ntir« circumference of the rectum; it t» m&de 
in two sizes, one li invhea and the. other S inches long, thus practienlly 
giving a view of about S incheK of the rectum. Up to the time of Kelly's 
pappr in ISS.*), this waa probably the most satisfactory speculum for 
rectal pxnmination, and it is still a very ugeftil inscnimt'nt in the local 
treatment of Iijemorrhoitlg, diseases of the crypts of Morgagni, internal 
blind fintula, and ulcerations in the lower portion of the organ. 

A liMuill laryngoscopic minor may be used in connection with this 
instrument in order to obtain a perfect view of the anterior and pos- 
terior enlS'de-smr of the rectum which dip down behind ami in fnmt 
of the internal sphincter. This mirror aUo serves to examine the 
crypts of Morgagnj, and to determine any fistulous openings about the 
lower portion of the rectum. 

The ordinary Sims's Taginal specuhini. such as ie posseeaed by every 
Burgeon, has been variously modified by Van Buren, Kelsey, Helrautli, 
and otiiers {Yx^- (H). The modilicatious all consist in removinf; one 
end of the fipeculum and n<idinp a 8troij(ht handle bo 
that the buttocks will not interfere with it* introtlnc- 
tion into the rectum. These are all nueful instruments 
and the rect-al specialist sliould 

7 possess them; but to the general 
practitioner they are not a ueces- 
eily, [or he i:nu gel along very 
well with the ordinary Sims'e 
specukm. For use in connection 
with this instrument one should 
"^ putJSCba some aort nf n rerlnl tv- 
Inictor. I . havK fouiKl Prali'w 
{Fi^. Ij5) very salisfuctoty, al- 
though the physician may easily 
arrange one for himself out of 




I 



Tio. M.— ViK BuB.«it'» 
Ssvuk SrKOULCic. 



T\a. BTi.— ruiirt 
Kid T A I. UKnucna. 



stiff copper wire, bending it to 
suit his own eonvenienee. 

The self- PC lain ing speculum 
of Mathews (Fig- 66) is a favorite 
one with many operators, espe- 
cially in the West: but it \» open to the same objections that have 
bei'in mentioned in reference to the 8iuii>'s rectal speeulum. 

Formerly the Fersiison tubular vaginal speculum was iiscd by the 

introduction of n rectal boujfie through it as an obturator, and thus 

introduced into the rectum. It formed a very satisfactory instrument 

for the examination of this organ so far as the instrument reached. 

In 1SG3, Bodcnhamer introduced to the profession a long steel tube 



EXAMINATIoy AND DU0N0SI8 



117 



SfKCFLIIV. 



f0> 



,0 



witli a sort of a spiral confomia(ton wliicli nmtlr it flexible at 
the end, and thus i^aabled him to psss il into tlie sigmoid Hi:xiire. He 
said by this means and a £>'5teiD of mirrors he could observe the condi- 
tion of the gut above 
tlic rec!to-signio)(]al 
juncture, and also the 
mucous nii'tiihrane of 
the rectum all the way 
as he withdrew it. Tlie 
inBtminent was aover 
genemtly adoptfil. 

Andrews, of Chicn- 
go, later on devised 
vluit h known as hU 
tubular specula, one 
being straight and the 
otiier curved so as to 
eonf onn with the cuxv- 
ntureit of the rt'ctum. 
Hu claimed that with this inRtrument lie wan able to examine the 8ig> 
moid flexure, and tn thoroughly observe all its cireumference by the 
aiil of a eonrare mirrnr which in introduced into the fipecuhim after 
the obturator is wi^lld^^^w^I. 

Cook, of Indianapolis, nleo devised a tubular specuhLin similar to 
Awlrews's. 

The advice in regard to their use by the inrentore is to lay the 
patient upon the nide, introduce the 9pe<!uhini, and examine tlie mue<)ii3 
membrane of the irifpstine as it pmlapwcs nver the end of the instni- 
nient upon it* vithilniwal. The principle of atmospheric halldoniiig or 
pneumatic distention ia Dever hinteil at in any of their trritingj, nor in 
any ol the books upon rectal dJAeases in which thc^e tubes are described 

and rt-com mended. 

In 1895, Kelly, of Johns Hap- 
kins Hoi^|)ital, tntroduect] to the 
profci^ion n set of rectal ond iiig- 
moidal tuhe-s of difTerenl calibera 
and lengths, designed for examin- 
iiij; the rectum and siginoid flenire, 
IW. «?.— K«LivV \ 1 There were no curves to these in- 

Mruiiienta (Fig. 67). Tlie inventor 
ahowcd, if not for the first time, at least more forcibly, that a straight 
inatrament could be introduced through the anus into the algmoid and 
up lo the dMecnding colon. Not only was this principle illustrated. 





118 rUE ANUS, KECTUM, AND PELVIC COLON 

but the application of (he ballooning of the rectum by atmospheric 
pressure was brought into promincDce ae an adjunct in the U3C of tubu- 
lar sppoubu 

^Inrinn Siniit, in 18>}.% deiiioiistrated to the world the advantagcfl 
of ntiiif>.iphi!ric prMKun; in l)a.nooii ing the viigina. Vhd Biiren, in 1870, 
demonstiatPfl to his clfuw in Tiellevue Ilnspilal the applifjition of this 
iiiflhod lo the rectum; at the same time he gave rrc<lit to Di\ 8inis for 
the discovery. AHinghnm advi«cd the line of thJA method and devised 
a lube fur it; he alw acrordni to Dr. Sims the honor of priorilv- But 
none of llicsf authors had und^rtaJten the scope of examination which 
Kelly introduced, nor had any of them used in this way the cylindrical 
tuhpiJ, cilhpr short or long. To Kelly, tliiTMfiin', bfloiigs not the inven- 
tion of n liihf, ilill lege the dipcoverj of the inllating power of atmos- 
pheric pressui-e, but simply their practical and ingenions application 
to rectal surgery. He [lupiilnrized ihc melhod, one may say. or at 
least showed us Its pus^^Ibilities. Ilia method is given in liis own woide: 
" Ana^sthcaia is unnecessary in iisinR most of the specula which are 
of amall enlilier. and none of ttio various manipulations are painful. 
The patient kneels on ac ordinary table (a common kitchen table is 
quite eonvenieni) with the elbows spread out at the eides so as lo bring 
Ibe ehest as eliise (o the lable a< po*jiible. while the lliiyb* are perpen- 
dicuhir to it, diippurliri^' ihe pL-lvis as high ns posMble. The buttucka 
arc drawn aparl, ami (he blunt end of the obturator is laid on the 
anus, which is inali'il willi vaseline. The iliirclion uf intriMluclioQ 
fbituld be at Srsl, downward and furward, and wJieu tin- ephinclcr is 
well passttl, up under the Mcral promontory. The moment the apecu- 
lum eluiirw llie t^piiinelcr ttiv«. and the ohlnrator h withihiiwn, the air 
rushOK in audibly and distends llie bowel. The bowel it; illiiminalej in 
tbf? following manuLT: a strong light — dayligbt will answer, hut an t'lec- 
(ri(' light is tiuist tonvcnieut- — in lield close lo the Haeruiii where a 
hcad-mirnir dirccls the rays through the tube inlu ibc bowel." lie 
reroinmendH iis a practical set of these instruitientK {Fig. fJS) sufficient 
for all oniinary purposes, a short proetoscopo 14 cenlimeterei (."ij inches) 
long and sa millimetorH (jj of an inch) in diameter; a long proctoscope 
of 2D contimt'ters (72 inches), and a aigmoidoaeope of 35 centimetera 
(13J iiiebee), all being of the same diameter. 

For examinijig the extreme hmtr end of the anus, a proctoscope of 
5 centimeters (2 inches) or less will be found convenient, and for 
Ircnlnicnt uiid operations in the reclum. tiihe.<* of various diameters will 
bii needed. Lung applirston* or dretining- forceps, specially devi8e<I for 
use through these tubes, are neceesary to wipe away mucus and adherent 
ffpca! masMCs which obatnict the view. A curette or scoop (B'igs. 6!?, 70), 
devised by Kcily, is very useful for rumoving fjpcal masses and curet- 



i 





ivM I 1 ■ --n 'ir iMinii nt.vr- i-k fiiviximo the Ksi-TliM *su Siumoiu. 



IM 



i 



ISO 



THB AXCS, BECTUM, AND PELVIC COLON 



tiag siuall ulcerated areas, as well an Tor obtaining KprrimenR of 
neoplaoDS for nucrosiwpic exammatioQ. Along with this »ei of instru- 
ments Kelly introduced a conical sphincter dilator (Fig. 71). It i& a 



Fio, 00.— Kxti.»'« Kk^ai. Cciurre. 

UFefiil instrument, ulthong:!] not a neccsnary one. Kelh''s dpscription 
of the use of the long sigmotdoscope is mther enthufiiastic. Uc says: 
" Upon intro<lucin{r the sigmoidoscope, the longeat speculum, the instru- 

. mont JH continued 



Fi«. VO. — Rbu.tV Bbotal 8o4Kir. 




Fio."!.— Ki.LLif'« SniiJttTim Diutuk 



Up intn the dilated 
eigmoid flexure in 
the false pelvig hy 
luming the handle 
to the right. At 
flomc point in the pnsstjge the aliiio^phcric dislentioD ceAtces. and the 
lumen of the bowel can then only he shown farther by cautiously push- 
ing the end of the instrument on through the. lax, coUapscd folds." 

IVom this one would judge that there was little or no diffieultj 
in passing from the reeiuni into llie 
sigmoid flexure, even with the obtura- 
tor of Ihe instninient wiHidrawn: but 
suuh a statement la unintenticmally 
misleading. 

Where the sphincter is relaxed, 
the coccyx movable, and the luigle of flexure between the sigmoid and 
the rectum is not acute, the stniight inetrument may be introduced into 
ihp sigmoid flt'iure with cnmparative ense: especially is this Lnie in 
women. But where the uppoi^ite conditions exist, where there ia spa^m 
at the rccto-sigmnid&l juncture, or where the sigmoid is bound down 
in the pclria, this introduction is not only ditTicult, hut extremely p&in- 
|ful and dangoroua as well. When the gut is well distended the lustru- 
menl may bo so directed as not to impinge upon the -walls; but un- 
furtuuatelr this disleiilion from almo'Sphcric pressure ceases (irdinarily 
in tile first loop of the sigmoid, sud from this point upwanl the edges 
of the tube scrape against the walk of the gut and frequently wound 
them. 

.AmrMhesia is adrjsed by some for nuiking such cxaimnations; the 
author, however, is opposed to this, helieving that the sensations of 
the palicQt arc Ox» safest guide as to how much pressure shall he used 




EXAMINATION AND DIAGNOSIS 



Fi«. ti— ALtiitm'B MowiriLATioM or 
Kelly'h Si'iKoinuKorK. 



m OrOeT~Fo Rvoi»I injury to tlie parts. Moreovor, there Iihvk ht^nn 
noticed occaaioually, after sigmoidoefidp y iiuder ciiloroform, a tL-mponiry 
paralysis of iieriHtaltic action anil great difficulty in recalflblishing the 
regular fa>cal moveinents. The exnct patliokigy of tl'is condition can 
not be Btateil, but it is one of those complieutions which uiaj follow 
the use of iheKe instrtiiii'^nts. 

In nrdrr to overcnnif the difficulty of past^itig the straight in-itna- 
mcnt around the promontory of the saermn, the author dcvigcd a 
modification of the 
Kelly tube, which 
conAit<t3 in the intro- 
duction of a lli'xible 
obturator by which tlio 
instninu'nt is given a 
Mcrcier curve(Fig. 72). 
By this nn inclined 
plane cumirs in LonLact with the promontory of tlic sacrum, and one is 
able to pa«« Ibis point more easily tmd with lest pain than with the 
etnught injatmmont. Tho modificjition i» only iu(>fu] in the longer in- 
Strumend! ueccsiiary for t'xanhning the sigmoid, 

Martin htm devised a modification of tlie obturator in the Kelly 
tuh(.>;«, whifli CDiisiatK in the introduction of certain yroovcs thruugli 
irhich ointmcuu may be applied to the inside of tlie rtttuin. Thi* 
obturator is oIm perforated, so that one may inject air or fluids into 
ihu bnwcl while the spctrulum is in puttitiuu. Bcacli hiw also iiiodi- 
fifd the inatninieut by carrying an electric light to it« inner ond 
tbroujrh a eupplemenlary tube, a" principle employed in tho endoscope 
and cystoHL-opr. The BueecHsful vsv of all thet^v instruments, however, 
de{»Ddii upon atmoBpheric dilatation of the reclum and si<fuiuid. The 
patient mnitt be placed in the uncomrnrtable knee-ohe»it posture, and 
e^on in Ihis position cases will occaaiuually be swn in which tin? uinioft- 
pherir prespure will fail to hallooo (he par1». In the majt>rity of 
CAsee this ballooning ceatiea in the first loop of tbc eiginoid, and notb- 
in^ more can be eeen abore thiii area than that portion of the mucous 
membrane which collapses over tlia open ond of the instrument. The 
author haa found in a number of ca«e8, in which there had been 
chronic proctitis or attacVs of pelvic cellulitis with adhesions of the 
uteniP and ovarie.* to tin* ni-tum, that the hitter organ did not balloon. 
and examinfllion by thcac tubes vaa very unsatisfactory. Such difTi- 
cullicj* have led to the development of artilicial meana for diuteuding 
the rectum. 

Pnmmatic Procloacops.—ln 1890, Dr. Franz IleucI, after luiving 
experimented vitli bis inflating endoscope, also made an attempt to 




nington. of Cliica- 
go, introduci.'il an 
inelnuucnt known 
as !iU pneumatic 
prootoseopf. This 
apparatus oongistt; in 
a iiiljo t'losLiJ liy an 
accurately fitUng 
^\&ss rji]i, et) that 
tliK rrchim tan bo 
(list^ndeil by air 
punipc'l into it from 
a lianil-bnlb. The 
light is rL-Hec-tctl 
through the g\aa& 
into the rectum. 
This method of illu- 
mination, howl;vc^^ 
\s not Batiefactory on 
ticcount of refrac- 
tion by the glass 
plAtc. 
Working iit tbc aame time, aud tfpon mdeppndcnt line*, Ijawg, of 
Phil«f]elphia, tlt'visL'J uu instrument mmilar in many respects to that 
of Pi'niiinjfloci, but 
which it) an imjirove- 
mrnt in tluit Mit; 
illuuiiudtion ie se- 
cured by an elec- 
tric li^ht i-arriiHl 
into Lliy iii«ii5e of 
the tube by iasu- 
liit«(l rodrt (Figs. 7S, 
T4). By this mains 
the whole cavity ia 
wdl lijihtea. this 

iiwlruiiu'iit was ii - ., , , „ , „, 

great iniprovompnt ^„ Tiirii*i-.L-,i„ A«i.t«ATio«, 

on any hilberU) do- jr,caRii«; jv,paip«u>r: 0,>pnir; /*, «In muvL 



Fio. TS.^Laws'b l'»ir«jino pRonmitcorc. 

£, i, f.-t, ol5iunii"r«; vl. B, (', tiiluM of tlfllori'iit nioai: A luut- 
(llo: J^,tait^vltli|tlni-» viiiiilniv: &', liilliiLiiiir liulb: ILimUmy 




EX;\MISATION' AND DIAGNOSIS 



123 



• 



viwd, Init certain foatures in it detracted from its usKifulnesw. The 
cap which closes the Instninient i» attached b/ a ncrew-tliread which 
5i>m<'tin)c.s himU. nnd Ihiis ncccssittilL-d tiiicom Fort able iimntiniWIon of 
tlie inslnimeiit in adjusting it; Ihf ebctric Ug^lil wrcupirs a consirlerable 
portioD of the caliber of the tube and thus obstmcls the Tision to 
tonit OKlent. [f there is much secretion or fstcal nialtei- in the bowel, 
this IB liable lo tiow down over the end of the light and obscure it, 
thus requiring it« removal and cleansing before the examination can 
be conliniiod; tliis is tediuun and nnnnyinfr, and often rpHidt-« in the 
breaking of the lamp. These objections nrc nnt vitfd. Thny nrc over- 
come by a mollification of thu iostrument devised for the author by the 
Electm - Surgical Iq- 

Htrumi-ut C'ompanv, of ^J> '' _. ■t^ ^;^^*'^^ 

HocJiester (Fig. 75). ^ W 

A uthur's Piieiimatic 
rritclimcojit. — Tiiisi i«- 
struineut in composed 
of a largy cyHiidcr (/*'), 
into one jiArt nf the cir- 
cumference of which is 
fitted a snuill metallic 
tube closed by a flint- 
gtaas bulb at its dJatal 
end. The cicclric lamp 
(<7) \s 6tte4l upon a 
long meliillic stem, anrl 
carried thmngh the 
small cylinder to the 
end of the instrument, 
03 is »boim in the illus- 
tmtinn. 

The proctoscope i» 
introduced through the 
anus with the obturator 
{A) ia poeitlon. As soon aa the internal sphincter is parsed, this ob- 
turator is wlllidrawn and the hayoneL-fitting plug {B), which eontains 
either a plain g\&As wiud^iw or a len^ focused to the length of the 
JD«tnin3cnt to be used, i« inserted in the proximal end of the instniment. 
This plug is ground to fit Hir-tigbt, and llius closes the instrument 
perfectly. The plug being inserted in the tuljc, a very slight |)rcsKUPe 
opoQ the hand'bulb will cause inflation of the rectal ampnlla to such 
an exieiii that tho whole reclutn can be observed and Ihc instrument 
c&D be carried up to the promontory of thu »ucruin without coming in 




A. olitumiiir; B. plug wiili sliuu »iiiiU>« doiinii pii>l<irittb«; 
C, hmidln; /I. tmitla wimcotliis liiMniment ftltli luitlisry ; 
£, [nllMluK ttiiponiuu; F. [imlii !ulieorproctrMHipF. 






124 THE ANUS. nECTL'M. AND PELVTC COLOS 

t'ontttct with the rpclal wnll. Further dilatation will show the direction 

of the oanal leading into the sigmoid, nnd by a little care in mnnipulHting 

the instrument and ke»'ping the gut well dilated in advanco, it can be 

curried up iutu this portion of the intestine without the least trauntatisin 

of the jmrt^. If any fivcal material obscures the light by being massed 

or smeared over the gloss bulb the plug can be remored, and a pledget 

of cotton, introducwl with a long <l rt^ssing- forceps, will wipe this off so 

that the plug oan be ryintrodiicod and the examination continued with 

\yry slight delay or iiiconvL'nifiiee. 

Th« adjustable liandli* (C) fitR on the rim of the inutrument and 

thus conrerts it into a Kelly tube. Thin inntrumL'nt i» operated with 

nn ordinary dry hat- 

ti:r>- of four cells. It 

is better, however, to 

have one witli sis 

eelU, a.1 it will not 

re()uire being re- 

<■ .. ^ . . ^ I. «' ch arced so frc- 

Fiu. TB.— TiTTii's Lowo SiowntnotcorB with Flexiuli Ob. ^ 

TLUATcm mviNa wii iNvrai-iiKXT tin Uiucicn Ccmvb. (JUentiy. 

The tubes are 
made of various lengths, from i to 14 inches. The very long ones 
are supphed with the flexible obturator, which givee them the Mercier 
curve (Fig. 7K), like that in the author's modification of the Kelly tubea. 

For Ihe heginiipr in the use of this instruniynt it is hettiT (o have 
a plain glaiis window in the plug, for magnifying lenses «re very likely 
to mislead liim with regard to the pathological eonditioos. 

The 4-ineh instrument i-nables one to fxaminc the entire rectum, 
but duL'8 not givL- any view uf the sigmoid tluxurc. Thi- lO-inch tube 
18 6u0icii'ut for any ordinary usuniinution of the rectum and sigmoid, 
but one should also have the 4-inch size for convenience. The very 
long tubes are v^>ry rarely called for, but they arc useful in largo indi- 
viduals with long sigmoids or loose mosoeolunB which may ponsibly allow 
the instiTiment to fnter into (he di^Ncciidiiig culou. 

With this iu»ti-umeut il is jio-'isihls to see all of the sigmoid flexure, 
and possibly even to enter the descending colon by very careful manipu- 
lation. Ordinarily it docs not require any anfpsihpsia. It can he used 
in the proue or Sinis'e poj^itinn, and the view which it gives is inctim- 
parabJy beyond that obtained by any oth«r means. 

In using it one inusl remember that the bright electric light 
intenniiGcs the coloring of the parts, and may lead to false coiiehwioua. 
Until one becomes funiiliar with the changeit in appearance E)r«dueed 
by such a liy;ht, it is belter to make separate examinations by reflected 
daylight so us to avoid this. 



EXAMI.NMTIOS AND DIAGNOSIS 



1S5 



it is perfectly fcaeililu to ))ti8a thcBt' lube* into the sigmoid 

flexure witliout introJuciuK tbc obturator. The pucumatic preesuro 

produced by the linnd-bulb straijiliteiiti out this organ, causes it to riso 

u|> above iIip pelvic bniii, mid thug facilitates the introduction of the 

|Btrni^ht instrunient. and al the sam« time allows uue to see considerably 

?_vond tlie i-iul of the IhUlt. 

It iiiav be i(iig^|:L'»U'd that there is ilanger of nipturing a weakened 

land ialluiiiod iiitc-atilie by Mirb diKtiiiition, but a» a nintter of fact it is 

lever «« j;reat iia lo produce any such pffcct. Whenever the pressure 

ics any force the uir will »'e«t|K! through tbe sphincter or the plug 

will &lip out. I n ctiecs of re'laxcd sphincter it is pot;i'ii.s ary to upplv a. 

collar of wet e olloii ur t^uiizc around the tubf, onil pro-ss it timih \ 

ajjamut I Ju' mui b in urjt-r to n^taiu sulllc-ifnt iyr lo obi n in biilUwiiin^ 

ami tints p'Tirui ibe pxniiiinntion. One precaution should not be 

tomitttii, auil lluii i^, when one lins finished hin etnininfition with ibis 

iHtruiiicnt he tihouhl rfniovc thr cnp and allow i}ie air to escape from 

Ifi fligmoiil iiiid r^y'tiiTii before he witlulraws tbe tube. 

Lflvt's's instruuifnt is supplied with a supplementary cap, through 

rhieb nn applicator can be introduced and medicines applied to any 

iven point. A furolto for scraping utcers nr neoplaj^nis may be used 

iroKgh this aperture. Thn author has found it more satitifactory, 

bowever, to locHtc the potholoj^ical condition which is to bo treated 

right over the pnd of the tube, remove the cap. and then treat it. In 

ita way tbeie is more room for the use of instruments, and one can 

rithilraw and reintroduce tlieiii at pleasure. 

Allien the examination is prolonged, eonden^attou of moisture ui>on 
le gloAS niay also obscure the view. To nToid this it is well to heat 
le glass by dipping it in hot water hcfere the cap is screwed on. The 
lianilnation of the rcctimi according to this method is practically pain- 
less. The Sinis's position is employed and is not iincoinfortablp, and 
ic results gi%'e the utmost satisfnttiou. These instniuicnts serve all 
ic purposes of the Kelly tubes, and the general practitioner needs 
'only the on« set. 

Atinoephcric pressure in fsamiuations of the reetuni baa been mado 
Blic of by Carpenter, of Kentucky, in connection with n duckbill epecu- 
Hllliu and ft long reetnl retractor; und by Martin, who dcsrrilies a method 
Kof dihU-ndiiig [he anus with tbu index lingers fio that the air ni.sbcs in 
Hpnd dilati>s the nxituui, thus alTording a good view of the parts. These 
^^nethoils are ingenious, but they are not fo be compared with those 

dcMcribud above, 
Wk 7'ht Limit of OcuUir Emminatiitn.^yha extent of the inteatinal 
^^■nal which can be seen through the rectum has greatly increawd by 
tboM modern methode of examination. Itefcrcncc boa been made to 




120 THE AKirS. RECTL'M. AND PELVIC COLON 

th« piuiKibUily of [•xunining Lhe dcMcciul lug (-iilmi. Fur » Umg lime the 
aathor was nnilcr the impression thnt lie had bi:%n able tn da this, but 
numcroufi cspcriiucnls nwdp uium t!ir <'nilavirr cDnvinwd him that this 
was prartirally impofwiljli!. Alil»ott, <if ^iiniifrapoiifi (American Ovnajc. 
and Obatet. Jour., July, lyoo, p. 2U), has duplicated these experiments 
aiid arrived at tht? same cunolu^^ioiiii. 

Ac-C'oril iii^ to hiH meiuuremi'nts n stritight tube paiu^cd Tarther than 
12 incheK would impinge ngninst the liver <ir diApliragm. There is no 
doubt that lie is lorrrct in the slatpmpnt that a l?-inch, ordinary 
Kelly lul>e IH as long an instriimenl as is evi-r nen'Siiary. Willi a pneu- 
matic prnctoftoope of this length, however, one may examine the entire 
aigmwd flexure, and very occasionally where the mrst*nteiy of the 
descending colon is ven,* long, may pofwiWy ecc into t!ii.-* porlion of the 
iuLemline. In the large majority of imtlanoc^s, however, the licld of 
ocular RxniTiimttion to liiiiit«^d to Ihv Bigmuid llexure. 

f'rtihrn. — The ordinary little silver prohe, 4 to ."i inches long and 
rounded at tiolh endKj is prartirally UHele») in examination of the 
rL'ctiim. Thrsi? instruments should he 8 or 10 inches long, and fiir- 
nislird with a hamlle nait«ned and miighrn<'ii on nnr side en that it 
can be manipulated with ease, and the operator can always tell in which 



?ia, T7, — Adthok') Silver Pkou. 



■^^QlUljQI^^ 



direction the pnd is pointing (Pip, 771. They should he made of pure 
silver in order that they may be bent in all (lirectione Ihnnigluml their 
entire length without danger of breaking. 

As an instmnu'nt to locate the internal cpeiiings fif (ifitulie the 
autlior hoH prncticaily discards! the prohe initi! tht* piitimit has Ix-'en 
Bna*«lhetized, for one can do this ^uite as well liy digital touch iiml 
with mueh less j>ain. After the patient ha,-! been ana'slhntized the 
instrument is of great value in following the tortuous course of the 
fistulous trnda as they pass (lirougli the cellular and musrulai- Liiwu(;s 
about (he anus to reach the rectum. A very fine probe made of pure 
silver is oflon useful in internal blind fistula', and especially in de- 
termining diseases of the crypts of Mnrgrvfrni. 

Kerial Sraops. — .Another InstniiiuMit ttEiieh is of grpat use and should 
be possessed by every operator upon reetal diseases is thai known an 



<^^^^ =>^ 



Ki«, 7S.— Ti ttlb'b ItiuTM SrotiH. 



the rectal scoop. That of Kelly h made of hard steel, Is sliarp. and 
can not be bent. The smaller acoop (P'ig. 7S), made of soft copjwr. 



EXAMrNATlOS AMU niAONOSIS 



is t)iE> mic wliii'li the tiulliur iiiu^t rri>r|iion(l,Y uaes to scniji*! ulT ImrdI 
fa'cal iiimtsi-!*, iIlnuisc IIil- crypts of Mort;iif;iii. or turdtc uk-ers. 

Alifitir/ilors ami Dresifinij-foTcrpg, — Applk-iitora lUiU droasing-forcfiw 
art: necOKsary iii^'tniinciitii m ivttal L-xumiunti'ju;^ Tlicy aUoiild bu long 
enough to roatli Ihrcmgh llie )>!oclOBi.o[»e ami clcnii*c the field of ob- 
servation. Ono ehoiild Iiavo a nunibt-r of applicators so it will not be 
uecetuary for liiiu to Mop and rvupply tlio eotton as lie proctmls tii bis 
I'samixiation; lht.*y Biioiild not havf ruiit;In.-ot.'(l fntls or wrew*. By » 
little carL- and iiiimuiil dtxlfrity oiif can ujiply toltoii on a perfectly 
binnotk wire so tliat it will not slip olT, but can \k remured without 
diJlifiiUv. 

Those infltrumcntfi slioiilil he. ai difTprotit lonjjtlis, as the very loag 
onea necessarj' for the ei^moidnl tubes are not convenient to use in the 



'^ 



Fia. }& — AvnioK'* Vnztaiaa-reataxrK 



FiA. 80. — ALLiOjfmR FnnnM mn Ush 

TimOCaH PlKHTMICOrK. 




shorter Ini-lpumonts. L^mj,'. etmijiht dn-JWiin;;- forceps (Fig. 73). with 
hiuidlM slijrhtly bent downward *o that the liand will not obseiire the 
Tiew, ie the most n>tefnl fortn, 

In addition to this one should also have n pair of long rilli||?iilor 
iorcvpi (Fijr. 80> by which he can ruBcli and sei-ep small foi-cigii bmiics, 
pnl^-jii. or villou)* growths for the porpose of rBmoval or examination. 
These forceps aru 
useful because tlicy ■ 
can be opened and 
itliut in II iTiiieh 
KtnnlUtr spaee than 
those in which the 
joint is in the mid- 
dle of tlie shaft. Tcnacula and fixation forceps arc also necessary in the 
examination of the rectum. The douhle-flpring tenaculum of Bums, 
to catch the ivctuni and draw it downward, might sometimes be very 
UMful. The advantages of nich an instrum«nt would prineiiially bfi 
to obtain (ipecimen>i for iniero«copie cxnminntion. Sponge- 1 ml dcis (in> 
praetit-'slly supersedtid at the present day hy the drejising-foi-ceiw or 
appi icator«. 

Blunt Ifoobi. — There are a number of varietieo of these of different 
ehapi» and fsizcs useful for the cxjiminaliua uf the crrgd^ pockets. 
Talvca, autl internal blind fiNtulic of the rectum. Hy luiving these 
inxtnimentH one is able to save considerable time and ln)ublc in bend- 
ing and twisting his probes t4) tiie proper shape; but their pooinMion 




128 



THE ANUS, KECTUM, AND PELVIC COIXIN 



IB not a iweeiisity, for a pure silver probo can be turned into a blunt 
licTok of any angle in a nioiiieut's time. 

{{(iiiffipx and Souniln. — !k'r(ii*e the duys of tiibiiUr Kpi^ciilu bougit-s 
aiifl Miiiiiils wrri- iimiji.' iiuitli uw.- uf to exiimJiK- liy the sense of toutli 
tliow! portiiiiui of tliu rectum a.ba\e. th« reach of ttic linger. At prctront 
they are not so much used for thit> purpose, altliough eoiuv ftir^cons 
still fldhcTG to them na diapnoetic ineans. Thpy are of groat "^*> '" tlio 
trealJUful of stricliires, eortain forms of prula|jsts and t'sitarrlial condi- 
tions oT lliii Kigicmitl tiexuru, but «f foiiiimralivcly little valuL- in diag- 
nosis. They are mmle of vnrioiLs forms, -iiRes, and nmlerials. Tliey 
arc conical, cylindricAl, and faKhinncd after the iirvtliral bougie li baule. 
In general it may be stated that litird, sti'lT mhil bnug:i<'s are very 
dangerous infltrurnents, and should never he uwd aboTe the lower 4 
inches, if indeed they have any place at all in rectal surgery. The 
old English reetal boiijiifl was mnde of wel) iind shellai^pd, thus making 
a smooth siirfHec, whieh by making in hot in-aLer beranic mnre or less 
ilexible. It was more HBcfnl than the hanl-nihhor bougies on this 
account, and nnlil the introduction of (he Wales inftnimenl was the 
one mo>st generally used. These instrumenls were made conical and 
eylindricnl. At one time it waa quite the (ad in England for people 
enilTering fruni eonplipation to ^v by eerluin ofliees on their way to 
business and have these iaitli-ument^ poi^sed. 

Other rectal sounds are made of metal and Tertebrated so that they 
bend in all direetionn. The objections to siieh instniiiienls are that 
thif joinffi boeome rusty, they lose their llexibility, and they ure very 
liable to break off in the rectum. 

In 1883 Dr. Wales iulrodiieed to Ihe iiiedleal profes^'ion ii mndi- 
iled reetiil bougie coitipusid of soft rubber, lie describes it as fol- 



lows: "A conduit runs (hroiigh the center and terminates in the 
pnint of the bougie for the purpo«e of L-oiiniianding a streJim of 
water that might be required at any moment to facilitate the intro- 
duction of the instruraenl.i. The point? uf the bonifies are made in 
various flhapee — tjdicrieal, eonic»l, and olivary — with the view of meet- 
ing the necessities of tpecial cases. The surface is perfectly poliahed, 
which, by reilneing friction, iiicreases the faeilitv of introduction and 
eliminnteti the unpleat-nnt senBHtioii of drugging caused by a rough 
inslrument" (Medical Chruiiicle. BuUiniorc. l&S'i). Some of tlicsr ia- 
Htnimenis are made with a sort uf bell-shafied concavity ivifh sharp 
edges in the olivary tips. This is very objeetiunable, and in ecIecLiag 



L 




EXAMINATION AND DIA6X0&I^ 



IS8 



it is ailvi«al)1c tn avniil thnw. A ronioni 18 better than an olivary 
Pi^. 81). Those iii^tnuiipnls are introJuoi?il by thoroughly liibri- 
cstiijp them, and passing them gently upwarJ until an ohstruction is met. 
An ordinary Davidson bulb syringe is tlifn altai-tivd lo llit* iiLitru- 
jncDt, and a stri-aiii u[ walcr i» ciuritd lliruii<rh in ontiT to pnttli out 
of Ihc way luiy folds of mucous int-inbrauv or miiKneii of ra?ral matter 
wbich niay ubslrucl its pasda^v. In IWis iiuinm-r the rrctuni 'n^ dilated 
by the Huiii, an«l iha bougie will pass iinobstnittvd to the promontory 
of tlte sneruni if there be no stricture to pi-ovent it. At this point 
Eomo little prpetmre is neceesary. and the stream- of water ithoiilil be 
persistently earriud tbruuyli in order lo pass this flexuri*. After Ihe 
ioHtminent bas ouce entered the sigmoid flexure tbi> force of the tttream 
will lift llie folds of niueouM nirinlirane froni in frtnit of it. niul it will 
poiiK without (lii1i[-uily into the giit. If it in long enongli and quite 
ft»iblc, it may be e\^ii pa«Aed into the descending colon. Th^^e are 
by all means the most satisfactory rectal bougies, both for the general 
prsi'litionor and for the sptveialist. They arc? made iii dilTerent aizes, 

^Being numbered from 1 to 12. The smaller sizes are excel]i>nt iustru- 
int>nltt to givn high enemata or rectal lavage. Wales also introduced 
with thin bongie a ihin nihlier cap or xhealh, which he uwtl as a dilator 
for atrlcturps afler the innlmnient had passed through the wine. This 
aheath wait tied to the bougie, and air or wnlcr van pumpeil into it until 
it ddalf«l Iwo or three »izvs ahwve that of the bougie, thus eti-elching 
llie stricture by a soft and olaMie pressure. The ordinary AValee bougie 
is about IV inehes long. Thin is not Hiillieient lo rcaeh and enter 
the cleacending colon. The author ie not aware that Wales ever rocom- 
memled their being made any longer; but Wyotli, of Xew York city, 
has had made for him a set of these instnmients 2ti inches long, includ- 
ing Ihe sizes 6 to 10. Tlifae long iustniments may be useil irith great 

^batiefsction in diseases of the sigmoid Jli-xurc and descending colon, and 
arc a most desinible'additiou to our armamentarium. 

The rectal bougie a houle (Fig. 83) is a very useful inntrumont to 
doirrmine the length or eitent of a ptricture. ;\fter the latter has once 
,li««n eAtahli^bed and the sizo of the opening in it baa l>ecn determined. 



^^P Fia. BS.— EtciTtL Booois \ »aviM. 

Iie«e 1ittt« aconi-abapcd bougies may be paoaed through it, and upon 
kdmwal, owing lo their obtuRi* base, will ealcli and thus more or 
bwcurately xliow the height to which the contracture extends. Tliey 
_ I of hard rubljer or ficxiblo wire, with different sized lips which 
screwed on according to the case in which Uiey arc lo be used. 



ISO THR ASnS. BKCTUM. AND PELVIC COLON 

Tin* atom is very flexible and tan be bt'nt in any directidii- Tliuy arc 
U'ttt used through a rylindrical tt(K-cul(iiii. The lulter in \>u»»v<l up to 
the .ttriclure, the Imiigie a huah i? carrieil Ihroiif^h tl and llii-n llirouj^li 
the stricture. By \\\\i means it is posi^ible to ?«i- act-urately the ojK'ninK 
into Ihe iitri<!ttir<' and Avoid any undm- ninnipulHtion nnd force in the 
introdnetion nf the hulbrnis b<m^ie into it. Andrews, nf (?liie«po, has 
devist^d an iii-sliunieiit of tliiR kind mink- iijMm an inth'xihle stom. nnd 
bent no iis tn conform to what he ftmsidcrcil ihe nnrninl curve of the 
rcdutn, hut this form of instriiiiieiil does not ^-eni eqiial to ihe oilier. 

In some tuses h)eal examinatioi) fails to delL-nniiie tlie niLlure and 
cause off rectal diseuse. The condiLion may Ite aljtne Ihe |Miinl of vAani- 
inalion, or t!ie maiiifeftatums may be so ob^cnre that it is im|wJ88ibl« 
to duluriiiiiit' their enart (iiinifilogy. In ndiplatims, one »hoiild alwnys 
remove a siwfiuien (or niierowopie oxaininfiltoii ht>fim- finally dwiding, 
upon their iriHligiiunt-y. In iithcr obsfiirc icaridilions. a earctul aiinlysis 
of i\w disihnrfjes «nd of the fat?a! contents of the howels U nt'L-i-ssary. 

Examination of rseces.*— Kxiiminntiun of the fiKces iti sMiomplishud 
by four methods: 

Macroscopieal, ilieroscopical, Bacteriological, and l_'ht.>iiiica]. 

FivcrB are the materials diflehnrped from the howelw. made up in 
preater part of the remains of food jtfter llie proL-eu!. of dipeslion. 
Associated with these remains are fluids secreted from tlio digestive 
tract, desquamated epithelial cetls. bacteria in large nuinbers. and occa- 
sionally fortuitous substances, such a» parasites and their ova. hlooil. 
pus, gall-etonee, etc. 

In health from 140 to 200 prammes p(>r day are dist^harpcd by an 
adult. Thouph varying within wide liiiuts, they are usually of a liplit- 
brown color. Certain foods and mud iL^anu^ntw may cause liiem to he- 
come very dark or even black, aa after the ingefltion of htickleWrrieH 
or iron. Agniii. when llic (low of bile is impeded Ihey uiiiy U-ronie 
light yelloiv or jiruy, in certain forms of enteritis, iia in typhoid or 
cholera, they may become pray or prc«n. 

Comiuonly the evneunlioiii; lake pla:eo oneo every twenty-four hours, 
but it ifi not uneommon to find persons in perfect hoaltli whose evnona- 
tioDs occur but once in forty-eight hours, and again others whose hahit 
it is to evacuate twice in Iwenty-four linur'*. In patlioloffical states 
these intervals may vary from ten to fourteen days or more on the one 
extreme, to intervals of a few minutes on the other. 

In ft healthy individiiul thp fiews are of a pasty or di>ngh-like con- 
fistenee, and are molded to the shap^^' ot the tsowel, sunietlmes as long, 
gausagc-shu])ed segments or a series of boluses closely masked together. 

• Ft* this seL'lion lln; auiliur ia indebted to Dr. P. M. Jeftries, clirtwlor of the 
Xbw York Piilynlinic Labiiritli>rf. 



J 




I 



» 



Distarbanpc? of dipt'ittioii fniickly all^r lliis ronHtnteiici' from the 
hard, dry masses of constii)ation and the drj-, claj-like stools of Uvcr 
(luitiirb&nct!8 to Ihp fluid and "watery stools of » simple entfiritiH, or of 
the graver dieturbances, such as ty|)hoid or cholera. 

lu additiou tu tlic observatiune as to color aud conBLsttoce many 
constitucnls may be observed iimcroscopically. Blood or pus in lar^ 
(]nati(itii'B mnv bo roc<»;rni2ed hb such; seedsi of fruitd aud reliables 
appear iiiielianjied, and in the lienteric Btatea all kinds of food pais 
through n-hoUy iinalfeetcd. The writer once had giibmitted to him for 
examination a pint or more of bodies about the size of hirknrj' nuts 
which a patient \ras ^id tu be paj^ing regularly, and which proved on 
examjiialioti to be halves of orangf segment* aans inastiealitin, saoa 
diKestiou. The M-ritor has also sfvn pills and oven compreaaed tablets 
nppcar unatToL-tud in the dejeeta. 

Skins and eceds of fruita and vegetables, as of apples and toma- 
toes, usually are readily recognizable, as aliio are ahrcds of vegetable 
fibera. 

Bntorotitha. which aru gall-stoiiea. inay sometimes be found, and arc 
of n conaidepable degroe of impoi-taute em nn aid tu diagnosis. They 
may readily be overlookfd. as they aru fre(|uently soft and of a ttay-likd 
consit<tt>ucc; but a cliciiiiL^al and iiiicroseopical examination will de- 
termine their character. 

Miieiiti, whieh normally serves to eoat the fmces when properly 
formed, may Bomctimes become greatly increat^ed and constitute a con- 
Bpiruniis part of the stools, fn cases of niucotis colitis the greater pnrt 
of each movement may be made up of uniciis. and frequently it fairly 
forms a mold of the inteatim- and is paased as long strands of a stn]c> 
tnrolesi*. more or less tough, whitisli iiihsm. Osier reports an autopsy 
where such a condition cxi.stod, and says that the intestine was lined 
as with a mpmlimne, and that upon its removal the mucoan appeared 
to be uninjured. 

la ulcerations of the intestine the stooU may occasionally contain 
fragments of intestinal mucosa. 

From their characteristics the stools of various diseates have re< 
coived oamee suggested by their appearance, as, for example, pea soup 
in tjfphoid, riee-walor in cholera, and tarry in yellow fever. 

The ehanicteristic odor of nominl fn>ees in due to the deeomposi- 
tjon of the food rcBidiie and to the secretion of glands about the anus. 
This odor variea in part according to the nature of the food ingested. 
In i*onii' di.'4ea.<4f'd <'ondition!i it l>e(<>mes very prouounecd and di.*agree4i- 
ble, and is largely due to niicro-organisms. Pure cultures of nonie of 
theae micro-organisms imparl an odor which ie readily recognised aa 
contributing to the fa?cal odor. 





THE ANCS, RECTUM. AND PEUVIC COLON 

Parasites and parts of parasites, manv of which lire recognizable 
hy the unaided vyv, are common cotiBTitiicnts of the dejecta. They 
compriRe a not incoasiderable group, «nd, oocording to Ibo literature, 
the lifit contimii>« to grow. 

It is nut witliiii tlifi inovince of thi* article to dpscribe the variouii 
forms occurring in fare**, but t!i«y will ttiniply be enumerate*! in the 
order aa claesified by Von Jaksch: 



1. ProCoKDn 



SporuiEiMi . 
Intmorta . 



ltL-|irL-?i'iiltHl hy ooccidia. 

M(>gUEUimii ■■iilrririmi. 
Trk'honionit; intKtiimlis. 
faramsiciuiucoh. 




■ P]iit(HLn, . . 



CnAcnim,. 



Trcmatutla.. 



2. Vcniien, 



Aitncliiifi, 

orilcr 
Xcmitto^la 



ft. tnscctA. 



Tipnia solium, 
Tn.-iiiiL nu^niinln. 
Tnnijt rifiiin. 
Tiuniu iliiiiiriulii. 
Tn'tiiikciKiiiiK-nriA. 
ButtirioC'cphnUii lulus. 
" [tisl'iniii hcf'iili I'll III. 
DisKiiTiii littu-PDlntiim. 
i^Cflinu KAliioiiJsi. 
iirim stiii'iiM'. 
inin ft'ijni'iini, 

{A»rurb liiml>rk'i>i<]es. 
Am-atis invMax. 
Oxyuria vrriiiLiiilnri?, 
SiroiigyliiliB Aiicliylonlwrnii liinnii'iiiilc. 

Tnd.otr„dvel.d„ | ^^J^I'I^I^h;:^'''"^- 



t>i' 

I' Di«<i 
DisUj 
Di^[<). 



TliB mioroppopical ehai-aetera nf the fa?eP8 are easily determined. 
In proceeding to examine imder the mierusccijie, the luateriiil iti spread 
out in a lliin Iiijer unLlcmcatlt n nivLT-yluss and i-xaiiuufd wilb low 
powers Bs with { and f inch objectives. It may be nwcsaary to dilute 
thrm with water or n .■!-pcr-i-i'tit nalt jioUition before they nro in a 
condition for microscopical oxaniination. The substances dcriv<'d from 
the food are first to be considered. 

1. Vegetable cells unaltered or iu various stages of diaint elation- 
isolated or grouped a* developed, doirie containing cliloropliyll but 
most devoid of it. 

2. Mu-sclc (ibcrs rrcognirable by their structure but appearing ew-ol- 
len and filained ji'llnw. 

3. Fat and nil gtohulea. 

4. Starch granules, liydnited and sometimes unhydratod- They may 
be recogniaed by tlicir blue color wliuu treatfd with a weak iodo-potas- 
sium-ifidide solution. 

5. Fibrous tissue of wliite fibrous and yellow elastic varieties. 



EXAMINATION AND IilAGSOStS 



nii 



ifu8. Granules Urge or email, grouped or iso18tt^(1. \)&\v or 
dark in color. 

7. Alwa>*» associaled with these arc bacteria^ which arc Bhundmit 
and of uiiiiHTwuc variotie*. proiniuont unioiiB whieli ure the Bucillus 
coli coninninc and the iiacilhi* proleus '■■ulgnris. None of iho hucteria 
nonniilly found ore of patho^nic chanictpr, nlthoii^^h they may oxhibit 
patliogenieily til times. 

8. Molds aud yomt fuugi are frequently associated with the bac- 
terial fiora. 

In ))Htlii>lo;;ii-iil eiuivfi Uk* bacteria may inaTuee lo an enoriiiouB 
iimount and the ixcvg nmy einiLaiu patliogouic bacteria, as the ty|jhoid 
bacillud in typhoid fcvcr, the camnm bacitluB in Asiatic cholera. Tuber* 
clc bacilli may be found in cascn of tiibortnifar nk'crationf*. 

The d*.-lt>ctiou ur Uif pathuyeiiic haetoria is not a eimplo procedure, 
and sbuuld be left tu thu ba^'teriologigt. 

9. From the iutcrsliiial Iracl ilM-lf i>{iil1ie1ial colla are constantly 
shed. Thfv may appear normal or in all stixK'^''' of disintegration, ac- 
cording lo the length of time thry have couKtituled a part of the stools. 
Tlii-y lire. a« a rulr, sUined yellow. 

By for the nio^t iiuifoilanl microscopical elements of th« f&cee 
are the animal parasitps. Some of theee are raicroscopiual, and others 
have ova which would eneaia' deteetion without inieroscopica! examina- 
tion. 

Amtvbi coli, which helonga to the rhizopoda, m found in certain 
5y«en(crie shiols, and nniirs uKuiilly in tmpital ur siibtroiHia! reiriniis. 
It can not Ik- distingui^^lied from Llie I'roteiiH aniielm, »u common in 
tho waters of all localities. It in merely a maes of prntoplostn devoid 
of a cill-niembpane, pousess^s a nucleus and one or more vacuoles. 
The jirotoplaum if! graaular. and fretineiitly eoutains clHIh and )|i"anulee 
of detritus which it has devoured. It exhibits the same motility notice- 
able in ita pi-utotype, llie Proleiis aniteba. It may he as small as a leu- 
cctcyle, or 50 large as miarly to (ill a field of a i-inch objective, in cafica 
where it« promrncv is Huspccted the tttoola should be examined perfectly 
frefh and «liould be kept wnnn. In selecting materijil for such exam- 
ination, gather up the panicles of viseoua or jcdly-Wke material. Such 
rtooU may bo kept on hand for future examinations if a little carbonate 
of noda be added and they be kept ai about the body leiiiporalnre. . 

A variety of cryritals may occasionally be seen in the fa-ees. 

Fatty acids are found in the form of minute, short, slightly curved, 

jrless ervstal*. They are soluble in ellier. 

The fatty cryataU have been found in abundance in alcoholic idools 
and the etoots of jaundice, especially in children. Tlicy are abunJiuit 
in the stools o< infante during lactalion. 




i:U THK AXE'S itKrruM, and pelvic colon 

P^fty Boaps, whicli (ipciir in long, colorlivift. npodlc-likc rrjstitls ar- 
ruiigt'd ill riU'llute groiijis, innv be won. They arc not soluble in ether. 

Hu>iimtuklin. crv^tjils, iittuall^ somewhat al^pir&l in ^triicliire, of a 
light -brawn cnlor. ivsi'iiibliiit; S'liiiewhnt an irregular sht-af of wheat, 
limy hn imiuil (rw ur I'lifUisL'ti in ;;lobu1ar iiiaascs of a substance re- 
BcmbliiiK iHuciu. They hiive Wcu observed in cases of chrouic intes- 
liual (ulurrl), m; thi* n'liult of ha'iii'trrha^e, and al»u in coece of iii.'phrili8. 

rharcot-Leydcn t-pyeloU are soint-tiuies found in fa-ccs as in anky- 
lOBtomiasifl. Tliey are coIorU'SS and are octahedral in form, rc^fcmbling 
those in syiiien iind iho sputum of aKthiiiaties. They have been found 
in a variety of conditionB, and by their almost constant appearance in 
conjunction uith tlie various entoxoa, their preienct^ may be considered 
as jioinlirig to an inficlinn hy some form of intestinal parasite. 

Cholfstcriii IK a normal coii»titUf^nt of the ficccs. but its aiipcarancv 
in cryatjiJIine form is vmu&ual. It occur* in the form of irregiilnr rhom- 
bic platc'fl which frcqufulty appear in j:roui>8. Tli^ey are olorle.'iis, thin, 
hij^hly rc'fnictivt', and ar^' solnhlu in other. When treated with <lihite 
sulphuric acid iind tincture of iodine they give a ehnraeteristic rttaelion 
of a violet color followed by blue, preen, and ro<l. No diagnostic im- 
portance ean be attributfd tu ilieBe crystals. 

Phosphate of caLciiim in the stooU app^ar^ either as we(lge-8ha])ed, 
colorless Ijodioft in ^rrmips. witfi converging; apicos. or yellowish, round, 
dunil)-l)ell or uvul boditr^, \\lik-3i iirv usually lissiircd. Their occurrence 
ie rare and of no climeal vnluc. 

4'ideiuMi cixaliite ory^tals. in the pj-ramidnl form common to urine 
sediments, frequently npiR-ar in Ihe fiveo!! in health or disease. They 
are in more abnndnnoe during a vegetable iliet. 

Triple phosphate cryslali* (aiumonio-niugiieMuin-phosphale) are com* 
uiou to (Uiid Mtools. They are usually in llie focm designated as the 
coffin-lid. and arc found only in alkaline stooU. They are readily 
aohible iu acetic acid. 

.<iilpfiide-of-lii(ininth cr)'.atftl8 nrc found in th« etools after the admin- 
istration of some form of bismuth. They rcaombic ha?niin crystal*, 
and nrc dark brnvvn or blaeli rlionihie bodies. 

linr/rriiilniprtil K.nimiiujtioK. — \» previously stated, the bacteriologi- 
cal eiaminjition belongs to the expert bacteriologist. 

The orgMniKins found even In healthy stools are numerous and 
dLverflilicd, and in nmiiy of lite inlluinumtury eouditione no new forms 
have been discovered. In catarrhal and diarrhoMil »lool» the buclcrio- 
logica! flora is cTfen.iivo. 11 would appear Ihnt these conditions ar« 
not nttrilmtnble to nny one nrgaiiii^ifi or gi-oup of orgnnianis. A germ 
to be an etiological factor need not nt autopsy be found to have invaded 
the oonnective tiwjucs; the bacteria may produce tlieir effect solely 



» 



KXAMINAI'IOM ASH DIAGNOSIS 

ihroufjli Uicir fniwoiious products. Aiiuiiiji tliose iiu-ntioncd na having 
hvvu (.-liultiKii'il faitiJt-!« art; »l re|»t(n"oi;i;us, staph jlotocuus, llacilhiti ]>yo- 
cviincni>. Bacillus lactig aerogcnes, Bacillus coli commune, spirillum of 
Finklnr mkI IViop. 

Olhor bjifterin are the typhoitJ Iiacillii* in typlioiti fever, th« cholera 
buciltiis in Asiatic cliok-raj thi- (iiphtherin biieillug in elijihUicnlic eit- 
terilii*. the lutanu» IjiicilliLt. (lit- BaciUiis aeropenes capsulatus. ami lhe 
Uihonlf biirilUis. TIub luat orgaoiism iii«,v W Jiacuvereil bj the follow- 
ing procedure: 

If the stools are f^uid, sntp-ar them in n thin layer on fiXisi elides, 
or if not fluid, they must be diesolved in water to a pasty consirteuM 
nnd then emcukred bs described. A number of slides should thus he 
propnrt^d, a» the ^jreat dihicion cauws tlit* Iwicilli if ureseiil to be widolj 
wattL'n-il. Afti'i" iillf>u-iti;c thi^ snu^ars In dry spuiittiuooui^ly in the 
ali)io»plK>i'«, (hey must ht* paiupd ralbc-r quickly three timw through a 
Riinflrii rtr uiiiiliol fliiiiK- to " fix '* them. Thea immeree them for half 
au hour in Hk- foUnwiug i^olution: 

Zieh t-Wrelsen's Carhol-fuchjiin 

Snturatotl alcoholic solution of fuchsin ]0 c. c; 

Five-por-CLTt carholie-ueid water SO c. C. 

RnnoTC from thiu ttolutiMit, carefully waiih in running waiter, and 
dccolori)!c fur almul two lulnuliit in a 5-pcr-ccnt solution of aulpiiuric 
acid. Wat^h in wattT u^juin and eounleri^tain for three minuter with 
AD alcohoUv soliilion of methylone blue. Wash finally in water, dry 
boiwiM-n folds of blnttinp-paper. and exunitno with a -|>j-inch oil inim<»r- 
aion objeciivo. If tnberfle bacilli are iireseni they will bo eontrasled 
by their hrij.dil-red cnlor. »» all oUier hwilli present will have rcactM 
to the blue dy»*. It must be borne in mind that they are never present 
in prcul uuiiibers. Jind ttidt beforu a HL'^iilivL- decision can be determined 
the invi-yli^tor iiiui^t linvc patiently wiirflifd over several prepunitious. 

The oheniirtti exttinimition of the ta-co« is of little imptirtancc owlnif 
to the pnneily of data thnt may I'*' "hiained tlieixby, or to the failure 
of Mich dftlii to he of any ehniea! vahie. 

Ihliicin is a constant constituent of Ifie fitools. For its deteelion 
the sttwda are to br dissnlved in water and an e<[ua! ipianttty «f linie- 
watrr Hilded. .\fler the mixture lias stood tor several limirs it is iiUennl, 
and to the (illrate an exceets of acetic acid \s added. If mucin ix present 
a lurhidily or elondiness will appear. 

Albumin in tht- xtnalK nviy be dcteoted hy mixing; them with water, 
end after allowing the mixture In »tam\ a short time it is flUerod and 
the fiUnite rendered acid by the addition of a small quantity of acetic 




IM THE ASUS, KECTPM, AND PELVIC COWS 

acid. Tliis ifi then put in a teet-tubc and heated nearly to the boiling 
[luitit. If albuiuJu is ])rL<)M-tit it (.■loudiiit-S'i wiU a])p<-flr. It is revoiil' 
mi-ut]L-(l llial the te8l-lu!«> bt iivmlv fillud aud tin- ii|)i>i.t purtioii only 
be heated, hd llmt llie Imvtr miheilted stmU liiuy be used t»T et]iii(mriHun, 

F((i- the detection uf pcpUme in the stouls Voti ifuksih reemnmeuds 
the foihjwiug pi-oiedure: Thf stools arc rendered pnsty by the addi- 
tion of wfltop, boiled and flUi?rcd while still hot. Tho filtnitc is to be 
treat^'d with aeetule o( lead tn [trwipitrtte its miieiu; it ia iheu filtered 
again, and tin- fiili-ate, whieh Hhuuld he not less lh«ii MO cubic cenii- 
nieU'ra in volume, is aeidiilaled with hydrochloric aeid. To this add 
[ihosphnlun^stie arid until a precijiitattt censeR to form. Thp fluid 
16 tlien inirnediiitely )ilt«rcd. The precipitate is washed on the filter 
with five parU of con rent rated uiilphurie acid in one hundred parts of 
water until the fluid whieli pattf-cH tbroujih is colorles?, to get rid of tlw 
salts. The precipilati' is then vufthcd from the filter with as little 
water as poKsibk*. Plaee in a ivaleh-gUiss, aild barium carbonate until 
the nii-tlure is alkaline, and then place on a water-hntli at the boiling 
point aud heat for iihont fifteen minutes and apply the biuret test as 
[oilows: Treat with nnifitic potash aiid add, drop hy drop, a 10-per- 
cent solution of riulphfttc of to]h|ier. Peptone is shown by the formatinn 
of a color roiijrinff from bluish-red to violot, and varying in inlensity 
aeeoniing to the (piantily present. 

UrcR is cine of (he normal constituent); in the alooU, and when it 
m de»:ired to &»eertain tho total qiiaiitily of nitrogenous substanee!) 
eliminated in ciue^lious uf metabulii^ni. it becomes neee^^sai-i,- to estimate 
the urea in llie stools. The method of Vnn Juksch is iiere recom- 
inendL-d. JJefore dryiiijr Ihc stools treat them with dilute acid to pre- 
vent the cvaponitiwu of ammonia. Dissolve the drifd stools in throe 
i>r four rimes their volume of alcohol, allow this to stand twenty-four 
hours and liller. Tlie prpcipilnte is washed on the filter ro]»eate(Uy witli 
aleohot, Ihe (iltrates are mixed, and the alcohol distilled off. The resi- 
due is treated with nitric acid, and the resulting cry&talliiie pulp allowed 
lo stand for some hours, when the crvstaltine masses which have formed 
are iiressed between fold* of blottine- paper, dieaolved in water, and 
treated with earbonaU: of bajyta until carbonic acid ceaees to form, 
and then dried on a waler-bath. Tho dr*- residue is then extracted 
with lioiiinp alcohol. On eva|K)rati«n the urea remains in long, slender, 
priKnifltic crystals. The usual tests for urea mny be applied lo ttiese 
crj'stnls. 

Of Iheearbohvdrales in the stools, starch and sugar are the two which 
will be considered. 

Slarch. as already slated, mny he recognized Tiiicrofieopical!y. To 
tost for cither starch or exrgar the fiecea should be boiled with the watw 



■ 



EXAMINATIOX AND UUGSOSIS 137 

ami tlie conwntraltdd filtralu twlwl. Kur starcli, u.w (he iodo-polassio- 
iotlide solution, whfii ils prL-st-uce will be iiiiini((.'t>tc>[l by a blue color. 
For Buj^iir, use FehlinK's or Uie pht-nyMijdrazm list. 

Varigiis uliurr subatiuitvr' wlijch amy \k fuuml iiormiitly or patho- 
logically in ihe fa^cw; are hanlly of sulficient iiuportauw lo wurranl 
mention in this work; and, besides, their detection and e&timation re- 
quire >^icillcil iii.-iiiipiiblioii jirnl (•liilmralL' liilioralorv Vjifililitw. 

Ansesthesia in Rectal Siuaset. — TIi4> putiontV Kc-nsHliun ia an imjior- 
tant aid in the diagnosis uf rectal cliKcsiM^!!; for tliis reanun, b(*oaii^ of 
llie ii-]ju>niiiiifL- uf piitiiMits, iinil un Mcinunt nf rfrnmle hut (xissihle *lan- 
g«ns, geiiiTiil uiuiiMthi'i-itt should \k nvoiili-d whencvir possihlc, In moct 
c&tiiH c.xuminaLiun cau be raadu by tbe linger, the ^ptTuliim, the hnugit;, 
or Ibe *i(,'itnij(iiwopo with v«Ty little pain, and in view of the dangers 
atli>iiding the use of thuse instruments under gem^rul aua>ijtlK'sia it U 
bettor to suffer slightly than la incur risks. Furlhernion.'. primary 
anipsthr^ia i^ oi titlle iimi! in these exanitniitious. fur ttti:' tiiiiii^ In alinost, 
if not quite, the last orxuu to Iusl- its sensiiiveiifss and rclK'sea; Lliere- 
fore nothing short of complete narcosia is aatisfactory. Sir William 
McKwon {Brit'sb >[edieal Journal. 11'04, vol. xi, p. 'i3'i) bu« tiilled 
attention to the dan^Touji di^iturbaneci^ of respiration durinj^ wpi^ra- 
tions on Ihe anus and nt-luTn caused by reflex action on the pncumo* 
yawtrie nerve, and sjiys it is not Mnfe t(t hfpin wuch o[Hiration.« until pro- 
found iiim>«lhei>ia has l«'pn attained. He .lu^gesls lh»t this dangi-r may 
be ovoided by local anaesthesia or liypuderniic injections of morphine 
before ctherinalion, but in exuminutiuus uloiie, if local anicsthc^ia of 
the tnus can hi- pnnlurt-d. thai h ail that is necoesury. 

In tlip fxaniiniition of hypeneeliietic patients general nna'isthesia ig 
occasionally dfinanded. In sueh ciimts it is advixnblo, if (xjssihie, to 
pteparo the patient for any minor operation that may be netwsi^ary and 
do it at the same lime. In oH^ce practice these operations arc limited 
to slreteliinir the Kphineter, ineiniiii; llpsun's or t^niall fi!*tiilii«. removing 
aniall isolated ha-uiorrhouN, cauterizing uh'vrs and ligating polypi, In 
floch casee the inhalation of ethyl chloride or nitrous oxide gas jinxluces J 

conipleli' ann-Htht'^ia, and the [lalii'nts can wifely n'alk uut in half an 
Iwur afterward. The former rcnjiiires no eomplieated apparattig for 
Ita adtninistration, and is praetieally frw from danger. In njxrating 
irilh either, n smRll dntw of morphine nhonld be given hypoder mi rally 
about ten uiiiuiii'S befoiv the anie.ithetic, to quiet mental excitement 
and to foreatull tlie acute pain attendant upon the rapid return of eoa- 
HciousncAii. With thi-iK> dni^s the furgeon !>houtd not begin oi»eratiDg 
until narcrxsis is complete; undue haste may excite the patient and 
allow a return to consciouBnesfi before anything i« areoniplisheil. 

In operations consuming more than fifteen minute« ether or ehloro- 




I 



I 



THE ANDS. RECTUM, AND PELVIC COLON 

form should Iw (•mpiuyort; tlilorofitmi rauapR losg naiiscfl, but cth<?r is 
«af(fr. and tin? iihur'H is larjiolj- ])N>vi>ntf(i by the prt'liiiiiimrv admini!)- 
Iraliun of etliyl cliloride or gHS. With these dnip* the ltlO^[^llin^-■ may 
be witbhrlil until the (•oinE)k'tion of the operation. Wht-w usiny tliloro- 
ioTin \l\v niiiwk should wlways be removed during the nlMcliiiij: of llif 
^phinaor, a» this iiroirduri' rxcites deep reapiration and invitee ilaiif^t-r 
from too rnpid inhalation of the drug. 

Hpinnl anu>t;tliL-i:iu is usfful in rectal nperntiting. but further experi- 
ence in nweasarv to viitabliiih its pxaet status in surgery. 

Locai AniP/ftliesin. — In ulcers, fissures, and grjinnlating wounds of 
the anus the pain of rxaminalion nnd treHtnient niflj be ainyliorati'd 
by the insufflation of ortlioftirm or aniesthesin upon the parte, or by tbe 
■pplicution of a rtronj; Htlntitm (1(1 per rent) of cocaine. Noue of 
tlicM' rcnit'dicsj has any marked etft'et upon the unbroken skin or muco- 
eutanenuti incrnbrtuw. The iiiucoui? iiLetiilirane mar If amci*thetizcd by 
coeaim- or t'UL'uinp, a[>plied on little pk'd<;L'ls of colton 1o whirh tlireuiU 
are lied in order that Ihe KurpluH naay be removed after live minutes' 
coiitact. The other loeal anawtlietiot have provwi practically useless in 
rectal fiurgcry. 

All minor ojKTalitins upon the rectum can bo done with romparn- 
tivcly little paiu hy the hypodermic injection of weak solutions of ooc*ine 
or eueaine into the pnrt*i, or even by inliltratiou with cold wnter a* 
advocated by Gant. Stretching the aphincter, an iitiporlJint part of 
these operations, id quite painful with such aii.Tsthe(iin ; Oanl there- 
fore advifies cutting this mu-scle, which departure from recnjrnizcd surgi- 
cal practice wc do not endorst-. In the infillrution method there ifi danjipr 
of infection from piim'tures tliroiijih tissues which it is iniposi^ible to 
sterilize, and from slouching after o]>criition. These imHliods of atiso- 
thc!<ia are chieflv useful in oHlec proelice, nnd Ihe evfent of their em- 
ployment deiJciuU u]Hin how iimch ojn'ratinjj one slioiild do and allow 
the pitient to go out itiiniediately thereafter. To those who beUev« 
that it is safe to tie olT Imrmorrlioids. to incise fissures, and to operate 
on fi!*tulas. and let the patient walk nbi'ul at once, such method* present 
a liirge field o£ usefulnesif. Such practices, however, appear to iQWtc 
unneaifsary dan)»cr, to ipnore the advantai^e^ of rest in a recumbent 
po(;ition after all operations on the reetiini, and to minimize lioth th*; 
operation and it>J moral elfeets. Moreover, one can do more thorough 
work uuUaiiipured by the ri'stlessDeas of conttcious, aasiouo patients. 




cuAPTKU rv 

CATABItUAL DIHEASKS OP THE RKCTVM AND SIOXOID: 
PROCTITIS; A\n SWMOJiilTIS 



» 



The Mruoture of the mucotiR mnmhranc and the functions of the 
rectum und »if;ruutil rrnilcr tticsc nrgans ppculiarly susceptible to catiir- 
rhul iiirt'clionit. Not only are Ihey oliidriiHl witli invriaJs of Licbcrkiilin 
fyilifU's, furming, as it were, little crypts for the lodgment of infectious 
mflterials, but it ie at these point* that the excrementitious matters of 
the aliinenlapj t-aiml in their most cnnoontratetl form lodge for varying 
periods befuTM Ueiiig paKwcd out nf llie hofly. 

The mucous membraiip hi-re absorbs from the fa-eii] mass a large 
proportion of its tluiils, in which are many bacteria ami infeclioug 
Kcniis, HiTif the fircul mass becomes hardened tbrongb this absorption 
of it« miiifllure, and by frielion and pressure excoriates, sometimes nctu- 
•lly wounde the mucous nicmbrune. and thus produces lesions that 
become infected and result in catarrhal proctitis. 

The inlinmte fcmnection and similarity of slructuri' bi-twcen the 
mucous ineinhraut- uf the ri'ctuiii, sigmoid, and colon rt>tid('r it ii!i[»«isible 
to iliiicuiu the diseusr in one part without talcing into crausideratiun tlie 
othuni. Morcovirr, inasmuch as the diicf symptoms of i-aUirihal inllam- 
rfiution of the piginoid and colon arc often n-fcneil to the rectum or 
■iotfd with some symptoms in Ibis organ, it Iift« become the provillCf 
of the rectal sjiecialist to look into and treat these diseases whether 
Ihcy are confini^d to the reetal ampulla or L'Xti-md to the caput coli 
it«elf. Since the invention of the inodtrn iiiglruments for examining 
the sigmoid flexure, the din^cl ohwrvatiim and iipplit-ation of n-medies 
to tliese pBi-ts has simplified their treatniem and iu many reaped* 
allen-d our vieirs entirely with regard to their pathology. It is impossi- 
ble in any vast- «f catarrhal disi-ajic lo draw a diviUing line where the 
condition begins und where it ends. In the majority of cases, instead 
of Ihe intlammfttton being confined to the rectum, it extends throughout 
the sigmoid flexure and upward into tho descending colon. There are 
instancex in which the disease is confinf<1 to llio reetnra: but it \% very 
rare that there is a aitarrlial colitis or sigmoiditis in which the rectum 

180 





no 



THE ANUS. RECTUM, AND PELVIC COLON 



in not more or leas uivoIvlhI. In coiwiJeriiig. therefore, the catarrhal 
(HsL-asea of the rectum, one can not confine himself to Ihi* orgnn alouf, 
liiit must cxIcihI his ubsiTviilions KiKhcT up in tta- iiitoMiiiiil cati^il. 

In thr iiPiilr fi>nii of protrtitis one iimy K'-iurulty rt'cof^iiiif u (U'liiiiie 
period of beginning', and come to some conchision with rciCurU to its 
oriftin; but the chronic fonnn are so insidious in their a|>j)roiU'h and 
mt devoid uT puinitive sviiiptoini^ in Uii^tr eurl^' !)tu;;L'i> that one can rare- 
ly tell how long they have exialed, their cause, or their probabk' dura- 
tion. 

('Atarrlial inflammation of the lower end of the intetftinnl tract may 
be divided into two brnad clnsses, Simple and Specific. 

Simple catarrhs lonj/^itit in acute cfltarrhal inHammation, atrophic 
catarrhal inflammation, hypertrophic cntarrhal inflammation. 

TJie Fpecific forms are gunorrlueal catarrhal inflammation, diplilho- 
ritio catarrlial inflammation, erysipelatous catarrhal intlanimation, 
dytienterie catarrhal infla.mmalion, i>y|)hilitic catarrhal iuflammatiou. 



SIMPLE CATARRHAL INFLAMMATION 

InHummations of the mucMiut! nirinbninc which are not due to 
any spccitic ;;erm yc-t rcco(.'nizod are anionp the most frequent dis- 
a&seB of tho human race. Kspecially ie this true in largo cities, and in 
those elimalcs ivhere the individuals are subject to frequent atul exceaa- 
ivp cliangc>i in fciitpHratin-e. overheated hiiiises, poor veiililation. in- 
dulgeiice in stimulating and highly sea-ionwl fofwis, und the laclc of 
ph^l-sicnl outdoor exercise. 

7V(T(/i'-*/jr(si7jnn. — Individuals differ in Iheir swsrefitibility to these 
inlliiniiiiatory proresses. Some patients live for years in certain cli- 
mates, resist the sudden changes and exposure that pertain to their 
environments, indulge in atmoet all eorte of excesses with regard to 
diet, and never gulTer from any catarrhal disorders; while others develop 
them on the slightest exposure or indisieretion. Sudden ehnnge of 
lemperatiirc, alleration in diet, indulgence in Minip sliiiuilating food or 
drink, or even change of water, will be followed in these individuals 
by catarrhal inflammation of the colon and the recium. Tliis pre- 
disposition is nndouhledly hprediUiry, for it can be traced from genera- 
tion to generation in fanulies. 

It ia impossible to state at what point the disease most frcfinently 
begins. It may develop at either end of the Inrge inlnBline. and pro- 
gress steadily toward the other as long as its treatment is nopleeted. 
In adults the 8ymptom« and history of the case may give gome indica- 
tion of its origin, hut in children this i* always too imreliahle to justify 
conclusions upon this point. ^Vc iuu8t therefore depend largely upon 



I 





ATHO'HIC CATAOnKAL 
PROCTdIg 



HVPeOTIIOI'HIC 

Catarrhal pRocrrTis 





rOLUOULAI MIMTITW 



vixeiunvK pfiflOTrTw 



INFLAMMATORY CONDITIONS 
OF THE RECTUM AS SEEN THROUGH THE PROCTOSCOPE 



CATAUKHAL DISEASES OF TIIK RECTUM AND SIGMOID 141 




IocaI cxnminatinn. Happily v-o can f'X&.m'mo a cluld's rcc-lum ]u^ oa 
rell ae an adiilt'i!, and nlionevor persistent constipation, dian-tiuja, or 
ritv in iIr' fa'L'ul iiiuveriu-nl!: u( an inrunl are ilis^-uvurod, a 
exAuiiiiaticni mliould \iv iiiadc- at otu-i-. Within tliu laitt year the 
author h&i introduced the *inaU proctoscope uito the w^moid flexurea 
I of four (rhildri-ti irmlrr llii- iij^t' n{ Iwo yviir.s (iniu liriti^ ]i.:ss thuii nine 
nioutUa old) witiKiul tin; *!i>jiHL>t Jilliculty. In tiirui- of tln;ni a marked 
I catarrhal intldniniation of the lower end of tin.' colon was found, which 
^K^i4>ld(>tl rr'iidily to loenl npplicslionti, and the pntionlu woro ra[>idly 
^Vciirod. The influence of agt>, st-x, and tieL-iipation vary in tlie diiryrciit 
I lypes of tlio (iiseaae, aa well as the Bymptuuw, and tliorefoi-c it is advtsa- 
^Hble to (li-'ciir-s Ofii'h vurii'ly M'punilcly. 

^V Acute Catarrhal Frootitis.- -Likt- cutarrlial infliiiiuimlion iu 6ther 
f mucotia tracts, thiii coinCK on suddenly, and itiay be frcriucntly traced 
i to a clearly defined oxcitinR cause. It may hv ushered in with a elight 
' chill, aching puina over llie body, ©epooially in the sacrum utid around 
I the pelvis, and slight elevation of tempcratHn'. Oeuomlly, however, 
I the patient does not observe tliese syrnptonis, but describes the diiieaae 
^^is dating from the firdl seuKatinuK in the rectum. 

^H h'ytnji/nmx, — The earlier aynijitoms are fulness followed by a sense 

^^of wvigiit. Iieat, and buniin;; in the ret-tuni. If llie (liwufie is lijgh up 

I there will be more disromfort than real pain, but tcnci!nnis, Waring 

dflTm, and desire to go to eto<il will be marked. Pains that ra<Uate 

to the back, legs, and pelvic organ«, rlifTurulty I n and a FregmMit dewjrc 

to niielurate. are notieed; tho bodily tempiTtiture iimy he elevated, the 

pulse i]uiekeniHl, th« tongue furred or coated while, and there may 

be headarlip or general nialnise. The patient ia always more coiriforto- 

I^^Jble lying down than in tin- creel posture. 

^B Some de^ribe a sensation as if a foreign body was in the rectum 
i^^caufling the sphincters tn cimtniet. and when the bowels move, the 
fff^al matter, which is generally fluid, is ejected through the niirrowed 
orifice in a Bmnll forcible Rtream. 

If the diopiiiie be severe, leue orrho'ft or cystitis may be prmlueed io 
coPnequence of the inliniaie nervous, vageular a nd lyniphatie counec- 
tions; but where these oeeiu'. one ttlmuld iihvay-' Btispr'el and pusilively 
eliminnle t he ;:(morrhn ' al elenu'nt an an etjolo'^iciil faetnr before he 
^concludes that he has to deal with a siiiiph- eatarrhul proctitis. During 
!)« first twentyfour hours of acute calnrrlial proctitis there will be dis- 
cd from the rectum a thin, fluid fa'cal matter; later on tliis fluid 
be tinged with blo'id -'md ennlnin iiiueus; if the inlUnmialitm per- 
tistti and is fterere, nleeration will take plnre; indeed, the whole mucous 
inciubrane of the reetuni mav ijlough ofT and be discharged. After tliia 
la diBcbuges ironi the rectum will be muco-pitnileDt or sanguinu^puru- 





143 THE AKUS, RBCTUM, AND PELVIC COLON 

lent, the fiecat materials beiiig mixcA with blood and pus in larg« 

(|llHlltitlL>tJ. 

KruriJ llio bi'yiniiiiig tlu' ilcsire to go to stool is frw|uciit ami inijiLTa- 
tive, Aii(] rcquire» lltt! [latiunt to remain i'.\a»e Ut tlie coiniiiuilt-. Tim 
act dops not relu'vc tlie desin', niitl tlir jiatipnt ccmslantly litrains to 
nil liimself uf what Bi-ems to be a foreign body in the rfclum, but 
which is nothin^r more than the inflamed, swollen, and tcilematoua 
mucous membrane. The sensation ia coiiipai-able to that of grimula- 
tion of thp conjiinclivn, whore theru ia coiuilant desire on the part of 
the jmtjent to >;ct rid of ^nmrtbing in the eye. In cihililnni tlic> inucous 
nienilirano frofjuontly pnjlaiiscs. pioifneing tlie condition (le!>criht>cl by 
Holder as " eelmpum recti." 

The introducliun of the linger or speculum is very painful, and 
may cvt'tt rfquirL- aiia-etbc^ia. To the touch the parts fee! dry, hot, 
and ttwuUun in thi.- (irat ctagi^»; after evcix-tion liais be>;iin they appear 
moist and pUniv, the walU of the rectum sirem close tojfether, (uid the 
caliljcr dijniiiishcd. 

Through \he spoealum the inonibrane apptars of a bripht-red eolor 
(PJatf I. Fig. 2), dry, and cedematons in the beginning; later on tho 
color is durkcr and ttif liiirfacv L-overud with iiiucus; occasionally thia 
usuim-s tlie apjuiartuitt.' of u pMi-udu-raoiiibraiie, 

Till' inlkiiiniatioM in acute catarrhal proctitis is gfni'rnlly conlined 
to the niucouH nicndn'rtu f and the Hubmutosa. litirt'ly the deeper (is- 
fiuts may be involved, and oven the mnecular wall itself may he per- 
forated, resulting, as Kelsey has pointed out, in aente peritonitis and 
death. Under ordinary eirciiniwtances lhc> inllaniTriation snb^ides under 
rvsl and propvr irL'atsiieiit. Ihu nyniplunis grow less marki'd. and the 
patient recovers in a few days; at otiier times the disease pas»e:« into 
the fliritnie fi»nn. Wlini nolhiiitj itiori- lliaii the iiiueou!< nicinbrane 
ifi involved^ this cmlt^ Ihe nnit^' i'liciinrnenii: hut when deep iileeration^ 
occurs, perirect/d abs(rc>^. li.-luln. ••r rlricture mm' ret^iill. 

MtioloiUf. — I'inwoniis, liiuibrieoids. impacted fa'ees, and foreign 
bodies may all set up a eatarrbal inftaiiimalion of the ri>eluni. Iin.- 
proper liitft, sneh as sauces, hiphly scnsoned foods, hot tanialnii, green 
pcpjitTS. tde,, are frequent eauwes of the aeute variety, Chnmic con- 
atipaliou is not very frequently the eaiise of acute proctitis; this con- 
dition is slow ia developiueut. ami the mucous membrane becomes 
accustomed lo a eondilton whicdi approiiehes by such gradual and insidi- 
ous steps. Fermentation or putrefaction in the intMinc, which some- 
times follows n change of diet, wati'r. and enrironmciil-i. may induce a 
sudden and acute catarrhal inflanunntion of the eolon all ;dong its 
course. This occurs mure frequently in summer and in hot climates 
than under other cimdUions. 



i 





I 



* 
* 



Teaches i\w si;;iiiui(I )U'\«iv mid iti Uiiii, iIil- iiioistiin* w lurjjelv absorbiil, 
aiiii tli« ]mnl, iiiMiliiblc HubatuiiLfS iin: liktiy lo stick oiil bcyuiid it and 
thus irriUtc vr wound Ihc mucous iin'riibraac*. Thie rcudL-rs the lower 
portion of Ihc bowel very liable lo infcctiou fi-om the bacteria always 
present. 

Rlioiuiiatisin and gout are cloaHy related to catarrlial mflamiiiation 
©( the intestiiiL'B ^Curling), but uwt as eUoIogieul factors. The same 
condilioiis whicli cause ihem, viz., fomieutation and putrefai-tiou in 
tlic iiittstiiial (■iiiml, arc fniiufully the (.'iium.' tit proctitis and ctditis, 

l'n)la|.'M.' im*\ iiitusmitjci^pliuii iiiav be the caiii^ of catarrlial jnllaiii- 
mation. This w brought abiout by the friction of the membrane upon 
iteolf, the irritation from the passage of fn^cal masses through a nar- 
rowed cbamifl, and a eireumocribed interference with the circulation 
of tin? porta. In prolapsL-, whori? the gut protrudes nnd recMles from 
time to time, it is irritated by thi« proceiw and by rubbing Hgiiinst the 
'clothing; its (.irculatiiui is interfered with by cnii I ract ioji of the 
sphincter, iind it is ib-Kicented by i-xposure to tbe atmoiiphere; as a 
rcsnlt catarrhal inflammation frmjunitly oceurB, Tuinora of the rec- 
!tum, uterus, and ovaries, dit^plncementi' of the uterus, t^tone in the 
bladder, and whatever causes undue niut unnatural preetiure u]h>ii the 
ret-tuni, will eautte a lofjilizod congestion at that point, and set up an 
1 inflanunation which may spread in all dirLH-tiuns, It may jdso bc^ i-iuiM^d 
by iiiflatniualimis of the utwnis and jta ap pi-tiii>i^r<"i tin- pmafiiln «ml 
ffeniinal reaielefl . 

Sitting »[ion cold utones or wet scats is vcr>* frequently the exciting 
Cfiiiec of acute calarriial proctitis. Coachmen are said to be particularly 
liable to Ihc disease on this accouut. The author has seen a number of 
Cflsea in young people who, after ojceiting exercise, such as tennis, base- 
ball, or cricket, have luit down upon the damp ground, tlius causing a 
Riitlden chill to the partis, which rei^ultecl in attacks of acute catarrh of 
the rectum and fdgmoid. 

.Vciite congpiilinn of the liver Bonietime-8 terminates in ratnrrbal 
inflammation of the rectum. <lne to obetruclion of the portal cir- 
culation, and alfto to the irritating influences of excessive discharge* 
of bile which follow such attacks. Mild attacks of this disease may 
alao be ,)H<Iuced by the action of irritating eatliartics, such as jalap, 
sluea, g»mbngi>, rhubarb, piKtopliyllin, and suniia. 

I-'inally, attention mitft be direeted to iwrsonnl idiiisvnerasiea witH 

rrgnrd tn the development nf this fllTasc. In the author's cxpcricucc 

an acute catarrhal conditimi of llu* lnwer end of the intestiital tract 

iroald be produeed in one individual by a single cup of colTec; another 

patient could nc\'er eat strawberries without having afterward an acute 
10 




144 THE ANUS, BEtTUM, AXD PUMHC COLON 

rectal catnrrli, aJmost dysenteric in its nature; another miffei-ed from 
thia coDditinn if he dmnk a magle glass of ordinary apple cider. ThesM 
idios^'ncru^ice might he uiultiplied. but tliey are not pertinent to the 
subject; each iDilividual forms a problem in Iiiai^olf, and no generaliza- 
tion can be drawn from them. 

Trfatmnit. — The treatment of this form of disease like all others 
domiinds llie removal of the cause if piwsible. When it is due to 
irritAting, infectious, or putrefying substances in the intestinal canal. 
tht'> should be evacuated at once either by ^line cathartics or intestinal 
lava;;!': if iIiitl- Ll- furui^ju bodies or impocted fuL-cs in tlu- rectiuii, these 
ehouh) be removed; but {jreat care siiouUi be excrcii^ed in their i-emoval 
to nToid nil traumatism and injury to the ptirte, The dilatation of the 
Bphinetera girt-s great relief to the patient when tlu' eatarrlial intlain- 
mation is low down about the anargin of the anus. 

Sttlini* laxfltiven. fiu»4i as aulpliate of mugnesia, sulphate of aocla, 
cream of tartur and suljdmr; or snmy of the iniaeral waters, gueb m 
Itubirmt, Hunyuili .Iilnos, or Apcnta arc exceedingly useful. One should 
mit lii-jiiiiitf jii lln' UM' iif Mi''^f [jiriHciTicH to irive a sunicient tnuiiilJl;: 
tfl product- H llii.n.iiijli \Mi>liiii;- MLii ..f llii' pa rt-'^ by l.lie walviv lln^v^'- 
ments which thev t "'fti)'i'--'> Small doses do more harm than good, and 
even in paticiit!; ulio iiru very iveuk uinl debilitated im bad reeult fol- 
lowij full-sized dowca of tln-w reuipdit'S. 

After the bowels havH been thoroughly cleaned out, antiphlogistic 
remedies should bi> applied; irrigiilion wilh cold vriiivr is very gmteful 
to moMt [latit-nts. to others very hot wuler sowlhes thi' parts more 
elfcehialiy, and in a nundier of ra»e(t alternaling cnirrenlM of hot and 
cold water may be used with rery gratifying results. The liard- 
rutber rectal irrigator (Fig. 83) of the author and a fountain syringe 
. . will be found very satififaelory 

— -' ^^^^ fur this purpose. It is made 

' _ • .. -. —J in various nizeo so that it can 

*^ ' " - ^^ be used vith compnralive com- 

fort in cjiaes with both con- 
Iraetcd and relaxed sphiuetere. 

Fio. 88.— TiiTTt.r'9 Kktt*!, i«iw**Toa. It coDsifits in A hard-rubl>er 

eyiinder, tlirougli the center of 
which runs a small tube eonneeting with three upuriLngx in tlie distal 
end. Tliis tube carries the fluid into the rectum. The large cylinder ]\a« 
mimerons openings upon the sitk's large enough to admit of the passage 
of small fjecal parlicleH, and ii i» eotuieeted at the outer end witti a dis- 
charge pipe, to wliieh IS attached u rubber lube ion^ enuugb to reach a 
basin on the floor when the patient lies upon the bed. The instrument 
can be taken apart and thorouglily sterilized. It is used with 



1 



1 



I 




CATARRHAL DISEASES OF THK BECTUM AND SIOMOID 145 






the patient lying upon the si<le, and iiny qimntity of fluid can be 
,U8 passed through the rectum without wetting the bedclothea or 
necuKKitaling a movi^iiu'iit of thiv bowols. When the hot and cold water 
nro altcmiilfd n Y-liibi? is uwcd td ronnwt th« irrigntop with two 
Byringen {.'ontaining the water. Bj this mpHng therapeutic agents may 
be applied to the parts; Bolntions of r«rboIic acid .5 to 1 p^r cent, of 
boric acid 5 per cent, of thymol 3 per cent, n itrate of siker 1 to g.OftD. 
of hydrastie I to 2 per cent, of the aqiieoug Tluid fxtraf | i?f "Icraqipiia jf 
to 'iO per Cent. After the irrigation lias been continued ten to fifteeo 
minutes, the fluid should all be drained out of the rectiun through 
the irrigator, and a suppository of opium and iodoform introduced. 
The parlit-ular siiluiinii iitifd for irrigation will depend iijion the indica- 
tions in ejudi indivirlual ciise, Kramcria and nitrate of silver arejthe 

most gent Tj^iJIy .•nii]ilf>vPfl. 

Sonictimea Ihe ijartt* altout the anus are ho tender that tlie intro- 
duction of (he irrigator emi iiuL ht buruu. lu »uch inntuncea two small 
rubber c-atliettTB cau be uat-d, one for the inflow and one for the exit 
of the irrigating fluid. The ubo of cDcmata ia not advised bccauM 
they only increase the ton4?«3tius and the desire to go to stool. Sorae- 
tiniea after the irrigation, thy iiitroduetiou of a small amount of flax- 
seed Iffl. abuut 1 uuueo, ivitli ^ lo 1 grain of opium and 'iO niininis of 
tin.* a({U(>ouH lluid extract nf kranieriu will pro%'e very snolhing to the 
partii, and be virectual to ijuiet lencsraus. Regulated, unirritaliug diet 
ahoiild be rnjninrd. Mowt writers insist uptm the u»v of luilk, but thi& 
artielv is eo prone to produce hard, tough seybaW whlcli eon&lipate the 
individual and irritate the inflamed surfaces by their piisAage over them, 
that thin gruels, beef, mutton, and chicken bivlhs, or some of the pro- 
pared fiiods, such ad Melleirs, C'arnriek's, or beef poptonoids, arc to be 
preferred. 

After the acute inflammatory stjige is piuwed, when sujipuration and 
Icerafion occur, the irrigation with antiseptic sidutions should he con- 
tinmil, and if the disease Is low down, the rectum may be sprayed with 
some astringent sohition, such a» nitrate of silver or arg>Tol: powders, 
eueh as bismuth, aristol, or antinoitino, may lie insutllated through a 
tubular speculum directly upon the ulcer if it be isolated, or all oTer 
the rectal wall if there ie geneml uUeration, hy placing the paiieiit in 
the knei-ehest posture and obtaining atmospheric dilatation. Sulphate 
of cupper, and aUo nulpho-carbohite of zinc, in mild solutions, have 
acted vrri'-well b« spmvB in this condition. 

Tlie Wwele should he induced to moTc at regular intervale, and the 
rectum should be irrigated after each movement. The patient diould 
be kept in bed until the put) and blood have entirely ceased to be dis- 
cbarged. The dietary regimen, however, should be ke[ t up for some littl« 




146 THE AKUS, HECTUM. AND PKLVIC COLON 

tim« after the piiticnt has got tip. If the (iiMtaso in hijfh up in the 
eigmoicl flexure or colon, lavage through the long rectnl lioiigic should 
be eai'i'ietl out with ihi? patient in the knee-ehest posture, and large 
i|iiHnti(ie8 of the solution should he Introiluced: as mueh a« 3 gallons 
of boric-atid soUition ora 1-to-lO.OOO hii'hloridi- of mercury may be thiia 
iutri>r|iic-c<l. Thf M>tiiti(ins rupidly come away, and there is no dan><er 
Irwiti the oiuimut of llii; i]ru>c whii;li will be absorbed. 

Mcdiiinc« by the mauth are not peneniUy clTective. Antifennent«, 
8Ueh a^ hettt-naplithol. salol, suljnitvate of bisiiiulh, and creosote, may 
8ometinit-8 be L'iTeetnal in tlie prevention of further formenlation in 
the intestinal eanal. The enteric pilU, composed of sulpho-carbolale 
of zinc jind covered willi ii toaling which is not soluble in tlie acid secre- 
tions tjf Mie sloiiiach, are uceaaionully elTettiml. These ciiBCa are mor e 
bi-ni-lited hy the uee of a pill that eunlnjns sulphate of copper j giaJti. 
and extract of opium \ grain than by any other dnig -i; these are given 
every two hours, and tlio reisiiU is Botnctiniea tiiagieal in the relief of the 
tenesmiia and Iho tendency to diarrliiea. Castor-oil, as a laxative, has 
not proved a« efTi'eliial in prodiiciny a nioveiueiil that \b watery and 
cleansing as have th& wiline preparaliuns, and, moreover, it leaves a tend- 
ency to coustipulion in the patient which is not aalixfactory; ncvcrthe- 
Ie»M, iiittny authors [irtfiT thin to nil other laxative nicdirines in such 
fonditioiis. III miuutc dosijs (.j miuiins), rc|n-ated every two liouru, it is 
sonictiniea vory soothing to the bowel and checks the tendency to dittN 
rhfea. Fluid extract of liaiiiamcliK and Hijuor of hititmith, of eaih from 
1 to 2 draidiniH, is spoken of vury highly- To the out-uf-town piiieti- 
tionera, who have not large phannaciuK to order from, the flaxseed lea, 
witch-hazel, and a»lringcnt waihes will generally prove quite satis- 
factory. 

CHRONIC PROCTITIS AND SIGMOIDITIS 

There nre two types of chronic catarrhal inflnninintion of the rec- 
tum and sigmoid, the Iit/pfT/mphir and ntr'ipliif. The acute forni may 
merge into a ehmnic stale, and when this t«kes place it generally dc- 
Telop8 into what is known as hypertrophic eataiTh. 

Hypertrophic Catarrh. — This ty]ie is someiiines deseribed as acute 
and chronic, l-nl practienlly it is always chronic. It has been confused 
in Bomc recent writings {Qu^nu, Hnmonic, and llecUis) with prolifcrtt- 
ing reetitiB, whieli ib a syphilitic intlaninintir>n. It i« not confined to one 
portion, but affects all of the large intestine, the sigmoid and rectum 
as well. 

Pirlhclfifiiral Atwhmy. — The mncous membrane and aubmucosa in 
this condition are always thickened; the glanduUr eleinenta of the 



1. 




CATARRHAl. D1SEA8KS OP TUB UECTL'M AND SIGMOID 147 



aru markiL'cUy liyiKTtnjphiL-d; i\\c liii-brrkuKn fullidcs are 
I, the iiitcrUibuiiir Kubstaucu ih incrcascd (Fig. 84), and there 
is an iDcroue in the number of g:obltit or mucut^-prmlucing cells. 
The conuecliTe tisinjc of the e-ubmucosa is increased; here anJ there 
L'1a»tk- [iboro art' found in 



I 



^^ four 

f^lpcl* 



Fin. M,— nrPKimioiniic Citaxkiiai: Piiocmii. 

Spvcimou vh-cwinit incraw-r in duiilli uT tiiUiIv uiiil 

InicnobitUr auWumco. 



I 



it, but there JB no evidtnco 
of L-iaitrit'ial foniialiuu. 
Around tht? bluud-vi-ssfU, 
which arc numLTous, and 
between them and the Irua 
mucosa, is 4 ni&as of em- 
bryonic tissue of variable 
tbickupsti. TliH bl«od-VL'S- 
evi walls iipiR-ar uurmal or 
Homewliat tliiuned. 

Bat'ti-rittl cviliiirf; fn>ra 
the snrupin^M of tliJH ron- 
ditiuu show only the eporOB 
and baoti'Ha ordinarily 
found in Lhc iDtt«tinul 
t. The niuco-puB, coj- 
lecleJ by HtTftjiin-.', shows under the iiiieroseope pus-cells. Ifiioocvtes, 
and various butteria. tngi'thir with small nmsses of IWeal matter and 
luidi^esti'd partiek'ii of food. 

Eliiflnfi;/. — The caiitte of this eomlilion may Ik- intra- or exlrn-inteS' 
Una!; it may follow acute colitis or proctitit, or it may devvlop from 
the «amc causes which produce these conditions. It may also be pro- 
Oficctl by cimditidiiH extorual to (be iiik'Ktiiie. Adhesive liiindB which 
cumtrii'l the culoii ur which rub agaiiisl it diitiiijc perii^tultic action may 
Vauso congestion, ihua netting up a hypL>nL'iiiia and hyperplasia which 
tiiiite ill hypertrophic catarrh. 

Ab dominal itimors or tlisplatol uleri that prcatt upon th« intgatine 
may Cicitu IIuh eondition; nuivnblc kidiK-yw, espeeinlly Ihosc which 
Jlidc Up and down with erm- respiration, and nib against the wall of 
the aecending or deseemling colon, may induce, or cerUiinly they inny 
keep up, an inflainmutorj' condition of thu large intfstJnc which ex- 
teniln tn the rer-tuni. CaUrrhul a|)peadLeitia also has its influence in 
producing or protniciing this disease. It has frequently been held that 
this form of appendicitis is due to the catarrlia) couditioQ of the bowel, 
a proposition which it ie iinpot^ible to prove or disprovi'. Tlie fact rg - 
mains. however^ thai a patient wit h fl vninrii-<^i -^( ip^n tioJi & t t h e euhrt. 
C0T niiliciite<l by ottarrhat npprndifitin , wi ll vory nTti^n r^-i-oyrr ^'^''y 
promptly if the appendix it; renioAiaL l*flthology and baetcriologj' have 




148 THE ANUS, HECTOM. AND PELVIC COLON 

Ihrtiwu nn particular liplit apon the ctiolojcy of tliie discaec, and it is 
onlv from clinical obs^rvatioiu that we can draw omt eonclnsions. The 
same irregulnhties in diet, habit?, and exerciee wliieh prodi,n'0 aeuto ca- 
turrliul coinJiliuiiB of the inlcKtiiiL' will also prnduue llii*. TIil> chiof t'lio- 
logieal factor in tlue diKtast" ie> said Lo bo cluonie const ipaLiun. 

St/mplomji. — In the early stages of this disease the syiiifitonu are 
vagiic hihI indnfinilc, uii1f.sk it nurcfi-dN nil arutr catflrrh, under which 
circuinel antes tlicrt; itt ciriiply an Mmirlio ration of ihe utiit.<; synijitoiua 
and a gradual development of thu chronic condition. The disease is 
not confined to the rectum; it Uflually affects the sigmoid flexure nnd 
colon aA Wfll ; ht'Dcfi the symp'oma may Ih? referred to a wide area. 
There are flatulenre, teiicHnius, loss of appetite, and gicneral malaise; the i 
tongue is flabhy Hiid loaled white; diarrhiea Koiimlinie-i alternates with 
constipatiiin ; lh<? stonls are either soft, N«iiilfluid, and rtiisrd with inueo- 
puR, nr they may be hard and round like sheep-balls, and covered with 
this mnrn-piin)lent secretion. As the disease progresses the ronntitu- 
tional and digcslivc symptom? become more marked ; periodic tenes- 
mus occurs, after which there is a profuse paspage of thick, glairy mucus 
mixed with pus, and sometimes tingnil with blond. The patient is nearly 
always aware nf the approach nf such attneks, and is much cvliuusted 
after the mucous passages. There is not much pain abmit the Inwer 
end of the rectum, but rather a feeling of weiphi nnd disenmfort. 

The seiTetinn fmni the mncoiia ijieitilirane is abundant, and some- 
times it oozes out through the sphincter, beeping the anal tlMues moist 
and macerated. Occasionally this produces an erythema or dermatiti* 
whieh may be mistaken for moist eczenia. The dincbnrgo is Bnmetimes 
BO profuse that a patient is ennipelled to wear n niipkiii. The rndial folds 
are hyperlrophied, and hptween them tbere frerjut^ntly oeenr small fis- 
sure)-, hut as the sphinrters are relaxed these are not very paintn!. Prtt- 
n"<».T is one of the mos t fre quent syuiptnm^. nnd sometimes the only one 
which induces the patient to consult a physician. The disease occurs 
most freqiicntly in plethoric, fat, flabby individuals, but it is also seen 
in thin, neurotic persons. 

Aruund the aims one may frequently see ln'7>ertrophipR of the papillas 
develop into typieiil eomlylnmata with dendririe formation. This condi* 
tiou extends well up into the anns. and becomes loss marked as the ano- 
rediil line is npprnjirlied. The hypertrophy, however, (leemg to begin 
again in the mueous inembrnne. and extends JndeflnitLdy. To the digital 
touch the raucous membrane presents a soft, doughy feelinji with a some- 
what closer approximation of the waits Ihan is normal, Through the 
flpec-uluni it appears o'dfrnatous, palnrthan urubI. and covered with thin 
I'oat of whitish secretion (Plate I, Fig. 5). The swoJlen membrane bulges 
out into the fenestra of the cnaical gpeculiun, or falls down and complete- 



k 



1 



CATARBHAL DlflEASE-S OF THR RKrTIIM ANH SIOMOID 



k 



ly covci-s thr end of the iirocloscopt-. Wlien tlic ruiico-jms is wij>eii off, 
the itienibratif presents through the magnifying glass & c&iiliflow«r-likc 
appearantie, whitish «ti() ^n^Dulnr. It does not bleed easily, and the end 
of a fine prt^be bein^ pressed down upon its aui-face, thv tissues will meet 
tojfether ahovo it. Ky spPHping with a rectal scoop one may nbtHin a cer- 
tain amount of tnuco-piinilent fluid the eninpoBition of which Img been 
already mentioned. HnTiinrrliiijres are not characteristic nf this dis- 
ea««, neither are ha-morrhoids. The latter sometimes develop, but iheV 
arc of the connective tissue and not the hemorrhagic type; the mucous 
membrane covering tlit-m is thickened, but the author lias never been 
able to e^tiiblisli the Iran? forma ttun from cyliudricul to ^trutilied pave- 
ment epithelium over the parts, aa has been described by Hamonic and 
Quenu. 

There is often n sensation after stool of something more to come 
BTay. This may result from a partial pToltipse or from the retention of 
a certain amount of mueuH iu s ptistprior or anterior rectocele. The in- 
troduL'lion of the lint;er into Ihe rectum will sumetimes result in the 
passnpe of this actumulution, and the patient will be a-Ucved. After the 
piMu^CK ^>f iiiucu-purulent matcrinl there is often & burning, itcliing scn- 
tttioD around the anus. 

Tho pnpillfp arnimd the upper mnrgin of the ppeten nre fTe(|iirnlly 
Hiueh liypL'rIrophicil. and the cpypts of Mnrpftgni are swollen and in- 
ilaniL'il. C»n>^ lipati' Hi bwoiiii'^ a iii Dst nnnoviu}; fi- iiture in the late r 
B t_af;e!i; llie pntit'iit dnew luit wUfU'rd in liavin^^ ii tiniVL-tiiL'nl of lhe_bow~ 
fl s willi'iLH tl»' L'rriitL-^il I'lForl . liiirKL* iloses of !ii\aliv(-s mid TL'cto- 
coluuic tluhliin/ urc noct-ftfury in order to provoke a muvunent- In 
the meantime between the stools the patient sulTers (vom an inelination 
to defecate, whicli renultti.. after mare or less straining; and tenesmus, 
in the passage of a small quantity of mucus, sometimes tingt-d with 
blood and pus. There are swellinp of the abdomen, intentinal griping 
pain, nausea, and vomiting. The patient* prmluiiUy develop vague 
nervous syiiipioniM, Ijccomc apiireltensive and hypochondriacBli, or tliey 
may have grave mental symptoms. 

Trfalmrnl.^'th<- Ircntnimt i)f Ihir" form of eatnrrh in ncoopsflrily 
prolonged and tedious. Where a tumor, floating kidney, displact'd 
uteriw, or tenderness over the appendix exists, one ehnuld not commit 
himself to a loo favomblo projjnosis frnm Incfil treatment, for it may l)G 
necL'Bwiri' to o|x.'rate for the compHealion before » cure citn In* ohtaintrd*. 

It may be asked why wc do not operate immediately in such cases. 
If it is an c.\trcmi;ly chrouic mndilion. nnJ modem irentment Im^ been 
trieij without rfTuL-t, tlitn it would Ik- perfectly proper to do so. But 
where Hk! cart ia a aubaeulc one, where the condition has lasted only 
two or three roontb;, where no proper dietnry repimon and loeal tfeat- 




150 



TUB ANUS. IlECrUM. AND PKLVIC COLOS 



mont haTie been rarrifd out, oiip run not bhv that nil the therapeutic 
mpasiires have iKX'ii i:xhnutitrtl ; thisr hhoiihl lie tried before any serious 
oper^itioa is uwlcrtakvji, provided life and geueral he&lth are not endan- 
gered by such delay. 

Aiutaniing tlist tlu; a-tiulogical facrtor is inlra-intestinal, the firft ob- 
jec?t in the trL'atim'nl should he U\ r<'iiicive it. (id rid nf whiitever irri- 
tates the iriti'stiiial iinifoiis nipiiibrane, whi'tlier it tie hardened fieeal 
nis.>uii>K, fermenting i ntist inal prmluclB, i^estodeH, or whatever foreign 
KuheUincc iitny lin in thf pnlicnlV liowi^ls or rcrluni. 

The befit thin^ fur ii^urli nidicnl eleimin^ out of the iiitci<tiniil canal 
is sulphate of magnesia 5 |mrti$ and bicarbonate of soda 1 part. A table- 
K]>oonful of this niixtuw lihould k^ K'veii before bnakfasit in the morning, 
and ri-pcated c-vt-ry two or Ihrt'f lioiirH until a Uiorouyli walery uvaeua- 
lion in obtained. Afd'r this tlie colon should be flnshi-d witli S or 3 
(fuurl^i of boric iitid or iiontiiil salinf wilulioiL The palifnl's ht|js should 
bL- elevated, or lie should hv placed iu ihu kiur-ihe»l pusturc; tlu? solu- 
tion sbonid jjasa in very nlowly; Ions reetal lubes iiru uuiieoessary for 
tJiia purpose. This fluid should be jiiven at a tcmpcrflturc of about 100'. 

JHet. — The patient .liiould bi* |)ut upon ii eiiielly nitnifp'nous diet. 
GHuten bread or only the crwiiit of state brend ghould be allowed. Meats, 
fowl, fi.sh, and eg>ii» are all lulnnssible; hnt in the vejjetable line only 
those forms should be used which are practically fnv from an^ar and 
starcliy elements. Of all articles of fnti d. w ]^ li- notnlioivs are the ni ot^t 
injurious in cfttarrhtil difcacei* of the interline; there is notbins which 
ferments more rapidly or furnisher a Iwlter medium for the growth 
and ioeroase of bacterial ppoduds than this vegetable. Spinaeii, Icttnce, 
celery, and jjuch vegetable* are all anlvi^ahle in these cases- A little 
wcll-cookcd rice may be allowfd. Siring licaiis. when fresh and gret-u, 
can also be given. 

The effect of coffee and ten is variable ; in some pnlients tliey hflvG 
no detrimental influence, M'hile in others no improvement can be obtained 
nntil those beverages have tx-wn absululely stof)iK.'d. 

The milk diet, sugi^fsted by iiiuiiy writers, has not proved ilsoK 
beneficial, Umiusc it forms hard. in*ulubk' stools whiili irritate the 
mueons membrane of the coloii as they pass through, and if there be 
any inflammation at tlif lover fiul of Ihe ifotuii], it often results in 
faical impaction tSicn' on atruinit of the paiu wliicli the patieat antici- 
pates from the stool. 

Siimulatinti drinks and nleolml in nil forms should he interdicted. 
Hot water Lff ore cae h jrieal someti n;iL'j^ ha »: ] \ most ex cellent effect. Ijnrge 
quiintilies should be advised in the beginning to (lush out the stomach, 
intestines, and kidneys. Two or ibrce glasses mav W taken before each 
meal; a pitidi of salt addtd sonietimen makes it more palatable. 



\ 



3 



CATARRHAL DISEASES OP THE RECTUM AND SlGMOlIt lil 

Sfedirinal. — The bowels should be rcgnl«ted by mild laxative* if 
neees^ary. Malt and eni-carn. tukfii upon going to l>od, is gGDcrally 
effective. Drugs that are preventive o( (eniientatioQ are bencfieial, 
Orvat beuofit will hn obtained from capaulea or powders contaiDiug 

Salol. 1 

, . . . I aa i;r. x ; 

PfliicrL-alin, j ^ ' 

Itoric ntid gr. v. 

To be ta-keii one hfliir aftvr nicaU. 



Beta-iiaphllinl has occasionally seemed to net more saliKfartonly tlian 
the aboYc en ml>i nation. Very good results have followfd the internal 
administration of irJitWo!, which is given in the forni of (.'ntcnc pills 
I'oiitainin^ y to 5 >;raii)s each. When thtre is a lendcntv to griping and 
dian'ha?a, ns there occasionally is in this condition, small do-ips of cajitwr- 
oU, 5 tn 10 drops takt-n in capttuW every Ihrw or four lumrs, will ^uiyt 
this mnliTialiy. 

The local applicalions will depetid very largely upon the estenl of 
the diwaso. Where the sigmoid nsonpe reveals the fact Ihnt the inflam- 
matory phenomena extend well Tip into the colon, local applications 
through the s]x>ciiluiii will be practically of little k'nt'fit. In such con- 
ditions it is well to place the patient in the knee-ehesl p'vjtiire. and with 
the long bougie, <h>scrilM'd ohoro, inlrofluct- I lo 3 quarts «f a 'i- l« lt).per- 
ornt solution of aigiieoiiii fluid exirnct of krameriji. I'eroxide of hydro- 
gen, 10 to 20 pPF rent, estrncl of hydrastifi. 1 ounce tn 2 fiuarts of hot 
water, a l-to-IO.OOfi sniiition of hiehloricle of mercury, or a l-to-.T.OOO 
solution of nitrate of silver may all be used in the same manner. Tht? 
kra meria. however, has given the best r estilta^_and generally nnder its 
ust; tlie comlitiiin rapidly improves. This drug as found ordinarily in 
the shops 18 absolutely useless. The preparation which is recommended, 
according to 8 formula devi-MJii for the author by Dr. Mtiller some teo 
ytmrti ago, Li jm-parud as folluus: 

Mocentc one {xiiitid of Unrk of kraincria iti a lonK iicnrolatiiiK lut'O for twenty- 
four hours. After ihi* a mliclurt' of 20 jter ei-nl (ttyefrin hikI 80 jmt eent walfr 
in allowfil iH jirrciiIiiU' tliroiigh il. TIn' p-rcolult- Khmild 1ji' rua-itantlj ^(i^^c'd and 
n-li1lrutiy) ihniug^li ihr Imrlc lUo epcoiid time. Ttie fiUratv \k I lipiievii|Hifiitcil ilown 
Co one {muadi Ilia* ulilniiiiTi^TBii aijueniiH fliiii:! i-xtmct conlaininj; ^'niin for groin 
all tbe tlienjwutic projiertleH of itic Lutk. The preparatloB sliould t>e kvpt in i 
dark place aail not exftowd U> tlic air. 

This can be mixed frwly wilTi water in any proportion, and tlirowg 
doim no sediment; it can be intrmlucvd into (he tenderest rectum with- 
(lut producing irritation: it is an astringent, and apparently eoothee pain 




15a 



TUK ANUS. RECTUM, ASP PELVIC COLON 



nod riMlucfs inflaiiiiiifttioii. For irrijialion it i? need in ttreiigtlis of from 
3 to 'iO pur t^L-tit, aiiU for luir&l upplicalioas it inav 1>e uned imn. 

If there 18 any ulceration within view through the sigmoidoscope, 
th<.' pnrts should )w wpongrd or sprtiyod witli r 2-per-cpnt solution ci( 
nitrate of eiWor. Applieatione of iodine or antinoHino are aUo tuneful 
under UiL>!;c circunistfinoeft. 

Inj<!i'tiuu» ut 8wei?t-oil mid iodoform h&vc not been snlisfactory Id 
my huiid^ in tliis furiii of culurrli. btil uccasipniilly relief has been given 
in the spasmodic atfacku by Iiigli injections of 6 ounces of olire-oU, with 
half an oudli; »rgh(.-crin. 

Keccntly some very good result* have been obtained from high injec- 
tions of 1 or 2 per cent ichthyol in olive- or cod-liver oil. Four to S 
ounoes aru injui'lt'd oneo in two or three day^. 

Bilti^r toniL-i;, cod-liver oil, liypopliosphites, bone mnrrow. and such 
products as proionuclein or organo serum should all be tried along with 
the lotal (rcalnicnl Ix'Torc ri'snrtin^' to surgical measures; but, on the 
otlicr liiitid, OIK- hlimili] tint wjiit on tlii^sc too long. 

Atrophic Catarrli. — Thin is the nioiit frequent type of cntarrlial in- 
flammation of the rectum, and it i« always dironio. It is found fre- 
quently in people aliout the age of puberly, and in fonatantly increasing 
Duniberaafl Ihey progreBs in years. The process may begin ia early life; 
it consigta in a genera! atrophy of the mucous nicriibriiiitf aud its glandu- 
lar ek-iucnta throughout 
(he rcetura and sigmoid 
fifxurc. It is usually lim- 
ited to these parts, and 
rarely a^eends ae high as 
the dL'BCwnding colon. 

PalhiAoijical Atiuloitiy. 
— One ubserveii upon ex- 
uiiiiiiing the mucous mcm- 
bniiic in these caisca on 
it regular, boKBuIatod, or 
granular appearance. The 
surface is dry, rough, iu- 
chistie. and without any 
salient vegetalions. At- 
tached to tlie surface hero 
and there arc snmll masses 
of dry fa'cal material. lUld occasionally little islands of necrotic epi- 
thelium or pseiido-nieinbraue (Piute I, Fig. 2). 

fcfieroscopie examination elion's Ihp epithelium nbpcnt in ninnv places, 
but always present in the deeper portions of the crypts of Lieberkithn. 




>■■■■ ■ ■'■ \i»..fni. r,t-ri.inE I '!:■■■ 1 ]-j IB 

Siwlijii'ii ^ilinHliii iitrii|<tiy Hti'J vxfiiliiiiiiiu i>r L-t>ltL«[lHl 



i 




CATARRHAL DJSEASBS OF THE RECTUM AND ^^IOM^)ID 153 

lese follicles are gpnerally atrophii'd, the intertiibiilar tissue decreased 
(Fig. 85), anil their goblet-celU are few in nuinber. The cylindrical 
epithetium is snid to aas«me the stratified pavement type in this dis- 
ease (Qwt-nu, Ilainonic). This change doee not extend more than 1 
or 3 contiincterti above the aiio-reetal lioe^ it ia coitllned to tlie c^upcr- 
ficial surface of the membrane, and docs not involve the tubules. 

'I"he ronncftive tissue of the siibniueouri coat \» dense and slightly 
thiekenc'd; it docs not contJiin embryonic tisr:uc and elastie fibers, as in 
the hypertrophic form. The solitary follicles are often enlarged and 
distended. At points there are distinct granulations and ulceratioo^ ae- 
conipanied with hypeneiiiia and inultipliention of Ihc bluod- vessels, but 
there is uo alteration in the blood- vl-*bcI walls. 

Elidloijy. — It has been ffiifrgu'stud that this disease may be prmlnwcl 
by emanations from foul closets and improiwr detergent material. The 
author at one time laid some stress upon thMp factors, but in recent 
years he has seen such a large increase in thiti type of di»^e:as>e aiaong 
a class of people in whom such factors eould not be frequent that they 
are no longer cousidered seriously. The fact that this condition is so 
freijuently ussociated with nliNrure syphilitic disease, leads him tn sus- 
pect this in almost every ease; whether it be aequired or hereditary, 
vicious or inntict;nl, it is a distinctly eliologieal factor in this type of 
inflammation. In the majority of cases there is a history of chronic coo- 
filipation a»i^o('iiil4>d with the habitual use of laxative pills, purgatives, 
and hepatic stimulants, all of whidi contain some resinous cathartie and 
irritant to the niueous mi?nibrnne of Ihe rectum. In most of Ihein the 
continuous use of rondimeiits, and stimulants to the appetite and di^jes- 
tion, late diiinem and midnight suppers, asaocialcd with little outdoor 
MCneifie anil nrduoun sorial fiinrtions, cftnlributo to the production of the 
disease. Excessive school duties, cloee. unventitflted study-rooms, and 
improper or insufficient food, all have their influenee. Many of those 
who suffer from this condition in early life ako suffer from n dry, eatar- 
rha! condition of the nasal mucous menibrane. which seems to show that 
the rectal condition it. a part of a general ininatitutional tendency. 

This type of catarrh may also result from the practice of sodomy. Ihe 
use of irritating enemata, and from foreign bodies in the rectum whether 
iDlrodiiecd voluntarily or acruniulnted by passage through the intf^slinal 
canal ; it also resulta bv vascular or Ivniphatie e vicnainn fmm phnnui;^ 
i nflammation of the pelvic and genito- upmnrv orif)i»g, Very froqucnlly 
it is associated willi old pelvie celluUlis and the iidhef^ioni^ that result 
from this romlition. PeriretUl abscesses, fistula.-, and hn-morrhoids are 
frequently aKsodated with the disease, but their etiological influence is 
very doubtful. 

Symptoms. — The patient will complain, as a rule, of tong^contittued 



i 



154 THE ANUS. RECTUM, AND PELVIC COLON 

conetipation. The stools nrc dry nnd hrinl, coated more or less with 
muL'iw, and nonietimoe tinged with blood; tlier« is often BWvera pain 
fltlvr Lhyiii, and this circumstance leads to the diagnosis of fissure in ano. 
Ilfat luid burning iu tliii region uf the jacnini and in the rectum are fre- 
([iicut syniiituiiis; the sjihiucltTs art? always more or less spasmodic. In- 
troduction of thu fiugcr or uf the specuhiin is ofttn paiiiTul. Stretching 
npart o( tlif folds of the buttoolis will produce cracks or miaute fissuree 
iu the muco-outaiicous tissue of the anns. Thos*; little tissurea nuiy be 
produced by the past;ago of s hanl fa'cal mosB, and rpRult in burning, 
itcfiin^, and soiiwtimos actual pain. They are very ghallow; they occur 
at ally poiut in th« circutiifcrfiict' regardless of the I'adial folde, and heal 
rapidly, only to recur when the parls are strelched again. 

Ila-morrhnids an- a cuiistunt com plication of this type of the di^^rasc. 
Fn-qucntly thc^c are asfumed tn be tin; cause of the diseasi! iusteat) of 
tlie result, and the patient in openited upon only to be disft|ipointecl in 
finding himself unimproved. To the eye the mucous membrane is bright- 
red and of a shiny nppcaranco, with little matixei^ of iuspis«alt'd fa-ces 
adhering to it here and there (Plate I, Fig. S). It does not protrude 
itw«lf into the fene-xtni, nor does it eollapse over the end of the tubu- 
lar speculum, ns in the hypertrophic form. The Hurfacc is dry to the 
touch, aiid adheres to the finger as the latter is pusJied upward ; there is 
a general atony of the walls of the rectum in old caecH; the nigap socm 
almost obliterated, and the valvea of llouaton stand out wort promi- 
nently than is usual. There is nearly always marked dilatation of the 
rectal timpuHa in Ihc^c cbsps. Often when Ihw finger passeti the internal 
Bphincter it glides into a widely distended cavity, the sides or top of 
which it enxi xcareely touch. In this pouch f:eca] mas-seii accumulate and 
frequently lie from day to day until they become quite large, and some- 
times result in fa'cal impaction. 

Ulceration is more frequent in this form of catarrhal disease thai] in 
the liypertrophic. The mucous membrane of the entire rectum may be 
«roded and more or less deeply ulcerated in spots (Plate I. I''ig. G). This 
is due to the traumatism produced by the passage of dry, hard faiccs over 
an impniperly lubricated mucous membrane and subsequent infection. 
The resting nf these hard niajwes iu one position may interfere with the 
circulation and produce ulceration. Constipation, flatulence, and indi- 
gestion arc always a part of this affection; the complexion may be sallow, 
and the skin harsh and dry; the tongue is frequently eoatud a dirty yel- 
low, and there is a bad taste in the mouth on rising in the morning; the 
appetite i« frequently im|iairi'd, and the pftiient loeet^ flesh; the stools are 
always hard, lumpy, and coated slightly with nmcus, blood, or pus. Pru- 
ritus is often an annoying symptom, and interferes with the patient's 
rest nt night. 



i 




CATAKItllAL DISEASKS OP THK UECTUM AND SKiMOlB 156 



■ 



Treatment. — TjiIk form of iiUlaiiiinutinii, In-iDg limilrd largely to the 
roctam and lower sigmoid, is plainly wjtliin view tlirough tht proclo- 
ecope, and cnnsoqucntly is inore suspeptiblc to local trvatmeat than the 
other forme. 

The wliolc field aff^cleil can be observed and treati'd from below, and, 
asa nifltterof fad, no tn-atinout fi-oni above is liki-Iy to iinnx- ullk-iu-iou* 
except iu so far as it prevents irritutiug and infwtimis matpriuls from 
passing through the diseased area. Whatever will pmdiice non-irritat- 
ing. ?oft, and oosy stooU will conduce to the ht^aJing of these parts, it 
will hi' unneccswary to eontinually fliish the colon by drastic purges in 
order to keep the parts clean. Thia may be acuomplishod by simple ene- 
mata. or more completely by Uivafju of the liigtnuid flexiin- and ri'ctum 
through ibe ordinary reeLal irrigator, and by this means the eonslant 
peri^laULs und motion of the part8 caii.<4ed by cathartics will be avoid»'<l. 

\\Uv» there Ik n-a^^on to Husiiert the possibility (tf syphilitic infr-ftinn, 
it is well to administer specific remedies along with the local treatment 
for this condition. As has been stated elsewhere, the use of mercury in- 
lernally is iiuidvisable on account of the jteristaltic action iind diiirrluva 
which it induces. It atlows no rest to tlie piirts. Inunctions, imTiniric 
liHths, and the hypodermic fldministration of the drug arc all sup(>rior 
to its itili>rn»l ndministnitinn in crsps nf this kind, .\t the same time a 
certain am'ount of iodides should be given if the patient's stomach doea 
not rebel against (hem. 

If there is no specific element in the case. tonie.«, such as cod-liver 
oil, hypopho9philct5, and some assimilable form of iron arc always called 
for. Aa a rule, however, iron is objectionable in that it tends to ennsti- 
patinn and the prodiiftinn nf h:ird, irritating stools, Miilt with various 
tonie constituent); is an excellent remedy; combined with the lluid ex- 
tract of cascai-a. and administered at l>edtinie, it give* a certain Init easy 
movement of the bowels on the day following. This and cold water 
rnemata are the chief remedies for regidating the bowels in this condi- 
tion; though oecasionally recourse must be had to others, such as small 
do^cs of calomel and ^odu, podophvllin, eolocynlh, and saline waters. 
The?o latter, liowever, should not !» rci»ated frajuently. 

The diet, while it should be as carefully governed in this condition 
as in the hypertrophic catarrh, is not necessarily so limited. Starchy 
products may be taken in moderation, and also a few sweets. I'utalocs, 
however, for the reasona before indicated, are interdicted. Coffee and 
tea are bolh injurious in the.*e cases, and alcohol is to be avoided. Pure 
food in generous quantities, fresh air, and outdoor esercise, especially 
horwhaek riding, should all be encouraged. 

Local Treaimfni. — For the local treatment a great many remedies 
an} reeoiunieudcd in the books upon rectal and general diseases, but argo* 




tse 



THE ANUa, RECTDM. AND PELVIC COLON 




uin, aitnit« of silver, ieIith3foI, hydrastis, und oil with glycerin are thow 
that will he found mant iiHefnl. Thciie rum(.>die» should lit applied after 
tlie rectti iii has been tlinroiighly emptied (-ithrr bv a Inxutivc or i:niil-wat<>r 
fnt-iiia ; tliev may be introdueeil llirough the Wjilcfi bougie, ami should 
alwuyg be earricd up into the sigmoid flexure as high as the disease ex- 
tends. The strengths of the solutions are governed by the eondition of 
the gilt. When there in Jin extremely dry cniidilinD of the mueous luein- 
brane, with tenaeious mi]cu« and inspisuited faM-al Tnasiies adherent to it, 
the parts should be wiped off with pledgets of cotton, and comparatively 
strong stiiiiulating applu-ati^nii made. Id such cartes the cavity should 
be swiibWd out or aprayed with u 8- to 5-per-cent solution of nitrate of 
Ivur. This trratiiieiil. however, if earriad out in liie sigmoid flexure, 

ducL's considerable griping and pain ; therufore. when tlie disease ex- 
tends high up the u£c of argonin in solutions of 5 to 10 per cent is to be 
prL'fcrred. Thi^i drug jx applied as follows: 

The patient in placed in the kuue-ehest posture, the pnouniatie sig- 
moidoscope h carried up well iuto the sigmoiJ llexure, the latter being 
dUteitdcd liy pneumatic prewsurc; uftcr this the eyepiece ol ttie instru- 
ment is renujvctl, lunl j to I ounee of the solution is pumrcd into the gut 
through the tube; the cycpltice \b then reiplaecd, and the gut again dift- 
tended tn the tube is withdrawn, leaving the solution well up in the 
sigmoid. As Men us the speculum is removed, peristaltic action car- 
ries the drug dowuward and applies it to all the portions of the intestine 
beliiw. 

Irrigation with hot water stimulates the circulation in these condi- 
tions, and hastens the absorption of any inflHiinmatnry products which 
may lie present. It is UHeless, liovrever, in inject a pint nr rjnart of 
hot wuter into the bowel for this purpose and allow it to be passed 
out within a few nionionts. The irrigation should be carried out 
by iricans of a rectal irrigator (Fig. K3), and should lie kept up for 
fifteen to twL'ULy uiiautes at a time. The water should flow very 
slowly, and the temperature should be gradually increased until it 
reaches llo' F. 

AfU-r Ihc irrigation, the applications of argonln or nitrate of silver 
will Ik morn effectual, inasmuch as ilhe mucus and pue will have been 
washed away from the parts. This treatment phould be cnrried out daily 
at first, and afterward the periods may be lengthened gradually until 
the applieationB are necessary only once a week. Sometimes whore the 
irrigatinii and stimulating applications eet up irritntinn in the rectum 
and sigmoid, it is well to inject into the sigmoid at bedriuie 2 nr 3 
ounces of a 20-per-cent solution of the fluid extract of Icrameria. These 
methods of treatment freqnently keep the bowels regiilnr without any 
laxative medicines or cold-water enemata. If there is much itching and 




CATARRHAL IHSEASES OP THE RECTUM AND SlOMoiIl 157 

burning, and if tlie nkin rrackii ennily abnut the margin of the anus, appli- 
cations of the fnMuwing tnisture will give great relief: 

19 Acidi L-arboliei 5j; 
Aeidi Mlicjliei 3««.; 
Gljcerini Jj. 

Thin Hliuuld be [}airilt>d ovor tiic nnu» nt hedtitne. 

Alter tliis an ointment of 5 |)er cenl ichthyol and 95 per cent lanolin 
is ajiplipil. Rj tn-fltnienl with the Wnlcs botigie the sphincter is grad* 
uully but gently dilulctJ. (lit* mucous nienibran^ Iw-'come* i»o/tt-iiL'd under 
the influenre of the idilh,vol and lanolin, the ilcliinf; is rclifvod hy the 
Cfirbolic compound, and the pntjvnt's eyuiptoins rapidly iiii|iruvt;. If 
necessary, a cold-water enema is >;ivuu ewry niumiu^ to muvc tlii; buwtU, 
Thin ninv be continued indclinit«ly. It not only induces fl proper move- 
ment, but aUo rediiccti tlio congestion of haemorrhoids. Oec-osionally 
where the lissure-likc onioks in the iniieous membrane involve the ends of 
the eengory nerve, streti'hing under nitroue-oxidc gaa or t'tliyl chloride 
will be necessary, Tlioac ra»c», liowcvtT, are exceedingly rare. 

Nothing fsti'pl soft i'ltlton i>r nioiHlcned tissue piijjLT shoiilil Im? UHt'd 
for dt^tcrgviit purpoxc^. In Ihiri condition washes and hjithin^ arc not 
injnnous nt all, inasmuch as they keep the membrane eoftcned and flex- 
ibk', and thus prevent to a eertain extent the cracking. Sweet-oil and 
iodoform have been used a number of times in this condition, but cspe- 
riuiiee shous tliey iirc nut equal to the rvniedies detterihod, and are much 
moru t.'x[K'nsive. Wbi^ii there are ukerutions upon the mucous inenibrunti, 
as ia Hale I, Fig. 6, un insutllation of antinoeinc directly to the ulcer- 
ated spot is nf great K'Hefit. The iitithor 1ms applied uitrutt- of silver 
to tlietw cnndition^, and hue. found that the healing hue bt-eii i-luw and the 
suppuration marked. Under the use of antinosino and iodine Ihcro is 
□0 suppuration to sfn-ak of, and th? Iiouling is exeeedingly rapid. In 
casefi in wbicb there is a marked posterior reetoetde care i^houKl be taken 
to sew that this pocket is well emptied, and that no Binall fajcal balU or 
foreign aubslanecs uccuniulnte therein. 

In Ten,- chronic rases iimrli benefit will (« derived from a nighlly in- 
jection of ? nunccit of olivcMtil and ^ ounce of glycerin. Alliulune with 
I ttcrcetil of cnrbolif^flcid or J |wroent ftf menthol seems to have a aoolh- 
ing effect in some ciises. Occasionally when the hjcmorrhoidn are riinrked 
and BO inflamed that local treatment of the parts is irritating and pain- 
ful, it is neccsfiiirv to operate upon these tint and treat the catarrhal 
condition aftcrward. 

With the patient under ana-slhesia for the hflemorrhoidal operation 
the author lm« sometime touched the nnicou.« meiiibriine at spots all 
MOUad with the thermo-caulcry, and has found that it had a remark- 




158 TUB AhXS. BBCTUM. ASD PKI.VIC COI-OS 

ablj good inHopDOL' u[iod ike conditioo. A* a rul«. tion>rer, it b Urtlur 
Dot to iolerfere with thu luetiiorrboidal ^rowlha in ihii conditioa until 
tbc catarrhal pIii-iioii>cna have bcuD coDtrolIt-d, nnd in a largv outnU-T of 
caM4 IbcT will he fouod to bavc di^appoaKd along with the catarrlial 
corwliticD. 

Fistahv and pxtcngivp ulcerations occur in conncctioD with thie dia- 
ea«c, and should Ixr tnratod hy tlii! uivthode laid down in iho diaptcrs 
upon Ilicsp eubjecl^. The treatment of the two conditions nwd not 
interfere with eucli other, except in thooe cases in which ihL- (islula is 
dissected out and the piirts M-wetl (ogethtT. Here one mufll wait uoiil 
tl»! )i«rt« have healed. Tnder other cirounif'taneeH the treatment of the 
catarrhal eomlition may be continued immediatelv after operation, aod 
ihiu considerable lime will be enveil. 

SPECIFIC CATARRHAL INFLAMMATIONS 

Of lhe«c wc have mentioned in our claiwification fotir ,-i".:ia! vari- 
etiM. Thff ponorrhtpal and syphilitic typcR will be trcaieJ of in the 
chapter ujioii Vener<^al Diseases of the Rectum and Sigmmd, 

Dysenteric Proctitlj and Sigmoiditis. — In imltr to umlerjitand the 
eireets uf dysfiitery in the reeluiii ami sigmoid, it will be neuessary to 
review tlial ilis'asi' brielly. Authorities ditfer as to the distrilmtiou of 
ihe lesions in dyi^entcrv; all agriT, hoii-ever, thnt fooner or later in every 
typo Ihey nre found at the lower end of the intestinal tract. 

Ktiohgi/. — Heat, cold, oxwesive exerci**, improp<T diet, bad water, 
fiuUy drnina;^e, Lhe ein-ironuieiiU of army life aud that in Jnr^fc elee* 
iiioMynary iii^tilutioiiK. have al tiini>ti Ijeen luoked u]>ou as eau^-g of dysen- 
tery, but il is now believed that the disease is alwinys lhe R'sult of infec- 
tion, When Couneilumn and Lulleur (Jolms Hopkins Ho?pital Re- 
ports, 1801) ussotiiited uniieliie dyscideriir wilh this disease il was 
thought itB etiolopy Imd been finally Heltled. Later, however, the bacillus 
of Shiga (Cenlralblalt f. Bnkt. u. Piiraiiitenli,, 1S1>8, Nos. 22 and -H) 
was nntionneed »» the only pnthnpeuic agent eniiiitanlly found in epi- 
demie dysentery nf .Tnpnn ; and when Kloxner cnnlirmed this observation 
it s«-iiied for a time that the specific influetire of the aincpbff had been 
disproved. The arj^iiiitent^ ajjainst the ama-ha? were: it was found in 
water; nho in other diseases; it was not constanlly present in epidemic 
dyeenlcry: it eoiild not be isolated as a pure culture. Flexncr finally 
conelnded that the nmcrhn? hnd some pathoj;enie infltiL>nee: he held, 
however, with Kiirtulis, Knise, PiiBchal. and Criiikshaiik that it must 
be nspnciateil with othiT patho^n-nie organisms in order to produce 
dysentery {.Inurnal .Vtiierinin Medical .\i'aoeifltion. January r>. l!ti>l). 
Pathologisls have sought dilit,t'ntly to establish the unity of dysentery, 




but Flexner, Vailliinl, Vf><l<ler, nii<l Duval (•loumnl Kx{H'rimi.*iital Medt- 
cme, IW'i, Xo. 3). anil Knise ( l»fi]|(=eli. BM."d. Woclu-ne<>l(.. 191)1. Niw. 2, 
3, iilt<l 24) havt.' ciich (lt'i»-rit)L'(i Icu-illi liy-ii'iiti-piss.' JilTt-rinji fnnn llint of 
Sliigii. KruBe iIl-w-ti k'o tlial ditiL-uvLTL-ii ly him ng " pseiulo Iweillu*/' 
but Gay and Duval claim tliat all tlw.'sv vftrioties lK.*long lo ouc tjjxt. 
A<!milliiig tin* Iiittrr, llic fiitl tluil iimiiy cases liavi- tx-i-ii obairrvi'd in 
wiiich the bacilli wi-n' abstiit mid Ibu u-^Klutinuiiuu ttats failed, and y*t 
ia which th« amtcba; dy»'iitvriir wcir ])n.'A-nt, \iae led to the conclu»ion 
that lUis unity of Ibc disease c-an not If c.-tublinbed. In th« discu^i^ion 
m the British Medical Aasd(viatioii in \Wi. it was cicorly proved thnt 
lliew arL' tl^l^■t* lyix« of dy«'iiti'ry : Tlie oalnrrlml, the amupbie, and the 
bacillary. To iIicm.* luiiy be added h foiirlh. diu.> to mi.ved iafed.ioQ8. 
Councilman and Lafleiir apiilied llie leriii trn|)ic»l dynealery lo those 
due to Buia>bic infectiou. This tunn in niinlmding, for it is now vctl 
known that uiiKebic dyjfenlery iilsi> i»ri;:iiioli's in tcmpenitt: <:liniiit<«; the 
author hai svcu it iu jiulifnts who have never been toulb of the thirly- 
IjKb parallel of latitude; and iu ttio goullieni portion of the United 
the di«'nt* occurs froquenlly. I'ulil reei'Rily it ivii« penerally 
ftnmud thai baeillary dyw-nti-ry was eonfmeil lo the warmer zonc«. 
Iteoent inve»igali«iiii, liou'(>v<?r. have provwl that ev^n this type may 
develnj) in tin* cnldi-r jinnes. Vrilder and Duval (op. cit.) have found 
llic bacilli in dysentery originating in the United ^tatc^. and more 
receatly Duval and Daatict (Aaicrican Medicioe, vol. It, page 417), Wol- 
lent'tcin, l.anilK'rl, and Jones have discovered it in the onlinary siinmier 
diarrhu-'tt uf children in and about Xi'w York. Sueli widi^sprcad prt'va- 
IfiDce of tlie or)!amHin in kucU clinieally dilTeruut cases svcnig to oast 
some di»nl)l upon its sfHiifie infliienie in liiii^ dywnlerj-. R«](priHl!y when 
we Cunxider tin; faef llial l-'uleher (.Journal Ameriran Medu-nl Assncia- 
tioD, August '41, Ii)t>3], in Itia repiirl uf 119 cases in Johns Hopkins 
ilC0pital, m\'6 ihflt all showed the prc-senw of anui'ba! dyscnleriu' and 
iwoe responded to the bncillarv teists. In the easee treated by the author 
iu vhich tho haeilli were found, ania>ba> were also prewnt; it wna 
imptntible, llierefore, to decide wliieh was the t-tiologieal faetwr. The 
weight of evidence, however, is in favor u( the Rpeeitie inlUienre of the 
Shiga boeillufi, and cliaiciuu are thcn-forc fonx-d tu the roncluaioii that 
the four typi-s of dys;-ntery nienlioiied uIjoyo are establishnl and must 
be dealt with accord iujfly. 

CaUrrhal Dysentery.— The etiolopieal factor in tlie peculiar dysen- 
tery seen in large elecmn^ynnry institutions has not Vet bwii disi.*ovon'*l, 
atid therefore it ia pbiceil in tbi» ela^. In [lie ubseiiee uf any tijieeific 
organUm ono muHt cotmidor this diM-a^e as nothinf* n:ion> than the acute 
ciitarrlinl inllanimatioti of the lower bowel, described in the tirst para- 
graph of lhif< chapter. 
tl 



teO XnE ANL'S. RKCTUM, AXD PELVIC COLOS 

Bacillary Dysentery. — This ty|>e at dysJcnttTj' i» due to infection of 
the mucous meiiiliraiit> itoelf by lht> Shigu bnpillim or one nf its ]>TOto- 
tyi"'s. Tlic WJtiru- wT llu- liactllus is prm-licallv iinkucm-n. It i* bii|>- 
jjKsccI to Ciller tlie iiitr>linc? through food nnd tirink, Ihuiigli il Itim not 
been discnvercd in ihpni. 

Sym plfjtni'. — Th« oin*el i» suddcrn. eii>ineiiim;f with a chill, foliowwl 
by a li^c in lemi>craturc, acute grii)it)j$ }>niii.« imd luniiii^ in Die 
rectum. Tlie sloolii are at first Bcmi-fHrmcHl, then liquid, and finally 
they arc composed of nnthiii^ hiil nmcii^ bikI frof^h hloml. Tt'iwwiiuis 
il* miirkisl, oitiiiciiition is rapitl, iiau»-i'H h frwuu'ul, ftml i-ollrtpi^L' lakes 
place early in the cotirse of the dijit-asL', The L-oiistitutioiial symptoms 
are dwe to toxins and not to IIil- uctivity of tlic Imftlli Iht-iiifclvL's. for 
it has been provi-d by Ia-uIx (llmidhuL-li d. path. MiirnxT^jaiiisiiiLii. Lit- 
fcning 7, page 380) and Todtl (British Mfdi<;»il .foiirnal, Ueeeinbtr 5, 
lOUS) that thcRc may be cauwd by the injoc-tion of dead ns well as living 
bncilli into tho subjcft. No reports havo iHvn made nf proetofioflpic cx- 
amini}tii>n>i in acute haeiltary dyseotcry. Tbo nwropjiies. however, show 
that rht> U'siojis are largely t'onfined to the lower end of the rolon. The 
iiifi'clion is siiinrilcial, and rarely spreads to the peritniui'iiiii or neigh- 
boring organs. The area of «)lon infeelitl is large, the ulrers a:wnm« 
irregular forms and bleed eui*i]y. The whole eireuinference of Ihfi 
gnt is involved in the intense infection, and the mucous membrane may 
alough away ieavin;:; a raw, granulating mirfaee over various lengtha 
of the eoloii. Tlw haeilli are found iibiindantty in the stools and in 
the K<L:rapings from llie inteslinal wall, but iiucrnscupical examinations 
have failed to demonstrate their presence in llie outer layer* ol the 
gut. The bases of the ukiTH are usually soft, hut in si^ven; ca!6e» they 
become fibrous and siliow iiiurktd ccmtritrtion on hiNiling, thus indicat- 
ing the possibility of stricture. The blood rwjjonds to the agglutina- 
tion tetil. ConvaleHft^nit iw i-Uw mid rtdaiisfn are fretiuent. 

Tretilmctit. — The expirif^m't' of Itnchuiiuii (Brltii^h Medieal Journal, 
February 1, 1900, vol. i, piigu SdtJ, and 1902, vol. ii, page 843) and 
Cruikslintik (Jour. Ainer. H«d. Assoc. inHl, vol. i. page S-i) show that 
treatnit:n( by birge do»-» of ^iilpliale of niuj^'iiesiiirii and sulpbule of 
eoda give the bi-»l reaulti*, e^^pi-eiully it associated with irriyatiou of the 
colon. Some prefer the use of castor-oil. and if taken early in tho 
disease it '\6 eometinics gHeeejyiful. Xorrial t^aline solution and a solu- 
tion of sulphate of quinine, 1-1,000, are the irripants rceomniended. 
Opium in jtiiniL-ient (jnantitiwi to eontrol lenesmui? and diarrhtea is often . 
necessary; intL-nial medieal ion otliLT than tonics is contraindicated. ' 
Il»ecacuanha has long bceu considered a sort of specific for dysentery, 
but the latest aulboriticis an- almost unaninioui* in condemning it. 

Tlie serum Ircatuieut of bucillary dyeentery is worthy of seriou* 



^ 



not to Ihe activity of the Imrilli tlieniselves. To coumerart this toxin 
an antitoxin i» iiL-c-easarv. Shiua, by pmyrcswively iininuniziTi}; liorsrH, 
prodiHTil 1111 niilituxic st-nim with which ^<i(i caHctt wrn* trcHlcd in (lie 
Irtbonitfiry howpita! in Jupun, with & niorlalily of 9.7 i»er cent. In the 
Piimp rpiHfmic thfrt- wua u iiiortalitv of 31.7 per wat in 'i,l'.iG cawf* 
trffltod without the i*eruiii ( I'nhlic Health Iteports, .fiinunry S, Hl(H>). 
Todd {op. cit.) lias matlo «oiiH' intoresting exiieriiiicnl* with fcrum 
ohtnint-il bv u dilTt-ri'nt jirrni-t^. In niiiniali; tlite seniTn sepni;* tn neu- 
trati2<> viruloiil toxin inJL'flt'd inti> llif blood, and if il provf* a** elTerlii«I 
in man we may soon huvc as useful an ndjuvant for the treatment of 
ba«illnry dyscnt<?r_v as we have for iliplitbt^'riu. It will Btill Lie neces- 
t(ury to um; laxativTs niid irrit^utiona, liowt-vor. in order to rid the- bowel 
of tlie bacilli and prevent further tos!rniia. The diet ^tioidd hv milk, 
aniniul broths, rirc, barley Wjitcr, ole., with u siilhcicnl nniuiiiU of stimu- 
lants to imiiniiiin the .■itren^illi of tlif pationt. 

Amoebic Dysentery. — Thisi form of the disooso i« due to infeetion 
and inliitriiljon of ihc ^tibnmcn^a by niiici'iKV dysenteriip; it is much 
nion- insidious in its onset tlian the bacillary. It may appear as an 
acute dinrrba'tt with dittehar^ei^ of bloody mucu8 and more or loss 
burning in the rectum; or it may come on as 9iinpl« loosener of the 
bowuls with ^iulujilly incrpiiHing stools; the pdtient may at first bnve 
nnly two op thrw* passages n. day, one of which mny be iH'pfcelly normal, 
whih' tile othfTji aro thin, walery, and etinlain mueh rnueiw, with or 
without blood. In the amte caw« burning in tbp reetiini ami frr.-qupnt 
ilosin; to di-frcule. lotu? of appetite, and slight elevation of temperalnre 
nre generally observed; hut severe constitutional eyniplomB are mark- 
edly nbHciK ; the stools may niiinlK-r from lliree to forty or inorL' a day ; 
tlie demand h imperative, but it \i rarely associflted with excessive pain 
or lenei^niiis. In some cjise« emariatiou come* nn very eiirly in the liia- 
fu«?, wliili? in otlicrs il iloi-iJ not oertir at all. One of its chief features 
is itM irregular rourse, consisting of intermiwiionit. relap**«, and ex- 
acerltulionit. The disease may last for yeani, with varied periods of 
qairBtt-nce and n-nirrrncr. Tbesi- <iuiesceiit periods may last for 
month*. The rreurrences Ijike plucc in coM as well as wariii weather, 
but moro frequently in Ibe latter .As Rogers pointed out and a* the 
writer bus observed, the tima'bic infeetion may exiel in n lat^'nt fonn 
and t'ven end in death from eom[iliefttion» without noticenble diarrlwra. 
The chief wim plications are extreme antemia. loealized peritonitis, and, 
above all. abiwfss nf the liver. 

The liH-al np)H>arance of the pnrls as observed in two acute chsvh was 
t» follown: Tlic TiuK'0118 mcBtbrane at the anu^ wok pouting, bright red, 




169 



TIIR ASUS, RBCTtlM. AKD PELVIC COLON 



aiid swollen; Uiv (v)<U wltl' u-di-nialouB and painful; tine wnlls of the 
rectum vqtq in cloiw apposition with oadi oth«r, hot imJ tender to the 
loiK'Ii. brij:1it red in iiiiiii-flrint-o, tir<i in mie •.'««.• IIrtl- vtctv Hevcral 
patolics of {i^L-uilo-iiii-itibrniie. At t!ii« etngu of tho diMi-ace no actual 
iilc^ratinn^ were obeerveil, but later on they dcVL-lopc-d in both caws. 
These iikiTS wi^re ttliallow. irregularly f^val in »h8[K:'. eli-vutcil in the 
center^ and Uad »lu|ii»j; I'dges. The ditTen'nee bLlwcen ttiL-m and those 
aecn in chi-onic «nKcbic dywntcry is attributed to the fact that llie*c 
oiisa* wfpc trc'Htf-rl (in the l>n.*is of a local infoftiftn from the beginning, 
jinil (111? iinm'lia' wi'ii' dfslrowd befni'p tlioy hint irvRiied the dwiitT 
Uypre nf the »:tihmue>»^a. RojierK Htntcfl thnt the losiciofl apprar Brst ns 
fninll Tvil ilols. wliirh suon di-virlop a yellow s[Hit in the ei*nler, due to 
the loss of epithHiinii. 'i'ht^ writer lia>t fri-fiiicntly s<ecn iIm?sc in chronic 
amoebic dysentc-rv; but he did not observe them in either of the acute 
ootseti cxannnod. 

In llic elir'>nie form the ulcers arc irregularly round, varying from 
a eplit ]>ea to one ineh in diameter. They are usualiy situated upon Uie 
emniiiits ot thu fold* of the mucong ineinbraue, tlio folds of Iloiiiiloii 
being favurilf »itvv. f<ir (hem (I'ig. SSa). The long a.\is uf the ulwr 

i& generally at right an^lea to that 
i)f l\w (.'III. but wliL-n it iiivolvrs a 
!ar«c area liiif rvile ifi revcrsi-d. Tht- 
i,4<iliitcd ulcers arc well deiined; th« 
I'l'iiter is eonijinsed of a yeltowiiih 
iiiii>>6 raieed abuw tlif level of the 
iiiueons ineinbrane; the edyes are 
ihtclci'iH'd. promiiifiit. iiiid surround- 
i-il by a dark n.'d ur purjili.ili zone; 
in the very chronic forni» they may 
af^Hume a trou;;h-like shape with 
clear-cut, overhanging edge* ( Fig. 
86), which dip down into the snb- 
niiicosa anil Mometiines erosa one 
another, pnuluciny a stellate ap- 
pearance. The raueous membrane between the iHoIatL-d ulcers appears 
to lie perfectly healthy. Rogers. Iti his niiinernus ncLTup^ier'. has ehown 
thnt Ihe leeione are lurjcer in the caput coli and ascending colon 
than elecwhere. In the trouph-like ulcers the base in hard and fibroim, 
and tlic inflammation nay extend to the peritonea! layer, causing 
adhesions. The yellow {jelatinou* ma^* vliich foruis the eenter of 
the ulcers \9 eompoeed of eubmueoea infiltrated with amoebse dj'sen- 
teriie. The latter nre rnnrc easily found in the «niall ulcers than in the 
large. In w-iere eaties. Itogera bag eccn large tlough^ comjHisctl of de- 




FlA. Son.— T t !'•■ *i. I i...t.it< Kv Amcnuio 
DyvurrsKr. 




(achod shrHs of imiconB nicmbriuie at the site ot tliw ulcer. ThoM cttwc* 
weiv alwiiv!^ mwoL'ialf'il wiili fltiia'I)u> abscesot'S of the liver which coTitffline<i 
otiivr |)»t I )»«;(.■ nio ur;^i)nii^iii;i, showiMj^ Ihiil tbe giinprrne was iliic to a 
tiiixHl iuft'c-tioii. TliL> tHior in thmv c-asis was guiij^'renoiis nnil fotul. 
whith is i-iiliii'lv unlike 
, tlut in ainiL-bic dy»eii- 
terj*. When lUe ulcers be- 
gin to heal, tlie yellow cfii- 
tur tJii-Us nway. nt^iiim'ii a 
gmyish tint, and gradually 
disiip[)ear«. Jeaving a ck-aH 
granular base, iwiiiewhat 
ilidurateil, ami wliich cnn- 
tructi^ as it hciils. 

Pixirihtiiivn of the Li- 
sions, — Tbt? aiilhor'fi ex- 
perionw dillerB from that 
<if the majority of obiwn*- 
ers with regurJ to this 
phaM.- of th<- dis<.'ai<c. Roof- 
ers, i*'iilehcr. (ind others 
vXkXc that the cip<mni. ap- 
pendix, and asecndiji^ colon 
■m Iho chief nitcB of 
the lesions. In IK! i'osvn 
Fulchcr rarrly fniind them 
in tho rC'Otutn and fi>;in6id. 
Strong and others, how- 
cvtT, agni' with the writer in tttatlng that Ittc^* ])ortiong of Ihe intestine 
■re by no meuxis infrequently alfeeti'd. In the oxpL'i-ienti- of the author, 
typical uIcernlioB;* of the n-ctuui and sigmoid were found in !>2 per 
cent of the eait-s. In every tti»tann' eictvpt one the charactt^r of the 
k-ston^ waa proved by iIr* deiitLin^lralioii of living motile nnuvba' in the 
eloola atid serapiugp from tlio*e ulcer*. Futcher basics his diagnosiu 
ajtOD the finding of flnuebw dystrntcriie in serttpin^ti from the reeial 
wallfl. In a numlier of inslanof!! oliserveil \\w ainn'liir ulei>r» deiTeasw-d 
in itize and frfi[iieiicy fruiu tbe rectuiu upward: iu several they eatirKly 
disappeaiTtl in tlie upper [lorlion of the ni^moid. Why tliew experi- 
ences rihinild dilTer no materiiilly, il is iinpo>«ible to say. unless it be 
,dlUt to the fact that the obicrvntiona ot the M'riler have nil been made 
living »ubjec-t«, while thone of the atithon' r^uoted were made ii|K>n 
[KBt-niurteiti specimens. There i* lie dunbt, however, that the rt'etum 
and tigtnoid are iavolvcd in a laige percuntagc of chronic dysenteries. 




AtiKcbn ilrMinteriiB were pmvut Id tliv rpvtitm ot tlm 
IliA0 tliU ilnwinit wiw uuiila. Tra>.-1iiuii>iiii> IntiMtl- 

bolitf wi;|X mUo fnUkUil ttl U(i* ltl4H>tj* Kt II IdIot poTidd. 





D\n(fH<mf. — The di&^09tic teet is to find in the stools, or in tlio 
Mrrapingii Trom the ulcers, living motile atuiplKv diseolcriip. It may 
n^quire several examinations before they caii be* fount), but wliea once 
iu>fii the diflfrnwiii Ik Itoyond iloubl. Tltt> mellio(U of vxaminalion for 
■m(i-b:p are delaileil in works on paiholojry. The -nrritcr would call 
attention, however, to two facts, namely: the anut'tic cran not Ik- found 
easily, tf at all, in slools that have once cooled off below 70" F., and 
«t*«»ndiy, the diagiionirt will be miich more positive if the amccbw arc 
obwr^'ed in the scrapin^H from the ulcers. The eperimens to be exam- 
int'd should either be kc'[il in an oven at the Dornial lemporatiire of 
the boily, or oxaniint.'d uyoix warm slides immediately afu-r collection. 
No exuniination can be considered diaguo«tic uule«s it has been m 
in tliin niuniiiT. 

'J'rratiiii-nl. — Thin disease is an infection and infiltration of the aub- 
mucosa by aiiMtbrc dysentcria' : lliere are rarely any serious coustita- 
(iiiiinl TniiiiifcrflfltioTiK esfi^pt when due In (Mimplicntiori?. There i* BO 
iiidicDiion. thi-ri'fon', fur nn iiiiti1n):in as in hiicilliiry dysenlcry. but 
nillii.T for a hU|i|Hirtinj5 tn'aliin-nl while the local inrcetion is being 
eradicatiHl, As the aiTKrliiP tire Inrgcly Imrit'd in Ihe tissues, it will be 
inipiisnihk' to ilci*trny thcin hy ciipertirinl washing or flus^hing of (he in- 
testinal ainal. TIk'su incthodp ari' im]Kirtanl to ^ct rid of those on the 
6iirf«(.v. but fionit'thinp m\M Ih* empUivcd that will penetrate the tissues 
iiud Jeslrny the biirifii fH'nne in onJvr to fouifik'lely cure tlio disease. 
Tliii reitiedies that nrc toxit? to amrvlxp dysciiteriie are inureuric fldoride, 
silver nilrntc. solutions of quinine, and hydrogen |}eroxide. Bichloride 
()f uicrcury in warm Hohitioiis apiwars to have no intliu-nce in dieckiug 
Ihf motility of iiimeba! unh'so the etrrnglh is co gn-&{ that it would ha 
diUijierons to injt'ct it into the intestinal cjinal. Silver nitrate in & 
solution nt ..'> per cent, if uned warm, does not destroy the umieba'; in 
huluttuni! of a |H.T cent it seeniK to do so. but in this stren^h it is very 
irritating lo thi' bowel, and forma a layer of silver albuminate over tlio 
ukvr which simply pn)tecta the buried org«nisuis. Uojri-rs Ihls shown 
Ihiit « whition of qiiiiiino sulphate, l-l.iKHI, failed to destroy free 
unuvhai after several hours' eontoel ; a soluiion of l-5l>ti stopju'd tlicir 
movetnenta in five to (iftivri niinutos. aUhnugh a temporary stimulating^ 
elTeet wag somi'tinies ohsi'r\(Hl. In serapinp* from the walls of amoebic 
absces^ses or idwrs Ihi- niua-ba- wert: only destroyed after long sonkinj; 
of the tiesuea in adulioos of 1-500 or cran 1-lftO. Harris, of Atlanta, 
claims that (|ninine is n^t jHrmicidal lo amodw (iyM,-nleri». but that 
hydrogen peroxide is. Neither of the*c authors state whether tlieir ex- 
|HTinfienl9 were made with cold or warm solnlion, but aa they reoom- 
mcml wiiPMi lujeetions it i* to lie sup|K)se.l that they ucil tile same in 
tlioir eiperimeuta. Admitting that both quinine and hydrogen peroxid* 



ion. 




are germicidal to the aratchae. it would be impoeeihk- lo liold the »olu- 
tioDB iu coiilaL't with the ulctT:* long t>iiougb for tho fluid lo porictralc 
tli« tiK8U(.« anil kill the tiuried gcrniti, for in most pftticnU thv iiiteeltncB 
are vpry inlohTaiit of the jiri-M-iu-e uf fitlur iJrug. The fact ihat tlie 

^l]ui^ille ami nihvT Mihitiotis fail to r<'jich the biiricil amrphse acL-Duiitiii 
ioT the recurrrnn* of the disease in piitieiita who havf been treated willi 
them. The ideal treatment mut^t therefore consist of istinie method by 
which thifl burierl orftanisiu euii be readied and det^trflved in eiiu. 
It viae obuervod that whenever the epocimen etool? or the glidcB upon 
which ania'lia.^ weri' h('i»g osauiined conlt'd 5k'Iow a tenijieniture of 
PO* K., the inulililv of Ibe nnid-bie wiii* liwl iind eoiild not be restoriHl. 
This guggeKted thnt if the temperature of the partu eontfltninK these 
orgaiiitinb lOuUI be reiliici'd licliiw ID" K-. their infectinji and reprodiic- 
Itive powers WQidil lie eliniinnti'fl. It v»s therefore determined to treat 
th«?sc cases by cold injeetioHg. At first krainrrifl, if-htliyol, quinine, or 
silver nitrate were introduced into the douches, hut one after another 
vrm diAcnrded, «« it wac fonnd tlinl i>iiiiple cold wiUer wa» jui^t as 
elTeetiial «s nny of the mediealud solutione to rid tlie bowel of arniplw. 
In some paticnte it was neeei^wiry to u«e the long rwtal tube in ordur ti> 
get the iliiid up in (In; i-oloii. but in the majority the nclnl tiji of a 
fountaiu ayrinj^' wa* suHieit-nt. The piilieiitK were placed in the kiiec- 
clwet posture and the fluid iilluvred to run in very rlou'ly. Tlie amount 
I of water that enn be n-iHrived raries; some patient!i can take only a pint 
a( first, but by perj»evernnce the}' lenrn to take even two or three ^uartR; 
the time of retention varies also; some can retain the wati^r fur one-half 
iir three-fjuarter* nf an hour, while others are eompeUed lo go to the 
toilet immediately after the injcdion. In the latter class it is neressary 
to repeat the injertion two or three times at earh fitting in order to 
I obtain th< effects desired. The tn-otnieiit ia nlwnyi? bcRun by tho adiain- 
i«tratiou of large doncs of sulphate of miigni-gium. and this proco^ it 
re|)eatcd onco every wwk during the efmnM" of trcalment. The time 
consumed in ridding the hnwul of tliu aina>ba' depends entirely upon 
the tolerance of the inleittine to cold water; in tlioite cases in which largo 
■niount» of very cold water can be retained the orffauisnis disappear in a 
very »Iiort tirae; while in Ihnse who lan only retain small tjuaniities for 
ehort period*, several weekM are required. In the ntiite cases seen the 
Bnm'iKi' disappeared fn^m the stools after three days' treatment by the 
cold injrtiiong and never rr-appcnred, In the chronic eaww the time 
required m longw and remirri'tieeii may lake place. Where then? ia leii- 
dcmeos over the <ivcum and lieiiaLiu flexure, an ice-lmg is applied over 
thwe n^ona for two hours twiw daily. When the howel is tolerant of 
hydrojren peroside. fi to Hi jmt eent of this remedy is inlrodueiil into the 
iruUr on account of its beneficial clfccl ou lh« ulcers and to combat any 




THE A>'US, RECTUM. A\I) PKI.VIC C01/>S 

mixnl infwtidiip Ihat may Iw prcfciit, Thr wiilnr rfioiild In' iie^'d at a 
twiiiMTiihiri' of 15" or lo*?. Il tlic ai'ulo oiiil (.iihBrutc caws c«lil is urati.'- 
ful Hiid lioutliing lo tile patient, lii thf chronic chhcs tlicrv is Itiw tolcr* 
arcc «jf it. 

The lornlized tilcers in the rwtuni ami sigmoid arc treatt'd evcijf 
other (l»,v bv locnl A[>]ilinttioii» of ni«lring4.'Qt and aQtiecptic substances; 
tincture of iodine ia one of ih* best, and aiitinosino insiifllaled upon the 
Bjiols is a niosi Buli^factorv method of apph-nifi it. Argyrol (50 per 
cent) is also etreetual. Silver nitrate U said to be a fipecific for theii« 
ulcers, t»ut we have never wen a ease cured by it. Its effects are too 
superficial to ruarh the iiuried aimelia;. The only internal niudication 
indicated 1.1 such as will be found neceRiary to a^siM digestion and 
maintain the strength of the individual while nnderpoing treatment. 
Opium su|)i)Ositones ai^e occarimially uec^sary to quiet rectal irritability. 
The diet f-hoiild be larttcly nilri);icrKiun, with fatn. buUer. rice, and stale 
or luat^led bread. In lln- I'spcricnte of tin- author, this line of treatment 
ba« sueeeeded altiiosl iiivariuhlv. bnt uni> can [fUf<i1,v euiuvive uf casvs so 
intolerant lo cold wattfr fliat it will be impussibk' to Hood Ihf ca^-um 
and thuB rentli the tent of the disease. In such CHse!'. n» Murray has well 
itUled, it will Ik- neccfsary to nfort to some Mir^icul nicuiis to rcuili the 
spot and treat the ulcers. There are two methods to do this: Ihc tirat 
is that of Weir, who malces a itninll inciriion thron^^h the nhdnminiil wall 
lit Slcllumey'^ point, drags Ihc ajipeiidix lliroujili tliis iuul suliire.* it to 
(he skin; after uninn Ims takfii place and tlie peritoneal cavity is shut 
off, the appendix is nriipiilated nnil its njicning into the c:pcum is utiliiced 
for the passage of a small calhclcr Ihrougli which the ndd water is 
introduot'd. thus n-acliinj: x\h- ii|)|Mr liniit« of the disease and flu^^hing 
the colon from above tlownward. The second method is by valvular 
colostomy as rceumnicnLlwl by (ilbson ami dewrilied on |hi^ J91. 
Heeogiiiziiifi tht! fact, iis statiil by KnjjtTH, Hint Ihe a[i|R-iidix niiii be the 
^eat of aiiuEbic infi^eliuii. It would ap[K-ar Dial the uictliod uf Weir 
should he the clioice. or ut leamt this orjian should be renioved in valvular 
colostomy. In tlie ca.-te? that have btrn reporti-d ni* treated in this way 
sutficienl lime Lad not elapsed when they were reported to warrant one 
Mying that the diefnsc van entirely cnrcrl, but judging from our ex- 
perience with cold water in amfi'bic infections of the rcdiim. there is 
eviTv reason to hclicn' thnl it nill be I'fFectnal in the npper colon. 

Diphtheritic Proctitis. — Psfuilo-mcmbranes sometimes iK-cur in the 
n-ctuni during llie hili- sla>res of exhausting disi-ascs. such ns septicicmia, 
Brighl'p, tuln-rculosis. typhoiil fiver, etc., but true diphtheria ol these 
is practically unknown, -Should itn existence in the rectum l)c wtab- 
lislicd by the iire>cn<'c nf Klcl'i-l-oelller Imtilli in the nicniliranes, it 
should bu treated by antitoxin injeclions and local antiseptic applications. 



i 



CHAPTER V 
CMROSJC COLITIS. MUCOUS COLITIS. MEMBRANOUS COLITIS 

Tub reetui specialist is so often consulted with regard to chronic 
dinrr1]a>a, must i[>ut ion, and tlie jmanuge uf mucuti and metnlirani!, with 
or witUout [>us and Itluod from the rt>ctutti, that it i.'' nbKolutcly t'^seotial 
he alioultl know (lie rondiliniis wliirli cause these, and W able to manage 
thciu. Form IT I _v such coiiditinns were considereil cnni^titutional atTeo* 
tions and treated Uv the gcnepn! prnetitioncr. To-day they are conaid- 
ereti by the best authorities as surpicnl. ami referred to Bjiecialial-'i in this 
line. Sonic ^till maintain thai they are ttie result of general eongtitil- 
tionni affectionf, such n« nnipiniti, chlorosiB, or neuroses; the inttor i? a 
very popiiliir view, and held by some of ihc' Ijest EenomI pmc-tttionern. 

Since writing upon this subjoct in 1888 the author has had the oppor- 
tunity, through the ci)ur1e«y of his professional friends, to (>!cainine and 
treat a large number of these casfs, after long periods of rest in bed 
and tru-atincMit on the neurotic tht-ory hud [irovcd unsuccessful, and 
fiivornbic nwults in these «isik have folloivi'd iimutifjeiinrnt u|»i>n the busis 
of a looil inflammatory di«ca«c. 

CIo«e investigation has led to the ccwicIuBion that th* three ty|wg of 
colitis menliont'd at the head of this cliajitcr, and described as separato 
dtauaatta in the works iip{iii j-i'iuthJ nu'dieiiu?. are praetieuUy one and the 
sanw, only iu dilT*?ruiit stages of developrnenl. The pathological change* 
are alu-ay-H the snmo, coiisii>ting in a hypertrophic catarrhal iiilkmniatiou 
of the colon. 

ElioUnjij. — The causes of this condition are the tame iis tliosc of 
hypertrophic proctitis, and have l*cn enumerated in the preceding chap- 
ter. The neurotic clement lias always appeared to be an effect rather 
than a cause, alUintigh, no doiilit, eliionje ratarrhal colitis may di>v«lop 
in individtialK who arc nlrendj afflioted with some nervous eoudition. 
Undrr siieh ciminisfanceit It in a eomplicatinn nttlier than a causes or a 
mult. If the dittea'ip was a neurosis, one would iind it much more fre- 
quently in insane in»^titniinns and hospitals for nervous diaciuas thoa 
nnywhen* else. Thompson, in an interesting article (New York Medical 
NewB, l&OO, vol. Ti, p. 84y), takes this riew with regard to the neurotic 




168 THE ANUS, RECTUM, AND PELVIC COLON 

elenient. In diBtrusHiiig & t-a^e lie fays: "* Aitliough ho bt-pau In develop 
hH the triiin nf ncrvouB gvmptoms itlinve refiTretl to, lln're can hv no 
doubt that none vt tlieni had any priniarv rplatinn»ihi|) to Ills troulile, 
but were pun-ly secondary. The bc-gitming of llie diM-fl-sc was rk-arly 
due to IochI irrilation eiciti^i] by locfil niiiM-H, arting first, on the lower rnd 
of the intestinal tract, and gradually exlcnding upward." He holds 
that tile orisin of the disease is in the lower end of the intestinal tract, 
either the rectum or the nijrnioid flexure, and estciulH upward from that 
point ; thnt the source of irriUI ion is gimerally hanlcm'ii fspcal masses or 
other foreijrn bodies that rest in ihediverticuliof thu intestine, and act as 
irritantii ; ;iiid that the condition niay !>e prndiicfld by hnrsehark pxeri'isc 
or bicycle riding. Irritation from the outside, such as pressure by uterine 
or ovarian lumors, may also oecasion the dipcafip. 

It is a wi^ll-known fael tliut liardeiivd fireal masite^ and foreign bodies 
may lie io the intestine for lonfi: periods of lim« and set up much irrita- 
tion, and yet Ihc patient may have liquid nr seniiltqiiid atools pi^riodleally 
without ninving them. Thi're arc cwrtain oth<>r conditions, Iiowovit, not 
mentioned in the books, which occasion colitis. They may b<" (.ailed reflex 
rather than nrtive cauiies; yet when they are removed, the symptoms 
disappear anil the patients mpidly recover. Among these attention is 
invited to three, which are very frequently a*»60ciated with so-called 
membranous and mucous coliti.". The lirst of theee is inflammatory 
adhesion of the colon or flipmoid flesnre to the pelvi<' orjjans or walls; 
whether the intlanuuatury process which occasions the adlicsion ex- 
tends to the mucous membrane of the rectum, or whelliL-^r thi; irritation 
|iroduccd hy its being held firm and immovable while the fict-al masses 
pass over nr rest upon it, is a question which is difliriilt to decide ; but, as 
a matter of fact, after attacks of pelvic or general peritonitis, the colon 
or sigmoid flexure may become adherent to some other organ of the ab- 
dominal cavity, the adhesive bands interfere with the functional motions 
of the intestine, and result in a localized cutnrrhat inllammation at the 
points^ opponitB them. This may In- due to the fact that the inleslino, 
bein;; held immovable at this p<»int, the peristallie action of the part* 
above produces a Icmpornry intussu-sccption through the R^icd portion, 
and thus by friction and more or less ohstruction the inflamed condition 
is brought about. One of the chief seats for such adhesions is in the 
noighborliood of the left ovary and in Oonplas's ntl-de-fac; another seat 
is in the neighborhood of the gall-bladder, where ibu trunKvi>rse colon 
paHiieH in vXom proximity to it, llmugli this adhesion is more rare than 
that in the pelvis. 

These pelvic adhe.'sions sometimes hold thft sigmoid so firmly bI- 
tflched in Douglas's rul'tJp-sitr, or Udiind the utenis, that it can not rise 
up into the abdominal cavity when distended with gas and fffcal matfl- 



1 




CHBONIC OULITLS, SICCOUS COLITIS, UEMBRAKOUS COLITIS i*i9 



* 



* 



rials. t'unfitipatioQ and fiucnl impnctJoD are fnt^^ur-ntly tbe result of 
this, and arc very difficult to overeoiue. Through thia process the fiecal 
tnaesea are rctAinod in the sigmoid unduly, eatAnrliu,! iiiflammatioD is 
eetablishiil. nml fvi>n ulccmliun may ri^uU. 

TKe 8v<.'ond cundilion, w)iich iimy hi} K^rmed rellcx in Lhe prcMluction 
of colitis, in subacutu iuHimiiuatiua of the vvrniifonii a[>i)eitdix. It has 
I»*n lliL' author's t;xjK:ricutf to six- u iiumliu-r itf pnlicnl^ who had 9uf- 
tvrvd (rum digL-Htivu i^vmiilunis, i-uiistiputiiiii, mucnuii nnd nit^iiibranaus 
colitis, with general dcbihty and nervouj) exhaustion, in whom the colitis 
could bf teitiporarily chwkcd or Iwnefited, and yet after brief period!' of 
time il would return. In 5 sueh caees the conditions were aasueiat^d 
with more or less Icnderuei^H over various porticmn of the abdomen. In 
only two of ttieni was it limited to the rcji^fin of thf vi*nitiform apiwiidix. 

la Diic lit tlu'w L-aws vi*ry rcrt'iitly oi»prali'd uptm ihe (symptoms w«re 
all in the pclvi-s, ami Hhnoting down the right leg. So much was this the 
case that the author was firmly con^'inced tliat the condition waf one of 
pclric adheF'iun that attached the sigmoid tlexure either to the perito- 
□eum of Douglaa'a cul-de-sac or to some of the uterine appendages. 
This Tik'ii' was not Nhamd by thn gynaK'ologiiits who wer»" esllnl in i-iiiisul- 
tatiuD, both of whom declared that the eondition wax a neurosis, and 
that there was no Inoal condition to justify an n{ieratiDn in the woman's 
CUM*. The fact, however, that tliesp adhesions produced jusi siu-li symp- 
toms, and had been reliererl by bmaking up the ndhrsivi? bands ami ro 
storing the (^igmoid flexure to its normal position, IrtI, against the advice 
of the consultants, to lapflroloniy for exploraton- and remedial purposes. 
It was a surprise wh<»n tbc hand was passed into the pelvis to find that 
the ovarian adhpsionn were so slight that they could not possibly have 
e80«rd the womnnV pains, and that they were not attached to the sig- 
nmid at all. On further investigation, however, it wa> found that the 
vcmiiforni appendix waa hard, thickened, subaculely inflonicd, and ad- 
herent to the peritonieum of T>oug]aft's cul-dt-fat; it passed directly 
across tlic cigiinnd Hcxure, ami thus prtjveiited the latter from rising 
up into the abdominal cavity, as it should dio normally. There wa» a 
•light adhesion of the sigmoid li> the anterior rectal wall, which waa 
oaatly brnken up. The appendix whs removed, the e»cuui restored to 
ita poaition on the right side, nnd the sigmoid flexure brought up alwve 
the brim of the pelvis and sutured to the abdominal wall. Within a few 
days after the operation the discbargea of mueiiM dt-crcui-cd, the bowela 
became regular, aud the woman's pain absolutely diaappearcd. 

In the other 1 ca-H-s the syniptonis were just a* marked, and finding 
nothing in the rectum or sigmoid flexure to account for the irritation, 
it was 4leeided to |»rfnrm exploratory laparotomy. The appendix waa 
fouad in a slate of aubacute catarrhal inflammation In 3; in 1 it oon- 



170 THK ASUS, HKCTITM, AND PBLVIC COLON 

tain«d pus, and in tho fourth the organ was 5 inches long nml ttdhcreot 
to the floor of Douglaii's ciAl-dt-sac It was iumovi?d witli the happy 
retrult that the sjniptonu iu all four eases diKappoared with roiiuirkable 
promptntsK. The reflex irifluentt-s, then-forv, of subacute appi-ndicitis 
in the production of muvoiis and mcnibrHnuus colilJH is well worltiy ul 
further study. 

In a recent acnte case of catarrhal appendioitis, in which the appen- 
dix became adherent to the posterior alidoiiunal wall ri^ilit over the spinal 
vertebra, symptoms of acute colitis and passages of mucus deveto; 
within five day** from the original nttnck, anri receded just »» promptly 
npon the rcmovn! of the iiiHnmfd nrpan. Such eases will eertHiulv have 
their bearing in the goarch for a cause in any oUciire ease of tnncous or 
Dienibmnou^ colitis. 

Another ttiruliiiuH. suggested as a cnuse of coHtiit, is floating kidney. 
How often this condition influfnces the inflaminalion of tlie colon, and 
whothtT it has any initial exciting effect or not, i» iinposailjilc to stale. 
The facts from per^^onfll experience are limited to a few oases, and to only 
two opomtiong for the relief of the same. In 4 cages of chronic mucous 
and nuMiibraiious colitis llie coexiglenee of movable kidney upon the right 
side \\&i bvvu obsLTved. As these kidiievs did not sot^m to be attaelied 
to the inteotiue in any way, it at Hret seemed iniprobttble that they could 
act U8 exciting muses nf Ihe clisetise. Finding, however, ciiseB in which 
no other cause fould he asrertaini'd, in which the kidney was nmre than 
ordinarily mobile, and therefore demanded restoriition anti fixation on its 
own account, it was decided to make the experiment and to observe it* 
inlluent'L' upon the iiitesliiiul comlitton. At the time of the 0|M.'rfltion 
the u'oinan had been treated for several wHpks by hwal applications with 
more or less unsatisftietory results with regard to the [lassAges of mucus 
and mendinine with lite stool. She was ()[K'Tjited upon on Octuber S4, 
ISfti), and after the incision wr5 mnde and the kidney exposed, the fol- 
lowing slate of uiTaim was obflcrred; An Ihe womiin lay upon her side and 
breathed dteplv under the influence of ether anesthesia, the kidney 
moved at least 3 inches with every reepiration ; npon inspirntton it shot 
dowuwflrtl Willi considerable force and slid ahing the posterior surface 
of the eolon for abmit ?J inehe*i, and on expirntion il shot upwanl ngiin, 
thus repeating this frictions! Hctinn upon the intestine. It seemed clear 
that such trnuniatism wnuld have an irritating effeet upon the hnwel ; in 
flic kidney it undniihtcdly produced congestion, hypertrophy, and gen- 
eral thickening, the organ being almost twice its normal size, and yet 
without any evidence of inlerfililirtl or cortical dit<ease. The capsule was, 
split, the b(idy of Ihe kidney sutured to the fasoiii nf the ninscles as well 
as the two lips of the ineifiinn in the eapRule, and the wound closed her- 
metically. Not a single eomplieatfonJor bad symptom followed, anj 



CHRONIC C01.1TIS, MUCOUS COLITIS, MEMBRANOUS COLITIS 171 






within one week from tlic time of operation the mucous di^charge^ abso- 
lutely ccnsod, and there has not k'^^n a return of the Giame up to the 
preHi'nt date, nltliough llic jiatit'iit still auffcn* pain in tlip rsfpim of the 
kidimy. j\ fuw local apiilii-utiuntt were miidt' to the cimiipstod nmeaUii 
menibnine in the rectum and the siifniold aftRrwftrdii, but )md nothing 
whatevfr Ijppii cIoiip to llip lining nipmhrane of the intestine, it Is be- 
lieved that the colilis would have been cnr«l by the reiuoval of this con- 
stant irritation. One olht^r cnse of this kind has been seen since niiting 
the above, in whieh Dr. Wyeth. on tin- autlior's advice. Anchored a float- 
ing kidney and relieved the membranous colitis it oausctl. 

Kffort has boon made to find some facts with regard to thi« fenturo 
of (he dineasp, but litcradire seems 1« furnish nolhilig. This espcrienoe, 
however, may lead in time to tho rclivf of a certnin class of oases vbidl 
have heretofore been jiignnlly Intractable. 

The occurrence of albtinilniirii] and ba'iiifiliiriu in winnoclion with 
colitU has been observed by ujany pnictitioiK-i'a. Tliompsun refers these 
conditions to the absorption of colon bacilli into the blood through the 
nbradcd mucous membrano of the colon. May they not be due to the 
inflammation proiluced in the kidney by iti; mobility? 

In eoiineetion with Ihejie extra Intestinal causes of colitis, attention 
may he called to the subject of abdominal anpurism^. In li rases 
observeil by the author and his associate, Dr. WclUirock. intraclnble 
mucous colilis has existed in connection with anennsnifl of the anrtn 
u(mn the level of the transverse colon. All of these jiatients have fliif- 
f«red from pain just above the urabilicu*, constipation, flatulence, and 
reflex digcittive disturbaneeB. The crises ortlinarily preceding the paa- 
Rage« of mucu.'i were abspnt in a large measure, and the rccttini and 
sigmoid were leHS alfeeted by hypertrophic catarrh than is usually the 
case. 

It wems that the undiic pressure of Ibe aneurism upon the transvenw 
colon and its interference with the solar plexus may possibly have some- 
thing to do in the caue^atioti of coUtia, 

Fathotogtf. — The fact that this is not a fatal dlflcaise accounts for the 
paucity of knowledge with reganl to its patholo;;ifiil anatomy. Moj^t of 
our information has to he drawn from the esaniination of thi* Ho-vnlled 
membranes thi'mselves, assisted oceasionally by pout- mortem examina- 
tion of pullcnt-8 who have sulTcred from this condition, iind vet died from 
some other cause. As these other causes arc genrrally e.'Ehauslive dls- 
oiises, ituch as nLpliritis. didbcles, pneumonia, and ^i-psi*. It is (lilbcult lo 
determine their exact influence upon the chronic condition of the intes- 
tine, for it is woll known that a certain kind of pseudo-membrane may 
bo developed In the colon during Ihn course of any one of these condl* 
lions. The niembronea dischargeil are generally flakes, tape-like or some- 



THE ANV8, liECTCM. AND PELVIC COLON 



Xtmes tnliutnr, lli»t rtpn'M-iit lliu caliber of tbo intt'^tinul ranal. Somc- 
tiutt Ihp tubM nr tape-like ttUMM are yary exteiuire, mt:-jL'>urJn^ 2 or 3 
f«l ; gcBLTullj', howover, they nrc only t few iiK'hv^ lorg. Tlicy arc cora- 
pAMd of n loiniimlpd elbiiininou; niHtcrinl, utrueturclci^ nntl devoid of 
fiber, atid t>iiclo&i> in lhi>ir laininsp smnll fa?ical inasees, numerous Iweteria, 
epithfliiil fiAU lliHl hiivc- undLTgono fitlty degenvration, ery^tal^ i>f rho- 
Iwterin aud idioHpliali-H, a cerUin quantit/ of |)u» and leucocytc-ji, and 
Mrnictiiiic-s the whole ppithctiul lining of the niutous folliclt's. Thr«e 
iihifdK or tiilii-H may be vpry thin or wjoiftiinL'S ni-arly } of an inch thick, 
quitu firm in parts, but shading olT into a trnarioits glairy niucut^, wtiirh 
cleivrly indiuilca llit-ir nature. They are, undoubtedly, formed first by the 
fiocretion of this glairy mucua from the glands, which becomes coagulated 
in layers, the foreign iiul)i>l»ncL'K and excoriated epitlic<Iium Iwing caught 
in these laniinie as they are sucwBKivply formed. Under the microscope 
tlujeu membranes nppear structureless and transparent. "Tlie inner 
surface nf tlie membrane appears to be reticulated, and present* depres* 
pionii or perforations which correspond to the mouths of Lieberkuhn fol- 
licles." Hpilheliul fellin arc occasionally grouped around tliesc openings, 
(iliowin» that the lining of the follicle has been cu»t olT and become in- 
corponilctl in the membrane. SometimcB thc«c arc larger than the nor- 
mal follicles. 

The MUiscular walls are generally thin and atrophied. The veins are 
often dilated. At certain spots or areas there are congestions and ex- 
coriations of the mucous nieiiibraiie; the latter are bright-red in color 
and present the appL-arancc of islmllovr ultvrutiun. The glamlular and 
Bubmiicous layers of the inte!*tinc arc liy(M?rtrophicd, distended with 
mucus, and the epithelial cell* oppoor to be undergoing fatty degenera- 
tion. There is no diminution in the caliber of tlie gut, but throughout 
its extent there is an hypertrophy of the follicles and glandular layer. 
The fa*"' 'hat the mcTuhnine is very rarely fdund post morlx-ni shows that 
it in not n-tained in the intestine for any length nf time after its forma- 
tion. W'hi-n it lias been found, tt lias Iwen confined to a limited nrea. was 
verj" easily db'tachc^l, and alcerutioii has Wen vpn- rarely seen beneath it. 
The question, however, which ie of great irterest in regard to these condi- 
tion!' is the fact that the passage of this mucus should be preceded always 
with such severe tormina and griping pains and yet be imnccoinpaniod. ea 
far BH poKt-niorlem examination bhowu, by anv Hevtre lesion in the wall 
of the gat. There is no reason why a simple inerease in the secretion of 
mucus and the pasi^age of an iinirritating soft mass of membrane should 
be preceded or arconipanied with severe pain. These masses are no 
larger, no firmer, no more adherent, and no more irritating than the 
ordinary f«cul mai^s. If it is true, as the pathologists tell us. that there 
IB no ulceration nor particularly active inSammation at the points upon 




CHIlliNtC COLITIS. MUCOUS COLITIS, MEMBttANOUS COLITIS 173 



I 



which those rut-uiljruru:*? arr formed, il st-ems impoesiblp to account for 
the pain through aii^v inflammatory procees. Thompson fltftti-a that this 
condilion U pmlinlilv <lu(^ to twdriH partutilar liactorin , which may cnme 
ibv pain, if liiich was ilic l'uw-. suiny form of l)a(rti>n9il orgaiii.-nii wuultl 
have been found more or Iiwh contitantly prtwnt In thi; dischnrgcf nf 
incmiirane am] imicus wliith havo linn so ciin'fnlly pxamincd hy path^ln- 
^Ifi ill thf litsl ffw years. Tin- only cxplaiiatitm of ihesc pnins (hat 
wciwi practical lies in adhesions, temporary \olvulua or intussiiROffption. 
The fact that the fwcal pas8flfje8oiiR'timt.'B prowdt'K the pasBaffw nf tniirus 
4)009 not oonlrairidicalf iIu'h.* i-uiiilittuii)>: it omly HigniCii'K that llif peri' 
Ktaltic Botion of tlie gut heluw the iutusiiUMi-opted portion currit^n whatever 
fa-cal iiiMlttT tlioro is in ihut purl ■of the howd dnwiiward, and pnidiices a 
niovL'iiii-nL willioiil yivin;: n-liff, Tlir irrilalinn prndiiccd in the niufous 
nicnibmne by intufiKusccjition or volTuliia may catioc a hypcrannJA and 
localized inflanmiatiou with inc-roased secretion of mucus, wliJi-h, being 
n-taiiiL-d, becomes thick, tcnariou-i, and membranous. When the intiia- 
suseeption relaxes, or the voIiiTihis untwists, this raucus or inerubtane ia 
|)di)tsL'd rapidly dowtiwar.t ami nut through Hip rcotuni, Thi* pjilient fj;en- 
erilly utlributp.s his ndici lo (he passage of imieus, but it s(?einK more 
rational to ancrilie the relief in the relaxation of spasm in the intestine 
■t the point of constriction. 

The muooue membrane of the rectum and sigmoid flexure in colitis 18 
clvrays congeettf^, sumelinici* slif^htly uUvralcd, thickened, and nccretes 
more or less mucus. The author had under his care a physician who had 
gufTerml from thi« mmlition fnr n long perind; the pspudo-meiiibnine iu 
hw CHM? was i*een frequently through the eigmoidnscope attached to the 
mucous membrane of the sigmoid flexure, and was wiped off with pledget* 
0/ cotton, a [wrt of tt bi-ing meiiibrunous and the rest gtOntinous. There 
was undoubtedly a prolapse ur intussusception of ihiB portion of the in- 
tcalitio into the upper rrttuin in his case, and when he suffered from 
hi« acute attacki?, if n long Wiles bougie was passed sullicicntly high and 
water injected to distend the ei^noid, the torijiina ceased, and his pnins 
were relieved; mon-over. if the^^e lumgii's were pn^ised r<>gularly. nlinnst 
rugardlcis of what medication w&s thrown in. the attacks could be 
almost entirely averted. This rase and several similar one* have led to 
the ciinnhisioTi that lliis intu^siisivpiion is the pnniipflE cause of pain. 

SjKOjpiom.*. — The di.-'enwe genemlly occurs belwct-n the ages of twenty 
and fifty. Some cases have hern obeerved under ten years of age, and 
otheri in thwe over fifty, but these are esccptionnl. It occurs in thin, 
anff-mic, hypochondriacal individuals, as well as in the woll-fed, rotund, 
and plethoric. The symptoms are chronic intestinal indigestion with 

^K flatulence, capricious apjietite, and a tendency to melandioha or mental 

^H dcpreuioa. 



174 THE ANUS, BBCTUM, AND PKLVIC COWH 

Con^tipalion i» lUe ni1i>, tb« dtcat mass often bein^ in liltip, rouni], 
Jiartl bftlls, and i^oateJ with iiiut-uh; tliouuli tliis londition may altenmtt 
vritli diiirriiu'ii. 'J'hf diiirrhcra \f iluf tii Hit- irritatiwn produc-ftl by tlic 
lodgtnciit iif siimll, lurd rnusm's lu tin- suwulcs <»r divirrtii-uli of tlic ia- 
tostJnc. Tlie fluid faves produced by this eaust' or by eathnrtic* pass over 
or around t\w^v iiiHiifiL'!^ and k>a\i' tliom in ^iu to t'ontinue ilit' irriUtioD. 
T)i<? |JultL>iit^« un! gt^iiuni 1 1y tiutit^itive tu c-old, uttributitig lliiK oonUJtion to 
imiwrfect dreulation; the loiigue U slightly furn?d with a whitialt coat, 
and the ahdoincn in gcntrully more or less distcadpd with giis. White 
Kltites that tlif^c piitii-nts sninictiiiK^s have i-ystitiH and pass mucus with 
the urinp. Hp ()11o1(?k Da Ctist-a as saying that they are frequently the 
Bubjecta of boilt;. 

The mental depreseion and intestinal evmiptoms, while more or Ims 
pre^mit at all timt-s, have pvhitdB uf exacerbation iti vhich there is aVo- 
hik' lai'k of appplitc, groat distention with pas, gripiiij! abdominal paius, 
aud iiicreased iionstipalion. Afli'r hours or days n( suffi^ring in this man- 
ner a maHK of membrane or mucuA in diitchnrgrd from the bowel and the 
griping reases, but the pain and soreness rpniain for several days. In 
seven! chbps these pfts*HgL's of niiiciis and niombrane may continue daily 
for a long time. Ordinarily they are not iui:(ed nith blood, but 6om«- 
tinies bright blood passes with thp meinbrane. Wliite reports a case in 
which this cmidiLion eonliniied for several weeks; the patient was to 
weakened that he gradually sank and died. The nuthor haa seen 1 eime 
in whirl) J a pint of this mucus was disehsrged ever)' day for a like 
period, but there was no hlood ; she had very little griping or pain vs- 
cept at periods two or three days apart. In other cases in whtdi the 
discharge of niueiis and membrane was very limited, the pains and ex- 
haustion have bof n very great. Tliis pAhnustion after the passage of the 
raunis and momhrane ia one of the typical sj-mptoms of the di^eaae; the 
patients are utterly collnpsed, eometiniei- unahle to sit up until hours 
aflf-r the stool ; they gradually lose strength and tolor, and Ijeemne sal- 
low and deprewed. with forebodings and fears. Their natures are greatly 
changed; this is proiinhly dne (o the fact that they suppose their ailment 
to be of a much more serious nature than the pliy.'tieians deem it to be. 
Authors have laid stress upon the cxiotenee of urates and uric acid in the 
urine as indicating a rheumatic or Koaty orifCiD of the disease; this is 
believed to Iw ernineous. 

Therfi is no relnlioiiship between eating and the periods of pain and 
griping: sometimes these occur just before taking food. s.onietimes im- 
mediately afterward, and sometimes at remote [wriod* from it. Insom- 
nia ia t|uite fretjuent ; whether it is due to the disease itself, to the pain, or 
to the mental anxiety eonceminf; it. is a nuestion very JitTiruU to answer. 
AcoDfiiscd state of the intellect ia not infrequently pru«c-nt and due prob- 



CHRONIC COUTIS. MUCOUS COLITIS, MEilBHANOCS COLITIS 1T5 



ably to auto-inloxication, anxiety, and broculing. The Ajmiptoms may re- 
mit and xhv mucus ceaw to be disch&rj;ed; then they recur with iQcrcoiied 
viruk-nce ami cunliniic for van,inp iKTiiuis, to diitAppPiir and reoiir time 
after time. Only IhuM' ou^ck eun bs tiaid to )>c positively ciitvil wliii'h nro 
pruvtfd to hiiVG been due to some reflex or Uk<i)1 raiisc wliicb ha^ Wcd 
absolutely removed; nnd even in cases where the ap|>endi\ hai* been at 
fault mid has been renioved. there have been oceu^iiona] mild reeu rrenoes 
of the dieeaw. As ia stated by tilai^gow (Journal »f the American Medi- 
cal Aeuo'ciatioa. IfOl), it i;< f^^entially a chronic disease, Ter)' ^cldoDi 
faUl, but of KTt-al annoYimoc t& it^ victims. 

Treatment. — From what hn* been *tnted in the preceding pofios ona 
can readily undiTs^taitil ihat there i«n very f;ro«t iliver>iity "f niiininn with 
reganl In the tn-nlincnt of lhi« cnnditJon, H\ tlione whu huld lha.i it is 
aiinply a neurosis, nolbinj^ ruoro i* ndvi^t^d than ^'cneral Ionic and beda> 
tivc treatment diri'L-ted lu iUu WT\uuf, sysU'in or (be mental eonditiun. 
Chuu;;v of resi deuct', travel, Ltith», aiiiusL-nierits, ucrve lonit^, eleetritity, 
etc., conipour the Knca of tn-aimcnt wbirh an- laid ihiirn by tbtwc who 
adhere to this patholopy. To llioj^e \rho Iji-Iievi' iluit it is simply a qnes- 
lion of chronic constipation, some method of emptying the bowel, and 
keeping it »o, B^eoeialed with tliose melius which pa to reelorc the nerv- 
ou* and physical tune of (he individual, nre nil lliat ii; neeeKHJiry. The 
length of lime, huwever, nnjuired fur the Iifalmt'iil of the^e ecindiliun« 
by ibc means and metliodn of thoMtr two sehools, and the tiumcrouis fail- 
ures of such treatment to improve Ihe condition even lemponirily, ftjieak 
volumes flgiiiniit the ciHTfctiiesh of any itueh theories. The idiolojy 
which has bvcn advanced in (he proceding pages differs eo materially 
from Ibo!^ that it involves un entirely ditTercnl lino of Iretidnenl. If this 
condition is due to intussusception, adhesions, reflex influences, such as 
appcndii'itisi, fluatiiig kidney, en I ero ptosis, or mil lpu»ii lions of the repro- 
ductive oryHHs in ttomeo, the tnfatment conHists in delennininjL: n» far as 
pnKsibIc which one of these conditinns is responsible, iiuil icmcdyinf; (but 
if feasible. Nearly all Uic authoni who write upon this Kuhjcct a<ree that 
llicre is a congestion or catarrhal hypcncniia of the mucous membrane 
associated with swelling of the glandular and submucous layer at the 
points upon which these inembmncs or niucons shreds have been found. 
ThoKe who hare esaniined the ret'tiiin and t^i^moid have verified the an- 
thur'a obwrvationa of the fact that there always exists a certain amount 
of hypertrophy and hyperplasia in the mucous membrane of these or- 
Cans ; whether (his condition is primnrj' or secondary to the mcmbraiioMa 
colitis it is very diilicult lo say, though the latter view seems most tena- 
ble, because the rectum and sigmoid may bo restored fre<inently to their 
normal c<^ndition bv persistent and well-directed lornl trentnii'nt. and yet 
the Cfindition will r«eur, unless the colitis above liaa been cured at the 
19 



ltd THE AXDS. EECTCM. ASD PELVIC COLON 

sADic time. (ilftRgow- {loe. HI.) KLates that vhile a l>rg^ number of 
thce« easei arc doe to appendiceal tnllaniniatiun, tixey eusy be treated by 
tberapeutir nieni^tiK* and the colit» cured. Ue advisee ilie u»e of \vh- 
tliyol inlvmally in 3- to 3-grain doses three times a day. The author bad 
used this remedy in coDDection with 3 of those eatet for a period of 
about on« year previous to the publication of Gla^^v'^ paf>cr; the 
drug i» not a specific, but it is a useful adjuvant to other lines of 
treatment. So far as the appendix is eonocrnvd, tbe radical removal 
of this iippeiida|;e Kheiiever ami wliererer ihi-ri' i* auy evidence of in- 
ttsnmiatidu or adhesion alKtut it is advisable. Mi*di<:al trealuiont i» n^e- 
ful for tbe time being, but iti results are not p«-miiiui-nt. A catarrhal 
appendix with just a little bit of tciidfrm-»». no tem]>cnituiv. and slight 
elevation of the pult^e, ifi a dangerous appendage. The part due:* not 
drain well, is likely to become infected at any time, and keeps up reflexes 
sonntinie^, ^uch ait membranouit or mucotut colitis and functional di»- 
Oldere of the <iige>itioii. for y<>an;. Such appenditw should be removed 
at ODve. and in tbe majority of iniitances ttie melaneliolir, anipmic, and 
dyspeptic palifnt^, who are »upi<(»ed to be tlie victims of neurotic co* 
litis, will immediately Wgin to iiitpruvc. 

Tbe influence of floating kidney uimn membranoas colitis is a matter 
upon which an expression of very po;«ittve opinion is not at present ad- 
viKHbte. in n scries of IS cttsa pubti^lu-d by Dr. Kinbom, in nil of which 
there were digestive trouble? and membranous colitis, 6 of them suffered 
also from floating kidney upon the right ^ide. In tbe author'^ ob«er\'a> 
tions 6 easeji of membranous colitis have been afllieted with very mobile 
right kidneys. The amount of mobility in the kidney does not seem to 
be in proportion to the irrttatiun whieh it prtnluces. Tho»c kidneys 
whii-h float loosely niouud in the abdomen. #omctimed descending almost 
to the pclvig, seldom give their po^cs^or? very much anno^'ancc ; whercM 
the kidney which slide*i up and down l»etween the posterior ntHlominal 
wait ami the tiscending colon, moving pome 3 or 4 inches downward with 
every ini^piration. and upward on expiration, have been tlie most annoy- 
ing fnrtik of this fomlitioii. and it is tbe only form in which there was nny 
marked degree of nicmbranouit colitis. 

It is not proposed to de^-ribe here the methods of removal of appen* 
dices or of fixation of floating kidneys : but it is saggestcd that when no 
otlier cause f«r enlitis* can l)c determined, and when there is » positive 
diagnoj-iK of either one of the^o conditions, surgical intervention may, 
and pndwihly will, result in the relief of tlie intestinal sj-mptoms. Opera- 
tive ineasurr.'* .*liould be preceded by appropriate therapeutic treatment, 
but it is not believed that these remedies should be persevered in for in- 
definite period)* unle(>s somt: iniprvn'cmcnt in the symptoms is observM. 

The therapeutic mc'asures advised arc: First, the absolute dean^ing 



OURpNIC COLITIS, MUCOUS COLITIS. MEMBRANOUS COLITIS 177 



1 



out of the intestiral ennal. TIw? Taet thai saline laxatives ]inulnr« largo 
and c'0|tioiu watery dffecatiutiK dot-s n«t li^ any awans pmve lliiU tin; in- 
teslines have beeu tliortiuglil_v cli-iiusi'd ; vue may be more cniifitlent of a 
projuT clL'iiiir'iH;; of the iiitustiniil caiiiil wlicii tlic [lalit'nt Iihs iiioderately 
soft, .■'inijolli. H'i-II-roniii'(l Iii'c-iil jinM^u^i-^. Fluiil iiiineniciits easily pns^s 
over hanlcned fa-cal bolts retninpd in the divcrticuli of the intestinal 
wall, and these ImiIIs may be lel't there for weeks and months to act as 
constant irritants, while Ihe |)ulic'ntt< «ro daily hiivinf; seinilluid move- 
inenU frimi the use of saline hixutives. Wylie has Kiiggcnted the use of 
equal part* of glycoriii and mBtor-oil as a laxative in these caseK, jliving 
a tal)te3))ui)iiful of codi tlin-e times a day, and tuiit inning this for two 
or Ihn'C weeks ; he s«y» Hint so far from its producing diarrhcr«. it only 
kcep« up a i^muuth, easy movement, Honietimes srniiflaid, and is the ninst 
guccestsfiil mean* to rc-movc the hardened fasiai masses wliieh accumulate 
and lodge in the folds of the colon; this eoiidjintttiim hm U'C-ii used by 
tlie author in varioil projKirtion^. liut never so prolraetedly as 'Wylie rms 
omnieods. The daily adniiniMlration nt a tnoderiite dose of malt and 
cascara acta jM-aclically in the same niauuer. This, witli inaiwage of the 
colon and lavage tln'oush the lunj; reelal lube, liax siieeeeded generally 
ia the reniovul of all the«' neLuniulntltmn. The use of a eiinnoii-ball 
weighing alioiit 5 or G pounds, and covered with ohauiois skin, it, very 
adrantageoii" for massage; this is used by the patient every morning; 
bejjinning at the ea'euin. it is rolled upward over Ihe nsi'ending cifkni, 
neross Ihe transverse, and downward over the descend ingeolon time aft«r 
tintc. It sets mechouieally. and aIho by stimulating peristaltic aelioii. 

Ai night, before tiie patient retires, it is a good plan to injwt tlinmgit 
the long bou^'ie, or, if this is impossible, by slow inistillatiun tliruugh a 
fountain tyringc, a mixture of colton-fteed or ewcet-oi! and glycerin into 
the sigmoid Hexure; the qunntity of this to be used depends upon the 
ability of the patient to retain it; some tnke only 1 or a 0Linre«, while 
others retain 1 to 2 jiints. This should be administered in the knee- 
cheitt [(osture. and injeeted very stowly in order that it may find its way 
as high as possible. Tlie patient should lie with his hips elevated and 
bis bead low duwn for Iialf an hour after the injeetion is given, and if 
|)i>s»ible he.-<hi)uhl retain Ihe mixture all night. In the morning his bow- 
cU »houI<l be moved by a cold-water enema, if ncceMary, and a regular 
time should he cslablished for this pro<'pdure. After thia I piul uf a 5- 
to lO-per-pent Bolutinn of the a'pieous fluid extract of krainena ehould 
be injeetwl through the long Wales bougie. IlydrastiH and hamsmelis 
are alfto useful for this purpose, but not as grtod an the kniineria. 

The diet ia of the utmost iniportanee, and, (■nntrar>' to the ordinary 
praeliee in these caaes. that recommended by Von Noorden has been 
fotU)<l to act best. This consists of meats in abundance— beef, mutton. 




TBE ANL'9. RBCTl'M. ASD PELVIC COLON 

fowl, fifth. 6gg9, and aaiihiog of Ihc nitrof^notis type are ndmiftsible: of 
regcUbIca — the k'guminous Ttrictiu, together with tho#e of s fibroa^ na- 
ture, such »6 Dftinach, oiiparagiu, celery, vtc, — may he allowwl. .Sur^-bes, 
tveeW, calffs', t«u, anil alcohol ubuuld all be avoidHl. As to brt^ad, i>iiher 
Gnltani or whole wheat brvad, as di^tiiigui&lied from lbo«e made from 
finer floorR^ arv the b«it to use. rom-brcud in much relUhLil by thrw i>u- 
tienU, atid does not ^ecm to have any ill cSvct when made without s}igtr. 
All wheat breatU should be n»ed staleor toasted to aroid the fennent«tiT« 
action of ini|trupfrly cooked yeast. The condition of achylia reported 
by Ut. Kinhuni hat not been luet with, and it can only l>e said that when 
there are eridcTKM of elomachic indif^iition, of whatever type it may be, 
it *hniil(! bo nttpudi-d to aceonlinj! to npprovpd molhods. 

Till' rn pen lie rvniodios u-vm to hsTo little or no effect except to reliete 
tlie i/mptoms temporarily; pancreaiin, boric acid, ichthyol, and ealul are 
proliabty the niosi satUfuctory drugs, and they are u»ed when there are 
tltttulL-nre and eTideocffi uf fortnrnlAtion. 'rouic)> urx? indicated iu tlioM 
eaaes in whirh there are feeble tirculutiou, lUia-miA. und tfcneral debility, 
but iron u contraindicated on account of its constipating effects. Drugs 
which stimulate the appetite and assist in a«similalion seem to have a 
^od erect. Feeding with the projier character of food, hovevor, n tha 
one eMonlial indieation. A» Du Cotita pointed uut nejirly thirty years 
ago, the milk dii.-t dot-it mope harm than good. Where there is marked 
luca) inUanimution in the recluni nnci .•tigmuid, with excoriation or ulrer- 
Btinii, Im-al tn^alimnt to tht-sp rnnditinns i^hoiild be carried out after the 
nicllioda dosuribed ia the cliaptere on proctitis nnd ulccralinn of the rcc- 
ttim. 

Outdoor ext-reise and mental and physical occupation are e^cntial to 
the eutL- of tlifrie patienttt, eiipecially th(uii> with marked depression and a 
tendency toward meliinchollA. A chnnge frnin h Inw, dninp etimate to 
high, dry, mounlainons arpan is fre^iuently of bpneRt. This, bowerer, 
ia not rfuw-ntiiil, as the condition ie a local one due to direct or reficx 
irritatinn, and when these exciting causes have been removed the mucous 
nnd mcnibrfinou^ dictcliur[;i-s will ceafte. the piitient will b(>;;in to ini;e»t 
and ansimilAte proper (iiiuiitiltf^ of food, and through thie the aoivmia 
and general pliyaieal dt-bility wilt be removed. 

Secondary Membranoni Colitis. — Thie term is given by Hale Whito 
to ihoni; cundilitmiv in whidi a nieinbranuus deposit forme upon the walls 
of the colon secondary to some other grave and constituliunul disease. 
There lire randy any symptoms of the fjonditiuii during life beyond a cer- 
tain amount of tendcmc»8 over the region of tlie colon and sigmoid. 
There is scarcely, if ever, any discharge of muam, and diarrluvn. if tliere 
be any, is generally of the iuToluntary typ<'. The disease is therefor© 
not a local condition, nnd as it presents few gymptonis referable to tbo 



CHRONIC COUTIS, MUCOUS COLITIS. MEMBRANOUS WLITIS 179 




'lower t-nd i)f the intestinni tract, its full ttnisidL-nitioii lien- would l>e 

out uf )iliice. Ocrasiwuully, huwcviT, in llif toursc of such iliBt'Hsp(= rectal 

tywptomi^ develop; blood, pus, and mucus arc di«chiLrgcd, tind the rectal 

[riali^t is cnlled in to (ietorminc the nature of tli<? c-f^ndition. It ^eems 

Ivi^nblo, lliprcfora, tu rt-'fer bni'llv to the ciiuMo*; «f thit^ nimlition, and 

low n^adcrs who are intereuted in the Hubjeet can frdlow it up in the 

jiiTiiul UtvraturH and in workw uijoii gt'ufral nw-ilii-inp. 

Kind, these inembraiii-'s may arisf from IruumatisniR lo the colon, or 

rorn Hwallowtng xoint: corroairc sulistuiicos, especially toxic doses of 

mercun'. T!ie cxplnnuliou of this, lu; giwn. by Virrhow (Herlin. klin- 

Iiecho Wocheuschriit, 18s7, No. oD) is, that the mert-uvy in absorbed 
through the etomach and email intestines and excreted into the coloo, 
thus forming an irritaliou or iujianiinution which results in the pro- 
duction of the niutus ur w>-fallcd membrane. 
I SeconJ, thid condition may be due to sepsis; patients with acute 
flpptictrniia in which tlm whole coni^titiitinn is involved in the toxic 
process, with great dcliijily. impHircd cirtulatitm, and low vitiiiily, are all 
subject to this disease. The colonic symptoms occur lale in the nlTcction, 
otiil the membranes formed are rnrely, if ever, passed during liff. White 
^^cite* n number of in:*tanoes in which these memhranos were found pi>st 
^pportRm;fln)on^ them a case of gnngrenntis umbilic-al hcrnin; 1 of fatal 
poerpenil fever; I of Roplii-aMtiia rlnc to preiiiature labor or abortion, in 

I which darii-green pnlcheti of invniliraDc were located near the sigmoid 
pexore; anothar ot general Mepmia with gangrene of th? foot, in which 
UwTc were (n^ayiTih lealticry nienjbrancs formed iu the rwtiim and sig- 
moid llesurc; another of Hep»i^ ami jt^'ncrul cystitis, in which the nicra- 
bnine begiui just within the unu» and cxtu-uded fur 3 inchve upward as a 
^Bgriiyi)i!i- brown coajfulittion with neeroj^ig and i^ubnnieou^ hn>niorrl)Bgcs 
^^xtending an higJi aa ttie splenic lloxure, and finally, one of acute suppu- 
rative cellulitifi of the neck with whitish patches in the ascending colon. 
There is nearly always aume involvement of the Icidneva in thc^e 
condiltonn. Constipation is more frequent in these cases than diarrluca. 
IP i^enernl peritonitis exists there will he Irmpanites, and sometimes ana* 
sjirca. The author has seen tlie condition once in a casu of pin^n-nc i)f 

■tlic IcK followed by general sejdicwmia, three timed in cases of em- 
l^ieraa with symptoms of general gepsie before death, and once in septic 
p«<ritnntti!) followinj; operation in u caiie in which a large tubal abscess 

■broke into (he peritonieum. 
\ Third, aecondiiry membranous coliti» may occur ia cases uf chronic 
brlphtV disease; both simple and ideemtive inHainmation of the reclura 
and sigmoid result from this disease. Wilks and Atoxon state that ihey 
obserrrd the formation of a tuiigh whitish meinbrani' attached to the mu- 
cotu membrane of the colon in patients who died from this condition, but 




180 THE ANl'S, RECTUM, ANP PBLVIC COLON 

Uit'y <lo not state whether Lhvre was imy eup|)urativc iuflanunation of the 
kidneys or not. DriBtowe and D«laQ(.'l<l both (-iaU that thf^ inflamma- 
tions of the colon muy occur in the l&te stages of Tntnl pneumonias. 
WUitt' has SL'Hii vaum occur during l\w ivmrse of falal diHU.'U'!*, nnd I'yo- 
Smrth hns nlwervi^d it in n iMse nf uirciuonw not oonnL'cti'd with th« 
intestine. The f«et that the condition dws mil |ire»ent nytnjiloiua during 
life, that it is rarely ohfiprved pxccpt nl atiloi»sii'». «rid that all thi- cases 
in which it has heen oljsenfd, excritt, ikt1iii|is, in ii fi-w folUiwing mer- 
curic poirtoning, havo proved fatal, renders a dLscuseioD of the treatment 
iinpossihlc at tho present time. 

Ulcerative Colitii. — Ulw^ration of the colon fiwiuently oecurs as a 
result of hrighfs disease, typhoid fever, tiibePcuIoniH, dysentcr)*, ami 
malignjiiit ni'riplHsin*. It is fw^iHently found in the pnsl-mnrtem n>iim 
after death from other ca-nsea in patlenti^ who present no anti^mortem 
symptoms of the condition, nnd whose intestinal functions, so far as their 
history h^howcd. iipiiearL-d lo Imvc bvw pt-rfeetly normal \ip to within a 
short liiiiv iM-fort.' dfuth. It Ih mil pr^ipoiced to discu»K lien; Ihi* condition 
that aritftfs from these spoeifie cunses, but to study thu^e caeet of simple 
iileernlive colitis with ihronic dinrrhtra and symptoms reforaWo to (he 
reetnm nnd lower i-nd of the in1i>)i:lin«I L-iimil. 

EUulmiy. — The caiise of ulceration of the («Ion can not always bo 
told. In !i«ine cases thers '\* a histon' i>f typlund f«?>*cr, dysentery, or 
chriiiiif iliurrhu-a; somclirics it develops during ttw course of u inciii- 
branous (»liti.s, at others the condition seems to originate suddenly and 
without any premonitory cymptomf'. It is said to omir fn-qiicntly in 
the insane. Campbell (IJritiah .Journal of Mental Sciences, 181)B. p. 52*1) 
reported *8 cases that occnrrcd in the institutions for the insane with 
which he WHS conmntcd. Cowan, Acklund, :3Md Turgctt claim (hat uleor- 
ation of tho colon miiy he duo to the disease of (be central nervous sys- 
tem, and White has reported 2 cases that occurred in Guy's Hospital 
wliirh seem to cnrmborate this view. 

t'owan rolls attention to the freqnent occurrence of ulceration of the 
rectum and colon in the insane. Enrich {Lancet, May 18, 1835), while 
adinittinjj that this is the fact, states that the lowered vitality of luna- 
tit's renders (hem an easy prey to all .sorts of disease.?, lie therefore 
believes that these ulcerations are not due to trophic neuroses, as Ackland 
and Tar^tp't elaim, but to some other cause that operates upon these 
Weakened systems. 

Age seems to have aome influence in producinf; it. In 28 cases re- 
ported liy Wtiitc iind C'oletiian. seventeen yi-ai-w wa^ llic youiif;e*t and 
fifty-nine the cldent. In the autopflicj! at the New York city aUiishouBe 
ulcerations of the rectum and colon arc amou;; the mo6t frequent putho- 
loffieal chaniffcs. Many of thcec have been due to tuberculosis or to 






CHRONIC COLITIS, MUCOUS COMTIS, MKMBKANOUS CULITIS 1^1 



k 




i 



•theroniatous changoii in the blood-vcasck The t:wuditton extended in 
patches from the re<!tuni to the c(P«um. 

Sei seems to have no preclominatiiig intlucnee. In White's casea 
lliere were fifteen men and thirlwri women. 

Climate and occupation havt- not been shuwu to have an3f decieive 
linfluciK-e in the production of the diis«?a»L': iu mild elimatcs it occurs 
|,W);0:)U ofti'ii as in till- wuniier rL*(iiuii», and cvt-n in the very cold sec- 
6f Ru7>aiu uiitl ihu ]ii;;li inuuuluinuu^ rcginiiti of the United Slutcs 
this ccndttioa «ccm8 to be quite as frtqucnt as in the other sections. 
liiborerDi in k-ud works, and miners who have considcmble to do with 
quicksilver and inepL-uric preparatione, seem to be affected with the dis- 
ease Koniewhat more frecptentlr than thoiie engaged in nther industries. 
The (luestion whether the al)snrptir)n of the metnl^ necasidos this, or 
wl»?lhi*r ihi' cniistipatiiiii produced bj these occupations is the c»iise of 
thi; ulceration, remains yet to be answered. Tlie fact that the cliscn.se 
occurs most frcr|urntlv in nnwrnic. hrokcn-di>wn individuals suffering 
witJi eotne other form of disease, or liavin^ sulTercd from some exhaustive 
condition, makes it likely that these ulcere arc due to trophic or circula- 
liiry I'ltangeH. On the iitlior hiind, they mnv l>e due In the invmfion iif 
wi-akcneil tissues by llie sejtlic hncteriii always prwsi-nt in the t'oUm. As 
malter of fact, it is now f^enernlly Wieved that there are present in the 
human system at all times the elements of sepsis and toxipmia, and that 
it is simply a qiiestion of perpetual war between these elements and the 
animal tis«ues. When the aysLem ie in a normal, strong, and healthy 
condition it resists the invasion of these hacterial enemies. When it ia 
wcjiliont'd by improper nourishment, overwork, anxiety, or disease, the 
balance is thrown to the other side, and the invasion of septic Imeteria 
becomes effeetive in the prodnetinn of disease. .Such mny he the cause of 
these ulcprations in the rectum and colon. The batauci' is thrown upon 
the side of the bacteria. 

Tht-re is often a history of some organic disease of the heart, liver, 
Icidoeyt^, «r spleen, hut Hah- White says in one'half of the cases the rest 
of the orf;an^ are perfectly houlthy. Itheumatism with it^ cardiac com- 
plicatiiins, gout with itt? thickened «nd cnlcnteous joints, hepatitis with 
ahflcew and biliary disturbances, and. nio>t frequently of all, diabetes and 
chronie Bright's diu^a^e. are awoeiated with this form of colitis. Camp- 
Ix'll (i'lc.cit.) found chronic Brijrht's disease in U out of 2ft cases of 
ulcerative colitis, and 8 out of 18 eawca of memhranows colitis, t^owan 
r«'|iort» a mmilar *tato of affairs in tlic institutions over which he has con- 
trol. The author has «'c« 2 cutos of the disease in which there was 
marked (Uabctcii, and in 1 the glycosuria amounted to 6 per cent. Yet 
the very large number of all these dinenios that are not associated with 
'iBlcen of tbo colon renders the conclusion necessary that they are not 




ISfi THE ANUS, RKCTUM, AND PELVIC COLON' 

exciting but rather prvdiEsposing rauses lo llie fondilion. This is throw- 
ing us b&ck oQcc mon- upon the ttu'on-tionl conduiiiuD that the ditieaa« U 
dne to the invasion of specific bacilli under the circumstauoes favorable 
to tht'ir exce^ive develrpnicnl. 

I'aiholuyri. — Much has been writt*"!! and said about the patholc^- of 
uWrutivceoIitis. Hiidjfoi there t*ecin8 to be very litlk h«niionv of opinion 
with R'BOrd *« tlic same. The ulcers may be found nnywhere from the 
i)n»l iiiiugin to the tip of the oppondix, even this latter organ being some- 
tinies involved, Their depth «nd extent are very variable, at time* 
beinj; ihe size of n split pen. at others being ne large as a silver quarter, 
and gradually sloping down to iht- baie; ueca^ionally they involve the en- 
tire drfumferunce of the eolon. The muscular wall of the gut usually 
fornm the hmv of the ula^r. but soiHetimos Uiey arc suiwrQcial and may 
not extriid to the »iibmufou6 tissur; in iithrr niaiw llicv (MJnotrate the 
muscular wall and ev«n the pcrltonaium, but ufiually thie riicinbranc ia 
healthy over the seats of the ulcers. The mucou»i nioinhraiie between the 
uleernlt'd utvi\6 U dark, purplinh, and <?oiiyeHtud, 

The tuudL'Ucy «jf ulwra ia to extend circularly arouud the intes- 
tine. Thyy may I«? so itutnerou):. howcicr, that nnly small patches of 
mueuuK ini-inbrune reniuin, which patehei: While dpscrilies as having a 
eort of po)y])oid apiienrHiire, and even having been mistHkeii for polypi. 
He reports n case in which then- were over one hiinilred superficial ulcxrrs; 
thf aullior has recently swn a similar case in which there was scarcely a 
square inch of mucous membraiie between the anu? and the aecum. 
Onierod and Barlow reported rasoji in which there were nurtierouR per- 
foratiiiiiK at one tiriu'. Dclalicld jiliileii that the follieles arc infiltrated, 
swollen, and brealc down, forming what he terms " productive nlcent," 
which from his descriptions closely tally with those refen-ed to here. 
The enrly iiUvrif weni to develop either along the lines (if the mesen- 
tery or of the longitudinal folds. The epithelium of the I-ieherkiJhn fol- 
licles 19 clouded and swollen; there in an uccuriiulntion of minuU cells iu 
the.-tubmui;oun layfr which is (pdcmatous and thiokcm-d.and thuif narrow* 
to a certain extent the calilier of the gut. The follicles may bo the scat 
of ulcors or they may lie cut off flush with tliu ulcerated surface, leaving 
a portion of lliein Iwlow this surface. 

Symptoms. — The disease may begin in a variety of ways. I>elafield 
states that in the large majority of in.*tuuct^s it begins in Ihi? rectum and 
travels upward. White says llmt it may licgin at any \mm\. in the whole 
course of the large inteKtiuc. In snmo caeca there ia a pudden onset of 
sharp lancinating pains in the course of the colon attended with griping 
and a tendency to frct|uent movements of the bowels. Tlicfle pains last 
for a short white, disappear, and the patient may feel nothing more of 
the kind for several days or weeks, when they occur again. Tlioy last 



^ 



L 



i 




I 



p morn. 
The slnnls do not nt first contiiir nny nmciis, pus. or blood, but i( 
the pnin is pereisleiit, ant! the reounence frequent, there will be evi- 
dences of ulceration in tlie Jii^oharjre of tlie»e substance*. H the iilcer i« 
high up the bluod and [ju» will be iiii-ved with the »tool, iiiiij Hie blom] wilt 
be dark and dLTOHijitiscJ or doited; if it is iu IUl" lower pnrt of the sig- 
n»id flciurc or iu the rectum, the blood will be fresh and will precede 
the stool. The periodical occurrontcs arc said by White to be typical 
of the disease. The pain, which iu the first attacks is not very st'vere, in- 
creaecti with (.'iieh rL'turnnee. The aniuuiil of pain huars no relationship 
to the aniuutil of ulewraluHi, nor is it influenced by lh« ingc-stiim of food, 
Tlie cause of ]iain in prolmbly not in the eiixtencc of an ulcer, but in tho 
irritation of the ulcer by the intentiiial contents, wbirh sets up irregular 
peristaltic or spnfimodic adinn of the bowet. The number of the stooU 
varies greatly ; in one case there were 35 to 3G stools « day for one week 
during the acute attack.in others the number reached anywhere froin 5 to 
15 or 20 stooU a day. The diarrhcpji imiy alternate with short periods of 
consti^Mition. A distinction between the dinrrhn>a in these caseti nnd that 
in (ly^onteric and nrute calarrhal intlflmTiiiitions of the rectum and colon 
should lie elenrly understood. In the latltr conditions there is a oon- 
utant tenesmus nnd desire to go to the water-closet, a feeling of incorn* 
pletcne^s in the defecatory net. a desire to remain straining upon the 
teat. In tlii» condition, however, tlie inclination in i»)t continuous. It 
is /rctjUent and imporativc at tho time. The bowels Uaring once moved, 
there u completo Tchef for the time being. Tbe patient doe« not sufTer 
in Hie intorim, but after a while Ihe iinperalive deirmnd rec-urs, and mii?t 
be yielded to at once. The t^lools may be thiu and watery, or they may be 
ftemifluid. Sornelimox hard f^cul IihHk, »*. in ruucou$ or rnembranous 
colitis, occur, but this is not thf ruli-. They are geuerally scinillnid and 
posKesK a foul, feculent odor, which is often very ituggestiTe of malignant 
diei^aHc. Mucus is not generttlly present, bul, mk said above, blood and 
pus eoon begin to appear in the stools. When the blood occure fts n clot, 
it is 5omctiuics smooth on one side and rough or. the other, showing that 
it has rco'nlly Imk'H detached from the floor of an ulcer (White). Along 
with the hloorl and pus there may come shred-like masses of sloughing 
inaterinl containing leneooytes, t*pith«lial cells, and small adherent 
roas)>f^ of fa?cal matter. 

Vuuiitiug in said to be an early sjniptom in the dtecaac, but in the 
author's experience it haa only occurred in occa«ioua1 and in \irf 
Mvcre attack!. When the nausea and vomiting arc very severe blood 
may b(« c«)ntairied in the vomited material, but this is generally due 
to (h? nipturc of Rome snmll venule in the Uiroat or cpsopbagus, and 
docs nuL cume from the ulcers of the intestine. The tongue i^ at first 




184 THK ANTS. BECTUM. ASt> PKL\1C COU)K 

cuatetl with a white furry coal, but it soon becomes red upon the 
edgtfs and more iir Ifss brown in the middle, verj* much resembUng 
the loiijrue of typhoid fever. The [naticnla suffer greatly from thirst. 
ProgresAiTC! luueiuia, hitu of flesh and etreiigtli, aiid great depression in 
spirit* are the natural *equent« of the discaac. The temperature in 
tlw disease is very irrvpulnr; in some ciisos it nerer goe« above 100* F. 
during the whole course of the malady, in otlier coses the te-iii[ieratnre 
has pniiD aK high as 104.5° F., and may vary at times 4 degrees 
between night and morning. It ftonicl imc« drops below normal, and 
within A few hours \h up again ooine A or 4 degrct-^t. The condition 
reaemhlcfl very cIot<ely typhoid fever with ulccratiou of the bowel. 

The (-oiirec of the discAse may W very short, patients haviQg died 
from it in three or four days. Such a result, however, ig probably 
due to perfonitinn and jiubtieqiiejit peritonitia. Under other circum- 
stauccK death from uleeraiinn occurs after lung jteriods of suppura- 
tion and gHneral sloughing of the mueouH nienibrane of tlie intestine, 
mid it is then due to exhaustinn or amylaceous degeneration of the 
organti. White slates that the prognosis is always grave, mid lliat 
he ia exceedingly doubtful in any case that recovers nhetlier after all 
the diagnosis wa£ correct. The coursiie, he says, ie fatal in about eight 
weeks. CoutijmuUB high temperature. ]>ersij?tent pain, tympanites, and 
very frequent stuoln asuoeiated with the lues of blood and increased 
purulent disc'harge. ure all unfavorable symptoms, 

Diagnnsis. — It i« likely to be confoiiudt^d with but three eoiulittons, 
vix. : dyst'iilery, typhoid fi^ver, and malignant disease of the large intes- 
tine. IMcroiifc has been matle to the distinction between dysentery 
and typhoid fever and this disease. In malignant dieeasc the on^ct is 
very much more gradual, the temperature ie never high except in tho 
very Inst stages, tho patient is not troubled with griping or diarrluea, 
but gc-nerally with eoustipation that requires ejiibiirtics to move the 
boweU; after the itioveiiient has once been obtained, the patient seems 
fairly comfortable for some time, later en the piuwing of nuieus and 
blood are inilicative of iiiuligEiaut diseiiee. One who it) thoroughly 
versed in the examinatiuu of malignant diflcases of the intestine will 
rarely be deceived by anylliing else, for the peculiar feculent, path- 
ognomonic odor frnm malignant ulcers is characteristic. In ulceration 
of the eolon tliere is riirely any discharge of glairy mucus, but the 
sanious pus is very abundant. 

TrraiinetiL — So far as any local influence of me<lica1ion goes, no 
definite resulte eeem to have been obtained in these cases by adminLi- 
tration through thL- luoutli. The rliicf indication seems to be to find 
out the cause of the debililulcd eondition of the system and treat that 
as far ns powiible. Tho ulcerated colon and rectum themselves need 



need 

i 



CHBONIC COLITIS. HUCOUS OOUTIS, MEMBKANODS COUTIS ISii 



I 




I 
I 



lot-Ill trLiittiienI tu^i*tlicr witli n bliiixl, unirritating diet m ortlor tu 
prevent further imlAtion aiid niultipiicatiou ol tlie ulcers. Ortliimrj- 
irriKfltion of the rectum throTiph the roctal irrifjator is of no practical 
b<'npfit in those vmf^, m the Diiid docii not rench high cnotijjK. The 
us« of loofj Uoiif?ii?(', oxen of the toft-niblKT typo, is dfiUfiicruus, bot^ausQ 
tbe rectal wall at the ulccmtocl spots is linble to be so thin that even 
the slightest tlistention or pressure may nipture it and Bet up a fatal 
peritunttis. 

The truatment that ftirorils the moet beucfit is this: Pliict the pa- 
ticut in the ^ifinikuec-tln-^t |K)ct\irc by i;levatin^' tlitr hips upon two 
or throe pillows and ]ettinj,' the shoulders, chest, and kneoa rest upon 
tbo surface of the bed; in this position introduce the rectal tip of on 
ordinary fountain syringo iiilo the ruetuni; (jlovato tht- fuuntaiu only 
about 2 fei't above llie level of the palieut, and tht-u turn ou tlie Btri-uni 
and let the lluid Hud iU way into the colon. By requiring the patient 
to reiimiii in thiw pDHitloii fur li-ti or liflrcii riiinuh'.s. bn-athhi;;: jr*^"iitly 
but dfL'pty, tlif lluid will ;;nuiiiiil!y jibj* into thi- intt-tttiual laiial jhi 
slowly that IJicru ia no danger nf (listentioQ and very little tendency 
of tlu- Iwwcls to reject it. The fliiirl ehould I>c started jit about IDS" 
or 110" F., a<i it will ynulnally cool off during the slow in^jtillatiuu. 
By this mcau!! it ia possible to reduce the frequeney of tlie lituoltt, 
to ehei'k the dischar^p of blfwd, and 1«};f>thpr with pnijier regimen, 
diet, and tonic niedicalioji, to rpsltirc the patients to ht'alth. The 
fluid injected has been one of two remedies: either the afpieous 
id extract of hrameria, whirh PwiriK to act l>ctler than iinything 
so for as checkini; the diarrlio-a and hiPiuorrhagc is concerned, or 
the fluid extract of hamaiuclis. The strength of theee solutions de- 
pemlH laryely upon tho eonditinn of Ihc patii'ut and the BeriBitiveness 
of tile ('olon; in aimie eaana tho krHineria may be uspd m tilrong bs iO 
per cent, in nthent it may be used in the strength of S per cent. TTam- 
amelis is not used stronger than 10, and generally in from 1- to 3- 
per-ti?nt solutions. The amount of (he latter used va-ies from 1 to 
6 pint«, and the patient is required to retain it as long as poHiiblc. 
Wien the hiemorrhages are frequent, in the commencement of the 
treatment a combination of ergot, cinnamon, and hydntftis may be 
tiMd internally; gelatin haa been recently advised for Uiis purpot^e, 
but the author ha« had no experience with it; by the combination 
of these remedies with the irrigation mentioned above the hsemor- 
rhagea may be checked very promptly in alt the caws. The ulcera- 
tion, howpver. is a more ohfltinate aifair, and its cure depends not 
only on keeping the intentine free from irritating eiibstaucea and 
washing out the septic germs, but also upon building up the patient's 
general condition. Stimulation of tlic assimilative organs and the ad- 





iB6 THK ASVti, HECTDM. AND PKLVIC COLON 

mioiitration of predigpjitec) and iioiirieliiug tooA» are of the utmost 
taiporliiiioi'. Honv miirmw, hicmiilinloitU, protoauclciD, fresh beef 
JHuv. j)lajiiinin. and auch remedips are used in sinall quantities and 
(rf(|Ut'ntlj, lufCftlier with a niifTicient amount of rich Burfomdy wine 
a« a ntiniiilnnt lo the liearl and digestion. Whon tlicsc Ifcal and gen- 
itbI incamirvs fail rooyuiv<' niii.v Ik- liad to functional rest of the parts 
hy uiakiiif^ an arLilii-ial auu» almvc! the uli,-c>nitt>d portion. ThiiH far 
thn aiitlior Uun tint round nm' whoso nmditiuu would admit of it who 
would gin! htJt roiiaent to havinjc a right in^timl anus made. So long 
an th(!y arr nnt di-^prriitcly Ml ihp putic-utn cling to tlit- belief in medi- 
cation an<l lr)cii) tri'iiliiicnt wit hunt npi-mtion. Whitv holds that 
when the diM?ari<> flhows no inclination to heal b)- local treatment, a 
right-aide iTiguhml oolotomy is not only juBtifiable but imperative. He 
ri'comiiR'ndH the injection of a 35-pcr-cent i^ulution of perchloride of 
inin BK lii^li up in llit^ eolon a^ possible, iu order to control hirmorrhage; ^Hj 
but llie author ha» cUcwhvre expretwed his olijcetious to this remoly, ^^ 
and rn'i'd not n-pi-al llu-m licrL'. IVltilicId, Da ('oiitii, W. H. and W. K. 
Tliuin|w<iii III) ndviM! the use of niHtor-oil in smiill dnscs fur the relief 
of diarrhivn. 'I'lic author hoe tried it many timee and fiud^ it$ action 
vnry nnoertnin; (toiiietimos it neenis almost a specific in the early stages 
of ihi! iltKi'iiitc, whilo in ntliers it t^eoms absolutely usolcse. so that he 
liaji cnnn- In i[onht its eflicaey in true cHses of ulcerative colitis. 

Pollicular Colitii. — Scalti-rwl throughout the mucous membrane of 
the rectum, n'igjritiid, and eulon, there are a large number of golilary 
follirk'B. upon the function of which physiolngiists fail tu throw any 
light. 'I'lu-y an' iiol ghuulular in their structure; they lire neither 
Mcretivc nor ahuorptive. They nrc much more frKquent in the colon 
than in the *iginoid iind rectum. Their seat is in the mucous mem- 
brano proper, hut their bases dip down into the t^ubmueou^ tieeuc. 
Ihiring thu euurMe^ or as a result of chrunic calfiirhal inllaiimuktions, 
theiw follicleg become inilanicd, the pressure upuu (he mBUibranc above 
them results in a necrosis, and smiill, vell-dcfiued, circular ulcere 
are left. 

White etatcD that this dincusc occurred about once in fire hundred 
potd nwrtcniB made at iiny'n Hospital. London. In a large number of 
autopRien mnilo at llic New York City Almshouse during the laet si* 
years only 3 cases of this condition have t^^en observed. Notwithstand- 
ing the fact that White says ihe comUtion is never diagnosed during 
life, the wrifer lia^i Been and recognized .1 cases of this kind iu hia 
clinic and private praclise. In 2 of these the disease was chiflly in the 
Hignioid, in ? it was junt holow the recto-sigmoiihil juncture, and iu 1 
it waa at the lower end of the rectum. 

Etichgy, — The cause of this condition ie very imperfaetly known. 



i 



CHRONIC COLITIS, MUCOUS COLITIS, MKWBRAKOLTS COLITLS IS7 

It occurs cUiring the cntirsp of, or a« thp result of, other IntliuiuiintoTy 
(liMTases. Holt reports having sppii (he fntHlitinn 2(t times in 'f> fatal 
ramm of nmi-tiihercular Hiarrha'a in infnntf); he ststefi that it never 
oc'currei] in aifcs of k'ea ihnn om- week's (iTiration, ami it wa* more 
fr^uent in those tlmt lasteil lon^i-r tlian eight or ten wi:ek». lu the 
80 ciises the ulcers weri; confined to the colon in 15, to the small 
intimtine in 2, and were foumi in holli 3 times. Those whieh were 
found ill the umall intestine were in the lower end of the ileum nenr 
the uptuiin. Those in the colon were most frequent in the »iif^nioid 
flexure, the lower portion of the deseending colon, and the rectum. 
In the ca^es reported hy White all of thcra are said to have died from 
some other dUeiUte, siinh a£ dysentery, cancer, membranous colitis, ty- 
phoid ferer, or tuberculosis. He calls attention to the fact that in the 6 
cmea which died from tuhereulosis nnd in whieh he found foUienlar 
ulcenition of the colon, there wns not n Kingle instance of tubercular 
ulceration of this organ. 

In the rases observed at the almsliouse 2 were in tubercular patients 
and ] in a case of chronic ulceration of the color. In the tubercular 
cafics the autopsies eonflrmecl the statement of White, and in the 
other case the follicular ulcere were dotted here and there between 
the larger ulcerations. In none of these eases were any tubercle bacilli 
or f^nnt colln found in the nlreri*. In the author's clinical cases 2 gave 
a history of having had "acute dysentery," which had rcHolted in a 
chnmie diarrhcpa, with hard, liinijiy stools occasionally; upon examina- 
tion there were evidences of typical hypertrophic catarrh. In utiothfr 
there was obstruction in the sigmoid and colon which, upon explora- 
tory laparotomy, proved to he due to adhesive bandri. These wore 
broken down, and under rest, proper diet, and sigmoidal irrigation the 
condition disappeared. In the lifth case, in which tlio infinmmalion 
wag centered around the lower jiortimi of IJie rectum, there was a 
historj' of chronic constipation, openitions for liiemurrhoids, Btretching 
of the sphincter, and iniuh instrumental iuterferencc with the organ. 
All of these ra^es, therefore, were associated with or followed some 
inflammatory process in the walls of the iuteetinc. So far a case of 
simple, imcomplicated, follicular inflanmmtion of the colon or rectum 
Ims not been met with. 

Falhtthify. — The pathological changes in this form of inflammation 
consist in a congestion of the mucous membrane around the follicles 
with hyperplasia and an accumulation of small, round cells inside of 
them (Fig. 87). .\s this increases the follicle beeomea distended and elc- 
TBled above the IcycI of the mucous membrane. Pressure from this dis- 
tention and friction from the passagK of the fa'cal maw over it cau«e 
sia of the epithelial coToring and rupture of the wall of the fotli- 




188 



THE ANUS, RECTUM. AXU PhLVlC C01X)N 



cle. Tin* Iwivw an ulcer with ehurply cut edges, slightly iindcrmined» 
Aod with a ilitl base, Dcver crater-like. Tiie ulcers aro not Jeep, aud 
rarelv foalosft>. althoiijfh the whoh> ^it may be hoiievLtmibt'd with tliuuL 
(Fig. 88). The/ vary in size from a hemp-seed tn a sjilil ^iva. 




Kia. KT.— Tiussmu* Sserioii oo IxrLAtran toixieiM. 

White and Holt stato that they ehow no tondoucy whatever to heal* 
but in the fifth caec^ mentioned aTiovCj and in which the affected"' 
mucous membrane was removed, thtre were several eieatrices which 
eet'iiiL'd to have uriginateil in fiiltii'ular uleerR tliiil had healed. So far 
no tajse lit jierfomtion of the gut from this condiLiim hits been recorded. 




Fia. se.— Qpix* ArrE*iu.ic« vr Mrnns Mkubrasi im PuLLtcTLut Couto 



Gaylord and Asehol! {Pathologtcal Histology, p, 168) have obBGn'ed 
a condition which they denomiuate " eolitts cystica "; it appeai-n to bo 
very similar to follicular colitis. They state that in chronic inflamma- 
tions of the colon the iiiuc-oi)i4 lueiiibrane^ U aliidded with minute, ek'nr 
vesicles which are produced by dilatation of the gland luiuiuu, Uie 



CHROmC CX>LIT1S, MUCOUS COLITIS, MEMBRANOUS COLITIS 189 



J 

I 



r opening of vliicli have bocomc ot't'luik-d. Chronic irritation of the 
mticoue membrane, tlicy claim, cnii»>£ sgglutinaLion of IIig iimuthe of 
the- glanJ». and tlii* cuntiniied ttt'crt-liijii (if the glands thus ulativcl re- 
stills in sm&II K|)lieriL'!il cysts uhic-li prujuct altuve tlit^ surratri? of the 

r^t. The clinical nyiiiptunis and macroaL-opit-al ttpj]L'araiitL*« ilfstribt'd 
by these auUiont cuiiitidv with tliopi; of fulli<:ulitr citUtiB. Tlw jiatliu* 
logical chaogve, however, ami lUv luiiuiirr in wliicli Uic cysts aiv funned 
ditTer materially from those ordinarily described in this di««.-asc. Jl 
lins to be dcteniiined, tliorefort', wliellifr tlijg ia anothi-r lilsoase or 
I'IKW pathology for the old tine. The aiitliur ri'eently ii.'mt>ved a small 
epherical ma&s from the rectum the histological exainiuallon of which 
seemed to point tu thf hitter vltiw. 

Stfmpiums. — Tht; Myiiiptunm in Iheae casus arc very etniilur to those 

\o( chronic inflainniiitiltJii ai tim rortitm and colon, and vary uccordiDg 
to the site of the affeetion. Where the disease in found in the sigmoid 
flexiifp and colon the gymptoint< are those of chronic hyriertropliic ca- 
ttrrh. When it occurs below the recto-giginoidal juncture the patients 
suffer chiefly from miico-pumlent discharges, frequent desire to defecate 
without any results, tendcrucsj over th« lower end of the spine, and 
vague pains shooting down the legs. 

In the caAC in which the discaue vns limited to the lower end ot 
the rectum the pati«'at'» iiymptom« wcru lhbt<e uf ulceration of the 

.rectum and anus. She had already had an operation for hitmorrhoids 
four months previoni^ to cnnsiiltiiti'in for the new condition. The 

I wound from this operation had not licnird. and thpre retrained a 
chronic ulceration in the anterior left quadrant of the rectiim. The 
patient had fre^iwcnt painful movements compoBed of pus in ahiiii- 
danro, some mucus and hlood. Every two or three days she passed 
small balls of fgecal matter, which became coated mih the contenta of 
the rtctum through which they passed. The nicer in this ease prac- 
^^ tically obacurcd the tiyniiitoruH of fidlicular disease, and the diagnoaia 
^B vaa made solely upon oailar eximunation. The condition .was so 
^^ marked that its benign nature was doidited; all the affecti-d mucou* 
niemhrane was excised and submitted to the pathologist for cxujniua- 
tion. 



I 



I 



PaOfile^l Rtport hj Dr. F. .If. JiifruM : 

"The maeitweopical ttppvamnci.' U n» lli'iii|,'ti tlie mupOHii were Ihieltly iM'wt 
with nailiary lutienrleH. Eairli uikIuIc U TDiind, projects tlighily above tin- surface, 
and U jellowiKh in color St numcrnUB nrt' tliey lliat eacti app«Br> to l>o in crt)n- 
tact vrllli ibiiii-iglibrir. Tlic oiilimucona acid utUHCulor cuaUaji]>car to be uaaUcctcd 
and devoid of Indonitidn. 

" MMnvwcnpical t; tliu mucoxa is Iwwt nith Holilnry fulllclnt or noiall axamft of 
lymiilimlrnaid limuv tliut nrwnibic in all n!i>|wctii, exct^pl uuititK'nc, the aonnal solK 
tarj' loUlcloo. 




190 



THR ASITS, RECTUM, AND PELVIC COLON 



■■BclwMti tli« follicles the uypte uf LJobcrkalin are nDnnnl, ai arc ako tli« 
■ubmueuiM ddiI tniiMrtilnr ixiiit^ 

'-At oni' puint v/iifm liiwiic nan M'lected fortniertMcopiailexaiiiiniitiun. grnnti- 
Llatlon tiMut! was oLsrrvcd juwuculnl witli tlie mibmucMa— prolMlrly U»: site of a 
pKVloua operation." 

All of Ihfiw: faacs HuffereJ fTOm flatulence and digpstivc dt*range- 
mentii; tlii-y found little ru'litf (rum tiie use of laxatives and rcmedir-s 
for iiidigrfition. In ouc ca»c ihc patient suffered with the most aggra- 
vated syniplome, mch as altcmiiting diarrhoea and consti{)atiun, dis- 
charges of pus with thin mueus, followed by extreme fshausition and 
tead(.>m«6u all over the abdoni<>n. Upon laparotomy, adhosjvc baiub 
wt-re fiiiitnl wliicli prudiii*ud a luiislrictiuii uf (lie gul; these w^rc 
brokfii duwn and the howel released. In the walln uf the ileum and 
Ihroughuut tlie colon there were myriads of little hard bodiea about 
the »i«e of \i). 2 shot, »ionic of thfiii as lur^jc as a fimall pea. The 
intestiuc WUB ii'ot upeni-d to dcteniiilie the luiturc of the»u bodies, but 
there is little doubt that thej were inJlamed solitary folltcle^. Ex- 
amiiial.jon of the thrw nther taseti thn)ugh the sigmoidoscope dliowod 
here and tliere lillle nodular swelliiign when the intestine was put 
upon the stretch. The summits of these elevations were soiiteiiitios 
ahriiik-d ami bled upon toueh (Plalir I, Fig. A). In the other eaM-a 
the (hrviitiiuis had diKiippeared and in their places tliere were amiill, 
weU-(lrliii((i. tfliallow ulrers- The bases of these ukera were smooth, 
flat, and jri-anulaling. The nuinis s<:'crrtod was not po abundant as that 
in hypLTirophie caUrrh nor so thick and tenacious as that in the 
atrophic variety. At the same time tliis condition may be complicated 
by either of lliese varieties of inttannnalion, and eonso()ueully one can 
not place much dependeni'e upon the character of the disehargeic. 
When the diaease ia situated low do^fn. one may feel witli the finger 
aniall nodular flevalions giving the impression of miliary tuherruloats, 
but this location of the disease is so rare that few physicians will ever 
have tho opportunity of feeling it. The diagnosis practically depends 
upon the eigiiioidoscope and ocular examination through it. 

Trtaltiieiil. — The treatment in ttiia condition dependa upon Iho 
cause and the location of the ulcers. Where there are eridencns of 
intestinal obMlnielioii. such as in the rasp r^'lalt-d above, thry ahould 
be removed. Where there is a catarrhal condition of the rectum ond 
sigmoid, the treatment should be based upon the character of this 
diBOOAc. If the ulccrationa are in the algnioiil and rectum within vicir 
through the sigmoidoscope, local applications of argonin, nitrate of 
silver, or aotlnosine may he made. 

TAniile there \s some tendency to diarrhma and frequent movements 
of the bowels, this con be controlled better by thoroughly flushing out 




CHRONIC COLITIS, MUCOUS COLmS, MBMBHANOUS C0IJTI8 191 



tlie inlcstinP \>y a Hnocl dose uf Kpsniii »ulLs or Lastov-uil trverj sftoud 
or ihini morning Ihiui by the uxc ol «|>iat«s. The ca^ in which the 
distaee wae lot*i{f<i ul the lower cfid of tho rectmii uppoars to ho unique. 
The treatiiwnt luioptfil, viz., tht- o-veitiion of all llie dirieasoii inueoiis 
membrane and BUtiiriiig togothor the hpalthy eJgos, proved perft-etly 
sjil isfaLtniy Un the linio hoing, hul thf poriad thai lias L-lapsed since 
the Djii^ratiun is too short to tlaiiii for it radical auJ |)eniiaiieiit i-urt. 

If the c-finditioii shtniM tic diagnosed as existing in thi; u|»|)cr |>or- 
tinn of tlio sigmoid niid troltiii, it should In; tn-jiird a« advificil fur 
ulcprative cnlitifi. In thorn; lai^cH in which this di«inler ii* coinplicatt'd 
by niFmbrauous colHiti thu tivatmcnl will be nci-e£6anly tediouB and 
prolonged, and one may bo liiially cunipelk'd to makt a right colotitoniy 
in (inler to atTonl ih(! jiai'U fiinuLional rt'at. 

Tilt' disagri'i^abli' featiiri'S of tliis method of treatini>nt have beon 
largely o%*nrtome hy (lihsnn's "valviihir colostomy " (Mi'iliral Hfrord, 
1901, vol. i, p. 405; Boston MnlicAl and Surgical ■Toiirnn!. vol. i, l!)l>8). 



Fi«. » A.— Fiwrt Tiui op Biotku m Valtwu** Colovtowt (OibMiti}. 

which is npplioable to all fonus of chroni* colitis, and in oarriod out as 
follown; The crppum i^ exposed by an intemiiuieulnr ineisioii an inch and 
a hair long pamllel to and just ahove Poupart^K lignmi'nt. An opening 
in then niadt- in the aiitorioi- Inngitiidinnl band of the gut siiffiiicutly 
large to admit a good-sizcd soft-nibher catheter. Two or threi; tiers of 
RUtiiree are then introduced in the serous surface of the gut (Figs. 88 A 
nnd KS R). i<o as to infold the latter and fomi a aoi-t of teat or valve 
protniding into the caliber of the intestine (Pig. 88 C). The ends of the 
last tier of siilnrt^ia are left long, and cnrried through the edges of the 
alKlominal uoimcl, thiit: closing the latter, at thr sanio time holding the 
gtit in apposition with the abdominal wall. The eatheler i« left in for 
ten dlj8 or more, until the parte have healed, .\fter thi«, it ia taken 
18 




IM 



THK ANUS, RBCTCM, AND PELVIC COLON 



out and reintPoducpd as ofton ns i« nopfftjarj' for the purpoii«it of irri- 
gation. The slight fwcal fistula i^ contrftlkHi by a finml) piwl, and the 
patient is not confined (luriRg the trentment. 

Bv tliis nwiiiL* Ihe (.-nlire coIod i* irripatorl fmm above ilonTiward 
with mcilicali'd HulutioDB, according lo the judgment of iJie surgeon. 



Via, BSB,— I^n Tiwi i>r St;ruHiia ih Cinoox^i McTnon. 

BoUon in his case used nitrate of bUvct 0.01 per cent, followed by a 
saline solution 0.05 per cent. 

The openvtion is praetirnlly without danjicr, nntl, while it does not 
tarn the fiecfll eurrent a*irle and givp fiinetinnnl rest to the eolbn, it 
enallee one to keep the latter free from imtating fiiibsUnces by fre<)uent 



Fio. 69 C— LoiramiDiNAL Skctioh miowixo Kuvli* ip iNroLMNu nr CIibboVi JlnnoD. 



irrigation, and at the eame time avoids the difiajfreeable featares of an 
arlilirial anus. The smjill (tpcal tistylft will close spontaneously after the 
use of tbfi rathcter is difieontinuod, or if it doe« not, it is an easy matter 
to diseect it out under cocaine anseuthceia and close it by sutures. 



CHAITKH VI 
TUBJCRCULOSrS OF THE ANUS. RECTUM. AND PELVIC COLON 

Tl'BEiK'VLOSifl JK iii)w rt'L-oguizt'd as llie eliolojjica] factor in a nutiiliiT 
of comli I ions altoul iSu' hiiuu ami rootuni, llm [mtholofty of which wiis 
/orroerly unknown. The diseaKe may iJpvp]o|i primurily or spcnmliirily 
in the- Kkin. iniico-ciitiincdu^i, mucous, nnd cellular tiii»ueH, and in alwnyx 
due to the tubcrclL- Imcillus. 

In the ekin and miicoiiB memhrane it assumes Bome intereflting types, 
each of which was not long ngo tonfiidercd to have a special patholog)', 
but which are novr kno^Ti to be due to this specific microbe. In the 
cellular tissuoti it develops abscossM nnd listuinx, and in the musoles fatly 
or di'struptive change-*, whirli prriiiani'ntly disalilc thpiii. It is projin- 
gati>d hy direct invasinn nf the adjni>ent tinsiieB nr tliroHgh the lym- 
^alltw. II advance-K in inverse proportion to the amount of fibrous 
tissue in its path; n pure ricntrix fornii* a barrier through which it 
Win not pass. In the precent ehapter titbernilar lesions of ihe skin, 
miKo-cutaneous tisaue, and nmcou-i membrane will be considered, and 
\\w 'ftudy of the involvement of the cellular nnd muscular tissues will 
be reserved for the chaplcw nn Ahsecsjia nnd Kistula. 

Owing to the ditTcrpnt atiiitomicul struetiirea nnd varied relation 
of the parts. tubcrcHlosis will lie dcserilK-d a* seen in the perianal ra- 
gion, the anal rannt, the rectum, and the peJvtc colon: 



PERIANAL TUBERCULOSIS 

In tlie akin about the anui^, rich in hair follicles, sebaecoua and 
sudoripanms tilands, foc-i of luberde bacilli oftoii lodge vm\ develop 
mo*"t dfulruclive processiyi. Tbi^y are divided into miliary, ulcerative, 
lupoid, and (tapillary or verrucmix tiit)errtiIosi». 

Miliary Variety. — Tlii.'* type of the disease is very rare; it in seen 
almost cntiu'ly in casee alTected with tuljerculosis of other orpuns, and 
i« eaid by Chiari to occur almost exeluaively at the muco-cutaneous mar- 
gins; the author haa seen it weU outside of this area in the perianal 
akin. 





194 



TUE ANDS. RECrrM, AND PELVIC COLON 



It develops a» iiiiuute nodules or inUltratioiu wliich tw\ like sniAll 
shot nr raillrt-set'da beuvalh tliL- c]»idtTi»i». 'I'hvy are alwuTs multiple, 
and groupd in crescciilic: or rin:ulttr i$lia[)c. TUcy dcvcloj) in the glands 
of tile fkin, untl gniduully grow IiirirtT until prfcsurc upon tiic over- 
]yms ejiitticlium causes uecroi^i^, uud it SaWa, Icavinj; sliallow, cup-shaped 
ulcers with nigirvd, iiidtimtt'd Uirders. Small niiliai-y nodulos may be 
Been eovfring llie surfaue and edges u( lliuse uleera. Tliey discharge a 
scant amount of sero-pus and do not bleed on touch. They are more 
painful than most tnhcrmlHr prnce»sce. As n rule, they n-main ittation> 
ary until the patient hijcaimhs to the pulmonarj- alTt'ction, but they may 
apread, tofllet^ce. and form extensile ulriTfi. OhserTrttinns as to the 
histology of the eiirrounding lis^iuee have not been made, but numer- 
ous tubercle bacilli were found in scrapings from the ulcers. 

Trfiatrtipni. — This local ontidilion is bo raro and nf so little irnpor- 
tanoe conipntftl with the intofitinal and pulmonan,- loaions which nopom- 
pany it that no one has formulated any treatment for it. The appli* 
cation of the galvano-eaii lery or X ray might destroy the bacilli and 
cause healing, hut the general constitutional condition is the chief factor 
in (he case, and all effort should be bent to remedy tliie. 

Change of climate, creosote, cod-Uvi'r oil, hypo phosphites, foicedl 
feeding, and all the hygienic measures adopted in general tubcrculosig 
ghoulcl Im* employed; hut after nil, nothing that is known at present 
can pnnlile one to give a favomhle prognosis in such eases. 

moeratire Variety, — All tubercular proeeseee of the superficial tegu- 
ment-s arrive sooner or later at an ulcerative stage. The characters of 
these ulcers differ according to the tissues involved and the con^titu- 
tional ctmdilion of the patient. 

Simple tiihepcalar ulcers of the anua begin iu nn obscure manner. 
They may develop from contusions, Tounds, and injuries, or they may 
be idiopathic. 

The patient generally has a history of tubereulosie cither hereditary 
or acQwired, Init there nay he no marked hiailization of llio diseatte. 
.'\ smaU induration or nodule occurs in the suiicrficial layers of the skin. 
Traumatiwrn, friction, or injury nmy caiiau a bri'iiking dnw-n of the tis- 
sues, and ulceration reaiilta. This may U' brought ahout by an attack 
of diarrhcea, n horseback or bicycle ride, or a thrombotic liieTiiorrhoid. 
It may start in the nnal cjinal or in the skin itself around the anus; it 
may be confined to the latter tegument, or it mav be limited to the 
anal ciinal. 

A» to the comparative frequency with which it attacks the two por- 
tions of the anus, it is difficult to decide. In nearly all of those cases 
which the author has olwcrvcd. the ulceration has at one time or another 
involved both the perianal tissues and the anal canal, llartiuaun, iu his 



i 



TUBERCULOSIS OP TUB ANUS, RECTUM, AND PELVIC COLON 1^5 



I 
I 

I 

i 



I 



pxliAUslivc sluilirs upon this gubjeut, iiIhIcb tlint he ha& four timt-s sern 
thp<;t! ulcprations almost I'litirclv Kurmund tli<* nnuti, dci^t rowing all tlut 
<TitaneouR tissues with the exrpption of » small liridRe of ekin which 
was Iffl intjtct without involving the iinal canal. They majr tleveloi)' 
singly ami spread tn both sides of tiie anus, or several ulcers may develop 
at one time and coaleece to form one large, irregular ulcer (Fig. 80). 
They are irregularly round, the edges more or less ragged, and they tend 
to Bpivatl circularly and upwanl into th<> anal canal at the same time. 

The borders are clear- 
cut, iinijf^rmin^, with a 
pale sloughing edge, which 
fades ofT into a rose-col- 
ored border in the skin. 
'Hieru is au induration or 
hjpertrophy around the 
nwrgin; the haso of the 
uloer is irri>gular, gniyish 
in color, and presonlA a 
sort of elevation in the 
cvnttT, with a dvpression 
around the cdgei; bcnimth 
thu* UD(lcrnu»<fd akin 
(Plate 11. Fig. 3). 

Thp grantilatione are 
pale, do not blewl easily. 
and an> of very uumjiuiI 
«tze». Here and there 
<icattere<l over (he ulcers 
an* amall yrltnwiah pim- 
ples or tuberclefl which 
eoem to be embedded in 

the tisKue. Those may be picke«l out with a needle or a sharp spoon, 
but they do not come away with gentle wiping or irrigation. When 
they am picket) out they will leavt? a sort of ravity, Bmooth and shining, 
and aboat the wxe of \o. H hinl-shot. Hartmann stated that the surface 
of these nicer* was always soft aud 8up])te except in two ca«c». Th« 
author has excised a number of them, and ha* yet to find one in which 
there wu not an imiuralion iK-iRUth the arm inroWed; he has found 
In (he scrapings tubercle bacilli, thus proving their nature; and be- 
nnth the gninulatiiig ti.'fsueBof the ulcers there was a smooth, gliislening 
li&iui* that showwl a lUmmn alteration of the tegumenU benculh. or, 
in fact, a real cicatricial development, in which no tubercle could be 
found. 




FlO. B»|— P»IU*»4'. TLIll.Bi.[.L.Vli Li.^1.11 -l 111... ■ Mils* 



ISe THE ANUS. KKCTL'M. AND PELVIC COLON 

FaJD is not a markvd e,vm]it<nii. OnliDarily Ibe patient suffers very 
little even frnm faecal pui^u^'cs or the direct huudling uf Ihi? piirls. Oc- 
catiionaJly, hoit'evcr, when the uicuratiun invade-^ the anal canal and 
assuniei^ the lorm of fissure, tlie pains become more severe at the time 
of (k'feciilion. Ad u rule, howuviT, tuliTcular ulcwrations of the anal 
caniU jLiul it-H margin sirw l)oili tompiinLtivL-ly fn?e from pain. Al- 
moni withtiut e.xcejitiuii lian this beuu tlie cjue lu Lhe lar^ uumbvr uf 
tubercular ulceratinnti of the ituii.s sren in eunhumptiTe patients in the 
tiospitnl cm Btatkwell's Island. In Iwn cjik'p in which the nlrt'rg were 
excised, previous to the operation ami inimpiiiately thereafter the i>a- 
ticuta aulTcrL'd no pain whatever; but when tliL- wound )iad aJmoitt healed, 
and there rcmuincd only a smull KrQniilatiun at the niarj^in of the aous, 
Ihey W-jjcan to cnmplain of sphincteric spiimii and piiiii following the 
f(w«l niovementif. 

In another cai>e, in which a tubercular ulceration was cauterized with 
thu Paiiu^Iin cautery, lliere was uo pain previous to it. nor aftiT lh« 
first cauterization; hul after the second, when the discharge had aliuoat 
a'UHL'd and the ukcratiuu was uppurcutiv hciiUu^;, the puiicnt suffered 
mure or less acute pain after fa'cul muvcments. At this time, cxamiua- 
tion of the slight discharge, and also the scrapings of the ulcers, faiU-d 
to demonstrate the prewnee of any tul>erelc bacilli. The tubercular 
pruw»;6 was aflerwurd rei^tabHdib'd in Chi^i wound, and it Itecauie ugain 
painless to the touch. It is JitrieiiU to umlerslaiid why those ulcerations 
an' not painful. There is the inflaniinatury element, th<^ development of 
llhrotK tisfiLc, the involvciiitnl of the seiisilivc ncr\-e iircss— in fact, 
fvcry elcmcEit uceesHiry I" account for thf production of pain, hut no 
satisfactory explamition of ita absence has been nfTiired. 

The discharge from these iileors is generally limited, of a thin puru- 
lent characli^r, and very rarely tinged with blood. Sometimes there 
may \ip. a mixed infeetlon, and the quantity of the diHchargc h mntcriallj 
increased. 

When this type of ulcer extends into the anal canal it does not 
usually assume the fonu of fissure, as do most other ulcers, but seems 
to spread over the radial folds and down into the sulci at the same 
time. It ie luually limited by the "white line" of Hilton, hut may 
extend upward to the border of the sphincter, and end in a clear-cut 
margin, somewhat indunited, with a perfectly healthy mucous membrane 
just above it. 

The progress nf tubercular ulceration around the anus is vari- 
able. Sometimes it is very slow, while at others it is rapid imd de- 
structive in the highest decree. Contrary io the history of svphilitic 
ulcers, there is no tendency to heal in one part while they progress in 
accther. A tubercular ulcer io the absence of trcatmeDt shows but one 



1 



TL'BERCTLOSIS Or TLB ANUS, EECTPM, ANI> PRLVIC COLON 197 



I 



tendiiicv, ujid llml is to progrpss in all directions; uiiJer geniTal con- 
Btitutional nnil local tn^atnirnt it may he healtdj but if left alone its 
onwflrd march is stopped only by death; it ie not, aa a rule, fatal io 
it«elf, but it remains as a dieturbinp elfuieat imtil the aul comcB 
through development of other tiibcrculnr lotion? or some form of in- 
tercurrent disoasu; ordinarily it 19 acute pulmonary or genito-uriiuirj 
tuberculosis. 

ANAL TUBERCULOSIS 

Tuberciilosif may atljick the anal canal oitlier by cxtcosiou fmm 
the pL'rianal rcfpon or priiiiarily. Indeed, it in oftvn a ciiii.>»tiun whetlirr 
tho diDtiase orif,'inatcii iu the perianal or intra-onaL tisstiog. Jn tlic 
anal canjd the niiliai^ or nodular typo ir< niri>ly obnervcd, but the itk'or- 
ative form is very comuinn. It n>utuinei^ the sliapc of tis^urc simply 
on account of thi? ronforinntion of the part*, the overlying niemhraiic* 
bi:ing corrupted or comprcstsed into folcja by the contraition of IJic 
sphincter. It docs not long remain confined to the sulci, but nijjidly 
(ittteml^ toward llie cutaiu-uiiH morjrin aud upward upon the radial folds, 
sometimes crasiiinx i>ver frum uuu Hulcua to another, c-ntirely destroying 
the muco-cutancons covering. 

Thu ulcew mny bt' single or ninltlpU-. In the latter case they snon 
coalesce to form oiu» idcor wliicli may entirely turrnund the eanal. They 
•re (]utingi)Lsht?d by their clear-cut though irregular bonSere, their 
grayish-yellow ba.sL>«, with here and tlii-rc round tubercles in the grnnu- 
lar inane, and by the little foci of diKcusc tliut i-xtuud into the subcu- 
tanoous lisBui'S like n-orni-liolci; in wood, and sometimes result in aiib- 
tcgumcntar>' fistulaa (Plate II, Fig. 1). 

The absence nf pain in any marked degree is the moat charnet-erislic 
foaturc of the intra-anal tulM-n-ular ulceration. All other forniR may, 
under certain iMreuiiiwIanci-s, produce acule, las-ting [»nin, re-«eudiliiig 
true irritable ulrer, but with tlie tulierculiir ulcerutinn this almost never 
occurs. It in true that tubcrculo«iH may be ingrafted upon an irritable 
ulcer, find we may liave the two conditions combined in the same 
anuH, but under such circumfilnnces one will have the history of lively 
paioii aud e>pasm of the sphinder having exititcd for a period entirely 
too long for the liiberciilar ulceration to have rcmaired so limited in 
extent. Had the bwion Ijcen tulH?riular at the beginning there would 
have bn>n gn-ater dewtnu-tioii nf tissue thiin in seen in such mixed casea. 
Chancres, muetmii patches, and rodi^nt uln-n* of the anu* are all much 
mon- painful than tlip tultcniilnr variety. The explanation of this fact 
may lie in the relaxation of the muscles, or it nmy bu due to Ihe fact 
that beneath and around tlie lulM-nular iilreratlon there is always formed 
B eoiinc«t»70-ti«suc cDvelopc or wall which is not thick, hut which pro- 




i 



198 THiC ASUS, KKCTUM, ASf* PELVIC OOI.ON 

tects the deeper tiaeuw from inicction by the pathogenic process and 
thus avoids the invoWcmont of the ReosUive nerve roots in a procoss of 
perinL-urilit; a»!i<x-iiLlL<J with mib^cuUr uoiiLraction. Involvement of tha 
lun^ Hiic] iitlicr urguiis ie itiucU itiuru fi't^quunt in tub«rculo»i)4 oi the 
anal ran)il than in tliat uf the perianal region. The higher the inrolve- 
mcnt of the. intestinal canal, the greater is the probability of general 
tuberculosis. 

Pathological Anatcmy. — The patholofrical e:iaminatioii of these 
ulcors *how3 qIw/iys upon the cutaneous bonier Jegeneration of the 
corneous layer of the epithelium. There is hypertrophy of the papillary 
layer and great infiltration of the chorion, which dips well down into the 
deepLT layi^rM of ihe derma. The granulHt stratum is deprv!S,ted by the 
inllamniatury proct-sses. The Malpighian bndies are sometimes hyper- 
trophied or swollen, aometinits absent. The blood-vessels present eri- 
[dencvR of tubi-rruloi^ii; in the tliickeiii>ij und fibrous con^lition of Ihoir 
rails. The papitlar, hyiwrtrophied und iuliltrutcd, compo** the fleshy 
granulations, and by their conglomeration produce the oascou? follicle*. 
These fleshy granulations ajijuar rough nnd t-lovnted in epottt, but do 
not hav(' deep sulci dippiuff duwn betwit-n llieiii, as in fondylomaln. As 
HurtmuEin saya: "In thcee masses there exists a number of caseous 
tr«i'1-s which start nut, in gi^neral, perpendicularly to the surfaiv of iJie 
nicrration. These tracts, which open proliably by small mouths upon 
the surface, are lined with epithelial cells, and result from the fusion 
of a large nunilxHr of tiilKTcnilous follicles, as is proved by a certain num- 
ber of isolated follicles." My examinations have not demonslratvd Ibeic 
facbt, but we must acoept the reports of such careful work as has bc«n 
doni! by Ihe nuthorK quoted (f'hir. d. rect., vol. i, p. 12-1), 

The muEvt imjiortant element in these pHthnlngieal oxami nations, 
however, is the cicatricial or fibrous layer which develops in the deepest 
tissues down below these tracts and outside of the area in which ths 
tubercles are found. This material not only involves Ihc smooth and 
striated muscular Gbere, but also the blood-vessels and the nerves; the 
latter are incliulcd in sheaths of embryonic cell? and a sclerotic tissue 
similar to that developed in the muscle. In this portion of the ulecra- 
tion we have to deal with a purely inflammatory process which foniis a 
sort of wall aniiiud the tuberrular focHs, thus obstructing the invasion 
of the surn>unding healthy tissues by the tuEicrele bacilli. 

The rationale of this is shown in the fact that where n cicatrix exists, 
the disease docs not progress beyond it. Cicatricial tissue is an absolute 
barrier to the extension of tubercular processes. A IuIktcuIuf ulcer may 
involve the whole circumference of the anuit and never dip deeper down 
than the deriua, bcL-aut^t? Ihis wnl! of mnncctive tissue is formed at its 
base. Qu6du relates a caise in which the ulceration developed near the 




J 




t. TUBLR^ULAft ULOEKATION WITK ntTULA 





a. uipoio uLCUi 



ANAL TUBERCULOSIS 



TrBERCULOSlS OF THE AKl'S, RECTDM, AND PBLVIC 



site of nn M fiRtoIoiis trnct, Btid stitce as e. very interesting experi- 
ence thnt the nlcoralion never crossed or broke down the eicatrix left hy 
the old nperetion. His experienw h by do itieang unique. It is easily 
eiiilained by the facts that cicatricial iUme h alincKt devoid of Lloud- 
veasels. and is abeolutt-ly free from lyiiipliatics, und the progrcjis of the 
tubercle is alwu)'^ along one of theoe lines. This is the ino^t iniporttiiit 
discovery with rejrurd to tuberculur iilcerH in recent years, nemnd only 
to that of the bacillus, and it formfl tht basis of all local treatment. 

Fatty degeneration of tlieee ulcew ia & very rare occurrence. In- 
volvement of the lymphatic planda occurs, if Ht all, early in the ppooeas. 
Pulmonary or genito-uhnnry tuberciiloitis may develop from the disease 
in the anuss, but usually they precede the latter. 

Treatmenl. — Jn the larpo majority of cases the local lesion Ja a 
minor consideration compared to the piobablc constitutional involve- 
ment. The healing of the sorL* depends upon the power of resistance 
in the tissues, and the better the physical condition of the patient llic 
^eatcr will be this power. All trontinent, therefore, wliicli de-presses the 
vital force*, which decreases the tone of the tissues in general, or which 
interffres with (lie free nnd full oxidation of the blood will be detri- 
mental in the nuna^aTiifiit of these canes. Thus, extennive operationa 
wliidi eonflue the patient to l)ed or even to the house are unadvi^ble. 
Prolonged local treutnicnl, vvluLh rc<|uiri» tin- patient to remain in 
large L-entere of populalinti, or t" be ennliued in hospital warda, is not 
likely lo prove suareHitful. l-'hange of climate, outdoor exercise, forced 
feeding with fats and hydrocarbnns, together with macsage and oil in- 
UDCtiiHlfl, will do more for Ihcuc coiidilious than liical Ireutmeut nr sur- 
gical D|)erations: at the same time Iho latter neeil not be neglt-cted. 

Tlie partu ithould Ix? kept clean by bathing with [H-Tniidi" of Imlro- 
gen, HoluliiuiH of bichloride nf mercury, or other anliw-piics, If the 
aleeration is extennive, a gaujce drex^ing niolHteiied with one of these 
BolatioRj) should be kept applied. Painting the ulcer with a folution of 
methylene blue, It* grains to the ounce, seems to have a good effect, and 
can be cirrled out by the patient himself. As a rule, powders seem to 
make these ulcers wftrs<^, but weently some very good results have fol- 
lowed the Bppliratinn of orlh«ifi)rm. In one ease u large tubrrculiir 
nicer, involving almost the entire anus and dipping well into the 
ifichio-rertnl fossa and the perineal triangles, has almost roraplctcly 
healed under the combined iniC of this drug and the melhylene-bUie 
applications. The same ulcer grew steadily worse during treatment by 
the actual CAutcry and many other methods ordinarily advised. 

Kt'cently the Hoentgen rays have lieen reeomiiiended for these ea»c9, 
bnl nothing dnilnite in known nn to the results of Ihia treatment. The 

aionat application of the actual cautery, together with tlie looal 



■ 



* 



THE AKL'S, KECTUM. AKD PELVIC COLON 

and by^CDic nieaaures indicated ahoTc, appear to be the most reliable 
raiHliod^. The caeee treated by ortlioform and inctJiylene blue, up to 
the present writin):, «re ton fpw to justify nne in recorafncinling the 
niothcid imrcsfirniily; il nppi'nrs, liowever, la be worthy of further trial. 

Lupoid Ulceration of the Anus. — Ft»r a lonjj time it vras believed that 
luptiB wan d sjH'Litie variely of ulcer. Reeent ttttidics in pathology, how. 
ever, have ftiiuuu it to be only one of tht> many manifestations of tuber- 
culoiiis. It it of a pitrticuturly aggravated form, slow In its march, yet 
feiirfully dcstrmrtive tif liKsmr?. 

Under the title Ksthiomt^ne nnd Lupuii Kxedeus this eoadittoo Han 
been described with groat detail by R. W. Taylor {Sew York Medi- 
cal Jounuil, .Tanuiiry 4. l»l«l)). Jjitu eonelut^ioDH at that time were tliat 
the L'oiidiliuii i» a Fiyphilitie iimnifeBtation, This view, liowever, has 
btfeu abaiidoiu'd, and wu now etiine to reeug^iiize in hipus only another 
form of tubenml(>!ii<i. ThnsR who fnriri«rly held that the condition was 
syphilitic: iiilvRnre the tliei>ry that the pccuHHr niursc of the ulceration 
was due to inortilation of tiilHTcnlnr or scrofulous individuals with 
eyphilii). Were the ulceration of n sypliilitif nature, as has 1k;cq held 
by these writers, constitutional treatment would have modified its course, 
checked its advances, and prevented it« reeurrcnce, but such is not the 
case. Upon these uJcerations syphilitic niedieation has uo effect whnt- 

The coadiiion is characterized by progressive ulcerative destruction. 
Ordinarily it begins at the nuioo-t-nlaneous margin eitlicT of the anus or 
tile \Tilva. The outline of the ulcer is irregular, clear-cut. and indurated. 
One sees at times a flight ti^ndc^ncy to cictilri/,e at cbrlHiii pifintf. but 
after a short time thctse ciciitrizutioDB break down, rculocrato, and spread 
farther in the tisBiios. 'I'siylur doe.* not ?t«te what wa* liie (inal result 
in the cases which hi! saw, but of the S niwes reported by Allingham, 
3 certainly, and probably .1, fiiuilly auecnnibrri to tuberculosis. Be- 
neath the nlcers there is always the devclopmciit of fibrous infiltra- 
tion identical with that wliicJi we have described beneath the sim- 
ple tubercular uleeration, and tlironph which the destruction of tissue 
docs not break until very late in the disease. Upon this point Keleey 
■ayfi, in rcGOHuting an interesting ca.ie upon which he openited and 
tried to remove the ulnerated enndition by scraping and cauteriza- 
tion: *' I was surprised to find it inipossiblR to rearh healthy tissue below 
the ulcer without removal of an immense m»ss of inflainniatory thick- 
ening. There seemed to l>e no healthy roiincctive tissue ni-ar llie sores, 
but simply a brawny, honeycomlied condition, resembling, after ecraping, 
a mass of hard cheese, with a network of tonnective-tiasue fibers run- 
ning through it." 

The Bpaees between these fibers were undoubtedly due to fatty de* 




TLHEROt'LOSlS OF THE ANUS, KECTCM, AND PELVIC COLON 301 



generation of th« muscular fibere and tubercular invasion of the lym- 
phaties and cellular tiit»ue. In this eame case Bpcoific tn^atmi^nt was 
cflrrti>(l to ilti full extent, but without efTect, and the patient Hnnlly iJicd 
from exhaudtion. The extent to which thi* form of ulcienition may 
proceed is extniijilifU-d in the following cascr rejtortej by Angus Mc- 
Donald (Kdinburgli Meiliciil Journal, 1R84, p. 910): 

Quoting Duneau's dpHcription of the ca)>e, he says: 

" ' A caee to which I wa» called aoiuc years ago if, so far aa I knew, 
BO unprecedented in the amount of destruction as to be worth describ- 
ing. I only .<««■ it once in ponsultatinn. Tlie disease wa» nt nnc time 
regarded as eanc[>r<)ii», 'I'ho patient, aged aboet forty, liiid had the 
di^^ase for at lea&t five years, and she lived many yenrn after my visit. 
\V1iile the ditiL'Ui*e vras alrcjidy extensive she borv a uliikl. On the liip«, 
jiii^t beyond tiie i^fliial Uibenisities. wert- lon;^ stars, ihiu mid blui.th, of 
healed uk-en*. Tlie entire ano-perineal region wub gone, tlicn- being 
a hollow spaa- aa bij; &^ u fatal head. The urethra was entire, as well 
as the mneous nienibranc between it and the cervix eteri, which was 
healthy. Except the anterior portion of the vagina, no trace of it, or of 
the nnuR or recltini, was discorernble; behind the eorvix uteri the bowel 
opvned by a tight aperture, just sulViL-ieut to admit a linger; when the 
ftwes were hard she could keep herself clean, but only then. Although 
the extent of uleenition was aeven; the piitient wa.s iiltending to lier 
hou^eliuld duties,' To this graphic description of the faw I can fully 
subscribe, with thi» addition, that latterly the ulceration went still 
higher up into the |>elviii, leaving thi^ bowel hanging loose for some 
distance from the upper level of iikenition. giving it the appearunce of 
the torn filoovc of a coat. This patient lived two and a half yenro 
afier the iinie referi-ed to by Dr. Dnncan, and died of e.\hau!tti()n and 
diarrha-a. KotM'illiMttmdmg this shocking amount and prolunged con- 
tinuooce nf uleerativc action, there woa no invohemcnt of inguinal 
or other glands." 

Allinghaw, Ball, and others have seen cases similar to this, but less 
cxtensiTo. Bender (Vierteljahr. f. Derm. u. Syph., Wien, 1888, p. 891) 
deKoribes one in which a large portion of the rectum was involved. Ordi- 
narily, however, the ulceration is limited to the eutani'ou* and raueo- 
mtaneous tij^sues. 

Oenerally the ulrer begins in one nr rnort' liltle eircular or semi- 
rirculur infiltrations in the fkisi or niueo-eutaneous ticeiie about the 
•DOB. Time break down, ulrerate, and, spreading at their borders, 
the little foci coalesce and fomi larger ulcers. The edges are flharp- 
ttit and not no much undermined ad in Bimple tubercular ii leerntionB. 
In one rwpeet it wrniB tn differ entirely from theKc. in that it has a 
tendoney to heal temporarily and produce cicatrization in certain areas; 



SOS THB ANUS, BECTUM, AM> PBLVIC COLON 

bot thia only laet« for brief periods, when it breaks down agftin, and the 
degtmctioo of tiiwue advanwg beyond tlie origiual liiiiilation>!. Soine- 
times the QlberBtiuiu umy lake oa a eerpigioous (onn, advanciDg in 
two or more narrow traL'(«. After a time the interrening tissue be- 
tween these tmd-'i gruiluiitly breiiks down, and ttie wliole urea becutucK 
a part of the origioul ulreratiun. The edges of these ulcers arc DCvcr 
thickeniMl or indunittxl to any great extent The granulations are 
gcDemlly palf, although occasionally they may be bright red and ex- 
uberant. Bender deucribes them as a reddish-brown, and eometimoe of 
AH oHIoreiicent type. The baBe of the ulcer itself jii soft, but the under- 
lying tnflninmatory deposit gives to it a stiff, inelastic feel upon linn. 
praMore. 

The iialhological examinations of these eases made hy Besnier and 
Schuchai-dt jilace the tuberculuuH nature of the nleers beyond doubt, 

In one case seen in the city ulinnhou&e. a man, aged eereiity-four, 
hud sulfcred from ulceration about hid rcttun) for a nutuber of ycftn. 
Jt never gave him any particular pain, and only rcquirii>d the wearing 
of a eloth to protect hi« clothing. When «cen by the writer it had be- 
come somewhat i3i(lic-ult to move his bowols or to walk. ExaminnlioD 
showed a vaxt ii k't-rated areu involving the entire cireumfereuw of the 
anns, and extending as high up as the up|H.'r border of the external 
ephincter. The skin for 2 inches around the entire anus wiis destroyed, 
and the ulceration diiJjtLMl down into Llie cellular tittnucs pustcriorly and 
at the sides of the rectum to a depth of j an inch or more. The mar- 
gins of the ulwrntinn were not indurated btit slightly undermined. 
There were nl points in its circunifLTency evidences of attempti^ at 
eieatrization, but there was no contraction or sppjircnl diniinution in 
the slue of the ulcers from these ePTorts al healing. The granulations 
well! not c.\iitM.-runt or efflorescent ut any poinl, but were more of a 
grayish-brown, proud-flesh iiuture. Beneath these granulations there 
was a liurd resisting ba:4e which extended outside !he margin of Ihc 
ulceration and iipwnrd until it joined the wall of the gut. At the upper 
margin of the ulceration the mucous membrane of the rectum, clear-cut, 
inHltrated. and somewhat elevated, seemed abg(dutely to limit the in- 
vasion (if the ilisen»e, and was perfectly heHllhy at a distam-e of one or 
two lines above. 

The patient lind ptilinonary tuberculosis at the time, and wa« taken 
from the hospital !*!ioi-tly nflcrwiird to a home in the counfrv. where, 
it was since learned, he died from the disease. 

The nren nf ulceration from side to liide meiisurcd 5^ inches, from 
beforp biickward 2J inelies, and the depth from the margin of the anus 
upward behind the rectum was about j an inch. 

There appears to be quite a difference of opinion between Ailing- 



I 

I 



J^ 




TUBERCULOSIS OP THE ANUS, RECTUM, AND PELVIC COLON 203 



hnm aod other observere concerning the clinical apponrance of lupoid 
alc'craUon, itti location, and the nnlure gf its invasion. The former liolds 
that it occurs in ihi- n'fttim, uiid ils ti-iidimcy is tti iitt»(^k tlio inurong 
membrane rather than tJie skin; tliiit it does not invade the neiglibor- 
iDg tissueg by infiltration or tliraugh the lymiihatics, forms no sec- 
ondary dfposili^. produces nn hardnfws, and does not aiTerl the follicles. 
He t^talL-^ that the diagneeis can he positively made on nit;hl. 

Others (Ball, Cripps. Kelsey, Gant, Taylor, and Qu6nu) «latc that 
itie fjererally found in conrortion with the disease in the fi^'mnte poni- 
taU, and is largely ponlinod in the akin and intien-cHUnpnoii iiioinbrniio; 
tbat thero i« induration about the haKC and edges; that microsenptc 
examiliation establishinp the prenenee of tubercle bacilli or giant cells 
is Decwfcary to distinguish it frimi epithelioma and syphilitic ulceration, 
and that it docs extend alont; the lyniplmtics. 

All BKn'L- thai it is e^^i-ntially a dci^trut-tivL- legion and of a tiibereiilar 
nature, with rk-an-cut, irregular, rarely symmetrical cdgce that luuy or 
may not be undermined. 

The writiT has ubnorved two eases nlmost from their incipiency. 
Both were in males, and te^an in (he skin at the anal margin. One 
developed around the eieatrix of an old fistula, aa in tlie cases of St'huch- 
ardt and Bt'siiiiT, and ttiL' nthcr in a skin-tab just btdow u iWurc. 
Both stnrtcd us little nodules or indurnttrd ma-sst-s in the akin. Thi-se 
8«omed to have nn n-Iation to the hatr follidps, but in one ca^e ap|H-uri-d 
like obstructed peliareous gtandfl. The nodule? in each ease broke down, 
diacbareed a sort of cheesy pus, and left round, dear-cut ulcers. These 
soon coaleaeod and fonned one large uleur, which slowly but steadily 
ext(>ndi>d iirnund thp anus and into llio iinal i-annl. In ohl' case the 
process involved the nnimus niPiiibrano to the height of J an indi, in 
the other it stopped abniptly at the ano-reetal line. In the fistula caae 
the cicatrix seemed to liinit its extent in nne diri'ction, sn that only 
half of the cinumferenee of the anus was involved. In the other the 
diseoae epread all round the aperture (Plate 11, Fig. 'i). In both casea 
there soon deVLdoped a fibrous or cifatricial depo>^it btneath tlie uleem- 
lion, which extended almost to the healthy skin outside of it. Thw 
mass was pcnetmted here and there by small, soft spots due to fatty 
degeneration of the miiitculiiT fiberu. 

The ulcerations were irrcjiulnr in «hape, with well-defined, indu- 
nilwi Iwinlers sliRhily undermined. The bases were brownish-gray, de- 
pri'SM.'d, and covered with scant, purulent secretion. There was prflc- 
lii-ally no pain in either case. 

Ilintolojtieiil examination of the Rcrapingn ohowed tuberele bacilli 
pnuent in both cnwf. The eslensinn ni'Rined uniform and not in the 
lines of any vceeels or lymphatics. Time and again in both cases the 



9M TDK ASUS, RECTUM, AXO PELVIC COLOS 

parts appeared to bv bcalioK and then broke dovn agkia. leaving tbe 
uker deeper and more extensive than before. In neither ca«e were 
bnf;ht-rtMl or efflort'««nl grBniilnlinna, *» dcHribt'd by Bender, suen 
except in very sumll epols. The ulcere did not bUwl pasjly on touch. 

Treatment. — Tbe uitual treutiuent uf (hbi condition omKists in the 
applicalinn of chemiciil ur actual cauterisation. Nitric acid, chloride of 
sine, acid nitrate of mcrcurj', etc., have been adviwd. ag have also tbe 
Paqueltn and galTana-cautcry, Where there in pain thie will be eoiiic- 
wliat relieved for a time by such application*, b\it the benefit is only 
temporary. Aceording to riffard, the nppttcation of strong solutions 
of peroxide of hydrogen used every few days eeems to be more effoelual 
in the destruetioii «[ the tulM-rcle bacilli and tin? development of hwiUliy 
fframilatioti!' thiin any of the other cheiuicHl agents. It may be veil 
in the beginning nf the treatment to cauterize the parto thoroughly 
bv the I'aqi]*>lin caHtery, but one iinist alwBvs remember that the 
stitutional condition uf the patient suffering from this form of disi 
is not euch as to justify any great ehock or de^tniction of tissue, 
that the lack of vitality in the {wrts may «iii»ie Buch a hum to result 
in eslennive Rluugh, and thus do more harm than good. While actual 
cniit privation is superior to chemical, or esciition, or curetting in these 
conditions, the author ran not hut sound a note of warning in view of 
the experience which he saw some three years ago in the New York 
workhnuBe. 

A young man having an extensive lupoid ulceration about the inar- 
gic of the anuB, whieh the attending surgeon looked upon as chaiicruiJul, 
wiiB etherized and the uleeralioa exeiaed, the base being thoroughly 
bumed with a Paquelin cautery. The patient sntrnreri estremelv from 
nhnck. There was great Jtlouyhiug of the tisKuet;, ko much indeed that 
the whole external sphincttT and lower ineh of the rectum for onmlialf 
of its rireiimfercncL- were destroyed. The piiticnt suiTi-red from incuu- 
tinence, and within a lew woekfi dcvelo^wd acute tulierculosis, from 
which he died in about five months. The cxaniinati&n of the specimen 
showed typical chiinioterititicn of tuU'rc-ular ulceration. CoDservatiflm, 
thtTL'fure. h (if the grculeiil iiuporlauce iti the treatment of thcae ulcors. 

Methylene blue, 2 per cent in water, has held the disease in cheek 
better (ban nny ullicr rtnicLly in my hands, but nothing liati cured it. 
Electrolysis uud the X ray have been recommended, and recent reporta 
seem to confinn it^ ueefulnese; tuhcrctilin has been tried, but in vaiu. 

Curettage, followed by the X ray, together with gencrnl conetiUi- 
tional trcatniMit liy tonica, cml-livpr oil, crTOsotc, and forced feeding, 
appears to give the most uniform results. 

Verrucons Tllcerations of the Anns. — A very rnre variety of ulcer*' 
tion of the anus iiH.s bwn ilcwribcd under the above name. The 



and 1 



TrBERCULOSIS OP THE ANUS, RECTUM. AND PELVIC COLON 205 



» 



I 



I 
I 



raeeti reported vrere by Toupct and Kouticr ( CoDgr6s pour I'l-tudc dc la 
tuberculosc, i6\>3, p. SOS) in 1893. At the same congross M. ilart- 
maim reported two easea o( this conditiou {ibid., p. 5!>). It resL'in- 
Llcs epitbelifimalouH ur papilloiimluus uk^niliou!^ uX tin.- luar^iu uf the 
■nus. Judging from lli<> duKcriptions givi^n by these authors, it would 
appear to l>e of the nature of tubcrmlnsis varic«sis iicuti-s or lupus 
papillaris raricoaisi, a» descrilH^d in the workn uprni di^rmatnlngy. In a 
case communicated by M. Duplaix the appearances of the ulcers are 
described m follows: 

" Scattered arouud the anus in places there htq small TC;getationa 
slightly jutting out Dboi'c tho healthy skin which surrounds them. In 
plnees the Rkin. slighfly ulcerated, siinwh ^ismll enUniins separated one 
from another, ngglomeraled and adherent at their hasee, but free at 
their other end. There i^ a mixture of small mammillutions and of tlio 
villous pointc. The lesion extends into the uiial caiiul uiul prolongs 
itaelf 4 or 5 ceutimt-ters into (he rcctuiii, wIiltl' one with the linger is 
able to feci numerouM anrraetuoMtiL'K xvparated by thn healthy mueous 
membrane. The whole rests upon an induratod base, and givoti an 
abundant purulent secretion, sometimes mixed with a little blood." 
(Qiifnu and Harlmann, p. 106.) Hartmann states that in one (;afie 
which he observed, the uteemtiun was in ihv nt'lghliorbn >d of a eold ab- 
Boeas of the margin of ttie unuH. and had thii- appi>»rance of a papilloma. 
The chief charaderiBtie of these ulei-rs it their pnpilhtr)' or maminiUnted 
a|>|»earnnce. They may hv coniiniHl to (!«■ ciitaneHun tissue, or they 
may penetrate the anal eanal and metuni, as tn the mM!fi of llartniann 
8Dd Duploix. The villous fi^miation i;omctiiiieii beeonies erustml over, 
thus forming a dry seab, which in a short time eoineti away, leaving a 
raw, papil]omatouB surfaee, the papill* being wparati'd by small bloody 
figBur«8. Th* basv of the uleer is indurated, but this uiduration does not 
extend into the surroimding ti.'isiies. The lyinphatie glanda are enlarged. 

The tulM:!n-ular nature of the ulcere has bL-cn verified by inoculation 
of rnbbitit and histological examination. In all the cflfH-» in which »eg- 
mente of the ulceration were examined, there were found in Ihe super- 
ficial part of the ekin and in the pnpillnry prolongationH of the chorion 
tracts nf embryonic eella containing giant-wlls and tuberelo bacilli. In 
one ense nartmnnn foiind verihibte (uIktchIous folliclos with tlia three 
typical zones conipo«ed of giant, epithelioid, and embryonic i-elU. In 
one case there was a fistulous tract which extended G centimeter uader- 
naath the skin and nuicous membrane. 

The patients did not complain of much pain cxa^pt in two in- 
BtanoM. In raws in which the ulceration invaded the rectum there was 
a diarrha-a accompanied by slight pain at the time of dofeeation. In 
one in^taocc there was fivcfll ineontincQci!. The ulceration appean in- 




THE ANUS. RECTUM, AND PELVIC COLON 

sidiousl;; the imliiriiL uoLieoit only a sliglit rougluicits at tind, tltcu a 
5wel1iii>; iini] ti-ndcrti'e«8 »f tlic parte, and iinallv a diiu^hargc of citlier 
pua or blood, in all th« euMS so fur rflported there hav* b«en evideace« 
of putiiionfiry tii borailosig. 

Treatment. — The nature of the uleeration being undotibtedlv tiibor- 
oiitous, liio troutiiiunt r^lioulil be based iijioii the same priiiL-iplus Uf iUum 
laid Jowu for the treatment of siiuplti tuberculuiui ulv«ratiuu uf tlie 
anus and rectum. 



TUBERCULOSIS OF THE RECTUM AND SIGMOID 

Priniar}' I iiberculo^is of tlie lowt-r purtion of the intestina] tract 
it cxceciliuv'ly rare. Thuru &re a few iiistunces in which the di-icasc 
hue been foiinrl in the reeta of children, but in adiiltit it in almost un- 
known. .\g Kecondary to the disctute in other orgajis, however, it is 
comparatively frequent. 

An exajiiination of 75 capes of tuberculosis in alt stages at.the Alms- 
house I[o*pitjil tliowetl uleeration of the rectum and sigmoid in 32 — M 
i. e., ay.3 per eont. This large percentage is due to the fact tliat manv ' 
of the cases were seteeted for csainination on account of haviDg had 
Bome intestinal dit-turbancea, The statistics of Luuis, Lehljert and 
Bajk', Willigk and Kisenhnrt Htate that li*sioiis of IIh' iuttntiut! occurred 
in 4il lo SO per wnt of their lul)«?rciilar patients. Thi^ ileum and cawum 
are the most fre([ucnt situs owing to the preponileraiice r)f KuliUry folli- 
cIks at thi'se piiinls. I-Vnwick in 500 aiilupKies ftmnd ttilx-'reular ulcera- 
tion of tln! n-ctum and sigmoid in 14.1 per cent and 13.5 per ccnl 
respectively. Xo cas* i^ reported, however, in which these were pres- 
ent without involvement of th« hinge and other or^'nns. We have seen 
two tn«lanecs which appeared to bo primnry tiiberculosi* of the rec- 
tuni. They were bolli small, round, or cllipticnl ulcers with ragged, 
nndemiint'd edges, gray, conical baws. and not indurated. A few tu- 
bercle bacilli were found in the scrapings, but no giflnt-cellii. In one 
ease the ])atient siihsefpacnlly developed pulmonary tnberculftsis, the 
other apparently recovered. It is possible, of course, that the bacilli 
may have come down through the intestinal canal, lodged in the ulcer, 
and niay not have Ijeen its cause. The facta and symptoms, however, do 
not warrant any such conclusion. 

Infection of the intestinal walls occurs through the invasion of the 
lymphoid or solitary folIJclps by tubrrclc Imctlli. These may enter the 
canal through the iugcftion of food, and there is no reason why they 
may not pass down and infect the sigmoid and rectum. Abrasion or 
injury is not necessary for the invaBton by the bacillus, but no doubt 
contributes to it. 



TUDKKCULOSIS OF THE ANUS, RECTDM, AND PELVIC COLON 207 

Sei?nnilur^' lubonulneia of (ln> n^crtutn ore'usinimlly owure »s miliary 
deposits U'nyath the luuoous nn'mbrani*, and frt'ijupntly as ulivratiuiis. 
Thf militin' tvpe is giMic;rally secondary to tubf!rrulo.>ilK of the gciiito- 
urinarj- opfpuiB, espo- 



Vm, iHi.— Till «.»! nun i. i-niitiiiiiK ur Tim Kxtmit wtnt 
Ri.iit(r(3i>iiii FiwTLLi. 



cittlly of tlif prostulf. 
In two of the cnaes ob- 
served, the eondition 
developed nfier the re- 
moval of prostatas 
which were provi'd 1>^ 
yoDil nil duuht to be 
tubereuloutt, iiiid in all 
cases there wltc sjitip- 
tonifl in<]icatin); Tulxr- 
culwu of the K""!*^*' 
tract. It ifi alwnjc, so 

far an our experience hKows, located in the anterior rectal wall. It 
conxii^t^ io little niiliiiry ileposiij* whiHi fed like bird-shot beneath the 
mticmis raenihrnne. Theae may ronmin stationary for a long time, or 
they may Ireak down and form hniall i'U])-like ulcera. The latter aome- 
tiuivs coalfjsce ami fonn larjifr iilefnitioiic, or they may bnrrnw and 
oolnneet with each titht-T liiHlenn'iilli the inueuiis nieinhrutie, thus fortil- 
ing Binall submuetnis listulan (Fi^*. yO). 

In ')D« taw it wii!i pl)!:'^ibIe to F^Liiijie out une of thvKe little miliary 
di'poKit». It was u riiiiiid. uliee^y luiiitit. (|tiitL- firm : and uiidt-r the 
niicn>Hc<>[x.- it jiliiiwed niiuuToiic round irlls luiderifoing eheeay defenera- 
tion, with here and there a tubercle boeilliig. ^o giaut-ccIU wore found 
in this Kpociiiicn, hut their abfienee i^ not iniiisiinl ia sueh tubprelea. 
The little nicer frnm whieh this toberole waa reiiioved bnaled perfectly 
after enuteriziitioD with carbolic acid. Thi> eondilitm hu^ not hfi-n 

seen by the writer above tht; 
rectum, and it is not reported 
in any of the KtAliHtica to 
which reference hae been made. 
Ttihtr&ular vieenilion of the 
ivctum and polvie e<don see- 
nndiUT til tuberculosis u£ the 
reapiratory or^ns i« not nn- 
niimmon. It is rare to find it 
in theae portions without its involving the ileum, ea-oum. and other por- 
liouit of the colon, but in 5! caeeis in which the patients died from jiul- 
monary hwmorrhajfe the uleerations did not extend ahnvc the sismoid- 
\ HiKtologitnl examinalinnH ehow that the disease bt'gins in the soli- 

k 




Fw, 81,— TK**»vui-r Sirrms -r Tiutin'i'HK 

t^i.rin rill Till nui-Tru. iiMwixn ElkvIiTiu 



i 




tliL'Sd tiU'i>ix ^Fig. !•]) shown a 
central elevation, whicli gntil- 
iialty (Iodines to the periphery 
b(>nniLlli the mucous inenihrane, 
thiifi causing an undermining 
of the latter. In the elevated 
))ortion or the hase smnll yel- 
low tubercles mny noTni'timcs 
li« seen with a low-power inag- 
tufvlHg-glHsB, or even with the 
rye. 

The ulcers are origioally 
round or elliptical in shape, 
but they epread by dt'KtDera- 
tiou of the hnriiers, or eoali'sce 
with oHf another until they 
foriri large, irregular patches 
(Kij<a. !>2, O-'i). The ulcers fol- 
tttw thii'fly the couriie of the 
hltfod-vesaels ; hence, in the 
lower portion of the rectum 
liioy spread in nil directions, in 
the upper portion horizontally, 
and in the nigiiioid their leu- 
dcricy is to encircle the cattal 
(Fig- !5-i)- In this and in the 
colon, where the ulceration has 
exteuded around the gut and 
thus followed the blood-vcesoU 
Hiul lyimplmtiefi to their end, 
ihe pniceas luay be antwled, 
the parts cicatrice, and a true 
stricture be formed. This 
pathology may he criticised, 
but the section of a stricture 
hnvinp tubcreuldr eharacterbt ies under the microscope, and with tuber- 
cular ulft-rs above and below it, is i>ri*«entffll in Fig. 95. 

Beneath all tubercular ulcers ther« i» a deposit of fibrous material, 
whether they occur in the intestinal canal or outside of it, which has 



fla. U.— TWBKRCI-I.AII tll^RK tXCIRCLntO Tilt 




TUVERCITLOSIS OP THE ANUS, UKCTUM, AST* I'RI.VK- COLOX 2U9 

been descritieil u an effort ou tho part of N'aturc to Jervml liKAiii'K againtit 

the ImcUH (Fig. 96). She builila. im it vft're. a wall arounU the iiifoc- 

tion, and m> luug ok it rfiiiaiiis intact the diis- 

rase vill br limited to that spot. Urccn and 

Martin have citllc-«l altoDtion to thii, saying it 

explains whj iiLTfomtious so floldoni lake place 

in tuhtTcular ulceraiiou of th*? iutustiiml tract. 

Symptoms. — The symptoms of tulH-i-culosia 
of the rectum and pi'Irir ndon will drpi-ud 
upon the Bite and extent of t he disease. Where 
it is localized they will be Itiuse of chninic 
iiinammadoD of the organs — \'ir... pain in the 
back, diarrliwa, or frequent desire to defecate 
without relief, diiichargiti o( pus, hlood, and 
rnucuK, and diaturlKinces of digt'i^tion. 

The di^harges are never no »1iundanl a^ 
in syphilitic ulceration, hut the oclor is more 
gangrenous. The bhind is never abundant; 
sometimes it i» fre«h, and at othcra tar-tike, 
indicating lliat it has heett retained fur a 
vbilc, and ordinarily it is mixed vith the 
<a?cea. 

Aslibjr says that fatal hieinorrhages may 
occur from these ulcers, but the statement i.t 
not corroborated by other observers. 

There is no acute pain at the site of the 
ulceration, and only very rarely is there any 
l«80eDiDj; of the caliber of the gut to cause 
obstruction to the fa?eal passa^^ in the rec- 
tum, hut this may occur in the sijimoid. 

To the finger the nieers gi^-e the impres- 
sion of a soft, granulating ma)u« on a firm base, 
and surrounded by irregular, slighlly thick- 
ened edges. Through the speculum they ap- 
pear aa irregular ulcerations with slightly 
derated, gray, sloping basce. surrounded by 
•lightly thickened and underininiHl edges 
(Fig. 97). 

In the lout staged of general tutwrculaiLi, 
where the whrle intestinal tract from the 
CH-cum doK-n ia involved, the patient will suffer 
from tencsmua, dmrrho-a. tympaniles. diges- ^,„, ^„„ i't^„*„„^ or 
tiv« didturbancM, and great emaciation. Tho nu Swmvuk 




SIO 



THE ANUS, HBCTDU, AND E'ELVIC COLON 



fiwuicncy of the tftooU is distrt-wmg, and th« diechnrKcs of pus ami 
Ijlttt-k. tar-like blootl are more abundant. 

Kxaiiiination with the finger in sneh eescs does not reveal inueli, as 
lliL' wliulf? ii'ctum is liiithcd in a slimy muco-pus which obscures every- 



Fiu. 



-rHUTuvicBoaiurn of TinERciiL^K Vuiii ur Tut SELTtin. 



tliini*. AfU'T thf euerotion is wiped awny. onL' may see Ihroiigh the 
ti]i(>L-Liluiii lar^L* an-ns ik'Hiided of iinicotis inoitibniiic* with little inlets of 
lifaUJiy tisauv here auti tliere. At other times there ajipear Uiienr ulcer- 
iitiiiiiK bnuH'hin^ lik>- the limb-* of a ti-iH> from a c-trnlnil ])i>i)it, and 
foriiiinjc lilth- ultirniUJ cmvifL-*. apjiarenlly fullowiti;; the hiio* of the 
arterial eu]iply. The muoou^ membrane between these tracts i» swollen, 
Te<), nnd iindormined. It kohii hri^nkn tJnwn, am] Hie whnle i« converted 
iTiti) cnio Inrge uhtr, umAi a* has jiist liM-n dcscrilKvi. This extreme c»m- 
(lition is only Keen in late utageH when clis^nhitinn h imminent. 

f}tiiitiirtxii. — Dinjcnusis nf initial tiihemilosis nf the rertum is very 
<li(liriilt. The nature of the ulrpr, as descri Iwd almve. Its tcmlemry 
to follow Ihfl course nf the lymphatics ar<l hlood-vesaels, the dcnd, gray- 
ish elevated base and undt-nninod odjiop. ar* all indicalive of the natnro 
of ihe diseaee. The discovery of lulKTele Im^illi in the iliiielmrgotf or 

HcrapingH from the nicer would, of 
t-oiirse. settle its putholojri' to a oer- 
lain (Ifjtrce, but one must always 
buur in tniiid that tubercle bacilli 
inuy be pii.ssi.tl through the intcft- 
tinal tract, and thAt they mijfht l>e 
II ml in the pti« of «n ulcer, which 
uiior itself \vn« not tuberenlar. .\ 
more positive and certain <liagno!>i» 
could be detcnnined by excLsing the 
ba^e and examining thi^ for f^iant- 
cells and tubercle bacilli. The cul- 
ture test is our final resort, but this 
is generally inipractieal. The clinical featuree of the ease, however, are 
fairlv veliablo. In Ihose eases assoeiatud with ;;eneral or pulmonary 
tuherculoeis the history of the case, the general phyaio^omy of the pa- 
tient, the character of the ulcers miming parallel with the blood aod 




Flo. ST.— Ti'BKiH-t'i ^« I'lJ-RR wiTn 8i"im 



i 



1 



TUBERCULOSIS OP THE ANUS, KECTUM, AND PELVIC COLON 311 

Iv-mpfiatic Bopply of tho Tectum, the great lose of Int, and the sunbon-in 
conditiiin of the anal mnrgin, together with Iho appearaocet^ of tuberele 
bacilli in tlie discharges from the rectum, will serve to ccmliriu a diag- 
nosis which is alwaj-g inferred when symiJtoma of diarrhLta. iudi^ntiuu, 
and inteMiDa] djiinirbancea utxur in the tubcrculuus. 

Treatment. — The Iryatiiieiit of tiilH-Teulo!!ii» of the rectum nnd pulvic 
colon ia Dot CDCouraginj;;. la a few luculixed conditiuue in the rcctutn 
the iiliyrs may be pcrnp^'d out, cauterized, and heakd under the best 
hygienic cnnditinn?, but these eases an? vorj* raro, Iii tb<! large uinjority 
g(?npnil luberoulosig of the reepiratory or goiiito-urinary syslem will have 
l*ecii cslablii^hed before any iiotict- ik taki>n uf the intestinal coiii|>lti:atiuii. 
All that can be done in such casea U to keep Iho parts clean ly colou 
flushing vitli anti^epLio ^oluiions. and protect Ibcni from inilutiou as 
far as« poi7«iblc by a bland bul iiouri!<hiiig diet. 

Thf hygienic and therapeutic nicasureB suggested in the section on 
anal lulii'reii1<>Hi!< iiTp iijtplicnbk' licpti, but thf prrtgnosis i*i not ko favor- 
able. It IB simply n f|Ui'-stin3i of gpneral tiihrrcutofiis, the cure for whieb 
bam iiot yi>t Ih'Cii fomid. 

Hyperplastic Tuberouloais. — ITuder this tillr, suggested by Coquet 
(Th^flc, Paris, IKiM). liaa liccii described a peculiar condition of tuber- 
cular infiltration of the intestinal walls. It occuntd most frequently 
in th« ileo-CTcal region, but was found ill other portions of the largo 
inteatine, partictthirly the reirlum. Delbot and Muuehot (Archiv. g6n. du 
mdil., 181*3, pp. 513, Ii(i8) rc'f4'rrcd to it under the titU? of mctitis byper- 
tn)pliir|Uo, prtilifcrHnte et steiiosantc. It i« eharacterized by extensive 
formation of Hbrmis and tuben'ulnuu granulation tissue in the wall of 
the gut. It induces a sort of fibrous hyperplasia instead of caseatinii 
and necrosis. Jn the large intestine it resembles scirrhoue cancer very 
much, and even Billroth unce removed a sectioa of the gut affected by 
thi» di«ea)<o under the impression that it wm carcinoma (Wien. mod. 
Preww, I8ft1, p. \m). 

lartigau (The Journal of Ksperimcntal Medicine, v(il. vi, p. 41) say»: 
" For years hyperplastic tuberculosis of the rectum hnn been coufu^ed 
with ayplulia of this vlgciis." The pathological nature of this iHindiliun 
in the i-ectum was first pointed out by Soni-dJIIc (Archiv. g(5n. dc nied., 
1895, vol. i, pp. 531 and ^97; vol. ii, p. H^. 

The walU of the rectum are greatly thickened. 3tifr, and indurated. 
Tlicy fonn a cylindrical tube which does not collapsp as doca the nuiTnal 
reetnm. The mucous membrane is frequently ulcerated, but not always 
so. Tlie chief seat, of infiltration by round cells and fibmuB tissue, in 
which tubercle bacilli are abundant, is in the submucosa and circulor niua- 
cular laytTK. Scattered over the mucous membrane are jmpillomatous 
outgrowtiut contiuuous with the submucosa. The solitarj- follicles are 




SIS 



THE ARVS, RKCTUM, AND PELVIC COLOM 



evollen and inflnmcd. Out^idi' of the muscular Ityer of th« ^t it & 
fibrous layer in which tlie liloofl-vc^clii prp**"!*! ertdcnces of peri-endar- 
teritis and cndarteriliii. The wrous coiit may be thickened or not; 
in soiiM" ciisi'j it is niiirk<H51y no (Ilnrlmunn and Pflliol). The whole 
pn?^^!.* a romhiniitiun n{ tiiberrulou* and simple inllanimatnry lesinns. 
liHrtigau flaims that it is purely local, if not primary, tubereulofiis, 
as till- lunge and other organ? nre rarely involved. 

The diagnoaie of Ihi." condition is exceedingly difficult. Itfi treat- 
ment 19 said to be purely surgical. The writer, however, eeriously 
doabffi the propritly of wpcrutivi' inlcrftTtiiPo in such a fliroiiii'. slowly 
progrtfisivt', tdht-riulnr rotnUtKiii. In the writtfr's opinion, local inttr- 
ferenoe in such ca*t», just a« in chronic tuhercular fUtuta. would likely 
excite n new activity in the dtsonw and do more harm than good. In 
all jiroiia 111 lily i-onftilutioiial trealtnent, fretb air, and t;4iod food, to- 
Itctlicr with such local treatment ns u indicated for the prevention of 
Boeondiirv iiifecti'Ui in tlif iik'trt:. would give ln-ttor resHlts, 

Aoute Tubercular Inflammation. — OpraHonnlly IIuti- ooeuro an acute 
irfliiiniiintinn of the rretuin in which the ?|)<fific ehnracler is rpoognia^d 
by the presenee of tubercle bacilli in the discharges and in the tissues 
themwlvcH, Earle. working under Councilman. describeLl this in 188? 
as seen in necropsie?. and Inter (Baltimore Med. College Alumni 
Journal, 18!);») as obBorved in' two clinical oase?. It ia charartcrized by 
"swt^lling of tlif! mucouF mt^mhrant', inti-ni^c hypenpinia, and iiumoroua 
umall uleiTs " ; mieroscn pi tally the tissues showed small-celled infillration 
of mucous and submucouK li<»ui><i verging n\Km taseation at points; 
uuincTous tulHTcle bacilli were prrstnt at thea' points, in the uiargina 
of the ulci-re, Hnd also in the inliltrated tissues where there was no 
ulceration. 

In three instance* the proee« wae secondary to pulmonary tuboroulo- 
818, and in two it «p[)eared to 1k> primary. The two rlitiienl cases 
recovered under thorough drainage, antiseptic irrigation, and eonstitu- 
lioual treatment for tuberculosis. 



CHAPTER Vn 



VKXEieKAl, VIStA.Sf;s OF THE ANUS AND BECTUM 



Vekbhbai, dispascs of the anus and rcclum arc comparatively rare 
in tltc United Stntcs. The cnlargod foreign population has increased 
tbe practise of sodomy and [wdi'miity. and i-very now und Ihun one 
meet)^ a case of primary vMu-rcal dii^fa-^L' in tliesu- organs. The (.-hief 
varielies are eunorrlicva. chaneruidf. ii^rpnt. and sjphitis. 

GonorrliCBal Proctitii. — Thif^ discuae i» not so niri- iit pn?spnt as in 
tlic days uf llitni.'^tt^'iid, Viiu Buii;ii, mul OUp, wlio stfitid thnt thuj hiid 
never met with a ca«c. lt« syuiptumti aru so ncurly iikct thoAC of Gimpli: 
neute <ntarrhal prootitia that until the disooTcry of thv specific genn 
bj" Xci^«cr one eould not positivtdy say wln-ther a givon inllamniutiua 
was of a simpk* or epGL-ific nalupo, and its existence was therefore a 
dispulM point for many ytarif. In 1874 Boniiiery made some interest- 
ing fxpcriniciils with regard l» tlu- suscirptibility of iho niiicuus Jcifm- 
brancs of the body to gono^rlKl^H[ virus; in a patient with ^onurrhuml 
ophthulmia and un-thritis thr puM from thi; infcclfd n-^ions ivas 
smeared upon the miicoui; membrane of the nose and anii^. The nose 
showed no eymptome of the disease, but on th* second day evidence 
of infeiiion wa« seen Hbont tho iinu*, and u]ion the fifth dny purulent 
gonurrh<Lnil discharge from tliis part was notiL'ijd. Hl* then injected 
the pus into the rectum through a hoUuw tube, but with negative 
n-Milts. From the n-petition of ihcM: irxiM-rimi-nts lie (•(included that 
all tiie mucous mrmbranee covered with pavprnent epithdiiiiii or sup- 
plied vith papillae and a tiuperfirial subrpithellnl network of lymphntie 
vessels are PUswptiWe to the gonorrha-al viruf; while thoFe covered with 
cylindrical epithrlhiiii and having a siiperflciiil Bubepilheliiil network 
of veins are refractory. 

Typii-al blcnnitrrhafjia of the anus is not an uticoiniuon affection, 
especially in women, aud it needs no argument or prolonged historical 
account lo prove it« existence. In the rectum tlie disease is coinpnra- 
tively ran-, at least it is rarely diapnoi-ed. Goslin. Billroth, liollet, 
Allinghaiii, Winslow, Bernard, and Tanliou, have all reported casea 
of tho disease, but these writers based their opinion* upon subjective 

S]8 



214 THE ANUS, RECTUM. AND PKLVIC TOIjOH 

and circumstantial evidence, llic Hpecific germ not having been discov- 
ered at tbc time of their observalions. Xeisscr liinisrlf lias obsfrred 
2 oasts of rectal gunorrlicca in which tJie microscope showed g^nococci 
bcvuml (he qufntiiin of a doubt. Bumin ((uotes a case observed by 
Wolfr with a distinct history of the praclise ot sodomy in which the 
discharge coiitfiiiiecl nuiiioromi wcll-dpfini'd gntmoowi. 

Matleratock, repoi-teO a case fmiii tho praetite iff Frisch in great de- 
tail; he not nnly cxmiiined the discharge during life, but also sectioun 
uf the iniieouB niembrane taken post uiortcm. The patient was ii girl 
suvcDiupn years of age. a soduiiiial by practice, who suffered from pain 
and huniing in the rectum which wuh uubearable at defecation. These 
Hyinpioiiis camp on about fifteen days after her last coitus per rectiini. 
Tiic anus was funnel-shaped, reddened, and >ihowed some loss of epilhe- 
iium. There was a perianal i-eZ4!um, and the pus ooned ont between the 
swollen radiat folds. This pUB eoutatned niniieroii» gonoeoeri, some 
free and uUii>rii enclosed in (hi> pus-ei'lU. TIktl' were both cylindrical 
and squamous epithelial cells floating iibuul in the pus, and now and 
then a puH-cell appcured which wiis literully sltitfed fUU of gonococcl 
so as to give the uuekuc a crcacutttie Bhupc. 

The woman also had a diiicharge from the genitals, in which a 
similar exJiihilion of gouoeocei wa* found. Through the wpccuhiiii the 
mucous metubrano of the nvUiiii appeared jiwollen, bright-red, and 
bathed in pns. At a Jislanee of about 4 ceutiiwcters {i^ inches) from 
the anal margin there was a shallow cioHiun ur ulceration of the luueous 
menibraue. This patient died from pubnouary diaetuse befuru the gon- 
orr)i<cal uircction was cured, notwilUstaudiug the treuLment had b«Ten 
kept up for about six mf>nthfi. The mucous membrane of the rectum 
was excised jmst mortem and the hii^tologieal exttmiiuitinTi showed a 
partial dif^iippi^ai'unco of the hieberkiihn follicles, together with exfolia- 
tion of eyliudncal epithelium : there was a typical proliferation of cells 
and eon neelive- tissue iufiltration of the bordem of the ulcers and coo- 
siderable inliltration uf the muscular walls of the rectum by round cells 
coutaiiiiiig single nuclei. In the polyiiucleated rtnmd cells were 
abuuduut gonococci, which were also free in the Hupi^rlicial layers of 
the mucosa. "Their presence was Limited to tho parts covered with 
cylindrical epithelium, while the infiltration of the round cells de- 
eeeudc'd to the margin of ilie externul !i|jhinctL'r" (Anuales de dermat., 
Paris, 18!>2, p. 330). These facts ure praelically coufiimed by Hart- 
niauu and (Jiii^nu. who slate that the limitation of the gonococci to 
the superficial layers of the mucnus nieuibniHc i» aecorapanied by dif- 
fuse inflammatory infiltration of the deeper tisKue» where the cocci 
are absent. 

In 181)2 the author reported (Jour, (,'utaii. Venereal Dijfcasee) 3 casoB 



i 




VKNBBBAL DISEASES OF THE ANUS AND KECTCM 



215 



of gonopocci of the rpctum, in whidi the il ischa rgtw, tnknn from 2J 
inches above the anal nmrgin, showed free gnnororei, and pus and 
epithelial r^Us crowded full of thrm. Sinrr that time 3 olher rnnca 
have befii obpervcd, in 2 nf whidi IhiTP was also llenncirrhagia of the 
anus at the same time. In thes« (i <&6qs iu which the i-ectum ha? been 
affected, the condiUon htu? not beeo as tfbstiuato aa that rcportcd by Mat- 
tiirstuok, allhou^h thL> pathological cxaminntinns have oxhibiti^d prac- 
tically the Slime changes. Tt is a question whether his eiisc ilid not 
have tiilierciilosis (if the reetiim coniplieatinf' the gonnrrlitea. As a 
matter of fact urethral gonorrluTa is always very slow in healing in 
tubercular patients, and tlie sainc may be the case in tliat of the 
rectum. While, therefore, one may aiy that the rectal mucous niciu- 
brane is less susci^ptible to the gonorrha-aJ poison than l« that of Uic 
urethra and anus, neverlheleg* it may be attjiekovl. K?pecinlly is this 
the eaae when there is eonstipntion or any other ejinse which produces 
slight trauniutii-tns of the mucoutt nienibrane during the presence of tho 
gonocoeci in the rectum. 

Elioloifi/. — The cause o( this difiease i* uudoubteilly the direct 
inociilaLioii "f the mucoiis mcmbrunr at the reeluiu or aims by the 
gonurrh(L<ul virus. This occurK through rxtcnsiuii of the iliiH.-a«f from 
the vulva to the anus and rectum, through careless handling of other 
part* affected with the disease, and oonseiiuent conveyance of epceific 
genna to the recluiii, or by tinoatural coitus, th* active party being 
afTivteil with the di!iu>aM<. U has been claiintHl that it may ucciir 
through mi' Uwtasis, but nueh an origin is iinlilcety. 

RoUet (I>ict. enryc. des scienee-s med.) has rtrported a case in which 
infection ocenrn*d in a patient who suffered from an unHhra! discharge 
tad introduced hia (ingor into the rectum in onler lo produce a move- 
meut of the bowcU. The linger was evidently infected with the dis- 
charge and thus inoculated the mticaue membrane of the recluin. lo 
MalterBloelc'H roBff, and in '.i of Ihe author's, the cemdition was brought 
oljuut by the practise of unnatunit vit^e, and lbi« is pLrhaps the most 
frequent noiiree in men. In women, however, gonorrhipa of tlie ujiua 
is usually due to secondary inoculation from vnfrinni discharge-*. 

Sym }dom^. — The symptoms of the disease are sensations of uncasi- 
nw9, itching, tind heat about tlu' amie, which may occur at any time 
ffftm twenty-four hourd to five days aft«r expoAure. Those rapidly 
grow more distinct, tho heat (-hangis into a burning, the itching into 
p«in, deftvulion beconuti onerous, iind the patient sufTi^rs constantly 
from dull, heavy aching in the sacral region. From the fifth to the 
snvunlh day the imtient will probably have constitutional diMlurbnuci-s, 
Uie pulse and tcmpentture heroining elevatwl. There is frequent desire 
to go to stool, followed by tlic pasaage of inucus and pw, and when 



Sl« 



THB ANUS, BBrriM, ASD PBLVIC COW)N 



tile fa-cal pa^agoi* occur thev are tinged with blood aod accom- 
panied by great pftin. The discharge ia at first thin and milkj-irhite, 
but Inter fprf-^'nish or brnvniah-yellow and very abundant in quantity. 
The appearance of the anu8 and rectum wilt depend upuo tht- habits 
of the patient and the parta involved. If he lie a 9odumist the anus 
vill appear iniundibiiliform, the iiphinclere will be relaxed, and there 
will liL> a pouting or exiiirdphv or iiright-red oedematous mucoits tnem- 
branv about Ibe orifice; the niuco-cutaneons folds will be bathed in pua, 
cxcoriatL-d or ulcerated, uud tiMurc^ fonued. Hfcmorrhoid^ are not 
gencnilly dcTcloped by tbia iutlauuuatory process, and will not b« pres- 
ent unle«e Ihejr existed before the infection. 

Wlien tile diwase involves llie ret'lum the mucous membrane be- 
cornea bright red, swollen, tense, and painful. It bleeds upon touch, 
in balliL'd in a profuaL- ni^eretion of mutx>-pu8 which dribbles from the 
anuH, tiiiit orifinr bi:ing iin|>erfpilly closed on Hcuount of the swollen 
folds. Ab llic diitcajM' progrcnaes (uilctics of excoriation or ulccratiou 
oocnr. Tliiit uleeratinn is Mipcrlicial, the edges arc never undermined, 
and th« bOM ia granulating. 

Crtndylomatii, fissure, and i^ubmiicous fistula may complicate tUo 
condition. The disease in tho Jiniu) is self-limited, and if proper atten- 
tion to hygiene and c-U>anlineK.i is obst-rved the patients will rapidly 
recorer in the majority of i-ases. Probably a very email jirofwrtion of 
these ras(« are ever seen by physieians; the invalids luring ashamed of 
their practices, suffer from their ailments and treat themselves rather 
tluui be exposed and degraded by the cxauiination? and admissions 
which medical treatment would eclail. If the dieeafe extends above 
the internal sphincter it may persist for long periods and become 
chronic. While no ease of Htricture fmm this cause hii-i been reporleii, 
it ia not iinmaNniiflhli> to suppose that the imme inilnmmiitory deposit 
and eientricial eontrnction wbirli follows this disease in the urethra 
may aUo be developed in Ihe walls of the rectum. 

Diagnosis. — The diagnosis depends largely upon the presenee of 
gonococci in tlie dischargc-s. The profiine and purulent nature of the 
latter, llio extreme irritation, and the coexistence of gonorrlitcal in- 
flauimation in other organs, are all indicative of the nature of the 
disease. The final te«t, however, is the firding of Neisser's coccus. 
The specimen? for etaniination must be eolleeted in a moiit careful 
manner in onler to eliminate any possibility that th« pus comeis from 
tlie genital organs; the anus is wiped off a* gently and thoroughly as 
possible with absorbent eottun, then Hashed with on antiseptic solution 
of boric acid or bichloride of mercury, nnd tlitn a fipwulum. such as 
the Kelly anoscopc or the author's uonienl instrument, j« intmduced 
with the patient lying upon the left aide or in the knee-chest posture. 



i 



VKXKREAti niSEA-SES OF THE ANDS AND RECTUM 



217 



Tile spccimi?!! should In; taken with h ptntinum-wire loop from the wall 
of the rectum and not from the discharge which fiows down into tha 
e|MN;uium, le^t hy tiny diance »i>nie of the pccrctiou frcit] the anus should 
turc Wii ciirricJ upward uu the i-ud u( the ia^lnitiieDt. Several sped- 
mois should be esuminod to (.'on-ohoratc one anothi^r. The methods 
ol stnintn;^ iind iho ty|iipnl npyK'arance nf ihesp f-oiiocom are well 
deicribed in booki* upon bacleriolojiry nml grnito-unuar_v diseases, and 
need not W detaile<l here. Blake anil SIniidhani tell ii9 ihat "when 
gonorrhu'a has rL-flchcd the t-hrouic iitage we may fail to find the dip- 
lococei or true gonoeocci, but encoimler iastcad pB(!udo-troooeoeci, 
sUphjrloeouci, strfptutocei. or tubercle barilli." TlK-refore tho ncga- 
tire diafrnMig ebould not depend alone upon not Unding thost: bacilli. 
Tlio history of the ease, the iijipearanee of the nnu*, the relaxed 
sphinclere, thu execseive discharge, the extreme pain on defeeation, and 
the fissures between the anal folds should all be considered in coming 
to a final conuluBiou. 

Protfitasif. — Tbi- pn>giio».is in thew cHses is favorable when the indi- 
TJdoaU an- olticrwisp hraltliy. If, howrver, there be a lijl)errular di- 
athe»if< or confitiltitionnl fvphili'^, manifcHtalionH of theee di»e«Heii are 
likely to develop diirinj; un attack of rectal gonr>rrhu;a, either of which. 
renders the propnotti-* wry ceriousi and the courae of the disease txcewl- 
inglv prot rac't^'d. ThiB w»h the eundittou in the casu ri'|Hjrted by Mal- 
tersloc-k, in which thfl dim^aBe lasted for over six inontliK, s!iowiji|» little 
tendency lo heal. Tlip patient died at the end of this period frou 
general tnherriiloNifl. Why it »hoiild be ho it in difficult to untswcr, 
bnt the fact remnins that anite iriHanmiationa of the rectum, from 
whatever oi«*(\ are very liable to become chmnic and intrflctable, otcu 
incurable, in cases afTectvd with pulmonary ttiberculotfis. Therefore in 
oanci! with Mieh dinthr-soa oiir prftpnosis >thnuld In? very guarded. 

Trreim^nl, — In ainil ponorrhrra thfi partH should be kept clean by 
frequent Kponpinp ititb Hntiseptir solutions, such as bichloride of mer- 
CHTj, Thiersrb's solution, or solutions of ercolin. Nitrate of eilver 
in mild |>crci'ritii(;<;'. nrj^'onin. arpyrtd. and pcrninnKanate of potash 
rapidly destroy the nom'cocei, and are therefore very useful; when llic 
ditcuc ha« progreft*ed to cxenriation, or when ulceration ha» occurred, 
thew local apjiticntione; should lie repeated two or three times n day, 
and the pnrti; slmitld fie protected from rubbing against each other by 
small pledgets of ganite or cotton *naknd in anli^ptici*. As soon as 
the gonocorri disii|>pcar from the disrliargi-?, it is well, after cleansing 
the parte' thoroughly, to apply some inert powder, such ae stcarate of 
xitw. oxide of zinc and enloiiw>l, siditodide of bismuth or arUtot, iiitiuf- 
Hating il well tietwwn the mucous folds frer|uently enough to keep the 
partii drj. It there are coudylumala they may be clipped off, <ir belter, 




TIIR ANTTS. RECTirar, AND PELVIC COLON 



still i-a utprizL't] wicti iiiDDoclitoracftic acid, and kept dry with the powder 
n* before. 

Wlierc the ulcL-mliuu is deep or elu^ish, cauterization vi\h ailrnte 
of liilvi-r i^liould be UH.-d. 

The bowtfU should be kept open, but it is not well to iaduco fre- 
quent (liaiTluval pasen^es because they irritate even uiort- than a solid, 
wvU-f^rmed mt>v'L'iiiL-ut. If lht>re bi' L'Lincoiuilaiit disease of tlie genital 
oryiins, the %'ugiiia should hv taiuitorieU n-gularly in order to avoid the 
dribbling dtiwn of tliL- fresli discharges froui tiii-se organs upon the anal 
surfaces. Oniiiiarily there will he au lU'efKisity to dilatt; iUv sjdiinc-ter 
in such c-asefi, and yet thfrre may arise cracrgcneiew from pain luid »|HU«m 
of this nnisirle which would neccrtsitate this procc-dure, which should 
be perfontied only as a hist renort, as it would lively deepen the fiesure- 
likc iiU-erations, ineroaae the inflammation, and probably rusult in the 
infeetion of lliL' rectum, wliL^rt'aK tb« disuase was origiiuilly limited to 
the anus. When thu ilinease lum involved ihe rectum, aetive and ener- 
getic meaHurcfl are rcqutsite; irrigation with lM)rie acid or very mild 
Miliilions of t>irhloride of mercury (1 to 1(),(M)0), or permanganate of 
potash (1 lo 4.IH1CI) nhould be nuide two or three Uniea a day. It ia 
scarcely necessary to remarlc here tiat rectal eneniata do not answer 
the purposes of irrigation in these eases. Permanganate of potash of 
a strength sunicieut to be bactericidal is very irritaliug to tlio intestinal 
eaiml if left there for any time, and brings on intense and painful 
griping. Tlien^fore it is important that a proper rectal irrigator should 
he used, AiH-li as that illustrated in Fig. H;5; or if the anus he loo tender 
fur tiie inlrodurtion of instruments like this, two goft-rublier eathctcns 
shonld be intrinlueeil and the irrigation carried on by using one of 
those aa an inflow and the other as an exit for the solution. 

If there is much spiLsm of the sphineter and pain from defecation, 
dilatation «f the muscles should be carried out under antt?sthesia. In 
such conditions this upi-ration may he resorted to earlier thtin in the 
cases in which the anus ou!y is affected, as there will be no longer any 
fear of infecting the rectum, and the o|HTHtion will furnish proper 
drainage and relief for the aeeumulatcd discharges. 

JuUien advises the vee of tannic aoid as au application to the onus, 
but it is too irritating and not as satisfactorj- as the powders mentioned 
above. Tiie iipplieation of pure ieblhyol to the fissures will hasten the 
healing. If a suhniueous fistula should occur, it must be laid open 
at once and treated as an ulcer so that it can not act as a biding-plaee 
for the gonoeueci from which they may break forth fuiil' reinfect 
tlio parts. 

'I'hc iirigations should not be discontinued until eight or ten (3ays 
after the Jischargc has entirely ceased, for llie gonococci are liable to 



TEKGIIEAL DWEASE.S OP TltK ANUS AND RECTUM 



SI 9 



be coHcpalecI in tlie follicles and the discharge may be lighter] up again 
several (lays aftrr it has niire reaped. 

Rei^t in bed i» eKfontia 1 to ^u<^c(!^1ful trei)tiiit.-iit, citiK'ciully when the 
roctum is involved; but thia, like every other rule, must liuvi- a ucrtain 
ain<>unt of i^laiitJoity. Ca»c» inc>lined to antpmia, d(*bility. and tuhcrcn- 
losis do not stand conlincinent in binl very well, and it is wise to alter- 
nate it with periods of mild exercise in fresh country air. Bitter tonics, 
cod-liver oil. predigested foods, and occasionally a little wine will be 
fonnd of advantage in bringing up the strength of thvsc patients, and 
aometiines aecompUsh a cure, w^hereaa the simple Iol'aI treatiaeut has 
resulted in failure. 

Chancroid of the Ann*. — This is a not infroquoiit diecaisc about tho 
anus, mid in lliit; posiliun <he chamctoriHtics vary, as may be amounted 
for by the nnatorriical reUtioiis of tho part^, their funcliuntil activity^ 
and the hygienic care uhieli in devoted to them by the lower clashes, in 
which the alToctlon tit gL-iiorally found. 

In the Unitwl Slalca it is conipanitirely rare, but in Europe and 
Uic Eutdem continent it is not at all infrctjuL-nt; nenrly all »if tliose 
observed iu the author's clinic have been negroes or emigrfinls front 
gouthern Kiiropo. Foiiniier states that he found the disease in 1 in 
44.'i men and in 1 in !) women sulfering from venereal diseases. Periodi 
found 2 out of l^.t eaues of veaei'c-al diHeaite, both in women. Slurgis 
found 8 in the »ianiL- number of I'ases, all iu women. Jullien in said to 
have found 14 casex of this condition in a total of 42 chancroidal ulcers 
(Qufnu and Hadniaiin, (.'hir. d. recluni, vol. i, p. lOt). Sick, iu his rc- 
Ticw of venereal diseaHos in the Jlainburg (icneml Hospital fiom 1880 to 
1830, found only 1 case of chancroid in tho anus in 9,881 men, whereas ia 
1 1,826 wotnen and infants he found 224 affected with it. From these lig- 
uree oue can rea<li]y observe that while in men chancroid of the anus is o 
Tery rare arteotion, it iu by no uicHua uncommon in women. This tro- 
qwency in the female nex results from the close prosimily of the anua 
to the genital organs and the facility with which discharges from the 
vagina may trickle down up()n the anal region. It is due occasionally 
to Contact with the male organ during the act of coition, uud also 
to the eoitiparativcly greater frequency of tlio practise of ?odomy than 
of pederasty. In (he iiiajonty of cases chancroids of the Mnu? arn 
secondary to ehancruids elM?whei'e, and therefore may bo said to be 
due to anto-inoculation. They are usiially limited to the perianal 
region and the anal canal, and randy extend above the muco-cutnneons 
border unlcaa they aasume the phagedenic type, when they nuiy involve 
tlic rectal mncoos morabrane and teexiM in great destruction of tissue, 
even of the muHCular wall of the gut. 

S(i«h^y. — ^Thore arc two theories in regard to the origin of elian- 




THE ANUS, BECTUM, AND PELVIC COLOK 

croid», in both of which it ie assumed that th^ clis^aw is the rraalt of 
the lofal action of micro-or^uuiHina. The laltr schools have gviK^rally 
ucRPptrd the thenry that a chaucniid is itothiug imirt> than au uto^ra- 
tion due to llie inuculation ot al)raih>i) stirfacuK by pyoyeiuc iiiicrobL-s, 
They at'cuunt for the siiwial chiirat.-teristirs of the iilrtTation by re- 
ferring them to tlic anatomical and physinlogical character of tiie pArt« 
ill wlilc'li thi'y tH-H-iir; they hold llmt tnociilation in (hi^ region with 
p\ii from utiier fiuppunitiiig eoDditioiis, audi as pus<tule«, carbuncles, 
or furunfles, will produce clmrBctoriatic chancroids, and finally, that 
these fore^ occur iu people who, owjn^ to their Iwd hy^ieiiie hnhit.', 
&rv- susceptible to infection by mleru-or^anisins. On the other hand, 
good Authorities claim that the chancroid i« dito to inoculation with a 
Hpccific vinM : they claim Iu havt^ found certtiiu haclcria always as«o* 
elated witli the pyogcaic iiiiero-urganism in cliancroiila) leaiuns wliiclt 
are capahle in pure cultures of reproduciug the ulcers even wheii the 
inoculation* are practised uuder aaeptic prcLiiulion*. ]u aupport of 
these theories they hold that a chancroid always result* from contact 
with the discharge from a chancroid, and does not result from inocula- 
tion by digelmrgi-ii froiu othor »uuree<t; that the elmncroid always runs 
a typical course in a giveu location; llial aiilu-iuoculatiuii can be suc- 
eessfully repi-atcd aIiiio»t indi-finitely, and that the inoculated ulcers, 
ftftt-r two or three jji-ULTations. cciise to conlnia pyogenic niiimiUrs. 

IJucivy. Wclundcr. anil Krt-'fting " dcucrihc a« the niH'rittc micro- 
organism of ehoucroid a dhort, thick bacillus with rounded cnda much 
like ft *luinb-h(>ll, nbout J n microinilliineter in length. The rnicro- 
organieni is foiinil in the ]>roto]ij«sni ami between tin- ei'Us, often in 
chains and gi-oups " (White and Martin., Venereal Diseases, p. ST4). 
They describe the chaiactenstics of this ulceration, and stalu further 
that iu no iustancc was aiilo-inoculatiou successful from a utiancroid 
in which this bacillus was not present. Many other observera have 
failed to confinn these observations, and inasmuch as proof nlfordcd 
by liic inoculation of pure culture is still wanting, one must conclude 
that the presence of a spocifio virus is sub judiee. 

Ffriaual Chancroids. — Clijineroids occurring in thy t-ulancous tis- 
sue around the anus ujKtn the perineal and coccygeal ri'gioD.s po.>iKe.-is 
the characteristics of erosions more than ulcerations. Tlipy are .-(hallmr, 
do not discharge a great ninoiint of pus. and show little tendency to 
spread. Si» frequently ore they associaicd wiili the comiilion else- 
where that one writer has termed them "satellites of other chan- 
croids." They are more often nuiltiplc than Bingle. as many as fifteea 
being seen in one caKt- (Fig, 98), Some doubt the chaneroidal nature 
of such ulcers and claim that they are only inflammatory [dienomena, 
but the facta remain that tlicy are secondary to chancroids elsewhere; 



VE.VKREAL DISEASES OF TOE AXCS AND BElTlTM 



221 



they arc >tito-inooiilal)le; Ihoy arc tuvwciated with hrpertrophv anil sup- 
puration of the lymphnlioi, mid <i(i not ttint] lo bumitr unUornfatb the 
skin. These characteristica seem to distinjriiish thum from pincral 
ulcerative conditions. 

Anal Chanrrrndv. — The sulci between the radiating folds of the 
anud form a most cxci-llent ludgittc-plnee for chancroidal germs, and 
owing to the frequent breaks in the mucouit mcnibrane at these points 
inoculation oceure with the prentest facility. Here the chancroids 
appear a» prayUh-yellow fi«t(uri.»^ between ihe folds, and uiiRJit be orer- 
looked in the beginning except for the pain which they produce. They 



L 



t'ta. 9tt. — MiLTiPLt J'iiiiAK*L OuHmaiM. 

may be di«tingiii«hcd from simple fissures by the existence of clian- 
croide elsewhere in the body; by their color, which 't» loss bright and 
red; by the secretion of pus, whieh is much more nbiindnnt; by their 
Ijuinj; roultii>le, jind (innlly by the faol lliat lliey are auto-iiioculnble. 

So far OM the ]taiu is runcerned tliere h no dillerence between the»e 
ulcers and the true irritable nicer of Alliiighnni. As a nilc they involve 
the cuUncous and itubculnneMus Uksucr ^rcr^ly, but Hccni to be arrested 
at the level of (he niueou* nuMrbraiio. They may extend through one 
of the sulci between Ihe radinl foId« nntil they roach the npper end 
of the anal rnnal. Here and below the folds they spread circidiirly 
around the anus and tlius take on a sort of hour-glass shape. In this 




figs THK ANL'A. RBtTUM, AND PELVIC COLuX 

poMliuD cxtri'iiiH clii"oiiiL'ity is tlic ir cliief dianiclL'risI ic. They advance 
Blowly iiiid hcnl equally wj. The crhiuiemiil iu uiie suIl-uh infit;(s uu- 
othcr nnd amttlirr iinLil tlie whole anul rirt-umfc-rriKf! may W JiivolTcd. 
Tlie haxp ii^ gray flnd shigpish. the ."ctTction is frof, sonirtimvs frtiil and 
tinged with blood, and occasionally Uttlt* lUtulas pasd through tho folds 
from one* eulcus Iv unolher. Molliere lias tttulpJ that if the L-ase be com- 
plicatwl with ha-nuirrhoids thfi virulciit'i' tiniy die out, leaving ttiinple 
variiwse ulcfi-s which are not aulu-jiuictdable (Maladies Ju reotmii, 

p. crfl). 

Extreme paiii folhiwJiiK defrralion brin^rs nn (-oi)i4i|)ation in thcKC 
coaca ju6t at it dnrtt in HJiiipIr lit^niire. The palJi-iits in conAcqUcnet 
BiitTvr all the (^ymptoniR of irif^iilar fscal movements, loea of filccp, 
and retles (ligestiv* derangenieiit?. 

Trmttnerit. — Thom in httle tendency toward spnntaneous healing, 
Biid rrL>i}iieutly it is iniputijiible tu bring this about witlioul forcible 
divuUion uf the Kfihincter. 

It should always he remembered hefore having recourse to the 
knife or forcible stretching of the sphincters, that these practices open 
up the lymphatic chnnnelR for the absorption of pus and nl,^y result, 
a» in the case of Ricord and Foumier, in i^epticii'inia, jihagedti'nn, and' 
death. One should therefore he slow in recommending such a radical 
moaiture. The excesaive pain and the eutrt>aties of the patient for 
rviipf, incline one to operate at once; Iml in one cs»e in whieli the 
Bphiricter was divulsed, the nigged edges of the hypertrophied riidiating 
folds cut off anil a dirty, irregtilnr, ulcerating mass surrounding the 
anus cU'ttned, the pain was relieved for Iwenty-fmir hours, then re- 
turned in all its severity and was followeil in n few days by perianal 
abscesa &nd & suppurating inguinal bubo. Kilher of these conditions 
might have oct-uprcd without the operation, but thoy were not present 
hefoi-e or at the time of tliu' operation, and it is po&sihle that the pro- 
cedure was the cause of tlietii. 

(Jonscrvativc Ircatnient therefore ought always to be, irnictised, and 
practised puticnlly before urulcrtakiiig any opt-ration. The bowels 
should be kept open by mild laxatives, not by cathartics, and the parts 
cleansed by frequent bathing with antiseptic golnttons and the applica- 
tion of soft, soothing dreswings. The following trentnicnt advised by 
the author in Morrow's System of Gonito-Urinary Diseases lias proved 
satisfactory in most of his eases: 

Tlie parts after being tlioroughly waslied and cUnns^d are touched 
with a solution that contains equal parts of carbolic acid und tincture 
of iodine. Tliis is followed by washing with lime-water or bluckwaah 
and applying a powder of calomel and oxide of zinc. If the ulcer vx- 
t^uds within the anus it may be neeeasaiy to introduce a speculum in 



I 



VENKEEAL DISEASES OP THE ANUS AND RECTUM 223 

ord«T to treat the parU thoroughly. One should do this evoa ii the 
pain is nevere enough tn uec'tiHi)itH.to thf ailmjniittnitton of nitrous oxid« 
or ulliy! L'liloritli- for t'vcry Inmliin-nt. MiMliylont' liliii?. 10 ^lins in 
each rtiiiil mmcv, is an fxccllent iippliratinn in thcKt- cases, cspcciallj 
where Uiere is a tRinlnnry to chroiiicity or plingeila-im. 

The inmifflation of nrthnfnrni upon these ulcere will in many in- 
Btancee relieve Ihe acute piiin produced by dressiiig tbeiii; it is iiot 
nnifonn in ita action, howercr, for in some cases it has not g^ivcu t)ic 
sliphtf'sl fttlicf. I(id(»fnnn is said to po^si.'ss ii sp<^oific action upon chan- 
cnJtilHl uli;ors; in lioBpirjil praetice one may hhc it freely, but ita diaa- 
greeahle odor has ostracized it bo far iis private patients are concerned. 
Aristol, anlinoniTi, and reainol may all be used in place of the above 
poMiler, as may ibe mixture of oxide of sine and calomel, which la 
simpler and niiicli less expensive. 

Chancroidal inoeration of the Rectnm.^SomL' few caseg fiavc been 
deecribcd in which tlie cliantrL-iJul uk't.-rutiou baa extended from the 
anus into the Tcctiiiti, but these can not be considered true rectal chan- 
croidK, A ebancroid of the rectum itself must originate in that organ 
and is iisuully due to sodomy. 

Chancroidal ulcere occurring around the margin of the anus do not 
pass easily beyond this region, from Ihe faL-t (bat the sphincter con- 
stantly closes tliis aperture and ads as a baiTier to advaiic-iiig gt-rms. 
The faecal nioveiueuta also sweep out before them the gemis that uiay 
have nearly gained access to the reetnl cavity. Those chancroids of 
the reetiim which have been reported hnvc generally been associated 
with others about the anns and upon the buttocks, and it i» much more 
logical to atlribute the latter ulcers to infection from within the rectum 
than rice versa. 

Ilint chantroida may extend from the anus into the rectum must 
^M• udniitted. All who have had much exjierience in rectal and venereal 
diaeaitcs have ^'cq such cases. The fact that the invalids affected do 
not even give up their vicious practices while the sore exista renders 
it jMJiwihli' Hint the vims may be carried upward intt) the rectiiiu, and 
the uleers are thus the result of nuto-inoculation. On the other hiind, 
a certain variety of chancroid known as phagedenic has a pcrrsislent 
tendency to progress in one or more directions, and If the Kphinelirr 
iiiuwle is relaxed, as it fn-'qui-ntly is in this class of patients, there 
will be no obstructive liarrier against the progress of the disease into 
the reetiim. 3Ia?'>n. \'an Bun.'n, and others have reported eueh cases &a 
this, and elnim that Ihey have seen strictnreB of the rectum caused 
by them. 

St/tnplumx. — Tlte srmptoms of ehaneroidit of the rectum are in the 
main those of iilreration, viz.: diarrh(ea, tenesmus, and n jirofuse dia- 
ls 





TBE AXrs, RECTUM, AXD PELVIC COLOK 

ri pas, lometimAi tinged with Wood. There may or may not 
fcp p«UL The patient is generallr unwilling to confess that b« has anj- 
kaovtedgr of the mii^e of hia dwease. 

71>e alcen are im^ilar in shape, grayish in color, and sluiUoir 
with nggf^d bonlers and pair, feeble graDatatioBS. They may be sU< 
tiooaiy or ha^ c a Ivodviicy to nipitilv vsti-nil. (Xvu^ioDnlly thvy involve 
tlie devpcr tUoui^s of tUv f^ut, iuvadi- the j^ubtuuojtut and muscular 
coata, and may even destroy the sphincter itself. Under such circum- 
•tanCMtfaey are termed pha^fedenie. When a tendency to spread iMista 
tlw pQS burrows underneath the mucous nieutbrani', and submiKOUa 
or sobniuscular fii^tuliv may deretop. 

Trralmenl.—Thf nutnagement of chancroida within the rt-ctuiu is 
pracliially Die saiiiL- us that of acute ukvralion of this organ. The 
patient should be confined to bed. The bowels should be kept rc^tar 
but not diarrhcnal, and the rectum should be irrigated with antiseptic 
solutions, such as boric acid, thymol, bichloride of merciiiy, carbolic 
acid, etc., two or thre« times a day. If the ulcer apponrs sluggish, 
slightly stimulating applications wilt Mnietin>es be u^^ful. If it has 
a tifudfucr to progress rapidly, the appHeation of pure nitric acid or 
the actual cautery to its cdgea will sometimes check this. lodofona 
auppofitoricfl are very usuful in tlicsc coiiditioiis; tliiiuf;l) pun- tarbohc 
acid applied once in llirce or four days, and the daily iutniiltatioa of 
tho zinc and calomel powder upon the ulcer produces execllcot rwolts. 
Pure iehthyol acts well in S^tgurcs when tliey exist. A hiand, unstim- 
ulating ditM should be enforced, and morphine should be aiJininistered 
if necessary to relieve the pain and control too frequent stools. 

Phagedenic Chancroid. — Any chancroid uiar ns;^uiiic a pha^Jenic 
coadiliou, which may be eitlici' acute or (.-lirouiL'. This change in the 
nature of the ulcers is due to consUtutiuual couditiou:^. Uiday and 
IJoyon (Thirapcutique dcs malad. vinor. et des mnlad. cutan., 1S76, p. 
184) have proved this fiict by experiment* with inoculation. Tlicy 
have shown that if n hoallhy person is inoculated from a pha;|redenic 
cliancroid he develops only a i^implo, soft stii-e: and on the other hand, 
if a person who sufTers from a plisgi?denic chuiic[-uid be inoculated from 
a simple chancroid, the puiut of inoculation will at once take on the 
phagedenic »yiuptoms. In the nrutr farm the piuijredenic chancroid 
resembles an intcni^c ccSlulitis at Hrfit. The deep tiwtucs become in- 
volved as well as the superficial, the parts arc swollen, ocdemalous, and 
pRinful, the temperature la elevated, the pul^e rapid and fei'blo, and 
the timgue dry and panly, Gre:it deslrueliun of lisi^ue results, targe 
suppurating cavities form, and the overlying teguments slough away. 
The ly III plix ties in ific vicinity 8oi>u becoiiit' involved and *ii[ipuraio, 
Jlollet statt'a that the ]iuk from these hubofd is not auto-inociilahle. 



d 




VENEREAL DISEASES OF THE ANUS AND RECTrM 225 

but this statement has not been corroborated. One cua not sny tluit 
these gi-netiil symptoius are in any way peculiar to ciumci'oids. Tlicy 
are coiu[iiiralili! tc pymniin and due to the absorption of pyoj^onic bac- 
tcria, whicli are ulwayii prenMit in chancroidal ulcers. 

Mi'tastaiic uLiscc-wps may form in any portion of the body, ami unlosg 
the ilisea.ic is rapidly checked it is likely to prove fatal. \V!i?n' tlie 
patient recoTcrs, it U generally through a prolonged eomaleeceuei; witli 
resulting large cicatrices in the region of the sloughs. 

Tn the chronic form of pha^cdcnie chnner'>i«l the onset is very 
itiKidioiiK; the ulnor first jthows a sluggishneas in the production of 
healthy graniilntions, e*peeiBlly at one or the other of its borders. At 
the anun it ha* a tendency to extend from without into the rectuDL 
While it is cicatrizing at one area it advancea at the othwr. Tlicre are 
no marked const it utioual syniptomii, and the ulcer is \vsa piiinful than 
acute ulcerations ahuut tlie anu^ u^iiully arc. The lyitijilmtic engorge- 
ment is less markL'd ihnn in the other vurictie* of clmacroidit, and 
soppuration of the glands is unusual. The ulcer tends to spread supcr- 
ficinlly and often involves only the mucous and submucous tissues, Oe- 
casioiifllly, howi'ver, it may involve the deeper tissues, and cause inllom- 
matioo and cellular iuGltraljon of the muBcIes that surround the anus 
and rectum. It is only in these rare instances in wliith the iikcnittou iu- 
Tolves the musculur nulls that chancroids can be Kaid to produce a utric- 
turc of the rectum. Duprt^s {Archiv. J. dc mfid.. IflfiH, p. 257) first dc- 
(tcribed this condition of phagedenic chancroid as an etiological factor 
in the production of stricture of the rectum; Maron (Amor. J. of Med. 
Sm.^ 1878, p. 33) wrote in confirmation of his theory ; Van Buren {Dis- 
eases of the Rectum. 1881, p. a37) stated that he bad seen a ulmmToid 
of the anus become phagedenic, extend into tlie rectum, and at a later 
period had verified the existence of a stricture due to its cicaLrixation; 
Bridge (ArchiT de Dermat,, 187C, p. 122) recorded the wise of & stric- 
ture of the rectum due to chancroidal ulcere in which it was necessary to 
perform a lumbar colotomy in order to relieve the intestinal obstruction. 

The weight of evidence eeenis to support the view that striclnro of 
the rectiuu may be produced by pliagedenie chancroids. The autlior 
liaa seen three cases of clianeroid!) of the anus which bad left contrac- 
tion of ihjit orlficp, but the strictures never Hseeiided higher than Iha 
iuterual sphincter, and could not therefore properly be called stric- 
tures of the rectum. On the other hand all of these cases were trcatctl 
by cAutcrixation, cither hy chemical agents or the actual cautery, and 
the queation therefore remains in doubt whether the stricture was pro- 
duce<i by the cauterizatioti or by the chancroid itaelf. 

Treiiimetit.~~ln the acute variety the patient's general eondifion is of 
paramount Importance. Abscesaes ahould be evacuated as soon as possi- 




ble; tbc operator should bo very careful not to make too viAe incinoDS 
]e»t lie oi)cii lip healthy tiasiip^ for infection with th& virus; yot Dcvertlic- 
\e»s ttie inflanu'il cellular tissue cIlouIiI hv fret'ly incisi-J. After the sb* 
gce(Mt.'» have Ix't^u tipeiivd the parl^ iiliuLihl be frequently Irrigated with 
antiseptic Holutioos, and in. the inwinlime !iot poultieea sliould be applied 
in (tnJer to iiicrv^iDe the oir(;t]liiti<m anO limit tliu sloughing aa much 
as possible. The tpm]ii;nitiin' slioulil Iw controlled (NtLer li>" Cold 
sponging, or, if nocessary, by tho use of eomc of the modem antipyretics. 
Those latter should be uswl with the greateel caution, as tliey are all 
depreusiug, and the eliief diftieuUy in these conditions is to maintain 
the patient's strt-nglli until the pywinic pracesses can be controlled, 
Tiiictliri; of tlie chSoriilc of iioii sJiould be frefjuently adniiuisteri'd, 
and bic'hiiiriilc uE mercury in Hitmll do«fs will generally have a very 
good I'tToet.. Quinine Reems ta act well in some coacs, vhilc in others 
it excites the patient too mucli to be of benefit. 

Assuming the condition to be one of sepsie due to the absorption 
of pyogonio bacteria, and not to any specific chancroiikl virus, one 
should apply llie prineiples of autisf'plie surgery and even resort, i( 
neci'^sary, to iutravtnous valine infusions or the injection of aiitistrcp- 
tocoeeua Hcrum. 

fn the rhrniiir form Hierc apppnrs to be a loral rnndition of Inwon^d 
vitnlity in the parts. The fact that tht^ ulcer heals upon one bonlur 
while it advances upon the other shows that the tissues of the kttcr 
have less power of resistance than those of the fonner. Wliere a well- 
developed, heiiltliy giiiniilntinn is nniv cstabliBhed, *lie jirogn-ss of the 
disease in that direction is checked. Sometiinea mild astringent or 
cauterizing agents sufTice to produce this granulation and thus check 
the advunccB. Nitrate of nilrer may be tried at tirst, and fallowing this 
one may have recourse to nitric or chromic acid, caustic potaali or acid 
nitrate of mercury, or finally to the "Paqnelln or giilvann-cauler)' itself. 

Tile modem improvement of the galvano-oautery enabled us to apply 
it now at every point in the circumference of the rectum, and if thor- 
OKj^hly done it will gpnprally cheek the disease. This upplioHticm, how- 
ever, is not without its dangers, as a patient has died from shock ivithin 
a few lidurB after the application of the PaqucHn cautery to a phagi*- 
deaic chancroid. One should therefore prepare his patient for such 
an ordeal by rest in bed, general constitutional and nerve tonics, and 
by strong stimulation. 

After the ciiuterization the parts shouTtl be dreswd with a 5- to 10- 
per-ccnt solutinn of picric acid, wliioh relieves the |iatn of burn-t. 

Maelaren (Kdiiiburph Clin, and Path. J., 1S3, p. €97) has recorded 
the cane nf a woman with a " pellagrous, pbagedenic cbancmidnl ulcer " 
which, notwithstanding cauterization and treatment by all recognized 



\ 




I 



VENEREAL DISEASES OP THE ANUS AND EECTUU 227 

HMthods, continued fnr eight ycara without material i tn prove m en t. It 
was noticed id this case that the coutact of the mCDstimal discliarg^es 
with the parts that had healed tnimedialely caused theia to break down 
3b thareforu sfrapt'd uff Hit gnuiiilatioue, diBsuntt'd out the 
itniMS bt^iK^ulh, aud bruu^^hl tlie jjurte as near together hh 
poesible by button 8utur««. After Ihiti the vaginn was tampone<l and 
kept so until some time aftrr hrr recovery, particiihirly at the nienstmal 
periods. Other ojicratora havo not bet;n bo Hiicceasfiil in their efforts 
to ehftck phugeda'ia by excision. Tlie experience of most has been 
that the fresh edges of the wound rapidly aesniiied the old pliagedenic 
condition, and the area of the ulcer is only inpreaaed. On the whole 
one must largely depc>nd upon constitutional troatmcnt, good hyj^enc, 
and occasionally the apidication nf the actual cautery for the cure of 
tliiii c-oiidtiion. 

Complications. — Chancroids of the anu* and rectum may be com- 
plifiitrd hy the coexistence of true Hunterian cliancre in the same lesion ; 
but tiilxed sores present no characteristic features at first beyond those 
of typical chancroids, which proceed in their rcj^lar course for some 
daya or weeis, when the hasps become indurnled iind flu> cicjitrizing 
edges undergo eollulnr inHltrntion. At the same (iitif! ilif^ ulcer will 
•ecreto more pus than a true chancre and is auto-inoonlahle. 

The appearance of secondary syphilis is the pathognomonic eTidence 
of the combined nature of the sore. 

Cliancroids may exist in connection with secondary syTibilis. 
Slyphilitic ulcerations and even broken-down mucous patches may re- 
nmble chnncroidul ulcers in a marked degree, and aa tlu'^e ulcerntiona 
always contain pyogenic germs, auto-inoeulation may produce a pus- 
tule and yet imt |je eonvineing ovidenee of their rhanernidjil nature. 
On the other hand, if one assumes in these cases that the disease ia 
chancroidal, he may overlook the syphilitic nature of the ulcers. Anti- 
syphilitic treatment should never be resorted to until secondary lesions 
appear to tleur up this con fusion. 

The occurrence of fistula, fj:^t<ures, and stricture as complications 
Vf chancroidal ulcers have been mpntioni-d. 'I'hcre \s one fonii of 
"-^itula, however, which deserves especial mention. !n chronie elmn- 
Ofoids witliout any marked phagedenic tendency about the anus there 
oecuniouitlly occur ^iiiall liubtegunienterj' fistiil.T Ihnt ritend upward 
underneath the radial folds or columns of Morgagiii; they may pene- 
trate the mucous membninc above, but they are generally of the incom- 
plete variety. When the ehanci-oid assumes the fissure-like tjiJC thcso 
little fistulaii arc very likely to be overlooked unless the parts are care- 
fally examined with a very fine probe. When they arc nut reeognizod 
and treated the discbarge from them keeps up tbe ulceration below in 




3 



828 THE ANUS. RECTUM, AND PELVIC COLON 

«I>itc of nil tlie treaiment which one can niiply- These little Iracto 
etiouid bu lait) o[)c-ii ttvtiiy and cauterized either with puru carbolic 
acid or with the ftalvano-cautcry. The rcflei coinplitalions which oceur 
in chancroidii of thn anus and rvctum are not peculiar to this particular 
form of iilci'ration; Ihoy occur in nil th*- inflammiildry involvomeuta of 
these org-ans and inelncle dysuria, frtiquent and painful urination, ii 
laritics of the inpnalnial functionn, and Rometimes in pregnant women' 
who have no gyiuptoius of syphilis, ahortioo. 

SYPHILES 

This protean disease manifests itaelf in piiniary, secondan*, and 
tertiary It^sions in the &1dn ahout the nnuR^ in the anal canal, and 
within the rectum. It is seen at all ages and in every class of society. 
It may be inherited from either parent, or the child may be infec 
with if during birth through the presence of the disease in the mother's 
genilab. It is ae(|uired through natural and unnatural vice, through 
accidental or innocent contact with dieeased persons, or indirectly 
thr<iiij,'li fho list' of toilot nrtiole? whieh have been used by «ypliiliticiu 

Chancre.— The initial lesion of syphilis is always a chnncre. It 
occurs in the amis somewhat more frequently than was formerly ad- 
mitted. Pean and Mala^ez. combining the reports of Basserean, Four- 
nier, Gere. Martin, and Carrier, present (Etude cliniqiie 8ur les uWra- 
tioDs annales. Paris, 1871, p. 88) the followinj^ statistics ; In 1,S37 extra- 
genital chancrL-s of all re^ion^ in men. they found 7 chancres of the 
snns, in 175 in women there were M chancres of the anus. From 
these figures it would Bp7>e«r that the infection occurs nt the anus in 
I out nf 177 cases in mm and in 1 nut nf 13 caj=es in women. Sick 
(tTa.bi-biifber der Hamhurgisclien Stnats-Krankenanstalten. 1890, t. 2, 
Leip.sic, ]8!)3. p. 453). in summing up the venereal diseases occurring in 
the general hospital of Hamburg, 1880 to 1800. found in ;i,8Bl males 
affected with venereal diseases 1,010 nmcuus palehej<, 1 (ruf L-haucrc, 
and I chancroid of the anuB; in 11,&36 females and infants alfectcd 
with the same (lisenses there were 986 mucous patches, 3 true 
chaiiereR, and 224 ehaiieroid.'* of the anus. 104 anal fiesiires, 3 periueo- 
annl ehaneren, 1 anal gumma, 2 rectal gnmmas, and 10 strictures of the 
rectum. 

Salsotto, quoted by Qutnu and Hartmnnn. foiind in SOI extrageni- 
tal chancres only 3 of the anus. Jullien (Traite pratique des mnludiea 
Tcnericnnes. Paris, 1879, p. 583) found 11 chancres of the anua in 
2,171 cases of extragenital chancres in men and 39 in 473 cases in 
vomen, making a proportion of about 1 In 119 in men and 1 in IS in 
women. Quenn and Hartmann^ gathering statistics from the services 




VENEItEAL niSEASBS OF THE ANUS ASD RECTUM 



229 



of Profei^eor Founiier. of Paris, and piibli^ilifd iit diffeiviit linics bv \ivct 
(ThiVge »le Paris, 1886-1887, No, -205), Moryl-Uvalk'S (Ajmaltfs ck dor- 
mat, et tic svpliilog., \8SS, |). 375), Vt'slin (Anmili-s (Jo dpntmt. et cle 
Rvpliilug., 1890. p. 3] .), Hiid Kfulartl (Animlt-a iIi- i!i>rin«t. et de syphilog.. 
1890, p.. 320, nud 1893. p. HOa). dctrniiinc that in TTS estragenital 
chnncTC* thoro Oficurred .13 trhrnifircs of llie anua, of which 2fi were in 
males, 95 in femalofl, and 1 in an infant. Fr-tirnier's latest tjlatiatics 
(L*s Charicn-'B pxlru-gt'iiiliiiis, 18«7, p. 4R5) give in a t^fftl of lO.WO 
chancTi'M, 52 of lU« amis and retrtuiii, :)? being in men and 15 in wnnipn. 
Tlie projwrtion in tlip two spxes is 1 in lltZ rastu in nii>n and 1 in 25 
cases in wonii-n. Duhring, nf Constant innple (Gaz. ile iTi^dic, de Parisi, 
898, p. 381), stjitr-s that out of 42 ertragpnital chancres 31 were foiind 
about tin; aniiP or witliin tlie rectum; wlint ie still more reniarltabic is 
the fact thai 2G oul of the 31 wci'e in children, and of the 5 in adulla 
4 were in males and I in a wonian. Tlie disparity between thcee 
figures and thusL' of Sick seems lo indiiute Iiow much more frcipii^tit 
is Ihi! pra<'tisp of iiniiiitiinil vire in the Krpneh capital than in its 
German neiyhhor. The rtatiMics of Duliring from the Turkish capital 
arc too liorriblf for belief. Pnapellow (Archiv f. Oermat. n. Sypli., 
1889, NoH. 1 and i) iim) Ncnniann (Wiener medic. Wochensrlir., IH'JO, 
No. 4) found ill SS2 cases of extragenital chancre 8 chancres of the 
8DUfl, all of which were in women. In over .'J.OOO cases of rectal dis- 
eases Ireali'd ut llif Polyclinic Hospital there wi're only 3 cases of true 
cbantTe nf the anuK, '2 of thnse beiu;;; in boys and the other in a woninn. 
'lliesi-' facts bIiow Ihat excwpt in Ihnse countries where the practise nf 
unnatural vice Ls frctjuent the disca.-ie is very rare and largely confined 
to the female sex. This Is also in keeping with the anatomicid facts, 
as refern?d to in (he earlier portions of this chajtlcr. In men the 
occurrence of the diecasc in these locations is almost positive evidence 
of the practise of sodomy, but iti women the possibility of the infection 
of these parts ihriHigli their uontact with the male organ or through 
the discharges from the vagina render ihem nmeli more liable to iina.1 
chanercK. All slatiNtic.<i, however. np»ii this subject must be taken 
riifii ijmno $alis, e-^pccEally in men. The shame of such practices as 
cause tint* local inoculation in males deters them from conaulting the 
doctor, and n» the symptoms are not iinheniablc, pndmbly a large pro- 
portii>n of them are never *een. Possibly many inses of secondary 
8^'phi1is, in which the patient denies any knowledge whatever of the 
original Kouree or site of the infection, may have originated in true 
chancre? of the nnug or rectum. 

The initial legion may occur in the skin surrounding the anaa, 
between the mdial fold*, in the anal canal, or in the rectum iteelf. 
ThoiiC below the ano-rectal line aru termed anal, and those within the 



THE ANHS, RKCTUM, AND PELVIC COLON 

spliiucterie ooiilraction above this line are teniiecl rectal clianrres. The 
coulagiou, as admittril by most observers, ia caiTJed in the blontl ami 
in the aetri-'tiuns IVora a chaitere or from eecondurj' lesiuus; the aoruial 
BL-cretioas, i^ui-h u^ suUva. ^M'C-at, milk, and ^ciuca, are snid not to convey 
the disease unlosa mixed witli rtisthargL's from come inflammatory leiiioa. 
Whatever tho source of Ihc eniitagion, the prinmry infection is Rlwn}-^ 
a trufl, hurd clianero at the soiit of itioculation. The infection may 
occur thmiigli iirimt'diate tuotact, and generally does so occur, Wt it 
may also be brouglit ubout by mediate contagion, sucli as the use of 
towels, sponges, cloths, syringes, ct^., whith buve been [ireviously used 
by patient* affected with the disease. 

The author saw a case of hard chancre of the anus in a priTato 
patient eomc years ago, in whom the disease was caused by the use 
of a syringe for taking a recta! onoma, the instnimont having been used 
by a bnjtber who was KufF(>ring from tionstitutitniiil sy|)hilis. ^Hiile 
r «ueh instriiiiients may be used wilb impunity so long as there i« no 

f lesion in the skin or mucous membrane, the moment they come in 

contact with a fissure-like crjick, an abraded ba*morrhoid, or a smaLl 
erosion of the pkiri, infection is very likely to occur. 

Anal Chancres. — The most common seats of these chaQcra't about 
the anui} are in the skin just outside of the radial folds and in the sulci 
between these folds. A Biifficient niimher of observations of thii ehur- 
acter him not been made to justify any generaliitation with regard to 
the comparative frequency in location. Of three cases of chancre of 
the anus one occurred in the skin just below thfi radial folds and the 
other two between them. Those which develop upon the skin around 
the anus do not differ materially from the cuiaucouM chaneres on other 
portions of the body. They are generally aupcrlicial and circular in 
the first stagos, resembling abrasions; thoir bases arc indurated, the 
edges red but not intiltrnted, and the center dark, grayiab, and some- 
times fissured. After they have existed fop a week or ten days the 
edges become infiltrated and the whole mass hard, indurated, and re- 
sisting. The sores are said lo bi' painleifN, but there ia always more 
or less diecomfort produced by them whether upon the skin or muco- 
cutaneous border. 

When they occur beti^een the radial folds or at the anal margin tbcy 
usually assume the shape of lissures. The dii^tinolion between them and 
true fissure in ano is snid by Ball, Quenu and Hartmann. Allingham 
and Kel-fey, to be easily made, owing to the absence of pain in the parts. 
Two patients aiTerted with chancre between tiie radial folds suffered 
just aa acutely after movement of Ihe bowels as they would have done 
from any other fissures of the same extent and location. The only 
difference between tbese ulcers and true fissure was tlial they were 



VENBREAL DISEASES OF THE ANUS AND RECTITM 231 

ii)(]urat4.>d aiid licaleJ ra|iidly without even strptching the sphincter; 
wlii-reaii tliu' mujority uf true fisKiirt's Iiavo no such trnilent'V. In the 
first KlagL-H i)f chiuiiTu occurring in thia location it will be vci^ difPicult 
to dutritlL- hrlwfcn Ihpsp two cnnditions, a* the indiiration is nut woU 
marked until trn dayn or two weeks after the devc-lopment of thL' initial 
lesion. The bases, it ts true, are hard and infiltratiHl at an earliL-r period, 
but as it ta difficult to graap these between the fm{fi.'r tlicy givu the 
impreBttion of cicatricial thickening rather than cellular infiltration. In 
one chancro between the folds the base wae at first a brownish-gray; this, 
hovrevpr, soon disappeared and left a bright-red, granulating surface 
which bled easily upon stretcbmg the buttocks apart. In both these 
cases the chancre healed in about four weeks, and in four cases that were 
observed the constitutional symptoms of syphiiie developed within the 
first cighl wcL-ks. 

IVhcre the chancre occurs a little higher up, or intra-onal, liart- 
mann states that the patient complains of a isenee of uncflsinc^s and 
discoDifort, never of an acute pain. In the cases that oocui* upon the 
skin and betwec'n the radial folds one may see the leBious by gently 
separating tliL- buttocks; in the intra-iinal foriii it is necessary to pull 
the edges uf the anus forcibly apart and sometimes even to use a 
apeeuliim iu order to observe them. Here the chauere aiisumes the 
circular or round form at fir«t, at leaet it appears so when the purtii are 
stretched c^pcn. The edges arc slightly elevated, the bast is smooth 
and indurated, although thia latter condition, it is said, is difHcult 
to make out. Thf muL-ous meiiibrano just above the edges of the ulcer 
apiiean* to Iw pisrfpctly hrallhy. T)ie etlgcn of the ulcer aru rose-«olored, 
and the ulcer itself seereteH a very scanty muco-purulent discharge, 
aomctime-s slightly tinged with blood. If the disehttrgc is abundant it 
is evidence of n mixed or eomplicatcii sore. 

Chancre may develop upon a prolapsing or Kypertrophied external 
bsunorrhoid (Jullien). In such cases the development is most ehamc- 
teristic and the induration very great. Whore the ehnnerc involves 
the muco-ciitaiieoua border there may develop intense intltinitioTi of 
the cutaneous tissues Udow, even almost cartilaginous in it» nature 
(Neumann, Annnles di* denriat., Paris, 1893, p. 133£). 

Slixed Sorrs. — ("haiicre may be complicated with chancroid, thus 
causing a mixed sore, as has been described ia a preceding section. 

.Aulo-inoculation is never a safe dingnostic guide in this region be- 
cause of the poftflible presence of p)"ogcnic germs in the ulcer which might 
make it Bueeessful even in eases of true ehanerc. Simple hard chancres 
may Iw so irritated and infected by the passage over tliem of farcal 
matter that they awuine a phagedenic type resembling chancroidal plia- 
gcdwna. Thua one must admil a phagedenic condition aa complicattng 




S3S THE ANUS. UECTUM, AND PELVIC COLON 

true chancre, such as is tlescribeil by Medina (These, Peris, l891-'98, 
No. S88J, and Queuu aod Hartinann {he. cit., vol. i, p. 79). 

Course of the Dkcate. — The experience of Foupnier, Carrier, and 
others, who stntp thnl the oournt; of thew? IijpbI sores is a very slow one, 
ha@ Dot been onnfirined; fnr those which the Huthur has seea have healed 
comparatively promplly. They say that the parts may be inflaintNl, 
assume a dark vcnoiisi color, sometimes reseinhling intertrigo, the radial 
fohls may hecome engorged, nnd in the midfit of these diffuse iRfiiona 
the chancre itaelf may be passed unolwerved. Si»?h a diffused con^^es- 
tion of the parts must be very rare, and would indicate to the writer a 
mixed infeetinn. 

Sometimes the folds bordering upon the ulcer become hypertrophied 
and flovelnp into iinicn-eiitfl neons tabs. French authors i^peak nf these 
as comlylninata. On this side of the Atlantic the term is not used with 
this significance ; here it means vegetnting exerescenees upon the skin 
or mucous membrane which have a warty nr pnpilloraatous character. 
These develop about the anus in the course of syphilis, but they are 
among the secondary Kianifcstations of the disease, and not connected 
with thf' initial lesion. The nipidiiy with which the ehuiiis of inguinal 
glands iipnn both sides of the body iMTome sueeessively enlarged is one 
of the most reliable diagnostic symptoms of chancre of the anus. The 
development of sceondary symplonis, however, is the only absolute proof 
with the initial lesion. 

The rapidity with which the chains of inguinal glands upon both 
aides of the body become miceesaivcly enlarged is one of the most 
reliablt' diugnoHtic symploma of cliaiara of the anus. The develop- 
ment of secondary syniplonw, however, is the only absolute proof that 
any given aori? is sy[thilitic. Chttncre with minor degrees o( hyper- 
trophy of the inguinal gitinds iiuiy iw the beginning and i^nd of sypliilis, 
or B patient may have a true chancre without any secondary develop- 
ment, nnd years Inter be affected with n tnie outbreak of tertiary syphi- 
li?; tbcK^ courses indioate that the systemic resistance fit the time waa 
Bufftcient to overcome the virus of diacasej but the seeds of constitn- 
tional infection remain latent, and at some period of depi'essed vitality 
overcome (his resistance iiiid develop with great intensity. At other 
times the secondary development may be so mild that it doea not make 
any impression on the pntit-nt. and jmsses iiway only to reappear years 
afterward in the shape nf eevere ti-rtiury lesions. These fiiets empha- 
size the necessity of the most careful observation for eonsideruble peri- 
ods of time nfler a suspected sore, nnd also to guard the reader against 
a toil favorable prognosis jn any kucIi case. 

Chancre of thf Rectum. — Chanerc of the rectum proper is one of 
the rarest of disea.seB. Martincau (Lemons sur les d4^formation8 mlvaire 




VENEREAL DISEASES OP THE ANtTS AND RECTL'M 



233 



enalr, IfiRG, pp. 152, 174. If6) has reported three i-SMea, I entirely 
JVC Ihc intcrnsl sphincter, 1 on its level, ojid I hctweea the two 
aphinctprs. Fonmier himself says that lie hw seen 4 cases, but of these 
the diagnosis yefta absolutely certain in but I (Loa Chum-ri-s fxtra-gpni- 
taux, I^iris, 1897, p. 4«6). Molliere 0'>c <"''-, p. d^ti] only credits one 
of thesp, that of Fournier. Ohmiuin-Dumogail (St. Louis Medical and 
Surgical Journal, 1900, p. 294) has reported two ehflJitTU's, one im llie 
verge of the rectum and the other 3 inches above the anus, bolh in 
vomm. Trelat and Vidal de Ca^is al^o claim to have seen cases. 
Hartley (Journal of Cutaneous aud (Ji-uitn-lTriniiry Discftses, ISilt, p. 
218) has reported a moet carciulty observed antl indubitable case a& 
follows: 

J. HcO., thiity-two, nulc, V. B., orguni.tt, wm ndoiittcd to the Rooscrolt 
Hcwpitnl. HcptcmtxT SO. 1890. 

famiij/ Ui4<<^ry. — Ko tubercular, renal, or cardioc ailincuti. No rhuuniallc 
r hbtary. 

Pmonal liutari/. — No tubercular, r«ual, or cardiac diHOOM. Dcolea nil pre- 
vioui vencrenl disptt*f!i. Hiid djM-uit'ry fconie years ago. 

Pr<aait V«i>Jition. — Abnut three «'icfkB ng<i the pntivat noticed severe pniu nt 
defccarlou, and a tiititill lump just willuEi tht- miiiti; jiaLii now (^>tiliniioi»: tcncs- 
mt» aft«r each pn^eii^; lilooil hiu been prMcnt at ittool at tinm. 11^ \\m nnSercd 
from const i I >n lion for a lung I'lfao. 

An alccr is found just 1 iuch from the annl marfn"- It '* about tho bIm of 
a ijiwrttT of a dollar. The base i* iudiiratwl and the ulccraiion is very KU|>crfici*l. 
Bacnil gUndA felt eolnrj^d, There i» no evidence of any other Icsnon. 

OfirnUiaii. — ^)>ier[ilHT SOth. UkuhI anlisfpsla. BJchlnridi; and boric-ndd 
irrigatian of the Ktrtuni ; ^jihinclcr dilated. Ilivulve npeoulun) UM-d. The ulcer 
im nxn jnot I inch wiihiti itic rectum; it is NupcTf^cUlly eroded with a di<itii)ct 
but not rartitn^innu» )>a»«. 

EttUion of Ulrrr. — Cnnterliation with Paquelin cuultry. Iodoform jHiwder. 
Supjioflitoiy of opium, gr, ij; opium jiiU, gr, j, t. i. d. Patient ordered to warda 
'kod to be watched for any evldi^ncc* of ityjiliili*. ^rpLcmher 2Ath : inovenieiil of 
bowels; daily irri^tiion. Sepl^mbor BOth : ulccni li^nlin^ rapidly. Oetolxr Irt: 
rMOttaifPffr (A« surfiut qfthe fht*t and nhl'mm. October Bth: dinclmrgcd ffum 
tlte hnKpiliil iniprovcd. OctotuT SOtli ; patii-iil njiplicd to-day for Crr'jitinriit. in tlio 
out patii-nla' de|Mulmcnt, staling that his mcdicmc tuid been awi] xip and thut ho 
'deiirpd more. Puticnt presents a papular Byphilide involving the fuce, forearm, 
tmnk, aitd porli«n.<i of the extreniiticJi. The ulcer of the iccluni la healed. 
Patient ia put ujiou anttoypbiUtic trcntin<'nt. 

A carrful intpjtry an to llie mmie of infectinn was inslitiited. Patient for tho 
firvt litne during Imm tn-iitment hcn^ udmilH thtit Ihn^e weckii liefun^ udmisdiou to 
tbe hospilnl. whili- in Uullimnre, ho wm the nctim of another man. 

Afl«r ihiK confcf^ion the piilient was loKt to view. 

The painle>tmcfiB of the U^inn dcsMiribed by nome nuthors ia not 
borne utit by the (nines of Foumicr and Hartley, both of whogv juitieaU 
complained of severe pflin, the sensation of a lump or foreign body 




oixasioDiil ] 
of blood with the fasces. The existence of chancre wilKin the rectiun 
wry positive evidence of sodomy, althougli it is possible lor the infec- 
tion to occur, as in the case of anal chancie, through the use of ad 
infected gjringe-tip. 

Symptoms. — The eymptora* of chancre in this location, os drawn 
from n few experiences, are more nr less ncute pain at the time of or 
following defecation; a dischar^ of mnco- purulent or purulent secre- 
tion, with or without the presence of blood. Examination gives to the 
fiugcr a SL-usution of an utot-r slightly depressed in the center, with 
t-leur-cut borders and an indurated base. Tlicae ulcerations are very 
eupcrlicial. The tacrul glanda may be enlarged if the sore has exUtcd 
for any length of time. One would not expect to find the ingiiiiiftl 
ginnda euUpyeii at so early a period a? in chancre of the nnns, owing to 
the fact that the lymphatics above the sphincter asecnd by a different 
roulL* from thoite below. 

The histology of chancre of the rectum doe* not differ from that 
of the aorc fouud elsvwhcic except in the tissues involved. 

Treatment of Initial Lv»ion. — The treatment of chancres of the anua 
and Tectum i? practically ihe same as that for the lesion elsewhere, 
with the exception that in these locations it ie much more difficult to 
keep the pnrts elenn, and it is more usual to have the snre complicated 
by iseptic conditions. Great care, therefore, \» necessary to sroid these 
comijlications. When the chancre is outside of the anns frequent wash- 
ings with nntiseptic soliitionfl should nlwaj-s be pmctised. After the 
parts have lieen thoroughly cieauBed and wijwd dry, one should apply 
some ef the powders racnlionod in the treatment of chancroid. The 
mixture of I'quiil piirtK of oxide of zi»e mid t-alomel is exi'iellent, because 
it is devoid uf iiiiy disagreeable odor, it is iuexpL-usive, and seems ijuite 
as efTective iis any other powder. There might be un objection to the 
use of criloiiiL'l vindi-r such circunistances because of the poiisibility of its 
bein;; ubsorbed, jind tliui^ masking the coDstiiutionitl sypliiliij or di'lny- 
ing its appearance. When ulcerative lesions are sluggish and ioclincd 
to Buppurjitf.', aiilino.tin or tincture of iodine stimulate them to gniQu- 
lation, and jippiirrntly luistieu the healing. 

After the powders have been applied, the folds of the buttocks and 
the radiating folds nf the nnns should be carefully separated by small 
pledgets of gauze or nhsnrljcut roltnn to prevent the friction or abra- 
eion occasioned by clothing or by their nibbing together. 

When the chancre is well within the anus or inside of the Tectum, 
it will be nefe.fsary to introduce a speculum in order to nleanse thn part 
thoroughly and apply any medication. Under such eircumRtances the 
fenestrated conical speculum is by all means the best, as it can be intra- 



I 




VKNBKKAL DISBASES OF THE ANUS AND RECTUM 



2S5 



duced with comparatively little pain, and the wincdial measures applied. 
SupputiitoriieH cuiituining Hudi drugs as iodoform, aristc), and doho- 
[tliL'iiu will III- itdviinlii^citun if tlii^ iikvr U wvW uilliiii llu' ri'L-tuiii, liut 
u.KeWiUt if it is id liw una] L-»iial. Tlu* Ixiwcls stiuuld Im.> krpt djilmi. Imt 
not hy drastic cuthurticK, which briiig uii diarrhii-a aod irriiatitin uf the 
ruutuin; one smoiiLh, giMillc iiitivi'tm-iil dnity is the nio^t witisfadory, 
and thie cuu bu vblaiiii'd hy a muruiDg eu^-um. If lliv ukxr i» iti Iho 
rectum, it may bo necessary to use opium to prevent too frequent 
stools. Irrigation uf tho rpctuin by borie noid or mild bichloride poIu- 
tion8 should be \m.\\ after oaeh stool. lu Hartluj's east? tho iileor was 
excised anil the ha^i? eauterizod with the actual cautery, and yet )«econdary 
eyinptuins proiiiplly upjicarcd. This iiietliud of livatiiiciit has nut met 
wilh tlii; geiiLTul a|)]iroval uf tlie jiiciEession, and cxju riitne with it liaa 
not been sueli as to encourage it* adoption in the tlt'ulment of anat or 
rectal chancres. 1 f kept clean and dry, and the patient remains rjiilct fur 
two or thrTO weeks, those Iceiona will gencrnlly hcnl ntid leave nothing 
more than an induratod spot, which gradually disappears, so that iU 
eitc i« iwin'mpiiznble. 

Secondary Maaifefltations. — Secondary syphilis manifests itself in 
this region in a variety of ways. Around the anus one may observe the 
same legions wliich occur upon the skin ebewhcrc in the body. They 
are modified to a certain extent, however, by the close approximation 
of the parts and th<>ir habitually moist condition. Thus, the macular, 
scaly, moist piipuiar and tubiTcuIar syphilides in this rngifin art' vory 
liable to he transfonneci into tnucnus patches or ulcerative enndiliontt. 
These two type'» are therefore most frecpiently Bcen. 

htucinis Pnlchfs, — Nest to the mouth and thniat the anus is the 
most freipieat scat of muaiuc palehefi. In women they occur iit some 
time in a large percentage of cases of constitutional syphilis. They fre- 
quently begin in W\v vulva and Hprcad t<i the anu», hut it ie not at all 
rare to eee the lir^^l patch devLdop in ttic kttyr situation. 

The course of their devtdopiiu'nt is as follows: There U first an 
crythemii Ix-twi'en (he fiilds nf the huttuek. Thi« may occur even before 
the initial lesion heals; when the latter is located in this region it may 
tnip(-rr(>ptildy ehanj;;e into the mucous patch, thus oceasioQiD^ a sprt of 
transfcriruttion iti eitH. In point of time the patch corresponds to the 
macular enipHon upon the »kin. It appears nt lirst nsi a dull n'd zone, 
vhieh f^radually fades into the surrounilin)^ skin. There is a sort of 
oedema bolow the epidermis which elevates the epitheliim ahove tho 
deraia. This oedema is not sudlcient to produce a vesicle or bulla, but 
the epidermis becomes macerated and falls, or h nihWd off hy the 
friction of the piirt^. leaving a superficial erosion. At Ihin period the 
eonditinn may be mistaken for an acute eczema. There is little itching, 



however, the ditidiiirgc iii fciinl iiud thiu, Diid tlicrc i» no cracking; of 
the tifrsuee, as occurts in that di&ca»>. Soon afterward there fornix upon 
Ihtf Kurfaci' a gTayWh-vUilv pt-llit'lo or iiioinljniiie sonievvhat t'lovatod 
alK>VL- (he levfl uf the ):kin. The t.*iitnni-uu): tit^Mie bonoath thit' U infil* 
iT&ted uud hypertrojthiyil in the 8U|jL*rfit'iaI layers. Thew? i-Iianges eon- 
Klitute tlic niuLous [mltlie*. Tlii-y iniiv he »in(fle or aggregate, and 
involvi! Ihc i-iilire drtuiufL-reuL-e uE tht- auutt. (Jent'rally they arc disk- 
Bhaped, nnci situated upon tliu Iwo folds of the buttoek. which lie in con- 
tact with one anothor. In the second etagc the pntrh nppcarj' iis a sim- 
I>lo, elovHled, jtoaHj spot situntod hjkhi b supple base of vcrj' rslightty 
indiirulud skin, and ie torniod the " pinqiic pffcrcelninique." As the con- 
ditiiin dev<.*lt>|is. the patches Ijccoiue more elevateil, but are pr^esed 
Hut b_j' ilie butt«<:kB, and secrete a thin, foetid fluid wLicli keeps the 
purta nioiiit and irritated. In tliis stage, an iiccount of their Qat sur- 
face and hroiid ba^u^, Ihey arc toniicd '' inmdvloimila lata " (IMate V, Fi^. 
1). The papilla.' owr which these pntehw arc situated, through cellular 
infiltration and irritation by thc9e secretions, soon bugiu to hypertrophy; 
the lirnnrlies shoot iipwai-d, the vessels nuiltiply and dilate, the summit 
of the growth increases in weight, while the base remains the same, 
and there is deveJopeit a cauliflower growth distinguished as vegetating 
mtieuus patches or venereal warts, This couilititin, while due originally 
to specific disease, is no longer a purely syphilitic affection; but, on 
the contrary, a papillomatous growth, which docs not yield in the least 
to internal antisyphilitic medication. The fact that the secretion from 
these growths* is imto-JHncubible wnuld seem to pmvc their non-nyiihi- 
Htic nature. Within the rtetum muoouR patches are said to be very rare, 
hut (he author hclieves they are more frequent than ie supposed. Biiren- 
flpniiig (('haTil(''-.Vnnal., ISfi.", ltd. vi, p. 57') long ago ohscrved them 
during the eruptive Atage of 5y{>liilia, and ^Iiimn (UaKctte m^., 1B73, 
p. S) suggested that stricture might result from their niccr&tion. 
MolUore reported a cast^ in which the patch was 5 centimetres above the 
anus. The colored drawing (Plate II!, Fig. 1) shows a pear-shaped 
miu-ous patch on the middle floustuu's fold, uhlcU was deiiion»<t rated 
al the clinic in May, ]!)0(l. They give rise to no marked symptoms, and 
are therefon* probably overlooked. 

R l^ang. of Innsbnick, examined 1 10 eaj<es (45 men and (i5 women) 
in the eniptive stage of syphilis with refea-nee to cceondary mani- 
festations of the disease within the rectum. He found plaques or papules 
in Id vases. They were loeBte<I generaUy on the posterior wall, but 
sometimes on the sides, and in 3 ea^s involvcil the entire circum- 
ference. The plaqnes were fretpiently ulcerated, but in only 3 was 
there pain in defecation or loss of bloocl. In 1 easie, in which the 
plastic was situnied very high, the patient suffered frum tenesmus (R 





YENERKAL DISEASES OF TGE ANUS AND RECTUM 237 

lAng, Pstliologie nind 'nii:>ra)]ie tier Syphilis, vol. i, p. 325). This expe- 
rience emphiwiics the impoHance of early rectal oxaminations in con- 
stitutional eyphitis, and pmvi>i< t!iat npetific iilriTalioiMi iiftc>ii occur liero 
unobeerved early in t3u' diseiinp. Tlicse ulcerations inay rscilo in-tlem- 
mator)' processes which resuU in stricture later on. Such strictures, 
although originating in eyphililio uU-eralinn, may bi? purely libroua ami 
pOiweBS no specific patholugiual ciiaracteritiLies, such lui gumiuata aud 
endarteritis. 

Small Red Pajiufex. — Along with, or sometime? before the appear- 
ance of ihc nnicniis palclies, there tnay occur !*iiiall red papules nronml 
the anus or between the ra^lial folds. They rapidly break down and 
leave ^mall ukvrei, nhiclt a.-'.'iuiiie Ihe ^hupe of li&^urcs when they occur 
in the lattt-T position. These lissure-liko ukcrs may aUo occur iiide* 
pendcntly of the papules. They ore said to be painlc»tt, but one tins 
to sec only a few sneh eases to have his mind disahu^ed of any such 
miscnnecption. They arc distinguished from the ordinary fissure by 
being multiple, of a grayish color, with raised edges, slightly indurated 
bac"e. and by the existence of other miinifestalions of syphilis in the 
individual. In one case a small red papule wag ecen 1 inch above the 
sphincter. 

Secondary Ulcerative iwioiw.— Betwwn the uccondnry and ter- 
tiary uloeratiouH of the antw it ir ditTieult to drave the line. Ijeaions 
ordinarily considered to be socondnry may come on years after the in- 
fection. The anthnr has reported elsewhere a typical nnieou.'i patch 
appearing in a [latient nearly four years after the initial lesion, and as 
ulcerative nyphilides are later mnnifestations than mucous patches, it is 
reasonable to suppose that they may occur at even more remote periods. 

Where the disease runs sucressively through the primary, secondnry, 
and tertiary stages it fades so imperceptibly from one into the other 
tliat it is imposMible to state when one begins and the otlier ends. As 
a rule, secondary ulceralions are eharaoturlsed by (heir early devclopirifnt, 
shallowness, small destruction of tissues, and healing without leaving 
cieatriifs. They may, hnwevcr, Tary in iXmtc rc»iH!ct-*, sometimes being 
Very deelniclive, when wcrurring in the early historj- of the disease, and 
At Other times they may occur in superficial form long after the initial 
lesion and secondary eutanenus uianirestatlons have passed away. Thus 
it seeiiiB that the diaracler nf the ulcer is of mueh more importance 
to deteniiino the stage to which it belongs than the ]x.'riod of time at 
which it appears, and ulcerations having secondary characteristics, as 
jusl described, may occur within the first few weeks after the primary 
l««t>n, or even ycarv aftcrwuni, »n<l clinically and histologically they 
arc identical in both periods. They ore eecondary ulcerations at whut- 
evcT period of the disease they oeoar. 




SSfl THE ANUS, RECTUM. AND PEbVIC COLON 

Tlii? ni<>tlio(i uf Iheir (lovplopnidtit is variuus. TarnuVHhy says: 
"Where a (MiiiKtitutinnnI sy}iliili.>4 exUts, but without any positive evi- 
dence of the diseasp, an nltrmiioii or Inrjil infliiTiiiiiatinii iimy lake "fi 
tlie cliaraoteristics of syphilitic iilrcriitinn, and hfjiliiig, ]cu\v /i char- 
acteristic syphilitic cicfltrix, ftniofith, white, dcpresfied, and pigmented at 
jtii borders." But thia ty)>e of ulceiation ordinarily occurs in the ter- 
tiary stage. 

MiicnuK patches tlimugli infection or tlie vinilonco of the disease 
miiy hrpiik ilowii dtid Iciivo ragged ulffrs iihont the nniis, such a* the 
FreiuOi call " rhagades." Papulnr, macular, and piiKtiilar gyphilide*, 
occurring about the anus, rapidlj become uleors;. They may also 
begin OH local inftaniiitfttorv effusions or cetlidar infiltrations. As 
these increase the circulation of tlie parts becoiiiea choked, the tis- 
sues break down, a.nd there results an irregular ulcer, gangreuous 
or bngjit-ri>d in color, with elevated edges, snmetimps bleeding oasily 
itpou Inuch, and conipar.itivelj paiuless. The ulcers are frequently mul- 
tiple, the intervening Lntcgiinient being perfectly healthy; whpn they 
fwcur between the radial folds, they assume the elongated appearance 
of fissures, the folds tlieniselves become hj7)ertrophied, have a gray, 
Bodilen appearance, and all the parts are hathed in a thin, punilent secre- 
tion; in these sites the ulcere are not painleHs — in fact, without other 
evidence of py])hili8, one could scarcely diatinguish them from simple 

fiBMUruH. 

Somctinii's the nnal ulcers cstend upward and involve the niiioouB 
ittemhrane, but ordinarily they heal or remain stationary and are 
ch rtinic. 

In the Rectnvi. — AIkjvc the ann-rcctal line one rarciy observes any 
eccondarj- wyphilitLc nianifcptntions idhiT than the ulcerative. These 
lesions may be either single or multiple; they probuhly begin in &n 
abrasion, Ihen folluHt; eelluhir infill ration, noLTooiD of the tissues and 
the formation of tnmll criilcr-fike ukrrs with elear-eut indurated borders; 
they rarcdy extend in the early stageii deeper than tlif submucous tissue. 

Unfortunately they [m-scnt few Myniptonis iit this time, ami are there- 
fore not recognized iintil they luivc reached the chronic stage, when tlicy 
are characteriBcd by their extensive area and great destruction of Hn- 
6110. The entire thickness of the wall of the gut may bo dcptroycd and 
t\\f sacrum left liarp. Tf situalcd tipon (he antoriiir wall of the roctura 
they may even perforate the peritomoum {Mollii>re. op. «(., p. 643). 

The tendency of all syphilitic ulccm ii* to extend in the line of the 
blood-vessels and lymplmtic)*. Thus about the anus thoy progress cir- 
cularly and forward toward the groins, while in the rectum they travel 
Upward. In the Intter position, however, owing to their niulliplicity.they 
Boiuetimes coalesce and entirely surround tlio organ, In ulcere about 



i 




VENKREAL DISEASES OF THE AUVS AND ItKCTUSL 



S39 



•nns, tlie lymphatira of the inguinal region ure the first affectcil, 
while in ulcers of tlie rtclum those in the hollow of tl»e sac^niin become 
enlarged. The eiilargetneut of theise latter gland* must ii(>t be mis- 
tnkrn for giiniiniila. If Ihu ulwration Iw-'i-oiiu-s chrunitr and devt-Iojw twr- 
tinry charactiTistic'N, tis it prugriisscs upward in the rwlum, it ciftcn heals 
at the h>wt-r nmrgin, leaving a bliUKh-white i-icatrix. The urallR of the 
rectum hctiealh the iilcrrs frd Iciithi-rv mid [mrchnient-lilje. The dis- 
t'hargc is grptnich-vpllnw, [mruhnt, tinged witli bliwd, and very abiiii- 
dsot. Mucus is ordinarily absent from the etoo]». The odor ia fmtid 
and disgusting, but distinctly different from that which characteriMS 
the diiioharg«s fnun tan-iLonia. 

The patioiit eulTeps frmn tuneHinua, a feeding of weight and jiaiii 
about Ihi- sacrum, mid frequent stouU. lie may rest fairly well at night, 
but 111)1111 rising in the rndriiing he will iinimidialidy pass a large (]uau- 
titjr of this saninua pus from the rectum. Later in the day he may have 
a oatural movement, but nt varinua (imea throughout the twenty-four 
hours he will be called to the dusct, only to repeat his early morning ex- 
pericnco of passing greater or lees quantities of thia greenish-yellow 
Gocrotioit. 

When the condition has oiisted for some time the sphincters hceome 
relaxed, the radial folds liyjferlrophy, and the fluid may dribble out 
throuffh the uiiu*. kuL-pin;; the part* moist and irrilatnl. From this 
irritulioii ihert- may dL-vdo'p uxteuwivc uh-L-rs about the, anus. When 
Uicy heal they sometimes leave u ragged coaditiou of the anal ftdda 
rriicmhling a rock's comh, hut not «o rod. This condition hat? tieen oon- 
«iidered by some n» pntlmgnomonie evidence of syphilid. Thii« Sir Jaiaea 
Paget days: " I wilt not venture to assert that these cutaneous growths 
are never found except in syphilitic disease of the rfctuni, hut they are 
very common in nssociation wilh it, and so rare without it that I have 
not seen a ca»c in which they existed cither alune or with any other 
difleaee than syphilis." While agreeing iu the main with what thi* 
eminent surgeon has naid, the nulhor still l)cliovcs that this condition 
may develop from other inflammatory conditions than the t>yphilitie. 

The developinenl of rectal ulccratinn in the early stages of syphilis 
is evidenced by the following brief histories: 

J.t thirty-lwo, itdmiltcd to the Workhouse Hospital, August SS, 1Sfi7. 
Fnmily liiiinrjr clvur IIiul twrn quite wrll nil her liTe, but giv4>ti to dissipation. 
FxARiiiuvtion shoviud cicitrlv • cn))|ifr roion-tl. tiinciilar «Tiiption over nil th« body 
sud upon t1i« face. She Rdmitled tiavinK lind u vulvar chancre during the lnHt 
«Mk in June. Thu Wtcd about four noeks, nod healed without any treatment, 
exoopt k«p(^ntr it clpan. 

J>MyinMi».—S*eonduy syphilis. Treatment, pTotolodlde of meromy. 

8e|>lmitMT Sih.— Patlrnt complaiiivd or urliinfiin htrliack.dlarrhcea.uiil pains 
ahoodng down bn kg*. ExainiDiition showed lli« unuii poffcctty health;, even 
10 



9'iO THE ANUS, KECTL'M, AXD PHI>VIC COLON 

ax ht(ih up n>; could lie. sct'ii li; fitrcitily m'luimtiii^ ilir ni'Iiul fulils. r|ina iiirro- 
ducing thi; linger into thi: rvctum u ^liutlow, ulccmU-d it|iut with un indurutcd l»i«o 
about Hid sup o( h 25-ci'nt put-c was felt. Tim I'dgcs wt-ri.' urrt piirtinilnrly 
elevated, and tlio tuucous nicmbrunc arouud tlic ulcei a|>|H-arvcl to be healthy. 
Through the tpeculutu the ulcer npiwared gravikh-wbile with acmter-liLe IwHe scad, 
iircf^uliu, cU'ur-CUt vd^tx. It iovulvoii the riglit irusteriur ijiiadniiit uf tli<: ie<:tal 
wnll. It WAN MijHTlScinl, hlud oiixily, and vccrt.-t^-d n (tn't-iiitili -yvl low ]iii« In abun- 
duDCc. Tliu eruption was :ilill present i]|wn thi- jmtiviit'i" Ijodj. Thu uncnil ginnila 
were etilntged, uh werm also thi! rpilrufhlnir niul pn-t-tTmeiLi. The ingiiiDal 
gliinds were not iiiiu§iiall^ cn|{orgi-d. The ulceration had occurred within t«B 
weeks a[ the initial lealan. 

The followiug historv of anolber case seen in Mard:, IflOO, in the 
Haine uistilutioii, sliowL-d tlmt tlio rtcUI ulceTuiion cocsisted wilh a 
churuL'tcnKlie ciccrtmilury cruptiun, nl»piidii »ihI mufrouii piiLchos in the 
throat : 

Liusic , aged twenty-four, a public proEtitiilc. Family hivlory indcfiailc, 

hahils rile. Sityn file nrver hnd any rencn-«l diat:a«L- until xix weckN praviouti, 
when she lind a " lireikkiiin out on her privntee." 

She entered the hospital February a8lh, C(im|)h»iiiiiig of gre«t pain with loss of 
blood ut eaeh do feeation, and though! xlic wll^^ su^rrtiig (rum [lilea. At the same 
lime the body was covered with [uipular H>|ihl1idti>, the liulr came out eaaily, and 
there were two mucous patehe* iu hor throat. I.oeaI txumi imtiou showed the 
radial folds -of the nnin hy|>iTtr<i|ihii;d. nnd brtwi-en ihrni then: wrre gmnulating 
fiuiiTCs which bled ciwily upon touch, or when tho part* wore forrihly Bepnratfd. 
There were no mucous pnt«ht'E nruund the anu», hut upon introducing the dnger 
into tlie rectum there was found an nicer exteiidint; upward for ubiout 3 incbee, 
alnioul entirely surruuiidin); the- rectum, and ronin-clcd below with lh«' Ilssurt!* 
betwt!{!n the folds. At the upper end the nicer terminated obniptly in healtli>t 
miii'oio nienilminc. The biiw; wn.i linril mtd lenthrry, lliv edges elevuitil and 
indiiruti'd. It was shallow, and bird eiuily upon toU'cli. 

In Ibis ca»e, as near aa can be estimated, the rectal tilcer occurred 
within eight wt>ets of the initial lesion. The third case was one aoen 
in private prai-tit-o. It wsis in a young man in whoin the initial leBion 
oc(-uiTt'd ou till! lip. Thu induration from tliis U-sinn h:ul not disap- 
peared at Ihe time of the pxaininatinn, ulthongh the miw had htaleti. 

He hml al the time nf exiiminiilinn a fiiint copimr-eolon-d eniption iiiMin his 
body. He eonaplnincd of hwwineiui nmi iiehini^ idiout the tinus, |inin Iwfore a 
movement oT the bowels, and a dmchar^^e of yva from the rectum. eHpecially upon 
riifing in the morning. The anna wa* healthy with the exeeption of hrpertrepliy 
In two of the radial folds. There were no fiswire* and no inllaninialory prorew 
apparent upon the O'Utsidc. The examination of the reetwm showed at the height 
of H ini;heii ii distinct iikTnttinn nilli cli-nr-cut l>ii'r<)ent. K'^'ing to the tlnfivT that 
leathery, piirchroent-liki' feeling no clmriicl eristic of syphilitic l»-iii«ni". Th* npcc- 
ulum conGnncd the impro^sion given to the linger. There appeared lit first a 
profujic^ yellowitih-Kreen purulent seereliou; when thi« wa« wiped a way an ellip- 
tical ulcer waa seen about 3 centimeters long and 1 wide. It waa nodular and 




TEKEREAL DISBASES UF TOE ANUS AND RECTUM 



'2il 



tliglitly Oc-prcKKi], tlie c-djL^-n indiirntcil, but not much elcTatcd, aaH tbo roctn] 
wsill Ix'ncHlli it Kcitrniil lu liucii IomL iU Miipjili:iii.^M. 

Ili^ xtuti-il iliiLt tlic toitt on hia lip Ant npgjvaifd «l«vcn voeks before codsuII- 
ing me. 

la thU case thi> uIccr«tt{>D occuirvd wltliJu twelve w«clu nftvF the init inl Icmou. 



Nui 



could be L-itt'd 



Hiloh the uk-orati 



huv< 



iiiicruu^ ci 

currcd witliio two, three, ol- four months after iiiuculatioii, but these 
apponr to be sultioiort to estiiblish tbo faet that they do occur in the 
early seeondary stngcs of syphiliB. The first two oases left the institution 
mueh improved but not well, nud it is impossiblp to &ay whnt was the 
final result in them, In tlie lat«t ca»e the pntient was uL»c>rvL'd fur over 
two years, and there wns never the slightest evidence of any strieture of 
llie rectiiiii. sliowinn that, if thc^e ulcers arc treated in their early 
stages, this didaatroti^ cuiiiplicAtion may be avoided. 

The fact that one can not obtain the history of initial lesions, pre- 
vious st't.'oiidary syniptnrns, or present TuatiifestalinTis of (he P[)eeifio dis- 
ease, oughl not to diiter him from mnkin^ a diaffnnsis in eases of ehar- 
acteristie syphilitic uleeratioD of the reetuin, sueh as the following: 

Mn. S. came to tbc Polyclinic HoapLtal, Octolwr IS, 189S, sufTering from a 
pTofuAC roctal dincharce which ahv euid hud vxist4;d [«r two muutlja. litem •naa 
nothing is ti«r npp^araoce to siigj^Kt nyphillK. Hcrhustinnd hud died from tube^ 
Culo*is one yemr i>n'vioii9. She denied ever Imvjiig^ j-nffiTcd frcrni ony Mn erup- 
tion or miy liii-jil nlri-mtkin. Her dhin whk rli-iir, itnd IliiTt- wiu> ni> nuirkfd i'n^Mr(.'i'- 
tncnt ot (lie lynit'Itntic glriDd!'. The unas wus normut nilb llic cxccpliuD of hyper- 
trophicHl rndiiil folil'. Tliprc wtr no Tilrtrs bctweon tlune folde. The apbioclrr 
in» icltixcd *o tlmt |nir\ilciit diiciiiirftcs from thf rectum constantly ooKcd out, 
necealtating the Hearing of a nupkio, EiiLHiJnation of the rtcturn Kbowrd extcn- 
■ire deatructiou of mucous tueinbranv of tliU ur^in »m high Aa4 inch«a above 
the anal niarf(m. and Hunrouiidici^ Ibe <'ntlrv gut. Tliv viiilh vetv stiff. InH«!itlc, 
nnd nodular, nnd bkd cn.iily ii|>nn loucb. The r<N;lftl nin|>iilla wiu conatantly 
ballooned, but tlu-rr wii« no cmilruction of the caliber of the (.(ut -it Ititu time. 
Aronnd the low<^r murgin* nf llin ulcemtion thi'iY' were dintiiict evidences of thr 
henlintt prorcsKCf ia (be cxiHtcncc of bluiAh>nhilc, depressed rimlricc*. 

The discluir^ wu & ycllowinh-^reen pua tinged with blood, and very iibtin- 
duiU At first tiilKrculoHi.t wm i>iiit]inr1'rd ui tlibi patient, htit cnnful em in bint I on, 
dny •fier dny, tailt^d to nhow t»ny tuhorelo hftcilll. Flnnlly, after three monMiB, 
the inliciit ciiiiM-iiicd lo tiike ether, ocid u »tiiull Kietioa aT tliu ulceralcil luucuiw 
metnhranc wu removed for oxiunination. 

nistological report by William Vissman, M. T).: 

"Tbii B|wcitoeD aliowB the epitbclium of tbe niucouN membraiK^ entirely dc- 
eUOjed. Tbe Lielxrkahu follicle* are largely otilitcrated, there bcinj; n fi'ir amall 
depRMlofiM. which appear like the lower eod of tiuch folHclca lined nitb cutuiiiiiar 
«|>llholIutn, Ther« la an intenae cellular infiUmtion of thr Milimuw^K tiHNuea 
dippjnii down Into the inuRcular layers, und prcMotiag the appcnnuiee of new* 
fonned tibroua celU. 




N 



343 THE ANUS, RECTUM. AND PELVIC COLOIT 

"The blood-vessels show distioct cndarteriti!). Euibryonk crllit «rp tlULrib* 
UCed along tlie wIioIli couric of theae veaselti, aoil at no pltico nrv lli«re^ ftnr {rinot- 
cetln or liilft^rt'lc lidclllt, iifir arc llit'TC ao)' ur.nimuljttinnii of c|iithrlii]m wliicb 
would iniikuitB owrdnoitift. On tUc ■whnlr, one would i]r*critic thiR (-ondilion as 
productive iiitlDnimiitiiut willi tibrmie uiii] rt'Ilulur iadltmlion. This la & cunditiun 
frvcjuontl}' fuund in dininie Hjfi>hilitiu tnllummntioiu." 

AntisyphilHic treatment wa» begun at once, but too late, for ihe 
patient shortljr afterward developed a papillo-sqiianious eruption all 
over her body, on the palma of her Jmnds. and on the solea of her feet; 
engorgement of the cercical glands was not found in his patient. 
Either the woman coin?eak'd the true histon,' of liiir casa, or it <'un.4i[itcd 
in a Inti^nt form of Bj-phi1itie iufeetion, which fitst exhibitDd itself in 
the rpctal ulceration, ami afterward in the ciitnnt'ous erutition. N"ot- 
witliKlanding the mnst vigorous antisjplulitir treatment, the use nf locitl 
remedies and constant dilatation, it was not possible to prevent eontmo 
ture in her rectum; and to-day, after seven years, she still has »om« 
ulceration, and fiuda it necessary to f&sa the recta] sound twice a wcc-k in 
order to keep the passage open. 

The aiithur had under his charge in the Polyclinie ITcispitul in 1901 
u catie with eYuetly similar conditiuns in the rt'etum. Her uleeratiou* 
develiiped about nine nioutlis after the Initial lesion, and have now con* 
tiuued for two years, Wliea the ulceratiuu haa reached tJn.' destructive 
stagi! general uiid Ictciil Ireatmcnt may linally heal the ulu-ra, hut thvy 
can not prevent the formation of stricture. Tliu pro^noetft ie therefore 
ttlway^ grave, 

T run (moat. — The treatment of thoeo secondary typos of syphilitic 
inlliiinmation of the rectum consists in the Qdniinietration of mercurj 
and keeping tlie parts clean, thus avoiding as far as possible any see* 
oudury infection by streptococcus or other pyogenic bacteria. Like 
many of the cutaueoua lesions of syphiUs, the secondary nianifcetations 
of syphilid in the rtrotum wiil »omctimC:i disappear without constitu- 
tional treatment under proper antiseptic care of'tlio parts, hut raediea- 
tion sihould not he neglected. A large number of destructive ulcera- 
tions and incurable strictun'S of the rectum, called jsyphililie. are not 
clue so nnich to the syphilitic virus as tii the septic Infections ntrurring 
through the k'niuns; because of tliis more stress is laid upon the local 
treatment of these eondilinns than upon the constitulioual. Thie sec- 
ondary infection explain* also the stfttemenl so often made by syphilojr- 
rjvplicrs and proctologist* that mercury and iodide of potash have little 
or no ofTeet upon syphilitic ulcerntions of the rectum. 

A mixed condition. i>pecifie antl septic, nnist be dealt with, and there- 
foi-e treatment should be directed in two lines. Complete drainage, even 
if the sphincter musclce m\i»t be dilated or incised, is requisite to heal 



L 




* 



TENEREAL DISEASES 09 THR AKUS AND KKCTUM 248 

tbcs« ulccn, and fre^iuent w&^hinga and dxcseings are iinpnrUnt in nrder 
that the parts mn} l>e kept free flOBJ septic bacteria. To accomplish 
this the pAticnt »(hotild be confined to Wd, if possiMo in u sanitarium or 
hospital, wliore tlio^o rJiivctions can be systematica !l_v carried out. 

Aft^r tilt! iilecTS have been titoroiighly waMlit>d aud irnvH from the 
aecrelloiw, thej' should be dusted over with some di-ying antiseptic 
powder, as autino^in, iodoform, arietol, calomel, nr borie neid. When 
calomel is used, it is wl-II to wnj'h the pnrli" off with lime-wuti^r after- 
ward, as it will remove the particles more cffeetuolly than any other 
fluid, ami i» nt the same time n good antiseptic. Sliniiilation of the 
alci?ratioti>i hy ttio uro of nitrate of silver, 8iilp)inte of copper, or other 
agents may Kometimes be neeessary. The tubular speeulum and the 
knee^chest posture enable one to iiinufQate powders upon atl parts of the 
rectum or to itpray ilieiii with various medications. The biiweb should 
be regulated to move oiice a day if poasibte; the admimslration of a a-r- 
tain amount «f opium to control the leadeQi'y to diarrlict-a is oftvu 
adrieablc. 

The constitutional treatment in those conditions is similar to that 
of eecondary nyphilis in any other portion of the body. It consists in 
the administration of mercury iu as large doses as tlie patient will bear. 
In rectal syphilis the drug should be given by inunctions, baths, or 
hyiKidermieally, as the internal udiiiini^trutiun is likely to ng^rnviile the 
tendency to diarrhiL'a, and should Uieirfore be avoided. Iodide of put- 
aah in this stage of the disease is adrjscd by inosi syphitographtirs, though 
its efHeapy is qiiowtinnable. Mercury is probably the only drug whieh 
han any direct effect upon the tipeeifie virus; the iodide aets hy KnKten- 
il^ the absorption of the inflammatory depnsitu, but probably doe« not 
affect the vims it.iclf. Innsmiich, therefon% an these pntientii usually 
BufTer from digestive distTirbunces, it is best to refrain from using this 
or any other medication by the stomach, except nich as are directed 
toward the iuiprovcinent of fiinctionnl aotion in the digestive organs. 

Tertiary Lesion*. — The chief characteristicB of tertiary lesions in the 
rerluni are as follows: 

(I, They develop in no regular order with relation to the initial 
leaion; they may enme on immediately 8ft^^^ the &L-comlary eruption, or 
months, even years later; indeed, they may never come at all. 

According to the stntistics given by Morrow (op. cil., vol. ii, p. 139), 
they only occur in about H) per cent of the eaecs of constitutional 
•fphilii. Of this number, about 35 per cent occur in the skin and the rest 
in the nerves, bones, and speeial organs of the body. 

6. Another ehnmeterislie is that they are likely to bo recurrent. 
They pane away or are disfiipiited by the action of medicines, and at long 
periods thereafter reappear again. 



THE ANUS^ HECTUM, AND PJSLVIC COUOS 

c. They are localized, involve the deeper tisiiuee, are destructive, and 
]cav« cicatrices on healing. 

d. Thoy do not yield readily to mereupy. 

c. Tlu>y nre only mildly contagious, and are ncRily nivays auto-ui- 
ocul&blf, showing that the uWni are mixed infcotionK. 

The chief types of these affections are guiniiiata, destructive ulcem- 
tioD, ano-roctal syphiloma, and proliferating proctitis. 

Qvmmata. — Cluniniata may occur in any portion of the body in 
which there is connective tieeue. At the anus they are exceedingly rare, 
while in the rectum they a.re somewhat more frequent, thus reversing 
the order of primiiry and Bceondary lesions. Foumier Htates that he has 
never observed n giuniiia of llie amis excppt in an extension of gumma- 
tous ulcerations occurring in the neighborhood, and in cases of ano-rectal 
fa^'pliilomn. Molli^re (p, G41 ) describes a goininia oceiirring primarily at 
tbr anns. Wmeiiil (Oa?;etie dcs hopitaux, IfiHft, p. 20^) hiiii n-portc-d a 
most intereating case of tins kind iti which the gumma appeared il» an 
induration at the margin of the anus, about the size of a small orange, 
and extending acroeis the iechio-rectal fo^sa; it was smooth, elastic, and 
paitilei48 to the touch, and, lH>Heving that the tumor contained pus, he 
incised it with a bistoury, but obtained nothing beyond a discharge of 
blood. Some days afterwani suppnratinn look place, and a fistula re- 
united, for which an operation was done. The ulceration and indura' 
tion having persisted, he placed the patient upon antisyphilitic treat- 
ment, and obtained a complete cure af|i>r a limited time, This case 
is in line with several that the author has seen, and reported under 
the head of BBtulie, inasmuch as he had not seen them in the gumma- 
tous BtagK'. TliL-rc WLTc induration and ulceration of the wounds with- 
out any tendency toward healing until antisijccific treatment was begun, 
after which it progressed promptly enough. A number of times nodn> 
lar deposits Ix-nrath the radial folds of the anus have been Been in 
cases of tertiary uktiration of the rectum, which may have been giim- 
mata, inasmuch at they dii?appeared under the influence of local treat* 
niont to llic ulcem iiiul couslituf ioiml treatment for the disease; they 
were not recognized a^ nueh, however, and seemed to lie simply inflam- 
matory deposits. Taylor (Journal of Cutaneous and Genito- Urinary 
Diseases. ]8S6. p. 226) records a case in which the gumma was situated 
in the reeto-genitaE sa-ptuiu. 

Qnmniata within the rectum have been reported by Bunifttead ami 
Tiylor (Venereal Diseases, p. 607), Hall (op. cit., 225). Zai.pula (Archiv 
f. Dermnt. und Syphilog., Prague, 1871, p. 62), Poelclicn (Archiv fiir 
Path, imd Phyeiolog.. Berlin, 18D2, p. 87). and Keuirter {ibid., p. 375). 
Tn fmi" ense, from whieh the drawing was madp (Fig. 9!)), the patient had 
siifTercd from syphilis five years previously. She had been treated at the 



L 




VENEREAL DISEASES OP THE AXCS AND RECTUM 2*5 

timo, and )iad notinod no manifcMstiong On ring t)ic throe y^n prccoiling 
the time of exajninjition. ' She compliiined of pain at defecation, bearing 
(Inwii, and the fueling an if sotiic foreign body was in thv rectum. Ex- 
amination ^howeil a dry, brittle condition of the anal iimt'ous membrane, 
with Bome haemorrhoids, imd a smooth, globular swelling about I inch 
above tbe margin of tb« unu», trody morablu both upon the miucular 



/ 



Pis. M.— I'liiiciiMii iKxiKtrii i>r (imMA or mx Bbctdil 

and mucous walls uf IbL- nut. An openition was porformed to overcome 
th* fis«tu«», tbu liKiuuiihuida vcrc removed, and the little nodular bwuU> 
ing v&f dissected out. 

Tbe |iathnlogi»tV report dejieribed the growth as typical gnmniatoua 
material, with graniilatioQ tissue in all stagor: of development. The 
patient va» at oumj put upon antisyplulitie treatment, and the operative 
wonnd^ all healed withnuL any com plication. 

In the ease of iiaiipiila there were found in the lower portion of the 
rectum some gloUilnr, »iuoi>th, etaelic ma«»e« i at a distance of about t 
t<en1imcter¥i (If inch) above the anu» there was a similar mass about 
the ai^e of n iiiimll linzelnut, and pHin1e>iH to the toudi ; there wtui no 
ulceration and no raebexin. The diagn»«if) wan pmprrly made, and the 
tuinom (]twip|»eare(l under the udininiBtration of iodidn of potash. Tfe 
atateti that c^mptoms of absolute obstruction occurred in thin pati^^nl. 



246 



THE AXUS, EECTTUM, AND PELVIC COLON 



but it ie diRicult to undc^rstatxl how a tumor of thi» $\ze in the rpctuin 
coiiM pogKibly oocflsion it; evidently thoro must have been other and 
lar^TLT giiininntft above, or the syraptoius were due to ftome other cause. 
MwIiiLTL' reiiorled u caae, eomewhAt similar to this, in which the giiinitia 
wua at a much larger size. When occurring in the rectum the^e tumors 
u[ipi!Mr UM rtiuriii, elaniic, anil jmriicsK Je[/Qsilf in the eiihmucous tisfuss, 
and in llirAr eariy ifta</eg are nul allackctJ t» cither ihe muccus or muscu- 
lar wall of the gut. I-atcr on they may involve both. They are gen- 
erally localizi'd. niny be single or multiple, and of any siae from a hcmp- 
eeed to a small urange (I'oeleheu's Path., p. ,11.). 

There is uo marked inflammatory zone about them, and they are not 
aceoTiipanied wi<b any oontraclilc fibrous bands in their L-arly stages, al- 
thungh thci-e may tie a »lighl de|)usil of fi1iruu» tii^aue in the neighbour- 
hood of tlic growth. They do not suppurate, but undergo & sort of fatty 
dcRonpration accordinjf to Molli^re, and thii* break down. The fact* that 
ihi'^ do fiot i^rotitice abscfusen, an not paitiful. nnd do not occur in 
chains dinlinguish them from engorged l^vipkatics. When they break 
down infection takes place, causing inflammation and an increase in 
the inflammatory' de[Kisit, The con^lition thus resolves itself into an 
ulcer, which, healing, leaves a contracting cicatrix tbat may cause 
etricltire of the rectum. Teiupui-ary stricture of slight degree may 
result from gummatous iuliltralion and likous deposit around it, but 
these strictures do not become pomianent unleRS there is some destnic- 
tinn of tissue liy necrotic or iilecralive processes. All the reported cases 
in which gumumta of the rectum have been rceognired and treated 
ttithout the occurrence of ulceration, have recovered without leaving 
strictincH, Thus one may refer to the cases of Znppula, Taylor, Fnur- 
nier and t!ant, in which all the ?yphililic manifestations disappeared 
under general treatment and left no contracture. 

When gimimnta disintegnile, the dc-^t ruction of tissue may be cs- 
tensivo, soinetiuies even piTfoTating the wall of the gut; if this occurs 
upon the anterior wall iti females, it may resutt in recto-vaginal fistula. 

Taylor HtateH that involvement of ihe rectum may be .fceondan.- to 
an "indurated ipdema " following infiltration and ulceration of the 
vulva or anus early or late in tlhe disease; that ulceration from sach 
conditions resembles the fhancroiflal. and that it has a tendency to the 
production of rlnge of connective tifnuc about the rectum, lie Bays that 
these rings are not gummatous in their nature, and the induration and 
swelling ocL'uwinned by them shnuhl not W mislakHU fnr this form of th« 
di»ea*(?. In oIIut wnnl*. llu-y are simple inflamnmtnry products and not 
syphilitic. The importance nf this slatement will he appreciated when 
we coine to the htudy nf strirturi' of the rectum, and Icaro that motjr 
strictureH in »^philitics arc not iit)iihilitic. 




VBKEBBAL DISEASES OF TDK ASUS ASIJ RECTUM 



24- 



Tertiary VJcerations. — One of the most frequent manifestations of 
Uirtiarv gypliilis is a dry, brittle condition of the niuco-outanetms tissue 
about the an«s resembling that seen in atrophic catarrh. Forcible sepu- 
ration of the buttocks or ^tretcliin^ uf the anal canal in tlicio cases vill 
produce little buttouhole-Like)>lit» in tlie iiieinbraue, which bloH uml itch, 
but do not cause actual pain. The pasangc of a hard stool or th* intro- 
duction of a boiij;ie will co«?<? these rents. They are ttometimcs points 
of infection, and uEeerations resnlt which eonibino both apedfic aiiJ 
wptic characteristic*. The process extL-nds upward bL'twfon the radial 
folds, and may invoire the mncoua meiiibi-ane of Hit reetuin to an in- 
dellnite height: the ulcers may become plia^L-dL-nic and result in great 
destruction of tissue, as in the case of Lane (Liimet. I^ndoii, 1831, 
vol. i, p. 486), where almost the entire perinieum, tOKclhcr with tlio 
anal and vnpinal orifices, were destroyed, notwithstnndinjj antisyphi- 
litic inedicntion. 

TtTtiary iilix^' rat ions aUo result from tnuiii'itili^m, disintegrating 
gtimmata. and from necrosis of tissue due to occlusion of the arterial 
supply by endarteritis. 

The anus and recluiii are subject lo frequent tr)iuiijatii<ms from 
bard stools, forei>;ii bodies, etc.; in women tliey are often injured dur- 
ing foilus, pregnancy, and childbirth; nil such injuries may take on 
ft B]»wilic nature in syphilitics, That they do not yield to mereury and 
indiden if duo lo their pnnstnnt irritation and infeetinn by tlie fn<nil 
passngef). Such ulcers Insp their H]K>eifie clinrneterifitirs nnder specific 
treatment, and bi.ttnlogioil examination (hcTi reveals only n chronic 
inllammatory cnndition: those due to gummatn and endarteritis usu- 
ally maintain their [Specific characteristics until tlicy are henled. beeause 
tilt process is more deeply scaled and requires a longer time for eradi- 
cation. 

Tertiary iilrers oeeur most freqii«ntly just within thu rei'lum; tliey 
are deeper than the semndan.- ulcers, are crater-shaped, have yellow 
indurated basea, sharply defined borders, and are rarely ever under- 
mined. Surrounding and beneath tltrm the rectal wall in thickened, 
Biiff, and inelastic, which condition, when it invotves any coni-ide ruble 
portion of the circumference, pooner or later results in stricture. 

lofccttoQ is an important element in their tardy healing, and may 
have much to do with the Klirous deposit that causes the conlraetupe. 
This, together with systemic eonditinns, such as diabetes, Brighl's di** 
ease, and tnbereulosis, is aeeonntable for those widely destructive phage* 
denie conditions, many of wbieh have been eolleeti-d and reported by 
Kahn (Arch. f. klin. Chir.. Berlin, 1883, p. 395). In one case, seen 
some years since, the entire anns and sphincters were destroyed, the 
mcmbraaouf urethra va» left bare, and the nmeons tnen.hmne of the 



249 THE ANUS, RECTUM, AND PELVIC COLON 

reotuni entirely obliterated to the height of over 6 Incbea. Notwith- 
etaniiing thore was a distinct history of syphilis in this case, micro- 
scopic examination nt the fijwcimen Temovecl showed only chronic inflam* 
iiifltioii. with here and there slight endarteritis. These iilceis not 
iufrt-quentty priforale the rectal wall and restitt Id fiatutaa of various 
types, n-hich do Dot diifer from simple Bstulias except in tardiQcas oC 

The guppurntion in extensive tileerntions of this typo is sometimes 
enormous. Kahn hns reported a ciiso in which it amounted to a liter 
per day, and reeenlly in llie I'olyeliuie Hospital a ease was tn?alL>d in 
vhich it was almost as much. The odor is not characteristic as in 
cancer. 

Ano-rfciai Sypkilama of Fournier. — Fouraier (ijGaioiw lertiatrca 
do I'amii ct rectum, I'arix, 1875') dc^cribct; under the above heading a 
specific fibrous infiltration of the rectal walls ; They arc thickened, mara- 
millated, and ri^nd in feelinjr, without any ulceration. He states that 
it is essentially a Iiyperplasitic! proetiiia tending to sclerotic change, as is 
seen iii ihe kidueys, liver, and othL-r orgwiis in late t^yphiliH. It liegins 
iii the fiiibmueuus tissue, and, jucordiiig to him, when ukeration uceurs 
it is the result of the proctMs and not a part of il. He says (Prance 
mWical, Oetoljer 31. 1S71> that " the caaeutial redoubtwhle phenomena 
upon whidi de[M.ndi^ all the evolutiim of this jmlliologieul process i» a 
tendency to contract. This contracture is, by virtue of its fibrous tissuca, 
comparable In this tu inrjdiilar lis>;iie, that il retracts without ecssatioQ 
upon itself." Fournier states tliiit ibe disease is always due to acquired 
syphilis, but Ball mentions a oise in a boy ten years of age suffering 
from congenital syphilis. Van Harliiigen (InlemattonnI Encyclopasiia 
of Surgery, vol. ii, p. 519) L'laims that the disease rarely extends beyond 
S| inches from the anus. This limitation, however, is not corroborated 
by other observers. Maelarcn (Edinburgh Clin, and Path. Jour., 1883- 
'8-1, p. 875} considers this a. form of inliltrating gumma. Hie micro- 
scopic reports, however, disprove this, for he says: " The tumors were 
composed of dense, fibrous tissue sparingly supplied with blood-vessels,'* 
a condition not seen in gummata. 

The majority of syphilograpbcrs have adopted the theory of Pour- 
nier, and the weight of nu(h()nty is therefore iu its favor. They atate 
that in tlie early stages it produces no symptoms such as pain, discom- 
fort, or obstruction to the movement of the bowels ; that the only method 
of diagnosing such conditions wnuh! be by early digital examination, 
which would ^how a thickened, infiltrated, inelastic condition of the 
rectal wall containing more or less nodular mftsses extending for sev- 
eral iiH'hc-s upH'i^rd froiri the anus: (bat this condition proceeds until 
constipiiliou fruiu gradual cuulracttou of the rectum results, and tbd 



I 



VENKREAL DISEASES OF TJIE ANUS AND HECTrM 



240 



! mufuuH rnt-tiibrmn; breaks down, nwitig to frirtinn, aljrasion, infection, or 

IkoUk; intcrf«ri;U(;t' with ite oirculation. Acrnrfiing to this theory the 

itrictuK OMurs first, and the ulcerattons which follow it are produced 

by other caueoa than tlie actual specific diseasG. There is no authcnti- 

^P cstod report of tlio careful ohstTvation of such a course nf events in a 

single instance, and it appears to the author, therefore, 08 purely the* 

^- oretical. 

^B The exiK-neiici's and opinions of otli(;rs upon fhie condition of the 
^P Tectum, Hu ably di-scribt'd and defended by Fournier, arc given here. 
^Uhough in miiiiy years' [experience in reetal exBiiiination^ tlie author has 
^Plwnr obeervcd & single typical ease of thiti ano-rectal syphiloma. He 
has observed a rmmber of eases in whit-h the patient had suffered from 
Byphilitio proelitis and uleeraliou iij the seeoiidary sta^s of the disease, 
which ule<*rations had healed, the patients had thought iheniHekes cured, 
and diseuiitii:wc(l Ireatitinit, but afterward found that the diNense had 
retumt'd ia the lunu ii( fibrous infiltration ami stricture of the rectum. 
In ercry one of them there were eliararteristie bluish-white cicatriceB, 
and the patients gave a history of having fiuffered from irritatio^n of the 
rectum and a discharge of umcus or pus at some previous time. The 
condition whleh Foitrnier described exiets, but it is associated with a 
history or ovidpnee of a previouit reetal uleeration. Founiit-r alone 
positively and uiuniuivoealiy elaiais to have observed this condition 
from the beginDiiig, and even bis reports do not eliminate the poBsi- 
liility of pri'vious ulceratiou. (^uonu and IlartitLunn. in tlirir excellent 
work, cite only one example of this cojidilioo, and this tht-y »a.v was 
pToccded by sypliilitic ulceration of both the rcctnm and anus (op, cit., 
TOl. i, p. 92). It seems, therefore, that the condition nripinfitei« in 
spMifie uleeration, whieh beeonios infected, and thus sets up a proctitis 
with flbrous intlltration. In proof of this we may cite the fact that 
mercury and iodidt's have no effect upon it, as they would do if the 

•infiltrate were fyphilitic in its nature. 
Proliferating Proctitis, — Under the title Rectitis Proliferante Syphi- 
litique, Paul Hainonio (Annal. m6d. chir. tranc, France et Strang., 
1886, Tol. ii, p. 3) has described n eondifion which he considers a petnil- 
iar syphilids, The di^eat^e potii>i»t$) in a growth eharaeterized by fragile 
villoua prolongationR. nf feeble resiRtanre. from ihp muiTius membrane 
of the rectum. Tn the cases cited the tumors filled up the rectum, 
and yet. according to Hamonic. they did not tend to fonii a atric- 
^^ture. Kcl;iey {op.cil., p. 83.5) has detailed a case, which may bo of 
"ihia same eharB<-ter, under the title of syphilitic ulceration of tlie ree- 
tiiin. The author ha« also reported a case of this nature, but in which 
true (iS«tnieti'in of tlie wrtuiii tonic place. Here tliere was a spfcifie 
.fbrooa Btricture underlying the hypertrophic granulations or vilbms 




^ 




S50 



TBE ANUS, KECTllM, AND PELVIC COLON 



condition. Suoh a ^tatc of atfaim may be brought about by irritating 
discharges from spcrific or Don-speciHc utcerRtiong. 

In the author's case the history of long-standing ulceration w«g dear. 
The condition entirely disappeared under antiseptic and aiiiii^yphiUtic 
treattucut after colostomy, but left only a narrow fibrous canal where 
the rt;cttim iiad been. 

Tbf piilliulo;,'ical cvamiuation of all these ulcerated type* of eyphilia 
of the rectum shows n consistent sequence of event*; first, the dcstruc- 
timi of the eyiindrieal epithelium of the mueous membrane, which may 
afterward be replaced by a corneous or pavement eptthelinTU covering 
a cicatrix (llartniann); second, a celbilar infiltration fay embryonic ele- 
ments 8ometimc8 containing yellowish nodules of a giimmutuus type, 
almost surrounded by a fibrous or sclerotic zone. In the early stages 
the blood-vessels arc multiplied end dilated: in the later stages they are 
decreaBcd, cnntrHotod, find alway* present evidences of cndarteritin. It 
is simply ii ijiiestion nf the iige of the proeeas, whether the cells are 
young and feeble or whether they are old and surrounded by strong 
zone.* of sclemtic ti.«sne, as to irhetheT it can ite resolved or not. 

Sijjihiliiif Striftiirf of the Rrcluiii. — Enough has been said above to 
indicate my belief that unadulterated syphilitic strictures of the rectum 
are very rare. There ie not an authentic case on record in which care- 
ful, systematic examinntione throughout the early stages of the disease 
have failed to show ulceration of the rectujii at some time prcvioua to 
the stricture. Any eolution of eontimiity in the niucouiJ membrane of 
the reetiim forms an open doorway for septic infeetion and ran.-<equcnt 
inflnmnmtion. 

While we know that a Inrpe number of strictures of this organ occur 
in people in whom thcTC is a more or less distinct history of constitu- 
tional syphilis, yet we must bear in mind the fact that because a patient 
once hiid syphilis will not account for nil his [mthn logical accidents in 
after life. He may have a stricture of the urelhrii, the n-ctum, or i^sojih- 
agUB, that is not syphilitic in itK nature, and upon whinh antisypliilitic 
medication will not have the least effect. Those who claim thwt this 
condition is due to a primary iiitiltrntion of the rectal walls by syphi- 
litic material fail to fortify their opinions by a record of careful prc^ 
liminflTy oxaminationn. Have they ever exAmine<l the rectum of one 
of these cases throughout the course of hia disease a month or a year 
before they found the Btricturo? All admit the process of stricture 
formation by uUfralioii, but try to explain away the eomplimting effects 
of infection by abstruse tlieories of »yphililic cellular infiltration of the 
rectal wall. 

The first stage of thrse strictures consiKt« in an nlreralinn, Imu- 
matic oT otherwise, nf the mucou» membrane. This is iollowed by the 



I 



H 



VfiNEKEAL DISEASES OF TH£ ANUS AND KECTru 



251 



deposit of a soft ombrjimie tissue in the siibmticoiis wall of the gut, 
together with infeclioo [>y colon bacilli or otiier gernis. This inflltrt* 
tion and infectinii penetrate Jownwiird into tl)« nuiaciilar wall. The 
mucous membrane may reform over this area, producing a eott cicatrix, 
over wliit'h the epitltelium, (.liaa^ed to a. ?tratilie<l type, is c^tabliabL-d, 
and presents a blui$h-whitc appcaraocc. This cellular infiltration hnviog 
once pGnelnLt(!(l thu munciilnr wall of tlie gut, PiikIs a. cbnnnel of least 
rcAiManct- between the eirciilar fibers, and tbus gradually intiltrates tli« 
whole circumference. The profound infiltration has a much greater 
tendency to nurround the gut than has the superficial, because in the 
euperfirial and submucous layers it follows the course of the blood-ves- 
sels. Thus we sanietimus find a limited ulceration upon the wall of the 
intestine with art extensive, deep infiltration almost surrounding the 
gut. In the early stages of this infiUrntion those tissues are sflft and 
dilatable. Thi'v bIbo yield comparatively gond rpsults to the adminis- 
tration of iintisyphililie medicHtion and dilatation, but if organization 
of fibrous tiiwue has tnken place, if the muscular fibres have become 
atrophied or transformed into fibrous tissue, medication and dihila- 
tioii arc no longer permanently effectual. One may give mercury 
and iodide and atrelch the parts to the highe-st limit, but they will 
recontraot. 

The comparision made liy Monot betwewi rectal stricture or iino- 
n><?tfll ityphiloma and syphilitic tosticle in not at all logical, Ih-cuusi- we 
have to deal in one ease with a true glandular organ, and in the other 
with u muMrulnr mid mucous membrane. Injur)- to the mucous mem- 
brane, infection, ulceration, nnd inflammatory deposit are the steps in 
the pn>duelion of cver>' atrlcture, and in the syphilitic this intlnmnmtion 
takes on the character of th« constitutionnl disease — viz., gitinmatouB 
depoaitB and ondarteriliB. 

For the palholugy and further oonsidoratioH of syphilitie strioturo 
the reader is referred to the chapter ou Stricturen of the HtJctuni. 

Treatment. — ThL* treatment of tertiary syphilis of the anus and 
rectum difTen? from that of the disunsc elsewhere in the body only in 
the management of the local coudilions. It coni<i#ts in the adminis- 
Irttioo of the iodides in a» full do*o? a* the patient cnn bear, inunc- 
tions or hypodermic injectiong of mffreury, and the topical treatment 
of local conditions. As many ol those patients suffer from dijiestive dis- 
tiirbanccf*. it '\% frequently found that the iodide of potash aggravates 
tliew conditions: it should be administcre<l in milk, the essence of pep- 
ain, or the elixir of laclopeptine. Giving it in moderate doses and fre- 
quently will often accomplish better results than a few largo doses given 
in water, ond at the same time the patient is being nourished; when 
milk 19. Dot acceptable to the individual, the iodide can bu di^olved in 




ass 



THE ANUS, RKtrrUM. AND PKl.VIC COLON 



it nn<l then converted inio whey by the ndiiitinn of a little rennet. The 
fluid portion of this wliej conttiiuR practioa 1 1}' all of the iodide, and is 
generally well home by the stomach. The iodide of potash may be 
alternated with the iodides of ?><)dii]in. lithium, and strnnlitini; the 
aJiiount which may be administered in a day is ven* varisble: ttoine pa- 
tients stand oxcoedingly lui^'c dofes, while others can take only moder- 
ate {lunntities; in gcuppal, one is Jible to nhtnin as ^ond results from 
60 to 100 grains of the dnig per day as from the enonnoui doses reeom- 
niended in eertain ^peeial works. 

As to tlie mercuric inunetions, (be methods of carrying this out 
are described in nil books upon therapewtics and genito-nrinary diseases. 
Very good resuits may be obtained by enclosing 3 or 4 drachms of mer- 
curic ointment in a flannel aniulot. which is fastened aTonnd the pa- 
tient's neck by n bund, thus allowing it to hang about iha middle of hia 
chest or between hif shouldpr-bladps; this is niiicli mnri^ cleanly than the 
oriiinarr iminctioiis, and Heerns to aecomplisb as good results. For 
hyptxleniiic administraticvn biehloride of inerniry has proved must Mitis- 
faelni-y, but salicylate of merrury seems to be very etTt-ctual. 

The local treatment nf the different manifestalions is practically 
the same as that Uewriljed for secondary syphilis. Rest in bed, functional 
rest to the parts by the proper regulation of the boweU. antiseptic irri-i 
gallons or washings, and owasioiially stJTiiiilaliuii by niild eaulerizing 
agents in tlie sluggish, ulcerative ciondilions,. are tlio gen^nil lines upon 
which this should U' condiii-ted. When there is extensive ulceration 
and profuse purulent discharge from the rectum, drninage of the parts 
Flinuld Im- estiiiilishrd by dilatation of the sphincterK. and if necessurr 
the intri>durtion of two small drainage-tubes in order to pn^vent the 
secumulatioii) of thece eeptie disehargos in the iinipulla. With the two 
tubes ill jilaee one may irrigate tlie parts fre<pieutly withont disturbing 
the patient very niucb. Solutions of benio-naplithol, horie aeid, ^naph- 
thol, bichloride of mercury, and chloride or bicarbonate of sodium are 
all useful for this purpose. 

The dilatation of the aphineter should he gently and euri-funy made 
no as to produee as little traumatism as po5sib!e. The swollen hypcr- 
trophied folds ni-ound the margin of the amis fihould ordintirily he left 
alone, t\s they will largely disappear after the inllaninuitory proce*g hatj 
subsided. Ooudylomala developing around the anus may In- treated by 
cutting them off with seigsors, cauterizing them with the actual enntery, 
or, better still, by the application of monochlorncetie acid, followed by 
eonie drying powder, such as has been mentioned before, .\tter the 
ulceratioiia have begun to heni, the rectal dilator or a large-sized bougie 
should be u*«d erery two or three days to prevent contraction. 

In those severe typos in which the mucous niembRine of the reetam 



i 



VRSBREAL DISEASES OP THE ASCS AND RECTDM 



253 



is practii-ally dL-Hroyed, llii^ ulinutil patioriLCf and ])erMtL'V(?ra»t.v will liav« 
to be oxLTLm-tl by both duutor aiiJ piiiifiit ; iimuths and years of treut- 
ineilt an; iifo-asary to Ik'hI sutti coiiilition^^. 

Tht're is no doult thai hi-ulinjj nmy be hastened by ubsoluti- rest 
throujifh the production of an artitieial anus, u proceeding thai may be 
juetiflL-d in ihose eases, nlthough vory few patient:? will submit to it. It 
has bct>n earrit'd out by Harlmaiiii, llahn, and suvoral othpr surgeons, 
< and tlio author has treatt-J thn-e ea»e» in this manner, all of whieh 
hfalcd {inally but not rapitJIy. In two nf them then.' was pemianL-nt 
stricture left, which rendered it inadvisable to close the artilieial onus; 
in the- other tlie ulceration healed in about tlirce month?, mid the 
colostomy was repaired shortly thereafter: but the rcetum never a«- 
Rumcd its nonnnj, smooth, chistie enmlition. In one of the first twn 
cases an artilieinl nnus hud Iwon ninrle and elosed by another surgeon 
previous to my seeing her. and the nleeration and strieturc of the rec- 
tum had recurred after the closure ; so it was bent to make a peiitianeut 
artificial anns after Bailey's method in lier ease. Such experiences lead 
to the concliiflion that, while these ulcerntions heal more ra|)idly by 
IgiWng the parte absolute functional reet. at the same time one should 
; bo very guarded in prognosis, for hi>ating even under these circumstnnces 
IS slow, and the eondilion is likely to r(>eur nftor the noniial rlianne) is 
reestabliKhcd. 

The treatment of stricrture will be considered in the chapter upon 
that !4ubjc'c(, and the nirthods nf making nrtifirini ani ran be found in 
the i-liHpler on {'olotomy. 

Hereditary or Congenital Syphilii of the Anus and acctum.— Lesion* 

of till' :i(ni- .iR' uirioMj; the enrlie-;! niai>ifet^tution»i of }u>re<liliirv syphilis. 

They limy urenr at any lime after birth up lo several yearw of age, 

^but tile niuHt fn-(|Ui>ut period at which they are ob^erred is during thv 

'first three montli.t. In the large number of hereditary syphilitica which 

ipaM through the cleeiuusynary institutions these manifestations about 

the anu» are unrecojjnixed, or comtidcnrd simple irritative lesions due to 

-lack of clcanlinesp and proper diAjwr!'. It is not until the later inani- 

[fMtatinns of hereditary syphilis appear that a true diagnosis is made 

fin the majority of eases. However, there an? instances in which late 

siwondflry cutaneous and osseous lesions have occurred in infants in 

whom early eiamination had failed to dist^lose any rL>ctal or anal afTec* 

aon». On the other hand, over 50 per cent of the children bom from 

syphilitic parents have mniitfcsled Ihe disease within the first six months 

I through lesionii about the anus. Besides thotie cascp in which the parents 
mre known to Im? syphilitic, the author observed in his clinic for diseases 
of children at Ihe Xortbern Dinpensary of Xew York, a number of eaiies 
st hereditary anal ay|>hili9 in infants whose mothers were free from any 



■tic 

I air 



254 



TUE ANUS, RECTUM. AND PELVIC COLON 



external iiianifcstatious of, uud ilenieil liaving suffered from, Uie did- ^ 
ease ; this would indicate, of courac, infection Tmrn Ihe father. 

Tlni iliePBR' fir:it appear* ill i:-hil(in>n a^ a sort of irythonm or fhirmn- 
tiliu arouod tlie anal region, ivhieh may oecur williin the first few ilnys 
of life, or it may be (]clay«d for several monthe. Elsewhere a cate was 
reported in wliic-li Ihe uutliur ubserved this ervtlienia at tlie age of 

jthree days (Morrow's Hystcin of Uenito-l-'rinary and Cutaneous Dis- 
B, vol. it, p. 436); eiuce timt time he has wen a child apparently 
boru wilh it, as (ht- cnDditioii was ])n.'af(it twenty-four hour* after birth. 
The parents of this cliild were both sy[)hilitic?. 

The erythema is often aeoonipanied by a fragile condition of tlie 
mucou« membrane and shallow fissures between the folds of tlie ntiiis. 
If tlici^e li»«uri>8 aw not present, they uiaj be produeod by the forcible 
separation of the buttocks. The condition is very easily confounded 
with Hint irriluled njiidilion oilled ohofin^. which ij> produced by contact 
with the urine and faxal materials ; the brittle condition of the iniicoaa 
membrane, however, and the nurrcrcu? email fisHires between the radial 
folds will lierve to diJitinguiwh those two conditions. 

In the early stages the skin \» slightly pigmented, red, or copper- 
colored iu a Konc extending about 1 or 2 centimeter^ around the anus; 
but after a few days the skin Ix'eomes somewhat thickened and elevated, 

'and thin, eero-purulent dischargee are set up, which toon assume a 
ftrtid odor. The little dry fiKsuree do not extend beyond thv inaT)(in 
of the sphincter in this early stage, but if the condition is not treat 
they may pouolrate the una! canal itself, beenme infei'ted, and develoj; 
into progroBsive ulceration of the anus and rectum. This ulcerntion 
may occur within the firxt three or four moTiths of life. Little fi)*smrc» 
may be complicated by hyj)ertrophy of the radial folds. When they 
have existed for a considerable period without trealnient they take on 
ae characteristics of true fissure — i.e., they cause pain, burning, and 

roonstipatioD due to fear of going to etool on account of euffering. A. 
marked inalanee of this was recently ohoerved at the elinic. 

A child fifteen moDlhti old suffereil from constipalinn nnd little in-' 
fiftmed tabH »bout Ihe margin of Ihe anuK. It had typical pigmentatiou 
and induration of the tiKSues about the orifice. The mucous membrane 
cracked cAsily nt varitHi!; pointH upon forcible Heparslion of the but- 
tockfi, the inguinal lymphatics were enlarged, and in the posterior wall 
of the rectum, about 3 inches above the anus, there was a smooth, round, 
elastic depoKit, over which the mucous membrane moved easily, and 
which itself eould be mo^-ed upon the muscular wall. There were no 
other enlargemento ahoi'e or below it. which would have l)een the caae 
in all probability if this was a Ij-mphalic en;rorgcmcnt. It is needless 
to Wjr that this growth was a true gumma. There was a distinct painful 



VENEKEAL DISEASES OP TDE ANL'S ANl> BECTVM 



255 



fiseiire ami Pt'iitiiiL-l pile, wlitcli tlie iUustratioii nhowa {I'IuIl* 111. Fig. 3). 
If Uit' ilia^iosis ui IIk-.si' iTjllR-niaLouA iriiUvt iuiis uIh^uI IIil^ uuud be 
in doubt, and if the liistorj- of the ca»c does uot justify one to usauine 
Hfphilis Ml bn the rtiolo^iral factor in tln'ir |tro(liic-lioti, he may wait 
fnr the ilt'velopinent of other symptoms to corroborate his opinion. 
Ordinarily tliese symptoms are not slow to uppeur. The lack of normal 
development in the patient, iht? appearaiicei* of ihe *i:jimTTioiis lesions 
upon the* soles of the feet and in the- jjuluis of the huuds, the Jiy, rigid 
condition of the llexurcs of the joints, Hutcliiuson'e teeth, ami fre- 
quently tlic dcvclopmeut of othtr cutaneous manifestations, Kill lead 
to a positive d;iajrD08i8. It is a question, however, whetlier in such 
caao« one had better not adopt the principle of Wood, and, admitting 
that there is a possibility of hyri'dilnry liyphilis in evt-ry eliild, treat 
it upon that principle^ and give Uit; itinueuiit 1>abt? the benefit of a 
doubt. Delay is sometimes diBaiftroua; whereas in most of the cmcb 
in wlileh tlit! condition m rt-cogTiizwl iriiitiL-diutcly flfttir hirlh, and 
tn.-utvd actively, fht disi-aac win hi: inafilcrtid, luid a coiupurulivcly 
healthy cliild developed. IVom the first to the fourth year lute mani* 
fefltatioDs of syphilis develop in hereditary cases. The little patient 
described above !9ufTor4.'d (io his mother said) with redness and chafing 
about the anus since he was born, though there had never been any 
other skin Icsioiis, and the child seviiied to hv fairly iiuuriKliL'd. He had 
typical Hutchinsou iccth and gL-iifnil glaadukr iMilargcmenla. Aside 
from this and the anal nianifvslations, there was no other cvideuct- of 
ft}'pfaili«. Thu mother ^tatcil that the father hud suifered from breaking 
out on the body and sore throat at varions limes. 

In 1893 a child two years of age, who hud suffered from shortly after 
birth with inflaiumaLion about thi! rectum, was brought to the clinic. 
This child not only had induration, lliifkL'uiii^, and piginontatiou about 
the anus, but also uktirative lesions about the folds of the nates. There 
wan an im-laittic, k'uthi-Ty uoiiditioii of the n-etul wall, and thm-e wcll- 
marki-d gumnmta in thu oryau. Tlicrc wt-rt; also i-n-sti-utit: patLlii-s of 
pu]>u]ar Eyphilidve at several points upon the body. Thv father denied 
VL-ncrciil trtint, but at the very time had a tertinrv cni[)tion upon his 
body, and was sulfehng from a ^uiiall Byi»hilitic ulcer in the rectum, 
which he Bupjiosed was an inllanied IiaMnorrhoid, I have followed thc5« 
cases up to within (he past year. The father is appnrenlly perfectly 
well. Tht child im» grown tu be a healthy uiaiden : the indtirntinn and 
thickening of Ihe rectum have entirety disappeared, and one could not 
n-cogniM the fad of licr ever having had Ihe discane. 

Mall (op.fit., p. ls-1) repiirt.'j a case in a oliild ten years of age in 
which there npjteared to be the cnnditinn known as ano-rectal syphiloma. 
In the chapter on Congenital Malformat iniM reference was made (o 



S56 



'THE AXUS, RECTl'M. AND PKIA'IC 00LO!f 



syphilis a» an ctiolofncsl fnctor in the production of eongonitAl etric- 
tun?8 of the anus. BodenhanitT {op. cit., [>. 63) look* uijoii this as an 
eetablished fact. 

NotwithsLauditig the niajorily of muititt^tation^ of cvpliilis in cliil- 
da-ii aro Kereililury, one ousht nlwuys tti bcur in mind Itii; possi- 
bility of it* bciflK acquired. Quonu and ilnrtmann pivc an intcrcst- 
inj; case of this kind, in whicli a child of two years of Age ))A«(«e<l 
throiigli a typical seqnonoc of early and Inle scoondary syphilis, fol- 
lowed by well-dcvcloped tertiary symptoms. The father of this ehild 
ii said to have contracted ^yphilii^ flfti;r the child's birth, Ihe mother 
was frt'p from the disease, and Ihercfort- by inference the authors con- 
cluded that it vf&» u.case of ucquired priiitiiry syphilis, and not liLTcditary 
disease Bearing upon this same subject, wii also refer ouce more to 
the remarkable statistics of Pnhring, of Constantinople, who stntM that 
out of 31 chancres of the nnu? and rpchiHi, 2fi werp in children, all of 
which nnist have been flcfjuired and not hcreditnTy, Whether these in- 
fections were due to accidents or unnatural vice the author fails to 
state. 

Syphilitic ulcerations of the anus and rectum in children do not 
usually involve uuy exteu^ive area, nor are tbey accompanied with any 
f^cat d«structiou of tissue ; th« process seems to limit itself to tb« 
cutaneous, mucouri, and the immediate underlying litisueH. 

Treatment. — The constitutionnl trpiitmcnt of hereditary syphilitic 
manifestations about the anus differs in no wise from that nf hereditary 
syphilis in other portions of the body. 

Mercuric iniinctinns cither through the stomach handnge, by rubbing, 
or through the wearing of the amuIi?t-Hkc bag containing mercuric oint- 
ment, are all good, and should be peraieted in for long periods. Iodide of 
potaHtfium or other .laltft in Bniall doHea, together with tonics, e.tpeeially 
liypophnnphil«H and cod-liver oil, should aluo be used. 

As to the local conditions thcmwelves, iippliration-t Kueh as haTC 
been mentioned for the trcBtment of IhcKc conditions in adults, only in 
milder proportions, should lie adopted. Equal parts of glyrrrin and 
cod-liver oil have been found to be an cscellcnt. remedy in these chil- 
dren, in that it is not only a nouriehment and a tonic, hut it aUo keeps 
the ffpeal movements soft and regular. 

Prognosis. — The prognosis in IhesG oasee h variable. Juet In pro- 
portion to the fflrly recognition and radical treatment adopted wilt it 
be good or bad. The majority of eases, if swn and treated during the 
first two or three nionlhs, will t'Kcnpe all later manifestations of the 
disease. In some children, however, the general vitality is so feeble, 
even at the time of birth, that n« trcahuent. spec-ific. tonic, or other- 
wise, succeeds in establishing good health. Kfipcciaily is this the caso 



1 



VENEBEAL DISEASES OF THE ANVS ASD BECTDU 257 

in foundling asylums and eleemosynary institutions, vrhere the lack of 
proper food and general hygienic surroundings make the conditions un- 
favorable. 

In the better walks of life, where every need can be met, and every 
luxury afforded, these children generally escape the manifestations of 
the disease, owing largely to the fact that the intelligence and general 
knowledge of their parents upon these subjects lead them to an early 
recognition of their responsibilities in the case, and the admission of the 
facts, BO that no time is lost. 

In the lower walks of life ignorance, carelessness, and lack of clean- 
liness all contribute to negligence and late recognition of the child's 
condition; hence the prognosis in this class is unfavorable. 



CH.VPTER VI n 
JfOX-SPKCIFW ULCERATIONS 

The temi non-spetific is employed here pimply Xn difitinguish the 
variouB types of ulceration from the venereal and tiiberciilar varieties. 
Many of thcni may be due to just as epecific bafiili, I.ut sn far thcee 
have not heen isolatfld and specialiupd. The general plau iilready out- 
lined will b<> followed, and the subjeet. will be divided into: 

TTleerations nf Ihc Pcrinnal Region. 

TTlcpration3 of the Anal Canal. 

Ulcerations of the Rectum and Sigmoid. 



ULCERATIONS OF THE PERIANAL REGION 

TJloerations at the luargiii of llii? aiuit and of the euUnynns tissue 
BurroiuidiH.g it ait! not Uiiiited to any age, sex, or environment; they 
are more frequeiitlir found in those in the lower walks of life where 
atleutiou til hypLiic and cU-aalint'SB is not inut-h ubserved. They are 
due to traumutisnis followed by infection, irritatiug discliargea from 
the anal aiid rectal canals, gouDrrhtea, chancroid, clumcre, gyphilii, 
horpce, rinjrT.roriii, tubereuiosis, and carcinoma. 

Traumatic TJlceration. — Ti-amnatic ulceraliana of the perianal region 
differ from eutaneoua uleeratiiiiia elsewhere in the "body only inflomuch 
a« thwy are iiiflumced Ity ihe luiatuiuieal relationd of the (iiirtM. liVlule 
tile Mkiti upoH the buttocks \& tough and thick and the epilhcliuin 
horny and dry, that around tlic lUArgin of the anus hecomi^ thiiincr 
and thinner an it approarliefl the muco-cutanooua snrfacc. In it are 
embedded sebaceous and hair follicles, together with many i>udoriferous 
glands and an increase of pigment. In the mouths of these little folli- 
cles and glands the bacteria and bacilli which norinally inhabit the 
inlestiual canal, and ari! ronsec|iiently brus^hi'd ovtT this area by the 
fieeal piii«sagei4, lind a habitat and are always present. Any trauinaliun 
or abrHsion of (he parls therefore bcconifs eftsily infcct<sl and mi uW-ra- 
tion reHuIt#, the progress and cstt-nt of which will depend u[Kin the cnrc 
given to the lesion, the vital reeietancc, and general constitutional con- 
8S8 



NON-SPECIFIC tILCERATIONS 



859 



dition of the invulid. UHien extreme cleanliness la observed, antiiwp* 
tic8 are iisud, and (lie parts are prolvctcd from constant friction, they 
generally Itca! liimlly ill individuals oIIrtwibl* licalthy; uiidpr other 
conditions th<.' infection become* lii-ogrcssiTC anJ thi;y may extend 
ovpr liirjfc ureas. 

Wlien the ulcer originates in a superficial loslon and a(T<;<;ts tlie 
Burface of the ejcin only, it will ordinarily limit itself to tliyse tiasucB; 
but thoee due to furuncles or perianal abscesses may extend to in- 
definite depths. 

Simple ulcerations are due to infection by Tariows pyogenic germs, 
including stflpliylococcus, pyogenes albii^ or colon bacillus. Tliey may 
be single or multiple. Their shape is very irregular; the edges are 
red but not much inflamed, and gradually elope down to the base, 
which ie erator-shajH'd, highly granular, nomctimen furrowed, ond 
bathed in n purulent di.iehnrge. 

There are no ponNtihilionnl Bymptom«, and the lymjihatics are 
randy involved. Wiping or cleansing the part* caH«»>8 a bloody oozing. 
The act of defecation may be somewhat uncomfortable, but dues not 
occuion acute pain; sometimes a slight bleeding follows it owing to 
the abrasion of the surface, but there is never anything like a lia>mor- 
rlisge. Pruritus is often a very annoying symptom. 

Tjittle abscetMips mny develop in the deeper Ijiycrs of the skin owing 
to infection of the sebaeeous or hair follicles, but they rarely pene- 
trate the euheutanoous cellular ti^uo. 

Trtatment. — The treatment of such ulcerations consists in the pi"o- 
tcction of the parts fmm fni-Uon and keeping them surgically clean. 

In ihe fifMt stage the patient should be kept very quiet and the 
part* wtwhcd frnjucntly with penmmganalc of potaah or peroxide of 
hydrogon, followed by a l-1o-2.*tOO solution of bichloride of mercury. 
A pledget of gauze soaked with the IntU-r solution should \w placed 
between the folds of tliu buttocks to prevent their nibbing against 
each other and thus developing other ulcers. ^VIlen the priirituH ii 
markwl, a solution of methylene blue may be painted over the parts 
oncff in twenty-four liotirs. 

.After the purulent dischai^ haa been checked, applicationB of 
Bome drj'jng powder, such as bismuth, etcaratc of zinc, or no3oph«no 
may be employed. A tni.t:ture of equal parts of Blnrch ami boric acid 
ia a veiT good and inexpensive application. Where the ulcer is alug- 
gish and disinclined to hL>ul, sn occasional touching of the parts with 
linrlure of iodine or nitrate of ailvET will hasten the proco«)t. 

Regularity in the fa-cal moveniout^ and attention to the gcoeml 
conittiiuiionHl (.•lUidition, giving toniwt, if uccessar}'. and regulating the 
diet by wholtisomc, Bon-irritating foods, will generally be eafHci«nt in 






260 THE ANUS. RECTUM. AND PELVIC COLON 

them ca^ea; but one should always bear in mind the poasiljilitj of 
sfcoinliiry infLclioii nf tlio ulcvr by tuWrcIe bttcilli. 

Herpetic Utcention of the Aunt — Herpei. — Herpes is not frc- 
<|Hi'ntIy sjuHktrii of ii^ uii iiffertioti of the rcctimi and anus. This is 
surprising coagidcrlng the number of cases which have been reported. 
Eiij^le-Reimcrs (JahrbuclH'r (kr IlamUirg. Slaata-Kr!ink(!nanHUilten, 
vul. ii, p. ys, IXifO) liaK reported iS caBc-s of herpes ani that occurred 
in 1,872 women affected with vener^l disease. 

Sjphilftgraphers in general aclcnnwtpdge its frequent appeAranw 
about the margin of the anus, ^Vliile it h not generally understood 
that it has any etiolojfical connection with syphilis or other veneri-al 
alfeetious. it ol-i-ui-h frequvntl^' upou the f^L-uital or^iiii!^ and seems to 
have some cuuta^iouD olemeul. It uccurs at the luar^iu uf the anus 
close to the muco-cutancous border, but involves the skin just as it 
does at the margin of the lips. It niuy follow malarial fever, acuto 
attaeks of indigeslion, or oeeur durtug the euiirsy uf pregminey, 

Palko!ui/t/.^Thv pathology of this diaease is not clearly understood. 
It wceura ax an idiopathic ufTecliuu, and is also a»soeiat<-d with riuiny 
diverse conditions. It nmy be due to a neurosis, tii luial irrJUitiuu, 
or to a special parasite, ae has been claimed by 8t. Clair Symmuia 
(Brit. Med. J., December V.), 18'JI). It is also claimed that it is duo 
to rheumatism or gouty diathesen, but this seems very hypothetical. 

Symplomn. — Heqiee occurs as single or grouped vesicles over which 
the I'pidemiis is elevated, and in whieh is an aeeunnilatinu of clear 
or milky-white serum. Thesw devcdop after h slight itching or burning 
sensation in the parts. They sometimes coales(;e, fanning one large 
bleb, around whieh there may he eonsidemble redema of the tissuca. 

Owing to the contact of the pnrls these blebs soon rupture and 
leave raw eurfacca. They do not bleed, and at firdt discharge only a 
serum which forms a sort of yellow crust over them. This soon drope, 
however, leaving iin open door for infeetion by the germs which are 
always present in the ekin about the anus or in the fmeal pa-tsages; 
thus an ulceration develops. Tn such cases the herpetic nature di.-inppears 
and we have to deal with a simple ulcer, .^t this period it is very difli- 
ciilt to distiuguish the disease froiu chancroid or even true chancre, eape- 
cially if the parts have been irrilalod by eauterant;< or acrid discharges 
from the vagina. It may generally be distinguished by the period of 
iueubatiou, alight amount of induration, tack of destructive tendency, 
and absL-nee of glandulnr involvement. 

TmiUi>i'n(,~\*\\va seen in its first silnges treatment is always rapidly 
eETerliial. The bleh should he opened and its thin covering excised, 
the parts should be washed with nu antiseptic solution, anil after this 
a eoothing drying powder ahould be applied. Either aristol or noeo- 




NON-SPBCIPIC ULCEItATlOSS 



281 




phenc act wxtrenielj well in lierjwtic; sores because they absorb moisture 
antt furm a sort oi i>Futcctiiig sliii-ld nvcr the parts. 

Tlic prcTCUtiou of rului^fics is uf pnratiiount importaTice in the*; 
CURL'S. The vehicles iirp liabk to return un the »light«til provotatJon. 
The parts should therefore be kept ecrupulously clean auJ protected 
from (rielioii by plcdgt'ts of gauze. They rIiquM be bathed in as- 
Iringeiit ^(iluticititi, surh na aluin, tntitiie iirid, and suljihittc- uf zine, to 
toughen the upidermix. Quinine, strychnine^ end arsenic tJiuuld also 
Iw administiTw! for their effect ii]ion malarial and nt-rvL* L'cimplainlii. 

Eczema of the Anm. — Eczema l» uut uii lufrcqueul afTu'Ctiun uf tlia 
anas. Ordinarily it appears under the erythematou* form and is ac- 
cotnpaiiicd hy superfiuiul lis^^uri^H rudiutiu^ frum the ceutur, whicli hdidu- 
times cstend iuto the anal cauul. It is very often aitttodntc'l with Uie 
BBine type on the scrotum and elsewhere in the body. 

In its chronic form there in a certain amount of inliltnilion of tlio 
perianal tissues. The likin is dry, britllu, and easily eraeked by any 
stretcliing. 

Tlie term uiojitt eczema is no longer recDfirnized by deniiatulogiHta^ 
but therL* Hotiicliiitcs ociurs un allerutiun in (he crythcinutuus form 
aruuud the rectum which juatirics thi» nomeuclulure. 

Vesicks Containing scniin, such ae arc described under the title of 
Ecsema Vesieulosuin, have not been observed, but around the margin, 
of the anufl and bvtwoen the folds of the buttock thei* occurs a moirt, 
red condition uf ihe skin folhmiiig the origiiml erythema aud chnrac* 
terized by burning, itching, ajid a watery discharge. Tiiis exudation 
p().<iiieN(c.<t that gluey cluiracter which stitTcmi fubrica aud gives them & 
slightly yellowish tinge when il rnnic« in couUet ni(h Iheiii, It is 
not asROfiated with any rm-mation of cruHlB, probably on aeeouul of the 
dose apposition of the parts, which prevents rapid evaporation. On 
the buttocks and in the periiieiil aud coceygeni i^iilci thi* moist, enuding 
eondilioii gradually fades ofT into the erytheiiiatous fonu upon lliu 
Bcrolum and skin. 

For tlie etiology of tliis disease the reader must consult the works on 
dcrmalologj'. 

Trtotment. — Attention to hygienic conditions, regulation of tha 
bowels, dietary control, anil the internal administration of such medi- 
cines us will overcome tho>*e diathetic conditions chariicti>rized by do- 
B«i«nt oxidation and imperfect functional action of the organs in con- 
wyjuence, wrill all be necessarj' for the sueeessful treatment of this 
condilion. In the lirnt place the uriciemie state, if present, should ho 
attacked by the admin intra tion of alkaline diuretics, the (lanhing out 
of tlie kidneys with large quanlilii-s of water, mid sometirues one will 
find pijferazinc n prompt and eirectiuil remedy. Araenic, sulphur, aud 



2(53 



THE AKL'S. BECTtlM. AND PELVIC COLON 



* 



Rmnll doKen of iodide of potash have been highly repomtiH'ndetl. Pif- 
fard Kpt-akH in glowing torms of viola tricolor m this condition, and 
states that it has n riciiilpd Hrtton upon the kidneys, to which is proba- 
bly clue its influence upon tlie rtisease. He advieeB its uev in small 
doses in acute cases, and in large ones in chronic conditions, varying 
in amount from mu- <Ir<i|i to n tPHspoonfiil according to the age of the 
patient and tho chronicitf of th<! disease. 

A» to the local treatment, it would require a volume to even mention 
the many combinations and preparation* suggeBted for the treatment 
of eczema ani. All irritating siib^tancea should be avoided. Hot water 
applied persistently is one of the be«t ways of relieving the congestion, 
itching, and irritotiun of the parts, and to thie one may add a small 
quantity of bicmrboQate of Koda. Some nuthon- strunglv disapprovo of 
washing the parts. Frequent ecnibbing and friction of the diseased 
area i» objei-tioiiable, but the application of hot water du4.<8 nut necessi- 
tate tuiy fluc'li friction; it is simply daubed on with a »uft wad of gatixo 
or a clean sponge and held to the parts until it begins to coo! ott, when 
■it mIiouUI bf ri?appU«'d tt« hot as the patient tan bear it. 

If there is mutli Hi-ro-puruleut dindmr^if. tlio appHcution of peroxide 
of hydrogen in the ^^trength of 10- to 2o-vn]unie solutions will some- 
times rapidly control this and aUo relieve the pain and itching. The 
old-fashioned blackwosh U very effectual in the relii'f of these symp- 
toms. Unguontiun zinci oxidi, ungueutum diachylon, bydrargyri ain- 
moniati, uiigut^utuni pii-is Ijqutdi, or lanolin in wliicli ih inL'orponited 
a small (KTM^ntage of bismuth, salicylic acid, resorciu, or carbcdif auid, 
may hv applied. The strength and selection of these dilfurent oint- 
iMcnts will dcptTid upon Ihc iudividuiil casi-s. Some arc found in which 
all washc» and oily ointments urc absolutely irritating, aud it in there- 
fore necessary to limit ourselves to some fonn of medicated powder. 
Lyeopodiuni or thi' ordiiinry liili'iini toili't-powdcrs^, the ^ubnitrate of 
bismuth, and iiometimej^ dunuatol act with good HTect upon the irritated 
conditions of eczema. All of these should be preoedinl by careful 
bathing with antiseptic solutions and gently drying the parts with soft 
absorbent gause before the powders are u))plied. Stcarate of zinc com- 
bined with a small percentage of salol or Bristol is very soothing to 
the patient and productix'c of healing. 

WTiere thf eezfirih i« of thi^ dry variety, with thickening and infiltra- 
tion of the skin, deep (isBUres and puckering of the mucous membrano 
about the margin of the anus, a more active Irciitirient may be necessary. 
Scarification with a cold or hot knife are inudvisable because iuft^ction 
and deep ulcers are likely to ensue. The fissures should be touched 
with »>truiig HoUilions of peroxide of hydrogen nr with (he actual cau- 
tery, and gr&plute ointment should then be applied, iehthyol, 5 to 80 



L 



KON-SPECIKIC ULCEUAT10S8 



aA3 



per cent, is an excellent rcmcdj in thv^c. cases. After thickening and 
infjltriilioii have ili«i|»|H-iire(l, the use of h<it water, ointments, and 
vashes 08 adviijed above uinj be be^m, 

Bodent Ulcers. — Under the nbove title Allingham orininally deseribcd 
a iiuinlHir o( ulcers nf dcstnictivf type occurring around the margin of 
the anus. Among thcBe he included n numbiT whieh were of q distinctly 
tuberculous nature. In the last edition of his work he divides these 
cases into two classes, the lupoid and the rodent ulcers. In tlie first 
clflKs he describes thoee wJth typical tubercular manifestations, and in 
which tubercle bacilli can be demonstrated. He still insists, however, 
Upon the occurrence about the margin of the anus of certain chnractcr* 
istio ulcers, which arc neither tubercular nor malignant. He states 
that they occur in otherwise henlthy individuals; that the edges of the 
ulcers, iilthoiigh hard and well defined, are less elevated, and the bases 
more indurated; that they are superficial in Ihe beyiuning, but have a 
greater leudcncv to eiteud into the dey|>er tissue; that the surfmi-s are 
more red and dry. and that tlie diselwrgc is much less Ihuu in lupoid 
ulcers. How llu-y urifjinate, whi-tluT in tniurintifim, moles, warls, or 
cellular iuliltrution, he does uol state. The dcjicriptiun giveu resemble* 
very closely the typical Jacob's ulcer or lupus cxedens of dermatologists. 
This type of iilwriilion doo^ not nttnek the mueoue or niuco-cutaneous 
bonlors. They are ordinarily deeeribi'd as attacking the skin about the 
face, where they attain considerable aize, and extend down to the bones 
themselves. Dennis states that they begin as a hyperplasia of ihe cpi- 
theltuiti belonging to the sudoriparous and sebaceous glands or the hair 
fullicles ; tliat tbe |>rcssure of this hyperplasia causes atrophy of the rete 
Malpighii, but not degeneration; that the ulcers differ from epitheliortiB 
in that the lymphalie nodes are less liable to lieeomc infeeti'd, there la 
none of that typicnl ingrowing of the mrfaee epithelium, and thu cbMb 
are Bnialler and the Tiuelei spindle-shnped. 

Fordyce states that the infiltralinn at the base of the.se idrers is 
always less than in true epitlielioma, and the distinguishing feature Iw- 
tween the two is the disproportion tbat exlets between the ulceration and 
the new growth. 

The di.'ieaso always oecnis late in life. It has no eonneetion with 
pulninnnry tutwrculnsis or any other I'onstitutional diBease. Its eounw 
is very stow, the pain is limited, and the lymphatics are seldom involved, 
Tlie discharges are scant, thin, and saniouj*. The ulcer itself is harder 
than the lupoid, hut (here does not exist below il that marked 
development of libroid or cicatricial tissue which cburacterinos the 
latter type. 

Ilistologioal examination shows agpregntions of epithelial cells ar- 
ranged Hymmetri(yilly throughout the etructure. The capillary blood- 




i 



aw THE ASUS, RECTUM. AS1> PKLVIC COLOK 

ve»*«lB arc largelj' increased, but there is no marked change in their 
wulls. TubtTclc baciUi and giant-cells arc absent. 

Trom tlicai; iucts one ia led lo the eonclu-'ion that this lypc of ulco 
ation IS nothing muru ^r lean than u wild £uriu vt eplthcliuiua mudilied 
by eenilc proccescs. 

Diatfiivsis. — It is almost impoesible to distinguish these ulcers in 
thyir uarly stages from thv j^iiupK' tuberi-uiar or lupoid Ijpea. Tlio char- 
actemtiex alove descrihyd are not well enough marked. They so cloaely 
ri'scnille the other vfirieties lliut one would not hL- justified to ri-ach a 
positive coiiilusion until n luiiTuseopiu exumiiiatiun luid leiui made, and 
it had <lemnn»trated the uii^t-ncc of tubercle bacilli nnd giaut-cells with 
their three inflnuininlory zones. 

Treatment.' — As the nvdent ulcer is ft typo of epithelial growth, iU 
treattneut should be earricd out upon this basie. The radical oxeisioa 
of the tumor will appeal to every surgeon: however, experience with 
excision of epithohoiiiiif; at tht aiial luar^iu has not Uinu as satisfactory 
as could be wished, because there seem* to be a great tendency to recur- 
rfncc. The author has aeen but one removed from this site Ihut did 
not return wilhiii two years; one tliut iiivolvid tlie iiiar>;in of the anus 
and about 1 inch of the niucoug membrane was removed in Ififll, and 
the pntient remains well up to the pre.«oiit time, but fmir others re- 
ninvod since ihiit time have recurred, IlndienI cure is more likely to be 
obtained by caustic potash or arsenical paste, used according to the 
niethnd.s of Robiii.'>nn, who has been so successful in the treatment of 
these rondittons upfln the face. There is no reason why the^e pastes 
should not be applied to the niargln of the anus as well as to the checks, 
lijw. and facial n^gions. Iii one case in which thi.i treatment was ap- 
plied the reHuIts wore very satisfactory. lj<)eal and internal nn-'dicalioa 
have litl!o or no effect upon the diseasL*. but of late some excL-lleut re- 
sults liuvf been obtained by the use of the Roentgen rays in this type of 
ulcers. 

ULCERATIONS OF THE ANAL CANAL 

The ulcerations previously mentioned involve the cutaneous tisanes 
and are outside of the influence of sphinctcric contraction. 

The etiological factors in tlie present type are practically the same as 
of those in the perianal region. Chancres, chancroids, secondary and 
Icrliury sy|)hilis, tubi-rculosis, epithelioma, traumatisnis, and infections 
may all prodmv ulceration of thiis tract. It may occur through exten- 
eion from the pepiamil region and from the ructal cavity itself, or it may 
originate in the anal canal. Where it extends from tlu* pi^rianal region 
into the anal canal the diagnosis may hn> made fmra tbo natun- of tho 
external ulcer, tho depth and extent being determined by digital and 



L 




NOS-SPECIFIC DLCEGATIONS 



366 



ocular examination. Whci'c they orijpnate in the rectum it is niucU more 
difficult, ns the nntiire of the ulc\>r below 1003- be entirely different from 
thnt wliiiTli fuusuH it. Carcinorm nnd stricture of the rccliiiu arc often 
associntMl with .■iini|)l(? iiictT of the nnus. 

Most ulcers of the anal canal assume the form of fissures at fir^t, 
nnd present the same symptoms — viz.. pain at or following stool, spasm 
of the ephincter, bleeding, and supparaLiun. The Ijpital painful ulcer of 
the anal canal is a fissure, ealled also irritafcie or intolerabk ulwr, which 
will Im! di.icnsiEed in n sopnrnto chapter, It i*^ not Riillicicnt thnt n pn- 
tiont conijilniii? of jiiiiii, s|)hineterie gpnsm, and occasional bleeding 10 
make a diagnosis of lif^snrc in ano. The nature of the alecr ie of the 
utmnst iiiipnrtance in lh^ dia^n»ii§ and IreatmeTit. Tubereulous, epi* 
theliomatoue, and venereal ulcerations betw^'cn the radial folds of the 
antis may nil produce these symptoms, faut treating them as euch would 
end diea^trou^ly. Ttaunialic ulcere tliat follow optralions or injuries 
may assume the ^hape of fissure, but without the eharacteristic pain 
and apaam of the »pliincter one would not chsracterizc them iig such. 
They aro simph', nnn-irritiililp, or tnlrrnhlp uIhtb. In niEiny nf Iht-sc 
cMiU's tli(' Rpliiru'ti-r will have been dihited dnrinj; the operations which 
produced them, and yet there will remain fissure-like ulcers, which are 
bIow to heal, ftlllmiigh painless and withmit any hypertrophy ot spasm 
of the muscle. This condition is due to repeated infection by the fjpcal 
pasBAgea. In distinction from true Bi^aure none of these ulcers ordinnrily 
occur singly, but oftim two, three, or four of the suk-t between the radial 
folds arc affycfed at \.\u- nann? time. Moreovur, tlmy p'nerally Hxteud 
more or less into the mueouii nienibrane of tlie rectum and outward upon 
(he fulam-nun tiwui-. The bases are nnt indunik-d. and lluTi: is an 
abundiint purulfut lUflcharj^t:, sometimes tinged with bluod, whicli is 
not the ease in fissure. 

Another fact of importance is that in ?inipIo, venereal, and lubi>rcu- 
lar ulwrs of the imdl canal the lo»iou is quite as frofiucntly upon the 
sidoa w at cither commidaure of the rectum, whereas in true fia»uro 
or irritable ulcer the lesion in 8.5 per cent of the cases ia situated 
immediately at or just to one side or the other of the posterior 
median line. 

'Hie syiitploms snd diagnoais of the apeciQc forms of ulcer will be 
found in the prcivdin^r chapters. 

Simple Ulcers of the Anal Canal. — As just stated, the-.ic are usually 
dun lo cttPn-iinn frnni oliier part* or lo tninmnli^m with infection. 
Thoy may alfect the niilei alone, or tbey may involve nil tin* rircura- 
f»renoe of the anus. Such ulcers not infre<niently fnllow o|>erations for 
hwmorrhoids. e.-ipeciBlly by the Whitehead mellmd. for o'sprtinn of the 
lower end of the rectum, for prolapse, and for recloculv. They do not 




964 THE ANUS, RECTCM. AND PELVIC COLON 

ordinarily burrow deeply, Init in healing, especially if their course is pro- 
trarted, tliey are ver^ likely to leave fibrous strictures. 

The s^fmplttms an- IfHilcmL-ss aud |iaiii at stuol or ou sitting down, 
a cnnstaiit discbwrgc of pus, and gradiifllly iiicreasin}( diflifulty in muve- 
ment of the howelH. Dinrrhtca or frcquu-nt dveirc to defecate, without 
satisfactory results, and aching pain in the back and testicles, arc often, 
present. Pysuria is frequently uii annoying symptom, 

Treatment. — Such uIcgw are often verj- diflieuU to heal even when 
the sphincter hag b«.'eii cut or Btrelclied. The protection of the parts 
againivt coimtaQt reinfection is not easy. An oily dressing coDtainiug 
ichthyol UHiially sccompliKh^A this as -well as any other, but Homctimes an 
application of nitrate of silver, aflrr thorough cleansing with hydrogen 
peroxide, will form fin alhuniinoid coating, whicK actn quit*- well. Moist 
absorbent dressings act better in these cases than drying powdere. 

Rest in U'd is almost a pn^requinit* for l-uh?, and if the hips can 
be kept ii little higluir than the chest it will be all tht* hotter. Owia- 
sionatly, however, when the ulceration Mirroundii the amil canat no local 
tn'atini'itt seems effcrlual, notwithstanding all such causeM as >iyphi!is, 
tubemdnHis, and epithelioma arc Hb»eiit. In such ra.-^es one may suo 
ceed by dissecting out the entire ulcer and suturing the edges of the 
wound together. 

ULCERATIONS OF THE RECTUM AND SIGMOID 

The rectum is very freqiiently the seat of Tarioua tj-pes of ulcere* 
tion, any of which may extend into the eiiginoid. Traunialic tcsioDs, 
and consequently infected ulcers, are much Ics^ frc(]U«nt in the latter. 
This is explained by the fact that the part» arc in relation with soft, 
clastic tissue!, they arc movable, and the eourae of the blood-vcsseU is 
drciiljir. Thu.« a hard faral njase does not bruise the pnlvic colon, as it 
would the Tectum; in straining, the fori^ is not pxertwl again«;t an 
immnvable and resistant wall, as in the rectum, and finally the sliding 
of the f.Trjil masfi over the nurfare, the erect posture, and abdominal 
pHTSJiure do not obstruct the circulation and cause congestion, as they 
do in that part of the gut where the vessels run op and dovm. Aside 
from the trauniatic, pressure, and syphilitic types, however, nlceratiom 
are quite aa frequunt in the sigmoid as in the r»>ctiim. Th« two parts 
are so iuseparahle, and the pathnUigy and symptomatology so similar, 
that it i» best to study them together, always bearing in mind, however, 
the dilTcn'necs tn relationship and ttnatoniical L*onstruclion. 

Fnim a pHthoIoglca! point of virw. and for convenience of descrip- 
tion, they may be divided into simple, specific, and systemic ulcera- 
tions. The term specific is atlll used here in the broad sense in which 



I 




NON-SPECIFIC CLCEBATIONS 



267 



it V)i<: employed it tha boginnin^ of thi» i^hnptcr. The simple ulcera- 
tions are tliose due to trfliiinati»ii or «iiy othei- cau^e rollottuU by infec- 
tion from the Iwuieria present in the inU'tttinal canal. They are — 

1. TniuitiHtkr. 

2. Cstarrlial. 

3. Varicose. 

4. Hicinorrhoidal. 

5. Folliculnr. 

6. Strictural. 

Tile specific nlcers are Ihoge due to infection by bncilli not nor- 
mnlly present in the liuuian systeni. They are — 
]. Tubt'rcnlnr. 

5. Venereal. 

3. Dyflenteric. 

4. Diphtheritic. 

6. Caivinurimtous (?) 

The Rjulcmie types nre those due, or at least secondary, to grave 
conKtitutional or organic diseases. They are — 

1. Nephritic. 

2. Diabetic. 

3. Trophic 

4. Hepatic. 
6. Maraaniic. 

Some of these divlnions overlap one another in a nicasiire, aft both 
pathologiejil eoiidltioiis may be present in the same iiidiviilnal and 
operative at the same time in the production of iilceralinn. In such 
casea there may be two distinct ulcers present in the same rectuiu, or 
we may have the two typi's combined tlicre, forming u sort of mixed 
ulcer. Thua there may be eimplu ulceration of llie uiticuus nteiiibniDe 
along with carcinomatouB involvement of the rectum at a hijiher pi>iiit. 
Catarrhal, luBiiiorrhoiilal, niid a|H'C'ific ulreratiiins may hi- nil pri'scnl nt 
tliename time in one individual. A simple traumntie uh^r may tifcorne 
inferted by tuliercuhisiii or syphilid, and thus its nature will bo entirely 
changeil from what it wim when first nbserved. It will bi? impossible 
(o repeat thrive conipliottinns under every type of ulrcrntidn, but thu 
pi-adcr should tHUiHtuntly bear them in mind, and in clinit-al work apply 
the diagnostic tests in every case. 

The cpecific uleurations having already been described, the simple 
and systemic types will be eonaidered, 

Btiohg^, — Certain predispoHing cauHefl and symptoms are common 
to many if not all typt-s of uUrration in the rwtum nnd sigmoid. They 
may Ihen-fore l»r enumcrBtfd here oncn.- for all, and referred to under 
the special varietica in order to avoid rcpctitioa. 



368 THE ANUS, RECTUM, ASI> PELVIC COLON 

Predisposing Causeg. — Ago : Rectal ulcorations are rare in veiy 
}ouii}r L-liiltlrt'ii, but in old pfojilu tliost Ij^l-s (Iul- to |jiv»6urL', variL'oee 
veins, and trojihic ehuiiges uro qjitc /rftiut-'iit. Tlif condition, Iiowi'ver, 
is niurli iruirt- frt'ijui-ntly sn-ii in tiiiilJIe liCir. This may be <lue in port 
in the prcfininlLTJimi- in tiunibiT:' at this agt; dvlt thi.' vt-ry old, but it is 
aha iiiHucnortl hy tho more coniilant *lniinin^ at oxt-reisc or labor, ex- 
posure lo acciiit'nts or injuries, and tho froqiicnoy of snrjrictil opcra- 
tioiis. In v'onion tho inouKtrual and ehild-bcaring periods alao pro- 
dis]>08u to it. 

Svx: WoitiL'ii art? inory Mubjuct to tilcfrittioii uC tliy avtuiu on ac- 
cuunt uf thi- grutttLT frwiui-ncy of uunstipatiim, pn-ssun' cm thf or^uu 
by miKplui^L'it nr grHvi<i utrri, funiors, biidly flttiiij; [M'saiiries, and in- 
juries (luring childbirth; «Ik« fnim tin- i-xpwsuro iil' thu organ lo the 
acrid and irritating discharges from the vagina.. The intlnontc of thcso 
conditions, togeihyr with the various inflflnimations of the roprodiictive 
organs and pelvio oelluliti« in thf production of rei'tal and eiginoidal 
diKease, is not su(Iiei«ntly upprcfialfd. Many eases of ptdvie disease 
in wuinen fail to obtain relief after opprations and treatment niniply 
bt'iau!**! thf inte«tinal conditions which they produer hiive not Imen 
treated at the finme lime. 

The intcrdcpondcntf of thesfl two clasws of iliKeariei^ requirec a tech- 
nicnl knowledge of both in order to treat either one snccese fully. 

Oecupation: Occupation has some infliienee in the produttinn of 
the diseahe, in thai tliose individuals who are Btandiiig upon their feet 
most of the time, whose dulti's icci^uirB iheui to lift heavy widglils and 
strain, and who arc pn-occupicd sulliciently lo interfere with mjruhir 
attention to tiic functional action of their howel.s, an- liable tn pulfer 
from constipation, congestion, nn<l other conditions, surh as bring about 
nkcrs of the rectum and sigmoid. Painter*, workers in load and phos- 
phorus, tailors, seamstresses, artists, etc., are all frequent subjooti of 
nleeration of the reetnm. 

Phijgiiilofficul Fiiiiclwns. — The functions and position of these parts 
are most important predisposing causes. Forming. h» they do, the ffna! 
portion nt the intestinal trad and servin;; as ston'-houscs for the har^h 
and indige^tiblt? refuse, tliey arc subject to coiitiniied pr(rs?ure by the 
maw. and to abrasions and wounds from the (ort-ign bodies whieh it may 
contain. Whenever the neeiiinulatinn of fft'eea remains for any pro- 
tnirted period in the reetnm or i^igmoid it l>ppome9 very hnrd, and by lis 
constant pres«ure and to-nnd-fro movements, eaused by piTigtaUis and 
respiration, it is likely to produce congestion, abrasion, or even actual 
wounds of the mncons membrane. 

Bacteria; The fact that there are always preneiil in the intestinal 
canal, especially at the lower end, numerous bacteria and bacilli, predis- 




NON-SPBOiriC ULCEBAnONS 



2iiV 



po«vB these or^ns to uIcRpati«n by the fncilitj with which any injury 
of the i>arts luav become iufectod. 

BAcilliie coli commuQe, staphylococcus, and tubercle bacillus are 
more OP li>K!i i-oiihlttiittv fuuml liun?, ami ii<> iieiiuuiiI of altcntinn ran 
keep the paiU frt't* from c-xposuri* tu inft'ctioii l»y Ihcni. In othiT ce-^l'S 
peculiar bacteria are found. N. Solojew (Centralbl. fUr Biikt«riologie, 
PaiTiHitfukumlc; uiid lufrkiiunnlernnkhcltcii, 1901, I. AbthpihiiiiB, vol. 
xxix, pp. 821-S;t()) \ms reported a fatal ciiHe of tiU^crntion of this eolon 
and rectum due to the balanlidium coli. The ulcers vere extensiv* and 
invrtlved the entire mueoda, dipping into the nniscuUr coat. Whi!e 
various iniero-or^iitiRiH were found iipim the surfaee, only this peculiar 
parasite penetrated the deeper parts of the uleem. He therefore cou- 
siiU'ra it the ('ticdogical factor. 

The author haji recently Been a case of chronic diarrhrea with tilrera- 
tion of the rectum and sigmoid in which amcebie dysenterin* were found 
at first, and later on mimerciUR trichomonaa intestinalif*. Thayer (The 
Journal of Experimental Medicine, vol. vi, p. 7S) mentions this same fact. 
He also calli attention to the presence of etrongyloides intestinalis in the 
colon in certain eaw-s of chronic diarrho'a with inteKtinal ulceration. 
The elioto^'ical influence of these paraHiteH in the production of ulcera- 
tion haH not yet been determined, but the large variety of such agentn 
found in the alimentary tract makes the wonder grow that we do nut 
more frequently obBervc infection and idceralions there. 

Anatomitai Caunnf. — The distribution of the superior hiemorrhoidal 
Teins. the fact that they posseM no valves, and that the collateral circu- 
lation below is ao feeble, prodispoaea the rectum to eonntant coiigLslion 
and ulceration. Especially is this true in consequence of the btoocl pres- 
pure upon thejie parts produ«vi3 by the erect posture. 

I*alhohfjieal I'redispasini} i'<jTi.ies. — Adide fi-oiu the Bpecific diseases, 
such as tuberculosis, syphilis, dysentery, etc., certain other constitutional 
ami organic diseases predispose to this condition. In general, one may 
say whatever enfeebles the circulation and reduces the cardiac force, »o 
that it does not move the blond rapidly through the portal circulation, 
vill predimpose In iKitigestion and uleerntiun of the rectum. Valndar 
diaeaee of the right side of the lieiirL, hepatic disorders, and atheroma of 
the arteries all contribute to Uiis dijteaso. 

As to the NjH-c-tiil dii'CHi'e^i there f^cem^ lo be some lack of harmony 
among writers as to whetlicr tlicy Hini|ily predispofc or actually occasion 
the condition. It is a question whether Bright'* disease has any pecul- 
iar influence in producing ulcers of the roctun through (he awumulation 
in llie sysleiii of poiaonoUB delrilus which «bouId !«> eliminated by the 
kidn«ys; or whether, as Da Costa has brought nut, in the later stages 
of thia disease the secretory organs of the body, especially Ihe liver, the 




STO 



TBB ANUS. BEUTITM. AND PELVIC COLON 



panL>reiD<, tlie splewi, and tli« li^iirt ns well, nil take oti more or loss 
of thu Bflerolic involvement nf the kidney, ami thus becrome u part, and 
parcel «f tlie di8eiii*e, the rectiil iilwrs lieing sRcondiiry' to (he involvi>- 
nicnl of tliese organ:*, and nnt due to the clironic inflnmmation of the 
kidney's uluuc. Of coume in tlioae cases wliirh aLwa^b «<:i.'ur in Ihu tatu 
«ta|^ i>r Bright '« cliseiis« tli«rc is feeble cardiac action, general valvular 
dilatation, and dccronsed blood pressuro. In fact, all tlie tissues of the 
body aro in a dpj;cnorntcd or enfeeblnrl coiiditiun, ami predii^pnm^d to 
sufftr more tlian usual from Blight traimintiniiis, an well ns boing «ibj 
vietiui^ to infection by septic bacteria. At the same time, as we shall bm 
later on, the type of ulceration seen in these cases is entirely dilTcrcut 
(rum uny other rectal ulceration, thus lending color to the view that it is 
due lo ilright's disease itself. 

The ulcers of the reetum that ore oauaocl by diabetes ate eimilar in 
Ihcir nature to ganjrpene nf other portions of the bo<ty af produced by 
thi« diM>8se. It in Bimply a gniigrenous or necrotic condition of the 
mucous membrane that results from traumatisms or thrombotic obstrue- 
tions in the venules, and may occur in acute as well as chronic cases of 
this disease. The author hais seen one cose in a woman whose diabclvs 
laated only a short time, and yet during that )M.-rio<] the in<)»t extensive 
ulccritioDS of the rectum and sigmoid occurred. There waa nothing loft 
fif the niucQUH membrane of thetrte two organs beyond little i>;lnnds or 
patches about the size of a silver quarter, ns high up as the Inngcot 
sigmoidoscope would reach. Tlio fact that the itlceraliun extended after 
the glycostiriii hud dinaiipeared is in keeping with oIIkt r(*|)ortK of u1e{>r- 
ation of the skiu JiiiJ jiaUKrene of the extreiiiilieit that otfurn'd after 
the glycosuria had disapfieured. 

Profound unujuiia is a predi^poi^iQg cause of uIcit^ of the nrctum, as it 
is of ulccns everywhere eUt. These patients are generally the subjects of 
obxtinali) eon»itipalion, the stools arc hard, and IraumatiKiu from tliia 
Bouree freijueutly affords an open gate to the baetorial infeetiun which 
results in th« nleenitive process. Xeuroses and inentnl diMtaxei^ have 
been frequently spoken of as predisposing causes to ulcers of the rvetum 
and colon. In the chapter npon mucous and ukvmtive cnlitis attention 
has been called to the fact thai these di^oases am vi^y fn^qiirntly met 
with in institutions for the rH>rvow« and the insane. Some authors have 
taken the view that it ia the rwiilt of trophic change*, while others be- 
lieve that they are due tospccifle, nnd even to conliigions bacilli (Cowan). 
On the other hand, lack of attention to the calls of nature, want nf 
exercise, and altered nervous conditions, such as reduce })vriBta[His and 
Ta«cular tension, all tend to protlurx' omditions which predii^pose to 
ulceration of the n-ctum and sigmoid. Four cases of ulceration of the 
reclQia and one of the sigmoid have been obscn'cd in casee of Don-eypht- 



M 



NON-SPECIFIC ULCKRATIONS 



2:1 



Utic, mulliplo «j)innl gelpru8i«; in one casv cvpd an artificial aiiiui faili-d 
to hi'al ilie ulcer. It ajipears, ihinvfori!, limt thebO nourowes mav be 
even more than pi-e(ii)>ii<Mitig onuMfK in ntnw c^svu. 

Rxciiing Causes, — TrBuniHtiiim or iujun,' in the exciting rniiw of 
the Inri^c Diajoritv ui uuu-apucific ulrL-nilioiiH h[ IIr* ivctiiin. Tlic^ niA)- 
tte du« to sui)(irjil o|KTali»]u, ruugh intrmlucLiim of syringe tips, the 
improper use of bougies, the application of taulorizitig agents, the injec- 
tion of eorrosivc gubetana?^ in tliv treatniL'nl of lia^iDorrhoidi), the paei- 
sHge of tiard fiecul nin^ci^, tbti iotroduetion into tin.- miits or pussugi* 
throngh the bowel of foreign bodivK, and tin; ruptiin- of hii^morrhoidal 
veina. 

Next to feurpieal proLvdurt« the jHiivtugc of forci]^ bodit-5, such a* 
bonett, pins, fniit swd?, ;;nll-£tniii>!i, dr., is tlie most frequent wiunH- of 
iileernfiona. The sharp points of these little bodies project out beyond 
the fa'cal niaxft and iicmli'li tlic mueoiia iuenibruni<, thus causing small 
wroiiiids, whi<'h soon heeoitie infeeted and eause ukeralions. 

Pri'ssure: Prolonged pressuru from iuipaeted fa-cv*. from arrest of 
tlic fti'lal head, from pelvic lumora, and from too large [»?*saries, may 
interfere with the eirvulatiou. eauttc HlutiKliiug of the uiucou« niembranc, 
and thus produce ulcerHlion of the n-etum. 

Crypts: The lodgment of foreign bodice cr smalt masses of hard 
fieoi^ in the crtpts of Alorgagni may sometime-^ eauito uherationK which 
extend upward and involve the rectum. 

Dnigs: Finally, the tosie action of certain drugs or chemlcaU, Hich 
as meix?ury. capi*{ciiin. mustard, photjphorue. ergot, and earlKinate of 
aninionin, have been known to cause ulceration of the rectum and (lelvic 
colon. 

Geneml Symptoms. — 'i'Uo symploms of ulceration of the rectum are 
very similar in many nstpecta for all \*arieliefl. The size of tlie ulcer 
0X8 rule beam no relationship to the amount of iliHturlHince it prtHluees. 
Extennive ulceration well abore the internal dphinrtpr may eaiine very 
Blight and indefinite aymptoms. whereas a verj- small ulerr situated 
low down may occasion gre&l pain, muscular spasm, nctTOus irritability, 
and reflex diaturbonces in nearly all the organs of the body. 

i)iarrhii-« ia one of the early syii)ptom« of this diseaee. U somc- 
tim«» comes on with an acute attack of griping and paiu in the eour&u 
of the colon. Such cai^ft are due in colitis, and are di>Boril»e<l iu the 
ohaptor upon that subject. Kreiiuently, however, it cecum aa n gradu^ 
ally increatdng frequency of fiecal movementa. At Rrat tbc«c will 
he cnniparalively nomial and of suflieient amount, Thoy will grow 
amallcr as the desire hccouu-s more fretjuent. ami instead of pasting 
fieeal iiuilcrial tht: [>atic-nt will have frequent calls to the etool, at which 
notliing more than a *m«ll quantity of mucus will be discharged. 

18 



THE ANU8, RBCTUM, ASD PELVIC CX>LON 

Somclinips t)it.s imiciis iii tinj^d vith I>I<km1, at othviti ihere ma^' be 
ronsidprnMt' (juaiilitie» of pure hloo<) poured out Hloug MJlh pus. Oc- 
casionally the patient will pufw ()nantitie» of umlcriul rfttcmblioji; built^ 
sago. TjaIlt oh tht-f^ diachargfs chaoge to a dark nnil ^nimnas tnat^rial 
due to decomposed blood mixed vrilh iiiucui), rm-vs, uod pu^j, Ttie 
character of the di^cliar^ dilTcr^ conaiderablv in tUc various Xjpea of 
ulcerations. Af will be deseribod under their appropriate ht*ailit!ga. 

Miirniuy Diarrkmo. — One ]ieciiliar charaeteriKLie of the diarrhica in 
nlceration of the rectum is that it is generally quiescent nt night, 
wherraa in tlie daytime the jKitieiit suifers from frequent ch)U to stool. 
He may have eight to ten ur more passagea during the day. and yet 
go to lied ami nh-ep all night wilhout any disturbance. Upon rising 
in the morning, however, lie will be «jUe<l upon at odc« to relieve 
the bo^peU. 

IXtaflehl (Mt-dieal Keoord, 1895, vol. i, p. S?T) stntes that this mom- 
jng difirrhtea is a const it iilionni or neurolic condition not due to local 
inllaininntion ur dii^easc. and dt-KiTibeii live varieties, according to tiw 
BOTerily of the symptoms, but leaves one to iiifar that there is no 
organic diBctute of the inlcslinal tract to ueeouni fur them. 

With tm-h au opinion every close obwrver in rccUl diseases will 
take niogt positive ittuv. Vr\i« morning diiirrha'^a, each as he hat dc- 
fcribctl in his last four divisions, is patliognonmnic evidonw of local 
inflammiition, stricture, uleemtion, or neoplasm of tlie rectum, Rigmoid, 
or colon. There jh no condition that more positively denuuid» an 
early and thorough exiimination of the nrtum and sigmoid flexure 
than tliin lendent-y 1o go to kIooI immediately u]H>n rising in thr morn- 
ing. eBpecially if that moniing ."^tool cnnsifits in mucus or purulent dis- 
charges. There are pereons who have a normal call to defecate as 
»oon as they rise, or shortly after ri.-«ing, in the morning; the pa^Migcs 
sro normal and there is do coutiniiouit call tlu'oughout the day in etich 
uueK. Bnl tJietu* are iin entirflly different elaits from tho»e dtwc-ribed 
by thi- author mentioned and nhieh are discussed here. Tlie morning 
dinrrhira, which conHJsts in the jiassage of mueuA or pits, in due ia 
almrntt every instance to wlcerntive dis^-flse of the rectum or sigmoid. 

Pain. — This is a verj* unreliable and indefinite s^-niptoni in ulcera- 
tion of the rcctnm. Certain individuals suffer greatly from it, while 
olhem have no pain at oil. If the ulceration ie high up in the rec- 
tum a ncBU! of n-eiglit and aching in the »icrul region i.1 the chief 
■dlDcomforl of whieh most patients romplaln. If it is situated lower 
down within the gra»p of the H[>hineter. and involves tlie mncn-ciitano- 
on» area when.' the scrisitirr nerve-ends center, pain of a shaqi, lancJnat- 
iag, or burning rharacter will be the chief Rymptnm. 

The amount of pain varies considerably with the character of the 



N0N-3PECIKIC tTLCBRATIONS 



273 



olceratioD. Tubercular iilrciB are nlmoflt entirely free from ii. Syphi- 
litk' ulcers vary conwilerably in Ihis regard; t^iurtiiiK'ri* lln.-y uro very 
seoaitiTe, at others the patient is almost ab»>lulely vitbuut tiny puiii, 
but tbiH (Ippend-i upon the lomtion. A« a rule ulceration of the rwjtum 
propvr iK nal an aeutely pninfut nlTtwlion. 

fncotitinfuet. — ItelajiatioD of the spliiDCter is Dot an infrequent 
symptom of ulceration of the rectum. Sometimes patients ubnust en- 
tirely lose conirot over cheir f^t-al imaaagee owing to this cuiiditiou. It 
does not occur, however, except whvrc Ihc diecAac has cxitttttl for a 
loDg time or lias been brought about cither by »crious com^tilutioiitil 
diseases or vicious practices. 

Tho itymptoms elicited by sight and touch rar%- with each particular 
olio's of ulcers. The;* variations when witbin wiiuh can be upprcciutt^d 
bj the educated touch, but the various iniitruiiieutal uidi« fur ocular 
lination of the rectum enable us at the prexcnt day to ili^ting^utsh 
bctwwn the ilifftrent ulcers much more clciirly thaii before. Tbruugh 
the pneumatic proclcwcope one can clearly sec and diugiioirc ulccni- 
tioiu in the upper portions of the rectum and in the sigmoid; tlic 
character of the ulcers can be determined and the amount of contrac- 
tion in the caliber of the gut can be accunilely nica^iurod wilboul any 
danger of perforation. The appearance of special ulcerations will be 

cribed under their proper headings. 

SPECIAL ULCERATIONS 

Tratunatio Ulceration of the fiectnm. — This form, termed also 
simple ulceration of the rectum, nlvny^ originates in some Injury to 
the ports. The nicerativo condition i? due to infi'clion of Ibn mw 
nirfacos bj the l>9ctcria always pretwnt in the rectum. 'I'his difitin- 
aes them from those ulcerations whic!i are due to specific bacilli, 
inch ajf tubcreulosis, typhoid fever, dyscnlei^', etc. 

Ulcerations following surgical opcnitions. when in patients other- 
wiw healthy, tend toward sponlancouit healing, but they may aome- 
tinicfl be proLrsctcd oD account of the irritation caused by the parage 
of hard fffical masecs and the impossibility to keep them clean. 

Tho lower the seat of an ulceration in the rectum, provided the 
sphincter is kept relaxed, the more rapidly will it heat, heeauw the 
fowal materials do not rest m pcreisleotly upon the parts and cleanli- 
DMB Is rendered more possible. Thus in open operations for hiemor- 
rlioids or fislulus the tendency is always for the lower portion of the 
wound to cicatrize l)ofore the upper portion. Anuthcr thing which 
tnnsl always be taken into consideration with regard to these traumatic 
Dlcere is the trophic condition of the ports. Whenever an ulceration 





272 



THE ASUS, EBCTTM. AND PELVIC COLON 



Somftimes this tnucus is tinged with blood, at oth«r« (here ma; be 
conaidvnibU- (juuiitities of pure blcxK) poured out nlou^ with pus. Oc- 
casiunuUy the patient will pass quonlititts of nuilcrial n.-svmbHn^ boiled 
sago. I^tcr on these disc-har^t^ rhan^ to a dark and ^rumons material 
doe to decomposed blood mixed with mucus, faeces, and pus- Th« 
character of the diechjir^e differs considerablj in tbe various tjpea of 
ulceratioUD, as will be deseribed under their appropriate headings. 

Morning Diarrhcta. — One peculiar charaeterislto of the diarrhiea in 
ulceration of the rectum is that It is ^uerally quiescent at night, 
whereas in the daTtime the putienl suffers from frequent calls to stool. 
He may have eight to ten or more paasages during the day. and yet 
go to Ixi] and sleep nil night without any disturbance. Upon rising 
in the morning, however, he will be called upon at once to relieve 
the bowL'Ifl. 

Delatifid (Miilical ICcoonl, ISD.'S, vol. i, p. 577) states that this ninm- 
ing diarrhfpa is a constitntionnl or neurolie condition not due to local 
inflammiilinn or dii*ease, and de*crihes five varieties, according to the 
Kcvcrit^ of the symptoms, but leaves one to infer tliat there is no 
oignnic disease of the intestinal tract to acconni for them. 

With s-uch an opinion everj- clo,*e observer in rectal diseases will 
take most positive iesne. True momiag diurrhoea, such as be hm de- 
scribed in his last four divisionii, if pflthognomonic evidenoe of local 
inflnmrnotion, etricture, uleeraiion, or neopUt^m of the roetiim. sigmoid, 
or colon. There is no condition that more positively demands an 
early and thorough exaiiiindlioo of the rectum and sigmoid flexure 
than this tendency to go to stool immetliafety upon rising in the morn- 
ing, c»pi%-i«lly if that moniing »tcKil con^iiets in mucus or purulent dis- 
charges. There arc pcnomt who have a nonnal call to defecate as 
soon as they riec, or shortly after rising, in the morning; the psisagea 
are normal and there is no continuous call throughout the day iu eiich 
cases. But these are an entirely dilTereat class from those described 
by the author mentioned and which are discussed here. The morning 
diarrhov, which consists in the passage of mucus or pus, is due in 
almost every instance to ulcerative dJM-ase of (he recttira or sigmoid. 

y'uin.— This is a very unreliable and indefinite symptom in ulcera- 
tion of the rectum. Certain individuaU sulTer greatly from it, while 
others have no pain at alL If the ulceration is high up in the rec- 
tum a sense of weight and aching in the sacral region is the chief 
diMcomfurt uf which moNt palientv complain. If it is ^ttnatixl lower 
down within the grasp of the sphincter, and involves the muco-cutane- 
oos area where the senRitivp nerve-ends center, (lain of a shaqi, Inneinat- 
ing, or burning rhann'trr will be the chief symptom. 

The amoimt of p>aiD varies considerably with the character of the 



tci^ratiuQ. Tubercular ulcers art aliunst «ntirrly free from it. Syphi- 
litic ulcers vary coa^iUcrably in thiA regard; HOimHiince (hey are very 
sensitive, at others the patient la almost absolutely vithout any |>am, 
hut this litpt-ndB upon the luLutiou. As a rule ulceration of the npotiim 
proper is not an acutely puinful airuclion. 

tncontintnet. — Relaxation of tlie sphincter is not an inrrequent 
Bymplom uf ulct-ration iif tlie rectum. Sometimes palientg almost en- 
tirrly lose control orcr their fn-cal passages owing lo thie condition. It 
Aoks not occur, however, except where (he dieeaiK has existed for a 
lon^ time or haa been brought about either by serious constitutional 
(LJHeaMoH or YicidUfl practices. 

Tlu! Hymptoma eliritcd by ttight «n<l touch vary with each particular 
class of ulcers. These rarintions when within reach can be appreeiatt^d 
by the educated touch, but the various in)^t^^nental aids for octilar 
examination of the roctiim enable iia at the present day to distinguish 
Itetween ihe different ulcers much inoiv clearly Ihuu before. Through 
the pneumatic proctoscope one can clearly see and diagnose ulcera- 
tions in tiie upper portions of the rectum and in the sigmoid; the 
chiiracter of the iitcers can he determined and the amount of contrac- 
tion in the caliber of the giit can be nceiirateiy measured without any 
danger of perforation. The appearance of special ulcerations will be 
clewribed under their proper headings. 

SPECIAL ULCERATIONS 

Traumatic Ulceration of the S«ctiim.~Thi9 form, tenned also 
Bimple ulceration of the rKtum, always originates in «ome injury to 
)e partfi. The ulcerative condition is due In infwtiou of the raw 

face* by the bacteria always present in the rectum. Thi« distiu- 
gaiihes them from those ulcerations which are due to specific bacilli, 
irach as tiilMTcnlosie. typhoid fever, dysentery, etc. 

ricerations following surgical operations, when in patients other- 
wise healthy, tend toward spontaneous healing, but they may some- 
timea be protracted on account of the irritation caused by the passage 
of hard fa>cal maffle» and the impn^sibility to keep them clean. 

The lower the seat of an ulceration in the rectum, provided the 
sphincter is kept relaxed, the more rapidly wilt it heal, hecauw the 
fveal matertaU do not rest go persistently upon Ihe jwrts and cleanli- 
ness \a rendered more possible. Tlius in open operations for [teemor- 
rhoids or fistulas the lendeney is always for the lower portion of the 
wound to cicatrize before the upper portion. Another thing which 
must always be taken into consideration with regard to these traumatic 

nrs is the trophic condition of the parta. Whenever an ulceration 





STO 



THE ANUS, nECTUJC. AKP PRLVIC COLOK 



jiaucrt-UK. llie ttpleL-i). aiit] tlie heart as well, till lake on more or \e»i 
of the R-K'roLk involvement of l)ie kidoey, and tlius becnine a part and 
jinrwl of the disea^v, the rectal ulcers beinj^ seeoiidarv to tlio inrelve- 
mi;nt of tlteoe organic, and not due tu tbe elirooie intlattinmtion uf the 
kidneys alone. Of cour.4e in tlioiie cAiieK which nlway*'' aivnv in the Ut<! 
etag08 of llright's dUeauL' there is fcphle cardiac aption, general vnscular 
dilatation, and docreaged blood pressure. In fnct, all the tissues of tli« 
body are in a degenerated or enfeebled condition, and predisposed to 
suffer more than usual from slight traumatisnie, as well as being easy 
victiim to infeotion b,v sc[jtie bacteria. At the eaine time, as we shall see 
later on, tlie type of ula-ration seen in tliesc case* is entirely dilfereot 
fmm any other rectal ulceration, thus lending color to the view that it is 
due to Brighfs disen«c itself. 

Tbe ulcers of the rectum that are eausod by diabetes are similar in 
their nature to ganpi-ene of other imrtiom* of the body a» produced by 
thiti disease. It is »iiiiply a gangrenoiu or necrotic (.-oadition of the 
mucous uieriibrnne (hat results from traumatisms or thrombotic obstnio 
tioiis ill the venules, and may occur in acute as well as chronic cases of 
this disease. The author has seen ojae tasc in a woman whose diabetes 
Unted only a short time, and yet diinnR that period the ino>it extensive 
ulivraHorifi of Ihe rectum and sigmoid occurred. There was nothiufi left 
of till' mucous iiiembrnne of the.'^e two organs beyond little islands or 
]iMtcIjes iiliout thi' size of a silver (juarter. as high up as the longest 
iiigiiioidoscopp wnuld reach. The fact that the ulreration extended after 
tile giyeuHuria had disappeared is in keeping with other reports of ulcer- 
ation of the skin and gangrene of the extremities that occurred after 
tlio glyeiiHuriii had disappeared. 

Protiiuud aiia-'iuia is a pred it-posing cause of ulcf-ra nf the rectum, as it 
it of ulcers everywhere else. These patients are generally the subjects of 
nliHtinutH cuuidipulion, the stools are hani, utul trauiniiti^'Ui from (his 
mmrcc frequently affords an open gate to the haderial infection which 
nr.<iult« in the ulcerative process. Neuroses and mental dit^cusc^ liove 
been fi-equently spoken of as predispos-itip causes to ulcers of the rectum 
and colon. In the cliapter upon mueous and ulcerative eoliti* attention 
has been ealled to the fact that these diaenscs are very frequently met 
witli in inslilntions for the nervous and (he in>jnne. Some authors have 
taken the view that it is the result of trophic changes, while others be- 
lieve that they are due to specific, and even to contagious bacilli (Cowan), 
On the other hand, hick of attention to the calls of nature, want of 
exercise, and altered nervous conditions, such as reduce perislalsis and 
vaseuhir lension, all tend to produce eonditinn» which prcdispow to 
ulceration at the n>etuni and sigmoid. Four raiies of nlceniti'in of the 
rectum and one of the sigmoid have been ob-scn'od in cases of non-sjphi- 



k. 



NOS-SPBCIFIC ULCEkATIONS 



271 



litic, multiplo spinfil sclproeie; in one cas« «vcn nn arttlicial anus fail&d 
to boal tlie xxk-vt. It aiifx-ais, therefore, that these iicuroscH may be 
even more tbuii piediiiposiug onuses iu same cusen. 

Excidfifi CfluJKM.— Trauiuiitisin or iujurv is the exciting cause of 
the large inajorilv of ii()u-.sji(!filic ulccnitioiis of the. rortuin. Thesp may 
be due to surgicnl oporatioas, rough introduction of syringe tips, the 
ini]»rupL'r use of bou};ies, tho appliration nf cauterizing agents, thp injec- 
tion of corrosive bulistanccs in the treatnifut of ha'morrhtiii.lrt, the pm- 
Ksgc of hard fa<('al nmiiscs, the introduction into the anus or paesage 
through tho lowtd of foi-oigu boiHies, and Iht? rupture of h:t>mori'h<>tJiil 
reins. 

Next to «urgieal procedures the passage of Aireign bodies, such »« 
bonei*. pins, fnnl sted*. >;nII-»lon[;s, rtc, is the most frwpirni soan'o of 
u](X:rratiiiiis. Tlif sharp points of thrfln littli- iKnlies project out beyond 
the fiecal ma^ and scratch the mucous mombntnc, thus i^auiung mnall 
wdunds, whi<'h «oon hfoonio infcott'd and fans* ulocrations. 

I'reiipiire: I'rolnn^od pi'csi^urc from itiiput-twd fa^cee, from arrest of 
thi! f(L'tal head, from pelvic tuinors. and from too lar^ [K<s«8rie8, iiiny 
intrrfcre with tbc cirrulaticin, cau8t> sloughing of ttie niucou? membrane, 
and tliufi prudutr ulcriiition of tbf rL-cluiu. 

Crypts: The lodgment of foreign bodies or aniall ma^aios uf hard 
ftcces in the crypto of Morgagni may sonictimeft cause ulcerations winch 
extend upward and invnhv the tci^Uim. 

Drugs: Finally, tho toxie aetton of certain dru|^ or chctnieftU, sueh 
aa nien-ury. capsicum, mustard, phoKphnnin, ergnt, and carlmiiate nf 
ammonia, liavc hi^n knnwu In cause ulreratinn nf the rectum Biii! [xdvic 
colon. 

Oentrai S'i(mptom>t.—The symptoms of ulceration of the rectum are 
very similar in many respects for all varieties. The eizc of tho ulcer 
as a rule bears no relationship to the amount of disturbance it producer 
ExtouMive ulceration well ahovip the internal epliincier may cauw vt-ry 
slijrbt and indetiniti! symptoms, whereas a very Mmnll ulcer situated 
low down may occasion gjeat pain, niuHcuUr K|>asm, iiorvous irritability, 
and reflex disturbance" in nearly all the oriirnns of the body. 

niiirrh<ra is one nf the early symptoniH of thij" diceni'e. El SDmc> 
timoft cometi on with an aciit<r attack nf griping and |)uin in the course 
of the colon. Such cases are due to colitis, and arc deserihed in the 
chapter u[H)n ibat Hubjeet. Freipiently, however, it oeeurn as n grndu- 
ally inereasin;; freijueocy of fn-cal movymenta. At first these will 
hv eoiupuralively norma! and of aufReient auiount. They will grow 
Binallcr as tho deiiin- beron\i's more frcijuent. and instead of passing 
fircal imilcrial ibr palicnt will Iiave frequent call« to the stool, at which 
uothiog more than a small quantity of nmeU8 will be discharged, 
itt 




3T3 



THE ANUS. RECTUM. AND PELVtC COLON 



SoQielinics tills luueiis i» tin^'cd with liluod, at others there itut^ be 
consiJerable quaiititiect of pure hloutl puuri-d uut itluti^ with pus. Oc- 
caaionnllj Ihv patient will piuss quaiititiea of material rejwiii bliiig boiled 
iJDjjD. Lutur I'll lhi'i<e JlselmrKeis dian>ri'- to a dark uud ^ruinous aiakrial 
duo to decomposed blood mixed with inuciis, fxcos, and pus. The 
charaeter of the discharge differs eonsidttrnhly id the vnrioiia tvpos ol 
uleentlJoue, a\i uill bo det^cribt^d undor th^ir appropriate headings. 

Mornituf Diarrhim. — Ono poeuliar oharact^ristie of the dian-hcea in 
ulceration of Hil- ru-ctum is that it is generally qiiiesoeut ut uiglit, 
whereas in the daytime the palieiit isufrurs frnni frci|ue[it calls 1o stool, 
lie may have i-i^ht to ten or inorc piuwmes dtiriiiK the dny, imd yd 
go to bed and fleep all nipht without any dUturbanee. L'pon rising 
in the morning, however, he will he called upon at onec to relievo 
the bowels. 

I>elalield {Medical Rt-euitl, 1M9.% vol. i, p. 577) atates that this inom- 
ing diarrliLi'a Ik a connliiutional or neurotic eondltiou not (Iub lo local 
inrtamiiiatlnn or dispHsp, and diNcriU^s fi»-e viirietii's. neconliiig to tlic 
Bcverity of the symplonis, hut ienves one to infer thai theiit is no 
orgiuiic disease of the intcHtiiial Iract to account for them. 

With eiieh an opinion every close observer in rectnl diaease* will 
take most positive issue. True morning' diurrlia-a, such as he has dp- 
BcribL'd in his last four divisions, in piilhojiunninnic evidence of IocbI 
intlauunaliuu, stricturi-, ulcerntinn, or npoplnsni of the rectum. sig3iioid, 
or colou, Tliere is no condition that more positively deiniiuds tin 
early and thoroujrh examination i)r llie nrctuin and «i>nn<»id llesure 
than this Icndeney to gn to stnol immediately ufxm rising in the morn- 
ing, Pfi{)(^cially if that niiirnin^' stool ronsihts in mucus <tT purulent dis- 
charges. There are persons who have a normal eali to deffcatc 
soon as Ihey rise, or shorlly after riniiig, in thf morning; the passa 
are normal and there is no continuous call tliroti^huut the duv in sneli 
case:«. But these are an enlirely different class from those deseribed 
by the author mentioned and which are discussed here. The morning 
diarrha-n. which consists in the jmiwage of miiem; or jius, is due in 
olmost evei"y instance to uleeratire disitasc of the rectum or tiigmoid. 

Pain. — This is a very unreliable and indetuiilc symptom in ulcera- 
tion of the rectum. Certain individuals suffer greatly from it, whilo 
others have no pain at all. If the ulceration la high up in the rec- 
tum a sense of weight and aeliing in the ^cral region is the chief 
discomfort of which mosi patients complain. If it is situated lower 
down within the grasp of (he sphincter, and involves tho rnuco-cutane- 
ous ah-ii where the sensitive nerve-ends renter, pain of a sharp, laneinat- 
ing, or burning character will be the chief symptom. 

The amount of pain varies considernbty with the character of the 




1 




NON-SPECtKIC U'LCKEATIOKS 



273 



ulceration. Tiiticrcmlur ulcers are almost entirely free from it. Syphi- 
litic ulcere rarjr cdnf^iderablj in lliin regHrti; sometinits they are very 
sensitive, at othora the patient is almost abflolutely without any pain, 
but this depeniU upon the location. As a rule ulceration of the rectum 
proper is nol an aL-utely painful affeclion. 

Incorilinentt. — Itelaxatton i)f thp sphincter ia not an infroqiicnt 
symptom of ulceration of tho re(;tiim. Somctimpfi pattentR almoRt pn- 
ttrMy lose control over their f*c«l passages owing to this condition. It 
docs not occur, however, except where the disease haa existed for a 
lon^' time or ha*i been brought about either bj eerions const itutionnl 
diseases or vici^ui* ]iractice8. 

The syraptO'Qis elicited by aij^ht and touch vary with each particular 
clasa of ulcers. These variatiniin when witliin rcinh can he appwciateii 
by the eclurated touch, but tlie various iniitruiiipntal aiile for oi-iilar 
examination of the rectum enable lu at the present day to distinguish 
between the different iilccra much more clearly than before. Through 
the pneumatic proctoscope one can clearly see and diagnose ulcera- 
tions in the upper portions of the rectum and in the sigmoid; the 
character of the ulcers can be detennined mid the amount of contrac- 
tion in the ealiber of the gut can ho aeeui'ately mcii.'<ure(l without any 
tlanger of perrorntion. The Rppenrance of t>peciat ulcerations will l>u 
described under their proper liearlinga. 



SPECIAL ULCERATIONS 

Traumatio ITIoeratioD of the Beotum.— Thi^ form, termed also 
simple ulceration of the rectum, always onginutus in some injury to 
the parts. The ulcerative condition ie due to infei-iion of tho raw 
sorfaccs by Iho bacteria always prceent in the rectum. Thi^ dUtin- 
guifilws them from those uleeratioiis which are due to spcoiflc bacilli, 
such an luberculudia. lyplioid fever, dysentery, etc. 

L'iceratiouii following aurjiical operations, when in patients other- 
wise healthy, tend toward spoutaneous healing, but Ihcy may some- 
times be pmtrartcil on dccnunl of the irritation caused by the passage 
of hard f«eal masses and the imposaibility to keep them clean. 

The lower the scat of an ulcerntion in the rectum, providc-d the 
s|diinetpr in kept relaxed, the raoro rapidly will it heal, because the 
fa?cal material* do not rest ito persistently upon the parts and cleanli- 
aeis is rendered more possible. Thus in open operations for lismor- 
rhoids or fistulas the tendency is always for the lower portion of the 
wound to eieatriKe before the upper portion. Another thing which 
must always he taken into consideration with regard to these traumatic 
(Uccrs is the trophic eondilion of the parts. Wlicnever an nlceration 



S74 



THB ANUS. RECTITM. AND PEI,V!C COLON 



in tiie roctuiii dliow* a tendency to ehrunicily it is ovidface that the 
resisting jiowxT of the timues iM not siinieicnt to ovcTt-oim; tlie cunstimt 
infc^ctioii frum tin; intt-stiuul t-onti-nta. Thr uirculntion in filliur ini- 
[iprfert., Ilic iktvc supply ie iinpairt'il, or thi; t;t'Ui:riil ri^paratoiT pro- 
cesscs are below par. ConstUulional treatment, ^lKT^;fol■e, becomes u 
nutvswiry ri'jitiire in the iiiunftgoinerit of ihese eawe. 

C-haTaderislies. — The apiiearaneL' of sueh uk-ers is largely the fonse- 
(juence of tlie injury or wound in vi liit-h they uncinate. If these involve 
only the mucous iiiembi-Bnc ttie ulcers will he itiipcrficiiil iiud Bssuitie 
the form nf the oriniiial lesion. If. however, the openitioii or injury 
involves the deeper lissues of the ^ut wall they will then u.ssuriie the 
penetralinjr form, and, if not properly treated, may burrow into the 
pcriroetal lisi^iios and form an abi^oe^s or tUtula. When upon the an- 
terior wall of the gut they may even [wrforate the pentoiiaHim or 
the vagina. 

The edges of tlie ulcers are generally smooth, sloping, and iion- 
iiidnnited. 'Hie ba^es are composed of ^itll|)h' graimliitiuns. neither 
nodiiiur nor proliferiiting. bathed in a thick, niilky-wliilc secretion con- 
tfiitiiii}]: pus-eells, streptot-om, colon bacilli, and tt.c other ba<:teria 
usually present in the rcctiim. 

When the ulceration extends low down in the rectun^, involving 
the anal canal, il Jiiay o^^unie (he form of a tissiiro in ano. However, 
ulcerations resulliug from surgical operalions very rarely present the 
syrnjiloiiis of this conJiliun owing to the fact that the sphincter is gen- 
erally well stretehed as a preliniinflry step. 

Sf/rnpfitnif, — Tile Kyiiiptoiiis of Iruutimtic ulccsrs nre praetically de- 
scribeil in the foregoing paragraph on general smptoins. They pos- 
BCjy* no peculiunliee beyond that of chroiiieity, and fref|ucntly this 
tendency is only coniparalivp. Ulcerations following operations for 
hieiMorrhoids should not hv expected lo lieal under three lo four weeks, 
ajid ihey may require five or six. while those prodiiectl by operations 
far fistula and ittricture sometimes require three to six uiunths in which 
to heal. The conMitutionnl condition of the patient has tiniLJi to do 
with this. The fact that au operation or an accidental wound of the 
reetuni or nuns is bIow in healing should not lead one tn coneUido that 
it is tuberenlar, syphilitic, nr ninlignnnt without much stronger cvi—i 
dene*. Assuming the erect jjosturc too »oon, too little and improperj 
attention to dn'^ftinga and cletinlinefii. aniienda, |)o.ir circulation, andi 
feehle reparative powers may all bring about tardiness of healing in a 
perfectly healthy wound. 

Trtatmenl. — The treatment of this type of uleera consists in perfect 
drainage, aseptic cleanlinc*;!, regnlation of the bowels, and rest in tlie 
recumbent pot^ture. If the aphineter is nut relaxed it should be dilated. 



NON-SPECIFIC ULCERATIONS 



275 



Tlic parte shouW 1)0 irrijraU'd with autisi-ptic solutions two or three 
tini« a dfiy, and applications of astringent solutious, aucli as nitrate of 
alvev, iciithyol, or Pcnivian baisam sJioiiM be made. 

Powders, such as liovc lieon mentioned under specifier ulci'ral iunsi, will 
be useful after the diselmrge is practically contrulk'd. luduturiu is 
one of the beat in thi« condition. 

Catarrhal Ulceration.— In tlie ehupter upon catarrhiil (liseiises nf the 
rectum il. was sluled tluiL uleifi-utiou iiitiy n.sult fmiti any ntif of the 
three varieties — the oeiltc, hj-pertrophic, or atrophic caliurli. 

The uleeraliona that result from acute catarrhal inftjiniiniition of 
the intestine are due to excessive influuuiiatury processes, followo'l by 
necroi^is of tbo mucous membrane and consequent sloughing. THix 
ulceration is a superficial condition, aiid is gt^nerally quite exten- 
sile, involving? more ur U-«s of the entire Uuiug mi-mbranc of the 
rectum. The symptonut an- those of an aeulc infiammatory diM-asc, fol- 
lowed 1>y a frequent desire to defecate luid the paj^sago of bloofl iind pus. 
The mucous ineinbrane around the margin of Iho auua is generally 
inflamed, and tvdeniatoue, if it is not also involved in the ulcer- 
ative process, Tlic jmlicnt avitTers froiti aculc paing upon defecation, 
aching and dii^eoiiifurl iiL the ttaeral regiuu, and alwuyti h»A more or 
lesa temperature at dilTerent times of the day, especially in the 
fveniog. 

T^lccrutions from the hyimrtrophic fonn of catarrh are very rare. 
They ant more lilieiy to aseunio the follteulur type and be locali^ted in 
the (tolitarv fDlliclcs or lymphoid glands. They do not produce any 
marked Bubjei-tive syniptums, they mrely bleed, and diwcliarge a iliin 
aero-purulent material which ia not feculent but quite irritating to the 
muco-cutaiicouo inenihrune. 

The uleerulioii enuwed by atrophic aitarrli in gfaerally more of an 
ertmion than an ulceration. It cunaiste in u localized breaking down 
of the niuroufl membrane. The cdgc» arc not elevated or awollcn, but 
gradually decline to a shallow cratcr-likc boeo. They bleed easily upon 
touch, though not excciwtvely. They diaehargc a thick tenacious muco- 
pus which can be »:ccn adhering tu the ^pote u'hen exarninatiou is made 
by the Mpceuluiii (I'liile I, Fig, ti), This iiiuco-pus often ci»ntains Mnall 
bits of itwpiiwated fa'eal matter which gives the discharge a dark-brown- 
ish i-olor at times. Owing to the scarcity of the discharge diarrha-a is 
nut a frequent symptom in Ihiit form of ulceration. 

The minute description and treatment of these vanutics of ulcera- 
tions litL8 bei'n given in the chapter upon catarrhal di^ca-tea and need 
not Ite repeatod here. 

YaricOM TTlceration. — Under the above ton» many writen have con- 
fused two separate and distinct varieties of ulceration. RokitaD)>kr 



276 THE ANUS, BECTUM, AND PELVIC COIjON 

(kfaminl of Path. An»t., vol. ii, p. 107) described under iLo name of 
" hn'inorrlioidal uleere " a condition wliich Oibbs, KeUoy, Curling, and 
others have called varicoae ulcers of the rectum. It is nece;^sanr for the 
propLT understanding of this subject to clearlv distinguisli between an 
uIciTuliou due to u variiOKu condition of the rectal niueoiia mciubnuiv 
and those due to injury, strangulation, or slougking of hiemorrhoidal 
tumora. An utccralocl liirmorrhoid or an ulcer that occurs in n weil- 
dovolopod lia'iitorHioid is an entirely diPforent condition from those 
chronic, inlrBL'lable ulcers which occur in general varicosity of the rectal 
mucous luGinbrane. 

The laim-ntrd (Jihhs, whose tragic dcatli was the first fatality in our 
kte war with Hiitilu, has clearly drawn this distinction (New Yrjrk Med- 
ical .Journal, 1893, vol, ii, p. 93), Ball deseribts the Bume condition, 
but unfortunately adypts the noincneUturc of Rokitansky, who first 
likened it to chronic varicoge ulcers of the leg. Tliy conditions are 
uliiioi^l ideutieiil, but if one v\aiiiiite>s these uleers iii the reetutii he will 
find no hyiicriilanifl or tibrouM thickening ln-neath (hem, such as is seen 
in vuritoBe ulcers of Mie le^. They show no (tuitency to cicairize, as do 
the latter type, and bltrd tnueh more easily, uwing to the thin va!*ciilar 
wuHk of this area. 

Again, the so-called varicoee ulcers of the leg arc associated in the 
majority of ea»es with chronic syphilis; those in the reclnm are not. 
Tlieir elirouielty is undoubtedly due to varieosilics of the su|ierior 
ha.>inorrhoida1 veins. The original cteiting cause, however, is unques- 
tionably stmio wound or iiijuiy tu the mucous meinbrane, or rupture 
of one of the varicose veins. Infection tukes place after this and causes 
flic ukeralion. Whatever tends to produce varicosity of the rectal veins 
is a priidisposing cause to the condition. 

Cripps {oj} fit., p. 200). Qu^nu and Uartmann (op. fit., p. 413) state 
that these ulcers are peculiar to old nfiv. In the scries of cases described 
by Gibbs there was a number under the age of twenty years, and the 
majority of them occuri-ed in people between twenty and fifty years of 
age. The author has seen tliia character of ulceration in a patient as 
young as seventeen years, and in the large immbL-r of old peopk- in the 
New York .'Mnisliousi^ lie lias only seen thn-e of these uhx-rationj4 in 
patients above the age of sixty, whereas in his clinical and hospital 
Herviees he haa aeen a large number that occurred in patients between 
thirty and fifty years of age. 

Mode of life, environ menl, flud initritiun seem lo have very little 
influence in its production. Heavy eaters and drinker.^ who take little 
cxereifie and are inclined to constipation are prrdisptised to this type 
of ulceration, but it also occurs In abstemious, active, and aniemic indi- 
viduals. The etiological factors iu one ty[Je of cjises arc congestioD of 




NON-SPKCJPiC ULCERATIONS 



277 



liver and conFilipationi and in the other feeble cardiac action and 

rcluxcd kloo<i-vci«!<«l walls. 
Symptoms. — Tile ulwr;; uaually oociir well ttlmve tlie mueo-outsneoud 
lordtT. As a rule, Ihuy (nodvict' vi-ry lew sjuiptouis liL'sidt'S Ihu Jrcqueut 
lesire to dvtwate. This iiicliuHtton is alwajs more marked in Uie day-J 
iiiit', the jintk'tit ofloii jmssiiig the whole niglil witlicnit boiiig (]i<iturbed.-j 
hen: is always an iiK'lin»tiuii In ga to ^luui inimodLuti^ly upuii Tiding in 
e morning, which gicncrally rc^ultt; in tlic paesugc of small <)UHnti- 
ties of mucus and \ms, with or without h|i>dd. Occa^ionftlly tlieee pa-j 
tiente suffer from quite severe harniorrliagx'a. One or two caecs have' 
en repurtt-'d in which death was caused l>y this accident, but ordinarily 
ileedin;; in not a iimrkud L-liiiriietensti*,'. 

Pain, other thau a dull aubing in the buck, Mometimes shooting 
.own the Ictg or around the peirin, is geuL-rally aUHout, u^i might be 
pccted from the Imatiiiii of the iilffr iihovc the inuL-o-L-utunittuK bor- 
Icr. Occaeiunully wlh^n thi'j invade iht^ in uco-eutunuoiu tissue at lUc 
of the auu8 the patient euUcni from more or Um acute pain. 
n this condition ipasm of tho sphincter will also complicate tho 
ee ration. 
The ap|K>arancu of the ulcent upon ocular exauiinulion is that of a 
eliarply dffuu'd. irregular di-im'ssiun in the muwius inembraue of the 
]tY:tuni. The udgcs are slightly elevuted, and tlie Iwsl's covered with a 
dluwi»h pu«, beni'ath which there arc hright-rcil grBUiitttlioDs. The 
of the ret-tum surrounding the ul{^fraled portion, and, in poneral, 
over the n'otum.are varicoiie, and when the patient slraiiia llicy Iw*- 
CDiue largely dilated. Tho patient may or may not have wpjl-developcd 
hemorrhoidal linuorc. When sutli is tho cace the iiU'eration occurs at 
the side of or between two such uia»ses. Ordinarily these ulcerations are 
■nperficial. bul. as Gibhs states, tlicj Bometimes eventuate in great de- 
strtictiou of iiviucj even perforation of the bowel. 

One striking churaelenstic is their extreme chronicity, with little 
or ao tendency t« extend either in area or depth ; one case was Been in 
which the condition exii^ted for live or six y<*ars, Ihe ulcrr mniaining 
about the size of n t.wi>nty-flve-cent ()icec, and with absnlutely nt» min- 
iun of the caliber of the gut. 
Tenei»mu*i and griping are nnlinarily absent. 

The Limdittou of the bowefe will depend upon other drcumatances ; 
when tbey are soft and t^emitluid, bleeding and pain will be generally 
abflont; when tlu-y arc htird. lumpy, nnd irrcgidar, n Ismail amount of 
blood will appear with mid aflcr Ihe stooiK, and a dull aehiiig pain may 
folloT and In^t for an hour or two. 

Digiliil exaruinntion mveals nnthing inon? than a li-sion of the mu- 
iia inembmne. with ulightlj" elevated edges, and a soft clastic ba o. 



l«:tu 
■belloi 



Bbou 




i7S TOK ANDS, RBCTUM, AND PELVIC COLON 

Tii«rc is little if auy hyperplaeia or tliickuniug of the intestinal walls 
about or l>eiieat)i theet! ulcers. 

Treatm^!nt. — Tht- ta'atuieut of vurieoac ulcers of the rectum is 
very tedioUK hik) fre«[ucutlj uiiKBtisfuL'tury. It ia very diilicuSt tu get 
patients to niipreciate the iinpnrtiince nf a condition wbich gives thcia 
80 little real paiu or inconvonicucc. At the sanii.' time it is almost im- 
possible to heal tli^i^p conditions without abeoluto roitt in bed. They 
tni;iHt upon silting up, if they yield at all to the advice of couSneRieixt. 
They want to lie proppfd up in Iit?d, t-lothe theiMBtdvus, and loungo about 
the room in i-lmirs ur iLpi>ii eofas, or even want to ultvnd to bui^iuess a 
few hours each day. In chronic casts*, with gent'rttl varicosity of the 
rectum, fVfh lax rcgimrn will rarely Buccci-d, The piitii-nl i^iiuuld be 
confinml ali»idutt;ly Ju a rttiiniug pflsturc. lie may lie ujioji hJi^ «id<;, 
his back, or his stomach if ho wishes, but his bead should be OD n level 
Willi or as little elevttti'd above Wis hijus as pnsj^iblo. The nindern treat- 
irieiit itf varii'(it;o ulwr* of the k'g by tlif fk'vatron of the liiiili liii-. piwvt'd 
Iwyond a doiibt the Ijenefit of removing the pressure u( the blood eolunm 
in llicjif eiiiidilioiis. Ho also in the rectum, in ivliich this coUiinii is even 
inert- uiisiipporlt-d than in the k-jr. there Ijeiii;; uu valves in the veins, it 
18 neccBsary to relieve the part* of that mechanical clemeal of conges- 
tion in order to bring about the hcnlthy cireulatiAn and cfinsoqucnt res- 
toration of tissue which has been doitrrtvcd. I f tliiii were conH('ioiiliou.ily 
enforced, it is believed tliat the majority of canes of simple nnd varicose 
uk'cration would heal of llieir own nceord. Nevertheless something may 
be dwiie lowaid hiintening sueh a cure. 

The diet should be regulated so as to eontuin a» little refuse material 
m ]Pos»ibk'. An aliMdiite milk diet iH Eiot best for the^e patients, us it 
produees a hiicd, leathery stool, which, when passed through the rectum, 
tears and irritatoii the already inflamed nurfaoes. An albuminoid diet 
asiioeiu(i?d with a reasonnhle amount of fresh garden vegetables is moro 
aeeeptalde as well ss more efTeetual. A eertain ninnunt of inilk may \m 
allowed with this diet. &s it is noun.'ikiTig and produces no bad effects 
in comhinfttinn with tlie other food. Alcohol, and if possible tea and 
coffee, phould be avoided, also all such condiments as muetard, pepper, 
and the varioue sauces. 

The bowels Hhouhl be kept regular but not loose. After the 'bowels 
have moved, and at least twice n day, the rertum should \w. irrigated 
with a cleansing solution, cither of hichloride nf mercury (I to 10,000), 
borir aeid. or Thiersch's NoUitinn, the ordinary reelnl irripator Iwing 
used for this purpnsr. By this means no arruimilntinn of ll\iid will be 
left in the rectum to irrtlale the parts and cause a tendency to defecate. 

As local flpplicjitions in theHc ulcerations a variety ef substances are 
ireful. Most authors advit^e nitrate of silver in mild solutions. Ooca- 



NON-yPKC-'IFIO ULCERATIONS 



279 



sionnlly, where the ulcer is ^higgiiiti and the bage ie elougliui};, Ibt? ajipli- 
cation of this agent may be of beDeilt. My own yxperieiit-e, liowever, 
hna been tliat tincture of iodine or a 10>]>er-eeiit solutiou of urgonln 
acts better. The ineutTlation of a powder of iodoforin, aristol, or, bt-ttcr 
still, antinosia iipoa theSL- ulecmtious emuis to hasten thcrir healing, 
and also gives the patient the impression thot sonaethinjr is notually 
being done to heal the pnrts while he is resting in bed. This should be 
done onee or twice daily through n fenestrated or diiek-bil] ^pL'euluiii. 
If tlie pain is severe a suppoiiitory of iodoform, upium. and Li^lludouDa 
may be introduced two or three times a day lo rsdieve the same. As to 
giTiog any deliiiite quantities ut these dni^fs, it is imputisililL' to judge 
what will relieve one patient by any txperiL-uce with anotlu-r. Some 
arc very susceptible tu opium, otiiere to belladonna, and ellll others 
to iodoform, and the proportion must bo varied in each indindual 
ca«e. 

Injections nf starch-wnler or of l\nx(-eed tea eonlaining gniall quan- 
tities of the tincture of opium, or ointments containing femall (pianti- 
tiefl of cocaine, may he of benefit, especially if the ulcers are so low down 
in the rectum as to involve the eeiiMiry nen'es. In the majority uf ca8*!6, 
however, the ayniptonm will not indicate the use of analgesics. Four to 
ten wcekfl or mor* may he consumed in healing. 

Dnigs, such as liypnjihosphiti'pi. cod-liver oil, protonnolcin, and 
*onietinip« Koiiie assimihible fnmi of iron, should I»e used in cases asso- 
einted wiih nnn'min and general debility. ^Hiere sign.* of improvenient 
do not manife-'t themselves very Ronn, it U wise to eliminate all posHibil- 
ity of syphilis by beginning mercuric inunctions. 

Mai^sngc is useful in all patients continc^d to bed, and makes up in 
a nieaeure for the lack of exercise. Forced feeding, such sb i« cmpiuyed 
in neurasthenia, should bu avoided in these eases. The danger is in 
overeating biuI eongt'tliou of the pnrlal eireulation. Sullleient whole- 
some food should be nllowed, but the digestive organs should not be 
orertascd. Water may be allowed in abundance, especially if taken hot. 
and when there is any urica'mic tendency, citrate of lithia nirty be added 
to it. 

Esemorrhoidat TJlcert.^ — In distinction to the above variety there is 
the le«ion caused by sloughing anti ulceration of a wcll-d«lined hiemor- 
rhoidal mass. This may bo due to thrombosis followwl by noerosi«, trau- 
matism from the passage of hard faM?al masses or foreign bndic.", strangu- 
lation, or too rough handling of the tumor in cffnrts to rcducu it. It 
may alwi \ie produced by tin* application of ir-e in onler to relieve con- 
gestion, nnd by the action of corrosive substances applied to the surface 
or injected into the body of the hamorrhoid for the purpose of cur- 
ing il. 





280 TUE ANUS, EBCTL'M. AKU PELVIC COLON 

Such ulcerations arc entirely dietinct from the varicorc ulocratiotu 
which have just b«cn described. They are a&jocintcd with & localized 
inflammatory c-ouJitiou; tho Iiafmorrhoidal tumor itself is swolloii aud 
harti; the ulceraliou uaually wiDsists in a fwsure-Iikf L-raek or split 
through itii ceuter, or in a prutrudiu)* stujnji from which the ha>morr)io!d 
has slouphi'd away. Wlu-re il is due to th^omlKl^iIi, truuwutistn. or cor- 
rosive iiijectioni>, it gi'tiL-rally asHumcH tl«' tissurc-Uki- aiiju-aniuci.' in tlip 
body of the tumor. Where it ia due to necrosis following strangulation, 
the application of ice. or cauterization, tlie summit of tlie tumor will 
slough off and leave an ulcerating, teat-tike ~-tunip. These ulocri< do not 
poness the extreme chronicity of the varicose variety — in fact, they have 
a ti-ndpncy to licul spuntaiwously. 

Sfjmptoms. — Thi> symptoms of this %'aricty of ulceration are : First, a 
history of the eristecce of ha?morrhnid8 either internal or external, and 
of prolapse, strangulation, efforts at rcdiirtinn, the application of ice or 
cauterizing agents for the restoration or remotal of the tumors. After 
theae coDdttiona a fulne.stt, throbbing, and aching of the parte will 
have been esperiyticed by the patient. Sometimes he will have suf- 
fered frum a chill and elevation of tempcnilure. Theae symptoms will 
have been suddenly relieved by the discharge of pii8 or blcKtd. Then 
follows an int-lination to frequent ninvements of the bowels, which arc 
gcn<'rally inclfectual, and aii*sncint(;d with considerable pain. The 
dischargt? is Bcanty and composed of pus and blood. Serious hajmor^ 
rhagett eometimes occur; there is always more or Ies3 spasm of the 
sphincter, and the pain is more marked than in the varicose variety. 
Where the hremorrhoid is only partly destroyed it may prolapse, and 
being gra^;p|^Hl by the sjilnnctcr, cause acute sulTcring. 

Morning diiirrba'a may or may not be prpsent, but the patient is 
frt?<iufntly awakened at night by the spasmodic contraction of the 
sphincter and Ihi- dcsin- to defecate. If Ihe ha-mnrrlioid is of the ex- 
ternal or ntised variety the involvement of the muro-cutaneous border 
may take place, and when such is the case the symptoms of Sssuxe de- 
velop. 

Treatment. — The treatment of this form ia entirely different from 
that of varicoae ulceration. It ia absolutely and unequivoeally sui^i- 
ciil. The palitTit shnuld be etheriKed, the spliinc-ter tliuniughly dilated, 
and the ulcerated ha>mnrrhnidul mass taken away cither by eruiiliJng. 
the clamp and raiitery, or by ligation. 

The clamp-nnd-cnnter.' npenition by He stimulating effect and bfto- 
tericidfll action eoenis to be ai^ near a specific as one can doeire. Wh«n 
tho ulcerated litem orHioid ie cleft in two by a deep furrow, each lateral 
promint'Uee slioiild be clatiiped separately and Ilie u)ct>ruting sulcus be- 
tween them cauterized with a tiariow-pointed Tuquelin blade, but il. 



i 
I 



L 




NON-SPKL'IFIC ULCERATIONS 



281 



the fiirroff does not ilip down llov\^, the whole mass may be includntl in 
the clamp and removed. 

The after-treatim-nl of such fasL-s is identical with that for ordi- 
nary hfenioirhoidal operations, with this fxceptiou; thai morp prolonged 
rest ID bt'd, aiiLi^i^'plit.- wiislii-s, mid n-ntric-ted di<'t will be necessary to 
obtain perfect results. 

Follicular Dloeration of the Bectmn. — Follicular ulceration la&y oc- 
cur at any portion; of the largo inlosliiu<. lis most froqucnt aitc ia in 
the descendin/r toloo, ^ipnioid, anil recLum. It has its origin in the 
acciimulatioa of siiiiLll rouiul l-hIIh in Kolilary follicles. This aeciimiila- 
tion causes a swi'lUiig of IhL- follii^li! followeil l>y pressure on the epi- 
thelial covering, whith llnally givL-s way. The follicle disintegrates, and 
au ulcer rc^ulta liavinj,' Kharply put edgrB, slightly undennined, and vary- 
ing in doplh (Plate J, Fig. 5). They vary in size from that of a small 
bin!-ghot to a sinnll hflz»?lniit. They may be aingte or multiple, the 
whole miicoue mem- 
brane being gtudded 
with them: Ihey are 
more frequent uhore 
tbo rci-to-tii^tnoidal 
juncture than bolow 
it; they do not oftt^n 
coalesce, but occasion- 
ally the mueons mem- 
brane between two niay 
break down, and thus 
form an irregular ulcer. 
White stalea that all the pationta in whom this haa been fonn<l post 
mortem have died from other cauacs, auch aa dysentery, typhoid fevur, 
tiiljcrcnkwiH, ennt'er. or menihranous colitis. He statai further that the 
diseflM^ oecure about once in 'lOO post-morten examinations at Gut's 
Hospital, and yet with this important percentage he says that it is ne^-er 
diagnosed during life. This latter opinion is nol in accordance with 
Uiat of other observers. The author lias certiiinly seen the condition 
in the rectum and sigmoid flexure of living subjects a number of tiniM. 
In the majority of cases catarrhal disease preccfles its development. That 
perfonition may occur from this fonn of uleeratiou ia exemplified in Fig, 
IW, illustrating the cavity of such an ulcer filled with fieces. It will be 
seen that only the perilonieum itself separates it from the nlMlominal 
eavilr. In this cnse numerous follicular ulcerations of the sigmoid had 
involred and almost perforated the intestinal wall. Healing occurs clow- 
ly, but is not accompanied by the development of any marked cicatrieial 
<]epu0it. Ball (W. lit., p. 119) states that this condition nuy result 



Fio. 100.— JupAcniD ¥mou w Cavitv or a Foi-umhii 



)|MU 



THK ANl'.S. KKCTUM. AND PELVIC COLON 



F 



in Hl4'no«ii of the bowol, but the writpr has nevtr Bvea a case of this 

kind. 

Symptomx. — Thp Hymptoms of this form of uWration are vciy 
iiiftijii-r In llw ri-i-tuin itnulf the pntient esperienrca no piijn ami ao 
uniNixint'M. There is some imlicfttion of inlt'stinal indigc'^tion associ- 
■tnti with iikon> or \k»» gTipin^ and tencdmue, but without any ivttl dlar- 
rhu-B. 

'llio (ioti<*n of the WwtfU may be perfectly iiormal «o far as 
tlltf wiiislitm-ncy of Ihe nous is conceme^l, liit tlic piiiitint will com- 
jilNiii of niopp or loss acute griping pains throughout the day imd 

lUmluirmT lian dworibwl liltk- iiiBP»es of inspissated mucus, looking 
iioilit'lhlHH like frxvtrV *piiwn »r loik'd sago, as having boen dij^chnrged 
front ihr l-'wels of |mti<'nt» differing with this eondition. The little 
lltDMi^ ar»» itnivt to l>o nu»n» or less of the nature of follicles, but Vir- 
(■hi>« hHf flii'wn ll»'"> 'o ^^' paftii'les of undigestt^d stareh. and (liure- 
foh' M (* doulitfnl if (hey have any real reliitionship lo follieuiar uk'cr- 
Ittttm III Iho wii'It »tagc«. before ulceration Uika-s pUee. one nwy occa- 
Mtonallv ftvl litltr niilU't<eeed-like foriiiatiDn» bcacath the mucous niuni- 
tiHiito, or clevaliima upon its surface, but it requires a delicate touch to 
dii IhU. Examination with the speeiiUim, whii^h is the only positive 
imiHilk iif diiignodin, phows iu thi» stage very slight elevations, ovor wluch 
Ihi* «»<mhnint' ajijiears smooth and shining. 

Tho en»»oa of this variety of uleeration are praetitally unknown, but 
liiiiniiinvh iif it iilwaya otvurs in connection with some otht-r intkniiiiatory 
ttiri'i'hiiu of Ihe n'L'tiiui, it fieems rational to regard it as an iufectiyn of 
l\w follicjfn by the discharge from these diseases. 

Trfotm^'nl. — ^L'hc trualnit^nt oun»>iHtti in attnrking the cnuxativc dis- 
tiMKf and ai>plying loeal remedies to the ulcers so far na they can bo 
pnu'lit'd. In the case illtislnitccl the patient wtis suffering froTn atropine 
diliirrh iif the rrrtum and sigmoid. The treatment consisted in that 
ih'liiiled in the chapter upon this disease, and the four or five ulcers 
which (uuld l>c reached were treated l»y wiping tlicin out with phiuU 
pledgets of cotton and insufflating antinosin upon the ulcerated spots. 
The patient recovered in about six weeks, and has not been troubled 
iritfi the foiulition sinee. 

Strictnral Ulceration. — Crippa (lacdL, p. 204) dwcrilies in detail 
n condition of ulceration which he states Is due to retained discharges 
fniiri a rccliil stricture, lie says: " It appears as if the superficial part 
of the mucous membrane is only uk-cratcd, the submucous tissue still 
forming a distinct membrane over the muscular coat, so that the bowel, 
instead of posaessing a soft, velvety lining, moving freely on the sub- 
jaeent muscular fibers, has a surface which, though smooth, girea a 



5 



NON-SPECIFIC ULCERATIONS 



t!83 



■ 




hursli cn-aky Bciisalioii to tlic finjiL-r, Jiiid is 3ntimiit(.'ly bli'ndt^d wilh 
tlw imiNcuitir cout, Thiit vxtcnaivc suiJLTficiH) ulc»;ration iiiny gmdunlly 
spread boyond tlio rectum to the color. At a poi^t-morlcm esnriijnation 
tlie iik-LTfltioii iri found to end very abruptly. Sn siinrp is (lie- line of 
deniuK'utiun lu-tweeii tho ulecratioQ and the Doriiml inembraiie tiiat it 
luoks U6 if cut wilti a kuifo.'' The casein of lhi« variety of uleer have all 
been afliicted with cieatricial stricture o( the rectum. 

The author lias seen a number of sueb cases with su|»er{icial ulcera- 
tion of the mucous rueinlrnne above tlic fitt- of llic strjeturi', but he is 
not tiuxivincfd of the patboloKj whicli L'ripps indicate* — vis., that liic 
destruction of the mucous nicnibntnc results from contact with purulent 
secretion. Nccroiiii; of epilheliTini or ulceratioii muit cxint iK-fore puru- 
lent accretion is oitnblislied. It appeiirn iiinre ratioiinl, ibL-n-fore, to 
attribute these ulcers to the irritation, traiiniatitiin. and infection pro- 
duced by forcing the fivcal mass through tlie narrowed channel or their 
retention above the stricture. 

Strictures of the rectum aru very liable to b« associated with consti- 
tutional condition!?, such as tul>crculosid. syphilis, carcinoma, or exltauat- 
ing diHeaiie, which rnnditions a\»n produce iiiflniiinialion And ulwration 
of the mucouB membrnne of the rectum nnd sigmoid. Morpover. where 
the piiticnt is* dchililali'd fr^m iiiipmjxT feeding, irrepiilnr move men t" 
of the bowels, ami rcilex dit-turbanccs of the digestion, (he nnicous 
membrane nf tlie intestine is very likely to take on a feeble circulation 
aMocinleil with a, cellular depoi»it in its gliimtnlar nrpans. which aivu- 
malatea until by its pressure it causes a necrosis and subsequent ul- 
ceration of the tisfiuea. The fact that in the case which Dr. Cripps 
quotPK tile strietun? whh cui and the nlwlriidinii iind rptentinu nf the 
diKchar>;e relieved, and yet the ulecration progressed until it involved 
the whole of the bowel up to the aplenie flexure, proves that there was 
some other etiolojcira! factor to Hcrounl for it. 

Si/mptom-'i. — The sym|»tonia of ulceration such a c this are pmctically 
thoee of stricture. There is ft frequent desire to defecate, and yet ina- 
bility to accomplish Hie Hame; only when the bnwcU arc fluid ean tlio 
(Militint BUceeed in having a satisfactory fitcal nioveiueut. When tlds 
has heea accomplished, his desire to defecate is usually relieved for 
twelve 1(1 foiirteirn hours, after which the inclination recurs ami fre* 
qiicnl small passages of pus or nmcus and blood tukt- place, 

Diarrhcra alternating with (mni<tipution, inability to pa»a well- 
formed fo-ces, t^-rapanitcfl, and the accumulation of fa'cal materinU in 
the intestinal canal are all symptoms of this variety of ulceration, as 
they arc of gtriotnre of the rectum. Tho discharge of pus and blood 
1J10W8 the presenee of ulceration. Tlie pathnlopy and treatment of these 
olcers will be found in the chapter on Stricture. 



Dysenteric Ulceration. — Tbia disease bus Wen tliscussed in h previ- 
OUB clin]itpr, l)ut it is necessary to snj tomt'tliiiig nmre conirming the 
chronic ulcers which follow it. 

Dysentery, while it may, and often does, involve the whole of tlie 
large inteiiline, has its seat most frequently in the sigmoid flexure aod 
recluiii. It IK in these lower portions of llie iiliiiientary caim! thai its 
chroiiir! n*sults oecur. This in logical from the fact that alt of the de- 
trttuH and infectious bacteria wbitJi an; discharged or carried down- 
ward by the iieristaHic action of the giit nhovc must pas? through and 
lodge for greater nr less (Kriods in I hesy lower si-gnietits of the gut. As 
a result, therefore, of aciite, sporadic, or epidemic JyecDtery one may 
BOiiieliineH nee a chronit' ciri'umstriU'd ulcer of thi.- rectum or sigmoid 
with the lypii-al syniploms of dianliuia, pnx, blood, and miiicus in tlie 
ttooU. These symptoms aa«mpun^' all foniis of a-clal iiltvration from 
whatever cause they arise, and render it ditlicult In disHngiiisb a true 
dyrtcntiTic ulceration from other varieties. Indeed, ulccnition of tlm 
rc<:tum and sigmoid arc often mistaken for and called ehronic ilysenlcry. 

The presence of the flnitebip dyflentcriiB or the bacillus of Shiga will 
positively establish the dysenteric nature of any gjvoii ulcer. As Kelsey 
states, there is no donbt that tlio disease in one uf the eausoit of ehronic 
iLkenilion and stricture. It begins in iiii iuliltrulion of the uiueouB 
ineiiibniiie with a fibrous exudation. This iufiltrution increases until 
it intcrfea-s with the blood »up|)ly of the mucous Hiemlrnne, the latter 
Bloughs, is cast off, and an ukcratton results. If this Mloiigh is supcr- 
jicial, the moiubrunc may \k soon restored to its nonual condition, but 
if the infiltrotion Iw dpop and involve the submucous tissue*, the loss 
of substance will bo more or loss oxtensivo, and eieatrjzntion and stricttiro 
Diay result. 

The ulcers may be small an(J localized, or they may extend over large 
areas, and sometimes entirely surround the eanal; tliey may be Irougli- 
like. stellate, or irregnlar in shape (Pig. SG); tliuy may be single or 
multiple. Perforatiun haa beeu known to uccnr, but it is not a frequent 
accident. 

Httbershon snys " the coats of the bowels may become sinuous ab- 
scessos," 80 that on dividing prominent portions of tlic nmcous mem- 
brane lietween two Kleors several drani:^ of pus may escape, 

Woodwnrd. in his Surgical History of tlie War of the Hebellion, states 
that there has been no case reported during or since tlie war of intestinal 
orreclat slriclure hnviiig followed dysenteric ulceration. Tliis is only s 
n^ative statement, however. 

Kebey (New York Medical Jonmnl, J891, toI. i, p. 733) reported n 
ense of n Btrorg, healthy mnn, who bad bnd dy«cutery niie yeiir Iwfore, 
and lud never recovered. Ue had lost 30 pounds; stifTercd from pain 



1 
I 



I 



NON-SPECIFIC ULCERATIONS 



m 



at the i?nd of llie spine, which va.* cuntinuuus during llie day, but nuL 
flo at night- Hl- liad six or eighl stools c!uriii>; the day, but at night he 
was not annoyed. The stools were foiil-smcllins;, eiiiititintrd bhxHl 
and iiiiicu!^, and were nii«i«lm[»t:;n. Jt si-tinj! pLTlcL-tly elt-ur from the 
history that the intostinnl irritation ori^nnatcd in the dysenteric attack, 
and thai thn enndHiim hml onntiniiod from that attaek t« tlit- time of the 
examination. Fjoe-al tivHtment having failed, Kulsey at oiicb purformed 
a left ingninn] colotomy, and exploring the sigmoid flexure while the 
abdominal "all was open, positively dettTtnincd an influtiinmtory stric- 
ture of the lower segment of ihie or^an. wliit-ii he slates Wl- bciliuved to 
have been due to dysenteric uleeration. The fad that all who have f\xn 
a number of cac>os of dysentery have also obsen-ed by rectal examination 
tho erosion, infhimiiiation, and even iileorntion which neeiir during the 
eourse of the dinensn', renders it imi)o««iblo to believe otherwise than that 
dysentery may regidt in chronic, extenBive ulceration with fibrous and 
cieatrieiiil deposit, which ends in stricture. 

Carcinomatous Ulceration. — The symptoms of ulceration of the rec- 
tum are so similar to tlio^e of carcinoma that il is sometinied very diffi* 
cult to determine between the two conditions. Absence of pain, morn- 
ing diarrhtcn, diseharpes of miiruii, blood, and piia are common to the 
two ennditions, and in any jrivpn eiiRP snffpring from such «yni|»t(tms iHe 
poKsihilily of ninUgnant neoplnsm i^hoiitd always bi> borne in mind. 

The fart thai rarrinnnin exist* in the intestinal wall.'*, and through 
its prrssure iind interfrrenre with the rirriilntion of thi- parts rauses a 
breaking down and shiugliing of the mucous meaihranc over thin neo- 
plasm, doea not prove that the ulcer itself is of a carcinomatous uature. 
Indeed, it may bo a simjile ukvr imptwed ujion or brought about by the 
neoplasm. The trealineiiL of the ulcer iu disliiitlioo to tliat uf the 
carcinoma may be soirietimes uf greut relief la the patient by reducing 
ihe aniennit of the di^iL-harye, thus obviating too frequent and exhaust- 
ing diarrliira, ami kci-ping the intestinal caliber sutliciuutly open to 
ndmit of fircal pasKagus. The subject is mentioned here ns a type of 
ulceration siniiily to impress upon the reader the necessity of constantly 
keeping in view the possibility of an uk-cnitivc condition bcinj; due to 
malignant neoplasm. 

TTIeeration from Bright'* Disease. — As mentioned several timos iM-frire 
in the c(jur(»e of this work, wi- fr^juuntly notice tn autop-'^ic^, where death 
has resulted From chronic Bright'^ disease, widespread ulceration of the 
rciTtum and large iutentine. Dickinson {Croonian lectures for 18?6) 
(inst called attention to this fact. The ulceration is always very ex- 
tensive but superficial, invftlvinfi only the mucous membrane o1 the 
gut. It o<Tur* in thi> Jnter stages of thi* disease, and until within the 
past few years has been rarely recognized during life. There in no 




S&Q THE ASDS, RECTUM, AND PELVIC COLON 

icndencj to perfiiration of the ^ut or any thickening or imiuration of 
its waits. The condition gcems to be clue to Rinfloid or Inrdacpoiui dc* 
generation of the nuicniiji inenihrHno and its glanilnlar orgBn*. 

SifmittQina:. — A-side from tlie geuL-ral coniititiitional and local mani- 
festations of ttie nephritic condition, &uch as uMleina, ana^anti. enfev- 
bl«d hL-art action, dubility. and t-udiitcd uriiiitry «t:i^r(.-tion», eyniptoiii^ of 
indiguslion, a. tnudoney to diarrha'u, and Kruat llatulency mark tins com- 
plication of Brif;lit'» disease. Th« patient suffers little if nny pain in 
the rectnTii. Ijiit nfter a period of c^omparntivc eonstipation. he firadnaily 
hegin» to notici' a lootionoHs of tlu- bowel*, wiili expensive Huitl di«ehnrge#. 
At firet these disciiarge* are watery, bwt later they become milky white 
And pURilent, and contain many sbreda of degenerated or sloughing 
lispiie. 

Examination of the rectum shows the whole OTgun to be denuded of 
its lining iiwmhrane. The sloughing or nleeration is not in patches. Ijiit 
upjiL'atv! US a getioriil tli^integrntion t>f the niueons menit)mne. While 
there are no marked hipmorrhngoK, the gramilatioTis bleed easily though 
not esrpKRivply upon touch. The griping and tenesmus are not marked, 
but the patient soon loses sphincteric control. The fluid passage.* run 
away from liim involuntarily, and his condition is pitiahlc indeed. Hap- 
pily this is one of the latest etageB of the kidney affection, and is in- 
dicative of an early termination. In one case which the author eaw 
souie yearn ago, the patient hud no idea that she wan .suffering from 
anything morn than iimemiii when she mnsulted him for an uncon- 
troliahlf dtfwire to defecate; she was having at the time some six or seven 
stoolH a day, which did not annoy her so much as the fact that when the 
desire occurn?d it was Impo.tsihle to enntrni the same or to wait a 
moment. K.saniinalion of the urine showed a large percentage of nlbii- 
miu with abundant granular and epithelial cacits. The mucous mem- 
bniiiG was denuded over the first four or five inches of the a'ctum, and 
Illy diiiuharges from the iiiteHtiue (.■uiisisited of lljin fieea! material and 
large quantities of puit. Occasionally a little blood was mixed with theso 
discharges, ulthougli tins was not frecjucntly the case. No local or cnn- 
Btiluliorml treatment avaihnl to rontnd the eymptoms, and the patient 
died, at the cud of four weeks, from urasmic poisoning. 

Treatment. — The treatment of this condition is hopelen*, but some- 
thing ran be done to relievo the fiiiffering. The rectum and sigmoid 
ehould bo washed out with saline or boric-acid solution twice daily, and 
after this has eome away. 2 lo 4 ounces of 25- to oO-per-eent riohilion 
of aqueous fluid extract of knuneria should Iw introduced into the sig- 
moid. A few minims of deodorized tincture of opium may be added to 
<iaiet peri?lulsi^ and control the diurrliu-a. The dii't should be bland 
And concentrated, such as milk uud incut extracts. Occasional Miliiie 




NON-SPECIPIU ULCEHATICNS 



287 



I 



purgeH to relieve the kidneys of loo much work will An no ham. liut, 
as » rule, it is better Li> ilci Ihi5 tiy keeping tlie f^kin active. Medication 
should Iw dirccti^d to the kiiliiev cunditlon. Tannic add, tauoigen, and 
such remedies ehoald be nvoiJod, but small doses of sulphate of copper 
or nitrate of silvtr are admissible, and Bonietitnes they cantrol the diap- 
rho'ii niiKirkjiljly ui'll. 

Diabetic IHceration. — During Ihe course of diabetic ylyoosuria cnn- 
!'tii>iilioii (lEleD cumL-s on in ccmBetiucncc of the iitnnic «tate of the Imw- 
fU, tlclic-ient t;scri!hf, mid tin- witlidrawal of cHrbnhy<lni1e foodii. Oo 
casionally, after tlii.s condition hat^ exiiiU'd for ^o^le time, llatuteace will 
be markedly developed, and some-times excessive perietaleijs and the tor- 
mimt renti/m of Kussumul iire etn^ily arnuied; with these conditions 
there appears a serous diarrliuea assoeiated with a discharge of pua 
and bloot], no Katisfaetory explanation of which has yet been piven. 
Clinicians iirc all nwurv of ilir tcndeiicy in diul«'tii-s to ukfralion and 
ganpru-nc of the lowur (;xtrL'mtlie» and of Ihc skin, es|icfinlly wlicru 
any prfsi<iire is exercised upon Ihr parts. I-'rerirhs, Ferraro, Kleen. and 
others hiive reported uWration of iho irtcstinnl c-anni iu patients who 
died from thi* di^eai^e. No one, however, bus established any etiological 
relation between the two conditions. 

Ii ocvurrcd to the autlior ttfuiie years ago that pressHre from tlio 
hardi'ned fa.>i-nl ma»Dc« during the constipated period of thi! disease 
ml^bt aUo cnuMO ulceration in the rectum and sigmoid. The examina- 
tion of three cancis which developed diftrrlia-a during the eoiir:*e of dia- 
betic >;lycosuria has enabled hiiu to verify tliia theory, in one the 
ulceration was limited to the rectal ampulla, a\ii\ extended over a space 
about ihe «ize of n silver linlf-ilnllnr; it wns isnlated and invnivert the 
mucous and submucous tissue; ibe edges were dn,-, and the base feebly 
granulating. Id the other two case* the uleerationii were numerous 
and extensive tlimuKhout the rectum and sigmoid flexure. Strange to 
eay, ju:^t about the time that these owiirred. or shortly thereafter, the 
excretion of sugar almost entirely ceased. In one of thei^e cases the 
ulcerations healed, but tlie diabetes recurred, and she succumbed Inter 
to thi«t diKeflM> with recurrence of the n>ctal coin plication. In the other 
two caacft the diulH'tes Imn not recurred, and (he patients have recov- 
ered from the uleeralive condition and remain apparently well. )n nil 
three c»»e» there was a history of marked constipation preceding the 
diarrhoea. 

In the two cfiscs with extensive uleerfltfon? the stools varied from 

eiilh! to twelve a day. They were composed of (juantitio^ of pus tinned 

with blood, and did not potwcfw any particularly feculent odnr. Once or 

twi«? durinf! the day they would pas.*, more or les* bartl, lumpy, faval 

material. In one the muco-cutaueoua margin was involved, oceawioning 
» 



I 



S68 THE ANDS, RECTUM. AND PELVIC COLON 

80 much pain that it woe neceNKan' to dilate the sphincter in order to 
give the patient tiny rest This patient also suiTered from bedsores, 
owiog to Ijiufi in the recumbent posture. 

Largf ilosei. uf ccideine Hs«d to control the glycosuria seemed to have 
no effect u[)oii the diarrhcea. Frcqueat irrigation, however, with a 'iO- 
per-eent oohillon of oquenuH fluid extract of krameria, together with 
iehthjol internally, succeeded in I'unlrnlling the cuuditiou, and restored 
the patient to health after about twelve weeks' treatment. Tliere is do 
distinct literature upon this subject, nor is it pfissible to base any very 
positive conclusions upon these limited ob««ni-ntii>n.<«, Init the condition 
is noted here aa it has been observed, and a u'ider experience, it is hoped, 
wiJl deterniine its true patholojry. 

Hepatic Uloeraticn. — Ulceration of tlie rectum not infrequently oc- 
curs in cases of chronic cirrhosis of the liver. There iu no spt^cific influ- 
ence in the hepatic diM>n.'i(^ to produce this result. The obstruction to 
the portal circulation caiiseit congetition and dilatation in the supe- 
rior bjemorrhoidal veing, and frequent hwrnorrhages from theae re- 
Bult. The infection of the rupture in the vein causes the ulceration. 
These generally aissume the form of ulcerated luemorrhoids. They 
occur upon the summit of the ha>morrhoidal mass, and not between 
them. 

'rreatment. — The treatment of this condition consists principally 
in attacking the disease of the liver. One may be tempted to operate 
upon the liffmorrhoida! condition, and thns remove ibe ulceration and 
check the hteniorrhages. This. hi>wevcr, is not ordinarily a wise pro- 
cedure. As stated in the chapter upon Hspniorrhoids, the checking of 
these periodic losses of blood is likely ti> be followed by acute anasarca 
and rapid aggravation of the hepatic disease. 

The btiwels should be kept freely open and the rectum irrigated 
daily witli iinliiseptic solutions. If there is a tendency for the hemor- 
rhoids to Wt'ome strjtngulaled by Kpasni of the sphincter, this muscle 
may be stretched. Beyond this, operutire interference is likely to do 
more hiinn than pood. 

Trophic Ulceration. — In the chugiter upon Colitis we have already 
called attention to the trophic ulceratione of the large intce^tine, and 
have reforred to thorn as occurring alao in the rectum and sigmoid flex- 
ure. Ackland and Tnrgott both cUiinM tliut ulceration of the lur^« 
intestine may be due to diseases of the central nervous system, and 
report cascf» which seem to confirin their opinion, '\\niitc has reported 
two cases occurring in Ouv'k HoB|)itii! whuh seem to corrulioratt- this 
view. 

Cowan and Eurich state that the gcnerol lowered vitality of 1h« 
insane rcndcr« ihcm an easy prey to all sorts of di«ea«e, and that tho 



L 




NON-SPECIFIC OU-BRATIUNS 



2S9 



Ofwen of iilwralinn of the rectum and colon in this class of pntients 
is more likel}' ihie to smuv other caime, such aw tmuniatisni and inT^c- 
tion, than to trophic nourosc-a. 

UlceratitiiiH of th« rcirtum occnrring in spinBl disease and neuras- 
thenia have been referred to. but tliere is no reason to suppose that they 
did not result frnni the usual aiuj^us. On the whole, while there are some 
evidences in favor uf ihis Ivpe uf uU-iTation, there are no eharatteristic 
sj-mptoms or positive jjruofs that it ac-tuall,v exists. 

It niaj be worth while to mi-ution in this connection two oaBW of 
uln-ratiim of the rLituni and sigmoid following injuries to the spinal 
cord, with iMiraplcgia and tonipcirflrv Iniis of sphini^teric control. In 
both of thcfJe cajies the paralytic syiiipt'>iiii' difappeart^I, but there was 
a. marked Jecrt-aee in sensibiUty atwiit the anus. In one there were 
numorous ulwrativ<> patches throughout the rectum and in the lower 
portion of the sigmoid flesuro. There was do tuberculosis or syphilis 
in eitbvr ca^e to at'couut for the condition. Without Wing able to dis- 
cover any other cause, it is thought poiwiblu tliat these might be cbmjs 
of trophic iiIciTiLlioii due to injury uf the cord. 

Hanamio lTlo«r*tioil. — Some ycare ago it wae the privilege of the 
ftuthi^r to innko oulopsio^ oil n number of children who had died from 
the condition known m marasmus. The njjcs extended from two 
months to three and a half vears. A number of lh(!se caset; turned 
out to be tuberculous, the mesenteric glands lx*ing enlarged and con- 
taining tuherL'le Imcilli, In others there were gummatous develup- 
moutjf in ditferent portionn of the body which indicated syphilitic dift- 
«ase. In 5 ca»e«, liowi'ver. there wa« no evidence of either of theev 
specific affcttioDs. The children seemed to waste away and die simply 
from mula»^iinilfltion and exhauiilion. 

An examination of ihe intestines in these eases showed in 3 of 
them extensive ulceration of the rectum, sigmoid, and colon. In one 
CMe the ulcers estonjed well into the ileum. The condition resembled 
rery mucli that sceu in the Intc atages of Bright'a disease. There were 
left here and there [»iitelies of mucous membrane, but these were always 
covered with a sort of flaky deposit rc^emblin}; very much the beginaiof; 
of diphtheritic menibranee, Microscopic examination, however, failed 
to reveal any spei'ifit' bacilli in them. Tlie walls of the jjiit were not 
itillltrated or tliiekened. and there was no approach to jwrforation in 
any of the eases. Two of these eases were being treated for nummer 
diarrhifa ut the time of their death. Tlic stools, howeTer, differed 
from the ordinary flncfulent. green ones of this disease, in that they 
contained conwdenible quantities of pus tinned with blood and very 
Uttte mucu*. 'Hie vxplanaliuo of this latter fact lies in the destruction 
of tlie epithelial layer of the mucous incnibrane and the consequent 




290 THE ANDS, BECTUM, AND PELVIC COLON 

absence of goblet-cells. In all of the cases there was a history of 
gradual wasting disease before the diarrhoea began. 

The stools at first had contained considerable mucus with blood, 
but they had gradually become thinner, containing more pus than 
mucus, until in the later stages they were almost entirely composed 
of pus and undigested milk. The condition is undoubtedly the result 
of impaired circulation, probably accompanied by thromboses of the 
intestinal veins. 

The sjTnptoms are those of a gradually increasing diarrhcea occur- 
ring in marasmic children. There is little pain or griping, and the 
stools gradually change from the green, mucous type to pus, serum, 
and undigested food. 

It is impossible to lay down any definite lines of treatment, aa 
every method failed in the cases seen. Reasoning from the condition 
observed, however, one would suppose that some relief might be ob- 
tained by flushing the colon freely with saline solutions. This would 
have to be done with the child in the knee-chest posture and through a 
long rectal tube, inasmuch as the sphincters are always so relaxed that 
the fluid would flow out immediately if injected into the rectal ampulla. 
The general treatment of the constitutional condition will, however, do 
more for the patient than any local applications. For this, however, 
the reader must be referred to works upon diseases of children. 




CHAPTEH IX 
FISSVKE jy Ayo-JUniTADLE ULCSS— INTOLERABLE ULCER 

The terni« which liva<l tliis clmptcr Imvc been used by various 
irriU'rs to Ucscribo u t.vfJi; cf uiml uUir ilmractcri2f<l liv ttculc |>ain 
daring or nfter ftool. 6o8«cIin first distinguished between the aeutcly 
Kennltivo Ifsidns nt tliis point nni5 Ihoso which were letw so, catling 
th4>iii tolerant ami intolerant ulcfrs, Allinglmni desipiates the sensi- 
tire type m "irritablB ulcer." MoUi^re siigge^ted the better terms 
tolerable and intolerable, holding properly that all ulcerations of this 
region occasioned sonii! pain. The wurd fipsure rtijrnifies a crack or 
«loDgftted break in the tJMnos. It may occur anywhere in the body, 
but in ccimnion pnrlnnce it is npplicfi pencrally to tlip lopion in the 
anug. It iii nn iiU-L>r, Init ilistinct from thorit' destnicltvc nii'i e.cteniiive 
types which have been described in the previoii» chapters. Technieally 
it id limitii'd tn the sulci between the nidial fold*: it upresdn up and 
down hut not circularly, tloes not involve the tegument covering the 
folds and cnhinma of Morgagni, and is painful at or after stool or npon 
the cueape ot gases from the anus. 

It occurs in all agc^ and conditions of life, but is more frequent 
in the young than in the very old. In infanln the diiiease ia very likely 
to U' the result nf fiereditury svpliilis. but this is not nnres-iarily the* 
CMC. It IB chiefly fmiiid in lulult life and in women, eBpeeially during 
the child-bearing period. 

Sex does not wcem to influence It materially. Mlingham aiiys it 
ia more frftjuent in women, and Uoodsall. mirking in the same hoeipiial, 
finda it oftener in men; in 32n cufct of li^aure he found it 190 tiniea 
in men and 130 in women. In 324 cason collected by the author from 
dilTerent >oun'ew it ticciirr*-*! Kii ijmes in women and 1 IS times jn men. 

It may bo single or multiple, but the typical painful fissure is 
nearly always ninple. The multiple variety i* rarp except in atrophic 
catarrh, gonorrhoea, and syphili!*, In these conditions nndtiple fiiwurc- 
like ulcerations are comparatively frequent. GoodsnII found in 221 casee 
thai fsaurea were single in SOB; there were 2 l)r«»urea in 12 caaes, nnd 3 
in only 1. 

Mil 





S98 



THE AXtJS. UtX^rUM. AND PELVIC COLON 



Shape of Ulara. — Much importnnce has boon itwchpd by in-itere 
upoD thin subject to the Bkape of the lesions. Most authors attempt 
to confine the term to those linear or elliptical ultvre which nre con- 

fmed lo lUe grouve be- 
tween two anal folds 
<FiK- 101). Recently, 
hmrrTvT, no particular 
importance is attached 
to ilio ahapo. It iiiav 
111' liEiL-ar, pL>ar-shapetJ, 
elliptical, or round. 
Quenit anil llarlmann 
in an ehihorate stutly 
of a nuniher of easi-6 
have come to the con- 
clusion that this tis- 
sure-Iike or elongated 
ehnpf is nnly appan-nl, 
nuil t}iat wlitTe it i» 
dissected out and laid 
Hat upon a block the 
ulcer aw^uines a circu- 
lar or elliptical farm. 
It is the liite bulween 
the iwl tal o r luueoua 
folds, within tlie grasp 
nf the Hphineter, which 
gives it tlie eluugutcd 
shape and charuetcrizea 
it. In itfl other fea- 
tures it does not differ from any aimple ulcer; the edges are generally 
inflamed and slightly elevated, but not indurated; they may be ragged 
(Fig. 102) and appear Blightly undermined, but tho latttr feature diaap- 
peara when the ideer is slretrhed open. The has*? is either a bright-red 
granulating sm-fate which bipeds easily tipon touch, or it may he com- 
posed of grayish, llMhy granidations covered hy a thick pus or pseudo- 
membrauc. The elevated edfes are folded or tucked in by the con- 
traction of the sphincter, so that they rest upon the base of the ulcer, 
thus irritating it and preventing healing as well as causing pain. 

At the Idwer end (if the fiasure there is rre<|Ut'nt!y a hypertrophy 
of the skin or inuco-cutaneous tissue whieh resembles an e.tternal pile, 
and has been called by Brodie the seuiinrl pilr (Fig. 103>. This may 
be divided into two car-like flaps by the fissure; it is always painful 




Fro. 101.— Km-H'iu! is Avi. 





PISSUttE IN ANO 



293 



to the touch, ami wlien dragg(*d upon it bring* on cli a met eristic 
pftinn. 

l,afai\Qn. — Tin? site of tlic fisBuro iii ano is variable and may nccur 
at any point from \\n: cutunooiu margin to the iippri' limitH of the 
columns of Mi^rgagtii; tht majorit_r begin jiiet aWve the ano-r«ct&l 
liu« and extwid d'lwmvaid. It uiiiy iilso oec\ipy any point in tlio anal 
oircumferenct". In iiifu Ihoy Hn> most frequently seen at or noar the 
postt>rior commissuri", and rarely upon the sidpst or anteriorly. In 
woiut-n ilipy are cnniparalivfly often suph at the anterior comniisstire. 
Jn 132 tai-es in men recordeii by Goodsall. the fisgnre was found at the 
anterior coniraissiire but once, and in 89 noniL-n it was ftmnd there 
13 tinier The signiticanoi- of llii-se louilions ivill be appreciated when 
the etiolopy and symiitouintologv of the discosc ar« studii-J. 

Etiolfjij. — If nil ulcers of the annl canal arc considered to be fissurCB 
it will bo neeensary to invoke a« etiolog-ienl faclora enlniTlial diK-aseg, 
p)norrh(i'a, ehancroid, syphilis, tiiberenlosi*. etc. The typienl anal (is- 
mire is an ulwration entirt'ly dititinot from llte*e types, not in its i^hape, 
for all of them may a».4ume the elliptical or irregular shape: not in Its 
depth, for this is variable in all varieties; hnt in its etiology, its symp- 
toAiatology, and progreea. From day to day, if one cart-fully observee a 
simple trniiinatic fia- 
Hire of the anoR, he 
may sett si^nit) of eica- 
trizatioti at itK mar- 
%\n which comes and 
lasts for phorl periods. 
only to break down 
again. Sometimoe 
«rcn the ulcer will 
heal complelt'ly unl 
remain i»o for a .-li-.n 
poriml, breaking dtmii 
again under Iht- intlu- 
enti; of hard fa'i-ul 
paa^gcs and strain- 
ing at stool. Surgi- 
cal npi-ratious may rennh in fianure-like uk-erations, but eventually tbeee 
heal in the majority of c-iuifa without leaving a typical cicatrix. 

Fimurea may oriipnale in any wound, oxooriation. eruption, or 
inflammation around the nnw, /Vnytliing which wcnkens tin- tissuea 
and fvnders Iheiii liable to nhra«ion will aet ae a predisposing cause. 
The exciting cause. howeTer, is nearly iilways the jvasaage of Ixanl f^'al 
masses wilh or without foreign bodies iu theiu. The fact tluit women 



^t-' 




Flo, I'-a.— lmi«*n'u« FiMi-Bi: on ImiiTiBLii Uii-fr''>t AwnL 





FlO. lis, — Fl""!"!!* WITII Stt-tTHHI. PlLB IK Birfmini"' '"'hii.i 

AlHQgham states tliat gelalinoiiH antl fibrous polypi are not oT all un- 
comnion causes of Assure: " The polypus is iinunUy situated at the 
upper ur iulornal fTii.1 of the fissure, hut it may Ijp on tlie opposite 
side of llie recluin." U'linlevcr cnuse-i narri^wjn^ of the anal cUDtl, 
guch lis congcnilHl nialf»miatin», h\*pi>rtn)[)hy and contraoturc oC the 
sphinrter or levator ani niuwic, ninl strirtiiru, may rrsult in fissure. 
Tho cMinlilion may also result from piirtiirition, the passng*" of the 
child's head thrnugli the va^na m diMenditiy the roctum as to tear 
the mucous inemhrane. It i* aUo Mid to result from ma1|)o»ition8 of 
the iiteriiSj (lucli as anlevereion and retrnvt-rsiiun. 

Tlie fact Ihat a large majority of patients suffering from figure arc 
alao nflliptcd with a proatcr or ti.-?^ doin'L'o of hn-inorrhrjidiil <!i^i';nM 
would indicate tiiat there vm some f^tiological relation between the 
two. The ^tfttomont of Qu^ntt and Hartmnnn (op.eii.y 421) that 70 
to 80 per cent of fissure* an' due to hn-niorrhoid" dopji not swin ii-nsuna- 
ble; it is more likely that the irritation produced bjr the fiasure resuita 





» 



* 



in a liir-pera-niia ami oongi'stion aboin ila- iiiargm of ihe amis, ami is 
thus the cause mtlier ihau tlic rt-^iilt of liivmorrhuid*. The aiitlior 
has *wii a iiiuubi^r uf tuws of list^uitr in wiiic-ii llit ha'iiuHTlioiilnl sviiip- 
tomu— ppotrusiou, bltjfdiuK, «»J backaeht.^ — itU came wu aftor the original 
eymptonis of fissure. Tlu- coeiivcnws which causes the fissure will 
aUo aei'oiint for the liiL-iiion-lioiiis, so Ihe reliilioii ihcrofdiv appears co- 
inciiloiil militT tlimi «^'tiologit>al. Bu^'t^r'ti lliL'urv Umt Uie lisaure in due 
to spnsmodic (•<nitrac-tioii of llio Kpliiiiulfr puU tlie cart before the 
horse and is uo longer consitU-reii iteiiously. 

Bull has advum-eil tlic idea Ihal tv])ical iWureK arc cltic t» tearing 
of the oryptB of Morsatrni. lit- fays Ihnt tlu-y arc brought about by 
Iwlffment of small f.T(jil inai45t-a in thcfic little pocket*;, which being 
Bed upon by hard stooU cause Iho edges of the valves to tear; this 
lent is gradually extemletl by evitry 8ubrie(|iieiit paMMige until the wliole 
depth of the eri'pl is Uirii througli ami the imuctt-eutaiieaus tittKU(> of the 
anu»t is thus involved (Fig. 104), This theory is very plausibli-, and the 
fretpieiity with which fi,'isnr(?H occur at the autmor and jiosterior cotii- 
«iiR!«ure i» entirety in keeping with the annlotiii<-al fact that the i-ripts 
arc more highly developed in thew areas than in any other portiim 
of the rectum. A series of examinatiou^ instituted after the publica- 
tion of Hall's flriiele 
(Brit.Med. Jour., lS!il, 
vol. ii, p. oSiJ) have 
(shown tlint upon each 
aide of the poHterioi' 
commissure there is a!- 
mofit Always a well-de- 
velo|>ed valve of Mor- 
gagni and one direetiv 
in the middle Vme of 
the anterior eomiiiiK- 
fure in women; and u 
study of alt the fanes of 
Assure observed since 
liaa shown that the ma- 
jority octur at tliP'^e two pointE. MoMOT«r> a careful exainiiiBtifin of 
liasurea will freipieutly show two litllp jiapillte or (oat*, which woulil 
indicate the tenring througli of a fold of the niueo-cutaneoug tinRue; 
fftinetimes this fold is not entirely torn through, and the fitwun? presenla 
a dlighl pocket iniderneath Ihe lower Imnier tK'Cunipanied with hyper- 
trophy of the .'•kin externally. Tlii« hypertrophy represienta the well- 
known wnlinel pile of Brodie which hii.< liven dworibe*!. From all these 
fact* it se^m? reasonnblo to eonchide ihnt while liii<tures may oeeur at 




■I : II i;v I;F^^ i"\' 

M'.'Jlli.tdM. 




THE ANUS, RECTUM, AND PELVIC COLON 



any porlion of tlit; circumf(;rfnt'c of the rcciuui tliruu;;h a solution of 
ctintinuity in the covering mpinbrane rnmi aiiy rnustr, it is Ukcly that 
many ta*e8 are due to the tearin^r of Ihtsc little cn-pts as claimed by 
Ball. There remajn, however, a large niimbor which occur m the very 
middle of the posterior L-ommistiuiv, above wIul-Ii jjoim there is no crypt; 
these are explaint^d by the ilirwljou of the canal alwve the eoinmissuro, 
vhich is buckwanl, hikI couseq;uenily the iiuum exerts ili greatest pres- 
sure thf-re. 

Pnlfinh^i/. — The pathological chtingi's in fissure viiry from the 
slightct^t abrahion to deep uli-iration and duftnuliou of ti»-uc. In Home 
only tlie most superficial layer of the luuc-o-cutaDcous tissue is inTolred, 
while in othere even the nuiM-iilar fibers tlieniaelven are either laid bare 
or become involved in an inftaniiiiatory process accompamud by Gbroufi 
depoEiitit and alterations in the vascular and nerve supply. In the 
superficial variety, those which may he railed atulp, there is no indura- 
tion of the base, no thickening of the edges, and no grciil hypiTtniphy 
of the sphincter musrle. In the chronic state, however, the edges of 
the ulcers are elevalwl. irregular, and thiclcenpd, the base is hanl and 
inelastic, and the sphincter muscle is h\'pertrophied and very resisting. 
In this slate it might lie verj- difficult lo distinguish the simple fissure 
frnni a true llunti*riiin ehiuicre. The time which it has oxistei) and the 
absence of other specific nianifcstation.1 during that period should 
decide this ijuestion. The elongated ulcer occurring between the radial 
folds low down occasions a higher degree of sphincteric spa-«m and 
hyi)ertrophy than doce the small round ulcer which occurs above the 
ano-rectal line. There is also more induration and inflammatory in- 
volvemetit of the neighboring tissue in the linear that in the round 
ulcer. 

Microsc^optc examination of excised ttKSures has been made by M. 
TTartmann (op. rii., p. 422); upon the surface of the ulcemlion there 
was a granulnr layer of round cells of une(|ual thiclEnc.s.s lacking in 
places; below this was a fibnius layer in which were scattered numbers 
of round rells and fiu^iforin graniilcs crnsi^ed by bossdatcd bloixl-veasels 
running parallel to the surface; still lower wns a layer of smooth mus;- 
cular fibers more or lose separated from one another by fibrous tisiiue 
and Id'low Lhie a eelliilar adipose layer in which ramified the htnnd- 
vesseU with their tunics and primitive ner\e-rnol!i. In the adipose 
region the nerves and the vessels appeared normal, but in the dwep 
muscular layer the nerve-trunks were surronndeil hy fibrous material 
(Fig. 105). They were altered and granular, and distinguished by their 
Inmellar sheath, and showed interstitial and intrafascicular aeuritis 
(Fig. 106), The mucous and miico-cutaneoiiB border of the tiloerBtion 
presented a cavei-noue trousforumtion, the epithelium a^uraed a strati- 



k 



FISSURE IN A»0 



297 



I 



* 



»■> ■ s 



^5 



^'^■"■^:-i 



Fi'i. lnS.~ri:)ti:iiiiKrTii> ix I'lilioMo FMat-IU 
itjui'tiu sad H»rmuiuii)' 



fied, trnn^lucont aitpearance, the iirolongnlions of tlie epidermis wltc 
destroyed, and then* vm aa infl It ration with gi-anul&r oulU acroinpaoied 
bj Tfnous thromboses and small in tercet In lar ha-morrliiigt>«. 

There wan no evideiRT jii any uf IIil- settiozin ol <r.\|K)siMl iiprvft-cnds. 
n»e histoid of the cases fioiii whicli thirsc euctioos were taken is not 
given in Ilartmnnn's report. It is well knmTn plinieally Hint the pain 
in fi»iiire» varipa aocordinp to their duration: at first it is burning, cut- 
tin/?, and lasts only a shorl time: bnt afitr ihey become t-hronic, it ia 
a (hilK tlirobbing ache tv'hicl) i'adiatL>!« to t]ii> buck ami down tJie Ir^h. 
lu [he first a »t*ti»itive nervL-end rimy lie found expospil, u-hfri'iiA in thfi 
second this sensitive nerve-end 
may have been destroyed by 
the ulcerative proceM, and tlie 
peri- and interstitial neuritis 
may have laken place in the 
nerve deeper down. It would 
have proved more interesting 
and instruetive if Hartmann 
had taken a wriea «jf east's in 
their initial i^Uges as veil as 
thwe flppareatly chronic cucx 
from which he innde tho mi- 
croBcopie exandnntions. At thi* 
eanie time thette stwdies are of 
the grealeat iinporlance, and 
enable us to explain in » meBA- 
ure the wid aohinp, throbbing, 
dull pain which follows defeca- 
tion in chronic fiaanre, even 
after they liavo healed by eica- 
trizHlion. f>n the other hand. 
its pathology will not explain 
the acute, burning, tearing pain 
which occurs in the early »ftages of acute fi&^uro. hecmitte in thew cases 
thifre is no induration, uo hyi»crtrophy of the sphincter, and no pt»«i- 
bility of the neuritis as above dewribwl. Here it is simply a question 
of a raw surface exposed to the irritating action of the fa'cal jwasages, 

ieh Burfncp clifTcrii in no wiw from thni at any other portion of the 

•, save that the tissues are somewhat more highly endowed with 

itive nerve-ends. It lis tnijxisriible. therefore, to conceive of a lesion 

in these lifiHurs without an exposure of some of those numei-oiia nerve 

filamentc whirb supply the niiril canal, and this expoaui-e account* for 

the characteristic pain in the early stages. 



t- 






'^ 



■JT 



ii^'J^y 



m 



'. y 






■M 



Fi*. lOii.— Iir»i(ji»*i«Mon.An Nenitri* in Ciibdkio 
t'lHCiti (Qii^nu aiiil Elnrtinii&nl. 





S9S 



THE ASUS, RBCTUM. AND PELVIC COLON 



Sr/mphtns. — Aft a rnle, patients can nol say when the first BymptotnB 
of fissure begin. Occasionally one will recognize a tim< when during 
a diniciilt teeal [lassuge iIuti- u-aa a H-UDaliun i>( sonu'lhiiig giviiiy way, 
afler wliicJn lher«? dcuurred a slight diacharge o( lilaod and rtcurrL'Ut 
pain nt each stool. Siuh a history, howevt^r, is rare. Ordinarily lie 
will state that for some time he has uoUci-d ciliiiT itching or Iiuniiug 
after atool, at-coinpanied with blood or rnueus, luid that he has a tuimll 
pile whieh is either always swollen or whiiih swells after defceation. 
The tiU'cduig is generally cvnfiued to one or two drops, or simply a 
etaining of the detergent material. The discharge of pus may not b© 
eullififut eveii to soil the linen, C^imslipatiou witl bt i-oniphiiiied of, 
but if one sifis Ihe facts, it will be st-i-n that tliis has been brought on 
more by Ihe fear of pain following fjecal tiiovenien1« than by any iaac- 
fcivity of the bowels; it is an ar^jntrcd habit rather than a funetioaal 
disease. In the beginning the pntirni could and would have had regu- 
lar movements of the bowtls had it not been for this fear of pain; 
there ia in most cases absolutely no obstruction to the ftecal passages, 
and in the oarly stages no lack of niuisture and lubrication in the 
intestinal cauul; it is simply a matter of Toluutary coulrol. The result 
(it this IS that the f,ecHl passages bi-eomc more and raure dry the 
longer they arc rL-tftiiicd. They are thus made harder and more 
irritating, and tinnlly when a movement does lake place, the irrita- 
tion is much more severe than it w*mld havi? been had reguhir move- 
ments occurred, and the injury to tlio fissure or ulcerated membrane 
is greater. 

Pain. — The pjiin asaoeiuted with fissure is very variiible in time, na- 
ture, arul duration. It may eome on at stool, immediately UiLTea f ter, 
or half an hour to an hour later. It may be acute, eulting. leariiig. hs 
if a winmd were bfing pulled asuiider, or it may be a Imrning. hot, irri- 
tating feeling accompanied with spasm and beariug-dowii seuHilioua. 
Finally, it may linvc none of these chiirueleristics, but assume a dull, 
heavy ache, with throbbing and distress similar to an aching tooth. 
The time which the pain \anls h ^hu a.i viiriablo ns its nature. Some- 
tinsDB it Ia»t^ for only a ft?w miinitoj, am! the patient is ttion able to 
go about his biisines!! without any further disturbance until the next 
stool. .\t otiicr times the pain uud smarting are so severe that lie is 
unable to move from his pusitton lit the toilet, or must seek liis bed, and. 
lie then- from lialf to lhrec-<]uurlcr* of an liour until tin; aeute agony 
ho? passed away. After this ho i* compnrn lively comfortable for the 
re-st of the day. In others still the pnin rloes not come on for somo little 
time after the ficenl movement, when it begins to ^mnrt and bum. this 
B«D»alion gradually changing into an aching, throbbing diiitreits about 
the anus and sacrum, which condition may last for several hours, or 



I 



PtSSrRE IS ANO 



299 



oven in sonic cases all day long. Certain patients ore never free iwui 
diaconifort. 

'Hiere is a pretty clear rolntion^liip butwucn tlicsu jtiiiii» uriU the 
clwractcr of tliu fissure. Those acitti' pains Inistiug for ouly u few nio- 
menU are ordinarily due to »iipet)icml tis^nrc-s whicli involve the uppcr- 
miwt laycri* nf the niuro-eutniieoiia tissues, henl pnrTinlly or entirely 
from day to day. and recur wiih each hard Rtool. Tliey enn !»o pro- 
doced hy forcibly Rtretehing the »nal folds apart, Sueli Ussuros are fre- 
ijuently ai^sociated with atrophic ciitairk and latu syphili.*. The pains 
which come on juai after stool, and ia»t for lialf an hour or mure, are 
ordinarily due tu tin ukvraliou W-tween the radial ftdds of the recluni, 
especially in the posterior commissure ; there is a slipht. red, granu- 
lated h(i»e, thickening of the edpeR, and a ^^entinel pile, or two little 
teatB at its lower end. The dull, nehing, throlbin^ pain which comes 
on some time after stool is penerally due to a fissure or ulceration situ- 
ated in the upjKT portion of the anus, and involves the internal and the 
upper fil»ers of the exteriial apliiuctcr. It is ordinarily of long standing, 
deepi-r and more indurated lliau tlie previous viiricty. but its edges ure 
not 80 elevated and thickened, iiud it doe,« not involve tin; skin ut all, 
and cnn only 1k» seen hy the u*e of a speciiliini or forcibly stretching tho 
ami? apart. 'rhe>;e lale [mins, oeciirrin;: some tiino after a fa«'al move- 
ment, indicate that the ulceration is liijjh up. while th08e occurring im- 
mediately thereafter wonld indicate a lower situation. In general, how- 
ever, it may he said that the acutencHs and severity of tlie pain is in direct 
proportion to the nearneM of the uleer to the anal ituir;;iii. The more 
of the mueo-ciitaiieous tissue involved the grtrater will lie the pain. The 
application of this is clearly brought out in the chapter upon Anatomy, 
whtre it is shown that tho sensitive nervH-lihera approach the anvw 
from below, and are distributed in n gnidually decreasing ratio a« 
we ascend into the anal canal, dis)ip|H<aring almost entirely after the 
mucous membrane has been reached. 

Rffiex Sifiniifumx. — With the local symptoms of fissure a variety o1 
reflex phenonit-na lunirs. sonietinies evt-n more annoying than the fi*sure 
iteclf. I>ysuria and painful urination are among the most frequent 
complications. The first case of fissure thnt the mithnr treated was a 
man who cnitiplnined of symjjtoms nf iirp|liml slrielnrc, and who lind 
been treated for the name for a Imig tiuic without nny material tiencfit. 
He was an orderly at the BlncVley TTospital in Philadelphia, and close 
()iie$tioning revealed the fart that Ms urcthml symptoms were alwaya 
more marked nt the time of and just after hii* ffccAl passages, and that 
At periods the farthest removed from the stool h« was comparatively free 
from his nrethral symptoms. Examination of the mnnV rectum demon- 
strated the existence of a small indurated tissuro at the anterior com* 




9U0 



THK ANVS, RECTUM, AND PELVIC COLON 



rnisuire of the anue. Incision of (hi* toon resulted in its can, and for 
two years tbtreafit-r the imtient wm aUolately free fictr any urethral 
or imnar)' symptt'm^- 

It is not noce««aiT, however, thac the fi^urp should be in the aiit«> 
rior commiMUie to produce these reflex urinanr distnrbance^. as prox- 
imity is not ihe L-au»f. The origiu of ihe m^rie swpply to both sets of 
orf^BDH t>i>ii)^ pniL-tii.«ll.v the same in the »i>\d»\ cord, irritation of tlie 
ncrve-emli^ in one in likely to be reflected in the other. 

Uterine (ind beariop-dnwn p«iD9 often occnr as a result of fissure in 
ano. Backache and neuralgia sbootinf; down the leg, iR(lei><l all over 
the body, may be the result of one of the>ie nagging, irritable ulcers of 
the anus. The»e widespread and vague di>iturbanee:i are. of ooiirie. due 
in a measure lo the nervous exliEuslion and etrain produced by long- 
eontinued Huireriug and irregular aetion of the bowels. Facial und occip- 
ital m-ural^ia. spinal irritation, and temporary strabismus have been 
Icnown to ditHippear almost immediatclv after operations for figure; it 
is not asserted that the latter v»g the cause, but it certainly seemed to be. 

iiiaifnoxig. —Tha- (lingnotii*! ni fissure is coiwidcred very aimjile. It 
is often made dimply from the det^cription of pains after etool, but pa- 
tients have these from many causes; foreign bodies, stricture, chan- 
croids, goiiorrhiea, syplulii*, uod wzt-ina all produce iht-iu. While thes 
symptoms arc of the utmoct iiuportance, one should not make a SnaT 
diug)i<)Kii> without careful local exaniinolion. This should be insisted 
npon in ever)' cose in which there are sj-mptoms of rectal disease, and in 
none is it more important than in thiii enndition; fir«t, heeouso mistakes 
in rectal diseases are likely to prove rapidly disastrous; and, second, 
because in this particular ilinen^e Iftcal Ireatment or operation is the 
only reliable uienns of cure, and therefore nothing can possibly be gained, 
by delay. 

To examine a patient for fissure, the seniiprone position is (lie most 
convenient. The patient should be laid upon his left side, tlie hips 
olerated upon pillowo, the thighs flexed upon the abdomen, and the left 
arm thrown ImckwunI, so that the tnink rests practically upon the 
breast. The hiittiwks should at first be pulled pentK apart jind the ex- 
ternal jnirfBce of Uic anun examined. If there be a sentinel pile it ran 
Ire en.'^ily remain iKed, or if the ulceration involve the perianal tissue it 
will also lie cIpBrly seen. 

Palpation around the anus will not only reveal the hypertrophied 
and hardened wnditi<in of the sphincter mupcle. but it will usually en- 
abk' one to di'tiTitiine lliu |>rr))»ible point at which one may expect to 
find the eauM> of the pain. PreRiture upon the margin of the anus always 
gives pain just below thf site iif an iiWration, even thnngh the ul 
itaclf is not [jressetl upon. With the patient's assi.stnnce, pulling upwai 



3L. 



PISSUIIE IX ANO 



aoi 



h 



tlie right buttock, while the surgeon pulls doviiwiird upon Ihp left, 
ianuK may K*''«'ni".V he everted sufficiently to st-c any typical fissure 
or intra-onal uk-cralion. lu wwiien thin may bo fac-ilitalcd by the in- 
troduction of ihf fingers into the vagina, anil (Hf^sing baekwanl and 
downward, 80 as to GVL'rt lln; reclmii (Fig. 107). Thoiie mnneHversalwaya 
ocCHsion more or luss p«in in true fiiwure. Soniptiines it will be 8o great 
tliHt Ihe pBlient tHH hardly .siand jiii cxaitiinntinn of this kind. Tlia 
introduction of a small quantilj of cocaine ii]M>n a pledget of cotton 
will oocilitioimlly iclievp this pain, and eimble one 1o i-xaiuiuv the fi.?.i^ure 
without (fTcat diaturbancc As a rule, however, cocaine is very poorly ab- 
eorbcd by p*anu- 
liilin;; surfaces, 
and is often dis- 
appointing ia 
these exftniins- 
tions. If the pa- 
tient can be in- 
duced to strain, 
fissures between 
tho ndial folds 
can ^nerally be 
brought into 
compftrati vely 
good riew. Fre- 
quently, how- 
evflr, this effort 
brinffB on t he 
tj'pieol paiu of 
tlMiire, and he 
will be unable 

to continue it. Under such c-irrumt^iauct.-'e, if one kccjw at hand su 
iiteaBlitiDg apparatue containing finely powdered anicethcsine, and will 
blow on ilie ii^wured surfatv a ^mall ((uanlily of (his drug, hi- will 
W able after a few uioiueuTB lu examine the partg in an almost 
paiolviu) nianuor. Occasionally this drug faiU, but in many instoncea 
it affords great relief in the examination of ulcerating cunditinns of 
tlie unu8. 

Uavin;; lhu« even what i» po#8ible upon the outside and lower por- 
tion of the anal onnul. digital cxaminution i>hoiild )>e made to detei^ 
Diiue not only the esisieuee of a tiiuiurv, but, if jK>M.iljIe, its caut^. Tlio 
elevated and thickened ed}n-», the imlurat<>d base, or the smooth, soft^ 
circular iiIot juwt almvR tin- margin of ilie exlerual sphincter, arc easily 
lecogoized by (he educoled touch. Allinghaui alalcs that at the xipiier 




Fiid 11/7. — Evutuon of Atrnuina Fiwi-nx ev Fixoir n mx 
Vauima. 




309 THE ANUS, KECTUM, ASlJ I'ELVIO COLON 

end of an anul lUsurt: uui' ollcn finds cUvute papillee nr ^mall polypoid 
growths which fall ibto tho cleft, and lh\u prevent hi^alinj;. Uo states 
that tliese growth* are not tlio cwum* of iis^^uFL': a» u ruk', hut that thev 
cerlninlj keep Iho wound open and (in-'wiil its healing. His further 
8tat«m«iit, however, that when auch growths are found it is not neces- 
sary to exaniitif tlie R-etuin niiy furthi-r invites triticisin. Assuming 
tliiLt he is right iu his slatviiK-ut that thirsu iittlir iii^oplasiuA arc nut tlie 
cause of liasurt', their discovery, thcrcfcrt*, will not have eolved the 
etiological probJcm. One should not stop at this pi-inl, but carry his 
exaniination farther, and determine if |)088ibl© whether there be any 
pathological or anatomical condition abovu tluii which will account (or 
the ulceration. 

In till- introduction of the linger fur the examination nf (i.-isure, it 
should always be prCMted to the opposite segment of tha nuus from that 
at which oun supposed the Ieai(m t« esi»l. Thus if the jmtitrnt com- 
plains of pain iu the posterior j^cginciit, the fiuger shoulil Ih; carefully 
pre.xsed forward and inlroduccd to iU full length. The rectum should 
ihcn ho esiiiiiinoii for any nimormnlitii-s, and the anus can he Bearchcil 
for nlcpratiou as the firigLT i* wiihilriiwn. With the use of annrathesiue 
and these precaution.'! very little pain is opcasinned by sueh exami nations. 
The ulrerntion.-i iin- largely within virw liy the M-paralion of ihi' radial 
folds, and, morcoTcr, they ran Ih: so clearly ami distinctly felt thtit their 
diagnosis ie always certain. The email round ulcer o£ tlic anus is not 
eo cattily made out, snd the sjiGculuni ie of advuntage to diugnosQ this 
condition. 

The best instrument for tlie examination of these ulcers is the con- 
ical feticit rated siicruluin (Fig. C3). Tin- segment of ilu' anus in which 
the uhenition rxisls hiiviiig bi-cn localed liy digitii! Lxuiiiiniition, the 
speculum shnuld tie intrftduccd with one of the j^lides opposite this area. 
Where the sphincter h tense and hard, the smaller sized speculum should 
be used. After the injilnirnent has been introduced to its full extent 
the slide should he withdrawn and the nleoration ean then bo clearly 
seen. The Sims's vafiinal speculum is also very useful in these ca.«ef*. 
The tubular specula and the anoscope are not useful in the examinalion 
of these conditions, inasmuch as they are very likely to clip out and 
give the palient a great dejil of pain just as the ulcers come into view. 
3[urc(n-er, the conical specuhini enables \is to treat these uliremtious 
locally through the fenestra, the rest of the eircumference of the anus 
being thoroughly prolretpfl from any applications which one may make. 

TTtalmeiii. — The trentnipnt nf final llssure is ordinarily described 
ns pnlliati'ce and curative. There is no place in rectal surgery for the 
palliative treatment of fissure. Opiates and sedatives which relieve the 
puin always increase the constipation and make the fiecal passagee not 




PISSUKE IN ANO 303 

^iT^iore paioful but itiorc injurious tu tin.- iliscused fondiliun. The 
tivatiiK*iil LbLTLrforL- rL-aolvi'jt ilsulf iiitu ihv noii-«pfrativc uiiil wpurative 

' nicthods. The first step consists in removing the cuusc if poMiWc. For 
lUosL- fuscsi iliio to ponistititlioiitil Ny|i)iiti»i, tho line of trentmcnt is laid 
down in tht* chapter upon Venert-nl Diseases. 

Tu those casL's in which a polypus or papilloma coaipHcatos ttic 
fissure it h uaL-k'S» to alU'iiipt local trcHtinont without the removal i>f 
tlit-sL' UL'ujiksuis. V\'hea- it is clix; to i'ou?tti|*atiou uiid ulrupliic catarrh, 
these ithwuld be la'utad along with the fissure, as the latter is WK to 
recur if thfSi; amditioOK peraiKt. 

The ix'giilfttion of the bowcle is of the utmost importance in chil- 
dren ftg wcU as in adiilU. Whpn the moTements are regular, biit the 
fotcal mass is hard and lumpy, au injection of a small ()uantity of sweet- 
oil and glycerin diiriu)^ (he itiuriiiiig huurs will generally afford great 
relie/. Tliis may be injected tlirongli a small syringe at a time some- 
what previous to the usual jioriiul of defcfalioii. One eiimotli. regular 
passage & day is Inrttirr tliiiu un oLeuhional piirt^ing. Aliiughaiu rucoiit- 
mends for tliia purpose the use of figs eouked in ewcel-oil, or onions and 
milk nt Ix'dtime. The unc of figs ns a laxative in rectal diiicaKC« is 
object ionnlile from the fact that the small eeedft are not digested in the 
iote»titial raiial, nnd are likely to lodge in tlie ulcerated areas and cnv^ 
irritation. Fho.«[ihalf of soda given in the uiorning iji *ornetiiaes effec- 
tual in the pmducf ion of such fa'cal passages. Saline laxatives, sulphate 
of niagiie-jin, r*ulphatc of soda, etc., and the cathartic watcrsj such as 
Hunyadi, Friedrichslmll, Aponta, and Rubinat, are more likely to pro- 
duce frequent thin, liquid pii«Mges, which are irritating. t^n.-Jcam with 
malt J8 quite ah ti» factory, but one must experiment with every patient 
to determine the nnionnt iteeessnry. The resinous cathartics, such a» 
giimlmgp, pmlopliyllin, aloes, etc., are all irritating to a fissured anuii. 
Cripps think-s highly of a confertion of black pepper and senna in equal 
partn, and rccommendi; two large tenflpoonfuls of this for an aduU upon 
rising in the inoruing. 

Th« diet should be carefully controlled, and if possible the bowels 

'should Iw regulated by IhiH means rather than by nieilieine. If there 

, are hH>moprhoid«, a cold rnema in the morning will relieve the congoM- 
Uon in these, and ordinarily produce a Mitisfactory movement of the 

f bowels. 

Xon-oprrativfi Treatment. — Where the fiwiire is acute nnd there is no 
marked induration of its bn&c, it may be cared without any operative 
interference. The patient's constitutional condition should be built up, 
and as much rest in the reeumbenl posture an podsible should \w en- 

lijoincd. Ex|>eriimce teachea that lying down ininiediately after ftecal 
moreiuentti preTents in a lai^ge measure the paina of fissure. If there- 





8M THE AKCS, RECTUM. A\D PELVIC COLON 

forp a patient's occupation prevents him from obtaining siicli re*t during 
tlic morning hours, it is wise for him to rvgiilato liii» bowels lo wore 
at an evening hour, «o that he can go to bed anil remain quiet afterward. 

Thv iuJL-ctluu ul' ;ii>Iuti(?nE) i^Ufli a* i^tarc-li-WHtcr uuil opium, iodoform 
tnd oii, and lead-water and landnnura after fawat paasagcs appears jrra- 
tional and proiJuclivt- of no good; the only poesibio roliof whieh they 
can afford to thu llt^eure U tliruu^h ubt^urption, and Llieir effect upon lUe 
nervous ELVstem ; they do not come in contact with the ulcer, and add 
more irritaliuu througli the intruductiou of the nyringe-tip necessary 
for their uditiiuii^truttuii. Jf mk li n-mediea an? net-L-ssury it would be 
belter to adniiuialer the upiiiLc hyiiitdcnniLully or by the nioutli. 

Crippi recommends an ointment conipostKl of ferri sulmilphAto, 10 
graiiu,and itngucntiim pctrolii, 1 ounce. In «oino patients this ointment 
gives pain, in others be sayg it is very beneficial. He ako Tveoniinendd 
the application of a email amount of Ihe following ointment to the 
flsgured spot a few moments before the freeal movement, and again 
after it has passed : 

^ Ext. conii 3ij; 

Olei rieini Siij; 

Ung, liiiioUuii 5'J- 

Allinghain stntos Ihtil there i» nothing better as a Toeal application 
than the following ointment: 

9 Hyc], Kiihchlnr. gr. iv; 

lliW. opii gr. ij; 

Ext. bellailonnaa gr. ij ; 

TTng. aambuci 3j. 

M. 

Ointments containing cocaine, bismuth, iodoform, aristol, rosinol. 
etc., and sometimes a certain uumunt of morphine, have been highly 
recommended by various authorities. As a rule, however, they are not 
of much benefit, save Ihe oiiitmont of eoniuiii, reeoiniiiended by Crippa. 
BcceQtty, however, the author's treatment of Assure in ano lias entirely 
changed so far aa ln«il npplicntinns nre concerned. It is no longer a 
qnetitinn ns to the Icngtli of time a fissure has existed, whether it is 
curable by local trentmcnt or not; the condition of the siihincter and 
the amount of induration, together with the depth lo which the ulcera- 
tion has extended, are the ini|)nrlant factors. If Ihe sphincter is hrper- 
trophied, hard, and spasmodicalI,v contracted, if the ulcer is deep and 
indurated at it^ base, with it:^ edK«s thickened and the sentinel pile well 
developed, one can not generally succeed in curing the condition without 
Bome operative intorfcreneo. Especially ia tliis true if the muscular 





FISSURE IN ANO 



SOS 






^ilberB are exposed and can \t(< ctenrlj swn by the use of a nmguifjing 
lllH. Wlifix', Iiowt^vtT, tticse cnnclititms do not exist one may confi- 
deott> predict a cure viltinitt any operation. The treatment consists in 
tlie application^ first, of small quantities of anjeatliesine in^ullUted on the 
surface of the ulcer; after a few minutes a pledgtrt o( tottuii suakinl in 
imre iehthyol is appHtd; theee applicationa arc made through the coni- 
cal spoeuiuiii, as was i!fwril»?cl alwvo. The trpatnu-nl in earriod out ovpry 
other day, to{iellier with thi^ fL-giilntion of Ihe buwcls. The jnirmhif- 
tion of thi" Hpetiiluni serve* to gradually dilate the upliinrter and lakes 
the plno,' of liouKic'H. It is now some five years since this treatment was 
coniliM-'nti'il, iiihI during Ihat time not mnrt; than 10 caspft of iineoiupli- 
cated fiaeure have heen seen, vfhich could not Ije eured without operative 
interfereneo. In tlie bi-ginning of this method of treatment ana*athe3inc 
was uol known, and solutions of (joraine were used to rolievi^ the pain. 
Soinetiniex thia wa« elliuii'iit aud !;t)niel i tcieh iKit. In ihuiu! vases in 
M-liirh cofHiiie was intffwluat the patient suffered Lonaiderable pain 
after tlie first two or llini' treatmrnts. htit it gradttally grow Ifss and 
less at each Buwi-i'ding one unlil the uUrr entirely healed. In the nifuii- 
time, however, the fa-cal passajre;' always becaine k*a painful after the 
tir«t application, and the pnticntd have always been willing to hear the 
pain of the nppliention rather than to submit to the knife. When there 
has ht!en much *|mnni of the sphincter the parts niay he smeared with 
HU ointjoent coitiposed of 



P 
P 



n 



u. 



Uhj;. stramonii, 

Tng. belladunnffi, J- aa Sit. 

Ung. hyosiyanii 



This alwaj's seemed to relicTO the epasm and eontrol in a largi? meas- 
ure the piiin that resulted from the application of the iehlhvol. After 
the vse of uiueslhe^inc this ointiiieivt is rarely ueLr»»ary. Whenever a 
hy|icrtrophy of the iteiiLinel pile esiata or theru nre little tentu, they 
should be eoeainized and snipytc-d off with seizor*. 

The nvorH>!c lenglh of time consumed in the tpeatment of flexures 
by tiiiti method has hei'ii something less than four weeks, but in the 
majority of aeute eases relief is obtained in ten day* to n fortnight. In 
a large number of c»9*^ three or four applications of the ichthyol have 
resulted in a mmplete cure. Where the treatment is not Buccessfiil 
within four wei-kit it ie advi«ihle (hat the pntit-nls submit lo operative 
interference. At the aame time, where the condition is complicated by 
hiemorrhoids or neoplasm* of the rectum, eueh aa polypi, adenomata, or 
pHpillomiila, loeai treatment will be of little aruit, and the method will 
be brought into diHrepute by its application in such uisea. Operative 





806 THE ASUS. RBCTTTM, AND PEri■^^0 COLON 

treatment should therefore be resorted to at once under these condi- 
tions. 

Tlie author? experience entirely agrees with the statement of Ailing- 
ham, tliat lutcral and unteri'^r Gssurei' ean always be healed vithout 
operative interference ; hut thiit fissun*. with indiimtinn and hypertrnphy 
of the sphinetrr, is nlways sure to rceiir when healed in thi» ninnnor. 

Nitrate of Biiver in solutions of from 2 to 30 per eent, and eome- 
times in the ^oljd tttictc, is a useful ivmedy. It stimulates sluggish 
ulcers, destroys exiiljeraiit sr»nulationi<. and forms u coating of albu- 
minoid of silver over the lesion, which protects it from irritation by tlie 
iiecea. Occasionally it relieves the pain after one or two upplimlions, 
and accomplishes rapid hcalinj;. Thi^. hnwovcr. only oecurs in sliallow, 
uncnni plicated fiKHureii. The other ehemitail cauturants iire not so good. 
Piiintinjr the ulcer over with iodoform, 10 per cent, and llexilde collodion, 
90 per cent, will sometimes give great relief. The parts should always 
be held npart until the ether in the collodion thoroughly evaporates, 
otherwise it will give great pain and blister the surrounding parts. 
Hea?nt exjicrienecu iiulicatc that a 'i^- to .il)-(«T-(Tnt solution of argyrol 
will prove one of our best local remedies in fissure. The treatment by 
it'hthyol, however, is the most wittsfaelory. 

Opfratirs Trftitmnif. — The operative methods for the treatment of 
fissure foiiiprii^e dilatation, incision, and excision. Incision and exci.sion 
are probably butb old<.-r muttiud^ than dilatation, and yet perhaps at the 
pa-Mut day the larjiri' nmjority of Iiissnres are trealL-d by fureible dila- 
lalioii. This ntctbod is usually credited tu Hecamier, but upon invcstiffo- 
tion it was found that hie method was not that of forcible dilatation at 
all, but rather, as he calls it, a " massnfif radenee." It ennsistotl in 
introducing the fingers into the anus and grasping the sphincter mn^cle 
with the thumb outside, «nd in this manner carrying on a massage all 
around the sphincter until, as he claims, it became softened and leas 
epai^modic. The results of this method are not clearly laid down in 
literature, but shortly thereafter Maisonneuve (Clinical Chirg., t. ii, 
18G1) advised and practised forcible dilatation. His method consisted 
in introducing one finger after nnnthi-r into the anus until the whole 
palnj of ihp. hand pasKod through the sphincters, then doubling the fin- 
gers up he further distended ihe parts with his fist until complete re- 
laxation of the sphincter was obtained. At the time of Maisonneuve's 
operation ana^thesia was little known, and such a method was not likely 
to become popular on account of the extreme pain it produced compared 
■with the simple operation of incision which Boyer had introduced many 
years before. 

The other method of dilating the aphincter, as has hiwn dpsoribcd in 
the chapter on Ila-morrhoids, couDtsted in introducing the thumb of each 




hfiml tlir»ugli the anufl, an<\ with the fingers upon the tuberosities of tliG 
ischii, diluting tlu? ll^[}|| meter thoroujiiily from liide to side, and then with 
the fingers upon the pubis and coccyx gently stretching it antero- 
poetPrioily. This procudurt- shoultl he Juu*? slowly ami f^ratiuallj for 
four or tivL> luiiiuti^K, stn^tdiitig thi; parts in all directions until 
the uinHi;lt< IwcoinuK so flaccid and Inose that then? in little tendency* to 
rLicontract, 

Tlu-re have been s good many theories advanced with regard to the 
process by which dilatation relieves the p&in of a fissure. Some hold 
that it is entirely due to overcoming the epaam of the sphincter, arguing 
that the suffering whirh patients endure is caused not by the ulcer itself 
but by the muscular cimtractions whieh aqucezc and irritate the exposed 
nerves. Others hold ihiil tlie relief is nceasioncd by the Ktrctching of 
tlie nerves, and is rnniptiralde to that which h seer to follow stretching 
the nerve in cases of sciatica. Still others hold that the relief is occa- 
sioned by the subcutancoiia and superfitial hemorrhage in such cases 
acting as a depleting, antiphlogistic agent to the local congestion. Re- 
cent experimental studies in this line ecein to indicate that il iimy pos- 
sihly he due tn the reflex effect up<in the spinal ei^nter due to tnnipnrBry 
traumutisni of the nervo-ends. What is exactly iieeniiiplislni(i by 
atretching is not clearly understood. Rxperimcnts reeoriled by Alling- 
hiini.and repeated upon dogs by Hartmami, dcinonstrHte that by stretch- 
ing, the muHcnlar fibera are not broken nor are their fibrous attachments 
anteriorly or posteriorly severed. There are no hiemorrhagcs in the 
muscular tissue itself, and there appear to be no alterations in the nerve- 
ends. The base of the ulcer is deejK'ned, but it is impossible to sup- 
pose that by this means alone a healthy ulrer can be established ; if, in 
short, the ulceration is due to infection of n tnnimiitie lesion, this infec- 
tion will still be ojjeralive after, as it was Itefnre the stretrhiiig. The 
operation can not change the nature of the ulcer. Hartinann's conclu- 
aions are that the relief obtained by forcible dilatation is due to thfl 
production of "a rGfl«x atony of the spliin'-terti." The (act that the 
rauacles soon regain their tonicity is opposed to this view. It appears 
mure prol>ahli' thai Ihe relief is due to the fad that by tht> fnn-ilile 
stretching, the nerves which are eaught and held by irifiHmiiialory 
proci-ssea are torn loose from these attachmenl«, released fnmi tliidr 
aabnu-'c, ami also from the stjueczing (^dnswiuent upon sphincteric 
contraction. This, like all Ihn other theoncK, is pundy hypotlietiral. 
The fact (hat incision relieve-s the pain quite as pmiuptly would indicate 
that the effect was duo to disabling the sphincter temporBrtly. ■ 

Suiue surgeons dilate the spbineter with divulsor^. eueli aic those of 
Sinui, ThelMiud, and Worbe — that iif Malhcws is one of the best. In 
OKA in which there is a very strong sphincter a Van Daren or Sims's 



808 



THE ASrS, RKCTUM, AND PELVIC COLON 



\aginal Bpeculum will be found to be helpful, but instrunwrnts arc rarelj 
nccrssftry iu this operation. 

In ihu fsce of the preponderance of testimony u to (he curative 
effect of fort^iWe dilotation in fissun*. the author is compelled to state 
that hia cxptTience <!">e< not corroborate the opinions of tJie majority 
of writers upon this subject; he has not only had it fail in hi« ott-n 
operations, but he lias wen a large number in whom the operation 
had bepii practised by other Kurgeoiir* without success ; at least the fissure 
returned wilhin n short time afterward. It is needless to eay that io 
those cases where there la u imlypus at the upper angle of the fissure, 
stretching alone will not ciin: the condition. U ib necessary to reraovo 
the complicating tumor. Somotimce it » overlooked, and this cxplaiiu 
the failoTe. The Fame mar also be ^id of sentinel pilei: at the lower 
anjile of the wound. But laying the^e eases aside in which the opt?ni- 
tiou may U: said to have been inLunipletely done, tlioro are still others, 
e«pe<:ially at the £)oslerior commissure, in which Rlretchmg does not 
result in a cure. Where there is considerable indumtioii and hyjier- 
tniphy of the edges of the ulctT, stretching, while it relieves the pnjn 
for the time being, will not result in a permanent cure, owing to twti 
facts: First, thewe hyiwrtrophicd edges fold inward and interfere with 
healing; second, the fissure is jiractically seated upon fibrous tissue at 
the juncture of tliL- muscular fibers as tiit-'y come together to form a 
sort of tendon behind the anus, ami these fibers are simply separated 
by the stretching aud not torn or paralyzed, The result is (hat iho 
infolding edgca prevent rapid heiiiing, and the muscles, speedily re^^in- 
ing their power, reproduce all tlic old symptoms. 

In auch conditions the edges should be trimmed o!T and the muscle 
incised, as will be described presently. There is a difference among 
writers with regard to the class of eases iu which dilatation should be 
practised. Allingham states that it is the safest method in old people, 
and in tuberuulous and vitiated eonslitutions. Mathews, on the other 
hand, states that the operation should lie avoided in snch cases. To 
one who has had very much experience in operations upon old people two 
facta arc prominent : the first is, that these individual do not recover 
mugculor tonicity with any degree of certainty ; the other is that they 
all bear suppurative diseases very poorly, whereas in aseptic conditions 
thoir tissues unite in a most eatisfaetory manner (Tuttle, Operations on 
the Aged, Journal of the American Medical .Association, vol. i, 1901). 
With these facts in view one can realize that the operation of divulsion 
may easily result in incontinence in tlie^e individuals. On the other 
liaod, incision may ctiuse huppuration aud death from exhaustion. It 
will be better in such cases to adopt a method by which both of these 
dangers can generally be avoided — i. c., excision teiih immediate sutur». 




aan 

■ the 

^P ccrti 



FISStntG IN ANO 309 

To cases of phthisis tlie Q^^siire is very likely to Iw tubereulur in its 
nattire, and inoisioii miii «lrL-tcliiug art* both umlt'sirulile. If L)ia lesion 
can be tlioroughly excised, and Xhv t-dges scwt-d togeilicr, it is perfectly 
proper to do so. If not. tliese wouiide bud U-ttur be treated by the actual 
cautery or b_v loai! aiP[ilicati<>iia. Where the fisnures are multiple, forci- 
ble dilatation is always advisable; and in children who dn not liear local 
treatment patierlly, tbis itiethi>d is exceedingly successful, except in 
thoM due to syphilitic dleense. 

Results uf DHtitalitm. — At tho time of dilatation there is always some 
hemorThatw, but it is never alarming. If larefully and slowly done 
there will be very little teariuK or traumatism of the partB; tlii're is 
altrays an extravusatinii of binod into the relhdar tissue around the atiiis 
and a consequent diseolorution and eongestinn for a fev days following. 
Kspcriments have ^hown that there m no e.xtravasatiou of blood iu the 
muecle, no rupture of iIh fibers, and no laceration of the fibrous rhaphe 
(t^uC-nu and llurtmanii, p. ■144). The length of time dnriug whieli the 
paralysis of the luustUs lasto is variable. K one will examine the 
anus of a healthy adtill patient after it has been divulsed, he will find 
that within an Imur following the operation there is no longer any ga|>- 
ing, and stimuUitiun l<i the muM-le will prodiin- a n-rtain amount of 
contraction. This eontrnclion continuop to inercaee until wilhin 
twenty-four to forty-eight hour* the patient will have regainod eon- 
siderable sphinctoric eontrol, and at the end of yeveiity-twu hours ordi- 
aarily, complete ephiueterie aeliou will have returned. Even within a 
few hours Np:L«modic twlli-hing is resumed in most eases. The idea (hat 
the sphinrtor rr^m.'iin.i psimlyzed for a sutHtient time for the ulcer to 
is not borne out by facts. 

If the healing of the fisi^iire depends upon the maiutouaace for a 
certain length of time of the paralysis of the fphiactcric contractions, 
the question arises whether it is not wine to introduce into the rectum 
either a firm plug or bougie, ami maintain it there for n few dny*, ro 
that by long- continued (ilrelehing thi;: paralysis will reinain more per- 
manent. This method is employed by many surgeons after operations on 
lueuiorrhoid?. and the author bus used it with good effect in fi«s«re. The 
IVuuingtou tuljea s^en-e exrelleiitly for Ihis purpose; by wrapping with 
gauze the plug can be made nny pise, and the rubber covering prevents 
tbc granulations becoming eaught in the meshe«, nnd thuB torn when 
it ia token awuy. The tut* ia best introduct'd through a bivalve eperu- 
Itini, and held in position by a safety-pin nltaehod to a T-lwindage. By 
this means the dilalition of the sphincters Is maintained, and. strange 
to say. after fnrtyH-ight hours the patient feels more comfortable with 
the ping in place than he does with it out. 

tiDqueetiuluibly this prolonged dilatatitio hastens recovery and makes 




THE ANUS, lUGLTUM, AND PELVIC COLO\ 

the ttecal pmnaga? at ftret much easier. It i^ udvixabic in any cn£C of 
•CTCie ll«Hure operated upon by the method of dilatation. I'crmnDcnt 
Jncftntinonoc lins been seen to follow divuUioii of llio unue, and a lo«8 
of pieniiation thnt indicales the npproacU oF fuHral ur ]j;a»fou6 pesigee is 
not at all infrefjiipnt. Tlie autlior lias had two palioiit« in whom this 
op(>ration hm^ 1h*pii follnwrd bv unctrnMrloua xtoola at night, rcfjuirtag 
tliC'iii always to wear a napkin. 

Melkad of fticision. — The second method of operating in anal fiiwurc 
consists in an incieiOD through the base oC the ulcer. Thifl method 
was Crst advocated by Boyer in 178S, and since that time has been 
dcdcribcd under his name. Boyer, holdinf^ that the fiBsure waa duo 
to spftRin of the sphincter, advised eomplole suction of that muscle in 
order to absolutely control this spaHmo'lie cnntrnctioQ. So far as can 
be learned, he did not advocate cuttinp tlirrmgh the base of the ulcer 
Bt all, hut even M>mrtiini^s iiiadp a section of the muscle upon either 
aide of the rerlum, thus completely pamlyzing it. The fact that these 
operations, which did not affect the uker jmr se:, resultt'd in immediate 
relief of the paiaful eymplouis. and a cure of the fissure lends color 
to his tliL>ory. He also mtrmlucfd a hard hongie suirounded with 
charpie, and thuH kept up contintiotis dilatation. Follnwing him, others 
thouglil that it WHS not nrcessary tn incise so deeply, hnldinif that it 
was only the superlictal iihers that kept up motion in the ulcerated 
surface and thus prevented healing. 

Mathews, even aa late aa IWM. advocated .scarifying the fissure with 
the edge of a kiiifo instead of cutting the muscular fibere, and olainied 
that ho obtained juet aa good resulta. Among those who believe*! in 
the supertlcial im-isiou inny he menliontfd the wli^liratnd Dupuytren, 
Curliug. and Cupfland. The latter even held that an incision into 
the niueoiis im-inhnine alone was siifhdent to cure a fissure. But un- 
foriiiiiatcty the nmjorily of lliese iitrrrs has nlready passed beyond the 
depth vl the mucous membrane and inviidcd the Enibmucous tissue^ 
Bometimcs even the rau«cular fihcra, and therefore this operation will 
not suffice. 

Tho depth of the incision and the point at which il should he made 
are of the utmost importance. It should he deeji enough to put the 
muscle thoroughly al rest. It shniild jilsn be ninde through the nicer, 
for olherwise it would produce a site for infection and possibly a second 
fissure. This appticH to ulcerB which are not directly in the anterior 
or posterior coniinissuro. In these cases it is only necessary to refer 
for a moment to the anatomy of the region to eee that an incision 
directly in the posterior conimia«ure would not sever the muscle. The 
fibers of the external yphincler Hnite iii a aort of tendinous prolonga- 
tion at the posterior commiasure. They do not decussate to any marked 



M 



PISSITIK IN ANO 




Fw, 108.— V-au*ni» IfiuinniN T'lB i'lit- 

■ UMH AP tHlll'u8t'tKllinOl>inilMUIU( 

or Till AxuR. 



degree, but propped pjirallcl with oach other bacT: to tlieiT insertion in 

the coccyx. An inoiiiioiL tlicrt^forf direeUy back to the tip of the 

coctrrr will result in llie sejiaration o( most of tht-se liben; and the 

cntling of very few. This will not put at rest the muscular oontrac- 

tion, ami therefore it will fiiil in fisHuru 

directly in the poAtcrior coiriiniiMuro. 

Moreover, those fibers which ari; severed 

by the incision will bo cut at an oblique 

angle, which is alwayu Blow to heal a.nd 

forms an irregular cicatrix which is not 

conducive to tli* best functional action 

of the muBcle. Thus it will be seen why 

in theae case-* openit iotiit by divulsion 

and incision have both faitcd. In the 

one the niUfiCiilar VAhth are dJtwbled for 

B short time and separatod by the force 

of strL'tchiu;,', in the olher Ihe fiburs are 

simply separated by the edge of n nharp 

knife, which may ciil a fi>w, but by no 

means cnonyh to paraiyzr thi^ action of 

the muscle. The cxptTiments of Qti^nii and the other Parisian surgeon, 

whom Ailini^ham <iuote» but iloee not give his name, are very iinportunt 

witli regard lo the obaen-ations upon this point. They say that there ia 

no rupture of the muscular fibers nor of the tendinous fibers. There- 

foro their contractility rclums very soon. 

All thiB di;rn"ssiou dwrivoH iis importance from the fact that it ei- 
plaina the failure of the commonly acceptetl methods in the troatraeiit 
of a pn-at many canes of fissure. Those at (he ef)mm insures should bo 
treat<-il by incision, and tliis nbouiil be inadii on one aide or the other 
in order to sever the muscles and put them at rest. The V-*h*P<id 
ineiBion {Fig. I(i8) aerveg excellently in these eases, because it piil« at 
rest Ihe tibers of both sides over which the uU-er is situated. 1 1 also 
outs them titjuarely across, thus eonducing to a siimll cicatrix. By 
thi« incision many eases can W promptly cured which are rebellions 
to the ordinary nits and to divulsion. It sut-eeeded in one case in 
which these nclhods had been tried five times and failed. 

Fjcnt/ih and Vrpth iif ftidnon. — The length of the incision should 
be a little greater than the ulcernlion, starting above it and ending 
slightly below it. The depth of the incision should extend about a 
quarter of an inch deeper than the deepest portion of the ulcer. These 
are the only safe guides. 

As Allingham points out, there is much more danger of failing to 
cure a fitwure by too superficial inciaioa than there is of incotitincncc 





819 THE ASUS. RECTUM. AND PELVIC COLON 

from a single tleep inoUion n.t right luiglcs thraugli the sphincter mus- 
clee. He Hays that it the incision is mule fxjtiarply across the mwt' 
cular fibcre the ulcei-ation will heal before these rounile, anJ when tbo 
union has been completed there will be a thin square cicatrix which 
will not interfere with the functional acti«u ti( the inuselo. If the 
incision be made at an angle the libers will nut entirely sejiarate, ihey 
will unite Urn soon, and there will be a long, irregular cicatrix and 
permanpnt lengthening and Ioai* of power in the muscle. 

It is therefore better to earry the ineisien a Utile loo (lecji than to 
take any chances of failure to cure the pntient by too great a con- 
een-atisiu. A slight superficial cut will relieve the pain temporarily, 
but it (loos not parahTie the sphincter for a BUfticient time (or it to 
result in the healing nf the uleer and a cure of tlic liasure. If, how- 
ever, the incision is deep enough to thoroughly divide the muscular 
fibers, they will retract and the iilrer will have abundant opporl unity 
to heal before a nufticiently fimi cicjitrix has formed to (^oablv the 
muscle tn act. 

The theory upon whidi this practice reete in caees of great hyper- 
trophy of the sphincter muscle is that this section and retraction of 
the muscular fibers put them absolutely at rest until the cicatricial 
union botweuu their ends gives thciii ;in attatrhmunt through which 
they caji exercise their powers. ,\t the samii titne this cicatricial inter- 
position lengthens their attachment and thus dcen-ases their eontnictile 
power. Thus a tt-mporarily complete rest and the clongatiim of the 
fibers through this interposition of the cicatrix brings about a partial 
atrophy of the muscle, restoring it, comparatively speaking, to it* 
original stale. 

One great advantage of operation by the kjufe at the present day 
consists in the taet that general anieslhesia is unnecessary. In divulsian 
it is almost a necessity, but by tin* hypinlfniiic injection of cocaine or 
cucuiuc it is possible lo incise any cas(? of lis-sure iibsidulely without 
pain beyond the .=ilight prick of the needle for the introiluction of the 
drug. 

The strength of the cocaine solution to be used may bo from 1 to 
4 per cent. The inllllratiou method of Sehleich is not only painful 
but uncertain, especially iibere there is any amount of iunaniiiiatiun 
ajwl iufiltmtion of the parts, A ?-pt!r-eent fwdution of cocaine or a 
4-]>cr-ccnt solution of eueaine is upon the whole the most satisfoo- 
tory. Five or 10 minims of the enraine soliilinn. if slowly and eiirc- 
fully introduced, will ana-stlictixe almost luiy anal fissure and trnablc us 
to inciee the mueclo and scrape out the Usstirc without any pain. It 
U necessary in these eases to use the finest h^1Jode^mic needle. First, 
in order tluil the miuiinum ajnouut uf puin umy be <K-i:rasioncd hj its 




introduction; and second, in onler that the amount of thi; fluid uaisil 
ma}' bo BO slowly iDJwted thai it wilt diiueininati^ it«plf over a largo 
area. Recent vxperiinents with medullary BiD^nthewin ahov what a 
powerful intlueui-e uiinule ■quant it ii-s of a weak snlution have when 
applied (lirretly tn the ncne-centeris or to the nervp-lissues theinsolves ; 
M) titat in tlicse opt-rationH it is only nf^cvwtary to bring the smallest ■ 
quantity of the solution into rontact with the nerve-ends or the ncrve- 
trunka in order to completely oua;ethetize the parts. Tiie best prac- 
tice is to inirodnce the needle through tlie lieullliy ekin just below the ■ 
fissure, and Ijy this une puiic-lure to carry the eocainr bcnouth and 
ujjou eat'li sid(- of it iJi «rih?r to Iiring tlH> dnij; in conlat-t with tlic nerve- 
trunks and nerve-ends supplying the dij^ensed area. After the eoeaine 
lias In-cn injecti'il for two or three mitintefl, a Sims or Van Bnren specu- 
liini ciui be introduced and tlie exact location and the extent of the 
ulcer wen. A competent rectal eiirgeon ought to be able to tell this 
by digital touch: but the addition of the sense of sight and the accuracy 
with which work <-an be done which is clearly in view, rompared with 
that done only by touch, can not poanibly bo of any dii^ntlvnjttagc to the 
moot expert surgeon, and It in an absolute ncceiwiity to those who only 
operate seniiorcasionally- 

1( there be any proud fleiih or exuberant granulations in the nicer 
they (>lioii]d be wraped out willi a sharp curette or a Volkiuann spoon. 
After thin the incision sliould be packed thoroughly with a fiuiall strip 
of iodoform or sterilized gaUKc and the patient kept in bed for forty- 
eight hours. This injunction wiLli regard tu keeping the patient in 
bed mnkeH the iiulhor liable to the charge of iucouKisteiu-y between 
pmetice and ti*aphing in the eyes of many of his old studentit. for they 
well know that more frequently than otherwise he oiicratc,-* upon these 
eases of fissure in liis clinic, allown thrin to get up and wulk bonu- an 
hour or 80 after>vard. and to resume their work upon llie following 
day. Many of the fitudents hare eecn case after cii*e return nt the 
next lecture absolutely free from pain and grateful for the relief 
■iTorded them. NeverthelcBs, in private practice, it is not wise to take 
the ehnnces whir'h one takes in rlini<:al work. Many of those patients 
in the clinic depend u|K>n their daily latior for food and support for 
tlieir wives and chilrlrcn, and it ih of the utmost importance that tliey 
keep about in order to retain their positions. As a consequence the 
majority of them would refuse to have anything whatever done which 
entailed the necessity of their laying up from work. Thus while the 
operation upon walking eases is not a method of rhoire, it is justified 
by thi* neeetwitied of the cane. The ivsulls of tins practice are Nuflicicnt 
annwem to the claims of French surgeonii that the method of diruldioa 
re<iuirc9 lc« bodily confinement than that of incision. The elTect of 



i 



8!4 THE AM0S. HECTUM, AND PBLVIC COLON 

geuer&l ana«lEi€£ia ilsclf dotaine & laboring man from liig work longi^r 
than a tvLuIu oporatiun by incision. Moreover, the latter ca,u».'^ iio 
trauinatiitm,. contusion, or extravasation of blood into the cellular tU- 
Buea, lis iioi-a furiiibk* utitatutiou. 

The iUu;icra ot iiariiio[i]iat,'f into the cellular tisauca following forci- 
ble dilatation arc not to be ignored, as will be seen from the cases 
doscriboii in another portion of thi^ work (»!0c chapter on Hajmorrhoids). 
It is uet'tlle^u to say that in the operation by incision all simtinel piles, 
polypi, papilla-, or bypurtrophiod edge* of tlw mucous meuihraue 
which fall down into the fiHsured tract or ulcer nhould be removed 
at the same time that the nmnck* la cut. Unless these prucaution!i 
are taken no operation, whether by incision or dilatation, will prove 
auccctuifitl. 

Other methods of inciKiou have been adviaed. Hilton advised pafis- 
ing a sharp-poiiiled liistouiy beuewOi the cxlenial it|iliintter nnigelc and 
cuttiuff Mpwanl Ihrotigh the iilceration. Demarquay (Archiv- g6n. de 
tuM,, IH-iG, \i. ;1T7) iidvncaled the submuenuK imndiou of the uiusele. By 
this nu-thod a bistoury in piuwed from the margin of the anus upward be- 
ui'iith (he inui^oiis membrane and ulepnitinii an far as the ulcer extends, 
and the sphinrtcr is then cut ouiwanl until rrlasation is produced, a* 
is done in the subcutaneous operations for contrnettid tendons. Aa 
Ball states, however, this operation and that of Copeland could only be 
applied to those eases in which the ulceration was very slight or in 
which there was no ulceration at all, but simply a congestion, in wliieh 
case no operation is necessary. 

Allin^hani calls attention to the necessity of restoriujr any rnal- 
formaliuns of the uterus before attempting operative jirocedun; for 
fissure in women. He also lays great strcse upon the ucfcssity of keep- 
ing tUcm in bed after whnlcvcr procedure is adopted whenever there 
is any uterine or vesical disease, ttiis advice is certainly wise, and 
Deeds only to be mentioned to bo appreciated. 

Excision vf Fissure. — In onr diseussioii of the pathology and eti- 
ology of fi^uif, attention has been enlled to a clu^ of cases in which 
tliere is marked induration and eicatriciaJ formation at the base. It 
baii been stated that in u eertnin Dund>cr, although Ibe ulcer vras com- 
pletely healed, the patient Btill suffered from pains of a dull, acliing, 
neuralgic charaeter about the rectum. These facts were explained by 
the histnlogicnl sliidies of Hnrtmann, which demonstrated that thege 
patients not only jiuffercd from an ulceration of the anus but also 
from a perineuritis in the deeper tt»(8ues Iwlow the ulcer, and that 
neither stretching nor incii*ion was absolutely sure to relieve this con- 
dition. Having seen & number of eueh ca^es upon which divul^ion and 
incision had proved failures, the author concluded some three yaan ago 





* 



Fli^SURK IK AXO 315 

that it would ho wise tD auch cases to diaecct out tho jndtinitpd mass at 
tiie wiim> tiini? that lit' t-itlier stretcliMc] or tDciacii tht- sphincter. Up 
to the present time he has operated ou 7 patients. In 4 the Qs^ure 
was iiiKrouiplicalt'il, and uftor disiieclin'; out tlio indurattid niiLS)« aitd 
indsiii^ th*.' sphincter, llit- fivshi'iit-Ll ciifji'S nf tho inua>U!i mcmbrune 
and «kiu were ftutiired over the bIIh; of tlio ulrcr. In 3 of tlii- 4 uisns 
priumrv union look place and tlic patient vraa absolutely wl\ at tlic 
end of one week. In the fuurth ca«« infection look place and Uio 
stitches had to be removed upon the third day. Tlie healing was soiiio- 
whnt protrnetod, but the pains were entirely relieved, and tho patient 
made a good recovery at tlie end of about five wneks. In thu other 
2 caisea in which the diseection was done the fissure was complicated 
wilh ha-iiiorrlioidul discnsc. In one of thcsp the inndified Wliilchead 
operation wus pi'rfunnetl after disKcclJun out the ciaitrteial ttMiu-s aboTil 
the fiaenux! and inciii^iDg the Ephincter mueclc upon each ^ide a£ illue- 
tratpd (fVp. lOS). In this c-use the result was ideal, both in re^rd 
to the hn'moirhoids and tlie fisduro. Primary union took place all 
around the amis, and at the end of ten days the patient loft the hos- 
ptial perfectly well. 

In (he sixth ease, in which the excision of the fissure was nmde, 
the elainp-and-eautery method wa» used for the removal of the ha-nior- 
^»id« »nJ left the fissure wound open to heul by jrra nutation. The 
ticnt suffered corwtdornble pain following thi- operation, hislin^ for 
■bout tive days. He was a hypcnesthctic individual inojipalde of ^iitTer- 
ing patiently, and wae in the habit of taking opiates for relief. In 
his ease, therefore, it was necessary to adniinixter numerous liypo- 
dcnnics of morphine; but after five weeks the parts were healed, and 
he has never had any return of his old pains, ha^ entirely discontin- 
ttsd his use of dn];;a, aii<l In- is now attcndinj^ to liifi ]praeliee. which he 
had jiractic/illy jjivcn up on aci-ount «f his fissure. Such a limited num- 
ber of CR»C8 ift too few from whirh lo draw any hro.Td (^nnelusions. The 
TWults, however, would seem to justify a wider npplicnlioii n£ llii^ jiriu- 
ciple in all eases in which the dull, aching pain following fireal move- 
ments indicates the involvement of tlie deeper nerve-lninki' in a pmrcss 
of perineural inflaininaiion. The possibility of specific taint, even in 
the moRl innocent, has led in all cases in which a fissure has e.ii3ted 
for ninoy months to f^vtoj; tbe patient moderate doses of mercury and 
iodide of potash, even lhou>(h no other mniiifestationii of the dineiwe 
were prcfienl. In 3 cases in which the fissure had already biwu incitied 
hy other operators and hatl not healed. iJio ulcer was cured by local 
applications together with the ad mi nisi ration of this mixed treatmcut. 
TfVTiether it affected an obscure, constitutional syphilis, or acted hy its 
tonic SDd alterative effect, it is impossible to Miy. The nccct^ty of 




81« THE ANUS. RBCTUM. AND PELVIC C0IJ3N 

coiutilutional troatmcat in cases with tubercular uDii auKmic tendenciog 
■hoiild not be overlooked. 

Oii(< otl)«r fealiirc u')iifh lioM afTordpd considorablp iiStisf>i«tion tn 
wime tif llit^HO caDi>(i has been tlie rot-o^'uition or rliL-tiinatic ur gouty 
K)'mpt()i[iti uUewhi^re in the body; thcuo inf1ui<Dce« may also u«uriit^ cod- 
Biderable itnporliuici-- in tlii' neuralgic mid uclliag psilu of flsRurc. 
Wherever this coii&Citutioiutl tuudeucy cxials it is well to jmt the 
patient upon aitrogcnuus diet and udmiui«tiT some anti-rhcunuitics, 
such ad Balicylatee combined witb allcaiios; Tiirkisli baths at re^rular 
intervals will also bo useful in order to koop the skin and kidneys 
active. 

In Donolusion, it may be wiid tliiit wliik' divuUion will bo sue- 
cesHful in the majority tif cat;e»i in which itic fiitsure is laterally located, 
and in which Uierc; is no coniddeniblc induration and ncuriti«, it U 
by no miiiuis an ahsnliilt-ly sure miMhnd for tlic trt«liiii'nt of fis»urc. 
Simpio incision is more ci^rtain, and will rnsiilt in n cure in tho 
large majority of cases. It has the advantage that it doos not re- 
quire gent'i-al ana'Btliosia, heiug done under tho influt'nce of cocaine, 
and it niaintainii the relaxatiuu of the uphiuL-ter inuucle for a nuiuh 
iMiger period tlian is accomplished by the method of dilaLutiuu. 
Mun-'ovtT, whi-re the ulcer is situated above llio external sphincter it 
fumishea complete drainage and aroids the accumulation, of pus and 
ftecal matter in tim dcprcKMon cau»pd hy the ulcer. This mcthml is 
Dot always succcsitful in cdses with marked indin-ation; in those the 
method of excision is the safest and suroHt so far as rapid and com- 
plete cure is coneemwl; and this also may be done under cocaine. 

Many of tlieso case* an' coiuplicaled willi ha-iruirrlioidal dint-ase, and 
the operation upon tlit' fissure will he delernuued by the method 
Bclectcd for the operation upon the harniorrboids. If an open opera- 
tion. siLuh as Ii;j(it«ire, crushing, or (he elmiip and eaulvry is chascn 
for tile bitniorrhwidft, it will ho useless to nltciiipt to i^uture up the 
woiind made by excision; but if the Whitehead operation is adopted for 
Ihfi hn'morrhoidp, then the edges of tho fls&uro wound should be closed 
at the same time. 

Suhmurfivs FisstiTt. — There is said to be a number of cases in 
wbirh the syniptonisi of fissure are associated with uu local lesions tliat 
can he made out by either digital or ocular examination. A case of 
this tyi)e has been deacribed elsewhere in the chapti-r on fistula. It is 
not a true fissure, but a &inali subiiiucou* fistula due to iilreration and 
burrowing downward from nno of the crypts of Morgagni. There is 
very little pua, apparently no induration, and yet tho patient suffers 
at and after evHrj- stool just a-s in ea»pR of aeute, uncoiii|>licat('d fissure 
in &no. It can be diagnosed by the introductioa of a bent probe into 




pfsstmn IS ANO 



317 



* 

» 
* 



h 



one after another of the crjpt»; when tlie discaspt! cryj-it U readied a 
very acute pain nill Iw excited. An incision of tht- muouus membrune 
overlying Ihie little f)^tuloiii< tract is nut t^unicienl to reliuve lUn cunili- 
tion; after laying open the ftstulu tlic gphiaeUr muscle should be 
incised throuj(hoiit the extent «f the tract and to the depth ot about 
n quarter of nn inch below its siirfnee. This will relieve the tiagure- 
like pain and in a eliort time i-adiwilly euro the trouble. This condi- 
tion is rare, but it is very cli^tre^sing to (he patient and puzzling to 
tlie surgeon. 

7'A* Complications of Fisgnn. — Fitf.surc is Buhjcct to tliL* aarae com- 
plications as all otlier ultrrw around Ihi; inarsiii of the anus and within 
the anal canal. Acute intlanimatory processes uiay set up from infec- 
tion of the ulcer tliio to its being torn open afresh by hard fa-ca! pas- 
sngcSf and there may he a eelhilitis, a phlegmonous abweg«. or a fistula 
as the result. Such an accident may al*o follow operations by incision 
or divulsion. It is necessary. thcrefLire, to tall attention once more to 
the necessity of antiseptic precautions in alt operntions upon the rec- 
tum. Admitting; tliut it is iiupussihle to produce absolute asepsis here, 
it is all the more imperative that it should be attained as nearly Ots 
possible. If the reetum is thoroughly cle-ftn.«c(! at the time of an opera- 
tion, and the wound is jineked with slerili/ed paiize, this will generally 
protect the freshly ent surfaces in a filter-like way until lienlthy granu- 
lation has been ii-stablished, '^VHiere there is already sepsis present in 
the parti*, it may hv udviftable to use a raquelin cautery in the cutting, 
in order thut the lymphulics and blood-vessels will be sealed at the 
moment and thus pri-vent infection by whatever ^crms may be present 
in tho Toand or in the intestinal canal. This, however, is rarely if 
ever necessary in the irealiueiit of simple lissiire; and an it is likely, if 
used in severing the sphincter, to cause grraler rontractioa of that 
muscle after henlinp, it Rliould be employed with tlic greatest caution. 
Ha-morrhage has been saiil to result from fissure in ano. Uudouhtcdly 
such might i»i>jisibly occur, as has been reported in the prcrrding pages, 
but as a rule tin.* bleeding is ouly of a trifling nature, coDai«ting in 
two or three drops of blood after fieeal niovumeuts. 

iDContinence is said to have reaulted frrym incision of tho sphincter 
nmsete for the cure nf fissure; when this oceuis it is dm* to thi? oblique 
incision of the muscular fibers. There are mentioned above 'i cases 
of incontinence following stretching of ihe sphincter muficic in elderly 
people. The author is of the opinion thnt as mnny cases of inconti- 
nence result from too rapid and too great divuli^ion of (he sphincter 
M occur from single incisions. 

Strictures of the amis and rectum have been said to result from 
tho irritations of Gsaure. I'ndongcd and spasmodic contraction of the 




918 



THE ANUS. RECTUM, AND PKLVIC COIjON 



inUHcle iH tniil by I'ripps to cause abnormal ^uTttming an<l librous 
ilitgrnt'mtion of Ihv muscle, ami to result iu true? alricture upon the 
\v.ye\ uf tliu itxii'rniil Hpliiiidvr, or tiiutv |turticul>irl;r iu tlikl pcirtion 
of the rcrtiiiii nml tiniis i^iirmiintleil by the levator ani. Tlie farU* 
wliicti liu sttitcft nrp plaiisiltt.e, and we must admit tlie possibility of 
«ucl) a ^(^sult. But this admission only empbasizea the necce^ily of 
«arly and radic&l treatment of all ulceratioiu and fi£6ure» abvut the 
ttuua. 




I 



I 



Thb Uhucs suiTuuiitliug llie anus and rectum are siibjpct to fre- 
quent inflammfltiong od account of llie vast amount of cellular sub- 
etADcc, the profuBC blood »upi>lj'. and the mimerous IvTiiphaticfi of this 
region. This may bo broujiht about l>y extension from rectal and anal 
inflAmiiiationsj by oWtniction to the circulatiftn, by the ino«ulatioi3 
of gfplio materials throiigrh gome of tlip >^lnndiilar tracts, or by the 
depo;«it of these agents from the blood or lymphatic cirrulations. 

Through varialiona of prt-asure due lo the presence or ahscnci^ of 
fa'cal ina«ec8 in the rectal ampulla and to changei* of posture, the cir- 
culation of the partg is at timea £rea.tly impeded, and at others abeo- 
lotely free. The influence of these variations in the production of 
inflammntory procesaca about the rerturn whs rtlorred to by Esmiirch 
iROuy years ago. The constant prusencn of iufevtiou.s biu-toria in the 
rectum and the functional action of the organ ahsorbiiig fluidK from 
the f»ces render it always possible for these agents to he taken up by 
tlie lymphatic* and sniul! blood-vesseln and Indged in the (Hirirectal 
tissues. That which iutereste us, therefore, from a pathological point 
of view is first, the character of the pyogenic bacteria, and secondly, 
the nature of their invasion. 

Recent bacteriological studies have thrown coni«tdorable light upon 
the infectious afjents in suppurating processes. We have learned to 
dl-itingiiiiili by microscopic examination between ihc varions kinds of 
pus discliarged from nl)»ees.s cavitic!*, and to baAc our prognoses largely 
upon the known phenomena of tbeae rlifferent pyogenic agents. Ainoag 
the bacterial contcnta of perii'ectal abscopiKs the tubercle bacillus i« 
frequently present. Koch haa stated that tubercle bacilli arc Dovor 
found in the rectum unltatw there cxiHlc! a lubercular uleeration of the 
intMttiucd. Sornianani, after a prolonged examiuation and gtudy of 
the subject, attemptx to explain the uhsenee of tubercle hsctlli in the 
fecal diftcharges upon the grouiids that these bacilli are destroyed by 
the action of the gastric juice and therefore diwipiwor in their passage 
Uirough the stoniach. Ilia exainiuationa, however, simply showed the 

819 





THE ANUS. RECTUM. AND PELVIC UOLON 

genenl absence of tubercle bacilli in the fiecal rlischarjce, and his 
explaitalion of thi^ aWcnce wae purely theoretical. On the other ham], 
vun JalucI) ami 011161*9 hiivc t^uccec-ded id (iodiu^ the tuWrc-lc bacilli In 
the atooU uf palieuts not alfected with inteetinal ukerahoii; and Vat- 
riire (('ompt. rendus aoc. biol., U)l, p. 1008) has shown by elaborate 
and patient pxperinicnts that cxposiin* of tubercle baeiUJ to both natutal 
and nrtificiiil piu^tric juieo for twelve hnurs or more has uo effucl upon 
their virulence. Simmons (Miinc-hener ined. Woch., 1900, p. 31»( has 
demnnstrated llmt while the gastric juice prevents the mill ti plication 
of tubLTflL" hucitii. it in no wisi' der*lroyo them, and after this Bcerction is 
QcutrulizL'd by the alkaline fhiidi^ of the intestine, the bacilli may go oi> 
find du-vc'lop just a^ if they had never been exposed to the gastric tluids. 
From thi'BC experimonts thero i* no longer any doubt but that tbe baeilli 
reach the sigmoid and reelnni thronjjh the digestive tract independent 
of uloerations higher up in the intoMine. 

It is no unusual experience lo (ind a tiiberculnr abscetw at the 
margin of the anus or in the perirectal cellular tiseueft, as the first 
Eoanifecttation nf tul>erculoi<iti. and it is unreaiKinable to suppose that 
the bacilhia enters throuj;li the rtjtpiratory apparatus and paesL-s through 
the lungs into the circulation, and then lodges in this particular spot 
when it in poesiblo to tnke n shorter ruiI more dirfct route thrungh 
the inleBiiual canal. How it enters the canal in cases with tuberculosis 
of the mires. Ihroat, and lungs, is very eaiiily explained by the fact that 
thesf patit-uts often swallow the discharires and sputa. The bacilli may 
he carriud lo llic parts by patients handling handkerchiefs or objects 
which have been ui<od by the tuberculous, and thus cause local infection; 
it is also possible that the use of syringe-tips, hnugiea. iind other rectal 
instruments which havi* been used upon luberculmis patiL'nts, may 
cari-y the germs and deposit them upon non-tubercular |>atient8. 
Whether it i« possible for these germs to I* carried by detergent suit- 
Stances, clothing, etc., or wafted ihrough the nir, is a qucsliuu for 
bacteriologists to decide. The fact, however, remains that we do have 
tubercular abacesaes and ulcerations around the anus, and sometime* 
in the rectum in caees in which there ave no other tubercular foci. It 
is impossible to come to any other eonclnsion than that these are local 
infections, and that Ihe bacilli reach the pnrts through the digeative 
tract. 

The next most frequent infectious agent found in abscesses and 
inflainiimtions about the rectum i^ the Bacterium coU. The fact that 
this bacillus is so often found in perirectal abscesses is not conclusive 
evidence as to its etiological intluence. Pathologists tell us it is the 
cause of suppuration, that it passes out between the tissues in the 
same manner that the white blood-corpuscles luid amieb:(> pass from 




PBKMNAL ANI» PERIRECTAL ABSCESSES 321 

tilt l>lu>D(l-ve»«elB Hiitl invade* aivm at a distance from the iutetttiiial 
tract. It is always pR'acnt in tlie largu ialfstinf, aud nffda only the 
eli^hti-Kt iiij'uiT of lliu cpillmlial aurfBct- to allord it aa i-utruiicf into 
ttic tia^ucx. Sucti k-»)0]ut arc frciiuoot uiiouj^h, and iua>Tmui;U hi thv 
bsciltus i« always proj-cnt, the iquestion ariso* why it sometimes forms 
fili:see«se8 ami soTiietitiioc tltifs not. Keeent studies by Vauglian eeoTn to 
point lo a jti-ubabk' i.'X|)luiiatiuu of these {act». Ho staled that the 
toxic principle of tbc bacilliiB is c-iiclosed in a capsule, and chat it does 
not product- intlaiunmtiou ur tuxic syiiiptoms until this capsiilt? is broken 
or di&scilred. Ordiiutry alkalitii-s havi- mt ciruct upon lhi.t cfniisulo, Nur- 
rnal fnuLric t>(!cr(.-licms will dit^sulvK it and set the toxic princijdt! fruc; 
and furthermore. h<' considers it possible that the blood (seruin may 
also have this efTect. Therefore, when the bacillus enlers into a tiasue 
largely rfupplifd with capillary firculalion, its capsule may be dissolved, 
thus netting the toxic print-iplc free and eslablishiuy iiilliiTiiiiiatory jjro- 
cesMHH which eventiiale in su|tpiiraliun. Thus the fact that uomial 
Bactfriiim coli is fmmd in ihe discharge frnm an abscess d<ie» not prnve 
that thin i» the ciiiiM" of the Rhs»vss. If its capsule is intact it is proba- 
bly innocuous. It is rarely found alone, hut almost always asiiociatcd 
with other pyogenic bacteria. Buch as the staphylococcus, streptococcus, 
aud tubercle baciltue. Harlmann and LielTring in a. study (Bull, do la 
eoc. d'anat. de Paris. ]SS3. jip, ilin, Kil, 5i;) on the charaeler of bacilli 
found in jn'rireelal abscesses, slate that in 7 out of 10 cases tliev estab- 
lished the existence of Inhcrcle bacilli. In 4 of these cases lliis bacillus 
was associated with the Bjictcriniii coli. In only 2 chm-s out of the 
18 studied were they able lo find the Bacterium coli aloTie. Twice i\u:y 
found the Staph ylncoccus aureus in a pure state. In 1 cane tiie microbe 
of tetanus was found, and in another ataphyloeooei a«8i>ciat<'d with 
Bnctenum coli and saproph^'tes. In numerous examinatiuns wliieh have 
been made for the author of pus taken from abseessee around the anus 
and rectum, no case has been seen in which the Bacterium coli was not 
wuHKiated with either tubercle baeilli. streptococci, nr staphylococci. 
Achard and r-annelonfrne fBuII. nu^d., 18^3. p. 73) have confirmed the 
oljuervationfi of Hartmann and liiefTrinp by the report of a cjutc o£ 
abscess of the margin of the anut*. in the pus froau which only the 
colon bacterium was found. Muecatello (Iji reforms' nitd., l^^i^, p. 145> 
lias also reported a similar cas^". In all eaBca, however, infecl ious genn* 
of Dome kind have bemii found. We may therefore assume that the 
septic nripin of perirectal ahscewes i« thorotijrlily established, and that 
the old theoriei* of idiopathic, gangrenous cellulitis, and suppuration 
are no longer tenable. 

Courat of luieH'\on. — The methods by which such infection gains 
an entrance to the tiwnce must therefore be studied in order to nccouut 
91 




333 TUB ANUS. KEC'TUM, AND PBLVIO COLOS 

for tlic vumtious in tliu.riict.LT uut! t-oursL- of those different tyijca of 
inflamimiliion. Tlie (irnt aad mani easily uudcrstnod method U through 
sonit' Iwion of the mueou* mcnibrane or of lh< skin in these re^on*. 
Wounds or injuries to the |>nrt* from whatever cause may alTord en- 
trance to the iiifoetious agents into the perianal er |)t>rirecta] cellular 
titMUL'ii. The niiture and depih of the wound somelime;; govern the 
extent of the infeetiou, but the cliaraeter of the genu and the aclivitj 
of the lyiniditttie and Keneral circulation have much more to do with it. 
These lesiotii?, wliile Ihey attomit for the i-ulruufi- of hacilli, do not 
fumish ux any iufomuitiaa as to the route that the; travel in their 
invasion of the different perirectal lisauee. There is a certain num- 
her of ahseessee whieh involve only the ekiu or mueou^ membrane. 
In tlte.se eaaeu the entrance of the baeillus i& probahty through some 
of the glandular orgaOB of these tegunjents, such as the hair folUclw, 
the sehaeeous glands, and (he sulitary or Lieberkiilin folUeles. 

The^tc iihsccsaes ure nutliiuK uiure than exaggerated furuncles, soine- 
ttmea limited even to lui aeneous nature. The lyniphntics of the skin 
may become involrod in those tasoB, and thnnigh then\ an infcetion, 
which originally only involved a small glandular erj-pl, will invade a 
larger ai-ea. Such abscesses remain in this superficial Ivinpliatic system 
and do not involve the deeper tissues of the iachio-rectal fosw or the 
superior pelvie spaces. 

Eczema, herpes, abnisionM from the clothiug, and irritfttion due 
to improper deterpfiit substauees. may furnish an eiitniuce to the iufeC- 
tiou* agents which are swept »ver tho pari during defecation. The 
course, however, ie the same as that jiwt described. 

Other mnrgimil abeeesees oeeur as the result fif thrombi or throm- 
botie ha-morrhoids. The ijuestiun has been asked how infection enters 
through a thrombotic hujuiorrhoid. If these little thrombi, due to the 
niptiire of smalt veins around the iiiargiii of tJie anus, are examined, 
it will be seen that they are very close to the surfaee of the akin or tho 
mucw-cutaneous tissue. The tenttion produced by the extravasation of 
blood in the cellular tissue is quite considerable, and it is altogether 
possible that tlui tension may result in rupture of :ome of the se- 
baceous or hair follicloe in the deeper areas of the skin, thus afTording 
whatever hncilli esist in these follicles or »|khi (he surface nf the skin 
an entrance into the subcutaneous tissue. On the other hand, pyogenic 
agents which circulate in the blood with impunity, when poured into u 
atagnant area may find a congenial menstniuni in whieh to niuliiply, 
and thu* produce infection. Necroses from pressure or ruptaru of tJie 
cutaneous or mucous glands are probably tho routes of infection in 
moat caws. 

Desprey formerly accounted for marginal abscess upon the theory 



k 



I 

I 

I 
I 



PERIANAL AND PERIRECTAL ABSCESSES 323 

suppurating phipbitis, but that disease is always accompanied by 
serinus constitxitionai njinptoiiifi. and in these cases siich are absent as 
a rule. Aa to the eulraute of bat-illi into the deeper perirectal tissues, 
certain casee inav be explained by the perforation of the rectal wall 
eithor by foreign badieH. Bueh ua pins, Rith-buni^fl, syringe-tipn, or ocnn- 
sionnUr by uh-mHtive procfSbeti in the mucous nii*nibraiie. It is hnrdly 
reamnable to Kup}H)Bu tliat infections originating in thiit way could pro* 
duce abscessps not coaiiEctcd with the rectum, and yet it is iindoubt- 
iCdly B fact that a large number of these perirectal absccsHrs have no 
connection with the rectum in the beginning. That they evcntiiate iu 
fietula is due in nio«t coses to delay in operative treatment or to improp- 
erly conceived Burgieal procedures. It is believed that perforating in- 
juries of the rectum and auul wall will account for only a very few peri- 
tveliil alxteesKeN. 

The reailer who has closely studied the arrangement of the lym- 
phaticH, B.1 (h'scrihcd in the chapter upon the anatomy of the rectum, 
will remember that the ^superficial vesHels of this syetem which sur- 
round the anus pa?*' forward through the perinjpum to join the inguinal 
chain of glands, or backward to that behind the eacruip; the deeper ones 
pass through the ischio-rectal spaces to the hypogastric chain, and those 
around the rectum [lass upward to join the sacral and vertebral ganglia. 
It has iKfen provwl beyond tlie shadow of a doubt that infection traveU 
along the lymphatic tracts. It is not the veins or the arteries In which 
septic germs are found in angeiohnicitis, but the lymphatic vessels. 
Septic infections of the extremities travel rapidly to the axilla and 
groin along the Ijiaphatic chaunela. In the same manner infectiom 
bacteria enter the perirectal tissues. It is not necessary that there 
should be a puncture or deep wound for thi,t to occur. The lymphalie« 
in the skin and periiinal tissues trnve] in a superlicial plane. Thus, 
infections which enter these, spread either toward llie scrotum and 
groin or baclvwani toward the sacrum. The lyiitphutics which originali; 
in the submucous area and in the columns of Morgagni pii»4 ujiward 
and outward through the muficular fibers of the rectal wall and into 
tlie cellular tissue which (ills up the ischio-rectal and the retro-rectal 
epac4Mi. These lyiuphalic networlts anastomose with one another, 
nithotigh the currents How in opposite dirfctions. Tho limits of the 
extension of sepsiu is explained by the fonmition of thnuubosis or in- 
Ramniator}' obstructions in these channels, thus demonstrating one of 
the conservative processes of nature. When the infection is chockwl 
in this manner in one direction it may flow backward and progrc** 
in another. TJnis an infection originating in the euperficial tisiiues 
may be checked in its progress, and through the ana«tomotii>! may in- 
TRde the deeper tissues and so produce a combination of tlic superticial 




i 



824 



THE ANUS. RECrUM, AND PKLITIC COLOS 



ui(] profound iufi.'ctioii. These (anu with regard to tbe thrombows of 
Ijrinjihatic Ininkii Imvv hei'U MmahMfiiei by the biict«rii>lagical studies of 
Sfirlt-'Iin ikoir unJ fj_v the clinical uhscrvationx of C'liuAtaignac. 

'\'\iL- fiif't Mmt iil«sircti»e» u4^^L'jLsiniiullj- ctevflup at a coosiderable 
ilijiLanco from iho aims, fuliowiii)^ miaor opuratioiu for haiinorrhoitii 
or liflsure, can only l)c cx])ltiitic><l tlirou;.'ti this method of iDva^ion. The 
l^mnlmlw By»t*m which coiiiiecte with those subteifuniiTiiary urcae of 
Iho butloc'Iu is that tleKci-ibed uti the middle haimorriioidal lymphatic 
ijritU'iii. Th<- superior lia'innrrhoidiil h-rnphatie system aoiineci* with 
the (,'luLeal li!u>ut-fl through thi* ischiatie notch aud the obluratur fu»- 
raen; thuii iajuntn in the unal canal are likely to he followed by 
nbm'UMM'M citlier in the iflrliin-rcrtal foK'tn or iti the cutani»us tiwsucs 
of the biittockft, while those thai ocfiir in the rectum proper are very 
likely to Ik- UHHoc'iuk'd with nh^ces^e^ of tbe retro-rectal space and of 
the deeper HuhniuHcii Iflr tissue of the tfitgh. 

The e[i(do}{ieal fnctom lhi>refnro in perirectal and perianal iuBam- 
matiimn or abdceaiiea are the vnrious infeetioui; gf^rms which are found 
in the rectum and the lymphiilir RVHteni which furnishes thi-se germa 
a nii'iL»!t "if (-migration inln the surrounding tissue)). " The rielmess of 
the iiubsphincteriar Ijinphatic network, the bunches of lymphatic 
trunks ooriUiiieJ in the coUunns nf Jlorgagni, the frequency with which 
thew lymphRtic« are exposed lo npeninjie by flight abraaione and be- 
come imriH'dijitely cootaminated, explain for u« the frequency of ab- 
Hceaiea of the aiiuo " (Quenu and llartmiinn, vol. i, p. l^ll). 

A nu'i'ut mid Rcii'nlilie cladsifiratitm of perireeta! inflammationi; by 
Qu^Qu and Hrtrlmann is m> elalKirate as to be cnnfusiug to the gen- 
oral Htuih'iit., tiowcvrr satisfactory" it may appear to the speeinliitt. They 
mny he htoadty clnHsiliet) as <'irruiuHi.:ri1>(-d nnd Ditfusn liiliiimnuttiona; 
and under these tlie special foniis may be arranged. A sort of tabular 
Rtntciiicnt of this division is aa folltiw>i: 



Oirouin*cril«i) inHauunmioiix or hIi 

AFOMHH 



{Ti's-uiiiciiliiry. 
SiibU';;iiiii<^iitiiry. 
Iwliio-ructnl. 
t IMro-rvtluI. 
Profound -' Superior jw^lvi-rci^liil. 
f Inlcr-liliul 

DlBusij liilioimimlions ^ ) Wffiise [itTireoUl MllHlitU. 

I OnTi^iinuji |ieiirucl«l eclluiStts. 



The order of sequence ordinarily adopted by writers upon thig 
subject is vudated in I his cliKijiifioHliDn becnuso thi> eireumscribod 
inllaniinat.ioiid are very umcb iikjiv frequent in nccurrRUL^p and less 
eerious ic tbeir nature; moreover, the diffuse variety may result from 
them. 

Of the circumscribed inflamniations, tlioee which are below the 




I 



Icvtttar ani muBcie are called suptrfidal, aiul liioso above il profound. 
Of «cii type there uro llirye varieticB, according t* tUu tiesuus ur uri*aa 
involve!. 

Saperflcial Abscesses. — -Tlie circumscribed superficial inflammations 
are tL>f;uiin.'ulary, subiv;;uiin-'titary, and ischio-rpctnl. 

Tegumentary Abscess. — This is thp stiiiplL>8t U\t\i\ »/ cirtiimsrrilM?d 
jn.-riuiiiil iiiilaijiniation. They are due ly infection uf the ftillic-ular rr 
glandular portions of the skin, and luuco-cutaneuus merubnim' alimit 
the margin of the anu:^. Thi-y may \ik v<rry pru|)i!rly lLTim;d folliL-uInT 
abscesses. Thi; term " tuk-ruux,"' usKid by the i'rcncb, dvswifjtivc of 
this form of inflainmation, is very misleading, in thnt it i^ often as- 
Bunied t(i nKprilx' a tiiliprciiloiisi etiolofiy to the condition. The inlUiii- 
matiun may be dut? to any one of the septic or infectious germs. It is a 
dired infection and not due to any lymplintie propagation. It may be 
brought about by irritation of Iheglaiula from chaling. horseback-rid iiig. 
improper detergent suhntnin.fj, rou{:h tJDtliing. and scratehing of the 
parte. Stout, widt-fed, inactive individuale>, not overly attentive to the 
hygiene of the parte, are very liable to this nilection. 

Thuy devuliip as little furuncles or lu-neouit pimples abnnt the mnr- 
gin »f the anus, \'arying in size from that of a bird-shot to a good-sized 
hazelnut. Their nyinptoms are identicnl with thuse of fnlliciilar in- 
Hamination of the skin elsewhere, beginning in a congestion followed 
by evrelling of the follicle, which eventually opern* spontaneously and 
di!*charges its contents either ns a linn purulent fluid or tw a necrotic 
mas* called a "core." Occasionally tliuse abscc3eeB usaume a graver type 
resembling n carbuncle. The inflammati<»n or infection extend? from 
one rnlliclp to annllier until a large nreii of skin is invnlvrd whiHi may 
open at several distinct places close to the mouths of the .ii-paratv folli- 
clen invoived. The final di*;ch«rge. however, of a central necrotic mass 
shows distinctly ihe nalure of the disease, noiwilhshinrling the fact 
that it eometimeg perforates the deiTna and invades the subcutaneous 
or submuscular tissues, This latter condition is a complication and 
not a part of the real tegunientary abscess. Patients generally de- 
scribe IheMe iibscesses a.% iHiils. They may l>e single or nmltiple. and 
sometimes one succeeds the other until the patient's life is made miser- 
able by thpJr eontinucd prc*ciice nrnnnd lhi> nmr^in of thr anus. ,\s a 
rule they do not involve the anal miitil it.-*elf, but are limited to tlie 
cutaneous tisBue about the margin. They do not therefore interfere 
seriously with defecation, and are not Ihe ffluse of any functional do- 
rtDgements of the intestinal ennal. They interfere with sitting or walk- 
ing, and may necetmilate eonfinftment to bed for greater or less periods 
of time simply on accoujil of thi? discomfort prodiicpd. Tlit^re are 
URunllr no contititutiouul symptoms such as chill, fever, and low of 




i5 



326 THE ANt'S, RECTUM, AND PELVIC COLON 

appetite, although ih« temperature may be elevated a degree or mow. 
It is & lomlizeil iliseutw. 

In a DeighborlirtiMl so richly emlowwl with Kmpliatk-s both of the 
deep «rnl Rupcrficial cliHtincU Ihen- is alway*- a poasibilitj- of septic gf?niut 
being taken up from any focii^ and carried to other regions and infi-ct- 
ing them. These lillle fibflcefiBCs are fairly well protecleil from such 
dangers hy the wallo of the follicles, wliieh are more rctiit^ling than the 
overlyinff epithelium, and hence o]>ening and drainage geacrally oecurs 
in the latter fUrcction before the eelluiar i\ss\ip is invnh-ed. 

Treatment. — The niniiajienient of thcAe eases is mther ihtfrapeutic 
than eiirgical. DjfTu«e inflamniation^ and perireetal abeueiises have fol- 
lowed the reekleftfi opi-niiij; of siipcrfitia] abacessea about the margin of 
the anus or upon the bu1toi-l:M. A good plan in theae cases is to make 
a very wnall opening and tlicn apply pure ichthyol or carbolic acid 
upon a fine applicator to the iiitiTioi-. TIik frw application of pure 
ichthyol will frettucnUy diaeipute theee littk intkinmatioDa or hasten 
tlieir resolution if simply painted over the surface two or three timea 
H day u'ilhoiit any ineii^ion being made. Heitziuan advised the applica- 
tion of an ointment of 10 per cent salicylic acid and 90 per cent of 
glycerin ointineut, especially in those eaaes in which tlieee little ab* 
ecegses liad a Ivntli-ncy to rorur; the oinlnu-nt was given to the patient, 
and he was iut>tru4.-tcd to apply it the moment he had any pain at a 
given apnt, and in this way Hiippnratinn haa been prevented in a 
nunibi^r of eases, but it is not uniformly Mieecdtiful in thi« respect. Dr. 
Swinburne stated that he had been succceeful in aborting suppuration 
in many of theae caaea by the injection of a strong solution of salcylic 
acid into \hn iufliimfd follicle. 

Atli^utioa to cleanlint-iis tK of the ulmottt imjiortance, and batbbig 
of till-' parts, especially after defecation, with antiseptic aolutiona, ahould 
be advised. 

Kxcitiion of theae amall isolated inflammatory foci hoe been tried 
a number of timee. In the author'^ hands it has not proved succeasful 
in the neighborhood of the rectum, owing to the fact that it is almost 
imposiiiljle to sterilize the? eutaneou.t tissuoM nf thi.i region. Moreover, 
as stated before, these abseesaea are confined to the derma, and com- 
plete excision would only neressitatfl thf invasion of the siibrulaneoiui 
tiaaues and thus expose parts to infection which are ordinarily exempt. 
It is better, on the whole, to depend upon the applicationa of ichthyol 
or ealieylie acid where these small ahflccp.'res open rtponlaneously; if they 
do not «o open, punctnrc the apex with a small bistoury, and after 
emptying the cavity fill it with pure ichthyol. The patient should be 
kept in a rwumbent posture until the acute inflammatory aymptoma 
have disappeared. 




PERIANAL AND PERIRECTAL ABM-'KSSiHS 



33T 



* 



Snbtegiimentary Abscesses. — Circumscribed injianunationa of the 
ftubciitiiiii^iiiis and -uluiuifoii!; li.>isHi'» are among the eoraoiono^t results 
of anal and rectal lesions, and are rarely if ever idiopathic. They are 
cauiiied by infection of the lymphatics. Althoiij^li tliey can uot always 
be iraced to any definiie solution uf eantiiiiiity in llie skin or mucoua 
Diembrane, it is lirobatle that in the large majority of caaea they 
originate in some siich lesion. The inrcclioii is carried thence by tlie 
lymphatics into the celhilar tissues until it is arrested cither in the 
glandnlar apparatus or by thrombus of the lymphatic trunke, thus 
limittng it to a focus in wliieh it jirtx-eeda to rauUiplv an<3 deetioy the 
ti^ues. causing a cifL-uiiificribt^d luJlaiiimHtiuu und absevKii. Chassaig* 
nac, E«1sey, Hartniann, and others claim that these abttcesses may 
develop in iH>hited external or internal ha'moiThoids due to a phlebilia 
of the lia-niorrhuidiil vcasels. They do not aeroiint for tluf phlchitia 
in any way, nor do they fltate whether the fthsceas causes thrambosea 
of Ihc veins or whether the thromboses precede the abacos^. Fw- 
quenlly such absceast?* follow what are termed thrombotic luDinorrhtiidBj 
but they always succeed the formation of a elut, and do not occur until 
several days latar. It Eh difficult to conceive of such a circumscribed 
phlebitis UK would cause clotting of the blond and ahsc-ess in one little 
ha*morrhoid without any inflammation of the other venous trunks with 
which it is connected, or any constitutional eymptoms such ag arc found 
in the ordinary phlebitic proces*'. It sceme justifiable therefore, in the 
light of modem pathological investigation, to assert that fubcutantou$ 
perirtrfal and perianal inflammalinnst are nlwayH due tu inferliaii of 
immeiHale or renrole iiijvrif.i Ui Ike nk-in nr mumus membrane, iivd lliiit 
Ui$ pTopatfatitm of this inftrUnn it alimg iht tracts of Ike Itfrnplmtie 
apjKiraltig. The sources of such injuries have already been mentioned 

»end need not be repeated here. These abscesses may be subculimcoun, 
submucous, or aubnnico-cutaneous. They ere more frequent in middle 
l^e, rarely occurrinj; in tht wry old or very young, with the exception 
0f one variety, th.^ tubc-rculoug, which does occur very frequently in 
children from two to six years of age. 
Symptoms. — The (fviiiptoiiu? of Ibis variety of abscpRs arc vnriaMe. 
^^ Sometimes they develop obscurely without chill or fever, with very 
^m slight if any pain, opi^ninp spontaneously and discharffing small quanti- 
^^ tics of white, thin pus. Such a cfMirse is generally indicative of a 
^^ tubercular prtN-csH. Ordinarily the phyficion is only consulted in theee 
^B coses after rupture and dischnrge of pua. He then dads a soft, boggy 
^^ mass with a small ulcerative opening either through the ttkin or inueo- 
outaneoUB tissue, from which there oozfn a thin, watery pii» upon pn*s- 
Inn. There in very little evidence nf inflammatory reaction Bueh as 
Endnration, redneas, and pain about the parts. The skin or muoo- 



I 





328 THE ASVa, aKCTUy. ASI> PELVIC COLOS 

cuianeous tii^ur is iindermincKl in alt ilirections armmd the opening', 
■nil if not propeily taken can n( tins l)iiriowiiig nr umlermining is 
likely lo proceed lo an iuJi;finite exteut. Sometimes it burrows ui>- 
ward beneath the muco-ciitaiieoue titties na<I forms a lisluloiis ti'flct 
b^'twccn the canis iif tlii* Pfoliim. Thin liurrowinjj nmy tftko plact' before 
thi? nlwe(?Rg opens. 'l"ho opftiinjr thi'n iiiaj occur in the rectal caritv, 
thtM foniiinff a blind iDU-iiml tistuln. 

At other times tht^^e ab^L-erisee aro ushered in bv inarkeJ constitu- 
tional syiiiptoDis. The paiiL-nt ii* iitliukcil uith a dii^tinct cliill. the 
pulse is aecfkTalfd, ihe ieiii|ierautre t'levatfd, aiiJ tht-re is a leeling 
of ifeuLTal niiilaise. Locully thcii; it at first a (cvVuig of discomfort 
which pradually incrfat^M to actual [lain. Local exainination discloses 
a hiu'd, swullon area af twmo ptn'tion of the anal circumference, hot, 
red, or violaceous, painful to the !rjueh, and throbbing constantly; 
cme^ with sueh aciile L'oni^iilutiunal M'ptic svniptoins, in which there 
was a hacU-nulu^^'ii-al extiuiiualiua of the conti^uu of ab^cesseK. hare 
usually siiowii the pre«L-ii(.t' of sli-ej>tociK'ci and colon bacteria. Theae 
seutL- intlaiiiniiitory «_vinpti>nis hare never heen au-t with in cattes o( 
|)iiro tubercular abseesKe^. The severity of lUe pain »«enis to be 
proportionate to the height of the ahwes*. This onn ho understoo*! 
for two rea»«ons: the farther we ascend into the anal canal the more 
closely are the skin and uiueo-eutinieous tjt^i^ues attached to the mus- 
cular and librous aponeuroses: lliere is Icsi!* cellular tissue in which 
the abscess can diwleiid, and the spa-oin of the sphincter produced 
by the inlltiiiimittory pr«Kr>ws also n»nlril>iiteM to luureiirte the pain. 
Sonietinicn the iibsrciifi(* develop entiioly within the aiiul canal, iu 
vhieh cfl*e one seos iii> outward manifestation of the aatiie until the 
buttocks are forcibly flisteiidcd op the finger is introduced into the 
anus, when a [jrotrudin';, f;li>bular naias, cither indurated oi- fluetuating, 
painful to the touch and obsiruetiiig the anal eaujl, will be found. 
If left alone lliey open spuiilaneou.-ily either thioiigh ihe skin or the 
muco-cutaneous tissuei*: tliey rarely open into the rectum proper; they 
may open near tlie ujiiier limits of the anal canal and thus form u'liat 
it termed an internal, blind mueo-ciitanenuB fistula, or tliey may open 
upon the skin to form an external blind fistida. The moment they 
open, nt whatever height or in whatever manner. Ihey constitute what 
iit eommonly called a fistula of one variety or anothpr. and what is atiU 
more typical they do not drain and heal as simple ahaeesses elsewhere, 
but remain listulous unle<ts Liitl open throughnnt their whole extent. 
No explanation of Ihij^ fart has been given, hut erenp' clinical objienrer 
is 90 familiar with it that he never hesitales in these siibtepiimentary 
absce«ge« of the anal eanal to carry his incision lo the full height of 
the cavity when he opens thoni. in order to avoid secondary operations. 



J 




I'EBIASAL AND PEBIKECTAl, ABSCESSES 



■nTirn llit«G &b£c«s8V6 o|m>u wilhin thp unns and upon the ekin At 
the same liiiif, as dioy 6oiiiE?tiint-B iln, tlioj' form complete sulitogii- 
roontarj' lisluta-. in u wry sniiill rnjinher of cm^t llie iufi-elioii nuiy be 
c-irfuniacriliL'Lt in tlu} suljiaucoue tissue of the iute*tiuai wall :ui(I tliiw 
fonii im iulrumunil iibiiCfss 
of the rectum (Fiff- l'^-')- 
Thc*o casos will Sp aceoni- 
|>aQii'(t witii mild corietitu- 
Liona) tivui])t»niK, i>iieh mt 
licatlachi'. a slifjht elorn- 
tlun of Icmperaniie, heari- 
m-s6 oikI arliing in thr pel- 
vis, [Hiin on <lefpcatittn,an<l 
sometiiues dysuria. The 
symptoitia resemble ihose 
of on iiiJlanu>i3, izitomal 
liieniorrlioid. hiii] un!i>9» 
one IS t>(liit'at(xl in <li(fital 
exominalion he may xiiia- 
take one condition for ihe 
other. In thet>c cases ihe 
finger will discover a glob- 
ular, (ioiiifhy, OP elHstic 
TiiaiW in the roctiim, some- 
tinien fliK^tiiatinR, somotiinos hard, generally in one or other of the ante- 
rior (juikI ranis. The imn'ons itHfUibiane ruay or nmy ant move over the 
surface of the mass. By |>res«ure dovrnward with the finger of one hand 
above the nias8, and thai of Llie other tijioii the extcrnnl inurgin of the 
anus, the SHflliiiK iniiy liv (mtlim-d oud jrrii«j'L-d, but it doe* not extend 
near the cutaneous tim^uc^. Its superficial locution in these cuc^ can b'e 
well determined by the ejqierienceii fiHrj:ean. It is a mntler of the great- 
est importanec that lhi« should he dune, for the o|i«'niug of UiPiie intra- 
mural abscesses by deep inei^jun through the skin and perineal tissueii is 
likely to rejiult in difTusc. iiitlaininatory {itfriprootilis, and is almost cer- 
tain to result in fistula. While llic^c siibtegiimentary abscess's are gener- 
ally cireu inscribed and of uniall extent, Ihcy may also assume a phleg- 
monous typ*"' extend over large areajs. and invade the deeper tissues. 

The author has fecn one case that originated in this rariety of 
Bhsc«C6 in which the whole ekin of the perinarum «■»« undermined fr<)m 
the Borotum to the coecvx, and from one tnberopity to the other. The 
abwwas or burrowing eventually extended upward and forward into the 
inguinal region, reHulling in sup[)uralion of the glands of these |>nrts. 
This {lattenl n-i-overed after prolonged constitutional treatment and 




Fw. lO'J, — IxtiuKt'tiAi. Oil Simaiti^oi:* Ahkimb or 



L 



3 



880 



TaE ASL'S. RBCTCSt. AND PELVIC COLON 



nujneroiu sargical operatioos. BarteriologicA] examinatim of the dis- 
charge* were cHTiffully niail«, but at no time wax the pathologist able 
to demonstrate the present of any other types than tha»e of Staphy- 
loGOCCUfi albufl and colon bacteria. Tho«e caries which progreee to the 
involvement of the deeper areas may be properly considered under the 
nibject of Ischto-recUl am) profound abscet5.5ee. 

Tnatmtnt. — The Ipeatmeot of sulitepimenlan,- ab^^egscs is purely 
8 Hurgioal one. fee poultices and antiphlogi&tic rc-modies have no place 
in lh« trralment of lhi« condition. Whenever a subte;iuraentary indura- 
tion orHwelling ha« been detormined, iinle^ complicated with gyphilitic 
or malignant dittea:^-, iniiiiediate and free incision should be made 
whether pus ba« already foniied or not. If tlie swelling be due to a 
Biibtegumentary hicmorrhagi.-, the extravo^atcd blood ought to be lib- 
erat<-d at the eariiest pcH^ible nionicnt. If it bo due to an infection, 
thoniugh (Jniinngo jind unti>!cptic irrigation will limit its progro»9. If 
pu» haa alrmily fomied, the prompt evacuation of this niatorial is the 
only RRfegnnrd against extension of the flb«fes.8 cavity. 

In all theme siipcrllcial ab^^ccsaea the operalLou can be pifrformed 
under hypodermic injections of cocaine or eucaine. One accuetomed 
1(1 the u«e of these drugs* can operate upon tin- nio:-! tensilivc patient iti 
BUeh conditions at) ttiim without any niurt pain than the prick of a 
fine needle, (."ocainization hflving been cetablinthod, the incision should 
be iniido in the line of the nuliid folds. Tliese nbscossea are generally 
monolueutar and cireumseribod. and require no curetting or bi-e^ilcing 
down i>f necrotic lia^ueit in their inid^t. .Simple Incision and drainage, 
iK'Miiiijtiiniud with unlisoptic waitliings. will cITcl-I a mpid and satisfactory 
cun- in the largo iiKijority of cases. The iticision. Iiowcvlt. must extend 
from the hiv'hest to the lowest point of the- nb^coF^d: diverticuli in acnte 
abscessoe will generally heal wJThont InlernI inci«ion«. The cavity 
fihouhl be wnshed out twice a dny with an antiseptic solulion, and a 
amall gituxe drain should be loosely pns^^ed into the wound- Stretching 
of the sphincter is necessarj* in those cases in which the incision must 
be carried through the anni canal And in the intramural variety. TheJ 
latter are almost the only abscesses which one is justified in opening 
by incision inside of the rcttuni. They are purely submucous, do not 
involve the nuwoular wall of the rectum, and if thoroughly opened and 
treattnl by di-ainage and Irrigation thov will heal without the formation 
of fistula nr other complication. The important point is to leave no 
pocket at the lower end of the cavity. Tliis is likely to occur when 
they open spontaneously. Under such eircumstances one will find some 
pus present in the rectum: he will still be able to discover the soft, 
compressenl .swelling, and through a speculum can see the diKbargo 
«xude from the opening when he presses upon tlw mass. It te needless 



I 



PERiAKAL AKD PEKIBBCTAL ABSCESSES 



331 



to sa>- llmt ill auch coDditioiu Iht cuvily bliould be kid open to its 
lowest fxtciit. 

Quiet and rest in bed are ce&cntial to the most satisfactory reftulla 
io iho trcainK-nt of ihcs? oa^es. 

lichio-rectal Abscesses.. — Tliese fomi a tvpieal variety nf what 13 
kiibuii OA piTirtiL'tal a!)M.L'8»e*. Il in yuiii'i-ally supposed that thcj com* 
pose llie large luajuricv u( perianal imd perirei:lal alisci.'jwt's; but, as 
has bt'fii shown by Kichepwe (Uta aW-s inthio-rectmix, Tli. de Paris, 
189'i, No. 352). ilwav tossw art' thi? bimiI of aboc-criHrfl In less than 18 per 
ccQt of tla- Uital uiuubcr of caeca occurring in hn»pital practice; and, 
furthcnaore, as the lar|;o majority of superlicial perianul abeceesc? are 
treAtvd by the family |)bysieian and are ai'ver neen in the hospitals, it 
is reufiunable to eonelude Ihal the jjoreeutayt- of these abiiceiiscs is even 
lower than Etchepare ctaiined. 

They are gi'nerally siliiutcd around ttie rccluni it-^olf and not at the 
margin of thu- aiiiu^. They are uutside of the niusLular and aponeurotic 
layers of the ri.'c:luTii 
and anal canal and 
beneath the skin, and 
BQperfieial fasciae 
(Fig. UOI. They may 
be limited to one 
side of the rectum, or 
may occur upon bidh 
Bidctt fiimultaui'i>iul)', 
becoming connected 
posteriorly (hrough 
tlie little spati-' be- 
tween the aponoii- 
nwes of Uie levator 
aai and tlie external 
sphincter muscles. 
When they occur 

upon one siile of the ■!«««. 

rectum and open 

sponianoonflly or are incised after they have existed several dayw, they 
are very likely to develop upon the opposite side within a period 
of four or five dayrt. When opened they do not exhibit a aingk 
large cavity, but numerous foci eonlnining pus, and may be dcecribcd 
Bs mullilucuhir abscessc*. Thi« lioneycomb-likc condition of the abscosa 
cavity 16 due to the connectivc-tiMue network which divides the cellu- 
lar mass into spaces, and in operating, unless great oare is exorcised 
to open all of these, the pua contained in them will burrow or infect other 






Fiu. iia— /I. i-1" 



1:1 



S, flDpvrior pdvl-rtcul 



883 



THE ANCS, REtrTCM. AND PKLVIC COLON 



Flu. 111.— BlLATlli™ 



Tegions, and there seems to be no limit to their exteut. \Vlien lioth 
spaces are iiivolved anO connect with each other [wwterioriy, ihey forni 
a iMirt of dumb-bell or horseshoe-shaped cavitT. Tliis cuniiiuioica- 
tion id not uniformly present. The Infection originating iti an 

injury of the anus nr 
lower portion of Ihe rec- 
tum, through which the 
lymphatics of tlie ischio- 
reftal fnsjsa het^onio in- 
voU'ed, may travel upon 
one side more rapidly than 
it does upon the oilier, and 
an abwfl** thufi derelopa 
upon this side eome days 
previously to its develop- 
ment upon the other. The 
author hail opened an is- 

«fc lUun-H I-««««ju«ir. chEo-reetal abscess ni h.8 

office on one lUiy. and 
with ciireful examination failed to find any implication or vxea 
tendemesfi upon the op{K>!^Lto side, and yet within forty-eight hours 
hft hae been called to open a aimiliir abscess at this point, and doin^ 
so uudvr )!:en«ral aun>8thesia has searched carefully but in. vain for 
any eonimunieatina t»elwt*n the two. As a nile. however, wlwre 
these abscease,'* develop upon hnth sides they fotnimiii Scale with each 
other ponteriorly through the foramen already mentioned, and ordi- 
narily in such crasns an opening will he fmnid in the pofitcrii»r commis- 
sure of the anus, thus constiluting a true horeeshoe fistula (Fig. 111). 
This little perforation o( the mucoua membrane at this prjint indicates 
that the origin of tlie iihscess and fiBliila ha.s pnihiibly been » fissure at 
this neat, through wliith the lyniphalics uf Iht; ischio-redal fossa have 
Ireeome infected. Abscefisea that originate in the ischio- rectal fossia rimy 
coummnicat'e with tlie rL'tro-rcctal spaL-c or vice i-ersa by perfuration uf 
the Icvjitor ani, and Ihiis there may be two main absL-ess cuvilics con- 
necting by a »nuiil aperture (Fig. 112), AhsceKtrCS of the pelvi-rectal 
Bpdcefi sometimes a])proacrh the surface and open into the ischio-rectal 
foBBfp, but whether thoao of the iechio-rectal fosae ever extend up- 
ward along the side of the rectum sufficiently high to involve tho 
euperior [lelvi-reetal symees and infect the organs with which they 
are in reUtiuuship. is dlffieull to say. .Ml the cases in wliich ,iti8C«8C8 
involved both sjmccs have given liislories which led lo the beliff that 
the abscess was originally in the superior space and hml involved the 
ischio-rectal fuesa by extcnifiou downward througli the libcri- ot ifa 



L 




PK&IANAL AND I'EKIUKCTAL AltiJCEiSSBS 



83S 



levator ttni muscle, cither suparatmi; ar napturiiiK thom, Tlieai' ab- 
eeesees may alito connect with iiiiliiuucous abscf^sos by tracts passing 
between the aphineter niusclos {Vig. 113) or directly throiigh them 
(Fig. 114). 

Tlie impoifant-o o( all this lies in Ihc fact Ibat il thcsfi eupcrflcial 
ab«ct.>e»-8 niav iiivulvt* iIil> hiipt;rii>r spaces it lends a gravity whicli is 
not cjniiiiarily attaclKni ii> tUmn. 

Eliologtf.^-The caust: of tticsc absceswa is nhvaj-s direct or indirect 
infectiuu. Punctun.' Mounds and injuriL-s from slmrp boJios within 
or outsiiitt of ihc rt-ctmii iiiiiy cany st-plic c^rius directly into the 
eelliilar tJMuc and thus prodneo absceesoa. VlccTBtion of the crypts of 



In. lis.— IwHik-ncicTAi. ixii ^iTHOiECTAt Abmmuu coHuimcinsa ■ami Each Oniix. 
The iwtum U (lloML-lul ulTuni diavru furwuiO. 

MoT;g;agni or of the ri-ctum pni)jer may rp«ult in isc-liio-wTUl iibsceiwie* 
through ilircrt cxti-nsiHii of the iiUrrntivi- prmn-M or by infrcfion 
through the lymphatics. The frcf|u<.nt «iiwc, however, of iachlo-rectal 
absc«S8(!(i ig infL>ettoii through ^niio U'.^ii'n '»f r)io nnnl canal. •Small 
fSesures or wounds in this r<.>]^'iun ari? vpry Hablo lu bFcume infoL-te!Ll, and 
as iho infection in tiki-ly !« affect the middle lymphatics, these wUl in- 
volve the isehio-rufta! Uim.v. Thvw abscessios frequontly follow opera- 
tions for fiHtulu, Htriclure, ami lia'tiiitn-buidB. In tlieste eases it is sup- 




884 



TUE AXUS. RECTUM, AND I-ELVIC COLOS 



1 






It they are metastatic. The aullior, however, hss obwrved, in 
tn-o cades in which isthio-rt'ctal alwcesaee foUoweJ oiwratLons for hapiunr- 
rhoidn, that upou o]ii*uiii^ ttic abeccu uivity there cwapcd a cumideia- 

ble amount of decom- 
posed or clotted blood 
along with thin tero- 
pos; either the 8»ip]>u- 
nilive ppoeeM caiiiwd 
niptiirG of the tiniAll 
vesi«els and hapnior- 
rhage into the fo«u, 
or tlie Teg*els were 
rupiunsii by the Irau- 
uiBtism necessary to 
<ltlate the sphincters, 
and infection occurred 
later. The latter view 
set-nie more ralinn&l. 
It 19 very poNiiblt.' that 
one of the lower 
hii-morrhoidal arlcrio* 
which ramify in this 
Bpaee may be torn by this stretching proooM, and it may go on bleeding 
until n diBlinet liit'ninloinn is formed in the eollnUr tissue, and thin may 
become infeetcd through the lymphaiifs leading from th« operative field. 
In the cases obaerred the syraptoras of abaceds appeared forty-eight and 
aixty hours after the operation. 

Dilatation of the sphiuutcr id small superficial abBceeses at the anal 
margin may result in isehio-rectal abscoasea by squeezing the pyogenic 
gorm^ out into the perirectal tissues. Contusions and prolonged pre«- 
»ure, Bueh as are caused by long horseback or bicyelo rides, may canoe 
these a1)«ces6es either by obstruction of the circulation or by produeing 
fimnll anal lesions which beeome inffrcted, 

SiiiripUmis. — A* a rule ischiu-rectat abscesses develop as nn acute 
inUamiiiatory process; the patient auffera either from^ a distinct rigor 
or a feeling of chilliness trfi-ping up and down the back and in the leg»; 
these are followed by ffVL-r. an-plerntrd piilsi>-rate, headache, and at 
first a diBcomfort about Iho rectum. This discomfort ehangcB to a dull 
aching, which gradnnily growe into an acme throbbing pain. In the 
initial stage lliere will be no Bwelliog apparent to the eye, but indura- 
tion may be felt around the margin of the anus upon one side or the 
other. Redness and discoloratinn may or may not be prtMont, aeeord- 
ing to the depth of the infectiou. In the very deep cases, in order to 



L 




PBBUNAL AKD PRUIRKCTAL ABSCK$SKS 



88S 



» 



ft'i'l tlK' imlurntiun it will he neoeamiry to intrixliKt.- iJie fingiT well 
into the n>ftuni «nil [iresii (Inwnnartl hiuI ixitwiini wlitio dvcp |iu)|>utiuD 
u made with the otlu-r hand iijioii the (rxteniii] aurfaeu. Out! will gvtier- 
nlly be able to niftke oiii iit siidi tmsea a distiiid cireuiuNL-ribcd rniiwi, 
(^lubulur niid tiiui-e ur lc»t fhicliuiting. WIumi Mil- iiiiiiLmnuilinn lm» 
existed for some duyH, swL-Uiii^, Ivasion, and n-ilncfis of the cutaneous 
tisftucfi about tho nur^iji of tb<.^ antie will appeitr. Defecation is ex- 
ttGmt<ly painlul ; \he paliont sulTers from difficulty i» unnHtinn. or may 
be utuibti- (u urimite al all. The iNiimtitiitionnl diMurbaiict^ may be* 
Cume very ^ruve ami H{i|iroiu-li a type nt true tiiept iciciii ia. Soiiielimcji 
the perisDfil area assumes an prv)>i|ielatnii8 hitish, and only n micro- 
SGa|)ic cxAminalinn of tbt^ blood and d iinctiart^eEi cnn di^tingLiiali liv'tweeii 
ihefle acntr. agpravated ca»(« of pcrirerlal L-ell\i]iti» with circnmdcribed 
absceMM and true er>'»ipeliie. Tlic intluniiiiulory {>riiceKiie« may hmt- 
round llie entire rectum and anu« and extend tliron^'h the pei-inu.-uiii 
into the wrotiim or injruinal n-jrions. These phenomena, only occnir in 
extremely wptic cukok ur those in which the treatment hns hecn 
neglecleid. If o|M>Tietl early the discharge from the«c absees^es, wluch 
are thou niiallj itt uf a 
creamy -while or dark- 
brownish color. Where 
the al>sce» hoi; been 
dui? to an extmvasatiun 
of blood, the clot may 
b<> diKrliarf;cd tm a 
whole, or it rmiy apjiear 
Bii disor^Autzed floceuli 
mixed witli puA and 
Herum. 

Sometimes the pus 
is thin and ichoro\iA 
and contninii necrotic 
shrada or fibroua tinsue, 
indicating the phlesr- 
ninnonj* nature of the 
ah^cess. Such c»aea are 
likely to be followed by 
general scptioiemia. Il possesses a fcettd, ^fangrenoua, disgosting odor; 

[this ha« b«en frcqueullv mid to indicate oonneeliou with the reetum, 
but it is not the fact. Many abBcesses possess this peculiar, fa_*eal odor 

I and hnv<> no couno<?tion whatever wiili ilie rectum. 

The escape of gasen from those uhacesses wlini opened bus also been 

^thoDght to prove their connection with the rectum. This is alao on 



Flo. 114. — I«.>Mla-iXi<TAL JUT) Slnuitiii* A»i>i>k* f^H. 
!(IIrT(» ST TkiICT rilHCKXdl TBI llLIH-LBa. 



836 THK ANU3, RBCTUH, AND PELVIC COIjOH 

ermr. In fact thoeo nbt^iceescs which have a connection with the rectum 
do uot euiituiu pi'ut-up gas. '^Vlu'ii, llicrcfore, an i^liio*rectal abscess 
in «)M'Ufd ttud g&A (■scaijos. it is (juite u reliable sign that it has no con- 
nection wilh ihc gut itm-lf. Tht-su ^luvt arc duo to bacterial (leoomposi- 
tion which taliee place in tlic ciivitjr. Wlien an ub«x'«« lia« ilevclofHMl 
upon one wiilo and opi-ns tiponlamtoutiW, or has been incised, the ttfmpera- 
ture will rapidly subside and all the constitutional symptoms, together 
with tliL' piiin, may di«ii|)(R'iir within twenty-four hours. The pains, 
however, may recur upon ilie Mime side ur upon the opposite side, the 
temppratuR' and cormtitutional syinptonw all reappear, anJ the patient 
siiiTi-r (luilc as rmirli as in the tint attack. Thtr-w symptom* are due 
to Ihi' dt'veh>pmcnt of another abscess in niic of the email comparlments 
oE the cellular lifwue wlijcli was not lirokrn down in the first opL-ralioD, 
or to infection ii)Mm the opptnitc &iUe. The appearance, symptoms, 
and diii^^noKiri of thii« condition arc, of courue, more or Icsa identical nitli 
tliouiL' uf the first abaeeas. 

All the physieal and local Bvniptonw of isehio-rectal abscess may 
occur from ha-niorrhage into the spaces which never become iufectcd. 
The author has npcncd wluit appenri'd to he a small, dee]>-M'atcd Bwelling 
of this kind and lurned out several hard dots with Mime blood seniin, 
but not A limp of p)ii4. The lent>ion and pain disappeared at ouce olid 
tl»e parts licrtlod without any Huppiiralion whatever. When sueli symp- 
toms oceur wiUioul the premonitory i>i)Hslilulional pbenoiiiena, one may 
Antieipate lindiu.^ tblK Lundition or a tvd)ercular prui-eits. 

7're.atntenl. — All surgeons agree that free ineitiion at ibe verj' first 
moment that indui-aliun eaii be nm<lc out is tho only ireaimeni which 
is justifiable in these cuHes, {'«ld uppiicBtioiis, Icecltes, hot poultieea, 
etc., have lonji since been found to be uaelcss in causing resolution. 
Thc-y may delay the foniialiou of the ubscesti and destruction of 
tissue for a [jcrjod and ^ive partial relief to the fufferor, but they 
never abort the duppurnlive proeess. When, Itiei-erore. a swelling or 
circumseribeil iiiduraliun can be made out about the margin of ilie 
amis in non-syphilitic fssen', the partK should l>e cueaitiixed and the 
induration incited whatever its depth. !*iincturing with aspimtiug 
needles to dolcmiine the presence of pu« in not udvtscd. It is not au 
ini]tortant question whether pus i» already present or not; the object 
to be attained is to furnish a free outlet through the shortest .ind most 
harinless chajinel to the inflammatory products of the affected area. 
If this contains only a clot or the products of non-suppu rat ive inflam- 
mation, a cleiui cut made with antiseptic precautions will do no banu. 
Pancturing with a needlR ran result in notliing more than to distribute 
the septic pr€)ducts through its track, and furnifih no drainage unless 
subsequent incision is made. The same objection hotdd good to puuc- 



i 




PERIANAL. AND PERIRECTAL ABSCESSES 



MT 



ture wilh Hinall l4?riolome8. Cttrt'Iul i1 iKiicc-tinn sliniilJ lie nmilo tlown 
upon till- imluraii'tl inasH or HL&iftw i-uvitv liy nicaris of jiii im-iniim w'tAv 
rnougti t<i give tlif operator a full virw of what In- U doing, Hud furnisli 
fn-u suliscr]ui-nt d niiiuij|i;ir to ilii- (lificluir^-. Tlir cxttimiit iiirUiuti 
iih»iilil In* wiili^r than the widest piirtion of tlip a.brt(n'ss. if jinsftililr, othrr- 
wiflc thero will be jux-kutt* niKi ilivcrticiili itUo wliicli the \m» will 
burrow. The incision should he made paralkl to bnt wel) outsitle of the 
tiWrn of the estunml wjiliinctt-r muiic'li!. 

After the abwehin itt (i|ipiu!d tlie fingor nhoiilil bo intrndiici-d intu 
the fiavity and all the lUth» hnncyponib-liko fo*isa? of the frolliihir tiiuiuea 
kIiuuIiI b* thorouglily broken down in cvt'ry dirwlion. BxiHTii-nin! 
teaches one the dilTeirnce lietween the fL-eling uf necrotic. Biipjniniting 
tJAtiue and hcultliy cellular i]ivi.-*ion»; it is theBu necrotic and suppurating 
fossil- which t<lii>uld he bruki-u down, und tliis ciin only hi; siirnly dono 
wilh the finjter itgeU. because curetting with ^thaqi steel ei)oon3 i» wvy 
likely to fio licyjind the diNeascd tissues nrd furnijilics nn indicalion of 
the condition «( the pariii. TJieec |)POpe)i>!(ii might to be t'arricd nn 
iimlcr coDstnnt irrigation with a l-to-2,ono bichloride solutioii. Shoulil 
there he considerable oo2ir^ or ha>nioiTliat;c after the cavity has brcn 
emplicij tlio roughly, it should he li^jlilly packed with guiize for the first 
Iwenty-four hours; lhi» packiiiK. however, shuuld be removed at the end 
of this time and only u li^Iit gaunc or rubber drain introduced there- 
after, bo(^«#e it IS of the utmost inqtortance that the walU of the 
absc<>et; cavity should be «llowed to apprnneh each other tut nearly «a 
posKibte in order that rapid union may tjike place. 

Where the iibsccBs involves both i^icbio- rectal fossae simultaneously 
Of BUCCG8niv*ly, tiic question of how to operate may jnizzlc the inex- 
perience!. Simple incision will empty the absfeij'& unqafntionably, hut 
it does not provide for the eumiuuiiicntin^ tnut bftween the two ab- 
Mceses posteriorly, when nuch existg. Hartniann etatca that under eueh 
cireiitn^taiice? he docs not open the abRcesscii IhprnHi'lves. but (ipeiis 
th« tistfuet) posteriorly between the coccyx und the anus, iiilrodiiL-iiig 
drains into the abseessee upon each side. The nbscpRs may be ojiened 
by nio<lL'rate iuci*ioii upon one side and by free incision, irxli-ndiiij^ to 
the posterior eoinmisMute o[ the antis. upon the other side, thus thor- 
ouifhly dniiiiing this posterior fistulous Iract in both dirertione, nnd 
effect good result*. In 2 rases in which tliere was a listuloiiii communi- 
«iition with the anus associated vritJi bilateral ischio-rectal abscess, coni- 
parativeiy Btnall openings won? mode in tlie aTHcrior liorns of the ab- 
^H teem and small wicks of silk thread were paBwd from these openings 
^^P Incktt'ard into the wound made »t the posterior commisaurc of the 
r r«tum. laving open the fistiiloug tract from the dkin into the anna 



* 




TOE ANUS. llECTLIM. ANl> PELVIC COLON 

Tn bntli of tlitwe cm^s tht.> van^s wBr^ ivnmrktih1> rapiil anil exceed^ 
inylj- sutisraL'lorv, boiii^; unacrcoinpnitiwl by any of Uie rutructiun and 
infiindibuUr e^Unpi: of tlic anun whii'h rraulu vrliun the caTittej vn 
both ftiilcs anil ptiHlprior to the anuin iiru kid <)|>en. 

The author has never seen fvcal incuiitin«ucc cueue from laying 
open the abeccse cavities freely, even thoufrh they entirely surrounded 
the rectum. 'J'he objeelion tu this ciimnitioii is that il rysulls iii re- 
traction of the anun, and leaves a deep depri'sninii between the folds 
of the hutlockn below the sphincter muscle in which faTal malvriiil ia 
lialile to be caught, and makes it very didicnlt to keep thoroughly 
clean. 

When these abscesses optn Kpontaneoiisly into tlie rectum or amis, 
u Ihfv may du, they constitute internal blind fi^^tnlu, aud should be 
treated as such. Tlie question, however, nrises as to the prot>abilitj 
of these HhseesspR rp^ultiTiR in fii^tula nfter they «re opened extornnily- 
Some writers htive held that this is eo likely in ea«e8 where the alv 
scefts apjiroHchett very closely thy racial wall it is advisable in all surh 
to convert them into (istiilaji at once, and operate by incision of the 
rectal wall to the lieij;hl of the deftest portion of the abscess. Such 
pmctiee can nut be uotuleiuntd too forcibly. While a tH^rtuin num- 
ber of abscesBe* will result in perforation of the rectal wall aubse* 
quent to their incigion, such conscf|iienee« hy no nieanr! justify Ihc 
praelice of siibjectinr; a patient to the danfiere of incontinence anil jiro- 
longed eiealrizalion which neees*arily follow the eonvei-sion of i»chii>- 
rectal abscesw?* into tnic listulous tracts. Wheri' no patholoeical ojien* 
iiig into the rnttiiii or )iiius c.xir'tM. it is iiu just! liable tu nnike siteh an 
opening surgically for the treatment, of perirectal ubscesses, Tliei-c is 
n-iison to believe timl the lar^i-' majority of perforations into the ret-tuni 
after the opening of ischio-rectnl abscw^ts arc due to iniperfiiet tech- 
nique in operation. The thorough but gentle dilfttation of the sphinc- 
ter niuselos in every ease of perirectal absccBS Ju an iTiiporlanl feature 
of the operation; it gives the patient relief from wbalever inuseular 
spasm may bo occasioned by the perirectal operation and inflaimiiatory 
process; it removes uhstnittioii to the pnswigcs of gns and fipcal matter 
BO that no undue pressure may be phiced upon the thin reeljil wall, 
which has lost more or less of its external support in the evacuation 
of the absoes*; it prevents a spasmodie eontraiCtion of the rectal wall 
and nlbiu'S it to more closely approach Ihe extenitil walls of the abscetM, 
thus facilitating rapid gmnnlalion and the closing of this cavity. This 
dilatation should ahvayw be niJide after the ahscesii has been eiiraeiiateil: 
attempts .-it dilatation before the abscess is opened are very liable to 
result in rupture of the rcetnl wall, beeaune this istalwuy.-* more fragile 
than the ov<'rlying skin. Moreover, the pressure and traumatism neces- 




PERIANAL AND PBKIRECTAL ABSCESSES 



330 



yV7 in HHcti diktatioD arc likely to squeexe llie piis conlaini^d m tlm 
:iunceBi» into tlie Iviiii'liatic?, di:^Iut,1^e the llimiiilii iu itiL-nc vi-sk(;Is, and 
«attM tlic ecptic process to extend into other nnd more remote areas. 
Tlicpefore, !«t thnHbiM'-oiw Ik? npencti frcply, iljj partition* be broltt'D down 
and n-imlml out witli aritiKejitic solutions, and ailev tills let tlic ttpliinctor 
muscle be thoroughly dilated befure the wound is dre^eed. Witli a 
draiiiugf-LulH! in the wound ti*iii|iorarily nnd a Pennington tube or 
rvctal [ilujj iu the rc*etmii in onh-r in fiicililiitt; ttie cscajip of gas hb 
well as lo hole] the rccitd whII in clonic ajipotiition with that of the 
abaccH, a fistula may b« arnided and a rapid healing he obtaineil in 
BUCh COBM. 

PROFOUND ABSCESS 

In the review of the anatomy of theso parts attention was called 

the retro-rectal and 8U])erior pelvi-rectal spaeeB. ('Hnieally these 
"pacw have hL-cn i-oiisidi^n-d im ono, and they are ralleil the superior 
pmrfetal fitacctt. Ilernit anatoinicHl eliidicfl have dcnicnnimted the 
fact that tliey are divided into three — two antero-lateral and one pos- 
t«iior. The Iwo liiteral oncfl have been denominated by Rlchet the 
'* euperior pL'lvi-recUl spaces '"; the posterior is the " retro- rectal spaee," 
K'hieh ocL'upica all the region between the rectum and the ant<^rior 
Riirfatp* i>f the saenint nnd coceys. The hlood-veiwels ritrnifyinp in the 
retro-rectal spaces come from the middle and lateral sacral artpriea 
with a few branches from the inferior mesenteric. Those in the 
mperior pelvi-rectal spaces come from tin- hypofjaslrie artery and are 
connected with the ji^vneml mrculation. The lytuphutics of the two 
spaces are aUo conipamtively distinct; thoi^c in the retro-recta) space 
develop about the lower posterior portions of llie pectnni and eoecyx; 
while those in the anterior spaces originate in the anlciior wall nrouiid 
the prostate, the neck of the bladder, the uterine orpans, and connect 
with the iliae plexus and the lateral trunk-t of thi' lymphatic system. 
With such (liHlinct anatomical divisimis, vascular supply, and lymphatic 
distribution, one ran clearly understand why n distinction is made 
bptwppn thfi circiimscribefl inflitmrnntinnH in thr^c two areas and call 
tlicm rttru-rectat and superior pelvi-reclal alsitisti. 

The interstitial abscew represents a class occurring at more or 
IGIB remote p«iin(s from the reetnm itself in the niuneular or eellulor 
tiHDes of the buttoekii and due to infection earried from the perirectal 
tiMUCB along the eonrse of the lymphntic« through the obturator fora- 
tn«*n nr the i^i-liiiiliV notch. 

Ketra-rectal Abscess. — This variety devclopH in the cellular apace 
between the rectum and sacrum above the iLttAchini;Dts of the leva- 
tor ant (Fig. 115). It may be due to necrosis of the boDc« of the 



THE ANUS, BECTU]f. AND PELVIC COLON 



I>clTis. (be eacmm, coccyx, ileum, or bodies of ihe rtrtehne; it may 

rcs\ilt from porfomtion of th^ recta] vatl by fthurp foreign bodies in 
the intestinal cnnnl or by inntmnK-nte, Riich ns bongieg or ^ringiN 
tips. One of the nio^t frofpicnt causes id the operation of posterior 
proctuUtiny or incision of strictures unaccompanied by Ihorougli drain- 
age. Fistuluuii tracts outniJt of fibroua strictures of the rectum niay 
also ofCBsinii it, (iiimiiinta, tlie L-aiK-iiliun and breukin^ down of ttibcr- 
t.-uloiui lymplioid midules, und iufi-vtiwn by propa^atiim aUm^ tht- lym- 

pliatic channcU from 
ulceration of the tw- 
tiiiii above the ex- 
ternal xphiiit-ter may 
all eause them. 

Quenti and llarl- 
manii atatc thai ab- 
sci'sses of the appen- 
dix may extend into 
tliid space and thus 
open into the ret-tum. 
'I'lii.' appendix being 
within th« peritoneal 
rJtvity and often cx- 
tendin;; iUtvu into the 
pelviti, it appearK that 
sufh ah.iee*!es arc 
iriiicli iiifjre likely to 
invinlc the superior 
polvi-reetal than the 
ri't ru-rc-ctiil spaces. 
The author had seen 
i>iu'. and had commu- 
nituti'd til him lhn»e 
iiHtiuiccfl in which 
siieh abaeeMea have 
opened into the rec- 
tum eilluT spontaneously iir by rupture during an examination of this 
organ. The caace were all in women; they flimiilatcd Irirc pelvic abaccjs, 
and the )>erfoiiiti(>n was always in the anterior wall of the rectum. The 
appendicular origin weji proved by subBetnient operation. X^Tille, there- 
fore, it is powiihlfl that Riicli abscesses may pfm-trate the T*'Iro-reotaI 
apace, from these facts and the anatumicali reliitioiis this course would 
appear verj- unlikely. It is not unusual for relro-reetal to follow isehio- 
rcctnl abeccssfs or varico*c ulceration; they are not at all uncommon 




FlV. ]Ut.~BKTI|II-llI(.-TAI. Abmim. 




PEEIAXAL AND PERIRECTAL ABSCESSES 



341 



~iWeT rpsM-Hons of the rectum, and tliey may also reeult from gunshot 
wouiitU of tbt pelvis. 

Symphmi. — Tht deVeloiiment of 5uch absccsseB is always obscure. 
Tlicy an- iiul usually ukIhtwI in Iiy (lislinct rijiiir;) anri etmstilutioiial 
maiiirt^fitatinuK. A dull lU'hiit;; in Mm Mirnini, uitii [iclvic weight auil 
*eia!ic pains «w«>ciatc«l with slight elevation of tcinperalure, general 
Jiialai^. C(iii>ti[>Btir>n. with or without i>ain at ttic time of dofecafinn. 
and a gradually increasing eallowiu'Sfl of the skin such tis accompanies 
chronic snappuratiim clsewliere in the body, are the general eyniptonw. 

PaljMtion around the margin of the niius and iu tiii; porimcimi 
dottd not, a« n niU', elicit «ny pain or induration. Kxatnination of the 
rectum with the finger iniiy Komptimrs demonstrate thp prcscncH of 
nndiiU'S niopo or less circiimKprilK'd and inflnnu'd, or » diffuse, boggy mass 
in tlte hollow of the sacniin. In the Iteginning this riia*i* will not be 
fluctuating, tt-nse. or pninful, but as the suppuration increases the ten- 
sion of thf! parts bccomea more mnrked, and partial ribi*! ruction of the 
rettal canul with <:1y«uria may develop. Eventually the abscess may 
bnrst epontanpously into th* rectal cavity, or it may perforate the 
It'valor arii, infect llie isHiio-rpcliil fossjT', mid finiilly open on the sfcin. 

Where ihe relro-recttil hIim'i'sji hn» esinted for some time, it may 
burrow b<'l.we»'n the IJbcni of the levator ani muscle and dpvelop in the 
wall i»f the rertiiin itself n snbniiK-mis iibm'e,*s such ns hn> been fovind 
ill a vane rrpnrted liy M. Qu^nu (Qiienu and Harlmann, p. HG). When 
tlie^e abpceesCH e«condarily invade the lower areas around the anus, 
conelitutional aj-mptomfi, aesociated ■with pain and great depression, 
always L'utiue. 

Au interesting ease of this kind occurred in the Polyclinic Hospital 
in 1S!)8. 

Abslmct of history: 

J. P., nf(vil fifty-two. janitor, hiid mScrcd for Mvcral week* witli • dull, 
■rhiiig iiaiti in lii» twck, difficiilly in iiiovcment of hu bowcl»i, find gnidiuilly 
locrttwinf; wi-iikncs*. Utily n (vw dii.v'r' iiri'viouMlj, li«w«vor, lir IiikI Iiih lirnt 
diNliiicE rigor. Thin wns followed liy & high ferer and ac?ut« pains in tllG buttocks 
and nround the mnrgtii of llie aniix. 

WI]L-ii dntt acta th« whok ])«rUual r«K!')o "^ dblt^nded, t«iise, hnrd, lliiriu* 
■ting, and of a darl< vinlacfouH cnlor thiit indtcaUd llii- rnpid upprt^nrti of )[au- 
Itrene nf thi^ fiiirti, Apiiuniitly it wim u nk->r nf dilTu«i-, »r|itir |MTi[»nK'1itiH. 
InHMtin, liow^'fcr, into ili« Urliio-rpctiil fnvMa giiv« i>uiii<! to iin inirrv-n^f <piiinlily of 
iiiimt firiid (III:*, So nick I'll inn; wiit tlii.* odor from tliiti dincliiirgi' (Inil nuvi-ml uf lliv 
ilndc'nt* «■«<■ nniiBpntrd and comficllcd to knvc th"" rrions. After pvariinlion nf llie 
iM-hio-rcclal rnrity it nnn found ihnt prcMurr through clic^ rvctum tovanl the hol- 
low of titc KHcntm ')(-rn»i(tnp(l a contlBUoua flaw of pus from tli« wound. 8i-nri-li- 
lofc th*(-'avily »ith tlii- lliiitrr, a small u)HMiirig *riii found Iwtweeii the ischiii-rt-ctAl 
fowkBud tlie retro wc-tnl «|miw>. Tlii« opcnitifr ^^an CDlBrg(.'d, and a lung utenn« 
prolw wu ititrudurcd tu its fidl length iipwnni ovit the iiroinoiitorjr of the sarrum 




TB8 AStVS, BGCTUM. AXD PELVIC COLON 



■iliiQH nadaag the vpfer limtu of tht a ba a m tmnty. Al tlte time, tlM itaOui 
wmtomwianA due tbb atatccM «ui due to aaeeRMbof uoc of (be bodin oi tbe 
•(ilaal *ert« JiM, ksd g»re aa uBrBTonl>l« firogoiMu with Kgxrd to tbe patient's 
tfoomtTj. Thv oalj wjmptaxiu coaLnindicvling uirJi » prognotti wrn; thr >rute 
•rf4k iibrancorn* wbiHi had occurred io tbc iMtrtUgmot ibt dii^^se. Such 
■faptonw nraljacrompanj tubrrcular abwnsnand tbow due to DccrtMu uf booc. 
Tbb |Mticnt mafk- an uovvrnlful rvror^r; >ftrr ftbout t«ii wewks' t«ffld«BCfi in 
Ibt hotfikul. Tbc limi- lietwixa tbe flnt cliill wid the dsle of ufientlioD va» 
•BtlMljr too brief for «ucb cxlrnnivr burrowieig upwaid to bkre takre plw^, and 
ttmntan it warn ttndoabtedl jr • cwc of nrtro-rcctkl ■b>oe« whidi had burat tbrougfa 
lato tbe iMliu^rMtal foan ud caused an acute sappuntiv« pronae tberc. 

Such abaceaaeR may aim burrow outward through the iacliiatic notch, 
forminfT diverticuli or pooketn in th« tismm of the buttocks. This 
counu*, liow^eTiT, ui verj* rare. Tho«p ocffiin-ing in this rpgiou are usually 
roetaxtatic or ioteratitial abscesses due to propagation bj the lyniphatic:*, 
■a atated abore. 

Trt'iliiient. — The (realniont coDtttete in thorough drainage. A netai- 
circular inui^^ion lictwecn llie anus and cmx-yx is lite best in tlivsc caev^. 
After thorough «Tacuation, th« cavity ehould be washed out with 
pflroxidn (if hydnippn followed by 1>to-S,000 bichloride solutions, Cralle 
curplling of lU waWa iiirv Ik> Hdrisablc sometimes, but one should be 
careful in doing thin latprally nnrl anicriorly that he does not ppnptnite 
tin- >iii)iTior pcIvi-rectHl spaocs or llie rwtal cavity itself, t'nies.". one 
18 rxpriienct;)! in these operations lie had better dt'^ist from such a pro- 
cedure aiul allow nature to take care of the sloughing tiasuee. 

Afl-cr washing out the cavity one should introduce two long rubt 
drainnge-tul>et> nnd maintain them in po!?ition by suturing them to the^ 
edges of the akin or pinning them there with a safety-pin. 'Hirough 
one of thcue tubes nn irrigntinp fluid may he earried in while it is dis- 
charged from tbe other, ami tliug tlie ahseewi cavity may be kept entirely 
clean. The ophincter should always be sfrctched after the abscess ia] 
cvat-uated, and llie jitools kept regular but not loi>9e. No packing 
further than that necessary to elieck the liist ooBinjj ot blood vhunld 
be used in these cases. It prevents drainagt and delays healing. Tonics, 
gond, nnurishing diet, and such specific medienliou a* seenu indicated 
ehould he pinplnjtnl. It. is hIho a good plnn to keep those patient* on 
their feel nioBt of the day, ns this faeilitatea tho drainage both through 
grnvilalinn and tlirmigh pre,is>ire upon the parts by the pelvic 
alidniniiud coiilriits. Sitting should not he nllowed until the aba 
haa practically healed, ns tliis posture interferea with the circulation 
and ilraimige <.>f Ihe |>iirl!<, 

Superior Felvi-rectal Abscess.^These arc not, as a rul«, dovclo] 
from rcclnl inflamnialions, but generally arise from alToclions of th« 
bladder, urothra, prostate, uterus, or broad ligament. In women the] 



PKBUXAL AND FKRIBGOTAL ABSCESSES 343 

arc ordinarily termed pelvic ahsceseeB, and arise from infectious diseasca 
of till? gcm'ralive or^jaus. lu uieu they oCteu occur as the ri-sult of 
po«l«riur urelhrtlis or intlujtuimtiou of the prostute, and simulatd &b- 
sceHS of Lhis organ. 

Psoas atwcewieji, necroBie of the Iwut* of the pelvis, guppuration of 
the broad li^mt-nt, pfirinepliritis, vesiculitis, and appendicitis may all 
cauAe It collection of pus in the superior pelvi-icctal »|)aceB. AbBcesaes 
may also occur heie m the rcttult of inflamuiations or injurivn iu the 
anterior rectal wall, the inrcotion beinj; carried by tho middle lymphatics 
and arrested heru owing to the .^uchk'n hctiA of the vesselg in the lower 
part of these iipnei**. Trniniiatisiii from pliiUlbirth op iustnitiienUtion 
ot the uterus or prostatie urethra, o|)(?ration6 for stone, proetnloctomy, 
and uterine lunior» have all Ix-eu koowu to produce tlieat? abBcossiea, 
but tbe ehief causL>8 are inila.iimia.tiuu» of tbu pruslate, uuiiiiual vehicles, 
uterus, and broud ligumcnts. 

tiympU/ms. — The premonitory liyniptotnfi of such absceascs are those 
of prostatitis, vcsicuUtiB, and posterior urfthritis iu men, and the 
inflammalory phenomena of pelrlc or uterine disease in women. They 
are often mistaken for ovarian and tubal abBeessee or tuniora of llie 
broad ligauieut. 

They are u.«ually usheretl in by chill, fever, aecolnrttted pulse-rale, 
deep, aching pain, and intt-rfiTrnee with the urinary functions. Onra- 
eionally they develop in a hIow, insidious nianniT without chill and with 
very alight fever. Dysuria, hiemorrliage from the bladder, and even 
complete obetruttion of tho urine due lo pressure upon the ureter* has 
been known to lake place, tKdenia of the aerolum and vulva with piiins 
in the pcrimi'um and tetttirleK are also Hometimea pre^snt. DilVieulty 
and pain in di'fecation are not marked sytiiplnuut in llie early stajfea. 

Where the inllammalion i.s of a tuberculnr lyjK- all of lliese symp- 
toms will be leiB marked and more slowly progressive. Where it is 
due to gonorrhten, tui it often Is in both (iRXeP, the te]ii|Jcriiture may 
rise very higli and the constitutional symptoms beooine alarminjr. Tho 
abfceescs have a tendency to burrow upward into the iliac fossa and 
outward towanl the nhdominHl wall rather than downward toward the 
perinieiim (Fig. 1 H>, Ji), owing In ihe greater reBistauee in this tatter 
direction. They may perforate the peritoneal cavity, cauaing aente 
aejitir piritonitis* and death within a short time. Inflammation may 
also ^prend lo this membnine without perforation, and ili-vclop either 
a Inealised or general peritonitis. Perforation of other organs, such 
fl8 tfie bladder and rectum, may result ut any time during their eoursG. 
Th« diwbarge of targv- quantitieti of pns from the reetiim or through 
the nrothm aeeompanied hy more or leaa relief fruai the feeling of 
tension, weight, and pain within tbe pelria, would Indicate tliia. 



^ 



344 THK ANUS, RBCTtTM, AND PELVIC COLON 

Perforation ihroitgh tho vnpiQ in wtwrip-n in nxv, but may occhp. Tho 
dia^ui^id of i;ii[)L>ri«r polvi-rectal ab»ct**w re»1« largely upon a historj* 
of disfUKve acid Kyiiiptoms coiinocted with the genito-unnary and 
n'profliictive a]j|iartttus; tlie palJuut rarelj giv(^s any account of previ- 
ous n^ctnl disciisi>; pL-riuLiul au«l jiL-rmi-til palliation only elicits a deop 
tendcrntwfi hut no nn-rlling or mdunitiuu. Digital I'xaminalion of the 
ri'ctum will generally elicit a tcndcmcuw ahorc tli« prostate ill niolo 
patients and to one side of the central line. In female* the abscess is 
UBUiiUy high up, and requirc-e a long reach of tho linger in order to 
delennine i1« esistL-nci", Paiu ujion presHure, induration, and thicken- 
ing of the rt'flal wall may \n> toll, togtlher with a c ircii luBfribod swell- 
ing, which in thin penple may be outlinnil by the Tuiger in the rectom 
and palpiition of the nhdoiiicn from abnvc. When the abscess huK 
e.visle<l for finine time ami lnHoiiie <]iiite tense, it may extrnd down- 
ward between the rcctwrn and tlie proslate, enter into the ischio-rcetal 
loBsa; by perforaling the levator ani mu&cle, or even penetrate tho 
retro-rectal space 

The diagnoaiit itt not dilliciilt in these late stages; it ia only in the 
early perimls of iiillanmintinn that one finds it hanl to determine the 
exat^t iiattire of tlip ivindition. It \» usell'^s to insist upon the impor- 
tance of this being made early in view of the grave complications which 
may result from delay. The fact that the palieiit has only slight eleva- 
tion of tijmpctnit u re or n comitaratively slow puUe-rate does not contra- 
isdicate the presence of deep pelvic abscess. Sometimes they develop 
a low grade of fnvor with typboid symptoitis, il iiirrho'a, and mental 
depression. These cmvn hiivf ln'on miatalcen fnr typlmid fover more 
than once. The urinary symptoms often mask the rectal symptoms in 
men, and patients go from one hospiUl to another, having soiinda 
passed, the urine dramn. and II11* lilndder wft.shed out for acute cystitis 
and enlarged pi'ostate, whereas the condition is due to pelvic abscess, 
wbtcl) i^ not din^nto^ed, if indeed a rectal e.\aminiition i« umile at all. 
In women thnfle symptofns, instead of being referred to the urinary 
apiJaratu-i, are generally taken to indicote an inllnmmntory condition 
of the uterine nrganw, and vaginnl oxtiminatlon is soon made. Oynspeolo- 
gists are in the habit of making rectal examinations in order to cor- 
roborate the informntinn obtained per vatjinam, and the result ia tliat 
aiich ahpcesses rarely escape notice in this sex. Tn men they are situ- 
ated, as a rule, anterior to and at uue ^id<' of lEic riTtum; Ihry may lie 
upon a level with or juat above the proslntc. In women they are liable 
to be more upon one nidi' than anteriorly, because the pclvi-rect 
Bpnees are praetieally snpnniled in front by the cloee union betwe 
tho rcctiim and vnginnl wall below, and because Ihe lymphatics which 
carry the infection run along the borders of the broad ligament and 




PRRiAKAI^ AND PKRIKBtlTAb AB.SCK8SIM 



:H5 



aro therefore dirtrjhutcd upon the sUlcs more than anteriorly. Tho 
general ccnirso wliioh such abscesses. piii-SHe and tlio oxlvnt lo wliifU 
tliey burrow have been already meutioued. They 8omeli)ii(.'ii entirely 
surround tlic rcctuiu and destroy all llie cellular lUaucs belween Ihu 
le'vulor ani and the puritunwuni. Thi-y may break a way through thu 
IcTalor am nnii*clc, cnt4.'r tlie iacUio-rcctd and retro-rectal spaces, and 
fiually make for Ibemsvlwx outlets ut ttonw paHJon of the circumfer- 
ence ol the anii^. WIk-ii, however, ont conicii to open 6uch a cavity 
or to examine the diseliarges he will find it almost impossible to de- 
U'miiiie the origin and patlinlofjieal rauBe, owing to th*- faet that the 
abat^etoi huA remaiiii'd ehntnie for so long that the prixUielion of phago- 
cytes and their deatruction of the pathological bacilli often render 
micmscopir cxaiinnatinn and eultiire* nefriitive. In such easps, where 
great dfwtniclinn of tiftsiic haa taken place around the rectum, the 
prolmbility of ah^ohite rafitoratioo of the functional action to the parts 
ia Bomewhat remote. Fibrous ami eicatrioial deposit are Hkely to result 
in Bliffne.^i ami contraction of tho gut wall, uhich it i.* very dithcult 
U) ov(!r¥onio. 

In the eai'Iy development of these abscesses it may bo almost impos- 
sible tu diaguijM' tiiL'iii. iilthuugb the geni'ml ayiiiptoms indicate pua 
fomtalion. Where the surgeon is unable lo make out the collectioa 
by combined ili^'ilut touch and uhdrtminul palpatiuu. an examination of 
ilie blood nuiv >liow a niarlied inrrcHKc of whiti' bl(Kn!-f«rpusilej', and 
niay give a fairly potsitivo indicaliun of the (condition with which he has 
to deal. Kxatiitnation nf the rectum by long rertal tubes, and even soft- 
rubber boiigieH, 18 eomraindieated iu eases iii which pelvic abKCCsses are 
Hucpeeted on account uf the danger of rupturing tho wall of the rectutn 
and ihuin op«ning the abKci'iis into it. 

Tretdmenl.'—'l'hi: trcatrueiit of tliiti condition consists in evacuating 
the pna at the earlimt powtible moment and aJTording the cavity a free 
drainage. 

The niethoda of evacuating theao abeeeesca ar« not so easily dc- 
Bcribod. Zieplcr an<l many of Iho earlier surgeons advocated opening 
tliem through 1he rectal wall. Where uo pathulogii-al opening in tlio 
rectum esistH, it i« nirely ju>itifiahle for a Kurgifin lo make one. A 
deep di.<ueetlon ihrough the perfnuHuii to find and evacuate the abscess 
cavity is the proper course. The rrrlum may be ilitwected iiway from 
its »ttaehirie7it-'« lo the pnistnte tiiiil blndder for n dii'tHncc of 2J inclica 
in onler lo reach an abnceafi in the tniperior pelri-rectal spac« and give 
free dniliagc. If possible the surface wound should always be eqiiol 
to the widemt portion of the abscesti cavity. It is only by making such 
ineiaions that diverticali or pockela can be avoided. Deep pimetiireg 
with aniall, »harp biatouries are likely to wound blood-vesaeU which 



1 



M 



34*J TUE AKUS, RECTUM. AND PELVIC COLON 

citn not be »i>i>n, they maj peaetrate the peritoitivuin, tht^j Wave long, 
narruA' tracts in which the ilUcharged pii8 causps iiifi-ction lunl sec- 
ondary aljflcesaee, and draitia^ is ncTer patistaotory through them. 
W'idf, fruf. open dissection to whatever depth the sbacttae nuiy be, is 
tht-refure lltu rule in Ihia cla^ of c-aao». Where the abscess ifi well 
defined upon oac itidc, the incision may be made upon that side in a 
lino parallel lo the tibors of the external sphincter, l>ut well removed 
fi"om the anus. Whero it apparently surroimdB the anterior nvtum, 
th(^ ineiaioQ should bo earned upward in the recto-urethral plane, being 
careful not lo wound the urethra or to tuvad« the peritoneal cul-dt'sac 
It the incision shouM extend a*t high ua 2J to 3 inches, the surgeon 
should I'Urry it upward hy dull diiisi'Ction and muke effort* to pueh the 
pcritoua-um aboTe by the finger rather than hy the uec of a knife, 

Wht'D the ah^cetig hae hoen reacbe<l and the pus begins to be dis- 
eharged, a long tube should be introduced into the cavity and thorough 
irrigalioii with [n'roside »f hydrogen, hiehlnride, or oarbolic-acid solu- 
tions shouid be tarried on until it is thonmghly evacuated. Aft<?r tliis 
the linger Hhould be iniroduced into the eavity, and as far as powible 
the extent and direction should he examined. Tearing or stretching 
of the opL-ning info the eavity in not advisable, heeanse the tissues arc 
tender and one never Itnows in what direction they will give ray; it 
may be into the peritoneal cavity, it may be into the bladder, or it 
niay bo into the rectum. Theri^fore we should int-ise the wall in the 
diroetion of gruattwt safety, guiding the knife or seissors with the 
finger, and thus widen the opening into the abscess cavity without 
danger of invading the olher pelvic organs. After the abscpss ha* thus 
been evacuated and free drainage furnished, the sphincter muscle 
shotild alwavp be thoroughly stretched, in order to avoid any obslruc- 
tiou lo the passage of gas and fa^cal matters which might add a» 
additional strain to the weakened saiptum, between the rectum and the 
nhseesis cavity. 

The curetting of such ahscpM cavities is rarely, if ever, advisable. 
Tlie author's experience dow not agree with that of Dr. Kelsey, who 
says in hi» latest work, " That to reacli pus by a perine«l incision would 
seldom be practicable in these cases," Any perirectal abscess which can 
be fell bfi Hie ftnyer in the rectum can be reached by perineal difsediim, 
and shrrutd be »o retichtd and opened. H by atiy possibility the urethra 
or bladder has been opened hy the tilccrative process, the conversion 
of the absce*8 into a perineal urinary ftstula will be by all means the 
safetit and euro^t road to cure. 

In iJiaIeK Ibfre iir. only one other procedure, and that is th» opening 
of the abHceaa through the rectum, which ia not only unsatisfactory 
from the point of view of drainage, hut it ia liable to leave pockets 




PERIANAL AKD PERIRECTAL ABsC'KSiiBS 



347 



Uid burrowin); diverticuli, and Jf Uicrc ih jicrfunitiun <if tlii< iinnar}- 
organ», will p^buH in recto- ve«iciil or pctto-urelhrjil fistula. Aside from 
this, it only opon^ n ik*w channel for infot^tion of tht' walla of tJie al>ftce»s 
by the badtiria of the intestinal caual. It need not thiTcforc be furtlier 
considered. 

Tlie praetict' of iniroduclng long aspiraling needles thmii^rb tliH 
pcrina-um or through the rectum into awellings or tumors between the 
roctura and thi* bladder or prostate is ubjcctionsbte for the reaeons 
that, introduced through the rectum, the pus is eurc to follow the needle 
outward, thus necegsitatlng an opening into that cavity: if thu tumor 
proreci to be a neoplasm, the needle oarri^d through the mucout' mem- 
brane iii very liable to in feet the same nnd produce an iib<;eotu 
lOraeplic oomlition. If introduced through the perlna-uni the dan^er^ 
lof wounding the peritoneal pouch, and thu faet that pui> will surely 
foilovr outward in the track of the needle if an ahsresti in present, lUid 
infect a tract which it may be impo».sible to ubsnlutely follow in ilitMLvt- 
ing down upon the abitctrMt, thim leaving a new line of infection whieh 
is not properly drained, urc eufficient to condemn it. Experience and 
judgment in the examination of these cases should render the operator 
ecrtain enough of Iuh diagnoeis as to a oolloelion of fluid in any ease 
in which he ean reaeh tlie Rwelliug with his finger, and whether that 
collection be a eysl, an ostravajuition of urine or blood, or a i«illection 
of pus, perineal incision and drainage should be made without the 
blind test of astpiraiion. 

As to draiuEige in these cases, a rubber tube is preferable (o gauze. 
' In many inatances gauze wicks have been introduced into the abdomen 
after operations for appendicitis, and into ah*cc*« cavities aliont the 
Tectum and in other portions of the body for dniinage, and yet when 
Uioae wieka have been drawn out there have been aecumulations of 
grvatcr or less quantities of pus at the bottom of the cavities, which 
the game wieka seemed to obstrucl rather than to drain. The gauze 
drain is not tntisruetorj- where there is a thick, tennciuus pas. Packing 
of the abscess cavity is always unadvisablc. The walU should be attowol 
to come aa closely in contact as possible. Therefore ttmall drainagc- 
tnbcs JQst sufficient to keep the cavities free from colleetiuns of pus 
are best. Frequent irrigation with antUeptic solutions is aUo impor- 
tant. Sometimes n strong solution nf hiehloridp of mercury (1 to 500) 
is run into Uie cavity, and this ia wasibed out with a niildtr :^olutiou 
(1 to S.OOO) immediately thereafter. If the wound exhibits a sluggish 
tendency and the ab.>ice»s does not heal as rapidly as the general condi- 
tion would indicate, it will nomelimes be advantageous to inject thfi 
otvity or swab it out with 95-pcr-cent carbolic acid or pure ichthyol. In 
order to apply the latter the drainage-tubee tnay b« taken out, and a 




THE ASFSi RECTUM. AKD PELVIC COLON 



iMmnr etrip of gante nturat«d with the drug intrwloced into the carity 
and left for two or tlinc hours. It sboulil then he removed and the 
drainaRO-tiihcs reintroduced. 

In (HiK-h upi-ratioDfi ihi- )iphinel4^r mnaclee arc to be sToidcd, but 
ineUioo of tho k-vutur ani u not ouly unavoidable but di>8iiiible. A 
simple iK-[)anitiun of the filicns may i-rai-iiato tho pu^ which m i^ituated 
jujit ahove them, hut as souo ax the diNifutiun produced hv tbu absc«a8 
hoii dinappearefl thcw fShera nill come tofrt'ther a^iin, and thu« tlic 
abiHiwit ravity will be very im|»erfeclly drained. The muBcle Hbere, 
ihcrerorc, tihoiihl be cut at right angles in order to prerent this rc- 
«oDtrac1ioa and iotrrfcrence with the drainage. 

In womi'n theee conditione are liliely to be TWy chronic and lo 
have existed for Innff iterirxlK of time bi>f»rt< being opened. The chnmic 
pelvic eellulitiii epoken of by different vrilors it; tiflen asMwiated nitli 
colh'ctionK of pus which neither incn-a«e nor decreaise to any jrrcat 
extent, hut which remain in statu ijtio for month after niontli. Ihi* eon- 
nective-t issue deposit thickening and increasing about it all the while. 
It ifl Ihrou^'h this process thai stricture of the rectum, even to the 
extent of absolute obstruction, nmy be produced. 

Confttipntion i>i nlw-ftyt" an unravomhle eyjnptoin in thew casoa, and 
the Inn^^er the nhweetw exists the more marked will it appear. When 
pun foniis. whether in tho tube or in the broad ligament, e*pceially if 
the superior pelvi-reetal Kpaee« are involved, it should he evacuated 
through the vagina, if possible, at the earlifjit possible moment under 
the strietcst antiseptic precautiunt<, and free drainage be obtained. 

Where tlie absccN^ points upward iibove the pubis or in the iliac 
foBia, openings may be made in these regions and drainage secured. At 
the wiriip linio hi^iling will be faeilitateil if the nlwcess is given a de- 
pendent drninnge by dinsectionj: U|)ward thi-ouph the perinicuni nr vagina 
into it* lowest prolongation. This prolongation can be detennined hy 
the use of a full-sized probe introduoed thro^igh the abdominal opening 
and felt with the finger of tlie other hand introduced into the rectum 
or vagina, 

Diffai« Septic Periproctitis.— Before tlic days of antiseptic sui-gory, 
aurgeiina wore aenistonied to meet n difTu»o form of iuflnmmation 
involving nil the perircctdl lisBUes, Tlie condition genernlly fn| lowed ■ 
an injury to^ nr an ojieration upon, the rectal wall. It has been de- 
scribed under the titles of perirectal eelluIitiB. septic ppriproctitis, and 
by Umilly (Archiv. geii. de med.. Paris, 187!), pp. 35, 163) aa diffuse 
pelvic cellulitis. The condition i» churacterizcd hy an ueute inllaui- 
mation of the perirectal tissues c«|)ocinlly those of the retro-rectal 
and ischio-rectal spaces. It is oss-eutially a «'plic process of very 
virulent nature. It conie« on at any time fi-om a few hours to three 



PERIANAL AND PERIRECTAL ARSCESSES 



319 



daj9 after an injurj- to, or opnration upon, tlic rectum. Strauguly 
enough a case nf this iliflcasc rarHy occurs tinlei^A perforation of tlic 
rectal wall itself lias jjreceded it, aail vi-t iu its destructive processes 
Uie walls of Ihe rectum and amis are rarely involved. The intlamnia- 
tion is gpnerally conliiwd to Ihe porirectal tiaaueK. The iniilLraliuii 
Btisuincs at tlrsl a sort of seminrrlid conditinn, fhiinging \ntvr tn a Kfro- 
punilent discharge when the tissues are laid open. 'I'he itiHaiuiualory 
process may extend upward and forward, involve all the peWi-rectal 
itpai:r-:*.und may invade EIil* jKTituiia-iiai tliroiigli extension, oftiiio&is of the 
aeptic ageutx. or hy ubsulutt- perfuration. In the Jirst int«tance the 
peritonitiH will k- <>f uii iiileiwe septjc LypL', or iiUra»e|)tic iis deaeribed 
by Qiiony, unaeoonii)anicd by any srrc&t adhcsiona between the ab- 
dominal organs. 

SgmpftiMS. — The patient dot's not uanally suffer from n dii^tinet 
rigor, but at a poriod somewhere between a few hourg and three days 
aftttr the operation upon or injury to llie rectum, a creeping chillinew 
cornea ou svieceodrd by acfcleriiied pulse, hinb temperature, headache, 
hrown-furrt'd longar, and Mometiiiifs severe vutiiiliug. The pain in 
Ihe wound i iicTeiim'H gn'iitly, with a cenw of (ulnvi^s and weight iu the 
encral region; the disi-hargc-fi chanijc (o n ji^rayish. Woody, fixtid elinr- 
actvr. and the pvrireclal tJsiBUeti ans^imie a brij:;hl-rod, tense, ami wliinlns 
sppearaui'i^. The iinieunu moiubiane of llio reetuui and anus remains 
unehaiigMl or bi!L'ome» iL-di'maluiiK nnd kwoIIoii. (ireat weaknesM and 
dwpreiwiiiii fcfUnw ra|)idly upon this condilioii, itiid ihe patient in sorae- 
timtM Keiwil with an exhausting:, liquid lUarrlurii. Thi; eunptilutioiial 
Bymptoms are thow of general si'iisii', very flo«ely rcsemliliiiK that type 
known as puerperal fever. All Ihe perineal and injtui no-em ral tissues 
may be involved in the proecss. HinieiiUy of urinnlion, even siqipre*- 
fliori of the nrinp, may eomplieate alTiiii'e. Complete loss of appetite 
and inability Iu retain ftKid iire urdinarily present. iHiring the rourse 
of the diNc^aae septic eiidocardiliit or perieiirdltis may develop, ihua 
hasloning the end. Unless cheeked by tn-atment the di!>ea«e runs it« 
course and Rnds in death from the seermd to the lentil day. 

Trmhiirtit. — The treiifnienl is one of prevention rather than cure. 
3t ia a disease which should not occur at the present day. Of course 
there may be cases in which accidental injuno*. eueh ae puncturing 
wounds, inny invade Ihe perirectal lissuee and thus ^'ivp aeees* t« the 
Tirus, but Mich cases are so rare Ihut one need liardly eonaider them. 
The nhole secret of prevention lies in antiseptic ])reeaufion)i and free, 
wide drainage in all operations about the rectum. The operations 
which arc more likely than any other tn he followed by such a complica- 
tion are those of proctotomy r*>r stricture or resection of the rccluui 
for tumors. If, hovever, the disease ehould occur notwithstanding 




860 THE AXtTS. RECTTM. AND PELVIC COLOK 

proper purgic-iil preomtionit, tlit* tri'Atment cciiutinU in told incuions into 
all the swollen and inflamed tiiuiueit, follovcH] hy frcquvnl antiticpltc 
irrignlion with tlie application of lirat in the interim in nrder to pi-o- 
mole the circulation and pieveut the occurrence of gangrene in the 
parti. A^ltere the symptoms of geacral sepsis arc rery marked, the 
injection of onti^troptocntcu* scnini may be of advanlaf^e. 

It hog boon 8iigg(>«tc<l also in ^uch cu«eii that »a\it%e infusiun^ into 
the veins will result in the destructioa of the bacilli in the blocxl and 
in BitsUining the ^Irengtli of the patient until the septic depression 
has passed away. In iuslancL'x in which llil« \[&» bcou done io very 
late stapes, doath foJlowed in due time; experience, therefore, does 
nict justify tlif Klalcnit-iit that this ptoci-durc will be of uuy pravticnl 
henolit. Xo drugs have tuiy piirticular ctTcct upon thi^i- si-plic condi- 
tions. In the light of modern therapeutic researches, administering 
carholie (ickl in 1arg(? doeve might possibly hu uf liomt^ b(?notit. It lias 
ht't-n demuniili'att'i] tliut thin drug can be udminititerL-d in duees of fruin 
3 initiiitu in. children to 12 mininui in adults, every tliree hours, wiLb- 
oiit the productiim of toxic syiiiptnms exc^'pt in ciises with pt-rsoual 
idiosyncramicH. It tl(>c« seem tn have some biirlcrit-idul iiillui-iicf iu 
such micrnhic di»riiM;K an whrxiping-coiigh, pneumonia, and typhoid 
fever. It might therefore be advitiable to administer it in septic peri- 
proetitie. Salol accompanied with strychnine or quinine will be of use 
to control the bodily temperature, white it i» at the same time au 
inti'stiual KTitiiteptie. 'rii<> main rpliance, however, will he upuu tlie 
frequent antiseptic irrigatinns and repealiM] early ineinioiiii into all the 
tissues involved. 

Idiopathic Gangrerom Periproctitis. — TTnder the title of idiopathic 
gangrenoiLS cellulitis, Funii-aux Jordan (Brit. Med. J., Jan. 18, 187!), 
p. tS) baa described an unusual type of perirectal intlammation. It 
consists in a slowly extending cellulitis uuattcndetl by much swelling 
and pain. It devi^topa iinually vtthout ttuy previous injury', but may 
follow surgical operations about the rectum. In its general aspect it 
resembles very much the condition seen in urinary infiltration of the 
[M^rinteum. It ocriin*, as a nile. tn Inrge. stout, well-preserved IndiTidiials 
and in acttre and excitable men given to hesvy eating and drinking: 
m Jordan wiyc: "In men sufliciently well-to-do to indulge at will, and 
who firmly believe that exce^pivc work ncfds excess of victuals and liquor; 
in men who are indifferent tn weather andjjavc been notably expoticd 
to cold and wet." 

The disease begins on the level of the anns^ or sometimes in tho 
deeper tissues. It progresses very rapidly, and there seenu to be no 
limit to its extent, fiihbon fljondon r^noet. IREIO, vol. i, p. 74*1 de- 
scribed a case in which the process extended to ttie scrotum and entirely 



PEltlAKAT- ASD PERIRECTAL ABSCESSES 



351 



dtstrujrt'd it. Wynian (AiiK-rican Lancet, Detroit, March, 1893, p. 244) 
liHK iv|iortttl u casv ill ivlik-li llii- wlmli- piTina'um ami skin over tht- but- 
tnrke »*<;iv ra[)j(ily ili-atruyuii hy Xln.: ^iiU;;ri'ilous process. Conca liavc uIm 
U:(.;n n;|iorlfd Ijy <JfrstLT and KcUty in this couutry, but iht; mtwl exten- 
sive and roumrkabli.^ ouc is that tvlatcd by (juciiu and llartmaan [op. cil., 
137). Tfiis tvaa liie t-aao oC a Invgo, strong luau, a hoavy ealop aud 
drmktT, who was s^izL'd willi iiains about the ri?giou of the auus with- 
out any known oauso; a ripid I utni> faction and n-driPKa o( thi* arsa about 
tlio anus atul prrina'Diii ftdlowrd, cxtf'ndiii^ lictwcen tln' scrotum aud 
the thigh upward into the iliflc region over the ahdoininal siirfare, even 
to the axillary region. Great phlegmonous infiltrntion with hlistere, 
gangrenous plft()iu*B. antl the development of gae in Ihe two ischio-rectal 
fo89a; eiieted. Puitlcriorly the infiltration pae«?d across the sacrum. 
The urinary apparatus in this cafie romainnd normol. The tonguo was 
rod and drj', and the tfni]K'ratiire reached 40' C. After about three 
mouths' treat ini'nt, with frLt|UL'nL ineit^ions and drainage of the involved 
aroax, this paliL>iit rucoveri^d. 

Eiialoffif. — Thus far no satisfactory etiology has been suggested for 
tliitt disease. lu Gerater's case there cxi«led a diabetie glytosuria, and 
he sug;;<;etrd the possibility that it cuiified the conditiou. lu Uie 
Other ca«o* roportod no such complication hm been obscrvwl. Dim- 
glifion, ftiiojuinij; the tcnn of i'uchs, doeeribod it under the title of 
proetoeaee. Aeconling to Fuehs it is a eomnion eoadition in Pern 
(Quito and l.inia), in Brazil, and on the nondiiroa and ytotucjuito coasts. 
It w called by ihe Porluijuese " hicho '' aud " bjelio di eulo." In 
Quito it is termed " nial del valle" on aeeount of its prevalence in 
the valleys. It is also known in .Africa, where it is called " hitioa de 
kis." Prom its frequenny in ^hesc regions one would judge that clinuttc, 
BoU, and niodce of life had something to do with it$ production. It 
haa been attributed to the use of decompoaed foods and cxce^sivft 
indHlgen('t» in eoudiraenta and spieea. On the contrary, all the eases 
mun by .Ionian oi^curmd in cold weather and in the high tahle-land 
of tnid-Kngland, and no i-ase has been reported in Ihe female »ex. It 
seenw, therefoiT, that eliniate ran not account fnr it. 

Sifmptoms. — The disea^^e conird on with a chill followed by high fever 
and great mental and ron.'ttitutiona] drprettsion. There la some pain 
in the neighborhood of the anus; the skin n red and brawny, the epi- 
thelium eletated and eoverod with amall phlyctjeiHs, which eoon break 
down and Uave black giiiigrenous maiwcit which dinoluirge an ichorou* 
fluid instead of pus. The ehief rhanict eristics of the diseaso are iU 
rapid extension and its tendency to light up again and invade other 
tlasnea afler it has once been apparently checked. Invasion of the 
ischio-rectal and superior pclvi-rectal spaces and thus upward into tb« 
23 




JtS9 



THE AKL'S, RECTCM, AND PKLVIC COIX)S 



ritoiUBimi is it» common couree. It may enter tlio rptro-TMUl spnce, 
passing out through lb# obturator foniin«n and invsdr Uie suhtego- 
uii'ntary Ubsuub, as lu unv case liesoribfd by Jurdan. Wlwrt-ver tlie 
]M!rit<iaa>uui beiromes iuvulved ilealli rapidly ciutue*. The t#mi>enitiire 
runs vt-rj- hig^h, the tongue in dry and red. anil the whole condition is 
charactcrijiiMi by prpst adyrmiiiiji. Kvi-n aftor frw incisltiin^ bavv Ikntd 
maOu in Ihe intUniniatory tiKiHi i\\v dUchurgc doi-& not oseimtt tbc 
nature of pus, but rather a sanious ichor of a most putrid nature. Tlie 
gangrenuU); pmei*^ is Kvlf-limited. If t)ie patiimt doi>ii not i^ueciimb 
to Begisis and ^-xbaunlion during llm aaily ptriuds of the dLsca«e, it will 
require the utmost skill and perse%'erauee to niaiutain his strength 
tlirwugh the chrnnic pnitoss of getting rid of the large necrotic muses 
■tthJi;h may be iircnrnpanied with frcnueni lupniorrhugee, any one 
which iiiny bring rm the end. 

Tre<itm<:nt. — The treutnicnt of this condition consists in early a 
repeated ineiflions through all the gangrenous tissues in whatever neigh 
borhood they may be, followed by antiseptie irrigation and hot anti- 
Mptic p»uUieL>)4. While these iueisious do riot give vent to any eir- 
cumsiTibed I'olletlious of |)UH or iehor, they open the cellular chauueU 
for the omiug out of the icdematous collection in tlic uucrotic masses, 
mill MiUtf relieve the tciisioii and prevent to a certain degree tliu absorp* 
tiuD of the prwduetf of decay. 

Owing to the fAct that the Mootl-vcsselB themeelvee frequently re- 
main intaet, mieli inei^ions may hi? aei-ompanied witJi dangerous hjptiior- 
rhngcs. Jordan luontiuns an iiiKtaiiee of t1ii>« kind in wtiiib llie ingemiily 
of the attending physician was greiitly e-tereiseil in order to control the 
bleeding. He finnlly Miceeeded in doing so by ihe intmduction of 
Bamee'a dilator into the rectum, and distending ihis organ m as td 
produce sufficient pressure upon the parts to control the hirmorrhage. 

Ligatures are not likely to prove j'lueefij'fMl, as the blood-vrssels ard 
E» brittle and alterfd that (hoy would likely cut through. Firm prcfl- 
■ure is the most reliable means of controlling the flow. 

flencral ^limulation together with In-podennoelysis i* iiecessarv. and 
all tboae thcmpeiitic and dietary resources for the iimiiiU-iiiuiee of 
etrengtb in adynamic dineHnes should be taken advsntageof. In the large 
majority of instances the dipeofie resultd fatally aooner or later from 
ficpticn'ntia or general exhaustion. 



see 




CHAPTER XT 



yiSTULA 



TiiK I^alin word fixltiln gij^nifiee a pipe or rood, and has boen applied 
to this (liKca^c on account of the occasional rced-likc shapo of tho tracts 
and the pa&4agc of ah' through thcin. It 18 a misnomer. }it>»vvL-i\ m the 
large inajoritv of listiilno are lurtiious, very irre^lar in sliaije, aiid gases 
do Qot pttjsi tlirough them. 

Deftjiitioa. — Ainj-n-ctal C^lula naj be <lcTmvd b« nntj unnahtral 
ehamicl cWrdt/ifi^ from ihf ,4 ui t)r mu<o-eutat\t^'>Ui hijutnent ob'>ul Ifir atntSy 
or from the mvrons membrane of the rtetum into or ihrotiffh the fvrround- 

The eKsuntial charaetoristie of the disease is chroii icily. A freshly 
opened ahKesti, eitlit-r ^xtenud or internal to the rvctiiin, furms a sinus, 
but (iiii! whirh may luiil 
compltti'ly in a nhitrt time; 
unless it \\aa both an ex- 
ternal and internal open- 
ing it would nnt ho termed 
a fiiilula until it had shown 
no tendpiiey In heal for a 
considerable period. It 
would save confusion if 
Ulc term were confined to 
tllAt type ordinarily knovi-n 
a« tile complete rariety. 
Under the neeej)! ed no- 
nicnelature. however, every 
chronic ahseesw rravity is 

a riKtiita. Accordingly, thejr arc bniudly clniwiricd a« inetmphh and 
€omplf(r. 

Classiflcation. — Incomplete Fistula. — This variety cmbraecB all those 
, c^MiU on ona lUrfAcc only- When the oponinj? is outeide of 
. Ifau it is called btind fxlnriinl (ii^tiila ( V'\^. 1 16), and when 
it u vitbiD the n>ctum> blind internal fititula (Pig. 117). 

888 




t'lu. Il(i.— Ulimi 11\ii.u>ai. ri--ii.Ljj. 





A, tubUcwnciilaiT; B, ttiUvpvaeanStc 



into the cavity of the amis 
or rectum (Fig. 118). 

Pi^tula^ are also classi- 
fied accordiug to the tis- 
-I sues iDroWcd. Those 
which simi>Iy pass nnrfcr- 
Dcath the i^kin, iniK'o-ciiU- 
neous or mucoiu tusnes, 
are teniiwl gublerfu mrn- 
iarg, stibmufo-eutanrcus, or 
submueou* (Figs. 117, A, 
UQ), Those whifh jiasa 
ontside oC th« utueculnr 
apparatus of the rccttun or 



tnm are called »iihinvgmliir or ^ihaptmeumtic (Figs, 116, 118). 

In addition to tlifw? divisions chi'ie are also simple, eumpttJ, and 
eompliraleJ figtidax. Tlie simple fSslula consiiiU in a sinus tract lead* 
hi^ from the ekin or tmico«3 niembniDi? into Ihc prrirectal tissue, or 
a roinplutc tract leading directly from an opening in the skin to one 
in the mucous ineiubrane. Tlic complex variety connista in Tariutioua 
of these conditione, such 
w w ide burrowi Dg and 
great tortuosity of the 
tnict, tht' existence of two 
or more opcniujpt on tlie 
akin with one in the ree- 
luin. or two or more in the 
rectum with one upon the 
akin. By the tenn compU- 
talfd fisiah is meant those 
oases which aro compli- 
oated by necrosis of tlie 
bono8, or by eonnfotions 
vith other organs. «ucb as 
the htnddcr. urethra, va- 
gina, uiid uterus. Tho )at- 
tf^r rfi^uire special coosidcratiou and peculiar treatment. It is there- 
fore considered vit^ to study them apart from ihe ordinary ano-r«clAl 
fiatul««. 

Fiuully, fi:ituUui may be classified aecordiug to their pathotogicAl 




Flo. ll^- 



VoDFUit* Sr>ir»XirE«Tto Ft*rcLA«, 



I 




M 



>caiL<(»i into specific imd non-xjKcif^c Ijjieg, TJie specific tyjMw are those 
duv to tub*' re ul OS id, carcinutiui, mid syj>!ii!i«; tlic noii-sprri fie are those 
due to simple itiflAminiitory prnccijses or injuries. (>n account of the 
tuberciilouH Tariety, this cliuuiiiinLtiun is of great importance. 

Fbeqcency of FifiTCLA. — The frequency with which fistula occurs 
in comparieou with oth<;r rvctal <lliieadc» may be j^athered from tho statis- 
tics of speciul hijspital ti«rviei>R. Jn St. Mark*Ei Hospital, Ix>nilon, as 
([uoted by Allinfiham, out of -1,000 rectal oaxm. 1,057 persons jiufffriKl 
iiom fistula anil 19(3 from ab8ct.>si)«(i, of which 151 subsequently became 
fistulas. One may therefore practically state that l,2l)S out of 4,000 
cues, or nearly one-third of all rectal ilisciuifs, were fistulas. These 
statifiticfi arc taken fnoiu the walking casas whcreaii the rcconls of the 
]iot!pital fihow thai lwo-thirJ» of thopo operated upon in Ih'S Mecca for 
these sufTercrs were cases 
of this disease. 

In examining tim re- 
port* of th« general hos- 
pital* in this city it is 
found that over onc-h.i!f 
of the ca3e» operatwl upon 
fur r«4.-tal discaaes in five 
years were Cslulae. In the 
author's service at the 
Polyclinic Hospital the 
peruentage is out so high; 
this may be attrihuleil to 
the fact, however, that all 
the intldinniatory and ca- 
tarrhal comlit ions of the lower inlcetino are treated in this clinic, where- 
as a number of fi-itulas fall into the hunde of general surgeom*, and 
therefore the proportion is reduced. Kven under thfse circumstances 
this condition oomprisea one-fifth of all rectal liisna.'sej*. 

With regard to the proportionate frequency of the ilifTerent varie- 
ties it may be said that complete fistula comprises ahnut TO per cent, 
blind external fistula about 20 per cent, and blind internal about 10 per 
cent of the oases recorded. 

As to the frrqurticy of simple and complex fistulas the experience 
of BiirgeouR differs greatly. If we consider only those cases complex 
which have more than one opcuing either exterually or internally, then 
tho complex varictv will only comprbe about 5 per eent of tlic cases 
Been. On the otlier hand, if «e consider those casies complex wliieh 
consist in tortuoue tmcta burrowing in ditTerrnl directionit, or partially 
iurrounding the onus, the proportion between the two irill be matcri- 




A, Uiciil umcrna] ; JJ, cumplvtB. 



856 THE ANrS. RECTUM. AND PELVIC COLON 

ally altcreil; in fact, tlie niajnrity of chronic fistulas am compHcaUHl hy 
Bome such diverticuli or hiin-owing tracts. It would complicntc matters 
to uouBiiicr all such cases complex; tlierefore it is better to coiifin« tlie 
term to those ca^cs which have multiple openings upon one eurface or 
the othor. 

Eti'iliiifif. — With few exceptions all fistiilw originnte in ahsicetuvK. 
They may weeasioiiallv be produced by penetrating wounds which ex- 
tend from the exlenial surface into the rectal cavitv. Two cages of this 
kind Imve cuiuc to Dii- iiotiee uf the writer: in one the patient uaa 
thrown from a wiijrnn hikI fell upon the iiiii;tallic sleni of an iiiiibrclla. 
which punrtiirctl Ihe i^kin ahoiil 1 inch from llLeiinuf, und piuucd thnui^h 
into the rectum IJ inch al>ove the anal margin; in the other the condi- 
ticm was caiLseti t>y squatting down upon the sharp Htump of a weed. 
This case lias been ri'r«rped to in the chapter on accidents and injuries. 
In each ease complete fistula rcsiiltcri. 

Oiinshnt and bayonet, wounds may produce them {Med. and Surg. 
iriMory of the War of ilie Hchelliou), Ordinarily intermediary ahscei^jwa 
occur in tmch cases, but always there is infection which gives to Ihe 
wound the chronic cimracterietice which constitute tli^tula. In general 
one may eay that ahsceea or destructive* \iUerEtion always precetlea 
fistula. Whatever pmdtice* thcee conditions may also cause it. Wounds, 
injuriHB, ttiherculnsis, wyphiliR, stricture, etc., are therefore ctiologicjil 
fatitors. Ulceration and burrowing from the base of mucous diverticuli 
in ihp reelum anil pelvic colon arc said by Cniveilhier (Anat. path, g^ni- 
rale. Paris. 18W, t. i. p. 51)4) and Frangou (Th.. I^yon. l883-'64, No. 19&) 
to he the point of departure for internal bliiid Jislulas. IVrfurating 
tubercular ulcers of the rectum liuvc lon#c hwra cousiderc"! the originat- 
ing catiec of the disease. Pulhulogical rewurchcs, howt-vtr, fail to con- 
firm this iHcw, which has been particularly elaborftted by Koenig (I>chr- 
buch *peeicllen I'hirurg., Keriin, 1899, vol. ii, p. 5;f!)). If thia were 
the ease, tliero would be usually other ulcers around the internal opening 
of the Hslula. as tubei'cular ulcerB of llie reutum are rarely single. A« a 
matter of fact, in the large majority of lljitula*. ulcers of the rectum are 
not prcBCiit except at the (istuIouN upcning. Thus, in H cases of tubcp- 
cuhir fwLulu cxniniiurd by M. llurtmann (Revue dc chiiur., 1S94) there 
wei-e ojily 3 caitcs i^ri which thcrR existed ulccratioufi of the rectum eepji- 
rate from the internal opening of the tistwla. Moreover, if the fistula 
originated iu a pi-rforating ulet-r of the rectum it would always assume 
the type of a blind internal fistulu at first, and present tin* symptoms 
of such, but this is n<it the rule cither in the simple or tubercular lypes. 
The discharge from the rectum does not often occur until after the 
symptonia of abscess have existed for some days — in aliort. the ulcer 
develops after the abscess. 



i 




B 



■ 



The qupstkin now uriBcs, If they all originate in nbscceees, whj do 
not these hm\, iiiul why Ihi^ chronii-ity wliich cunstilutes fistula? Many 
theories anil conditions have been evoked in the explanation of thin fact. 
It is easy to understaiid why a conipk'tt fintula du(*s not t'luw on ai:cniini 
of the constant jjassage of fii-cal mattei-s and giis<-'S through its trart, thus 
preventing by median icu I at-tion th« agglutination of its walls. More- 
over, the coorstiuil rcLufection of the Kurfaccrs by such paesagea prevents 
healthy gmmilation and healing. In Inturiial blind fistula one can also 
explain why healing does not take place on account of the imperfect 
drains^ and the con&tmil I'ti^^'upo of UdvhX inalerial into it. 

ThesL' theorios, howovt^r, du not apply tn hlind external fistula, in 
which there ii< no pasMage of fiscal material or gases into the eavity, and 
hcucc no amslnnt irrilatitm or apparent recurrent infcctitm of the walls. 
TIic ciiUBH hiia in-cn iiwcrrihrd 1o tlii" niohilily of the rectal wall which 
forms a portion of tho fistulonfl tract; the ronstaJit motion of a part will 
prevent its union with another, and there is oonptant motion of the 
rectal wall due lo ruspiratoi*)' and iiivohintar'y pi?ristalti(- action, 'i'he 
irregularity of the ahticeeta cavity, the existt>nci' of necrotic ttwtues in 
diff«rent portions of thw tract — whrn the opening is nnt sufficiently hirge 
for tliorcuigh drainage, and when these tissues have nol heen rcniovt^d by 
curettage or di-sscction — may prevent the closure of a blind external fis- 
tnta. Thc-se, however, dn not explain those casRe in which widt^ incision, 
thorough dniinage, and the removal uf sloughing tisaue hav« been prac- 
tiBcd, and yet they do not heal, notwithstanding the fact that the most 
careful and pen^isteiit «Hari-h Iiuk fiiiled to rL'veal any opening into the 
reelal ornnnl canals. In such ensoa llartnmnn lian suggi'sted the osniotie 
paMage of gasos and infecting agents from the rectum thmugh the thin 
rectal walb into the ahwesi* cavity as a cause i>f pcreistcnt infection 
and consequent delay in healing. While such a theory is iiig(>niuus and 
posnililc, it ie utterly without proof. 

The whole stiTct of ehn>nicily in blind external fistula lies in two 
facts: first, in imperfect drainage; second, in porrtistent ruinfeet ion, which 
may oomo thrtuigh an opening into the rectum which has not been found, 
or Ihmugh the origiiuil tract of infeelion, the lyiiiphatii' i haimeU. He- 
ferring to the chajhli-r upon iseliio-rectal and periri'clal abwiKscs, it will 
be remembered Ibiit the large majority of these was ascribed to infection 
fnmi some small lesion iu Ihc rectal op anal canals, the soplit; material 
being taken up by the lyinphatictn and curried into the surrounding tis- 
mes. The abscess becomes circumscribed owing to a thrombosis of the 
lymphatic tninks. TIjis Ihrombosia stops for the time the current of 
fieptic m«l<^rial from the original source, but att soon as the abscess opens 
or ia jncitwd, the thrombosis in the lymphatic tnmkn no longer obstnicta 
the circulation io the distal tracts. Therefore these little lymphatic 




1 




358 



THE ANL'S, HECTUU, AND PELVIC COLON 



waseilB, still in connection with the rectiLl surface, contioiie their infce- 
tion of Die abscess eavLty. 

Su]i[mrali«ii exluinliiiji from the u^sci-es or from the rectal wound 
may evi'ulually /olluw aluug tlivM- tracts and t.>nlarge them eiiificiently 
for tlin admission of a prole, wheiva* in the orijcLiial cuudition they are 
too Bmnll fnr Itir |>B««igf of citiiiT tin- [mf or thu probu; aiid thtrt-fyro 
while tliiTc actually cxii^ti'tl ii coiiiuiunicaliun, it tnie loci EtiuiU fur [Ud- 
covery by the ordinary moans of research. According to this new tlio 
etiological factor in the conversion of an absociw into a fisliila is iU pwr- 
eititcnt conne<-tion with the rectum or anal cjuiaI either liiruugh the 
l3rniphatic tracts or through a distinct opening. 

The repair of al)8ce8« caviiies depends upon the proportionate pro- 
duction of round cells and their destniction by nucrobic agent* <Qu^na). 
If the production exceeds the destruction, repair will proceed, and vice 
rersfi. If. lhiTi'fi)rc. ii wottiiil hi- properly clcaiiwil of iiifcelioiii^i iiiatoriol