COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX00034622 Digitized by tine Internet Archive in 2010 witin funding from Open Knowledge Commons http://www.archive.org/details/diseasesofrectumOOkels PLATE cM! ':•; K (S^uxruyLo^ux^ zOr ^CAAXu/y /x^\A^ ymLvxi/. DISEASES OF THE EECTUM AND ANUS THEIR PATHOLOGY, DIAGNOSIS, AND TREATMENT OHAS. B. KELSET, A.B., M.D. New York PROFESSOR OF DISEASES OF THE RECTUM AT THE NEW YORK POST-GRADUATE MEDICAL SCHOOL AJSD HOSPITAL ; LATE PROFESSOR OF DISEASES OF THE RECTUM AT THE UNIVERSITY OF VERMONT, ETC. THIRD EDITION, REWRITTEN AND ENLARGED WITH TWO CHROMO-LITHOGRAPHS AND ONE HUNDRED AND SIXTY-EIGHT ILLUSTRATIONS NEW YORK WILLIAM WOOD & COMPANY 1890 Copyright WILLIAM WOOD & COMPANY 1890 PRESS OF STtniHtR, LAMBERT * C< 2?. £4 A 9t REAOE ST , NEW YORK. PEEF ACE The great advances which have been made during the past few years in the surgery of the rectum and intestinal surgery generally, have necessitated many changes in this, the third edi- tion of this book. The chapters on the treatment of stricture both benign and malignant, and on the formation and closure of artificial anus, have therefore been entirely rewritten, and much new matter has been added. The attempt has also been made by the addition of numerous illustrations, and by clear and definite descriptions, to supply the general practitioner with a safe guide for the performance of all the operations called for in the diseases of the rectum. Chas. B. Kelsey. 25 Madison Ave., New York, 1890. 385381 COl^TEl^TS. CHAPTER I. PAGE Practical Points in Anatomy and Physiology, 1 CHAPTER II. General Rules regarding Examination, Diagnosis, and Operation, ... 41 CHAPTER III. Congenital Malformations, 73 CHAPTER IV. Proctitis and Periproctitis, 93 CHAPTER V. Abscess, 100 CHAPTER VI. Fistula, 115 CHAPTER VII. Haemorrhoids, 152 CHAPTER VIII. Prolapse and Invagination, 207 CHAPTER IX. Non- Malignant Growths of the Rectum and Anus, 263 CHAPTER X. Non-Malignant Ulceration, 291 CHAPTER XI. Venereal Diseases of the Rectum and Anus, 317 VI CONTENTS. CHAPTER XII. PAGE Non-Malignant Stricture of the Rectum, 339 CHAPTER XIII. Cancer, 369 CHAPTER XIV. The Formation and Closure of Artificial Anus, 404 CHAPTER XV. Constipation and Faecal Impaction 487 CHAPTER XVI. Pruritus Ani, 450 CHAPTER XVII. Wounds and Foreign Bodies, 456 CHAPTER XVIII. Spasm of the Sphincter— Neuralgia, 475 LIST OF ILLUSTEATIOJSTS. Plate I.— Chancroids of Anus and Vulva. (Pean and Malassez.) Plate II. — Haemorrhoids and Prolapse. (Esmarch.) Fig. 1. Intermediate Haemorrhoids. Fig. 2. Prolapse. Fig. 3. Internal Haemorrhoids with Prolapse. Fig. 4. Inflamed External Haemorrhoids. FIG. PAGE 1. Exaggerated Antero-Posterior Curve of the Rectum, 2 2. Horizontal Section through Urethra, Vagina, and Anus, .... 5 3. Section of the Normal Rectal Wall, 9 4. Section of the Rectal Mucous Membrane, 10 5. Semilunar Valves of the Rectum, 10 6. Sacculi of the Rectum, 11 7. Side View of the Levator Ani, 15 8. Levatores Ani seen from Behind, 16 9. Rectal Veins seen from Without, 20 10. Rectal Veins seen from Within, 21 11. Nerves of the Anus, 24 12. Injection Apparatus, 45 13. Skene's Rectal Irrigator, 46 14. Lamp for Examinations, 47 15. Electric Forehead Light, 48 16. Rubber Pus Basin, 49 17. Soft-rubber Bougie, 51 18. Bougie a, Boule, 51 19. Scale of Rectal Bougies, 53 20. Rectal Retractor, 55 21. Helmuth's Rectal Speculum, 55 22. Author's Rectal Speculum, 56 23. Fenestrated Speculum, 56 24. Sims's Bivalve Rectal Speculum, 57 25. Aloe Speculum, 57 26. Rectal Depressor, 58 27. Uterine Depressor, 58 28. Sponge Holder, 62 29. Brush on Flexible Handle 62 30. Cup for Fusing Nitrate of Silver, 62 31. Applicator, 62 32. Office Instrument Case, 63 Vlll LIST OF ILLUSTRATIONS. FIG. PAGtt 33. Air Cushion for Operating, 64 34. Clover's Crutch 65 35. Bottle for Antiseptic Ligatures, 66 36. Paquelin Thermo-Cautery, 68 37. Canula for Packing Rectum 69 38. Rectum ending in a Blind Pouch, 77 39. Rectum ending in a Blind Pouch ; Anus Normal, 78 40. Rectum ending in Glans Penis, 80 41. Rectum Ending in Bladder, 83 42. Rizzoli's Operation, 91 43. Superior Pelvi-rectal Space • . . . 105 44. Varieties of Fistula, 115 45. Submucous Fistula, 116 46. Submucous and External Fistulfe, . 116 47. Blind Internal Fistula. 121 48. Gorget, 125 49. Operation with Gorget, 125 50. Spring Scissors for Fistula, 126 51. Ordinary Steel Director 129 52. Author's Director for Fistula, 129 53. Horseshoe Fistula, 130 54. Horseshoe Fistula, 131 55. Ordinary Incision for Horseshoe Fistula, 132 56. Proper Incision for Horseshoe Fistula, 132 57. Proper Incision for Horseshoe Fistula, 133 58. Complicated Horseshoe Fistula 133 59. Incision for Horseshoe Fistula, 134 60. Recto-labial Fistula 134 61. Incision for Recto-labial Fistula, 135 62. Eye Knife, 13? 63. Author's Fistula Knife, 135 64. Double Blind Internal Fistula, 138 65. Cicatrices of Fistube, 139 66. Fistula over Hip Joint, 140 67. Operation for Incontinence 141 68. Operation for Incontinence 142 69. Cicatrix of Fistula 143 70. Cauterizations to Tighten Sphincter 144 71. Result of Operation for Incontinence, 145 72. Allingham's Ligature Carrier, 146 73. Helmuth's Ligature Carrier, 146 74. Enterotome of Richet 147 75. Incisions for Recto- Urethral Fistula, 148 76. Closure of Rccto-Urethral Fistula, 149 77. External Venous Hsemorrhoids 154 78. Sharp-pointed Bistoury 155 79. External Ha-morrhoid after Injecting Vein, 157 80. External Cutaneous ILemorrhoids 159 81. External Hiumorrhoid, Showing Increase of Connective Tissue, . . . 160 82. Intlamed External Hiemorrhoids, 162 LIST OF ILLUSTRATIONS. IX FIO. PAQK 83. Internal Haemorrhoids, 177 84. Haemorrhoidal Syringe, 179 85. Pile Forceps, 189 86. Author's Clamp, 189 87. Smith's Clamp, 190 88. Paquelin Thermo-Cautery, 191 89. Forceps for bringing down Haemorrhoids, 192 90. Luer's Haemorrhoidal Forceps, • . . 193 91. Incision in Whitehead's Operation, 197 93. Stretcher for Whitehead's Operation, 198 93. Stretcher in Position, 198 94. Transfixing Pile in Whitehead's Operation, 199 95. First Form of Prolapse, 307 96. Second Form of Prolapse, 308 97. Third Form of Prolapse, 308 98. Anatomy of Prolapse, 309 99. Prolapse of all the Coats of the Bowel, 311 100. Cautery Iron for Prolapse, 319 101. Prolapse of Invaginated Intestine, 334 103. Intussusception, - 325 103. Internal Rectal Hernia, . . 353 104. Rectal Polypus, 364 105. Villous Polypus, 365 106. Glandular Polypus, 366 107. Vertical Section of Glandular Polypus, 369 108. Fibrous Polypi, 370 109. Fibrous Polypus with Mucous Membrane Attachment, .... 371 110. Non-syphilitic Vegetations, 374 111. Condyloma Lata, 379 113. Congenital Tumor of Perineum, 387 113. Tubercular Ulceration, 299 114. Esthiomene, 303 115. Bulb for Injecting Fluids, 315 116. Rectal Insufflator, 315 117. Ointment Applicator, 315 118. Syphilitic Ulceration of Colon, 331 119. Stricture due to Plastic Exudation, 340 130. Stricture from Fold of Rectum, 344 131. Stricture with Hypertrophy of Connective Tissue, 347 122. Proctotomy Knife, 362 133. Operation for Stricture at the Anus 365 124. Operation for Stricture at the Anus, 365 125. Operation for Stricture at the Anus 366 126. Operation for Stricture at the Anus, 366 127. Operation for Stricture at the Anus, 367 128. Operation for Stricture at the Anus, 367 129. Malignant Adenoma, 370 130. Cancer of the Rectum, 380 131. Allingham's Operation of Excision, 388 132. Allingham's Operation of Excision, 389 LIST OF ILLUSTRATIONS FIG. 133. Allingham's Operation of Excision, 134. Kraske's Operation of Excision, . 135. Kraske's Operation of Excision, 136. Artificial Anus at Sacrum, . 137. Truss for Artificial Anus at Sacrum, 138. Simon's Sharp Scoop, 139. Hook for Operations on the Rectum, 140. Hook for Operations on the Rectum, 141. Opening in Lumbar Colotomy, 142. Colon without Mesentery, . 143. Colon with Short Mesentery, 144. Colon with Long Mesentery, 145. Incision in Inguinal Colotomy, 146. Operation of Inguinal Colotomy, 147. Operation of Inguinal Colotomy, . 148. Colotomy with Harelip Pin, 149. Opening in Inguinal Colotomy, 150. Resection of Intestine, 151. Suture in Enterectomy, 152. Suture in Enterectomy, 153. Suture in Enterectomy, . 154. Suture in Enterectomy, 155. Intestine after Enterectomy, . 156. Abbe's Catgut Ring, 157. Method of Intestinal Anastomosis, 158. Method of Intestinal Anastomosis, 159. Method of Intestinal Anastomosis, 160. Spur formed by Colotomy, 161. Enterotome in Position, 162. Szymanowski's Operation, . 163. Szymanowski's Operation, 164. Szymanowski's Operation, . 165. Szymanow.ski's Operation, 166. Skin in Pruritus Ani, . 167. Stone removed from Peritoneal Cavity, 168. Stick removed from Rectum, PAGE , 389 394 . 395 395 , 396 402 . 402 402 , 411 412 , 413 413 , 415 416 . 416 417 . 418 424 . 424 425 , 425 426 . 427 428 . 429 429 . 430 430 . 430 433 . 433 433 . 433 451 , 472 473 DISEASES EECTTJM AND ANUS. OHAPTEE I. PRACTICAL POINTS IN ANATOMY AND PHYSIOLOGY. The rectum is the terminal portion of the large intestine ex- tending from the sigmoid flexure to the anus. In its natural position its length varies in different persons from six to eight inches. When dissected out of the body and straightened, it will be found to measure about two inches more. Its position in the true pelvis is comparatively fixed, and its fixity renders it the more liable to those displacements, such as invagination and prolapse, which are due to straining at stool ; and accounts also for the fact that, when denuded by the destruction of the surrounding cellular tissue, it remains separated from the walls of the pelvis, and cannot come in contact with the adjacent soft parts and thus undergo healing. The upper limit of the rectum is difficult to determine with accuracy, except from the fact that it is separated from the sig- moid fiexure by a slight constriction which becomes more ap- parent when attempts are made at dilatation. From this upper point it gradually expands below into a pouch, the ampulla, and then again suddenly contracts under the grasp of the muscles which close its lower end. Curves. — The curves of the rectum are exceedingly important in a practical point of view. There are two, one antero-pos- terior, the other lateral. The former is double. From above downward it follows the curve of the sacrum and coccyx, being- concave in front and convex behind. When it reaches a point 1 2 DISEASES OP THE RECTUM AND ANUS. opposite the tip of the coccyx, it suddenly reverses its direction, turns sharply backward, and ends at the anus about one inch in front of the tip of that bone. By this backward curve of its lower end, which is repre- sented in an exaggerated form in Fig. 1, it is separated from the vagina in the female, and from the urethra in the male, by a triangular space having its base at the perineum, its upper wall at the vagina or urethra, and its lower at the upper wall of the rectum. The angle of junction of these two curves is well marked, measuring from twenty to thirty degrees ; and the curve is not without influence in the function of defecation, Fig. 1.— Exaggerated Antero-posterior Curve of the Rectum. since, by it, an obstruction is formed to the downward course of the fseces. The lateral curve is generally a single one from left to right, starting at the left sacro-iliac synchondrosis and ending at the median line at a point opposite the third sacral vertebra, from which point it generally passes straight on to the anus. This curve may, however, pass beyond th6 median line to the right in its lower portion, and again return to the median line at the anus. It is subject to many variations, and the upper portion naay be more or less twisted on itself like the sigmoid flexure. The sigmoid flexure inay occupy an unnatural position, and the rectum, instead of commencing at the left sacro-iliac junc- POINTS IN ANATOMY AND PHYSIOLOGY. 3 tion and curving toward the right, may commence at the right and curve toward the left. In one case, reported by Cruveil- hier, ' where the sigmoid flexure was in the natural position, the rectum passed almost transversely to the right side as far as the right sacro-iliac junction, and then returned again very obliquely to the left side. Divisions. — For convenience of description the rectum is usu- ally divided into three portions, named first, second, and third, from above downward. The third extends from the anus to the tip of the prostate, is about an inch and a half long, is firmly closed by the sphincters, and gives attachment to a portion of the levator ani muscle. On account of the direction of this por- tion, which is the reverse of that next above, the finger should never be passed toward the sacrum, or even directly inward, in making an examination ; but rather toward the pubes. Bearing this simple anatomical point in mind will often save the patient much unnecessary suffering. The second portion is often de- scribed as reaching from the apex of the prostate to the recto- vesical fold of peritoneum ; but, as the point of duplicature of the peritoneum is not only variable in different individuals, but at different times in the same individual, it is better to adopt a fixed bony point, as the third piece of the sacrum ; in which case the middle portion will measure about three inches in length. This portion, it will be remembered, is convex backward, following the curve of the sacrum. The first portion extends from the third sacral vertebra to the left sacro-iliac synchondrosis ; its lower part is partially, and its upper completely, surrounded by peritoneum, which, in the upper part, forms the meso-rectum attaching it to the sacrum. Note. — Treves ("The Anatomy of the Intestinal Canal, "etc., 1885), as the result of one hundred dissections, denies this arrangement of the first or upper part of the rec- tum. He says : " The segments of gut termed the sigmoid flexure and the first part of the rectum form together a single simple loop that cannot be divided into parts. This loop begins where the descending colon ends, and ends at the commencement of the so-called second piece of the rectum — at the spot, in fact, where the meso-rectum ceases, opposite about the third piece of the sacrum. Tliis loop when unfolded de- scribes a figure that, if it must be compared to a letter, may well be compared to the capital Omega. If at any time new terms should be introduced, it might be well to call all that segment of the bowel between the ending of the descending colon and the ending of the meso-rectum the omega loop, and to limit the term ' rectum ' to the short piece of practically straight gut that is now described as the second and third parts of the rectum." Relations. — The most important surgical relations of the rec- 1 "Anat. Path.," Amer. Edition, 1844, p. 377. 4 DISEASES OF THE RECTUM AND ANUS. turn are on the anterior surface. The third portion is sur- rounded laterally and posteriorly by a bed of connective tissue rich in fat and blood vessels, and may, therefore, be incised on either side, or backward, with comparative safety. In front, however, it is directly in relation with the membranous urethra in the male, and with the vagina in the female ; though at the anus it is separated from them both by its backward and down- ward course. This intimate relationship with the urethra is often taken advantage of in catheterism, when by passing the finger into the rectum the tip of the instrument may easily be felt ; and it also explains why in all operations on the urethra or vagina the rectum should first be emptied to save it from being wounded. In the second portion, also, the lateral and posterior surfaces have no special surgical relations ; while the anterior is in direct contact with the prostate, the base of the bladder, the seminal vesicles, and sometimes, at its upper limit, with the peritoneal fold of Douglas. This portion is closely connected with the bladder in the male, and with the vagina in the female, by con- nective and muscular tissue ; and the two cavities may easily be made to communicate by any morbid process or by a sur- gical procedure. It was at this point that the trocar was plunged from the rectum into the bladder in the old operation of punc- turing the bladder through the rectum ; and Hyrtl ' speaks of a man who was only able to pass his water after first introducing his finger into the rectum and raising a calculus out of the tri- gone of the bladder. A somewhat analogous case is reported in which a long, slender calculus perforated the bladder and pro- jected into the rectum, from which it was easily removed." The prostate, when large, may project over the sides of the rectum, or the latter may receive the prostate in a groove on its upper surface. The first, or upper portion, unlike the other two, has impor- tant surgical relations on every side. Posteriorly it is in whole or part covered with peritoneum, and is separated from the sa- crum by the pyriformis muscle, the sacral plexus of nerves, and the branches of the internal iliac artery. On its sides it is in contact with the adjacent convolutions of small intestine, and lower down, with the levator ani muscle and the connective tis- sue of the i«chio-rectal fossa. In the male it is in relation, in front, with the posterior surface of the bladder, from which it ' "Topog. Anat.," ii., p. 103. » Gooch : "Chirurg. Works," London, 1793, vol. iii., p. 316. POINTS IN ANATOMY AND PHYSIOLOGY. 5 is separated by coils of small intestine. In cases of retention, either of urine or faeces, the two may be brought into actual contact. In the female it is in relation, anteriorly, with the broad ligament, the left ovary and Fallopian tube, the uterus and vagina. When the rectum and uterus are empty, the coils of small intestine pass down between thein to the bottom of the fold of Douglas, and they may even escape through the posterior wall of the vagina in case of injury. From these relations it is apparent that enlargements and malpositions of the uterus must act directly upon the rectum. Fig. 2.— (After Henle.) Horizontal Section through Urethra, Vagina, and Anus, considered as about an inch long, and including the terminal portion of the rectum.) (The anus The vessels may be so obstructed by uterine disease as to cause haemorrhoidal troubles, or interfere with operations for their re- lief. The recturq, may be entirely occluded by the pressure of a uterine tumor ; and a hasty examination of the rectum may lead to the diagnosis of a tumor in its anterior wall, when in reality the normal uterus alone is felt. The advantage of a rectal exam- ination in all doubtful cases of pelvic disease is also manifest. The Anus. — The rectum terminates below in the anus, which is tightly closed by the external sphincter muscle. The skin around its border is thin and pigmented, covered with fine hair 6 DISEASES OF THE RECTUM AND ANUS. in the male, and contains a great number 'of sebaceous follicles and muciparous glands. The skin passes deeply into the anal orifice, and its point of junction with the mucous membrane is in some persons indicated by an indistinct white line.' This white line of junction also corresponds to the division between the external and internal sphincter muscles ; and also to the point at which many of the terminal filaments of the internal pudic nerve perforate the gut. Both skin and mucous mem- brane at the anus are remarkable for the development of erec- tile tissue ; the arteries coming from the inferior haemorrhoidal, and the veins being very numerous, winding, and twisted. After these general considerations of the position and rela- tions of the rectum as a whole, the individual parts may be taken up more in detail. The rectal wall is composed, as are the other parts of the intestine, of four layers : an external or peritoneal ; a muscular, divided into longitudinal and circular ; a submu- cous connective tissue layer ; and, most internally, the mucous membrane. The total thickness of these coats collectively varies greatly in different subjects, the variation being chiefly in the muscular coat, the others remaining pretty constantly of the same thickness. Peritoneum. — The upper portion of the rectum is entirely sur- rounded by peritoneum, and has, besides, a fold of attachment to the anterior face of the sacrum, known as the meso-rectuni. The meso-rectum is about four inches long, blends with the meso-colon above, and extends down as low as the third or fourth sacral vertebra, from which point its two layers are re- flected over the sides and anterior surface of the rectum on to the posterior wall of the uterus and upper limit of the vagina in the female ; and upon the bladder in the male, forming the cul-de-sac of Douglas. The meso-rectum may be so short as to disappear when the rectum is distended, or it may be entirely absent : in which case the peritoneum passes directly from the sides of the rectum to the sacrum. Between its two layers may be found some loose connective tissue, the haemorrhoidal vessels and nerves, and the lym])]iatics. In passing from the tliird piece of the sacrum behind to form the cul-de-sac in front, the peritoneum covers more or less of the lateral and anterior surfaces of the middle portion of the rec- tum. As before mentioned, the point at which the peritoneum leaves the anterior surface of the middle portion of the rectum, to be reflected upon the posterior surface of the bladder in the ' Hilton : " Rest and Pain." POINTS IN ANATOMY AND PHYSIOLOGY. 7 male, or of the vagina or uterus in the female, varies in dif- ferent subjects, and at different times in the same subject ; and hence the differences in its distance from the anus as given in different works on anatomy. In new-born children the bottom of the cul-de-sac touches the upper edge of the prostate and ap- proaches to within about an inch of the anus. At five years it rises in the pelvis with the development of the seminal vesicles and internal organs of generation ; and in old people with en- largement of the prostate it is carried still higher. In women it generally covers the upper part of the posterior vaginal wall, so that the latter is separated from the rectum by peritoneum for about one-third of an inch. By every expansion of the blad- der or rectum, as well as by tumors of the pelvis, the fold is carried further away from the anus, as may easily be demon- strated on the cadaver by forcible injections of the bladder. The average distance from the anus to the point at which the serous coat leaves the anterior wall of the rectum is, therefore, very difficult to determine. Dupuytren gives the distance as seventy mm. , and less when the organs are empty ; Lisf ranc gives six inches in the female, and four in the male, but does not state in what condition of the organs the measurements are taken ; Sappey, Velpeau, and Legendre give five and a half cm. when the bladder is empty and eight when distended ; Quain says four inches ; Allingham from two to five or more. Cripps,' acting on the idea that the fold is not easily displaced downward by traction on the rectum, has experimented by fill- ing the peritoneal cavity with plaster, and then thrusting a needle through the skin of the perineum till its point struck the plaster. In this way he has obtained an average measure- ment of two and a half inches when the bladder and rectum are both empty, and an additional inch when distended. ^ Muscular Coat. — In the fact that the muscular coat is ar- ranged in two layers, an external longitudinal and an internal circular, the rectum resembles the other portions of the alimen- tary canal; but in the further arrangement of its fibres it resem- bles the oesophagus more closely than the intermediate portions. The fibres are spread out into two uniform layers, and are not 1 "Cancer of the Kectum," London, 1880, p. 129. ■^ The following authors give the following measurements : Malgaigue, males, 6-8 cm. ; females, 4-6 cm. Luschka, 5.5-8 cm. Hyrtl, 8 cm. Lisf ranc and San- son, 11 cm. Richet, males, 10.8 cm. ; females, 16.2 cm. Blaudin, males, 8.1 cm. ; females, 4.1 cm. Ferguson, males, 10.5 cm.; females, 15.4 cm. Esmarch : "Die Kj-ankheiten desMastdarms und des Afters." Pitha u. Billroth : "Chirurgie," p. 7. 8 DISEASES OF THE RECTUM AND ANUS. arranged in bands crossing each otlier in basket network and leaving sacculi between the meshes as in the large intestine. The longitudinal fibres are the direct continuation of the Jihree longitudinal bands of the large intestine. Upon reaching the rectum, these blend into one continuous sheath which, how- ever, is somewhat heavier on the anterior surface of the bowel than on any other. At the point of contact of the rectum with the bladder and prostate, these fibres are in part reflected with the peritoneum on to the posterior wall of the latter, and thus form a firm band of union between the two organs, as has been particularly described by Dr. Garson.' They have been named by him the recto-vesical fibres, but I have never been able to es- tablish the fact of their existence. The ending of the longitudinal fibres is worthy of note. Ac- cording to Horner," when they reach the lower margin of the in- ternal sphincter a part of them turn upward between it and the external sphincter, and ascend for an inch or two in contact with the mucous coat, into which they are finally inserted ; hav- ing, therefore, an obvious influence in causing protrusion of the mucous membrane. In the lower fourth of their extent, these fibres become weaker and less distinct, and some of them finally blend into elastic tendinous tissue which passes between the bundles of the external sphincter, and is inserted into the subcutaneous connective tissue of the anus. Others are inserted posteriorly, by means of an elastic tendon about an inch long, into the anterior sacro-coccygeal ligament — an arrangement pointed out by Luschka ' as analogous to what is found in most mammalia, in whom a considerable number of the longitudinal fibres are inserted into the base of the coccyx, giving a fixed point for the rectum in defecation. The circular layer is reinforced at certain points, notably at the internal sphincter, which is merely a collection of these fibres, and at a point higher up where they are again gathered into a bundle either partly or completely surrounding the bowel, known as the third sphincter. This supposed muscle will be de- scribed more fully later. Submucous Coat. — The submucous tissue forming the bed upon which the mucous membrane rests is sufficiently lax to ' "The Arrangement and Distribution of the Muscular Fibres of the Rectum." Paper read before the Brit. Med. Assoc. Reported in Brit. Med. Jour., September 6th, 1879. ■^ "A Treatise on Special and General Anatomy," vol. ii., p. 40, Philadelphia, 1826. 3 " Anat. des Menschen," vol. ii., part 2, p. 308. POINTS IN ANATOMY AND PHYSIOLOGY. 9 permit of considerable sliding of the mucous membrane on the muscular coat. In it the blood vessels ramify, and from it per- pendicular processes are given off which perforate both the in- ternal and external muscular layers and are finally lost in the sheaths of the muscular fibres, or go entirely through the mus- cular layer and blend with the fibrous stroma of the surround- ing fatty tissue. These processes from the submucous tissue, together with the lymph and blood vessels, serve to bind the various layers of the rectal wall together.' (Fig. 3.) Mucous Memhrane. — The mucous membrane of the rectum corresponds in its general characters with that of the other parts of the bowel, being modified, however, in certain particu- lars to suit its location and function. Its thickness is about three-quarters of a mm. ; it is redder and more vascular than that of other parts of the large intestine ; it glides freely on the Fig. 3.— Section of the Normal Rectal Wall. CCripps.) tissue beneath, and is so ample as to be gathered into folds at various points, which are of considerable surgical and anatomi- cal interest. At its point of union with the skin of the anus, it is gathered into vertical folds which diminish when the bowel is distended, but do not entirely disappear, and hence are not due solely to the contraction of the sphincter. These vertical folds have received the name of columnce recti, or columns of Mor- gagni ; and Treitz states that they contain bands of muscular fibres running longitudinally and terminating above and below in elastic tissue. Kohlrausch ' also describes a thin layer of longitudinal muscular fibres under the inucous membrane at this point, and has named it the sustentator tunicce mucosce ; ^ Cripps, op. cit., p. 38. ^ " Anat. u. Physiol, der Beckenorgane," Leipzig, 1854. Boyer also says they are strengthened by muscular fibres: " Traite d'Anat.," t. iv., Paris, 1815. 10 DISEASES OF THE RECTUM AND ANUS. but most anatomists, with Henle, have failed to find any thing- more than the stratum of muscukir tissue common to the whole mucous coat, and known as the iHuscuIaris mucosce. Between the lower ends of the columiuE recti little arches are sometimes stretched from one to the other, forming pouches Fig. 4.— Section of the Rectal Mucous Membrane. (Esmarch.) 1, Follicles of Lieberkuhn. 2, Jluscular layer of mucous membrane. 3, Submucous connective tissue and vessels, with a soli- tary closed follicle, over which the tubular folUcles are wanting. of skin and mucous membrane. These are more developed in old people, and may retain small pieces of hardened faeces or foreign bodies in their cavities, which are directed upward, and thus give rise to suppuration and abscess. Fig. .5.-1, Ani columnse; 'i, Interjectae iisdem valvulae semilunares. (Morgagni.) These little pouches, or sacculi, have quite recently been br(night into rather an undue prominence by the attempts of certain charlatans to locate in them many of the causes of rec- tal disease. They have always been known to anatomists, as Figures 5 and fi will prove (Fig. 5 from Morgagni and Fig. 6 POINTS IN ANATOMY AND PHYSIOLOGY. 11 from Horner). But the fact is that both these drawings, and more especially the first one, are diagrammatic exaggerations for the sake of clearness. For some years I have been on the watch for these pouches in my rectal examinations, with the result of concluding that they j do not generally exist to any such degree as these dia- grams would indicate; and that, even when one or two of them are found, they are, in the. majority of cases, of no pathological significance. I have slit them up on a director, sometimes two Fig. 6.— a Vertical Section of tlie Anterior Parietes of the Anus, with the whole canal displayed so as to show the relations of the sacculi of the middle region, and their relations to the sur- rounding parts, their orifices being marked by bristles. A, A, Columns of the rectum; B, B, rudi- ments of columns; C, internal sphincter; F, external sphincter; I, rudimentary or imperfect sacculi; K, K, radiated folds of the skin, terminating on the surface of the nates, n, A bristle in one of the sacs. (Homer.) or three in the same patient, and I have mistaken their orifices for the internal openings of blind fistulse ; but only in a few cases have I found any inflammatory process concealed within them. I have, however, a few times discovered a pathological condition similar to that described by Vance under Ulceration of the Rectum, The mucous membrane may, for the purpose of study, be 12 DISEASES OF THE RECTUM AND ANUS. divided into three separate layers, the muscular, glandular, and epithelial. (Fig. 4.) The muscular layer {muscularis mucosce, sustentator tunicce mucosce) is a layer of unstriped muscular tissue about 0.02 mm. thick, which is everywhere found in the deepest layer of the mucous membrane, extending from the oesophagus to the rec- tum, but is more strongly developed in the region of the anus^ where it serves to hold the membrane in place and prevent pro- lapse. It consists of bundles running in some parts both longi- tudinally and circularly, and in others in one direction only ; and which send prolongations up between the glands to the villi. The glandular layer is about 0.07 mm. in thickness. It con- sists of a layer of Lieberkuhn's follicles, with an occasional solitary closed follicle below them, the situation of which is marked by a slight depression in the mucous membrane, and an absence of the tubular follicles at that point. The follicles are tubular depressions arranged with great regularity, and set so closely together that the width of the intervening tissue is, on the average, about one-sixth the diameter of the follicle. The length of the tubes is four or five times their diameter, the re- spective measurements being: length, 0.35 mm.; diameter, 0.08 mm. These tubular depressions or follicles are lined with epi- thelial cells arranged with their bases resting on the connective tissue and their apices free in the cavity of the follicle; and the cells of one follicle are directly continuous with those of the next, hanging freely into the lumen of the bowel as they pass over from one depression into the next. The appearance of the cells is analogous to that of a bee's honeycomb, the intervening wall being common to two cells. The intertubular tissue con- sists of a fine trabecular network, the meshes of which are very long in the vertical direction running parallel to the follicle (Cripps). The follicles of Lieberkuhn are simply inverted villi, and answer the same purpose of absorption. There are good rea- sons for the substitution of follicles for villi in this part of the canal, the former being less subject to injury from hardened faeces ; and the fact of such substitution gathers great weight from the fact that in certain cases where an artificial anus has been established, the whole bowel below that point has been found in after-years covered with a growth of villi. ' Muscles of the Rectum and Amis. — The muscles which may ' Specimen No. 1288, Museum of College of Surgeons. (Cripps.) POINTS IN ANATOMY AND PHYSIOLOGY. VS properly be included in a description of the rectum, and anus are the external and internal sphincters, the levator ani, ischio- coccygeus, retractor recti or recto-coccygeus, and the transver- sus perinei. External Sphincter. — The external sphincter muscle is a thin layer of voluntary fibres, about half an inch broad on each side of the anus, surrounding it in the form of an ellipse, and having a, narrow, pointed insertion anteriorly and posteriorly. It is sit- uated immediately beneath the skin, and extends about two centimetres up the bowel, where its upper limit may sometimes be seen by the white line between it and the internal sphincter already mentioned. It is divided into a superficial and a deep portion. The superficial is inserted, both in front and behind, into the subcutaneous cellular tissue. The deeper and thicker portion is inserted posteriorly by a narrow, flat tendon into the posterior surface of the fourth coccygeal vertebra. Between the tendon and the bone is a bursa about the size of a pea — hursa mucosa coccygea of Luschka. Anteriorly it is inserted into the central tendon of the perineum in common with the transversus perinei and bulbo-cavfernosus, and in women with the sphincter vaginse. The action of the muscle is to close the anus and, under the control of the will, to antagonize the proper dilators of the anus as well as the peristaltic action of the bowel and the contraction of the diaphragm. The superficial band of fibres acts only in puckering the skin. The nerve supply comes from the heemorrhoidal branch of the internal pudic, and the hsemorrhoidal branch of the fourth sacral nerve. Great variations will be found in this muscle in different per- sons. In some it is strong, in others weak. In some it closes the anus so tightly that a finger cannot be inserted without great pain ; in others a full-sized Sims's speculum can be passed with- out difficulty. . A condition of weakness causing a patulous anus is a very common symptom of grave disease of the rec- tum ; and the same patulous condition is considered by the French writers as a proof of the constant practice of passive paederasty, but without sufficient grounds. The muscle is adapt- ed for frequent contraction and expansion, and there is no reason for believing that the frequent introduction of the male organ should cause its paralysis any more than the equally fre- quent passage of faeces. However it may be in warmer cli- mates, I know that it would not do in America to infer the prac- tice of unnatural vice from a relaxed and funnel-shaped anus, as seems to be the case in France. 14 DISEASES OF THE KECTUM AND ANUS. Internal Sphincter. — The internal sphincter is an involuntary muscle situated immediately above and partly within the deeper portion of the external sphincter, being separated from it by a layer of fatty connective tissue. Its thickness is about two lines ; its vertical measurement from half an inch to an inch ; and it is a direct continuation of the involuntary circular fibres of the bowel, growing thicker and stronger as they approach the anus. It also is supplied by the hsemorrhoidal branch of the internal pudic. In dissecting this muscle for demonstration, it should be ap- proached from the mucous surface of the bowel. It will be found answering to this description in a general way in most cases, but is subject to many variations, due to its different de- grees of development in different subjects. In some it is very well marked ; in others scarcely distinguishable from the rest of the circular muscular fibres. Recto-coccygeus (Retractor recti, Treitz ; ' Tensor Fasciae Pel- vis, Kohlrausch). — This muscle consists of two flat lateral bands of unstriped fibres, each of which is about four mm. broad, which diverge at an acute angle from the anterior coccygeal lig- ament at the tip of the coccyx, and, passing forward and down- ward, embrace the lower end of the rectum on each side like a fork. It is located directly under that portion of the levator ani which forms the floor of the pelvis between the tip of the coc- cyx and the anus ; and blends partly with the longitudinal muscular fibres of the rectum, and partly with the pelvic fascia surrounding its end. Its function is to hold the end of the rectum against the coccyx and to give itj a fixed point in defe- cation. Levator Ani. — The levator ani and ischio-coccygeus muscles form a true diaphragm to the pelvis by giving an uninterrupted muscular and tendinous plane from the lower border of the py- riformis, behind, to the arch of the pubes in front. That part which is named ischio-coccygeus is usually described as a sepa- rate muscle, though in no way differing in function from the larger portion, and only distinguishable from it by its more ten- dinous structure. It is situated just in front of the sacro-sciatic ligaments, and arises by aponeurotic fibres from the sides and tip of the spine of the ischium, from the anterior surface of the lesser sacro-sciatic ligament, and often from the posterior part of the pelvic fascia. It is inserted, also by aponeurotic fibres, into > " Vierteljahrsschrift f . prakitsche Heilkunde," Prag., 1863, bd. i., s. 134. Henle: Abbildung 2, 183. POINTS IN ANATOMY AND PHYSIOLOGY. 15 the border of the coccyx and lower part of the border of the sa- crum. Owing to its tendinous origin and insertion, the greater part of the muscle is composed of aponeurotic fibres. It is in relation superiorly, by its concave surface, with the rectum ; in- feriorly, by its convex surface, with the sacro-sciatic ligaments and the gluteus maximus ; posteriorly its border is in contact with the lower border of the pyriformis ; and anteriorly it is directly continuous with the fibres of the levator ani. Its action is to draw the coccyx to its own side, or, when both muscles Fig. 7.— Side View of the Levator Ani. A, anus; B, bladder; C, coccyx; R, rectum; L A, levator ani muscle; S, pubic bone sawn through external to symphysis. The fibres of the levator ani are seen arising by a tendinous attachment from the pubic bone; the posterior fibres then cross the rectum at nearly right angles, two inches from the anus, to be Inserted into the coccyx.— Drawn from a dissection by William Pearson at the Royal College of Surgeons. (After Cripps.) act together, to fix that bone and prevent its being thrown backward in defecation. It has no such action as would justify the name of levator coccygis, given it by Morgagni, Its nerve supply is from the anterior branch of the fourth sacral nerve. The levator ani proper, which constitutes the remaining por- tion of the pelvic diaphragm, is in its general shape an inverted cone, supporting the pelvic contents in its cavity and allowing 16 DISEASES OF THE RECTUM AND ANUS. the rectum and prostate to pass throug-h its apex. Considering each lateral half of the muscle apart, we find it made up of a delicate layer of muscular fibres forming a thin, curved, and quadrilateral sheet, broader behind than in front. Its upper border is stretched across the pelvis from the pubes to the spine of the ischium, arising from both these bony points and from the tendinous line of union of the pelvic with the obturator fascia, which runs antero-posteriorly between them. Its attach- ment to the pubic bone is at a point on its inner surface near the middle of the descending ramus and a little to one side of Fig. 8.— Levatores Ani seen from Behind. The prostate and vesiculse seminales have been drawn upward by hooks. The free posterior borders of the levatores ani are seen passing downward from near the symphysis to the coccyx, partially encircling the rectum in their course.— From a dissection by William Pearson at the Royal College of Surgeons. (After Cripps.) the symphysis. This attachment will be found to vary some- what in different dissections, being sometimes a little higher or a little lower on the bone, and sometimes on the cartilage be- tween the bones. The muscular fibres may also be traced at times upward into the pelvic fascia above its junction with the obturator. (Figs. 7 and 8.) From this extensive though delicate and in great part mem- branous origin, the fibres proceed downward and inward toward POINTS IN ANATOMY AND PHYSIOLOGY. 17 the median line. Those most anterior unite with those of the opposite side beneath the neck of the bladder, the prostate, and the adjacent portion of the urethra. These fibres are con- cealed by the pubo-prostatic ligament or anterior fold of the recto-vesical fascia, from which they also sometimes take ori- gin in part. They are in relation, in front, with the posterior surface of the triangular ligament. This portion is sometimes separated from the main body of the muscle by a cellular inter- val, similar to those often found in other parts of this thin mus- cular sheet. The fibres which arise from the tip of the spine of the is- chium are inserted into the side of the tip of the coccyx, while the fibres immediately in front of these (precoccygeal) unite with those of the opposite side in the median line and form a raphe which extends from the point of the coccyx to the pos- terior border of the sphincter, and thus complete the floor of the pelvis. • The fibres which arise indirectly from the upper part of the obturator foramen and from the brim of the pelvis by means of the pelvic fascia, pass downward and inward, forming a curve with its concavity upward, and may be divided into vesical and anal. The vesical pass into the sides of the bladder. The anal fibres in part pass backward and meet behind the bowel, and in part blend with those of the external sphincter at its upper border, there being no distinct line of separation between the two muscles. The relations of the levator ani are of great surgical impor- tance. Superiorly its surface is covered by the superior pelvic fascia (the recto-vesical layer of the pelvic fascia), which sepa- rates it from the peritoneum and pelvic organs. The space be- tween this fascia and the peritoneum is the superior pelvi-rectal space of Richet. (See Fig. 43.) Its inferior surface is separated from the obturator internus muscle by the obturator fascia, and beneath this is the ischio-rectal fossa. The posterior part of the muscle is in relation with the gluteus maximus. The actions of this muscle are various. First, it acts as a support to the pelvic organs, and antagonizes the diaphragm and abdominal muscles when they act upon the abdominal con- tents. By enclosing the neck of the bladder the muscle acts upon it also, and in the act of defecation, when the muscle is contracted to open the anus, the neck of the bladder is pressed upon and the urethra closed. In this way is explained the well- known difficulty of passing urine and feeces at the same time. 2 18 DISEASES OF THE RECTUM AND ANUS. By enclosing the bladder, vesiculse seminales, prostate, and rec- tum in its grasp, the muscle produces a sympathy among these parts which will often be found very distressing in diseases of the rectum or after operations for their relief — such as impossi- bility of micturition, erections, and lancinating pain due to spas- modic action of the muscle. It will often happen that after a complete paralysis by free division of both sphincter muscles in an operation upon the rectum, the patient will still complain of a sharp, spasmodic pain at intervals— just such a pain as is caused by spasmodic contractions of the sphincter. In such cases it is the levator ani which is at fault. The muscle also aids the longi- tudinal fibres of the rectum in their opposition to the dragging of the fteces ; and the anal fibres also draw the rectum upward and forward and compress it on the sides, and thus aid in the expulsion of its contents. The voluntary sphincteric action of this muscle in connec- tion with the ischio-coccygeus is of considerable power. It is brought to bear at a point about an inch and a half above the anus (above that of the involuntary internal sphincter), and no doubt in a measure accounts for the partial control over the passage of faeces often seen after destruction of both the internal and external sphincters. The muscle receives a filament from the fourth sacral nerve on its pelvic surface, and another from the internal pudic. Transversus Perinei. — This also has an action in defecation. Its fibres do not always blend with those of the opposite side in the median raphe, but the two muscles are sometimes continu- ous, traversing the anterior extremity of the external sphincter. In such a case the two muscles form a continuous half -ring, the concavity of which is directed backward and embraces the an- terior part of the rectum, assisting powerfully in defecation by pressing the anterior against the posterior wall of the bowel in conjunction with the external sphincter (Cruveilhier). Arteries. — The rectum is supplied with blood from five arte- ries, one single and two pairing. The superior haemorrhoidal is single and is a direct branch of the superior mesenteric. It is the direct continuation of the parent trunk, passing into the pelvis behind the rectum in the fold of the meso-rectum, and dividing into two branches which extend, one on each side of the bowel, to its lower end. About five inches from the anus these subdivide into smaller branches, about seven in number, which pierce the muscular coat about two inches lower down. They then descend between the mu- POINTS IN ANATOMY AND PHYSIOLOGY. 19 ecus and muscular layers at regular intervals to the end of the bowel, where they communicate in loops oi)posite the internal sphincter, and anastomose with the terminal filaments of the middle and inferior haemorrhoidal arteries. The middle h hemorrhoidal arteries — one on each side — are not constant in their origin, sometimes coming from the hypogastric or the inferior vesical, and sometimes from other sources. The inferior hsemorrhoidal arteries — also pairing — are usu- ally given off from the internal pudic near the point where it crosses the tuber ischii. They cross through the fat of the ischio- rectal f ossse, and are distributed with the middle heemorrhoidal to the lowest part of the rectum, and to the anus and adjacent skin. Veins. — There are three sets of rectal veins, as there are three sets of arteries, the superior, middle, and inferior ; and these are so arranged as to form two distinct venous systems — the one, rectal, and returning its blood to the vena portse ; the other, anal, returning its blood through the internal iliac. The first, or rectal circulation, is made up of the superior hsemor- rhoidal vein ; the second, or anal, is made up of the middle and inferior hsemorrhoidal veins, the middle receiving its blood from the anus, and the inferior from the adjacent integument. The middle hsemorrhoidal ascends obliquely into the ischio-rectal fossa ; the inferior starts horizontally from the skin of the anus and empties into the internal pudic. The middle hsemorrhoidal is formed from two venous trunks, one on the anterior, the other on the posterior aspect of the rec- tum, which, by anastomosing with the corresponding branches from the opposite side, surround the sphincter in a venous circle. From this circle spring the collateral branches, which by their successive division and anastomoses form a true venous plexus. The inferior hsemorrhoidal vein also has a plexiform arrange- ment at its origin, but its branches are situated between the skin and the inferior border of the external sphincter. The rectal pouch is not, therefore, supplied with blood from the external haemorrhoidal veins, but only the anus and the region of the sphincters. When, on the other hand, the venous circulation of the rec- tum proper is injected from the inferior mesenteric vein, three or four large venous trunks may be seen on the external surface of the rectum ascending on the sides and posteriorly. (Figs. 9 and 10.) These veins make their appearance suddenly by five or six branches, which perforate the wall of the bowel about three 20 DISEASES OF THE RECTUM AND ANUS. inches from the margin of the anus. If the rectum be opened longitudinallj, and the mucous membrane dissected up to a suf- ficient height (about four inches), it will be seen that these five or six large veins, already visible on the outside of the bowel, come from within, and that they have already pursued quite a long course under the mucous membrane. They are formed by collateral branches, and especially by about a dozen primitive branches, which originate about half an inch above the anus V.H.I .„,. VHM. Y^M. VHE Fig. 9.— Rectal Veins seen from without. CDuret.)' Amp., rectal pouch; S. E., external sphinc- ter; P., skin at margin of anus dissected up and turned back; V. H. I., internal hsemorrhoidal vein; V. H. M., middle hsemorrhoidal vein; V. H. E., external hismoiThoidal vein. and ascend in parallel and flexuous lines for several centime- tres to unite into common trunks. Each of these little ascend- ing branches has its origin in a minute pool of blood, the size of which varies in the normal state from that of a grain of wheat to that of a small pea. ' "Recherches sur la Pathogeniejdes Hemorrhoides," Arch. Gen. de_Med., De- cember, 1879. POINTS IX AXATOMY AND PHYSIOLOGY, 21 These little sacs are arranged in a circular form around the extremity of the rectum. If carefully dissected they may be seen to be connected with the little veins before mentioned, and also with another little vein which perforates the internal sphincter near its lower edge, and empties into one of the rudi- mentary branches of the external hiemorrhoidal plexus. Many of these little communicating branches between the external and internal hsemorrhoidal systems pass through the substance Fig. 10. — Rectal Veins seen from within. (Duret.) M.q., mucous membrane dissected up and cut away below; M. cl., muscular tunic; Sp. I., internal sphincter; Sp. E., external sphincter; P., sMn; H. I., internal haemorrhoidal vein; H. M., middle hsemorrhoidal vein; V. H. E., external haemor- rhoidal vein. of the external sphincter. It results from this that when the external sphincter is contracted the anastomosis between the two systems is prevented. Yerneuil has laid stress upon the fact that where the in- ternal or superior hsemorrhoidal veins perforate the rectal wall from within outward, they pass through "muscular button- 22 DISEASES OF THE RECTUM AND ANUS, holes " surrounded b>' no fibrous tissue, and liaving, therefore, the power of contracting round the vein, closing its calibre, and preventing the return of blood to the liver. In this anatomical arrangement he believes he has found the active cause of in- ternal haemorrhoids. The disposition of the rectal veins into two distinct systems, the one internal and the other external, is fully in conformity with our knowledge of the development of the rectum and anus. The rectal cul-de-sac is at first situated at some distance from the perineum, and as it descends it carries with it its own proper vascular supply. The anal depression is of necessity provided with an independent set of veins, and when the rec- tum and anus are finally united into one canal the two venous systems also unite. The internal heemorrhoidal veins also communicate freely with other branches of the internal iliac around the trigone of the bladder by means of minute branches, from one-half to one mm. in diameter, which pass through the prostate and vesiculee seminales. Xerues. — The nerves of the rectum and anus are derived from both the cerebro-spinal and sympathetic systems. The former are branches from the sacral plexus, the latter from the mesenteric and hypogastric plexuses. The spinal nerves are derived from the third and fourth sacral, which supply visceral branches to all the pelvic organs, anastomosing with branches from the sympathetic. The muscular branches from the same nerves have already been spoken of in connection with the indi- vidual muscles. The fifth sacral nerve also sends a small twig- to the coccygeus. The posterior branch of the superficial peri- neal nerve from the internal pudic supplies the skin in front of the anus, while the anterior branch gives several small fila- ments to the levator ani. The inferior hsemorrhoidal branch from the pudic supplies the lower end of the rectum, the external sphincter, and the skin of the anus. This nerve may come direct from the sacral plexus through the lesser sacro-sciatic notch. The posterior branches of the sacral nerves also supply the skin over the coccyx and around the anus. According to a brief contril)uti()n of W. Krause,' the nerves end in the nmcous membrane of the anus, in club-shaped bulbs, about 0.05 mm. in diameter, which lie under the bases of papillae. ' Esmarch, op. cit., p. 10. POINTS IN ANATOMY AND PHYSIOLOGY. 23 The tonic contraction of the external sphincter muscle is, in J3art at least, due to the influence of a nerve centre located in the lumbar region of the spinal cord. ' If the nerve connection of the sphincter with the spinal cord be severed, relaxation of the muscle takes place. The fact that division of the cord in the dorsal region does not affect the sphincter, except tempo- rarily by shock or depression, proves that this centre is not located above the lumbar region. This nerve centre is subject to various influences ; and the sphincter may either be relaxed, or its tonic contraction increased, by local stimulation, or by the influence of the will or emotions. Though the dependence of the sphincter for its tonic con- traction upon the lumbar nerve centre seems so great, still it is not absolute. In the case of a man in whom the sacral nerves were entirely paralyzed by an injury, and in whom, therefore, there was no nerve connection with the lumbar centre except perhaps through the sympathetic, Gower° observed the main- tenance of a certain amount of tonic contraction, which could be inhibited and relaxation produced by stimulation of the mu- cous membrane of the rectum and anus. From this it would appear that the tonic contraction of the sphincter, as is known to be the case in the arterial system, is habitually dependent on a spinal centre, but may, nevertheless, exist without the action of that centre. The paralysis of the muscle which follows brain lesions is probably due merely to inhibition of the spinal centre, and not to the injury of any centre located in the cerebrum." The distribution of the spinal nerves serves to explain many of the reflex and so-called anomalous symptoms of pain which are encountered in diseases of the rectum and anus. Brodie * 1 Masius, Bull, de I'Acad. Royal de Belgique, xxiv. (1867), p. 312. (Foster's ■"Physiology," p. 387.) - Proc. Roy. Soc. (1877), p. 77. 3 Foster's " Physiology," p. 388. Philadelphia, 1880. •• A lady consulted me, says Mr. Brodie, concerning a pain to which she had l)een for some time subject, beginning in the left ankle and extending along the in- step toward the little toe, and also into the sole of the foot. The pain was described as being very severe. It was unattended by swelling or redness of the skin, but the foot was tender. She labored also under internal piles, which protruded externally when she was at the water closet, at the same time that she lost from them some- times a larger and sometimes a smaller quantity of blood. On a more particular in- quiry I learned that she was free from pain in the foot in the morning; that the pain attacked her as soon as the first evacuation of the bowels had occasioned a protrusion of the piles ; that it was especially induced by an evacuation of hard fa?ces ; and that, if she passed a day without any evacuation at all, the pain in the foot never troubled her. Having taken all these facts into consideration, I prescribed for her 24: DISEASES OF THE KECTUM AND ANUS. relates an instructive case of pain in the foot over the distribu- tion of the sciatic which was cured by curing prolapsing hae- morrhoids — the irritation being primarily at the termination of the internal pudic, and conveyed thence to the sacral plexus, to be carried to the termination of the great sciatic ; and I have the notes of an exactly analogous one in a man. In the same way a fissure of the anus or other disease of the rectum may cause pain in the lumbar and iliac regions, pain, loss of sensa- tion, and cramps in the legs, and symptoms of bladder and ure- thral disease, besides more general nervous phenomena. (See Fig. n.) The chief nerve supply of the rectum is at the lower portion and around the anus — the middle and upper portions possessing very little sensibility; so little, in fact, that the gravest diseases, such as cancer or ulceration, may exist and not manifest them- Fia. 11.— Diagrammatic View of the Nerves of the Anus. (Hilton.) a, Ulcer on sphincter: b, the filaments of two nerves are exposed on the ulcer, the one a sensory and the other motor, both at- tached to the spinal marrow, thus constituting an excito-motory apparatus; c, levator ani; d, trans- versus perinei. selves by pain. This also explains how large masses of faeces may accumulate in the rectal pouch without causing suffering. Puncturing the bladder through the rectum is not a painful operation, and applications of strong acids to the mucous mem- brane will cause little suffering if the skin be properly pro- tected. Exactly the opposite condition obtains at the anus, the extreme sensibility of which is well known. the daily use of a lavement of cold water ; that she should take the Ward's paste (confectio piperis composita) three times daily, and some lenitive electuary at bed- time. After having persevered in this plan for a space of six weeks, she called on me again. The piles had now ceased to bleed, and in other respects gave her scarcely any inconvenience. The pain in the foot had entirely left her. She observed that, in proportion as the symptoms produced by the piles had abated, the pain in the foot had abated also. — Medical Gazette, vol. v. POINTS IN ANATOMY AND PHYSIOLOGY. 25 The pelvic plexuses of the sympathetic are placed one on either side of the rectum and vagina. Each is composed of pro- longations from the hypogastric plexus above, united with branches from the sacral ganglia. The spinal branches to the sympathetic are mostly from the third and fourth sacral nerves. From the back part of the plexus thus formed are given off the inferior hsemorrhoidal nerves, which join with the superior hsemorrhoidal from the inferior mesenteric artery and perforate the rectal wall. Lymphatics. — The lymphatic vessels of the rectum are ar- ranged like those of the intestine generally, in two layers ; one beneath the peritoneum and one between the mucous and muscular coats. Immediately after leaving the bowel some of the vessels pass through small adjacent glands, and all finally enter the glands in the hollow of the sacrum, or those higher up in the loin. But just as there is an internal and external system of veins, one proper to the rectunij the other to the anus, so is there an- other lymphatic system, which comes from the integument around the anus and passes to the glands in the groin ; and these two sets of vessels freely communicate with each other. A knowledge of this fact is of importance in the diagnosis of cancer of the rectum ; and the glands which are deep in the pel- vis along the sacrum should always be felt for, as well as those located in the groin. Defecation. — A study of the anatomy of the rectum would not be complete without some reference to its physiological functions. We shall, therefore, in this place consider the func- tion of defecation. In regard to defecation the question at once arises, how, after destruction of the lower end of the rectum, or paralysis of the sphincters, there still remains a certain amount of control over the evacuations ? Such an injury is often only noticeable through a constant discharge of rectal mucus, and an occasional involuntary escape of fluid f seces when the patient is suffering- from diarrhoea. This leads naturally to a consideration of the third or superior sphincter muscle,' whose existence has been ' Gosselin : " Retrecissemeuts Syphilitiques du Rectum," Arch. Genl. du Med. 1854, p. 668. Henle : " Handb. der systemat. Anat. des Meuschen," 1873, bd. ii. Hyrtl : " Handb. der topogr. Anat.,'-' Wien, 1857, bd. ii., pp. 108, 109. Sappey : " Traite d'Anat. Descriptive," Paris, 1874, t. iv. Cliadwick : " Trans, of the Am. Gyntecol. Soc," ii., 1877. 26 DISEASES OF THE RECTUM AND ANUS. supposed to account for such control of the evacuations as exists in this condition. It is now about half a century since Nelaton first described the third sphincter muscle, and. in spite of all that has been written concerning it since that time, it is only a few years since Van Buren ' characterized it as an organ to which ana- tomy and physiology had been equally unsuccessful in assign- ing either certainty of location or certainty of function. For the original description of the muscle by Nelaton we are in- debted to Velpeau, who writes that he has verified the existence of a sort of sphincter of the rectum, lately discovered by Nela- ton, and goes on to say that it is a muscular ring situated about four inches above the anus, just in the place Ayhere retractions of the rectum are most often found. If, after turning the rec- tum so that its mucous surface is external, it is moderately dis- tended by insufflation, the muscle will be seen to be made up of fibres collected into bundles. Its breadth is from six to seven lines in front, and about an inch behind. Its thickness, on the contrary, is much greater in front, where the fibres appear to be collected in the angle which corresponds to the union of the first and second curves of the rectum, while behind they are scat- tered over its convexity. After thus adopting the description of Nelaton, Velpeau'' brings out one other anatomical point — the attachment of the muscle posteriorly to the front of the sacrum. The functions ascribed to the muscle by Nelaton were those of keeping the rectum empty until a short time before the act of defecation ; separating the faecal mass and preventing its re- gurgitation during defecation : and of opposing the continuous and involuntary escape of fseces after the destruction of the lower sphincters. Hyrtl refers to this description, and himself describes the muscle as being six or seven lines in breadth anteriorly and an inch posteriorly, but does not always find it present. He also in Petrequin : " Traite d'Anat. Topogr. Med.-Chirurg.," etc., 2me ed., Paris, 1857, p. 414. Houston : " Dublin Hosp. R.," v., 1830. O'Beirne : " New Views of the Process of Defecation," etc., Dublin, 1833. Buslie : "Treatise on the Malformations, Injuries, and Diseases of the Rectum and Anu.s," New York, 1837. Kohlrausch : " Anat. u. Physiol, der Beckenorgane," Leipzig, 1854. Ro.sswinkler : Wicn. med. Woch., 1852, p. 435. Foster : " Text-Book of Physiology," Philadelphia, 1880, p. 387. ' "On Phantom Stricture," etc.. Am. Jour, of the Med. Sci., October, 1879. - Velpeau : " Traite d'Anat. Chirurg.," 3me ed., 1837, Introduction, p. 39. POINTS IN ANATOMY AND PHYSIOLOGY. '^7 one case demonstrated, the attachment to the saCrum. Sappey admits its frequent existence, and locates it at the level of the hase of the prostate, in the middle portion of the rectum, six, seven, eight, or sometimes nine centimetres from the anus. It never completely surrounds the rectum, but only one-half or two-thirds of its circumference ; and it appears to him to be caused by a grouping of the circular muscular fibres, some being gathered from below upward, and others from above downward, to the same point. Its breadth is one centimetre and its thickness two or three millimetres. Situated sometimes in front, sometimes behind, and again laterally or antero-late- rally, it is constant in nothing except its direction perpendicular to the axis of the bowel. In place of one, he has sometimes found two bands at opposite points and different levels, and in one specimen which he has preserved there were three. Henle adopts Sappey 's description in the main. Petrequin found the muscle irregularly oblique, less marked in the front wall than in the back, and consisting of a collection of weak bands of fibres. Chadwick asserts that no distinct muscle exists, but describes in place of it two agglomerations of the circular mus- cular fibres, one on the anterior and one on the posterior wall, corresponding to two semicircular constrictions, which may be felt by digital examination, and whose effect is to give the rec- tum its sigmoid curve. The third sphincter muscle and the valves of mucous mem- brane in the rectum are not, as might be supposed, one and the same thing, though it is true that they have become almost hopelessly confounded in surgical and anatomical literature, and are often spoken of as identical. As far as possible, we shall try to consider them separately, without doing violence to the text of the authorities. The valves of the rectum (we use the word simply as expressing the folds, of mucous membrane) were first described by Houston at about the same time that Nelaton described the superior sphincter ; and it is worth re- membering that the two authors were writing about two en- tirely different things, and two things which stood in no neces- sary relation to each other, so far as we may judge from their descriptions. Houston's method of preparation was by filling and distending the gut with spirit before its removal from the body, and then laying it open longitudinally. He states that the folds disappear if the bowel is first removed from its natural position and then distended, but that they may be seen in the natural condition of the parts soon after death, before the tonic 28 DISEASES OF THE RECTUM AND ANUS. contraction lias disappeared ; and that they are then found to overlap each other so effectually as to require considerable manoeuvring- in order to pass a bougie or the finger along the bowel. It is also remarked that this is just the arrangement necessary to prevent the faeces from urging their way toward the anus, where their presence would excite a constant sensa- tion demanding their discharge. According to this first and clearest of all the descriptions — for the whole article is written with a force and clearness of style which have perhaps had an undue weight in disarming criticism as to the facts — the valves exist in all persons, but vary much in different individuals as to location and number. Three is the average number, though sometimes four, and again only two are well marked. The largest and most constant is about three inches from the anus, opposite the base of the blad- der ; the next most constant is at the upper end of the rectum ; the third is about midway between these ; and the fourth, or the one most rarely present, is attached to the side of the gut about an inch above the anus. The first one generally projects from the right wall ; the one next above from the left ; the uppermost from the right ; and the one nearest the anus, when present, from the left and posterior wall ; the arrangement being such, in spite of variations, as to form a spiral tract down the gut. The folds are described as semilunar in form, with the convex border attached to the side of the bowel, and occupying from one-third to one-half of its circumference. The surfaces are sometimes horizontal, but more often oblique, with the sharp, concave, floating margin generally directed a little upward. In breadth they vary from one-half to three-quarters of an inch or more in the distended state of the gut ; and they are said to be composed of a duplicature of mucous membrane enclosing some cellular tissue and a few of the circular muscular fibres. The palpable weak points in Houston's article were very soon pointed out by O'Beirne, in a work of marked and almost amus- ing originality. The views were indeed '* new," but they are to-day accepted in many points by those whose judgment is worthy of the most confidence in these matters. O'Beirne seems rather to regret that he is unable to accept Houston's statements as to an anatomical condition which would account so fullj^ and so easily for the physiological emptiness of the rectum and ful- ness of the sigmoid flexure on which his own views depend ; but nevertheless he sets himself to the task of demolishing them with great vigor and considerable success. Although he believes POINTS IN ANATOMY AND PHYSIOLOGY. 20 the rectum to be normally empty, except just at the tim.e of de- fecation, he believes that condition to depend upon the anatomi- cal arrangement of the sigmoid flexure, joined with the narrow- ing of the upper end of the rectum, which is entirely independent of any folds of mucous membrane. He not only denies the existence of any such folds, but states flatly that Houston is al- together incorrect in his statement that Cloquet or any other anatomist before his time makes even the slightest allusion to them.' He believes the folds to have been produced by the method of making the preparations — distending and hardening all the parts with spirit before making the incision — and asserts that this method is anything but natural, and nothing more or less than an attempt to exhibit natural appearances by placing the parts in an unnatural situation — such a situation, indeed, as is not known to be necessary for the exhibition of the valvulse conniventes or any other valves of the body. He meets the statement, that by the ordinary procedure of distending the rec- tum after removal from the body the valves are made to disap- pear, by the question, why, if such valves really exist, and if muscular fibres enter into their structure, they should not be discoverable at any time after death, or in any state of the in- testine — a question very difficult of solution. Four years later the voice of a ISTew York surgeon was raised against these folds, and in almost the same language as O'Beirne's, though from an entirely independent standpoint. Bushe declares that he has never, in the living body, been able to detect any valve of such firmness, and capable of exerting any such influence upon the descent of the fseces, as Houston de- scribes, though he has frequently met with accidental folds pro- duced by the partial contraction of the bowel; and the proof that they are accidental is that, in the same subject, he has on dif- ferent days found them to occupy different situations, but they were always unresisting and easily displaced by the extremity of ' Regarding this question of fact, it may be well to quote Cloquet's description from Bushe, op. cit., p. 60 : " The inner surface of the rectum is commonly smooth in its upper half, but in the lower there are observed some parallel longitudinal wrin- kles, which are thicjier near the anus, and are variable in length. These wrinkles, whose number varies from four to ten or twelve, and which are called the columns of the rectum, are formed by the mucous membrane and the layer of the subjacent cel- lular tissue. Between these [columns there are almost always to be found membra- nous semilunar folds, more or less numerous, oblique or transverse, of which the float- ing edge is directed from below upward toward the cavity of the intestine. These folds form a kind of lacuna3, of which the bottom is narrow and directed downward." It seems evident that the sinuses of Morgagni are here referred to. 30 DISEASES OF THE RECTUM AND ANUS. the finger. He points out that, by the method of hardening the rectum after distending it with spirit, these accidental folds are rendered permanent by the induration resulting from the action of the alcohol ; and that, by the method of inflation and drying, the projections resembling valves are produced by the angles formed by the setting of the intestine during the process of de- siccation. Kohlrausch describes and figures one important fold, the plica transversalis recti, which he locates at the same point as Hous- ton's most constant one, projecting well into the lumen of the bowel from the right side. It forms rather more than a semi- circle, and runs further on the anterior than on the posterior wall. Here also we meet the direct statement that this fold is now known as the sphincter ani tertius. though Kohlrausch does not consider such a title justified by the anatomical condi- tion, inasmuch as the circular muscular fibres do not enter into its texture, and are not more developed here than elsewhere. For, though both these things may happen, as a rule neither is the case. Sappey says he has found in the empty state various folds of the mucous membrane, but that these have no determinate direc- tion, and are generally only slightly marked. Three times only, in thirty recta which he examined, has he met with anything which at all answered to Kohlrausch's plica transversalis or to Houston's chief valve. There is nothing to prove that they per- sist when the rectum is full : on the contrary, it is probable that they are effaced by the simple fact of distention of the latter, at least in great part. The name of valve is not, therefore, appli- cable to them, and, admitting even that it might be used by one of those abuses of language so frequent in anatomy, Houston would still incur the discredit of having presented as normal a fact which is only observed very exceptionally. Henle divides the valves into two varieties, the temporary and the permanent. Of the former he describes several, which may be present or absent in the same individual at different times or in different states of the bowel. Of the permanent variety there is only one — the plica transversalis — and this one is only present in a minority of subjects. Hyrtl describes two folds, both constant : one on the right wall lower down, and one on the opposite si.de. Rosswinkler also describes two folds, but locates them on opposi|;e sides to those of Hyrtl. POINTS IN ANATOMY AND PHYSIOLOGY. oi Otis " has undertaken some elaborate investigations on the cadaver concerning- this point, with the aid of new instruments and appUances. The subject is pkiced in the knee-chest posi- tion, the anus is held open by retractors, and the illumination is obtained either by reflected light from a forehead mirror, or by a small electric light carried directly into the bowel. Three precautions are used : the body is placed so that the abdominal organs are relieved as much as possible of all pres- sure anteriorly ; the rectum is thoroughly emptied of faeces, to allow of the entrance of air ; and the bladder is emptied. In this position the rectum is in what may be called a state of natural distention, having both definite form and fixation ; and its cavity is seen to be lined throughout with smooth mucous membrane which no longer appears too large for its external coverings. Its general direction above the perineal curve cor- responds with the curve of the sacrum and coccyx, but its in- ternal surface is not that of an even cylindrical tube. It con- sists of large, saccular dilatations, marked off from each other by intermediate partitions or folds, projecting alternately from left and right, one beyond the other. These partitions or folds are semilunar in shape, involving rather more than one-half of the circumference of the internal surface, and extending a little further on the anterior than on the posterior wall. They consist in great part of a duplicature of the mucous membrane, projecting at the centre, where they are deepest, from 1 to 2. 5 cm. into the lumen of the bowel. The number of visible folds of this kind was always two or three, two of which were constant, the other variable. When two were present, the first was on the right side, about 6.5 cm. from the margin of the anus; the second on the left, about 2.5 cm. higher. When three folds were visible, the first was on the left nearer the anus, varying from 4. 5 to 6 cm. from its margin, being in some bodies well marked, in others scarcely perceptible. The other two folds were always well marked and practically the same as those just described when only two were seen. The presence of three folds is more frequent than that of two. This saccular appearance is equally well seen in the lithotomy as in the knee-chest position. The exterior of the rectum is divided more or less regularly into segments by transverse sulci or semicircular constrictions. These are confined to the sides of the rectum, and, as a rule, do ' "Anatomische Untersuchungen am menschlichen Rectum, undueueMethodeder Mastdarminspection," von Walter J. Otis. 32 DISEASES OF THE RECTUM AND ANUS. not extend beyond the median line in front or behind, where the longitudinal muscular fibres appear to be thicker. The number of these constrictions is not always the same, nor are they in all subjects equally well marked ; but generally three or four are quite constant. One very noticeable constriction is always to be found on the right side, marking the upper limit of the rectal pouch, extending from a point opposite the upper border of the triangular portion of the base of the bladder, just a little below the lowest point of the peritoneal pouch, behind the right seminal vesicle, backward to a point opposite the up- per part of the coccyx. These ridges correspond to the folds on the interior of the bowel, and with the mucous membrane cov- ering them form the sacculi already described. The longitudinal muscular fibres of the rectum are not dis- tributed in a uniform layer, but are collected into two groups, one in front, the other behind, with a thin layer of fibres be- tween them. In the colon the longitudinal fibres are collected into three distinct bands ; one of these, the posterior, is placed along the attached border of the intestine, and can be traced down the posterior surface of the rectum as a distinct band, spreading out laterally and increasing in strength in its lowest part. Tracing the other two bands, they are found to gradually converge in the lower portion of the intestine, sometimes com- ing together for a short distance in the sigmoid flexure; then separating, to again unite at the commencement of the rectum, and to pass down its anterior surface as one broad band, spread- ing out laterally and increasing in strength at its lowest part. On the sides the longitudinal fibres form only a thin layer in the upper part, gradually thickening toward its lower end. These two bands of miuscular fibres, anterior and posterior, are shorter than the intervening parts, hence the sacculation ; and the con- strictions on the lateral aspects of the tube are the divisions be- tween the sacculi. The folds described within the bowel are composed of mucous membrane and bands of circular muscular fibre in greater or less proportions. The longitudinal fibres do not enter into the construction of the folds. Dr. Otis suggests that the longitudinal bands on the rectum be called " ligaments of the rectum," ante- rior and posterior, corresponding as they do with the ligaments of the colon. Excepting that this description of the arrangement of the muscular fil^res and folds of mucous membrane is more exact and definite than any previously given — and as to this constancy POINTS IN ANATOMY AND PHYSIOLOGY. 33 of location my own observation does not lead me entirely to agree — the author's conclusions from his dissections are not dif- ferent from those of other writers. The valves and folds have always been accepted, though their definite and constant loca- tion have not been. Regarding the so-called third sphincter, the author describes it simply as one of the thicker bundles of circular fibres on the lateral aspect of the bowel, without certainty of location or par- ticular function beyond that of the other circular fibres. There would be but little profit in following these descrip- tions of different writers, each of them an authority on the sub- ject treated, any further ; ' and so far as we have gone, we have carefully endeavored to avoid any violence to the meaning of the text in thus separating the thickening of the muscular fibres, which can alone constitute a sphincter, from the projec- tions and redundancies of the mucous membrane which Hous- ton first described under the name of valves. It will readily be seen that Van Buren was correct in speaking of the third sphincter as an organ to which anatomy and physiology had been equally unsuccessful in assigning certainty of location, for we have seen it described, on equally good authority, as both mucous membrane and muscle ; as on all sides of the rectum, and at almost all distances between two and four inches from the anus ; as single, double, and triple ; as composed of mucous membrane and cellular tissue without muscular fibre, and of well-marked muscular bands located at the base of the mucous folds and extending into their substance. From these very dif- ferences, perhaps, the true anatomy of the part may best be deduced. It is the old question of the gold and silver shield. There are bands of the circular muscular fibres of the rectum located at various points in its upper portion. These bands are more or less developed in different subjects, and are also found in no constant location, being sometimes lower or higher, and sometimes more marked on the anterior or again on the poste- rior wall. There are also found various folds and duplicatures of the mucous membrane, which stand in no constant relation to the thickened portions of the muscular fibre, and have no defi- nite or constant situation, but may alter their shape with the ^ Morgagni (" De Sedibus et Causis Morborum ") says he found valves in two subjects, situated about an inch above the anus, in one of a circular, in the other of a crucial form. The references of Portal ("Anat. Med."), Glisson, and Boyer ("Traite d'Anat.," Paris, 1815, t. iv., p. 377) probably all refer to the sinuses of Morgagni. 34 DISEASES OF THE RECTUM AND ANUS. varying condition of the bowel, and are found at different points in different subjects. These folds vary also in their structure in different people, being larger and firmer in some than in others, and occasionally containing a few fibres of the circular muscle of the bowel. This is also the conclusion reached by Gosselin, who says : " I do not find the line of demarcation (between the upper and middle portions of the rectum) established by a special sphincter analogous to that which some authors have indicated by the name of sphincter superior. I am convinced, indeed, by the ex- amination of a large number of specimens, that the sphincter does not exist as an isolated muscle, and that, when we are led to admit its existence, we have to do with subjects in whom the bands of the circular layer are more developed than in others. I have often met this isolated development of some of the circu- lar fibres, but it is by no means always present, and for this reason the superior sphincter has not always been found by those who have searched for it. When it exists it is at a vari- able height, sometimes between the middle and upper portions, sometimes at some part of the circumference of the latter, or at its very upper portion ; and I explain in this way why O'Beirne has placed his superior sphincter at the junction of the rectum with the sigmoid flexure, while Nelaton has placed his lower down, without assigning it a determinate position." It will be remembered that Hyrtl argued backward from what he considered the physiology of the rectum to the exist- ence of a third sphincter ; and that Houston, in describing the valves of membrane, asserts that such an arrangement as he discovered was just the one which was a posieriori probable, and which best accounted for the accepted theories of the physi- ology of defecation. Nelaton, too, though he described the mus- cle before he gave it an action, assigns to it the same function as Houston does to his folds, and as Hyrtl believed it must of necessity possess. It is plain that each was led by a certain chain of reasoning to believe in the existence of an obstruction to the passage of faeces from the sigmoid flexure above to the rectum below ; and that two of them found it in the muscular structure, and the third in the mucous membrane of the bowel. The facts upon which the necessity for a superior sphincter are supposed to rest are briefly these : the normally empty state of the rectum, and the ability to retain both wind and motion after destruction of the anus and its muscles. The force of this line of argument cannot be disputed, but were some other reason- POINTS IN ANATOMY AND PHYSIOLOGY. 85 able explanation found for these two facts than the existence of a third muscle, that muscle would soon be dropped from the de- scriptions of the anatom}^ of this part. The whole tendency of the physiology of the day is to furnish such an explanation. The "new views" of O'Beirne with regard to the process of defecation were simply as follows : The repeated descent of faecal masses causes the sigmoid flexure to become distended, and to ascend from its position in the cavity of the true pelvis into the left iliac fossa. When this occurs, the flexure, in pro- portion to the rapidity and degree of its distention, begins to turn upon the contracted rectum as upon a fixed point, until at length, like the stomach, it directs its greater arch forward and upward, and its lesser backward and downward. By this move- ment the contents are brought somewhat perpendicular to, and so as to press directly upon, the upper extremity of the con- tracted rectum. But as the mere weight is insufficient to force a passage downward, and as this end cannot be accomplished either by such gentle pressure as that exerted by the alternate contraction of the diaphragm and the abdominal muscles in or- dinary respiration, or by the efforts of the flexure itself, in con- sequence of its muscular power being so inferior to that of the rectum, the faeces are compelled to remain stationary until such time as the increased accumulation and distention produce a sense of uneasiness sufficient to call into action those great ex- pulsive agents, the diaphragm and abdominal muscles. These muscles, instead of acting alternately, now act simultaneously, compress the abdomen and its contents on all sides, urge the free and floating mass of small intestine downward and even into the cavity of the pelvis, so as to press forcibly not only upon the sigmoid flexure, but also Tipon the caecum and urinary bladder. By these means the contents of the distended flexure are acted upon in every direction, and so as to be impelled against the upper annulus of the contracted rectum with a force sufficient to compel its parietes to separate and afford a pas- sage. The nisus now ceases, but as soon as the rectum becomes filled it is aroused to make an expulsive effort by which its con- tents are driven or impacted into its pouch. Here they produce a great sense of weight and uneasiness in the perineum, an urgent desire to go to stool, and a still stronger nisus, by which the sphincters are forced open and dilated, and the final expul- sion of the faeces is effected. This reasoning, it will be seen, is entirely based upon the normal empty and contracted state of the rectum, which O'Beirne not only states to be a clinical fact 36 DISEASES OF THE RECTUM AND ANUS. capable of easy demonstration, but gives many reasons for, the chief being the great relative thickness of its muscular wall. He clearly pointed out also (what has been frequently verified since,, and especially by those who have passed the hand into the sigmoid flexure of the living subject) that the upper extremity of the rectum was absolutely the smallest part of this portion of the bowel ; but that nothing of the nature of a sphincter mus- cle, located at this point or near it, entered into his calculation any more than did the folds of mucous membrane. Compare, now, these teachings of O'Beirne's, in 1833, which we have already said are to-day accepted by those who have the best right to judge of these matters, with those of Foster, in 1880. He says the faeces, in their passage through the colon, are lodged in the sacculi during the pauses between the peristal- tic waves. Arrived at the sigmoid flexure, they are supported by the bladder and the sacrum, so that they do not press on the sphincter ani. Defecation is a composite act, being superficially the result of an effort of the will, and yet carried out by means of an involuntary mechanism. The voluntary effort is com- posed of two factors — a pressure effect produced by the contrac- tion of the abdominal muscles, and a relaxation of the sphincter ani muscle. By the pressure of the abdominal muscles the con- tents of the descending colon are driven onward into the rec- tum, but the sigmoid flexure itself is shielded by its situation from the direct force of this pressure, and a body introduced per aniun into the empty rectum is not affected by even forcible contraction of the abdominal muscles. The sphincter muscle guarding the anus is habitually in a state of tonic contraction, capable of being increased or diminished by a stimulus applied either internally or externallj^o the anus. This tonic contrac- tion is due, in part Jat least, to the action of a nervous centre situated in the lumbar portion of the spinal cord. By the action of the will, by emotions, or by other nervous events, the lumbar sphincter centre may be inhibited, and thus the sphincter itself relaxed; or stimulated, and thus the sphincter tightened. This relaxation is the second of the voluntary elements in the act of defecation. By these two alone the contents of the descending- colon might be pressed onward into the rectum and out at the anus; but since the sigmoid flexure itself is subject to neither of these influences, such a mode of defecation would always end in leaving it full ; and therefore there is superadded to these two voluntary elements an entirely involuntary increase in the peri- staltic action of the sigmoid flexure itself. The order of events POINTS IN ANATOMY AND PHYSIOLOGY. 37 . is the reverse of what we have stated. The sigmoid^ flexure and large intestine become more and more full, while stronger and stronger peristalsis is excited in their walls. By this means the faeces are driven against the sphincter. Through a volun- tary act, or sometimes at least by a simple reflex action, the lumbar centre is inhibited and the sphincter relaxed. At the same moment the contraction of the abdominal muscles causes firm pressure on the descending colon, and the contents of the rectum are ejected. It should be mentioned that the one fact on which these phy- siological views rest, viz., the normal empty state of the rec- tum, is not universally admitted. Indeed, as Hyrtl says, the rectum will be found, by any one who practises frequent digital examination, in very different states in this regard at different times in the same individual. This may or may not be entirely due to changes produced by constipation in those examined ; but even he admits that it is more often found empty than any other part of the canal ; and the difficulty which an opposite view leads to will be seen at once by the attempt of Bushe to ex- plain the act of defecation, starting from the point that the fae- ces accumulate slowly in the rectum, and gradually lose their thinner parts by absorption while there. He goes on to say that they give rise to no uneasiness until a considerable quantity is amassed, when a sensation is created which demands their ex- pulsion. This sensation is, he believes, not due to the mere con- tact of faecal matter, for the latter generally accumulates in large quantities before the sensation is felt. ISTor is it due to any peculiar acrimony which they obtain by their stay in the rectum, for when the faeces are fluid this sensation is produced as soon as they reach the rectum. Again, when once the sensa- tion is felt and not attended to it passes away, and does not re- turn till the next accustomed period ; and the longer it is un- attended to the less likely is it to return at all. In truth, he says, we are ignorant of the cause of this feeling, and must, in the present state of our knowledge, admit that it is organic, and consequently dependent upon some spontaneous change in the intestine, of which we know nothing. Rather a lame conclu- sion I Nor is the cause of this periodically recurring desire to evacuate the bowel touched upon in the exposition given by O'Beirne ; and this is the weak point in his argument, and the one which renders Foster's explanation complete. We need cite authorities no further to show that physiology no longer teaches the existence of an ever-present mass of fa?ces 38 DISEASES OF THE RECTUM AND ANUS. in the lower bowel, ready to escape at any nionient when the ac- tive watchfulness of the sphincter muscle is relaxed, or to prove that into our present understanding of the cause of the empti- ness of the rectum a third sphincter niuscle does not enter as a necessary element, but that the true explanation of the condi- tion lies in the anatomy of the sigmoid flexure, which, by its large size, great capability of expansion, loose mesenteric at- tachment, and position, is peculiarly fitted to act the part of a reservoir. Nor does the phenomenon of retention of fseces after the de- struction of the anus and its muscles necessitate the belief in a superior sphincter. So far as our reading goes, no one has as yet attempted to prove the existence of a fourth sphincter in the ascending colon ; and yet the same control over the passages which has been noticed after extirpation of the anus, and has been supposed to indicate a third sphincter, has been observed to follow an artificial anus in the transverse colon. ' There are several ways of accounting for the slight control over the evacuations which many patients are found to have after extirpation of the anus, apart from the existence of a third sphincter or of the valves of the rectum. Indeed, the physiology of the act of defecation itself, which we have just described, goes far to explain why there should be a certain warning of an ap- proaching evacuation, and this is what is generally meant when the patients are reported to have a certain amount of control over the movements. The control will be found in most cases to mean rather a consciousness of an approaching movement, a warning given in sufficient time to allow the patient to make necessary arrangements, than an ability to absolutely prevent the evacuation which is about to take place. Of actual control there is little, because the sphincter muscle, whose duty it is, under the power of the will, to prevent an evacuation, is absent. To the performance of this duty a healthy sphincter is abun- dantly equal, as every one has the chance to prove on his own person ; and it is this ability to delay and postpone an evacua- tion of the bowels, rather than a constant action in preventing the escape of fseces which are ever ready to escape, which best expresses the ti-ue function of the muscle. After extirpation of ' The case wus tliat of Fine, of Geneva, in 1797. " He formed an artificial anus, by which the fjecal matters escaped, not continually, but once or twice a chiy only, and with a sensation of impending necessity whicii gave the patient time to make the slight preparations necessary to avoid soiling herself." — Manuel de Med. Pratique de Le Louis Odier, de Geneve, 2mc ed., 1811. POINTS IN ANATOMY AND PHYSIOLOGY. d'.) the anus, this one element of natural defecation is destroyed, but several others are left. The fseces tend to remain by their own consistence unless actively urged forward by the peristalsis of the bowel ; and. this peristalsis is not constant, but recurs peri- odically. The relative increase in the muscular elements in the rectum tends to keep it closed and empty until fseces are forced into it from above. Again, the pressure of the fseces, owing to the S-shaped form of the rectum, is not in the direction of the axis of the tube, but constantly against the wall, and at the points of greatest curvature the resistance is greatly increased. To these let us add the contraction of the cicatrix after extir- pation, and the natural redundancy of the mucous membrane which may block up the new anus by an actual jjrolapse, together with the voluntary sphincteric power of the levator, and we have the factors which account for the clinical fact of control so often seen. On the other hand, the constant escape of faeces, which at first almost always follows these severe surgical operations upon the rectum, is best explained by the irritation of the wound and the constant reflex action which it excites. That the folds of mucous membrane, such as have been de- scribed, are of the nature to form an obstruction to the pas- sage of the fseces, would seem to admit of no reasonable doubt. But this obstruction is passive and not active, and is by no means sphincteric in character. When it is sufficiently great to form a real obstruction to the descent of fseces, the condition is an abnormal one, but such a condition is sometimes seen, and is one which is not to be disregarded in the pathology of stricture of the rectum. From a study of the literature of this question, and from the results of dissections and experiments which we have person- ally been able to make, we are led to the following conclusions : 1. What has been so often and so diffierently described as a third or superior sphincter ani muscle is in reality nothing more than a band of the circular muscular fibres of the rectum. 2. This band is not constant in its situation or size, and may be found anywhere over an area of three inches in the upper part of the rectum. 3. The folds of mucous membrane (Houston's valves) which have been associated with these bands of muscular tissue stand in no necessary relation with them, being also inconstant, and varying much in size and position in different persons. 4. There is nothing in the physiology of the act of defecation, as at present understood, or in the fact of a certain amount of 40 DISEASES OF THE RECTUM AND ANUS. continence of faeces after extirpation of the anus, which necessi- tates the idea of the existence of a superior sphincter. 5. When a fold of mucous membrane is found which con- tains") muscular tissue, and is firm enough to act as a barrier to the descent of the faeces, the arrangement may fairly be con- sidered an abnormality, and is very apt to produce the usual signs of stricture. CHAPTER 11. GENERAL RULES REGARDING EXAMINATION, DIAGNOSIS, AND OPERATION. To one who has been trained in the habit of making a diag- nosis before undertaking treatment it seems superfluous to in- sist upon the necessity of a physical examination in cases of rectal disease. The majority of patients who seek advice for this class of troubles come to the surgeon with the diagnosis of piles or fistula ready at hand, and, I am sorry to say, many of them come with the authority of some physician for that diag- nosis, in whom, nevertheless, the merest inspection is suflScient to prove the existence of much more serious, and often of in- curable, disease. This is not due to ignorance, but to careless- ness ; to too great faith in the statements of the sufferers, and often to a false modesty on the part of the practitioner which leads him to accept such statements in lieu of a thorough exam- ination. The symptomatology alone may be of great value in the diagnosis of rectal disease ; it is almost never sufficient in itself for a diagnosis. There is a train of symptoms common to al- most all diseases of this part, and which infallibly point to trouble of some kind, but they do not tell what that trouble is. The pain of a fissure is sometimes almost diagnostic, but it does not tell what troubles may be associated with the fissure ; and so it is in every other affection. For this reason the practitioner who attempts to treat a case of disease of the rectum without first making a direct examination, uselessly risks his reputation as a diagnostician ; and in my own practice I am guided by the simple rule that patients, male or female, who have not yet come to the point which makes them willing to submit to an ex- amination, have not yet reached a point which admits of treat- ment. An examination, especially in women, is sometimes, though not often, difficult to obtain, and the dread of it keeps many sufferers from seeking relief ; but still the rule I have laid down is the only safe One, and the surgeon who allows 42 DISEASES OF THE RECTUM AND ANUS. himself to be persuaded into ''recommending something for piles "' will sooner or later have a mistake in diagnosis laid to his charge, nor will the fact that he was moved by consideration for the patient's sensibilities save him from blame, I generally find that, to one unaccustomed to the examination of patients suffering with disease of the lower bowel, the diag- nosis is surrounded by many purely imaginary difficulties. This is shown by the fact that the first inquiry of almost all such practitioners is, " What speculum do you use ? " as though there must be some mechanical contrivance by which the senses of touch and vision can be so improved upon as to render the dis- covery of obscure troubles much simpler than it otherwise would be. The same idea is well fixed in the minds of patients who, under the false idea that an examination and diagnosis neces- sarily mean a painful use of instruments, will defer treatment until disease has made irreparable progress. The surprise of such patients when a diagnosis is made by mere sight, or at most by a painless digital examination, is only equalled by that of the young practitioner when he is told that only in excep- tional cases is it necessary to use any instrument whatever. The secret of successful diagnosis of these diseases consists in taking nothing for granted. Every affection of the lower four inches of the bowel can be both seen and felt, if the practi- tioner will only take the necessary trouble to go about it in the proper way ; and a disease which can be felt and looked at is generally easy of diagnosis. The man who fails to detect the nature of a rectal trouble is generally the one who has refused to employ the necessary and yet simple methods by which alone a diagnosis can be reached ; and the man who acquires a repu- tation as a diagnostician in this department is the one who sim- ply uses his eyes and his fingers, and refuses to deceive himself by jumping at conclusions in the dark. To one in the daily practice of any department of surgery a routine practice soon recommends itself as most likely to elimi- nate errors and lead to a correct conclusion ; and the following is the one which has been adopted by myself, and the one to which . every jjatient, great or small, male or female, submits. The patient's name, age, condition in life, etc., are first en- tered in a case book. Next he or she is urged to tell the story of the disease in all its details, and this story is never interrupted or cut short ; for in the nervousness of a first visit, often made at great expense of time and trouble, and with the fear of a pain- GENERAL RULES REGARDING EXAMINATION, ETC. 43 fill examination before their minds, nervous jjatients will often begin the history of their sufferings backward, and if allowed to recover themselves by a few sympathetic words will not infre- quently give the gist of the whole matter at the very end. This takes time, but time is never of any moment until the diagnosis has been made. It is often necessary to devote an hour or more to the first examination of a patient, but no patient should be allowed to end his first visit until a diagnosis has been made or the surgeon acknowledges to himself his inability to make such diagnosis. By the time the patient has told the story the surgeon should be in the possession of certain information, and if not he must proceed by a few direct questions to try and obtain it. What he must know is this : How long has the patient been sick ? Is there any pain ; if so, of what character, and is it in any way dependent upon the evacuation of the bowels ? Is there any protrusion of the bowels at stool ; and if so, what is its charac- ter, and does it return spontaneously or is it necessary to re- place it ? Are the bowels regular, or is there diarrhoea, and of what character ? Is there any bleeding ? In addition it must be discovered whether there has been emaciation, febrile action, and discharge of any sort. From such a verbal examination much may be gained. In fact, the positive diagnosis can sometimes be made. But, on the other hand, it is astonishing how often the most intelligent patient will utterly mislead the examiner ; and, though I have great confidence in this indispensable history as a prelude to ac- tual examination, considerable experience has taught me never to trust to it alone, for the simple reason that, although it may convey all the information necessary, the surgeon is never sure that he is not being unwittingly led upon a false track by the most intelligent answers his patient is able to give. For example : A gentleman, whose medical fame has ex- tended wherever medical literature is read, came to me some time since for "piles which had troubled him ever since he could remember." He was sure he had them when seven or eight years old, and an examination showed three very large fibroid polypi. Another told me he suffered only from severe pain at defecation, but asserted that "there never was any tumor to speak of." Of course I. examined him for fissure, but none ex- isted. Then, after an enema, he again placed himself on the table and showed a cluster of well-developed, prolapsing, inter- nal haemorrhoids, tightly constricted by the sphincter. 44 DISEASES OF THE RECTUM AND ANUS. An intelligent young man, aged twenty-eight, tells me that ever since he was a child he has had rectal trouble the same as now. He never can remember when he did not pass blood and when his bowels were not inclined to be loose. Three years ago he was treated for piles by a quack, and so great was the bene- fit that for a time he supposed himself cured ; but after a little while the trouble returned. He is no worse now than he has always been, and the symptoms are the same. Here was a per- fectly clear history, pointing moreover directly to polypus, and for polypus I started to examine. He had epithelioma of about one year's growth, as near as could be judged from its devel- opment. After this line of investigation has been exhausted, the inev- itable examination by touch and vision follows. General practitioners tell me they have difficulty in obtain- ing the consent of patients to an examination. I never have had, save once. That case was a foreigner, who told me, when I proposed it, that he " had entirely too great a respect for me to allow me to do such a thing. "' My only answer was that I had too great respect for myself to treat him without knowing what was the matter, and we parted amicably. And yet an examination to a lady is not a pleasant thing. It is in fact a thing which will cause her to suffer silently for many years rather than submit to it. It is only when suffering has forced her to it that she will submit, but that point has al- ways been reached when she consents to consult a surgeon or a specialist for treatment. Then she expects to be examined (in fact has very little respect for the surgeon if he does not exam- ine), and it remains for him to make the unavoidable examina- tion in the way least offensive to his patient. I have often found that the best way to secure an examina- tion in women was to resort to ether, with the understanding that whatever surgical procedure is thought advisable shall be performed at the same time. In this way a patient's sensibili- ties may often be spared, while both diagnosis and treatment are included in one examination. For an ordinary examination of a lady a trained female at- tendant should always be in waiting. After the history has been taken and the physician has in a measure gained the confidence of his patient, she is handed over to the nurse in waiting, who gives the enema, arranges the patient on the chair, covers her with a sheet, and, when all is ready, signs to the doctor. His work may be done at a single glance, or may require careful GENERAL RULES REGARDING EXAMINATION, ETC. 45 investigation and examination with finger or instruments ; but when it is done the patient is again given over to the nurse, and when she is once more herself the diagnosis is made, and the question of treatment may for the first time be entered upon. I do not know that it is necessary to dilate upon this point any further, except* to say that I have found it best in my own Fig. 12.— Apparatus for Injections. practice to have two entirely separate waiting rooms, one for ladies and the other for gentlemen. It is pretty well known that all patients who come to me have rectal disease, and ladies do not care to take their turn in the presence of several gentle- men. I have also a special apparatus for the . administration of enemata, and in immediate connection with the examining 46 DISEASES OF THE RECTUM AND ANUS. room there should always be a retiring room and water closet. This is absolutely indispensable, both for decent privacy of the patient and for thorough examination. The enema may be given in any way most convenient, but often requires great gentleness on the part of the giver. For my own use I have rather an elaborate apparatus (Fig. 12), con- sisting of a glass jar holding one gallon, which stands upon a shelf seven feet above the floor, and is filled by a rubber tube connecting with what is popularly known as a barber's faucet, by which either hot or cold water can be drawn from the same tube at pleasure. This, however, is useful for several other pur- poses besides the administration of an ordinary enema, one of which is hot-"water irrigation through Skene's rectal irrigator, shown in Fig. 13. The temperature can be regulated by a ther- mometer placed in the jar, and the flow may be continued in- definitely without trouble. Fig. 13.— Skene's Rectal Irrigator. A small, smooth glass tube may often be introduced with less pain than the usual metal tip of the Davidson's syringe, and a small, soft-rubber catheter answers an equally good pur- pose; but whatever instrument is used should be either in the hands of the surgeon or of an intelligent nurse. The examination may be made on any ordinary operating table, or on a more elaborate gynaecological chair, as the opera- tor prefers. Since, however, there is a good deal of gynaecologi- cal work to be done in connection with this specialty, the pa- tient should be enabled to assume Sims's position with ease. For a rectal examination alone, in male or female, the left lateral position is the best, and the correct Sims's position is not neces- sary. Either natural or artificial light may be used. For many cases there is little choice between the two, but for illumination within the rectal pouch artificial light has the advantage. For this reason I have long been in the habit of using a large and powerful lamp and lens, such as is used for laryngological ex- aminations, and is figured in the cut. (Fig. 14.) Such a lamp may easily be fitted with an electric light, if desired. GENERAL RULES REGARDING EXAMINATION. ETC. 47 The small incandescent electric lights to be introduced into the bowel are of little use for ordinary examinations, because, without ether and stretching of the sphincter, the lamp and speculum fill up the entire space and nothing can be seen, but under favorable conditions with a widely dilated anus they may be of great practical advantage. A better form of electric light is that manufactured by the " U. S. Electrical Co." and shown in the cut. (Fig. 15.) It has Fig. 14.— Lamp for Eectal Examination. this advantage, that it is portable and is never obstructed by the head of the operator in his motions to obtain a good view. A very convenient means of obtaining light at the patient's home or at night is the burning of a strip of magnesium, and it is a good plan to have a sufficient quantity of this in the operat- ing bag for emergencies. A simple inspection of the anus and adjacent skin and mu- cous membrane is often sufficient for a diagnosis, though it should never be trusted to alone. External haemorrhoids, and internal ones when brought down by the use of the closet or 48 DISEASES OF THE RECTUM AND ANUS. enema, external fistulse, ulceration, skin diseases, many venereal affections, pin-worms, abscess, and fissure, may all be recog- nized in this way. A glance at the anus, too, may indicate to the practised eye the existence of serious disease within the rectum proper, for a discharge may flow from it which marks ulceration above, and it may be relaxed and patulous from over-distention or partial destruction of the sphincter. A sunken condition of the ischio-rectal fossae, and a retracted anus surrounded by a profusion of soft, fine hair, may also properly excite a suspicion either of grave rectal disease or of some constitutional affection which is causing emaciation. • By using gentle force in pulling the anus open with the fin- gers, the mucous membrane may be everted to a considerable degree, especially if the patient can be brought to assist by an Fig. 15.— Electric Forehead Light. effort at bearing down. In this way a fissure may almost always be brought into view without the use of a speculum of any sort, and the internal opening of the great majority of fistulse may be reached, with a good view of the radiating folds and lacunae. Suppose now that the patient has described a distinct protru- sion at stool, but when the enema has been given, and the sur- geon comes to examine, no such protrusion is visible or can be brought into view by any effort of the patient. It has simply ''gone back." Under these circumstances I cannot too highly recommend an examination with the finger while the patient is straining in the ordinary position of defecation. Under these circumstances the expulsive effort has the greatest possible ef- fect, and a flight protrusion often becomes perceptible to the touch which cannot be seen with the patient in the lateral posi- tion on a table. Suppose, again, that the enema has been given, the patient is GENERAL RULES REGARDING EXAMINATION, ETC. 49 in position, and there is no protrusion, no opening of a fistula, no fissure just within tlie anus, and no capillary hsemorrhoid (to be described in the next chapter). In fact, no disease is manifest. The next step is the digital examination of the rectum. With the patient on the left side, the right index finger should be used to examine the posterior wall, and the left for the anterior wall, so that the whole rectum may be felt by the palmar surface of the finger. The condition of the sphincter muscle is first to be noted. Its resistance should be overcome by a slow and steady pressure with the ball of the finger, and not by a sudden exertion of force, for such an attack is always met by increased contraction. The force of the muscle will be found to vary greatly in different people. In the aged or debilitated it is lax; in the strong and healthy it is the opposite, and the finger can scarcely be passed Fig. 16.— Hard Rubber Pus Basin. through it without great pain and sometimes a slight laceration of the tender mucous membrane. When inclined to spasmodic contraction, as it sometimes is in persons of nervous tendency, a satisfactory examination may be impossible without the use of ether, on account of the pain. Unless an obstruction is encountered, the finger may be carried up the bowel its full length, and pressed as far as possible beyond this point. Additional distance may be gained by passing the three remaining fingers backward along the inter-giuteal groove, instead of closing them in the palm as is generally done, and pressing the knuckles against the soft parts ; for the knuckles prevent the full passage of the index finger. An inch more may be gained by having the patient stand up and strain down upon the finger in the bowel. In this way three and a half or four inches of the rectum 4 60 DISEASES OF THE RECTUM AND ANUS. may be carefully explored, together with the prostate, the neck of the bladder, the uterus, and the anterior surface of the coccyx and lower part of the sacrum. With an exceptionally -long finger it may even be possible to feel the vesiculse seminales and vasa defer entia. In other words, all that part of the bowel which is most subject to disease is brought within reach. But after this is done the examiner may be no wiser than before, for to appre- ciate fully the condition of the rectum by the sense of touch alone requires a facility in this method of exploration which most practitioners never attain. In the majority of cases a digital examination will be made to discover whether or not the patient is suffering from internal haemorrhoids ; and in the majority of cases also the examiner will be no wiser on this point after than before, for a soft internal hsemorrhoid is a difficult thing to detect by the finger alone, being readily mistaken for the natu- ral mucous membrane of the part, especially when the latter is abundant and gathered into folds, as it is apt to be. Ulceration is another condition which it is sometimes difficult to detect, especially when superficial and not attended by much induration ; and so is the opening of a blind internal fistula ; and yet, so well educated may the finger become that other methods of examination may be almost completely discarded. To carry diagnosis to this point it is first necessary, by oft-repeated exam- inations, to become perfectly familiar with the feel of the normal bowel. After this knowledge has been gained, a gentle sweep- ing of the ball of the finger over the whole inner surface of the lower three inches of the rectum will detect any change in it however slight. I wish it were possible to describe plainly the different sensations which are conveyed by the different patho- logical conditions, but this is a thing each practitioner must learn for himself by practice. A stricture of small calibre cannot easily be mistaken, though one which admits the finger without constricting it may easily be overlooked. A stricture small enough to engage the end of the index finger firmly, marks the limit of safe digital examina- tion, and the finger should not be forced through it for the sake of feeling what is above, for an attempt to do this has been fol- lowed by a fatal rupture of the bowel. In case of a tumor of any kind, advantage may be taken of conjoined manipulation through the vagina in the female ; but these are the troubles most rarely met with and most easily diagnosticated when encountered. The cervix or fundus of the uterus, when pressing upon the bowel, may be distinctly felt with the finger in the rectum, and GENERAL RULES REGARDING EXAMINATION, ETC. 51 may deceive the unwary into a diagnosis of a new growth. The prostate may do the same. The different varieties of ulceration have each their peculiar and often diagnostic feel. For examination by the sense of touch above the reach of the finger, recourse may be had to bougies. Of these there are two forms which are of value. One is the red, soft-rubber in- .strument with tapering and slightly bulbous point, shown in Eig. 17. This is made in twelve sizes, and for diagnosis a No. Fig. 17.— Soft-Rubber Bougie. 7 is about the best. They are perforated to allow of the injec- tion of water through them. Another useful form of instrument is shown in Fig. 18. The conical tip should be of hard rubber, and the shank of pewter or copper to give flexibility. These are also made in several Fig. 18. different sizes. They are decidedly more difficult to pass than the soft-rubber ones, but when facility in their use has been ac- quired they are more accurate in diagnosis. The old-fashioned red, hard-rubber bougie is unnecessarily stiff and dangerous, and should be discarded, having no advan- tages over the softer ones either for the purpose of diagnosis or for that of treatment. The better fitted a bougie is for being forced through a stricture, the more dangerous it is. 52 ■ DISEASES OF THE RECTUM AND ANUS. These instruments are all used for the same purpose — that of feeling for a stricture located above the reach of the finger; and with any of them the unpractised hand will generally detect an obstruction in the perfectly healthy bowel at about four inches from the anus. I have had patients in whom I have never been able to pass any sort of a bougie without first injecting the rec- tum, no matter what manoeuvring I resorted to ; and I have seldom told a student to pass a rectal bougie that he did not at once discover a stricture. To pass a bougie into the rectum is rather a more difficult operation than to pass one into • the ure- thra, the triangular ligament in the latter being replaced by the curves, the folds of mucous membrane, and the promontory of the sacrum in the former. Independent of Houston's valves of mucous membrane, it is not improbable that a slight degree of invagination of the upper into the lower part of the rectum may often exist, and into the sulcus formed by this condition the point of the bougie may easily pass. For the sake of overcom- ing these folds of membrane, the most minute directions have been given as to how the bougie should be introduced and gently urged along each successive inch of the bowel ' by changing its direction and manipulating the handle. But such rules are of little value, for the simple reason that the obstruction is seldom of the same kind or in the same place in two different persons. Esmarch '' gives the good general rule that the patient should lie on the left side, as the chief and most constant fold of mem- brane, the plica transversalis recti of Kohlrausch, projects from the right wall. The instrument should be passed gently, for force is never allowable here more than in the similar operation on the urethra; and when an obstruction is met with, the handle should be gently rotated, withdrawn, and again passed onward till by frequent repetitions of this manoeuvre it is made to pass. If this does not suffice, a Davidson's syringe may be attached to the lower end of the bougie and a stream of warm water thrown into the bowel until it is moderately distended, when the bougie will generally j^ass with ease. For measuring the extent of a stricture there is no better in- strument than the bougie a houle in a delicate hand. For the purposes of exact clinical study and report, a scale such as is shown in the cut (Fig. 10) should always be at hand for measuring rectal bougies. ' Houston : " Dublin Hospital Reports," vol. v., 1830. " "Die Kranklieiten des Mastdarmes und des Afters," Pitha und Billroth's " Chi- rurgie." GENERAL RULES REGARDING EXAMINATION, ETC. 53 I have been using for some time a set of bougies exactly- similar in make to the soft-rubber ones, but six instead of twelve inches in length. They are adapted for the patient's own use when prolonged dilatation is necessary, and are much safer than the long ones. I see by the last edition of Cripps's work on can- cer that he has also utilized the same idea after extirpation of the rectum. In case disease actually exists high up in the bowel, the at- tempt to pass an instrument is full of danger. A patient may easily recover from a false passage made in the urethra, but such will seldom be the case with the rectum, for here when the instrument leaves the bowel it enters the peritoneum. To un- derstand this danger it is only necessary to remember that the bowel is generally ulcerated both above and below the seat of the constriction, and is sometimes weakened to such an extent Fig. 19. — Scale of Rectal Bougies. "that it will allow a bougie to pass through it without the use of any appreciable force on the part of the surgeon. The bowel may also be lacerated without being directly perforated by the bougie, for the stricture may be pushed upward or dragged downward on the point of the instrument till the bowel gives way. Supposing, now, that a rectal bougie cannot be passed eight or ten inches up the bowel, is it safe on this account alone to make a diagnosis of stricture high up ? I should hesitate long before doing so, and should make many careful attempts to pass the instrument at different times, resorting to ether if neces- sary, carefully exploring through the abdominal wall for indu- ration, and watching for the usual signs of obstruction. There are one or two points worthy of remembrance in this connec- tion. The first is that the obstruction due to a stricture will always be at the same point in the canal ; and another is that when a bougie has once become engaged in a stricture it is 54 DISEASES OP THE RECTUM AND ANUS. firmly grasped, and the resistance to its witlidrawal is equal to that encountered in introducing it farther. The feeling con- veyed to the hand under these circumstances is diagnostic, and is like that which is felt when the effort is made to withdraw a sound from the grasp of a stricture in the urethra. And yet the value of this means of exploration is very great, and although a bougie may pass a stricture without detecting it, successive failures to get an instrument through into the sig- moid flexure would, in my own practice, lead me to diagnosti- cate an obstruction. Let us suppose now, once again, that all this has been done and yet the examiner has discovered no disease. At this point he must take a decided responsibility, for if, from the patient's history, he believes that rectal trouble exists, he must still go on and find it ; but if he has no reason to believe this, he may abandon the search at this point and commit himself to the opinion that there is no rectal disease. If he decides to go still further, there is but one line of inves- tigation to be followed, and this consists in the administration of ether, the dilatation of the sphincter, and the use of the speculum, or else in exploratory laparotomy. It will be noticed that up to this time the question, "What speculum do you use ? " has not been answered, and for the rea- son that up to this point in the examination I use no speculum ; and as the vast majority of examinations will lead to a diagnosis before this point is reached, it follows that in about ninety per cent of all my rectal cases I use no speculum at all. An entirely too exalted idea of the value of the speculum ex- ists. For ordinary examinations it is unnecessary, and the dis- eases which cannot be detected by the routine practice already described will not very often be detected by the simple use of any variety of this instrument. So strongly has this experience been impressed upon me that I have abandoned the use of every form of speculum for ordinary diagnostic purposes, unless at the same time its auxiliary means can be employed — the admin- istration of ether. With ether, a light, and a speculum, a diag- nosis may often be made which would otherwise be impossible ; but to use a speculum without ether, for the purpose of explor- ing the rectal pouch, is merely in the vast majority of cases to inflict useless suffering. This does not apply to the question of treatment, but simply to diagnosis. For there exists a certain class of diseases, nota- bly circumscribed ulcers, which, when their situation is accu- GENERAL RULES REGARDING EXAMINATION, ETC. OO rately known, can be brought into the field of vision by a specu- lum and thus treated by direct applications ; but this is a very different matter from taking a patient who complains, perhaps, of but the single symptom of rectal pain, introducing some variety of speculum by which only the most imperfect view can be obtained, and because nothing is discovered (as in the vast majority of cases nothing will be), pronouncing the patient free from disease. Fig. 20.— Author's Retractor. I cannot make this point any stronger, perhaps, than by add- ing that whatever success I may have gained as a diagnostician in doubtful cases of rectal disease has come from the simple rule of etherizing my patient, dilating the sphincter, and then look- ing at what at once becomes plainly visible, viz., the whole Fig. 21.— Helmuth's Speculum. lower five or six inches of the bowel. Under such circumstances the simpler the instrument the better. A medium-sized blade of Sims's vaginal speculum answers every purpose, though Van Buren's modification has a great advantage, the notch allowing a very much larger surface of the bowel to come into view. Hel- muth's modification of Van Buren's is better with ether than without, the club-shaped end rendering it harder to introduce. (Fig. 21.) My own, as shown in Fig. 20, is simply a strong fenes- 56 DISEASES OF THE RECTUM AND ANUS. trated retractor which I have found very useful in major opera- tions. It will still sometimes be necessary to try and see into the rectum without ether or an assistant to hold a speculum. To meet this want I have myself added one more to the number of these instruments, made after a pattern suggested to me by Dr. Fig. 22.— Author's Speculum. Sass, and shown in Fig. 22. It is one which I use especially for office work without an assistant, and it has certain advantages. It avoids the especial objection to all the two- or three-bladed in- struments, which is that the blades separate at almost an equal distance along their entire length, and that an equal amount of Fig. 23.— Fenestrated Speculum. dilatation is therefore brought to bear both upon the anus and rectum— an amount which, when brought to a degree which is unbearable at the anus, has still done no good within the rectum. With this instrument the hinge is at the anus and the dilatation at the other end of the blades, and in a patient with a lax sphinc- ter the instrument can sometimes be opened to a considerable GENERAL RULES REGARDING EXAMINATION, ETC. 57 •extent, and permit of an inspection of a considerable part of the bowel without stretching the anus enough to cause much suffer- ing. The fenestrated blade must be made of steel to give it suffi- cient strength. It is an instrument, however, much more useful for treating an ulcer within the rectum, the exact seat of which is already known, than for finding the ulcer in the first place. Fig. 24.— Sims's Rectal Speculum. The fenestrated instrument, Fig. 23, is sometimes useful for inspecting the parts just within the anus ; and a long, cylindri- cal vaginal speculum, with the end cut at such an angle as will best expose the mucous membrane, may sometimes be of service in bringing into view a small portion of the inner surface of the bowel high up. But, after all have been tried, none will be found better for any purpose than a small-bladed Sims's vagi- FiG. 35.— Aloe Speculum. nal speculum, and without ether all will be found eminently un- satisfactory. Almost the only other speculum besides these which I have found of any practical value is the bivalve invented by Sims for the rectum. This is particularly valuable for operations, and of little use without ether. It gives a better view of the whole rectum under the former circumstances than any other instru- ment. The one which I use is made an inch longer in the blades 58 DISEASES OF THE RECTUM AND ANUS. than the original, and this measurement may in some cases even be increased with advantage. In a few rare cases — such, for example, as small, blind in- ternal fistulee, or small spots of ulceration — advantage may be taken of the reflected image seen on a mirror through a fenes- trum in the speculum. The Aloe speculum shown in the cut answers this purpose admirably, and I have been able to detect by its use disease of this kind wdiich could not be seen in any other way as well, except by etherizing the patient. Fig. 26 — Rectal Depressor. (Van Biu-eu.) In connection with a speculum a depressor is often very use- ful. Many of these have been made. Fig. 26 represents one made by Van Buren ; but the ordinary uterine depressor shown in Fig. 27 answers as well as any. The stretching of the sphincter is in itself an entirely harm- less proceeding, but one which necessitates the previous admin- istration of ether. It should not, however, be done, as was at one time the usual method, and as it is often done at present, by •introducing the thumbs back to back, and forcibly and suddenly separating them till they touched the tuberosities on each side. Fig. 27.— Uterine Depressor. In this way the mucous membrane is often lacerated at one or more points, and the paralysis is not as effectual as when the stretching is done more gradually. A better way is to introduce first one finger, then two, and finally four in the form of a fun- nel, and gradually bore into the anus ; or to introduce two fin- gers and make pressure on all sides of the opening till it becomes patulous. Instead of one or two seconds, tliis procedure should occupy five minutes, and should be done so gently as not to lacerate the mucous membrane. The dilatation should also be GENERAL RULES REGARDING EXAMINATION, ETC. 59 made to include the internal as well as the external muscle. If this dilatation be carried to a sufficient extent, the firm, cord- like feel of the external sphincter may be made to completely disappear. The paralysis induced in this way is always tem- porary, and I have never but once known it to be followed even by a temporary incontinence of faeces. After coming out of the ether, the patients are usually conscious of only a sense of sore- ness in the part, but are never incapacitated for their usual duties. This stretching of the sphincters is a necessary prelimi- nary in almost all operations w^ithin the rectum. From what has been said it may readily be seen that the diagnosis of stricture above the reach of touch or vision is a dif- ficult matter. So difficult is it in some cases that no less an authoritj^ than Syme has written that there is good reason to suspect the honesty of a man who pretends to detect such a condition. Such is indeed the case; for "strictures high up" are favorites among a certain class of quacks, and the passage of a bougie two or three times a week for an indefinite period is profitable business. In reality strictures above the rectal pouch are rare ; when they exist they are usually malignant, for this part of the bowel is not subject to the influences which, by ex- citing ulcerative action, result in the cicatricial contractions which so often affect the lower three inches of the rectum ; and malignant disease of the sigmoid flexure or descending colon will manifest itself by a well-marked train of constitutional and local symptoms, and can generally be felt better through the abdominal wall than per rectum. After the use of the bougie, which is at best an uncertain means of diagnosis for this condition, and after a study of the symptomatology and a careful examination through the abdo- minal wall, there is still one other means of exploration open to the surgeon if he have a sufficiently small hand — the passage of the whole hand into the rectum. A hand which measures seven and a half inches in circumference can generally be passed easily ; one measuring more than nine is unfit for the purpose. With a small hand there is no danger of permanent incontinence of feeces, but the sphincter should be dilated gently and gradu- ally, rather than forcibly torn open. ' 1 Dr. R. F. Weir (New York Medical Record, March 20th, 1875) was led to the following conclusion from his investigations of this subject : "A hand of less than 26 cm. may be introduced 17-19 cm. without inconvenience, but not more." His measurements showed the greatest circumference of the rectum to be at 6 or 7 cm. from the anus, where it may reach to 25-30 cm. At the upper part of the middle 60 DISEASES OF THE RECTUM AND ANUS. When the anus has been sufficiently dilated to allow the hand to enter the rectum, if the bladder is empty the arch of the pubes may be felt above the prostate ; if full it will be easily distinguished at the same point. The uterus and ovaries are easily made out anteriorly, and the whole curve of the sacrum may be followed posteriorly. The next point to feel for is the spine of the ischium on either side, and with this as a guide the greater and lesser sciatic notches may be outlined. The whole brim of the pelvis may be traced, and the external and internal iliac arteries followed with the fingers. All this may be done while the hand is in the rectal pouch, and it may be done upon almost any patient, male or female, though inore easily upon the female, and with a small hand, without causing any unpleasant after-results. But in many persons this is all that can be gained by this method, for the anatomical reason that to pass the hand above into the sigmoid flexure is often at- tended with great danger from the narrowing of the bowel at this point. When the hand is met by a sense of constriction at about the level of the third sacral vertebra, where the lateral fold of Douglas is reflected from the bowel, the limit of ex- amination has been reached, and no force should be used to overcome the constriction, which can only be accomplished by a rupture of the peritoneal coat. In many cases, however, by- carefully following the natural windings of the canal, and by a semi-rotatory movement of the hand, combined with alternate flexing and extending of the fingers, this point of danger may be surmounted and the hand be passed fairly into the sigmoid flexure, and sometimes into the descending colon. Here the common iliacs, the bifurcation of the aorta, the left kidney, and, in fact, nearly all of the abdominal contents may be touched. By this method of examination, a stricture situated in the sigmoid flexure, or even in the descending colon, may some- times be discovered after all other methods of examination have failed : but, as we have shown, the method is not always appli- third it is not more than 20-25 cm., and thence it rapidly diminishes, being not more than 16-18 cm. at the middle part of the superior third, while the narrowest part is at the commencement of the sigmoid flexure. For an early case of manual exploration see " Medico-Chirurgical Transactions," vol. i., p. 129. Referred to by Copeland : " Observations on the Principal Diseases of the Rectum and Anus," London, 1814. See also G. Simon : " Ueber die kUnstliche Erweiterung des Anus und Rectum," Arch. f. klin. Chir., xv., 1, 1872 ; Dtsch. Klin, f. Chir., November, 1882 ; W. J. Walsham ; " Some Remarks on the Introduction of the Whole Hand into the Rectum," " St. Bartholomew's Hospital Reports," vol. xii., 1876, p. 223. GENERAL RULES REGARDIN(4 EXAMINATION, ETC. 01 cable, and the diagnosis of stricture high up still remains one of the most difficult things in surgery. In the great majority of cases in general practice in which such a diagnosis has been made, it may be proved false by the introduction of a full-sized bougie after a few trials, and in the remainder the diagnosis will be confirmed sooner or later by the well-marked symptoms of intestinal obstruction. I have recently seen a case sent to me for examination by Dr. Janeway which illustrates jDarticularly well the difficulties surrounding the diagnosis of this condition. The patient, a young medical man, apparently in robust physical condition, complained of occasional bloody passages and of pain deep down in the left iliac fossa, from which point he was convinced by his own sensations the blood came. The most careful exami- nation failed to detect any lesion, and a medium-sized bougie was passed without difficulty. I was guarded in my prognosis, as was Dr. Janeway. At the same time I told him there was no way of making a diagnosis short of an explorative laparotomy. This I did not advise, nor would he have submitted to it in his good general condition ; but a few weeks later he died very sud- denly of obstruction, and a post-mortem examination revealed a small, annular, malignant stricture at the junction of the rec- tum and sigmoid flexure. From what has been said it must be evident to every reader that the successful examination of any doubtful case of rectal disease consists merely in making use of the ordinary senses, with which we are all provided. There is no occult faculty in all this, no deep power of knowing what is concealed from the majority of mankind. If the beginner will be honest with him- self, and will insist upon seeing what is to be seen and feeling what is to be felt, he will — ^except for the experience which only practice can give — make as good a diagnosis in his first case as the specialist who has practised for a lifetime. I can add nothing more to what has already been said on this point, except that the man who has foolishly allowed himself to be beguiled into prescribing some salve for a cancer, when he thinks he is treating haemorrhoids, because his patient objects to an examination, need not feel hurt when he finds himself placed in a ridiculous light by some better man than himself who has made his diagnosis before beginning treatment. All his tender regards for the foolish susceptibilities of his nervous lady patient will bring him no mercy in her judgment. She is willing to admit that she may have been foolish, but she will 62 DISEASES OP THE KECTUM AND ANUS. make no allowance for the foolishness of her physician, and in fact he deserves none. There are but three ways of making a diagnosis — by ques- tion, by sight, by touch. The man who has exhausted these will seldom fail in his diagnosis, and, should he do so, need not be Fio. 28.- Sponge Holder. ashamed. The man who neglects any one of them will sooner or later make some error which he might easily have avoided. The things necessary for daily office practice, besides the specula of various forms and the bougies, are a Davidson's syr- inge, ointment, cotton, sponge holders (Fig. 28), brushes (Fig. Fig. 89.— Brush on Flexible Handle. 29), a cup for fusing nitrate of silver (Fig. 30). an applicator, of some metal easily bent, around the end of which cotton may be twisted (Fig. 31), towels, basins, etc.; and these should all be placed within easy reach of the hand. In the matter of probes almost every variety is useful, from the hard-rubber uterine Fig. 30.— Cup for Fusing Nitrate of Silver. probe to the finest wire of pure silver; and directors also should be of many sizes. A convenient case for these things, and for other surgical instruments, which is intended to stand on the floor by the side of the table or bed, is represented in Fig. 32. Fig. 31.— Applicator. This should also contain a pus basin, towels, ointments, solu- tions, etc. Within the last few years many so-called '* rectal cases " have been put upon the market, each supposed to contain all that is necessary for the rectal specialist. I have never arranged an operating case, for the reason that to hold all the instruments GENERAL RULES REGARDING EXAMINATION, ETC. 03 necessary for any emergency that may arise it would necessa- rily be very cumbersome, and because I prefer to pick out what- ever may be needed just before the operation and roll them in chamois. But the universal acknowledgment of the value of an- tiseptic precautions in all surgical work has rendered the prepa- rations for any operations upon the rectum much more elaborate than formerly. No surgeon meeting with an unfortunate result after any of even the simpler operations would feel quite blame- less had he neglected these precautions; and he certainly would Fig. 32.— Instrument Case. not be considered so by the profession at large. What is true of the minor operations applies with much greater force to the ma- jor ones. The possibilities of diffuse inflammation, to which the perirectal cellular tissue is peculiarly liable, and of blood poi- soning, are always to be borne in mind and guarded against. For this reason I have for greater convenience arranged a bag which is always ready, and contains, not the instruments for any particular operation, but the things which in addition to them are essential for every operation. I find that much time 04 DISEASES OF THE RECTUM AND ANUS. and annoyance are saved by this expedient, especially if the bag is carefully rearranged after each time it is used, and kept al- ways ready for the next. The bag is arranged on the general plan suggested by Dr. Gerster, modified to suit the particular needs of rectal surgery ; it contains: 1. Operating gown of white muslin, clean from the wash. 3. Two rubber sheets. One of these is a yard square to pro- tect the carpet and hold an ordinary wash bowl, which can al- ways be obtained in any house; the other is one and a half yards long by a yard wide, and is long enough to protect the bed and hang down into the bowl as a trough for blood and fluids. A spe- cial air cushion with apron attached has recently been invented for this purpose, which it answers well. The cushion forms Fig. 33.— Air Cushion. about three-fourths of a circle, and the apron hangs down to the floor. 3. Fountain syringe with a loop of strong cord attached to the metal ring at the top so that it can be hung on top of a door if nothing else is convenient, and plenty of rubber tubing to reach a considerable distance. This is for irrigating, and the bi- chloride solution is made from the tablets as wanted and of any strength required. 4. A Clover's crutch (Dr. Peters's modification). 5. Ether and inhaler. 6. Small bottle of pure carbolic acid (all glass bottles should be in metal cases to prevent breakage). Half an ounce of this to the pint of water, poured into a shallow dish, answers for im- mersing the instruments during the operation. 7. A small jar of carefully prepared sponges, each of which is thrown away after being used. GENERAL RULES REGARDING EXAMINATION, ETC. 65 8. Long-handled sponge holders. 9. A rubber bag full of picked lint and bichloride gauze. 10. Iodoform in an insufflator with a long nozzle. This is much better than the hard-rubber sprinkling box, with which it is very difficult to carry the powder within the rectum. 11. Bandages and suppositories. 12. Small graduate. 13. Vaseline or carboline. The things thus far enumerated are necessary for every cut- ting operation about the rectum, and although their preparation and use entail some little care and trouble, it will be more than repaid both in actual results and in the sense of security. Fig. 34.— Clover's Crutch. As the above-enumerated things are necessary for a simple operation, and only a few others are needed for a much more extensive one, the latter can easily be added when required ; these are : 14. A jar full of drainage tubes of various sizes, kept in car- bolic acid solution. 15. Bottles of catgut and silk sutures of all kinds, A very convenient arrangement for these is made by fitting a rubber cork tightly in a large-sized test tube, and attaching to the corll: a bobbin divided into three compartments for different sizes of ligatures. (Fig. 35.) 5 66 DISEASES OF THE RECTUM AND ANUS. 16. A bell-shaped sponge with vulcanite tube and a bottle of dry subsulphate of iron, for packing the rectum in case of heemorrhage. 17. Hypodermic syringe. 18. A small flask of brandy. With this bag at hand the surgeon is ready for almost any emergency in rectal surgery. The cutting instruments, forceps, Paquelin cautery, ecraseur, specula, artery forceps, etc., can be Fig. 35. —Bottle for Ligatures. taken from their case and be ready for use in a very few mo- ments. The details of the antiseptic precautions suitable for the vari- ous operations \iY>on the rectum will of course differ, but the general principles are the same as in other branches of surgery. Cleanliness, irrigation, and drainage cover nearly the whole ground. The same rules as to clean hands, clean instruments, and clean clothes apply to an operation for haemorrhoids; fistula, or artificial anus equally with a laparotomy or an amputation of the thigh. Some of them are even more import^ant here than GENERAL RULES REGARDING EXAMINATION, ETC. G7 elsewhere. For example, sponges used on the rectum should not be used again. Grooved directors, artery forceps, and any in- struments having teeth, as well as rubber sheets, operating gowns, and the points of syringes, are very apt to be contami- nated with fsecal matter mixed with blood, and require special care in cleansing them. Again, any operation involving a divi- sion of the wall of the bowel, as fistula, proctotomy, or excision, carries with it the danger of cellulitis, and drainage is of per- haps greater importance here than almost anywhere else. Before attempting any extensive surgical operation upon the rectum the bowels should be thoroughly emptied by a cathartic. It is well to begin with three compound cathartic pills or with five grains of mass, hydrarg. on the second evening before the operation, where the patient's general condition admits of these remedies ; to follow them with a slight saline or a dose of castor oil on the night immediately preceding ; and finally to clear out the rectum with a simple enema an hour before the operation. After this the bowels may easily be confined for a week, if desi- rable, without inconvenience to the patient, and the passage of hard masses of faeces over a wounded surface is avoided. In all operations in which ether is used, two assistants will be necessary and four are preferable. Each assistant should have his place assigned to him — one for the anaesthetic, one to keep each leg of the patient in position and to hold the specu- lum, and one to assist the operator in whatever way may be necessary. A state of profound anaesthesia will generally be necessary, though with intelligent patients I have often taken advantage of the primary anaesthetic state which ether produces for opening abscesses, dividing fistulae, and cutting off external haemorrhoids. Accidents are not common in operations about the rectum, but there is one for which the surgeon should always be pre- pared — haemorrhage. For this reason a bottle of dry subsulphate of iron and a Paquelin's thermo-cautery should always be at hand. The thermo-cautery as now made (Fig. 36) is not at all cumbersome, and is exceedingly useful in many operations about the rectum. The bulb containing the sponge for the ben- zine should never be filled with an excess of fluid, which may run down into the point and interfere with the working of the instrument; and the platinum point should be tho rough J t/ liesit- ed before the assistant begins to use the bulb to drive the air over the sponge. If proper regard be paid to these points the instrument is a most reliable one, and in every case where 68 DISEASES OF THE RECTUM AND ANUS. haemorrhage is to be apprehended it should be ready for use, and an alcohol lamp or gas jet should be ready to heat the point — a detail which is sometimes forgotten. Haemorrhage seldom occurs from the rectum after a surgi- cal operation — so seldom as to be almost unknown — which can- not be controlled either by the ordinary methods or by the cau- tery and by packing the rectum. The rectum may be packed with either sponges or lint, and these may be used either with or without the subsulphate of iron. Most cases of bleeding may, however, be controlled by the use of simple ice-water and a moderate amount of pressure properly applied to the bleeding surface without the necessity for a systematic packing of the r i(i. 36.— Paquelin's Thermo-Cautery. whole rectal cavity. It is not long since I was called in the middle of the night to stop the bleeding from an incision which I had made into an abscess of the ischio-rectal fossa about eight hours before. I found, as is too often the case, that the patient was thoroughly immersed in a mixture of blood and persulphate of iroUj which covered him from the pubes to the middle of the back and had thoroughly permeated the bed. On entering the room I was informed that the wound had been carefully stuffed with lint and persulphate of iron " several times," and that the case was undoubtedly one of ha?morrhagic diathesis. A case like this is easily managed. The treatment consists first of all in providing a good light, next in cleaning up the general nastiness. GENERAL RULES REGARDING EXAMINATION, ETC. 09 then in finding the bleeding point and making pressure upon it. In this case the bleeding came from a small, spouting, cutaneous vessel, and was at once controlled by filling the incision I had made with picked lint thoroughly pressed home into the wound and leaving it there. Most cases of bleeding may be controlled in the same way, but where the haemorrhage is within the bowel it is not always easy to make pressure upon the right point without packing the entire rectal cavity. For this purpose Al- lingham ' recommends the following procedure, which is equally simple and effectual. Take a medium-sized bell-shaped sponge and pass a strong double ligature through the apex from within outward and back again, so as to include a considerable part of the sponge in the bite of the ligature — enough so that when the cord is pulled upon strongly from below it will not tear out. After wetting the sponge and squeezing it out, it should be powdered with the Fig. 3r.— Canula for Packing Rectum. subsulphate of iron and passed as far up the rectum as possible with the aid of a rectal bougie, the apex being upward. The whole of the rectum below the sponge should then be carefully filled with pledgets of cotton wool powdered over with the iron, each roll being carefully and firmly packed away. An exceed- ingly large quantity of cotton may be crowded into the rectum in this way, and when the cavity is filled the sponge should be drawn down by means of the string hanging out of the anus, so that the /whole mass may be tightly compressed. If the bowel has been thoroughly emptied as recommended, such a plug may be left in for a week or more without causing any dis- comfort, and no bleeding can occur while it is in place. If, however, it is intended to leave the packing in for such a length of time, it is better to pass a large-sized, stiff rubber male cathe- ter, or the metal tube made for the purpose (Fig. o7). through the apex of the sponge and pack the cotton around it. In this way ' Op. cit.. p. 154. 70 DISEASES OP THE RECTUM AND ANUS. a chance is given for wind and fluid fa?ces to escape. By this simple means, when properly used, any haemorrhage after an operation upon the rectum may be controlled. After operations upon the rectum or anus, a suppository of one gTain of opium may generally be placed in the rectum with advantage, and the surgeon should always be provided with them. Those made of gelatine by Mitchell, of Philadelphia, have given me great satisfaction. They are smaller, softer, and less irritating than those usually made of cacao butter, and they withstand the changes of temperature better. The usual dress- ing consists in placing a pad of lint and a soft towel over the anus, and fastening them in place with a T bandage. This form of bandage will generally be found the best in any case where a continuous dressing is needed. Wounds of the rectum will always heal more kindly when the patient is in the horizontal position than when standing or walking, there being less tendency to venous congestion in the former case. Almost any operation may result in a sluggish open sore if the patient be allowed to disregard this rule. Retention of urine is of frequent occurrence after operations upon these parts, both in men and women, and it should always be in the mind of the surgeon. It is not generally of long dura- tion, and it may often be overcome by a bath and hot applica- tions without having recourse to the catheter. The following case conveys a lesson in this matter which should never be for- gotten. Case. Death from Retention of Urine. — I was requested several years ago by a gentleman to make an autopsy on his brother, who had died very suddenly and unexpectedly after being confined to his bed about a week with an ischio-rectal ab- scess near the anus. Before the abscess appeared the man had been in perfect health, and was apparently doing well up to the moment of his death, as the abscess had been opened on the day before, with great relief to pain, and was discharging freely. I made the autopsy, as requested, and found a bladder distended to the point of rupture, the urine dammed back upon the kid- neys, which were gorged with blood, and the cerebral vessels greatly congested. The man had died very suddenly in a con- vulsion. A little questioning revealed the fact that from the first day of the disease there had been retention of urine with dribbling from the overflow, and that for the pain arising from this condition opium had been freely given up to the day of death. GENERAL RULES REGARDING EXAMINATION, ETC. 71 Once during his sickness an old woman in the house had ap- plied a hot flannel cloth over the bowels, and the patient had passed an immense amount of urine. The condition of the blad- der seemed to have entirely escaped the notice of his medical attendant, as it probably has escaped the attention of most sur- geons at some time, though, fortunately, without, as in this case, a fatal result. With the discovery of cocaine it was thought that a new era had begun in rectal surgery, but the hope has been in great measure fallacious. Injected in quantities of five drops of a f our-per-cent solution at three or four opposite points of the cir- cumference of the anus, it is sometimes possible to dilate the sphincter almost painlessly for purposes either of exploration or operation. Twenty drops of the same solution thrown into the rectum will also greatly diminish the pain of any examination or operation within the canal, and this action can be relied upon with greater certainty than the former ; for it is sometimes dif- ficult and practically impossible to do away with the sensitive- ness of the anus to an extent sufficient to allow of painless, stretching of the sphincter, without producing grave constitu- tional effects of the drug. I remember one case in particular in which I found it impos- sible to do this without using an amount of cocaine which I con- sidered dangerous. The patient was a strong, healthy young policeman with an ulcer — the mouth of a blind internal fistula — about two inches within the rectum; and in the attempt to reach this I injected about two drachms of a four-per-cent solution of cocaine at eight different points in the substance of the sphinc- ter, producing full constitutional effects without reducing the local sensibility sufficiently to allow of the operation. The co- caine was finally abandoned and ether substituted. It was a case analogous to this that caused the Russian surgeon, some few years ago, to commit suicide after having caused the death of his patient with an overdose of the drug used for this pur- pose. Practically I have derived the greatest benefit from this drug in small operations, such as cutting off external or prolapsed in- ternal haemorrhoids, incising fissures, etc., where the parts im- plicated do not cover too much area. Little or no benefit is to be expected from rubbing it on the skin of the anus. It should either be used subcutaneously or applied directly to the mucous membrane. I have also done several operations for extensive hsemor- 72 DISEASES OF THE EECTUM AND ANUS. rhoids with the drug, injectmg each tumor separately and ap- plying the clamp and cautery, and in these cases the drug may be used satisfactorily if it be not necessary to dilate the sphinc- ter ; but for dilating a tight sphincter painlessly by injections at different points in its substance, the drug has frequently dis- appointed me. OHAPTEE III. CONGENITAL MALFORMATIONS. The study of embryology has revealed the fact that the rec- tum and anus are developed separately, the former from the in- ternal and middle layers of the blastodermic membrane, the latter from the external. The lower portion of the primitive in- testine terminates at first in a cloaca common to it and the ura- chus. About the eighth week a partition is formed dividing this cavity into the uro-genital and the rectum, the partition being the perineum. At the same time a depression has been forming in the skin at the site of the anus and gradually extending up- ward to meet the blind rectal pouch. These unite about the end of the fourth week. The malformations of the rectum and anus found at birth are due either to a failure on the part of Nature to form a depression in the skin sufficiently deep to meet the closed rectum above; to failure of the rectal cul-de-sac to descend sufficiently to meet the depression which is formed; or to an arrest of development of the tissues between the rectum and genito-urinary tract. These congenital malformations have been classified by dif- ferent writers into various groups. We shall adopt in the fol- lowing pages that of Papendorf,' which is the one followed by Bodenhamer," Molliere,' and Esmarch.* 1. Narrowing of the Anus or Rectum tvithout Complete Oc- clusion. — A congenital stricture of the anus, or of the rectum at a point more or less removed from the anus, has been occasion- ' " Dissertatio sistens observationes deauo infantum imperforato," Lugd. Batav., 1781, 4to (Bodenhamer). '^ " A Practical Treatise on the Etiology, Pathology, and Treatment of the Con- genital Malformations of the Rectum and Anus," by Wm. Bodenhamer. New York: Wm. Wood & Co., 1860. ^ " Traite des Maladies due Rectum et de I'Anus," par Daniel MoUi^re. Paris, 1877. ^ Op. cit. 74 DISEASES OF THE RECTUM AND ANUS. ally reported. Serreinone ' particularly insists upon congenital narrowness of the anus as a cause of fissure, and has himself observed such cases ; and the same condition in the rectum is generally included among the causes of benign stricture. The narrowing in these cases may be very slight, or may reach such a degree as hardly to admit of the passage of meco- nium. It is generally annular in form, resembling the contrac- tion which would be caused by tying a tape tightly around the tube ; though it sometimes involves a considerable extent of bowel, as in a case reported by Cheever {British Medical Jour- nal, July 29th, 1886), where the narrowed portion above the sig- moid flexure was eighteen inches long and was impervious to solids. The child died of chronic intestinal obstruction after two years. There may be no symptoms caused by such a con- traction, and the child may grow to adult life suffering only from obstinate constipation ; nor do such contractions lead to the ordinary changes in the mucous membrane above and below the spot, which are usually seen in cases of stricture of the rec- tum. On the other hand, when the stricture is tight it will give rise to all the usual signs of such a condition in the child — ab- sence of free passage of meconium, distention of the abdomen, and vomiting. The diagnosis is easily made by a digital exami- nation, should the symptoms be sufficiently marked to lead the attention of the surgeon to the rectum; for the stricture is gen- erally near the anus and may be felt as a ring with sharp edges. ^ Such a case was sent to me for treatment in January, 1888, by Dr. Spitzka. The patient, a gentleman thirty-eight years old, was in very good health, except that he complained of always having been constipated and thought the trouble was growing worse instead of better. He never had been able to have a passage larger than his little finger, and recently he had been obliged to strain more than formerly to accomplish even this. On examination there was found at a point one and a half inches from the anus a falciform stricture not admitting the passage of anything larger than the tip of the index finger. This was nicked in several places so that the finger could be passed beyond the second joint, but it was very unyielding, and ' Inaugural Thesis, No. •>'5.'). Strasbourg, 1861. ' See also Gosselin, " Clini(iue Chirurg.," 3d ed., Paris, 1879, t. iii.. p. 706. B6- rard et Maslieurat-Lagcmar, Gaz. Med. de Paris, 1839, p. 146. Demarquay, "Journal de rExperience," t. ix., 1842, p. 273. A.sliton, " Diseases of the Rectum," London, 1854, p. 27. Devilliers, Rev. Med. de Paris, 1835. CONGENITAL MALFORMATIONS. 75 nothing more than this could be gained without dividing all the thickness of the bowel ; for the constriction was not due to a membranous partition which could be broken down, but to a narrowing of all the walls of the bowel which could only be overcome by proctotomy. Trelat records a very interesting case of congenital stricture first diagnosticated at the age of fifty-two. The patient, a woman of vigorous constitution, free from all important mani- festations of disease, in whom the most careful questioning failed to reveal syphilis, was subject to growing constipation. The passages, extremely difficult, were at first accompanied by a few drops of blood, then by decided haemorrhage, and after a time by glairy mucus. Things had reached such a point that the pain and tenesmus, with the prolonged constipation, had af- fected the general health ; and after a period of constipation lasting twenty-four hours, followed by a violent discharge, the patient decided to enter the hospital. At the first examination it was easy to perceive the existence of a narrow contraction five cm. above the anus, with some irregularity of the mucous membrane, but no ulceration. This was evidently neither cancerous nor syphilitic, and after gradual dilatation, continued for some time, it was found to be a valvular contraction with healthy mucous membrane. Dilatation greatly relieved the patient. The diagnosis of such a stricture is easy, its congenital nature being made plain by the absence of any disease which could cause it, and more especially by the absence of any asso- ciated ulceration or deposit in the adjacent parts of the rectum. The mucous membrane is perfectly healthy, and so are all the surrounding tissues ; and the stricture has a thin, knife-like edge which is not seen in those of acquired origin. How common this form of malformation may be will never be known till examinations of the rectum in cases of prolonged constipation become the rule instead of the rare exception. The fact that a patient has lived thirty-eight years with such a condition as this, and only suffered slight annoyance, cannot be taken as any indication that the balance of his life will be equally comfortable ; for after the period of middle age has been reached the local trouble may quite rapidly assume a graver phase. It is impossible to find many statements as to the ultimate results in after-life of congenital strictures in chil- dren. The symptoms which they cause are marked by various epochs. With some they occur in infancy, in others only after 76 DISEASES OF THE RECTUM AND ANUS. thirty or forty years ; so that it is difficult at first to understand how such a lesion can exist so long in a latent state. Possibly, however, the fact may be explained in the light that a great many affections of congenital origin do not manifest themselves till late in life — for example, certain forms of tumors, and der- moid cysts in particular. On the other hand, in infancy and youth the tissues have no tendency toward contraction or indu- ration, for this is the period of suppleness and elasticity. The function of defecation is carried on at this time much more easily than at a later period. Thus it can easily be understood that slight contractions do not constitute a serious obstacle to that function for a long time, but that at a certain period of life the modifications in the constitution of the tissues and func- tional intestinal troubles change the favorable conditions. Congenital strictures are often accompanied by abscess and fistulse at the lower end of the rectum, or they may end in time by setting up a periproctitis, extensive adenitis, or deep pelvic phlegmon. In one case quoted by Trelat, a peculiar hepatitis and interstitial nephritis caused the death of the patient. The treatment of this form of obstruction consists either in gradual dilatation or in proctotomy. My own experience in these rare cases tends to the conclusion that gradual and syste- matic dilatation will accomplish all that can be accomplished. Nicking is of little use, for if dilatation does not relieve the ob- struction it must be divided with the knife ; and in that case the whole wall of the rectum must be divided down into the peri- rectal cellular tissue. 2. Closure of the Anus by a Membranous Diaphragm. — The membrane in these cases may be of greater or less firmness and thickness, and may be composed of skin or of mucous mem- brane. It is sometimes so thin as to bulge out with meconium when the child strains or coughs, and has been known to rup- ture spontaneously. It is also occasionally perforated, like the hymen, and allows the escape of considerable quantities of me- conium, thus tending to conceal the actual condition till the faeces become solid and actual obstruction takes place. This is the simplest of all the forms of congenital malforma- tion of the anus, and, unfortunately, one of the rarest. It is easily diagnosticated by simple inspection of the parts ; and the treatment consists in making a crucial incision through the membrane. The remains of the membrane, like those of the hymen, which it strongly resembles, will shrink up so as not to cause trouble or deformity. I know of one case where the use CONGENITAL MALFORMATIONS. 77 first of a trocar and subsequently of the finger to dilate the open- ing thus made was followed by fatal haemorrhage on the second day, though the child's life could probably have been saved had the surgeon been notified of the bleeding. 3. Entire Absence of the Anus, the Rectum ending in a Blind Pouch at a Point more or less distant from the Perineum. — In these cases there may be a slight depression at the point where the anus should be found ; or there may be no trace of the anal orifice, the raphe of the perineum extending over the spot and back to the coccyx. The presence of a slight anal depression is not to be considered as an indication that the rectal pouch is Fig. 38.— Rectum ending in a Blind Pouch. (MoUiere.) near the surface — in fact, some of Cripps's figures would seem to indicate exactly the reverse. The external sphincter muscle is also sometimes present and at others entirely wanting. The pouch of the rectum in these cases may hang loose in the pelvis or abdominal cavity, or be attached to some adjacent part ; and the space between it and the perineum may be filled up with cellular tissue, or, in other cases, a distinct fibrous cord may be traced from the rectal pouch to the skin, as is shown in the plate. (Fig. 38.) If the pouch of the rectum be not at too great a distance from the skin, a sense of fluctuation may be felt by firm pres- sure with one finger over the anus and the other hand on the 78 DISEASES OF THE RECTUM AND ANUS. abdomen. In females, valuable aid in diagnosis may be ob- tained by the introduction of a finger into the vagina. The use of a stethoscope over the anus, and of percussion on the abdo- men, have been recommended to detect the rectal pouch filled with gas (Bodenhamer, Molliere) ; and also the irritation of the skin over the anus to provoke efforts at defecation. ' An effort should always be made, where there is complete absence of the anus, to discover whether the rectum may not have some outlet through the bladder or vagina, which shall place the case in one of the classes soon to be described. 4. The Reef N III iiiaij be the Saute as in the Last Variety, and the Anus he Norma]. (Fig. ;30.) — The septum which separates Fig. 3emng. D F, deep submuscular track, having same internal, but separate external opening. found in the rectum, and the internal orifice will be found just within the external sphincter. It may sometimes be felt in this location by the educated finger as a small tubercle, and in other cases it is marked by a distinct loss of substance. In some the internal opening will be found in the radiating folds entirely below the fibres of tlie sphincter, and in others it may be much higher up the bowel. ' The internal orifice does not in all cases mark the superior ' Ribes : " Recherche.s sur la'Situation de I'Orifice interne de la Fistule de I'Anus," Rev. Med., t. i., 1820. FISTULA. 117 imit of the fistulous track. This may run several inches up the iDOwel under the mucous membrane when the internal orifice is just within the external sphincter. (Figs. 45, 40.) The track of a fistula is sometimes straight, extending di- rectly from one orifice to the other ; in other cases a track, prop- erly speaking, does not exist, and both orifices open directly into the original abscess cavity. If the external orifice be very small, the cavity may at any time become distended with pus and give rise to all the symptoms of a fresh abscess till the pus finds an exit through either the old opening or a new one. The external orifice of a true, straight fistulous track is generally large, and sometimes free enough to allow of the escape of gas. The track is lined with lardaceous tissue the result of chronic inflamma- tion, and in this may be found numerous blood vessels of new formation. This tissue, by preventing all contact of the walls, necessarily prevents healing. On the other hand, the track is sometimes lined with healthy granulations which are capable of being formed into new tissue, and for this reason a fistula will sometimes heal spontaneously. The history will sometimes afford valuable information as to the general character of the case. The history of a slight ab- scess and the escape of a small amount of pus generally means an insignificant fistula with external and internal openings near the margin of the anus; while, on the other hand, the his- tory of a prolonged inflammation and a free discharge of pus means a large abscess cavity mounting to a considerable height and with its internal orifice at a correspondingly high point. The symptoms caused by this class of fistulse vary greatly. At first they are those of the abscess in which they originate. After that the one great symptom is the incessant discharge, sometimes slight, at others abundant ; sometimes purulent, at others serous ; always fetid ; sometimes containing f seces and gas. It is generally the stoppage of the discharge and the con- sequent filling of the track or abscess cavity which induces the patient to seek the surgeon. Besides the discharge there may be no symptoms at all, or there may be more or less uneasiness in the part, and pain on defecation, with the constipation which arises from the fear of a passage, and the symptoms to which it gives rise. Such a state of affairs may exist for many years without aggravation or causing the patient to seek relief. Fistulse resulting from ischio-rectal abscesses differ greatly in their extent and gravity from those last described. In them the track is large, and often double or branching, and the 118 DISEASES OF THE RECTUM AXD ANUS. external opening may be far away from the anus. The whole perineum and gluteal region will sometimes be found brawny and indurated, and twenty or thirty openings may be counted, "vrith the scars of others which have closed. In such cases pres- sure over one trochanter may cause pus to escape from an open- ing over the other. The fistulee resulting from the deep pelvic abscesses are of many different varieties, all of them severe. The track is deep, and the probe passed into it can hardly be felt from the rectum. The external opening may be far away from the anus, and there may be several tracks and openings whicl;^ may branch off from each other, or all communicate with a common abscess cavity above the levator ani muscle. The track in some of these cases has been known to take a remarkably irregular course. Sir A. Cooper ' mentions an au- topsy where a fistula opened in the groin, followed the course of the spermatic cord, and ended in what seemed like an ordi- nary fistula in ano : and cases in which the pus has burrowed under the gluteal muscles and finally opened in the thigh, or even nearly at the popliteal space, are not uncommon. This form of disease is rather more common in males than in fe- males. Blind Iniernal Fistula. — Fistulfe with internal openings alone have a somewhat special pathology". When caused by an abscess it is generally by one of the deep variety which has opened into the rectum high up and continues to discharge in this w^ay. The abscess causing such a fistula may, however, be a small submucous one or a large subcutaneous one, and the symptoms will then be pain, spontaneous discharge of pus from the bowel, and subsequently pain after defecation resembling that of a fissure. There is another and perhaps more common class of internal fistulre in which the opening is not the result of the breaking of an abscess, but in which the opening is first formed by ulceration, and the track is a secondary consequence. This pathological fact was proved by the well-known investiga- tions of Ribes, Avho believed that the internal orifice was always the first formed : but here he was undoubtedly in error, A circumscribed ulcer which perforates the mucous mem- brane and results in internal fistula may be due to several causes : to the inflammation of one of the lacunae just above the sphincter from the lodgment within it of a particle of hard ' " Lecture on Principle and Practice of Surgery," with notes by Tyrell, t. ii., p. 326. FISTULA. 119 faeces ; to rupture of an inflamed internal hsemorrhoid ; to the application of strong acids to hsemorrlioids ; to operations upon thel rectum, generally for hsemorrhoids ; and to the peculiar ulceration met with in tubercular patients. Such a condition is a very painful one. The opening, which may be large enough to show a distinct loss of substance to the touch, catches and retains particles of faeces, causing a burning pain which may last many hours after defecation. As a result of the opening an abscess forms _after a time, with the usual symptoms, the induration of which may be felt externally. When the abscess is small and the induration not extensive, a speculum, examination may reveal the ulcer ; but the fistulous track and abscess may escape — a mistake which will render all treatment directed toward the cure of the ulcer of no avail. There may indeed be several ulcers, only one of which has a fistula connected with it. Fistulae of this variety differ very much in character ; but taking them as a class, I know of no branch of rectal troubles so apt to lead to errors in diagnosis or mistakes in practice. Some of them are perfectly apparent by even a cursory examination. The internal opening may be so large that the finger enters an abscess cavity on introducing it into the anus, while the skin of the ischio-rectal fossa is reddened and thinned and the pus is about to break through the surface. This condition is most fre- quently seen as a result of ulceration of the rectum in phthisical patients. On the other hand, the internal orifice may be so small as scarcely to admit the finest probe, there may be only a small straight track and no abscess cavity, and the condition may require the most thorough and careful examination under ether for its detection. The patient may complain only of pain strongly resembling that of fissure or simple neuralgia of the rectum, and the purulent discharge may be so slight as to escape notice. It has been my good fortune to cure a fair number of these cases ; and when a patient's trouble is evidently obscure, when he has tried many kinds of treatment without benefit, I have learned to suspect and search for them, more especially when a small ulcer is found in the rectum. The base of an ulcer cannot be examined too closely ; nor can the rectum of a patient who complains only of pain without apparent lesion. Tubercular fistula, like tubercular ulceration of the rectum and anus, occurs in two forms. In one there is a distinct tuber- cular deposit causing the disease ; in the other there is merely an 120 DISEASES OF THE RECTUM AND ANUS. unhealthy sore in a tubercular patient. The former can be defi- nitely diagnosticated by microscopic examination for the bacil- lus. The occurrence of primary tuberculosis in this locality, though rare, is not entirely unknown. Ball reports a case and Molliere one ; but generally the state of the patient's lungs will indicate the nature of the pathological process in the rectum. These fistulse are generally easily diagnosticated by the large internal orifice, showing a distinct loss of substance and a cavity which will allow the entrance of the tip of the finger ; by the undermined and unhealthy appearance of the skin around the external orifice ; by the size of the abscess cavity, the absence of healthy granulations, and the thin and sanious character of the discharge. Diagnosis. — The mere diagnosis of the existence of a fistula, except in the blind internal variety, is usually attended by little difficulty. The examination of the extent and variety of a fistu- lous track, however, is a matter requiring delicacy and skill. The best position is on the side with limbs flexed on the abdo- men. The examiner should be provided with probes of every variety, from the small, pure silver one shown in Fig. 52 to the urethral bougie or hard-rubber uterine probe; and it is better not to begin the examination with any preconceived idea as to the direction of the track, for this is exactly what the probe is to determine. The instrument should be allowed to follow the track, and not be forced toward the gut, or indeed in any direc- tion. After it has gone as far as it will, the index finger of the other hand may be introduced into the rectum and try to detect the end of the probe. Sometimes it will be found free in the rectum; sometimes it can be felt covered only by mucous mem- brane, but no internal opening can be discovered ; and again, rather to the surprise of the operator, it may not be felt at all, having passed directly away from the bowel. I must confess that in my own daily practice, for reasons which will be better shown under the discussion of treatment, I do not usually de- vote much time to the discovery of the exact extent and charac- ter of a fistula until the patient is under ether and on the ope- rating table. The vast majority of them have to be cut, and in the operation their course becomes manifest. In the diagnosis of the blind internal variety there is a chance for much skill. I have known a case of a small fistula of this kind to escape detection by a dozen different men, and to be treated for almost every other form of rectal affection. The absence of any external orifice misleads the superficial FISTULA. 121 examiner at the beginning, and the failure to make a thorough examination completes the error. There are two signs of this condition which will in every case lead to a correct diagnosis. The one is the discovery of the internal orifice, the other the induration which invariably at- tends a track of any size. Agaiil, there is something significant in the history, and I have learned by experience, when a patient gives all the usual symptoms of fissure and yet has no fissure, to examine under ether for a blind internal fistula. I say ex- amine under ether advisedly, for a complete examination with- out ether and a large-bladed speculum is an impossibility. Often a careful search over the lower three inches of mucous mem- brane will reveal a small ulcerated opening, and a probe passed into this will run for an inch or so under the mucous membrane. Fig. 47.— Blind Internal, Submucous Fistula from Carbolic Acid. In other cases the finger will first detect an indurated spot or track, and a careful examination of this will show the opening of the fistula. In the submucous variety there is little or no in- duration, while in the submuscular the induration is likely to be distinct. This variety of fistula is not, in my experience, very uncom- mon. It may arise from an abscess which has pointed into the rectum and not on the skin, or it may be due to an inflamma- tory or ulcerative process commencing in the rectal wall and re- sulting in perforation, such as tubercular disease. It is some- times caused by inflammation of an internal hyemorrhoid, and I 122 DISEASES OF THE RECTUM AND ANUS. have seen several cases directly and unmistakably due to the in- jection of carbolic acid into haemorrhoids. The acid not infrequently sets up a circumscribed inflamma- tion, which results in a small abscess breaking on the mucous surface and burrowing- under the mucous membrane, if it has been deposited directly under the surface ; or under the muscu- lar coat, if it has been more deeply placed. These fistulse are generally not very extensive, the track being an inch or so long and generally single, unless more than one injection has been followed by the same result. In a feeble patient with phthisis and relaxed fibre I have seen the mucous membrane undermined in almost every direction as a result of a course of treatment with injections of thirty-three per cent acid ; and in a patient of different fibre I have seen a large abscess of the ischio-rectal fossa, with brawny swelling of the buttock, bursting high up in the rectum, follow an injection of the pure acid. The larger the abscess and the larger the opening into the rectum — it is sometimes so large that the end of the finger will pass into it — the easier the diagnosis. It is only the lesser forms of the disease that are liable to be overlooked, and yet even the lesser ones may render a patient's life very miserable. There are two other points in the diagnosis of this affection that may be useful. One is that the internal orifice when small may sometimes be detected, by gentle pressure on the adjacent parts which shall force a drop of clear pus out of it ; the other is that in cases of circumscribed ulcer which refuse to heal under treatment, a blind track leading from the base of the ulcer should always be carefully searched for. Treatment. — A fistula may heal spontaneously or after a very slight excitement to reparative action, such as the mere passage of a probe in making an examination. It has been mentioned that the track is sometimes lined with healthy granulations, and that these may result in new tissue which shall close it. I have the notes of one such case where a fistula of several years' stand- ing closed spontaneously without even the passage of a probe to excite it to reparative action. Setting aside these cases, we are at once brought to the ques- tion which will often be asked by the patient, and which the surgeon may not always be able to answer to his own satisfac- tion — whether or not it is always best, or even safe, to try and cure a fistula. In certain cases of Bright's disease, cancer, car- diac and hepatic affections, etc. , all surgical interference may be plainly contra-indicated ; but the question is most apt to arise FISTULA. 123 in connection with pulmonary affections. There can be Uttle doubt that phthisical patients are especially jDredisposed. to this affection, and, when not due to a deposit of tubercle, the reason is probably in great measure a mechanical one, depending upon a loss of fat in the ischio-rectal fossse and a resulting loss of sup- port to the hsemorrhoidal veins. From this there results a ven- ous congestion and final dilatation or rupture of the vessels, which, with the cough and concussion, leads eventually to ab- scess. I believe it to be a safe rule to operate on phthisical patients as upon others ; being led by the idea that one exhausting dis- ease — phthisis — is better than two — phthisis and fistula. I have many times followed this rule with happy results as to improved general health after the cure of the fistula. Once only has it happened to me to see the cure of a fistula followed by a marked increase of the lung trouble, and even in such a case the relation between cause and effect cannot be established. There are sev- eral rules which should be carefully regarded in this class of cases, however. No cautious practitioner would think of ope- rating either in a very advanced or rapidly advancing lung trou- ble. Cough, when violent and frequent, is also a decided contra- indication, interfering, as it does very certainly, with the heal- ing of the wound. Moreover, in every case where there is any suspicion of tuberculosis the whole extent of the fistula should be thoroughly curetted. The after-treatment of a phthisical patient is always a matter of great importance, for these incisions may refuse to heal even when they look perfectly healthy. The patient should not be confined to the bed any longer than is absolutely necessary, and if his general health is better in the open air he should be en- couraged to go out as soon as the wound will permit, even though rectal wounds do heal better in the recumbent posture. But here the general health must take precedence. The diet should be the most nourishing possible, change of air should be sought, tonics of all varieties should be given, and the local treat- ment should be gently stimulating. It is often useless, however, to change local dressings and to worry over the wound. If the cut shows no tendency to heal, and there be no sinus to account for the sluggishness, it is the patient himself who must be cared for, and the particular form of dressing will make little difference. In cases of fistula in phthisical patients the sphincters should be interfered with as little as possible. They are apt to be weak at the best, and the less cutting of them that is done the better. 124 DISEASES OF THE RECTUM AND ANUS. Having decided, then, to try and cure the fistulaj many ways are open. In certain selected cases a cure may be effected by stimulating the track and allowing a free discharge of pus without any cutting operation. For this purpose dilatation of the external orifice by sea-tangle tents, the introduction of drainage tubes, injections of turpentine and iodine, and applica- tions of nitrate of silver and caustic potash have all been suc- cessful. Treatment by any of these methods requires time and patience, and the result cannot be looked upon as at all certain ; and yet all of them hold out a prospect of success, if the patient be in condition to submit to their trial. In cases of recent abscess of the ischio-rectal fossa where the pus has broken out on the skin but no internal opening has yet formed, the chances of success by this method are very good. The patient should be kept in bed and the outer opening be en- larged to allow of free escape of matter. Then by free drainage and injections of bichloride 1 : 2000 the abscess cavity is very likely to heal. In older cases where ^ true pyogenic membrane has formed, the applications must be much stronger, and in these turpentine, iodine, or caustic potash will succeed much better. When it has been decided to lay the fistula open into the gut, there is but one method which can be thoroughly recommended, and that is the knife. The elastic ligature and ecraseui' need not be considered except in cases where the incision is so deep that concealed haemorrhage is to be feared and guarded against. In ordinary cases involving only the ischio-rectal fossa, the silk ligature is unsurgical and the elastic ligature and galvano-cau- tery wire possess no advantages. Licision. — The operation for fistula by incision may be greatly facilitated by the observance of several minor details. In this, as in other operations on the part, the bowels should be thoroughly emptied on the previous day. Care must be exer- cised lest in the endeavor to free the alimentary canal a diar- rhoea be excited, for this will prove anything but an agreeable complication for the operator. In all cases in which the track is of any considerable depth, or in which, on account of sensitive- ness of the patient, the surgeon has not been able to assure him- self of the exact extent of the disease and the absence of any side tracks or diverticula, ether should be given and the anus gently and completely dilated before the operation. It is only in the simplest cases that the incision may be made without ether, and then the best chance of a thoroughly satisfactory FISTULA. 125 exploration is missed, and the way is opened for an incomplete and therefore unsuccessful operation. With regard to position, the operator may choose between placing the patient on the affected side or on the back, though for myself I prefer the latter with Clover's crutch. —Gorget. For deep tracks the knife should be strongly made, for it is not a very difficult matter to break an ordinary scalpel in a deep fistula. A heavy steel director may, also be snapped in an at- tempt to bring the end out of the anus preparatory to making the incision ; and should the internal orifice be high up, and the external at some distance from the anus, so that the amount of tissue to be divided is large, it is often better to use the wooden Fig. 49.— Operation for Fistula with Gorget. (Bernard and Huette.) gorget to guard the opposite side of the rectum, and dispense with the director after the knife has been passed. (Fig. 48.) The end of the knife may be firmly fixed into the wood and both withdrawn simultaneously (Fig. 49), or the incision may be made by cutting on the gorget. Allingham prefers a pair of 126 DISEASES OF THE RECTUM AND ANUS. spring scissors, one blade of which runs in a director the groove of which is more than a semicircle, for cutting deep tracks. (Fig. 50.) When no internal orifice can be found, but the mucous mem- brane feels undermined and the probe can be felt by the finger in the rectum, separated only by a thin layer of mucous mem- brane, it is a good plan to force an internal opening and treat the fistula as though it were complete. When there are two in- ternal openings, both should be included in one incision. When, after the incision, the diseased integument is found to overlap the cut and hang into it, it should be cut away ; and in old tracks the healing may be hastened many days by thoroughly scraping out the lardaceous wall with the handle of the scalpel, or even scarifying it in several places, so that a healthy repara- tive action may be set up. Fig. 50.— AUingham's Spring Scissors for Fistula. Where the fistulous tracks exist in great numbers — twenty or thirty in some cases — two or three operations may be advis- able at intervals, rather than to attempt to do all at one sitting, lest the patient's reparative powers should be unequal to the task thrown upon them. In such cases there will often be found two or three tracks which may be considered as primary, into which the others run; and each of these, with its branches, may be dealt with at a separate operation. Many of the tracks will be found to run away from the bowel under the skin of the buttock or toward the scrotum, and these may be induced to heal by laying them open, without interfering with the sphinc- ters. It will sometimes be necessary to divide the sphincter several times, however, before the cure can be completed, and a certain degree of incontinence may be expected as a result. In such cases ,the anal region is generally greatly hardened and infiltrated, and free hgemorrliage may be expected. The best weapon with which to meet it is the cautery of Paquelin. FISTULA. 127 In the matter of dressings after the incision much skill may be displayed. Immediately after the operation a dressing of dry picked lint, or, if there be an abscess cavity, of lint soaked in carbolized oil, is as good as any, and this should be kept in place by a T bandage. To save the patient as much pain and annoyance as possible, this should not be removed till sup- puration has been established. Subsequent dressings may be of the same material and should be changed daily. The wound should not be tightly packed with lint. It will heal from the bottom if its surfaces are kept apart or separated daily by the finger of the surgeon. Care is always necessary to prevent an immediate union of the cutaneous edges of the incision. I have seen a remarkably well-pleased patient come to me and report himself as entirely cured a week after I had divided his fistula, in consultation with his medical attendant, and have found on examination that the incision had healed very kindly by first in- tention through its whole extent, and that the fistulous track was exactly as it was before the cut. In my own practice I sel- dom use any dressing at all after the first, but merely introduce a finger into the wound two or three times a week to secure healing from the bottom. Healing may be indefinitely delayed by too frequent dress- ings or by stuffing the wound tightly with lint, with the inten- tion of forcing it to heal from the bottom. Under such treat- m.ent healthy granulations may entirely disappear, and the cut surface assume a mucous-membrane-like appearance and so re Tuain. Standing or walking always delays, and may sometimes entirely prevent healing. During the treatment the burrowing of pus and the forma- iiion of a new pocket should always be carefully watched for ^nd met by incision. The hsemorrhage in an ordinary operation for fistula is sel- dom profuse enough to cause the surgeon any uneasiness, and is almost always easily controlled by packing the incision with lint and making firm pressure with a compress held in place by a Tibandage. A free arterial haemorrhage from a vessel well up the rectum may, however, be alarming, and if not controlled by the admission of air or the application of ice to the part, the rectum must be tamponed. Under the most favorable conditions a fistula which is but a straight track may require so large an incision that a couple of months may be required for healing. Dr. Emmet has succeeded in saving this long delay by a simple method of introducing 128 DISEASES OF THE RECTUM AND ANUS. deep sutures to approximate the sides of the cut. The old pyo- genic membrane must first be completely removed and the track put into condition to heal by first intention. Two or three wire sutures are then introduced to draw the deeper parts of the cut together, and the edges are approximated carefully with cat- gut. If the attempt be successful much time will be saved, and if it fail nothing is lost. The general idea of the operation of cutting a fistula in ano is a very simple one. It is that a director should be introduced into the external orifice, brought out into the rectum through the internal opening, or at a point where its end approaches most nearly to the mucous membrane, then bent and brought out of the anus, and that the tissues upon it should be cut. This is the idea conveyed to the student by his lectures, and to the practitioner by his text books on general surgery ; and in raiany, perhaps the majority, of cases this simple procedure will be curative, for many fistulse are straight tracks running not very deeply into the tissues, and it is to them, and to them only, that the operation applies. But no practitioner will cut many fistulse in this offhand, toutine way before meeting with a case in which such an operation will either prove a signal failure or will result in irreparable injury to the parts. Perhaps the first lesson taught by an unexpected failure in effecting a cure by this operation is that a fistulous track is something to be followed by a careful dissection, and not a thing to be laid open by a single sweep of the knife along a di- rector which has, by more or less force, been entered at one opening and made to pass out at the other ; for by this course not only is the track often left in great part undivided, but the director is forced into healthy tissue and parts are needlessly sacrificed. Instead of this, the track should be followed step by step from its external opening along its whole course ; and to do this the director need only be introduced a short distance at a time. By thus following carefully the course of the fistula, and dissecting it out to its end, no unnecessary sacrifice is made of adjacent healthy tissue, and side tracks or diverticula are recognized as they are met. This is much easier than to pick them out in the bottom of an extensive, bleeding, and irregular wound. A word about the director. The one ordinarily used (Fig. 51) is too blunt at the end for fine work. It should be of steel, deli- cately made, and probe-pointed ; silver is too flexible for ordi- FISTULA. . 129 nary work. These have been made for me in three sizes by Tiemann. With regard to side tracks or branching diverticula, the rule is that all such should be dissected up exactly as the main track should be ; but to this there are very important exceptions. The rule may perhaps be modified in this way : As many tracks should be divided as can be done without risk of incontinence of fseces in either sex, or of destruction of the perineum in women, or of too great injury for the reparative powers of the patient. As a rule, both the sphincters in either sex may be divided once in the median line without danger of incontinence. It is Fig. 51. — Director. better, however, to divide as little as possible. The inner should be left intact, if possible ; the division should be straight across the muscular fibre, and not slanting ; and a double division of one, and especially of both sphincters, should not be resorted to as a primary operation. In women and phthisical patients there is more risk than in men otherwise healthy. In these modifications of the rule of complete division cases of tracks running upward along the bowel are not included, for these should be divided as are those nearer the anus. ci.^\t^^^\^^\ a..ca. Fig. 52.— Author's Director for Fistula. Here the supposed danger of hsemorrhage often stops the operator with his work half-completed ; and one of these tracks will often heal spontaneously after the opening of the lower one into which it empties. But it is not safe to trust to this chance. These upward branches are of two distinct kinds. In one the track runs directly beneath the mucous membrane, and may be so found with the director ; and in this .there is little danger of haemorrhage in its division, for the blood vessels are all beneath it. In the other variety the track runs deeper in the wall of the gut, under the muscular layers, perhaps even away from the rectal wall into the perirectal tissues. In such cases there is 9 130 DISEASES OF THE RECTUM AND ANUS. g-reat danger of hsemorrhage, and the division may be more safely done with the elastic ligature or the enterotome. The exceptions to this rule of complete division will be found in three classes of cases — those of the horseshoe variety, the recto-labial variety, and the old cases of extensive disease where the whole anal and perineal regions are riddled with openings. In these cases all the ingenuity the operator pos- sesses will be demanded to. effect a cure without resulting incon- tinence. Horseshoe fistula has been defined differently by different writers. In a typical case it is a form of fistula in which there are one or more external openings on each side of the anus and Fig. 53.— Horseshoe Fistula. an inner opening in the rectum in the median line behind. It is shown in Fig, 53, after Goodsall.' But a horseshoe fistula may have only one external opening, and yet the abscess which has caused it may almost entirely surround the gut. Nor need the internal orifice be in the median line, either behind or in front. The name applies better to the shape of the abscess which has resulted in fistula than to the location of the openings. In this form of disease the pus in its burrowing has extended from one side of the gut to the other, and the resulting fistula may be complete, incomplete, or of the blind internal variety. The in- ternal opening- may be at any point, and the external may be on the opposite side of the body from it. (Fig. 54.) ' Britisli Medical .Journal, 1888. FISTULA. 131 In these cases I think it will generally be observed that the openings do not lead into distinct fistulous tracks of any great extent, but rather into one abscess cavity of considerable sizb. It is evident that in operating upon such cases as these there is a chance for much skill in effecting a cure at one operation and still preserving the sphincteric power. And I may say that a patient who has been left with incontinence of fseces after this operation is apt to be very unforgiving, especially when it hap- pens to be a lady who has been rendered loathsome to herself, afraid to trust herself in society, and doomed to the constant wearing of a napkin. I have seen several such, and by means to be referred to have relieved some, but from the ill-fortune of others I have come to warn my own patients that incontinence Fig. 54.— Horseshoe Fistula. m.ay possibly result, when I see any reason to anticipate such a conclusion. , Taking now a case of horseshoe fistula, such as is shown in Fig. 53. The ordinary operation would consist in two complete divisions of the sphincters on opposite sides (Fig 55), probably resulting in incontinence. The correct method, as is shown by Goodsall, consists in one complete posterior division, and then the opening of the lateral tracks into this posterior cut, as shown in Fig. 56. This principle may be made to cover nearly all of this class of cases. Where several external openings are grouped around the anus they may all be connected by one incision, and from this incision a probe may be passed through the internal oper ing, and this, too, divided with the sphincter. 132 DISEASES OF THE RECTUM AND ANUS. A more complicated case of the same variety is shown in Fig. 58, and the incisions by which it may be cured with but a single division of the sphincter are shown in Fig. 59, after Goodsall. In case the external opening be at a considerable distance from the anus, and on the opposite side of the body from the Fio. 50. internal, as shown in Fig. 54 — drawn from a case of my own — the method is essentially the same, the thing to be avoided be- ing a slanting cut through the rectum and healthy tissue. By following the ordinary rule in such a case— passing a director FISTULA. 13.- into one opening and out of the other, and cutting upon it — all but a small portion of the lower end of the bowel would be com- pletely severed by a deep incision. Fig. 57 shows the cuts that were made by which a cure was effected without incontinence. Fig. 5T It may easily occur that in a complicated case it is found impossible to divide all of the tracks without a double or even triple division of the muscles. In such cases the safer practice is to do such an operation as has been indicated upon all the Fig. 58.— Horseshoe Fistula. tracks that can be included in a single division of the muscle, and to trust to other means of cure for the balance, at least till the first wound has healed. The most reliable of these other means is the injection of 134 DISEASES OF THE RECTUM AND ANUS. strong tincture of iodine into the uncut tracks. Many of them will have been thoroughly drained by the first incisions and will Fig. £9.— Incision for HorseshoH Fistula. heal with the additional stimulus of this treatment. They may even be thoroughly cauterized with fused nitrate of silver at the time of the operation. '^v<«'^ 0%° -^'--^r :ti*a2^ Fio. (jO.— Kecto-Labiui Fistula. The second class of cases in which it may be unjustifiable to divide all the tracks at the primary operation is that of the recto-labial fistula*. FISTULA. 135 This form of disease is in most cases due to inflammation of one or both vulvo-vaginal glands or their ducts, leading to sup- puration and the final escape of pus, both on the labia and with- in the rectum. There may be numerous external and internal openings. In the case shown in Fig. GO, recently operated upon in consultation with Dr. Kennedy, there was a labial opening on each side. The right track had opened on the anterior wall of the rectum in two places, the left in one, and the right and left tracks communicated by a submucous track in the rectum. In such a case the division of both tracks would result in a com- r Ur. iU.— Incision for Rectc -Labial Fistula. plete double division of the whole perineum, as well as of the external sphincter. The cuts made at the primary operation are shown in Fig. 61. A probe was first passed through the track on the right side, from the external opening down to the verge of the anus, its end cut down upon and brought out through the skin of the peri- neum at the point B. From this point it was carried along the fistula to the internal opening on the same side, and this part of the track divided with the sphincter. The director was then again passed from the opening D to the first cut, and the cross- 136 DISEASES OF THE RECTUM AND ANUS. track divided. Finally all of the submucous tracks were slit up, and the track on the left side from its internal opening as far as was possible without complete division of the sphincter at that point. Setons were then passed along what remained of the original tracks, and tied. The result was not a perfect cure in the first instance, only the rectal tracks being closed, but by the primary operation the subsequent treatment of the two straight perineal tracks was rendered much simpler. Dr. I, E. Taylor ' has made a careful study of this rare form of disease, and describes two different methods of operating, both, however, with the elastic ligature. The first is that recom- mended by Barton, in which a ligature is passed from the labial to the rectal orifice and brought out at the anus ; an eyed probe is then passed from the labial orifice down along the perineum till it reaches just outside of the sphincter ani low down, its point is cut down upon, and the labial end of the ligature is drawn through this artificial opening and the ends fastened. The other operation is the same, except that the stages are re- versed, the artificial opening being first made and the ligature passed from this through the rectal opening and brought out at the anus. In this way the track through the perineum is not divided, but is left to close with appropriate stimulating applica- tions. The only rational treatment for the blind internal form of this disease is by incision into the gut. The only exception to this is in acute cases of ischio-rectal abscess seen within a day or two after the pus has forced its way into the gut. In such, a free external incision and a thorough cleaning out of the abscess cavity may avoid the necessity for cutting into the bowel and dividing the sphincters. Where the probe readily enters an abscess cavity or a track running downward toward the skin, it should be bent into a hook, brought as near the surface as possible, and a counter- opening made upon it. Through these two openings a director should be passed and the whole cavity laid open into the gut. In whatever direction the track leads, it must be followed to its end and freely divided. Much delicacy and patience are some- times necessary to accomplish this so that no side tracks are missed ; the probes and directors may need to be very delicate, and much time may be required ; but the success of the opera- tion depends upon the thoroughness with which it is done. Free drainage at the most dependent part of the incision should al- ' " Transactions New York State Medical Association," 1885. FISTULA. Vol ways be provided, and to do this it may or may not be neces- sary to cut deeply through the sphincters. The treatment is simple in theory, but sometimes difficult to carry out. Large abscesses of the superior pelvi-rectal space which have opened into the rectum should be treated by the in- troduction of drainage tube and daily washing out with boracic acid solution. Those located in the ischio-rectal fossa should be opened on the skin, thoroughly cleaned out, and treated by drainage and injections to give the internal opening a chance to close without dividing the tissue between the two openings, Fig. C2. which is often considerable. Should this fail the ordinary ope- ration may be done. In the lesser cases of small tracks without abscess cavity the track must be laid open. The rule is to enter a director at the opening into the bowel, bend it so as to follow the track, and then lay the latter open by cutting. When the track runs upward, as in Fig. 47 — which, by the way, was a case due to carbolic acid, which attracted considerable attention be- FiG. 63.— Author's Fistula Knife. fore the cause of the patient's suffering was discovered — this is not difficult, but when it runs toward the skin, and both opening and track are small, as in Fig. 64, it is a very difficult and uncer- tain proceeding. Where the induration approaches near enough to the surface to be easily felt, I have in some cases cut directly down upon this through the skin without any director, and have then found no difficulty in passing a director onward through the internal opening. If, however, there is no friendly induration to guide the knife, the track must be carefully dissected out from the internal opening. It is easy under these circumstances to 138 DISEASES OF THE RECTUM AND ANUS. make a false passage with the director, and thus lose the true one, and fail, in spite of free cutting, to cure the case. In the case pictured in Fig. G4 I found it nearly impossible to follow the track with a bent probe, the opening being a conside- rable distance from the anus, but it was finally satisfactorily laid open with the curved knife shown in Fig. 02. These are opera- tions requiring patience and care, but with the rectum well ex- posed, under ether, there need be no difficulty. The knife of my own invention (Fig. 03) is sometimes very useful in these cases. In fistulfe with very long and deep tracks, or in those with many smaller ones, a cure without an amount of cutting which shall necessarily lead to incontinence may be impossible. Fig. 05 is taken from a case of the latter variety, where the openings Fig. (54. — Doiil)li' Fistula. 1, Orisiual incision; 3, secondary track; 8 nicer remaining. and tracks were so numerous, and the patient's general condi- tion so bad, that a cure was for some time despaired of. By several operations, however, undertaken at intervals, they were all finally laid open and cured, with the result shown. In these cases care must be exercised not to overtax the strength of the patient by too much cutting at any one time. The tracks can often be divided into two or three main ones, each with secondary side tracks ; and it is better to attack one main track and its branches at a sitting, leaving the others till the patient has gained strength by change of air and appropriate treatment. In cases of a single but very long and deep track it may not be best to divide everything at a single sitting, as, for example,, where one opening is high up in the rectum and the other in FISTULA. 1;j'J the middle of the thigh. The question as to how much it is safe to do at one time must depend in great measure upon the strength of the patient ; and it is often better to begin at the ex- ternal opening and follow the fistula up to the buttock at one operation, leaving the remainder for treatment by injections or subsequent cutting. In these deep tracks a galvano-cautery knife or wire may be better than a bistoury. A very strong knife may easily be broken in sUch a case as is shown in Fig. 00. The external Fig. 6").— Cicatrices of Fistula opening here was over the great trochanter, and the case was very naturally mistaken for hip- joint disease by several opera- tors. The track had been laid open under this impression seve- ral times, but never induced to heal. It finally came under the ca,re of Dr. H. M. Lewis, of Brooklyn, who succeeded in passing a probe into the gut, but the knife broke in the callous tissue. An ecraseur was next used, with the strongest picture cord doubled, and this was broken. Finally the ingenious idea oc- curred to the operator of passing a chain saw, and by this means the cicatricial tissue was finally divided and the patient cured. 140 DISEASES OF THE RECTUM AND ANUS. The cause of incontinence after operation for fistula has been the subject of considerable argument, for in some cases a single incision through the external sphincter has been followed by this untoward accident, while in others very extensive and nu- merous incisions have left the patient still with good control. Smith believes it to be due not so much to the division of the sphincters as to division of the circular muscular fibres of the lower part of the rectum ; while Esmarch holds rather to the theory that it is due to division of the nerves supplying the mus- cle more than to the division of muscular fibres. "- ' r .'5^. h 'it^X Fig. 66.— Extensive Fistula. (Lewis ) In my own mind the explanation lies in the fact of vicious cicatrization, by which the ends of the divided muscles are not brought into apposition in healing. On this supposition it is easy to understand why a single cut may result in loss of mus- cular power, the ends of the sphincter being separated by an in- terval of half an inch, and the muscle therefore having no fixed point of support ; while in other cases several incisions which have healed properly may still leave the segments of the muscle in shape to act as one undivided circle. The simplest form of the same condition is seen in lacerated perineum in the female. Here a single rent is followed by almost complete incontinence; FISTULA. 141 and although the perineum may seemingly be perfectly restored by operation, there will be no return of sphincteric power till the cut and separated ends of the muscle are brought into appo- sition. The condition is one which entails a greater or lesser degree of misery, depending upon the consistence of the fseces and the regularity with which they are voided. To a man who has one solid, natural evacuation before going from his house in the morning, there may be no suffering and little annoyance, ex^^ept what arises from the involuntary escape of wind and the soiling of the person with the natural mucous secretion of the bowel. The fact of inability to control the passage does not necessarily imply that the passages escape in a way to cause annoyance, for Fig. 67. when they are of natural consistence and passed with regularity there is generally sufficient warning to allow the patient to seek the closet, which he has learned never to be far away from at a certain hour. The greatest suffering comes in women when the bowels are loose ; then there is absolutely no chance to avoid the consequences ; a napkin is constantly worn, and the patient soon becomes a confirmed invalid. If the anus be open and patulous, more or less prolapsus may follow ; and this is a fresh cause of tenesmus and discharge, complicating and increasing the original trouble. The train of nervous symptoms following this condition is often in itself serious, and apparently out of proportion to the physical dis- ability. In the treatment of this condition the operator has an ample 142 DISEASES OP THE RECTUM AND ANUS. field for the exercise of all his ingenuity, for no two cases will be found exactly alike, and the operations must vary accord- ingly. Some will be seen at a glance to be manifestly incurable, such, for example, as the one shown in Fig. 65, where the sphincters have been cut again and again in different direc- tions till the anus has lost entirely its original shape, and it would be difficult to find any trace of the sphincter by the most careful dissection. Most cases, however, are amenable to ope- ration and relief, and a successful operation brings much sin- cere gratitude to the operator. There are two guiding principles in operating. The first is, to find the ends of the sphincter and unite them by suture ; the Fig. 68. second is applicable where the first is impossible, and consists in producing an artificial tightening and closure of the anus without much regard to sphincteric action. The first indication may often be followed out at the time of the original operation for fistula, and is, in fact, done in the operation for immediate closure of the incision by suture of the wound, under antiseptic precautions. In extensive tracks and abscess cavities the operation may fail, but in single deep cuts it often succeeds, and it is always worthy of trial with the ob- ject of obtaining direct and immediate union of the ends of the muscle and avoiding possible incontinence. In cases such as are shown in Pigs. 07 and GS, the operation is the same as in lacerated perineum — cutting down upon the FISTULA. 143 ends of the muscle, freshening the edges of the original inci- sion, and bringing them together with wire or catgut sutures. In a case such as is shown in Fig. 09 the operation is much more complicated. This patient, in spite of all the cutting which had been done, was still suffering from a blind internal fistula when he came under my care. In the figure the parts are not at all stretched open. The anus is seen as an irregular circle composed of cicatricial tissue, which held it wide open. The cicatrix extended an inch and a half into the rectum on all sides, and no mucous membrane was seen till beyond this point. Fig. 69.— Cicatrix of Fistula. The anus and lower part of the rectum presented an open tube about an inch in diameter, entirely without any power of mus- cular contraction. At the point where the folds of mucous membrane first appeared there was an opening leading into a deep sinus in the right buttock, and this was opened up, reliev- ing the patient of the pain and purulent discharge from which he suffered. Even in this case, with anus and lower part of rectum con- verted into an open, unyielding tube, the patient did not com- plain of incontinence, though there could have been no action of either sphincters or levator, and hence no control. He sim- 144 DISEASES OF THE RECTUM AND ANUS. ply had a natural passage every morning and was never subject to diarrhoea. In such a case the anus could only be closed by a plastic operation. The plan I proposed was to dissect the mucous mem- brane loose, draw it down, and stitch it to the skin, after fresh- ening the cicatricial ring of the anus so as to first give a mu- cous lining to the parts: then, by a subsequent plastic operation, or perhaps by the cautery iron, to close the outlet of the canal. But after the fistula was cured, the patient, suffering really no inconvenience, declined further operation. The case proves better than any I have ever seen that loss of sphincteric power is not always attended by any inconvenience. The following case will illustrate the operation of tightening the anus by the use of the cautery : The patient, a man aged twenty-seven, was originally sent to me two years ago by Dr. McCready, suffering from ischio-rectal abscess. Although this was at once operated upon, it did not stop the burrowing of pus, Fig. 70— Cauterizations for Incontinence. and eventualh' a fistula was formed, opening into the bowel well above the internal sphincter, and out on the buttock a con- siderable distance from the anus. This in its turn was divided with the knife, but the result of the division of so much of the bowel and of both sphincters was a considerable degree of faecal incontinence with all of its necessary attendant evils. Treat- ment of the incontinence by the passage of bougies, the use of cold, etc., resulted, after a year's continuance, in great benefit, so that the patient seldom soiled his clothing with faeces, except when tlie bowels were unusually loose ; but there was an occa- sional passage of a slight amount of fa?ces, a frequent escape of rectal mucus, and a constant annoying sense of insecurity in the patient's mind which made him anxious for any further re- lief which surgery could afford. The actual cause of the open condition of the anus lay not so much in any weakening of the power of the sphincter, which always contracted firmly around the finger in the rectum, as in the peculiar shape of the anal FISTULA. 145 orifice, resulting from the contraction of the cicatrix formed by the operation for fistula. This was situated on the left side, was firm, deep, and hard, and, by its contraction, had resulted in a decided drawing of that side of the anal orifice over still more to the left, so that no amount of sphincteric contraction could close it. The condition may be seen by a glance at the diagram, in which C represents the cicatrix. To remedy this deformity I made with a Paquelin cautery the burns represented by the radiating lines, and also removed Fig. 71. — Result of Operation for Incontinence. two longitudinal strips of mucous membrane from the inside of the bowel, clamping the tissue deeply with Smith's clamp and using the cautery freely. The burns represented by the figure were also deep, going fairly down to the sphincter, and extending from well within the anus to the distance of an inch upon the skin, growing deeper as they reached the lower end. The operation was followed by more pain and local disturb- ance than I anticipated, and there was at one time a brawny hardness in the cellular tissue of the right buttock which made 10 14G DISEASES OF THE RECTUM AND ANUS. me uneasy lest the patient should have another deep abscess worse than the first ; but all this passed away, and after three weeks* rest in bed he was again able to attend to his work. The burns were just sufficient to produce the desired effect, and this, it is evident, is the delicate point in the operation, and the 1 Fio. 72. — A.llingham's Ligature Carrier. Fig. 73.— Helmutli's Ligature Carrier. one for which no rule can be laid down, but which must be judged of by each operator in each particular case. Fig. 71 shows the result in tightening the anus and also in drawing it to one side. After what has ])een said of the origin and extent of ab- FISTULA. 147 scesses of the superior pelvi-rectal space, it is evident that there may result from them a class of fistulse which are not to be ope- rated upon by any of the methods we have described — fistulpe so deep and extensive as to contra-indicate all operative inter- ference. And vet much may be done, even in the worst cases of this kind, and by proper treatment many may be cured. The first attempt of the surgeon should always be toward effecting a cure without cutting the track into the bowel. External and com- paratively free incisions may be made, which shall not implicate the anus, and through them drainage tubes may be passed into the abscess cavity so that it may be f reel}^ emptied. Through the drainage tube stimulating injections may be made, and the ab- scess treated as an abscess elsewhere would be, by rest and at- tention to the general health. A cure may sometimes be effected in this way in a very unpromising case. Fig. 74.— Enterotome of Richet for Deep Fistulae. When all these measures have been exhausted and it becomes necessary to open the sinus into the bowel, the danger of hae- morrhage may be overcome by the elastic ligature or the entero- tome. Of these the former is preferable where the tissue to be cut is soft and vascular. The cord in this case is of solid rubber, which is drawn as tightly as possible — the tighter the better — and then held on the stretch by slipping a soft metal ring over the ends and squeezing its two sides together close up against the tissues. In the course of a few days the ligature will be found to have cut its way through the included tissues, the time depending on the quantity and quality of the mass to be cut. Various devices have been recommended for facilitating the passage of the ligature. The best known is Allingham's, Fig. 72. In using it, remember that it is intended to draw the cord from the rectum out of the external orifice, and not vice versa. Helmuth. of New York, has modified the instrument, and I think with advantage. Fig. 73 ; but the least elaborate and most 148 DISEASES OF THE KECTUM AND ANUS. effective instrument for the purpose in iny own hands is a simple silver eyed probe which is threaded with the elastic cord and then passed from the external orifice through the track and out at the anus. I once had an awkward accident with Allingham's instrument, which broke in my hand in a moderately deep and hard track. If it be deemed advisable to use the enterotome, the form shown in Fig. 74, which has been invented by Richet for this purpose, is the most convenient. Where the track has burrowed to great length much may be accomplished by modified operations. In a track, for example, which has one opening near the anus and another in the middle of the thigh, a counter-opening may be made between the two. Fig. 75. — Showing the anterior wall of the rectum, and opening 'into it at E a sinus fi-om the menobranous and prostatic urethra. B, cul-de-sac, which undermined the right margin of the opening. A, A, line of incision, along which the flaps were dissected as far inward as C. For their nutrition the two lateral flaps depended upon the limit between the dotted line C and the margins of the opening E. t), the perineiun. (Wyeth.) and the further extremitj' induced to heal while drainage is maintained from the middle opening, by the use of injections or caustic applications. Should these means not succeed, and should it appear that a free division was likely to result in a cure, the incision may be made according to the ordinary rules of surgery. Such operations have been done, and tracks of great length extending under the gluteal muscles have been di- vided with the ecraseirr with good results. I have myself fol- lowed a track directly across the perineum and exposed the membranous urethra in the incision, dividing in the operation the sphincters four different times. Such operations may some- times be necessary to save life, but they may be too great for the patient's powers of recuperation. FISTULA. 149 An abscess between the prostate gland and the perineum, where the pus is confined by the perineal fascia, may result in both a rectal and a urethral fistula. The operation in such a case is the same as for other sinuses, that leading into the rec- tum being first divided, and the others which communicate with it, later. In fistula complicating stricture of the rectum, attention should always first be turned to the latter, for if this can be cured there is a prospect that the former may undergo sponta- neous closure, and if the stricture be not relieved it will be of little avail to cut the fistula. Many awkward mistakes have happened to good surgeons by failing to detect this complication of diseases. Recto-urethral Fistula. — This is generally due either to direct Fig 76.— Schematic. Transverse Section through the Urethra and Rectum, showing the method by which the flaps were turned from the mucous membrane of the rectum to make the floor of the urethra, a, Urethra; 6, the right flap dissected from b' ; c, the left flap from c'; d, the sill£worm- gut suture in position (not entering the cavity of the urethra). CWyeth.; traumatism, surgical or otherwise, or to some ulcerative or sup- purative process. Wyeth has recently reported the following- case, which well illustrates the operation to be performed in such cases : The patient, a man aged twenty-seven, had a urethro-peri- neal fistula resulting from an operation for stone. Four at- tempts had been made to close this without success. In the last of these a drainage tube about one and a half inches long- was inserted in the perineal opening and left with the deep end in the urethra. This tube, about three-sixteenths of an inch in diameter, was lost sight of, and both doctor and patient sup- posed it had fallen out and been thrown away in the dressings. The last operation was followed by considerable persistent pain. In the course of three months an abscess opened into the rectum 150 DISEASES OF THE RECTUM AND ANUS. through the anterior wall, and the urine began to flow freely in this new channel. About this time the perineal opening was closed and an abscess formed in each tunica vaginalis, which were incised and healed. At this date nearly all the urine passed per rectum, and the patient suffered so greatly that he had to be kept constantly under the influence of opium. An examination per rectuni revealed the presence of a stone, the end of which was on a level with the anterior surface of the rectum, about one inch beyond the anal aperture. This was removed through the rectum by means of strong forceps, and found to be a concretion around the lost drainage tube. The patient was then etherized and placed in Sims's position, and a large Sims's vaginal speculum introduced. The opening through the anterior wall of the rectum measured three-quarters of an inch in length, with an irregular width of from one-eighth to one-quarter of an inch. It led directly into the urethra near the junction of the membranous and prostatic portions. The floor of the urethra was entirely destroyed. The right edge of the opening was slightly undermined. It was decided to attempt the formation of a new floor to the urethra by turning the mucous membrane of the rectum into this position. Two crescentic incisions were made, about paral- lel with the edges of the opening, but approaching more closely at its upper and lower angles. These incisions went deeply into the wall of the rectum and included the mucous and muscular la^^ers. The two lateral flaps were dissected up and turned towards each other, their raw edges meeting in the middle line, while the raw surfaces looked into the rectum, and the mucous surfaces into the urethra. Sutures of silkworm gut were in- serted about three-sixteenths of an incli apart, so that they did not penetrate the cavity of the urethra. A Nelaton's catheter was carried from the meatus into the bladder, and through it the urine escaped at intervals. Whenever the urine accumu- lated enough to create a desire to expel it, about six ounces of Thiersch's solution were thrown in to dilute it, and when this with the normal contents of the bladder was evacuated the same quantity was thrown in again and immediately expelled. In this way the wound was kept free from irritation by the urine ; the bowels were confined for nine days; the sutures were left in situ, the wound healed promptly, and the patient left for his home three weeks after the operation. Under the heading Rectal Hernia it will be seen that as a complication of an old i^rolapse a fistulous communication FISTULA. 151 may sometimes be established between the small intestine and the rectum. Esmarch describes one such case, and Schroeder ' speaks of a similar anastomosis having been formed intention- ally to cure an artificial opening into the posterior vaginal cul- de-sac. Ball also speaks of communications between the rectum and appendix as a result of disease. For the treatment of faecal fistula the reader is referred to the chapter on Artificial Anus. 'Ziemssen's " Cyclopfedia of the Practice of Medicine," vol. x., p. 531. Quoted by Ball. CHAPTEE VII. HAEMORRHOIDS. Although haemorrhoids may be defined in a general way as varicosities of the anal or rectal vessels, thej^ present themselves under so many different forms and modifications that such a definition conveys but little idea of their characteristics. For convenience they may be divided into external and in- ternal ; and these may always be distinguished from each other, though both may exist at the same time in the same patient. An external hsemorrhoid originates in the subcutaneous veins which surround the anus ; it is, therefore, entirely below the sphincter muscle, and though it may be partially covered by mucous membrane, it does not come from the rectum proper, nor can it be forced above the external sphincter muscle. An inter- nal hsemorrhoid originates, on the other hand, within the rec- tum, and may exist for a long time without appearing externally. When it does show itself outside of the anus, it is a result of straining, of increase in size, or of a lax condition of the sphinc- ter ; and after long exposure outside the body it may become changed in character and appearance till the mucous membrane covering it takes on something of the character of integument ; but it may still, with proper management, be returned within the bowel, though it may not remain there for any length of time. The distinction between an external and an internal haem- orrhoid is not, however, a purely arbitrary one, the one being below and the other above the external sphincter. A different set of blood vessels is implicated in each case. An external hsemorrhoid is generally a varicosity of an external hsemor- rhoidal vein, and is, therefore, an affection of the general venous circulation. An internal hsemorrhoid is a varicosity of the middle or internal ha?morrhoidal veins, which are parts of the visceral venous system. A glance at the venous anatomy of the rectum and anus (Figs. 0, 10) will show the arrangement of these two sets of veins, and will also explain how, from the PLATE II. eJiAM'. >. ^.la. S. Syxq-A-. 'f Qm^/X/\\lOlAA\OX€U) . HEMORRHOIDS. 153 free anastomosis which exists between them, it is improbable that one should be affected without influencing the other to a greater or less extent, and how, judged by this test alone, it may be impossible to tell whether a particular haemorrhoid be- longs to one system or the other. For practical purposes, there- fore, the first definition is the better one — an external hsemor- rhoid is one originating outside of the external sphincter, and an internal one is one originating within that muscle. Other secondary diff:erences, which may arise from various causes, in the development, appearance, and characteristics of the tumors, will be considered later. A third class of haemorrhoids may with advantage be made to include those which are on the dividing line between the ex- ternal and internal, partaking somewhat of the characters of both. (Plate II., Fig. 1.) External Hcemorrhoids. — A person of middle age who has not at some time suffered from an external hfemorrhoid is in- deed a great rarity, so common is this affection. In the major- ity of cases it is allowed to run its own course, and only when the pain is unusually severe, or some untoward accident has happened, does the patient consult the surgeon. It is perhaps useless to seek for the causes of a malady which is so universal, beyond a few which are well recognized and manifest. Amongst these are straining at stool, pregnancy, affections of the internal organs which interfere with the return of venous blood, and constipation. Outside of these cases where a manifest cause exists, external hsemorrhoids will be found amongst all classes. Those who smoke and those who do not ; the high liver and the abstemious ; the laborer and the professional man ; those who stand and those who sit, are all affected about equally. An external ha3morrhoid may appear in three different forms which bear little resemblance to each other. The first is a small, round or elongated venous tumor. (Fig. 77.) This is simply an extravasation of venous blood into the deli- cate subcutaneous connective tissue of the anus. The patient, often while in perfect health, and without any appreciable cause, feels a sense of uneasiness at the anus. An examination made by himself shows a small, soft, painful lump, from the size of a pea to a grape, which disappears on pressure, but immediately returns. This is extravasated venous blood from a previously weakened and dilated vein which has ruptured. After a few hours the tumor becomes harder and more painful, and. if near enough to the surface for the blood to show under the tense skin, 154 DISEASES OF THE RECTUM AND ANUS. it Avill appear as a bluish-black, circumscribed swelling. The discomfort caused by this condition is out of all proportion to its apparent magnitude. The patient generally tries to keep about, but can neither sit nor stand with any comfort. The pain is a sort of dull ache which it is very hard to bear, and to gain tempo- rary relief efforts are generally made every little while to force the lump above the sphincter. The pressure often gives a mo- ment's relief, but not more, for the tumor does not come from above the sphincter and cannot be made to stay there. When left to its own course, a bloody tumor of this variety Fig. 77.— External Venous Haemorrlioid. (Smith.) may gradually decrease in size from the absorption of the fluid elements of the clot, the pain decreasing at the same time ; and after a week or ten days of discomfort it is changed into a cu- taneous h«3morrhoid. Or the opposite course may be taken, and the tumor may show all the signs of an abscess (Plate II., Fig. 4), and finally rupture spontaneously with the discharge of a little blood and ])us, and with an instantaneous ending to a week of suffering. For during this acute inflammatory process the pain is often very severe, the discomfort constant, and there is more or less febrile excitement, all of which will pass away the moment the tension is relieved. HEMORRHOIDS. 155 There are two ways of treating such a tumor. The first and best is to lay it freely open and turn out the clot from its bed. The bistoury should be sharp-pointed and delicate, the tumor should be transfixed from the anal surface outward, and the in- cision should be in the line of the radiating folds. After such an incision the pain will almost instantly disappear. A little styptic cotton should be placed between the cut surfaces, a large towel folded into a pad applied to the part, and the patient told to sit upon a hard chair, with the compress under him, for fif- teen minutes till there is no longer, any oozing of blood. The subsequent treatment consists only in bathing with cold water two or three times a day, and the cut will be healed in three or four days. If the surgeon undertake this method of treatment, there are one or two hints which may be of value. The incision itself is very painful, and should therefore be done with a sharp bistoury of the form shown in Fig. 78, and it should be done instantane- ously. Whatever deliberation is required is better exercised before entering the knife. Again, care should be exercised to Fig. 78 —Small, Sharp-pointed, Curved Bistoury. empty the clot entirely out of its bed, otherwise a small wound remains which will not readily heal, because the sac is prevented from contracting, and the patient is obliged to wear a bandage, perhaps for a week or longer, to keep from soiling the linen w4th a sanious discharge. Under such circumstances, also, the pain is but little relieved by the operation, Again, I have in a few cases seen the incision heal by primary intention and the sac again fill with blood, thus leaving the patient in the same con- dition, as regards suff'ering, as before operation. This is best avoided by placing a shred of lint in the cut. These, however, are untoward accidents which may attend an insignificant ope- ration which usually gives relief to suffering, and allows the tu- mor to shrivel up and disappear except for a small tag of skin which may remain and form an external pile of the second va- riety. This operation is so trivial and the relief so immediate that it is generally safe to perform it without any previous explana- tion to the sufferer; but should it not be permitted, another plan must be followed. A cathartic containing podophyllin (pil. po- 156 DISEASES OF THE RECTUM AND ANUS. dophyllin co.) should be given at once to secure two or three free actions of the bowels, the patient put upon his back on the bed or sofa, and a rubber ice bag filled with finely powdered ice placed against the part and kept there till the pain subsides. Cold usually gives great and immediate relief, but should it not, a poultice may be substituted. Under this plan of treatment the patient will probably be relieved in two or three days, so as to be able to get around with comfort, provided the clot is to be absorbed. In some cases, however, suppuration will occur, and in about a week from the time the swelling first appeared it will open spontaneously and discharge a few drops of pus. As soon as it becomes evident that this is to be the course of events, poultices should be applied and continued. This form of hgemorrhoid is comparatively trivial, but it often causes great pain and confines the patient to the house for several days, and the suffering is often increased by improper attempts at treatment. Instead of being freely cut, they are often punctured with a needle by the patient. The result is the escape of a few drops of bloody serum, relief for an hour or more, and then renewed suffering from the bruising and squeez- ing which usually attend this attempt at surgery. I have seen them leeched by physicians, with the result of starting a slight bleeding which continued for several days, without, however, giving any relief. They are not infrequently injected with car- bolic acid by those who have heard of this method of treating haemorrhoids, and it is only by great good luck that suppura- tion can be avoided after this has been done. Those who have once been troubled with this form of haemor- rhoids are very liable to repeated attacks. The veins are deli- cate and feebly supported, and a little unusual strain upon them is sufficient to produce an extravasation. This may happen after a constipated passage, an interference with the perfect discharge of the hepatic functions, or from a cause too slight to attract the notice of the patient. The preventive treatment of this, and in fact of all other varieties, consists in the mainte- nance of as perfect a state of the general health as possible, per- fect regularity in the action of the bowels, without straining, and the daily use of cold-water ablutions to the parts. Tobacco and alcohol' must both be used in moderation, if at all, over-eat- ing must be avoided, and if a careful regulation of the diet will not suffice to produce a regular, daily, natural action of the bowels, a slight laxative must be taken daily. One who is in the habit of having a passage each morning may easily bring HEMORRHOIDS. 157 on an acute "' attack of piles " in a few hours by going to business without taking time to attend to this function, and may be able to relieve it by an enema or a glass of mineral water almost as quickly. All patients with any tendency toward haemorrhoids should use cold water to the parts freely, at least once a day. In the morning before dressing, after the daily movement, or at night before retiring, it is well to sit on the edge of the bath tub, turn on the cold water, and with a large sponge apply it freely. The parts should not be rubbed either with the sponge or in drying with the towel ; but the sponge full of water should be placed against the parts, and gently pressed out fifteen or twenty times. This is the best tonic, astringent, and anodyne of which I have any knowledge, and its habitual use would prevent a very con- siderable portion of all hsemorrhoidal difficulties. Fig. 79.— External Hemorrhoid after Injection of the Vein. (Froriep.) The second variety of external hfemorrhoid is a tumor com- posed of enlarged and varicose veins at the verge of the anus, and is shown in Fig. 79. Here there is no extravasation of blood, but a simple dilatation of the vessels, with perhaps a slight increase in the amount of connective tissue. The tumor is therefore of gradual and not of sudden formation. Its devel- opment goes on with so little suffering that the patient is often conscious of it only by the gradual increase in the size of the tumor. During and after the act of defecation the veins are turgescent from straining, and the tumors swell up so that they are very prominent and cause more or less uneasiness for a short time ; but with the re-establishment of the circulation these symptoms disappear. In examining such a patient, the verge of the anus may at first sight seem normal, but when the patient strains the venous tumors at once become prominent, and individual veins, greatly enlarged and full of blood, may be 158 DISEASES OF THE RECTUM AND ANUS. seen through the skin. These tumors are not circumscribed, as are the last, and it is difficult to mark out their boundaries. They are generally multiple. I have been called upon to treat this condition, existing with- out other disease, oftener. perhaps, in physicians and in very nervous patients than in any other class ; though it is not infre- quently united with other haemorrhoidal tumors for which any patient may seek advice. As a rule, I think, when there is no other trouble, it is better to treat it by cold applications and regulation of the bowels, as already described, than by a sur- gical operation. If, however, the patient be under ether for a more severe operation, it is generally easy to include enough of these tumors in the clamp or ligature to cure them at the same time. As there is no distinct mass to be removed, I never ad- vise a cutting operation for these alone, and thus far have con- fined myself to one of two methods — the injection of carbolic acid and electrolysis. There seems to be little to choose be- tween them ; and yet, if preference is to be accorded to either, it is probably to the latter, on the ground that it is not likely to produce a slough. If carbolic-acid injections be used, the strength of the solu- tion should not exceed ten per cent of the pure acid. This will generally cause a smarting sensation for a few moments, and no further trouble, while a thirty-three or fifty per cent solution thrown into one of these veins, showing as a black line under the skin, will cause it to immediately change to a whitish hue, and a few days later the patient will appear with an ulcer of considerable size, which will take some weeks to heal. The idea is to produce induration without sloughing, and to be sure of doing this the injection must be weak and repeated several times at intervals. I cannot overcome the idea in my own mind that there must be danger of embolism in thus injecting carbolic acid into an enlarged vein through which the blood is freely circulating, and on this account I have abandoned the practice, though without (fortunately) any clinical data upon which to support the idea. I now much prefer, with the patient under ether, to gently ap- ply the point of the Paquelin cautery, heated to a dull red, to each of the swollen veins. Electrolysis is not generally very painful in its application, nor is the subsequent suffering very severe. In the use of electrolysis a current should be secured suf- ficient to cause coagulation in the white of an egg in a glass. HEMORRHOIDS. lo'J The positive electrode should be a fine cambric needle, intro- duced into the centre of the tumor. A sponge over the buttock or sacrum answers for the negative. Cocaine may first be in- jected into the tumor with advantage, and the positive needle should be introduced and separated from surrounding parts be- fore the negative is applied. The current should be passed for at least ten minutes, and after a short time the cautery action at the point where the needle pierces the tumor will be plainly visible. There will be some pain at the time of the operation, and perhaps considerable on the following day, but after this the tumor will be found considerably reduced in size. In the • third form of external hsemorrhoids the vascular ele- Fig. 80,— External Cutaneous Hagmorrhoids. CEsmarch.) ment is insignificant as compared with the great increase in con- nective tissue which occurs. This tumor seems at first sight to be only skin and connective tissue, and is often improperly spoken of as a condyloma, though we shall reserve that term for an entirely different condition. It is shown in Fig. 80. Such a tumor may result directly from either of the other two varieties, or it may gradually form as the result of the irri- tation of more serious disease within the rectum ; under the latter circumstances being generally due to the contact of irri- tating discharges with the skin. When the first variety has un- dergone acute inflammation, as it often does, a tumor of this Mnd is the natural result ; for resolution is almost never com- 160 DISEASES OF THE RECTUM AND ANUS. plete. The venous tumor becomes harder and larger, the skin over it firmer, it loses its vascular character and becomes a con- nective-tissue tag such as is shown in Fig. 81. These connective-tissue growths may be single or multiple, and vary in size from a pea to a tumor the size of the thumb. The anus may be so completely hidden among them as scarcely to be discernible. They may be pendulous or attached by a broad base partially encircling the anus. They are often excoriated on the mucous aspect, and thus give rise to an annoying and of- fensive discharge. At the base of one of them a fissure will often be found, and it has sometimes seemed evident to me that the latter was directly due to the violence resulting from the weight and dragging of the former. The origin of these tumors should be well understood. When found at the anus in connection with a stricture of the rectum, they are supposed to indicate syphilis as the cause of the stric- Fio. 81.— External Haemorrhoid with Increase of Connective Tissue. (Esmarch ) ture. I have no faith in such a statement. . To me they indicate nothing but a continued irritation of the outlet of the rectum. They are. according to my experience, as frequent iii cancerous as in syphilitic stricture, and often as well developed when there is no serious rectal disease. It is safe to say that the surgeon will seldom be consulted for these tumors alone when they are quiescent — that is, when they are not acutely inflamed and therefore cause no pain. But they are liable to become inflamed on very slight provocation. The same causes which will produce the last variety will cause acute inflammation and suppuration in this. Then the patient pre- sents himself with much the same symptoms as in the last case, except that the pain has been more protracted, because the pa- tient is more accustomed to the annoyance of the tumors and is slower to seek relief. The patient will come with the history that he has had piles for a long time, that they never go back, that generally they cause little annoyance, but for a week back he has had great pain, there has been considerable swelling, and HEMORRHOIDS. IGl he is unable to sit down with any comfort. An examination will reveal a hard, tender, somewhat oedematous mass of tissue just at the verge of the anus. Its attached base may surround nearly one-third of the anus and may be fully half an inch thick. It cannot be forced above the sphincter, or, at least, cannot be made to remain there. There may be two or three of these tu- mors. The outer surface is composed of skin, and the inner is smooth and shining, being composed in part of finer skin and in part of the mucous membrane in which the skin ends at the anus. It is plainly a connective-tissue tumor, having its attach- ment outside of the rectum, and not one composed of blood ves- sels covered by the inucous membrane of the rectum. It is necessary to be thus particular in the description of this form of haemorrhoid because of the painful errors often seen in its treatment. It never, when uninflamed, belonged within the canal, and it naturally cannot be made to stay there by any amount of force when it is swollen to three times its usual size. It is not a vascular tumor to any extent, and therefore the leech- ing and scarifications often resorted to never give any relief, while the force used at attempted reductions, sometimes under ether, invariably makes matters worse. If allowed to take its own course it will seldom suppurate, but will gradually subside^ and in a couple of weeks the pain will in great measure have disappeared, the tumor always, however, remaining somewhat larger than before the attack. The treatment of this variety is essentially the same as in the last, although the cutting to be done is more considerable. It is particularly in this class of cases that cocaine may be used to the best advantage. If the base of the tumor be small, five drops of a four-per-cent solution should be injected into it, and when it is^ no longer sensitive it may be seized with forceps and snipped off with strong scissors. There will be some bleeding, but generally only a little, and styptic cotton, with a compress and bandage, left on for a quarter of an hour will stop it. When the base is larger,, say an inch or more in length, cocaine must be used at two or three points, and I prefer the clamp and cautery to the scissors. ISTo after-dressing will then be necessary except cold water, or possibly a poultice to relieve pain. If the tumor be small, the patient will generally be free from pain and able to attend to his business on the following day. If it be larger and the clamp has been used, it is better to keep him in bed for sev- eral days, with cold compresses or poultices to the wounds. These operations are best performed when the tumors are 11 162 DISEASES OF THE RECTUM AND ANUS. quiescent and not acutely inflamed, as the pain will then be much less and the recovery much more speedy. But, unfortu- nately for the patient, he seldom wants anything done till he has had a good deal of suffering, and the doctor is seldom consulted except during an attack of inflammation. Under such circum- stances nothing is gained by waiting for the attack to subside, although the operator must allow for the infiltrated condition of the parts, and not remove enough skin to cause subsequent stricture. One of the most extensive cases of this form of trouble I have ever seen is shown in Fig. 82. The patient was under the care of Dr. Hemingway, of New York, with whom I operated in consultation. The man had had haemorrhoids for years. About Fig. 62. a week before I saw him he had been drinking hard and had ended his spree with a heavy dose of cathartic pills. On wak- ing in the morning he found his piles much worse than before and entirely irreducible. On examination two hard, oedema- tous, intensely painful masses were found, forming a complete ridge around the anus, each about the size and shape of the thumb, and meeting in front and behind. They were covered externally by skin, and internally by the smooth, glistening- mucous membrane of the verge of the anus. The finger intro- duced between them passed readily into the healthy rectum, but there was no sphincteric contraction appreciable. On account of the extent of the disease the patient was treated for four days with absolute rest in bed. poultices, and anodyne applications, but without causing any decrease in the size of the tumors. He was then etherized and the masses re- HJEMORRHOIDS. 163 moved with the clamp and cautery. On account of their size, which was too great to permit of grasping the entire base in the clamp, each one was divided at the middle down to the mar- gin of the anus, and clamped off in two sections — the cautery thus being used four times. After this the anus itself was burned through posteriorly and on each side, to cause future con- traction of the orifice ; for, from the very dilated state of the anus and loss of power in the sphincter, there was reason to fear fu- ture prolapse after the haemorrhoids were cured. The patient made a good recovery, with a tight sphincter. I mention this case as an illustration of the proper method of treatment, though the condition was much more serious than will often be seen. Supposing now that the patient declines operation, the case must be treated as follows : Absolute rest in bed, laxatives daily to keep the bowels free, an ointment of equal parts of extract of opium and extract of belladonna, with sufficient vaseline to ren- der it soft, kept constantly and freely smeared over the parts, and hot poultices constantly applied. By this means the inflam- mation will gradually subside, and in an ordinary case the pa- tient will be around in a week or ten days. There is nothing else to be done. Attempts at reduction always do harm and can by no possibility do good, and the same applies to leeching, scarification, and incision. Injections of carbolic acid will cause suppuration, and, failing this, can only make the patient's con- dition more unendurable. Should suppuration occur the result will very likely be a subcutaneous fistula. Internal HcEinorrhoids. — External hsemorrhoids were de- scribed as varicosities of the external haemorrhoidal veins ; and internal hsemorrhoids may also be similarly defined as varicosi- ties of the middle and superior hsemorrhoidal veins, but they are more than this. In describing these tumors it is only necessary to make two classes, the capillary and the venous. The capillary hgemor- rhoid is in reality an erectile tumor, composed of the terminal branches of the arteries and veins and of the capillaries which join them. This form of tumor is never of large size, and never projects very far into the cavity of the rectum. To the naked eye and under the microscope they strongly resemble an arterial nsevus. They may be situated high up in the rectum or low down by the sphincter; their surface is granular, and the mem- brane covering them is always of extreme thinness. This ac- counts for the chief symptom which distinguishes them clini- IG-i DISEASES OF THE RECTUM AND ANUS. cally from the other varieties — the free haemorrhage which follows the slightest bruising of their surface, even in the act of defecation. Such a tumor never appears outside of the anus unless accompanied by some other rectal affection, but it may sometimes be seen by a careful pulling open of the sphincter with the fingers, and from, some part of its strawberry-like sur- face there is pretty sure to be a jet of blood, coming per saltum. The disturbance caused by the gentlest examination is sufficient to start this bleeding, and it almost always occurs at defecation. This is the form of haemorrhoid to which the name of "bleed- ing '' most properly applies. In my own experience it is not as frequently met with as the varieties to be described later ; and this probably for the reason that after existing for a longer or shorter period in this form it is changed into one of the others, and that patients do not seek relief till after such change has occurred. After a time the mucous membrane covering such a tumor becomes thickened, and as a result of repeated irritation there is an increase in the submucous tissue. The haemorrhage decreases in frequency and finally ceases as the capillaries be- come obliterated by the increase in the connective tissue, and the capillary tumor is succeeded by the venous one. The one symptom of a capillary heemorrhoid is the daily haemorrhage ; and as this haemorrhage occurs at the time of defecation, and there is no pain at any time, the patient may be entirely ignorant of the fact that blood is daily lost. This is particularly the case with the class of patients seen in public practice who give little attention to themselves. In the higher walks of life such a loss of blood seldom occurs without the knowledge of the patient ; but unfortunately it is often disre- garded, especially in women, who are in the habit of losing blood at every menstrual turn and who always shrink from an examination. It is not necessary to relate in detail the train of constitu- tional symptoms which may follow the daily loss of a conside- rable quantity of blood. The anaemic look, the disturbance of the heart's action, the troubles with the digestive apparatus and with the sexual organs, the cessation of menstruation, are all well known. But it is curious that, as in a recent case in my own practice, a very intelligent medical man, who understood perfectly his own condition, should allow himself to be brought to a state of profound anaemia by a little haemorrhoid of this variety rather than have anything done for himself. In this HEMORRHOIDS. lOo case a single application of nitric acid to the bleeding surface worked a permanent cure. The following case, seen by me with Dr. Watson, of Jersey City, will illustrate this form of disease and the appropriate treatment : The patient, a lady thirty-five years of age, had been mar- ried fifteen years, and ever since marriage had been troubled with occasional profuse rectal bleeding. As much as half a pint of arterial blood is said to have passed at a time. There had never been any protrusion, and the blood was passed, not with the stool, but some time after by itself. Frequent rectal examinations by the finger had failed to detect anything ab- normal, and arrangements had been made for complete dilata- tion and examination under ether. Before doing this the usual inspection of the parts was made by gently pulling down and opening out the folds of the anus, and just within it was de- tected the bright-red, slightly raised mass of blood vessels, which, to my mind, was sufficient explanation of the history. Without making'a complete examination of the whole rectum, it was decided first to cure this, and two thorough applications of strong nitric acid. Dr. Watson tells me, entirely stopped the ha?morrhage. This is the only form of hsemorrhoid in which applications of nitric acid will be likely to result in permanent cure, and in this it works so well that it is hardly worthwhile to try other things. If the application be made thoroughly to the whole surface, a single one will be all that is necessary, in most cases, to entirely cure the disease. The only other cases in which I use nitric acid are those of well-marked internal hsemorrhoids which bleed freely at stool when protruded, and in which for any reason — such, for exam- ple, as pregnancy — it is inadvisable to attempt a radical cure. By touching the surface of these tumors with strong acid the bleeding may cease entirely for a considerable time, and the tumors may even diminish in size. The Venous Hcemorrhoid. — In this form of tumor the capil- lary network has disappeared and in its place is found a mass of freely anastomosing veins bound together by connective tis- sue. The veins are tortuous, often varicose and dilated into sacs and pouches ; and there may be one or more arteries of large size, especially the one which enters at the base of the tumor, the pulsations of which may often be distinctly felt by the finger. Such a tumor is often of considerable size ; it is 166 DISEASES OF THE RECTUM AND ANUS. firm to the touch and smooth ; it is liable to inflammation, ero- sion, haemorrhage, and prolapse. Tlie haemorrhage which oc- curs is arterial in character and apt to be abundant. The classification of haemorrhoids into capillary, arterial, and venous, which is due to Allingham, has not stood the test of observation. Cripps, in his work on the rectum, says : "The fact of blood escaping in jets has led some high authorities to regard it as arising from some arterial twig. With due defe- rence to such eminent authorities, I am of the opinion that they are mistaken, and do not believe that the blood ever comes from the arteries, but that the jet is due to its being forced as a re- gurgitant stream through a minute orifice in a vein by the pow- erful pressure of the abdominal muscles." He reiterates this opinion, holding that the fact that the blood escapes only when the abdominal muscles act and the veins are subject to pressure shows that its source must be ve- nous. If it were arterial, the effect of straining and pressure would be to diminish rather than promote the spurting. Apart from this evidence, he has more than once detected the actual opening in the vein from which the stream escaped. In one case, that of a woman reduced almost to death's door by hae- morrhage recurring for many months when at stool, he ob- served on the summit of one of the piles a little adherent clot of blood. On removing this it was found to be blocking up a minute circular opening in the wall of a dilated vein, into the interior of which a fine probe could be easily passed. In another case in which the jetting was a prominent symp- tom, he discovered an exactly similar opening after wiping away a projecting clot. On telling the patient to strain down, a minute jet was immediately expelled a distance of several inches. He believes there is no evidence, either from life ot post-mor- tem examination, to show that a pile ever consists of varicose arteries, and in this I agree with him. Nevertheless Alling- liam's classification is not without value, inasmuch as it calls attention to the fact that in some varieties of internal haemor- rhoids there is a larger proportion of arteries than in others. Sympfoin.s. — The two main signs of internal haemorrhoids are protrusion and Ijleeding, but there are many symptoms less diagnostic than these, but of fully equal importance. For exam- ple, there is a peculiar train of nervous effects which is quite characteristic of the disease, and which may be well marked before either bleeding or protrusion has appeared. These are, a feeling of discomfort in the rectum and a sensation that it has HEMORRHOIDS. 1G7 not been thoroughly emptied after stool, which induces the pa- tient to sit and strain for a long time ; difficulty in micturition, diminished sexual power and desire, pain in the genitals, loins, and thighs, and formication in the lower extremities. A very marked case of this last symptom was sent to me by Dr. Spitzka. The patient was himself a very intelligent physician, who had consulted Dr. Spitzka for supposed incipient locomotor ataxia; but no disease of the spine being found, he was referred to me for rectal examination, under the suspicion that a disease of this part might account for the condition. Such was found to be the fact, there being well-marked hsemorrhoidal trouble which had never manifested itself in any direct way, except by a slight uneasiness after defecation. Pain in the rectum of a sharp, lancinating character may be present as an early symptom, but it is not generally complained of until the tumor begins to descend within the grasp of the sphincter and appears at the anus at each act of defecation. If the sphincter be firm and strong, it is then apt to be very severe and the tumor may become strangulated; but after the disease has existed for any great length of time, and especially in per- sons past middle life, there is apt to be a loss of power in the muscle which, though it facilitates prolapse, decreases the pain attendant upon it. The study of rectal reflexes is a very interesting one, and one into which I hope some time to have the opportunity of enter- ing more fully. In connection with hsemorrhoids I have seen some remarkable nervous phenomena. I had a patient not long- ago — a muscular young man — who was nearly overcome at each act of defecation by faintness. There was no pain, his piles were of moderate size and easily reducible, but every time they came down he very nearly lost consciousness. Another symptom of rectal disease which I have never been able to understand is what I have often termed rectophobia — the sense of impending evil which is so common in rectal trou- bles. There is hardly any variety of pain or of functional ner- vous disease that I have not cured by the simple removal of haemorrhoids, and this applies as often to men as to women. It will occasionally happen that internal hsemorrhoids, though fully developed and of many years' standing, have never been known by the patient to cause any loss of blood, though such a case is very rare. In ordinary cases the patient will reduce the tumors when they come down on defecation. They may, however, become 168 DISEASES OF THE RECTUM AND AXUS. strangulated and be entirely beyond the patient's power of manipulation. In such a case, after a period of rest, and after the relief which may follow a spontaneous escape of blood from the over-distended vessels, the haemorrhoids may return of them- selves or be put back by the patient. If the strangulation be more intense, gangrene may set in and a part of the mass may slough, or a part may suppurate and pus be discharged. Under these circumstances there will be great pain and more or less constitutional disturbance, with fever and loss of appetite. The gangrene is very evident to the eye from the greenish or blackish color and foetid odor of the part, and is rather a favorable termination to the trouble, as it generally results in a radical cure. Diagnosis. — It is not always an easy matter to discover an internal hseinorrhoid, even though it be far enough advanced to cause haemorrhage and more or less uneasiness. When it has become hard it may be detected by the accustomed finger in a simple digital examination, but when soft and not over-dis- tended it may escape detection. An examination should be made directly after the rectum has been emptied by an enema of warm water, when the water and the straining have brought it into prominence, and should be made with a speculum when there is any doubt. Under these circumstances it may gene- rally be brought plainly into view. An examination in a case of internal hsemorrhoids should never end at the finding of the tumor. An inch or so higher up there may be a stricture, malig- nant or simple, which has given no sign of its presence except the haemorrhoids, and this is not a good thing to overlook. It is not safe to say that a patient may not be suffering from internal haemorrhoids simply because he denies either protru- sion at stool or bleeding, for haemorrhoids may cause many other symptoms even when these two are absent. Perhaps one of the finest points in digital examination is to detect internal haemorrhoids by touch alone. I had been a rectal specialist many years before my finger became trained to this point. The existence of haemorrhoids in children has been denied by excellent observers of large experience. Gosselin does not ad- mit the existence of the internal variet}', and says plainly that he will believe in external ha?morrhoids in children when he has seen them, or when a good observer, after a thorough examina- tion, will say he has seen them. On the other hand, Tranka, writing in 17!i4, speaks of thirty-nine cases in cliildren under fif- teen, eighteen of them being under five, and five under one year HEMORRHOIDS. 109 of age. Unfortunately, at that time, bleeding from the rectum and haemorrhoids were nearly synonymous, and the differential diagnosis of these affections was hardly accurate enough to allow us to judge exactly of the value of this statement. It may be safely stated that internal and bleeding hsemorrhoids in young children are exceedingly rare. Of the external variety I have seen one perfectly clear case in a child of three years, the son of a physician. The tumor was of the external venous variety, contained a large, dilated venous pouch in which the black blood could be distinctly seen, and was about the size of an ordinary grape. It "was caused by the straining tg) urinate, due to a congenital phimosis, and disappeared spontaneously with the removal of the cause. Treatment. — Before recommending anything in the way of a surgical operation, the surgeon must consider whether the case before him is one in which such a procedure is justifiable; and this brings us to the consideration of what have been called symptomatic hsemorrhoids, as distinguished from those which are apparently idiopathic. Internal haemorrhoids may be symptomatic of disea se in a number of the viscera. They often indicate structural changes in the wall of the rectum at a higher point, such as malignant and non-malignant stricture ; and, under such circumstances, whatever is done in the way of relief must be done to the stric- ture and not to the haemorrhoids. Again, they are often secon- dary to disease of the bladder, to enlarged prostate, or to stric- ture of the urethra, and in these cases where it is possible to remove the cause it must always be done. If haemorrhoids are dependent upon a calculus or a stricture of the urethra, they will probably disappear when these affections are cured. A man with enlarged prostate i§ never a very desirable subject for a surgical operation, and if such a man's haemorrhoids can be rendered endurable by the palliative treatment already de- scribed, the better way will be not to use the knife. In women haemorrhoids often depend upon disease of the uterus, and in every female patient this dependence should be carefully inquired into, and, if found, removed before operation. It occasionally happens that a pregnant woman will suffer so severely from this complication as to demand surgical aid. Though it is better not to operate until some weeks after deliv- ery, except in a case where the haemorrhage or the pain ren- ders it unavoidable, still pregnancy is not an absolute barrier to surgical interference in this more than in many other affections. ITO DISEASES OF THE RECTUM AND ANUS. Haemorrhoids may also be symptomatic of disease of the liver, kidney, heart, or kings. There are few liver affections which need prevent operative interference in a bad case, but such interference should be preceded by general treatment pointing toward relief of the hepatic circulation. An excess of alcohol in the daily diet should be stopped, and a blue pill may be given with advantage every other day for a week before the operation. Affections of the lungs, except in a very advanced stage, need not prevent an operation. The condition which most positively stays the hand of the operator is that of al- buminuria, whether dependent upon heart or kidney. Before undertaking the treatment of a case of haemorrhoids, both patient and surgeon should come to a distinct understand- ing. The latter can assure the sufferer that he may be cured at once and forever if he desires, and this applies to all forms of the disease. The only cases in which this cannot be said are those in which the patient is in such bad general condition that no interference is justifiable. If he be suffering from advanced disease of heart or kidneys, for example, and at the same time be troubled with old haemorrhoids, it may be safer ^to do what can be done by palliative measures, and avoid anything like radical treatment. This is the only thing that should prevent the surgeon from attempting a positive cure. Ordinary disease of the lungs has never prevented me from operating and getting a good result. -^ Just at this point the surgeon will have many questions to answer, and one of the most common is whether nature did not intend that a great many people should have a painful affection of the rectum which should make a part of their lives miserable and cause them to lose two or three ounces of blood every time they go to the closet, and whether it is safe for the sufferer to have this beautiful condition interfered with. This question will come from very intelligent people, who will back it up with the authority of some physician that by suffering in this way they are escaping something worse. Should the same physician who advises that this daily bleeding be allowed to continue make a practice of opening a vein in his patient's arm once a day for years, and withdrawing the same amount of blood, what would be thought of his practice ? And yet one would be as good practice as the other. The next question will be whether the patient can be cured without an operation, and at exactly this point many a patient will disappear. The answer will depend, as will be shown HEMORRHOIDS. 171 presently, upon the form of trouble present. Many cases can be cured without an operation, and many more by procedures so trivial that they carry no terror in the thought ; but some can- not. In the latter class of cases the young practitioner must not, for his own sake, allow himself to be placed at a disadvan- tage which is pretty sure to end disastrously. Unfortunately for the public, they almost all consider them- selves pretty well educated on the subject of piles. Cures " without knife, ligature, or caustic" have caught their eyes in the daily press for years, and they come to their doctor, not to be guided by his judgment, but to have him relieve them, if he can do so, subject to the restrictions they may impose. The condi- tions are these: ''If you can cure me without an operation I am willing to be cured, otherwise I prefer to be let alone." There is no blame to the patient in this, for he has a perfect right to make his own bed and lie in it ; and it may be possible for the physician to do as he desires and cure him without ether, without confining him to his bed, and without any "operation," as he considers an operation. But the young surgeon must not be too anxious for the case. He may be forced to say, "What you desire is impossible," and let his patient go ; but he never must be led into a line of practice which is not safe, for when trouble comes no mercy will be shown him. The patient is practically doctoring himself, with a physician to assist him, and in his heart he knows it. The case goes badly, and the doc- tor has all the blame and deserves it. The rule in my own practice is, I believe, the only one to be followed. After my ex- amination I recommend the method of cure which seems to me the best, and from that I never allow myself to be shaken. If it seems to the physician that the clamp should be used, he must in honesty use it, and not allow himself to be placed by his patient in the false and untenable position of recommending one treat- ment as best and then employing another. To be sure, he will occasionally see his patient go elsewhere, but less often than he fears ; and, on the other hand, he will avoid bad surgery with its unpleasant consequences. He must make up his mind at first that a great many patients had rather suffer all their lives than be cured by any operation, even as safe and painless as this ; and he may strive to find some method of curing, or at least relieving this class, which is free from the terror of a cut- ting operation ; but he will probably discover in his search that haemorrhoids are bad things to experiment upon, and his first accident will greatly dampen his ardor, in the light of the fact 172 DISEASES OF THE RECTUM AND ANUS. that he already has at his hand a means of cure which surgi- cally leaves little to be desired. On this point let nie say that the profession in general, the great body of practitioners scat- tered over the country, have been unduly worried about a partic- ular method of curing haemorrhoids by injections. The secret remedy is known ; it has been faithfully tried in hospital and private practice by representative men both in Europe and Ame- rica ; it will be fully described in the course of this chapter, and its advantages and disadvantages compared Avith other recog- nized means of treatment. I also venture to predict that as a popular quack remedy it has seen its best days ; for the reac- tion in the public mind has already begun, and where a year or so ago every patient was determined to have nothing but car- bolic acid, they now not infrequently are just as anxious to have nothing to do with it. If the surgeon wishes to try this method of treatment, at the demand of the patient, he is justified in doing so ; but it is not equally adapted to all cases, and in some respects its action is very uncertain, as will be shown later. Some patients will deliberately choose a course of palliative treatment, even knowing that it is not curative, rather than be cured by surgical means. For such the practitioner must be prepared to furnish what relief he can, and this is often very great. In my own practice ointments and suppositories have very little place in treating internal haemorrhoids, and rectal sup- porters have none at all. The line of treatment has alread}^ been alluded to. Perfect daily regularity in the movement of the bowels, and the free use of cold-water applications, are wor- thy of the greatest reliance. The latter will be found a much more effective astringent than either tannin or iron. It is sometimes necessary to treat a patient with internal hae- morrhoids for the complication of strangulation when he is un- willing to submit to anything looking toward radical cure. His piles, owing to some accident, some nervous strain or irregu- larity in living, are down, have been down a day or two, and no manipulation on his part will put them back. Examination shows them to be exquisitely sensitive, engorged, and possibly even gangrenous, and the sphincter grasps them with a power which cannot be overcome. This extremity may be the doctor's opportunity, and many a patient is willing to be radically cured, after forty-eight hours of such suffering, wlio has always been too timid before. Under such circumstances nothing is to be HEMORRHOIDS. 173 feared from an operation, and nothing to be gained by delay. The patient should be etherized and the tumors removed with the clamp and cautery. The cure will be as rapid as under ordinary circumstances. Should, however, the patient still object to radical treatment, the following is the best course of procedure: Place him on his face, with a hard pillow under the pelvis, smear the whole mass and the right hand freely with olive oil, cover the tumors completely with the fingers, and make gentle and firm pressure on the whole mass at once till a part of it slips up the bowel. If a single tumor will give place the others will soon follow. This is not a matter of half an hour, but of one minute. If it does not succeed at the first attempt it probably will not at all ; and the next step is to give ether to the point of primary anses- thesia and forcibly reduce the mass. With ether internal hae- morrhoids can always be reduced when strangulated by a tight sphincter. Should the patient object to this, there is nothing to do but leave him in bed, with ice to the parts and the ointment of opium and belladonna freely applied. The tumors may slough at one or two points even without the ice, and the ice must not be pushed too far on this account; but sloughing under these circumstances is one of nature's means toward a partial cure. Generally after a couple of days' rest in bed the patient will be able to reduce the tumors for himself. Though it is difficult to conceive of a case of haemorrhoids that cannot and ought not to be cured, where the patient is in any condition to bear treatment, there are some which can only be cured after prolonged preparatory treatment, and these are generally in women. The doctor who does much rectal practice becomes of necessity very familiar with many of the diseases of women. He will not be long in practice before he encounters the following combination : A lady comes to him with haemor- rhoids, upon which he operates, with perhaps the usual good re- sult, though possibly only obtained after rather a slow and pain- ful recovery. In the course of a few months the patient returns with much the same symptoms, though the haemorrhoids have been cured. Another examination is made, and the patient is found to have an enlarged uterus with a lacerated cervix, a rup- tured or greatly relaxed perineum, and a proctocele, all of which should have been cured before the operation for haemorrhoids was attempted. Many patients dread the taking of ether more than the ope- ration itself, and will refuse radical treatment on this account. 174: DISEASES OF THE RECTUM AND ANUS. When cocaine was first introduced I had great hope that this objection might in the future be overcome, but the drug has not fully realized the expectations held concerning it. Nevertheless it answers in a great many cases and should always be at hand. By it small tumors may be removed with absolute painlessness, and I have operated both with ligature and clamp under its in- fluence, with great satisfaction in some cases of large tumors, but have been disappointed in others, before I found out by fre- quent trials the limits of its applicability. Where the tumor or tumors to be removed are small, or where a single large one can be separated from others and cocaine be injected with the hypodermic syringe into the exact part where the ligature or clamp is to be applied, the drug will give satis- factory results. In this way several large tumors may be ope- rated upon at one sitting, or at intervals of ten days or more, and the patient cured. But where the whole margin of the anus is involved and turns out with the hasmorrhoids, and where it is necessary to bring the entire circumference of the rectum for a considerable distance upward under its influence, the drug is apt to be unsatisfactory ; for the reason that to bring all parts of the wall under its influence at one time, as is necessary in stretching the sphincter, dangerous symptoms may be produced before a sufficient quantity of cocaine has been injected to per- mit of painless operation. In the New York Medical Journal, August 7th, 1886, I re- ported a case of this sort. It was necessary to dilate the sphinc- ters, and with a large speculum carefully examine an exceed- ingly sensitive ulcer for a blind fistulous track emptying into it. One hundred and twenty minims of four-per-cent solution of cocaine were injected into eight different points around the cir- cumference of the anus without giving sufficient anaesthesia to operate with any comfort ; and on account of symptoms of gen- eral cocaine poisoning which developed, the operation was fin- ished with ether. The only explanation I have of the difficulty in getting anaes- thesia of the whole of the lower end of the bowel, without some- times using doses of the drug which are dangerous, is the actual very large extent of surface to be affected and tlie great number of sensitive nerves to be brought into local contact with the solu- tion. On the whole, my experience has been that in minor ope- rations the drug, when used hypodermically, is perfectly satis- factory ; but in larger ones it is not to be relied upon absolutely, and may have to be supplemented with ether. HEMORRHOIDS. 175 Let us now consider in detail the forms of treatment which have not ah-eady been described ; and I shall hope to do so in a manner which will enable the practitioner to answer his patient's oft-repeated question, " How do you treat piles? " with the simple statement, " In a great many ways, depending on the case." Of all the time-honored operative procedures known to the profession for the cure of hasmorrhoids, it is but a waste of time to discuss at the present day more than four — the ligature, the method of injections, the clamp, and the method of excision. The first of these owes its present prominence to Allingham, and is often described as his opefation. In the way now gene- rally performed the name is correct, though the treatment by ligature is very old. The principle of his method is to dissect the hsemorrhoidal tumor away from its attachments for a certain extent, and then to surround the remainder of the base with a silk ligature. His belief is that the chief arterial supply to the tumor comes from above, and that all of the lower part may be dissected away from the muscular coat without causing any serious bleeding ; while the ligature thrown around what remains is an effectual barrier against haemorrhage. The advantage of this method is that the ligature is not placed around the skin at the margin of the anus, for this is divided with the scissors before it is applied, and the ligature lies in the groove thus made, and by this means much pain is avoided and much time is saved in the treatment. Regarding the details of the operation but little need be said, so simple is it in its performance. The tumor to be tied is seized with strong forceps and drawn down, the patient having b«en etherized and the sphincter previously dilated. With strong scissors the lower attachments of the tumor all around, and especially the point of junction of the mucous mem- brane with the skin, are divided ; the ligature, which encircles what remains, is tied as tightly as possible, both ends are cut off short, and the greater part of the tumor below the ligature is also cut off, only sufficient being left to form a good and safe stump for the ligature to hold. The patient is prepared for the operation by the previous administration of a purgative, and the bowels are confined for a week or so after its performance, and then relieved by a cathartic. This, in brief, is the operation practised by Allingham, and it is an exceedingly good one. I began my own practice by always performing it, and did I not believe that something else was better, should perform it still. It is as safe as any opera- 176 DISEASES OF THE RECTUM AND ANUS. tion can well be, and when properly done it cannot fail to cure : and perfect safety and surety are two great points to be gained in any operation. But a considerable experience with this operation led me after a time to begin the search for something just as safe and just as sure, without some of the objections which any large number of cases will be sure to show pertain to this method. The first objection which developed itself in my own practice was the great pain which the patient often suffered for the first week or ten days. Allingham distinctly claims that after the patient has recovered from the ether there is often no pain. I can only say that though this is sometimes the case, it is by no means the rule in my own practice or that of other American surgeons. My explanation of the pain I have often seen is that a nerve is compressed by the ligature as well as an artery ; but no matter what the explanation, the fact remains that, having folloAved Allingham's method in every particular, I have more than once been forced to keep the patient constantly under the influence of morphine till the ligature came away, aiid I know that many others have had a similar experience. A second objection was the frequent necessity for the pas- sage of the catheter for several days after the operation. A third was the amount of blood lost during the operation, and the frequent necessity for leaving a considerable wad of lint in the rectum on account of the oozing, which caused great subsequent suffering and was only removable after three or four days, and then with considerable pain. A fourth was the length of time required by my patients be- fore they were able to resume active business. It will be seen that none of these objections were of vital im- portance. The patients still recovered and were radically cured, and in the end were satisfied in spite of these difficulties ; but still tliere seemed to me an opportunity for a more satisfactory operation. For these reasons I was finally, by the advice of Henry Smith, led to adopt another operative procedure, which on the whole has served me better. I still occasionally use the liga- ture, but I never apply it where any of the sensitive tissue at the margin of the anus is included in the loop. If a tumor be well circumscribed and pendulous, and a ligature can be thrown around its base and still l)e well above the external sphincter, it may be applied without causing any great amount of reflex irri- tation or pain. In this way I have not infrequently seized a HEMORRHOIDS. 177 j)rolapsing tumor of considerable size, injected it with cocaine, and after a few minutes tied a string around its base and cut it off without having- much subsequent pain. But when it comes to a case of large, prolapsing,, internal haemorrhoids involving the margin of the anus and attended by a good deal of the ever- sion of the skin which is shown in Fig. S3, I prefer another' operation, because I believe, though no safer and no more cer- tain to cure, it will cause less subsequent pain, and less confine- ment to the house and bed, than the ligature. Treatment by Injections. — As far as my own influence has Fig. 83.— Internal HsemorrhoiJs showing Line of Junction of the Skin and Mucous Membrane. (Curling.) gone I have done what I could to take this method of treatment from the hands of the quacks and place it uj)on a recognized basis. In the July number of the American Journal of the Medical Sciences, 1885, I reported about two hundred cases treated by this plan with very satisfactory results, and in the New York Medical Journal. Xovember IJrth, 1885, in answer to numerous questions. I gave full and definite directions as to its methods of application. The fact that since then I have had a succession of bad and troublesome cases treated by this means, and that these cases 13 178 DISEASES OF THE RECTUM AND ANUS. have led nie in a measure to be less hopeful of the results of the method, in no way invalidates the reports of my own carefully observed cases up to that time. In writing now I shall use less glowing terms than I did then, but I have by no means aban- doned the practice. It is still, to my mind, a very good way of treating 'a great many cases, having in certain points excep- tional advantages over all others ; and in the fact that it does not apply equally well to all, and that it will occasionally be fol- lowed by disagreeable consequences, it in no way differs from other operations. I say this so plainly in the beginning because I have so frequently been accused of having first advocated the practice and subsequently abandoned it, while all that I have really done has been to state fully and freely the objections to it, as at other times I have with equal plainness stated the ad- vantages of it. It is now at a point where every practitioner may try it for himself and come to his own conclusions regard- ing its value. All that can be said of my own practice is that while for a year or more I used it almost exclusively and was much pleased with its results, a succession of bad cases. has led me to modify my views of its value and universal applicability, and that, though I now use it occasionally, it is only in se- lected cases. For years back a great number of irregular and often very ig- norant practitioners have been travelling around the country in- jecting and curing haemorrhoids with solutions of carbolic acid. The instrument was an ordinary hypodermic syringe ; the solu- tion was for a long time a secret, but was finally discovered to be pure carbolic acid mixed with oil, or glycerine and water, in certain proportions. About the success of- their treatment there could be no question in a great many well-authenticated cases upon ordinarily intelligent patients, who said that they simply felt the pricks of a needle and were cured. By this simple pro- cess large haemorrhoids which had been bleeding and protruding for years disappeared after a single visit, and this often without any subsequent pain or symptoms of any sort. So often was this delightful story told me by patients upon whom I had recom- mended other and to them more formidable procedures, that I was at last driven in pure self-defence to try and discover what there was in this practice, and I therefore armed myself with several preparations of carbolic acid — a fifteen per cent, thirty- three' per cent, fifty per cent, and the pure acid — and proceeded to inject them into a large proportion of my cases. The results in many cases were surprisingly good. Some HEMORRHOIDS. 170 were cured without being confined to the house at all, and with- out any pain which interfered with their daily occupations. Others did not do quite as well. They complained of severe pain coming on an hour or so after the injection and lasting sev- eral hours, but it was rare to have them give up their work and- go to bed, or to use the opium suppositories with which they were provided in case of necessity. Once in a while the injec- tion would cause a slough and this would put an end to the treat- ment for a couple of weeks till it had healed ; but the pain of this condition was generally bearable, and the patients expressed themselves as perfectly satisfied and greatly preferring even this amount of suffering to any "operation." The cures also seemed Fig. 84.— Hypodermic Syringe for Injecting Hasmorrhoids. to be permanent ; none of my patients returned with a fresh pro- trusion of the tumors which had once been operated upon, even after an interval of many months. At this time it was rare for me to have the tumors slough after an injection. Generally there was a hardening and shrinking of the hsemorrhoid suffi- cient to prevent either haemorrhage or protrusion, and this was produced by solutions of thirty-three per cent and fifteen per cent. At this time I published my cases and also the rules which were to be followed in this method of treatment. The solutions of carbolic acid were made in pure water with sufficient glycerine added to make a perfectly clear and colorless mixture, and of these I kept constantly ready one of fifteen per <3ent, one of thirty-three per cent, and another of fifty per cent. 180 DISEASES OF THE RECTUM AND ANUS. The g-lycerine and carbolic acid should both be perfectly pure, and as soon as the solution begins to turn yellowish it must be discarded. The needles should be fine and sharp, and the syringe in per- fect working order — one with side handles (Fig. 84) is preferable — and after each time the syringe is used it should be thoroughly washed out and left standing in fresh water. Before making an application give an enema of hot water, and let the patient strain the tumors as much into view as pos- sible. Then select the largest and deposit five drops of the solu- tion as near the centre of the tumor as possible, taking care not to go so deej) as to perforate the wall of the rectum and in- ject the surrounding cellular tissue. The needle should be en- tered at the most prominent point of the tumor. If the hsemor- rhoid does not protrude from the anus, a tenaculum may be used to draw it into view. After the injection has been made the parts should be replaced and the patient kept under obser- vation for a few minutes to see that there is no unusual pain. The injection will cause some immediate smarting if it is made near the verge of the anus ; if made above the external sphinc- ter, the patient may not feel the puncture or the injection for several minutes, when a sense of pressure and smarting will be appreciated. In some cases no pain will be felt for half an hour, but then there will be considerable soreness, subsiding after a few hours. If it increases instead of disappearing, and on the following day there is considerable suffering, which may not perhaps be sufficient to keep the patient on his back, but is still enough to make him decidedly uncomfortable, it is a pretty good indication that a slough is about to form. For the reason that it is impossible to tell absolutely what the effect of an injection is to be until at least twenty -four, hours have passed, it is better to make but one at a visit and to wait till the full effect of each one is seen before making another. If on the second day there is no pain or soreness, another tumor may be attacked : and this will often be the case. By following these rules all went well for a time, but soon I began to be troubled with a constant succession of sloughs with their attendant pain, and the worst of the trouble was that I never knew beforehand when a slough was likely to be caused. My old solutions were all discarded and new ones made to re- place them ; the syringes were all sent away and renewed ; and yet the sloughs continued, and I began to expect to encounter this objection whenever an injection was made, for the strength HAEMORRHOIDS. ISl of the solution or the character of the hsemorrhoid seemed to make no difference. A solution of fifteen per cent would cause sloughing where one of fifty per cent, or even of the pure acid, would produce only a circumscribed induration, and vice versa ; so that after a time I was forced to confess that I had no means of determining beforehand whether the patient was to undergo the pain of an inflamed and sloughing hsemorrhoid, though the injection made should be of ten per cent or of pure acid. The next complication was the occasional occurrence of small marginal abscesses after injections, and as these always caused a great deal of pain this was a serious objection. They usually appeared three or four days after the injection, and were situated just at the verge of the anus, causing a tumor about the size of the end of the thumb, covered partly by skin and partly by mucous membrane. They showed a decided tendency to break on both the mucous and cutaneous surfaces, and leave a short, subcutaneous track connecting the two openings. These marginal abscesses were never at the point of the in- jection, though always on the same side of the gut ; sometimes, in fact, they were fully two inches below the injection. Still these complications were not of sufficient gravity to cause an abandonment of this plan of treatment. The small abscesses caused a good deal of pain, but were not serious in their ultimate consequences ; and the sloughs healed kindly with the aid of local applications, though they greatly prolonged the time of treatment, as I always thought it best to discontinue the injections, after once a slough had formed, until it was en- tirely healed. There are, however, still other objections to this method of treatment. In my own practice I have had one case of diffuse inflammation and suppuration, lymphangitis, ischio-rectal ab- scess, and deep fistula following a single injection of strong- acid into a small tumor ; and I have heard of other cases in the practice of other surgeons. I believe that this serious accident was due to landing the strong acid entirely below the tumor and imder the muscular coat, but I cannot be sure. Again, within the past year I have several times been called upon to treat a rare form of fistula arising directly from injec- tions. These fistulye were of the blind internal variety, having an opening near the anus within the spliincters, and a track running upward from this under the mucous membrane for a considerable distance, and ending in a cul-de-sac. One of these cases was in my own practice, and three different tracks of this 182 DISEASES OF THE RECTUM AND ANUS. kind existed, each of which I have no doubt was caused by an injection of carbolic acid made by myself. As I have no objec- tion to reporting my own bad cases, that others may derive the same benefit from them that I do, I will give this in full. The patient was a professional man of middle age, who had long been a sufferer from htemorrhoids of large size, and was in a very weak condition, having lost much blood, become dyspep- tic and nervous, and having slight pulmonary trouble. The tumors were quite large, the sphincter much relaxed, and the margin of the anus very much like what is shown in Fig. 83. Injections were made several times, the solutions used being the weaker ones and never exceeding thirty-three per cent. On the day following the first one the following entry was made in the casebook: "Considerable pain following [first injection. Pa- tient has been in bed most of the time." Two days later the fol- lowing entry was made : " The single injection of five drops of a solution of carbolic acid (one to twelve) has caused great pain up to the present time. The patient has been able to be about more or less, but has suffered constantly and taken considerable quantities of opium. Examination shows the mass of tumors on one side black, inflamed, and angry-looking ; and though the injection was placed in a small nodule springing from the cen- tre and most prominent portion of this mass, the whole group has become involved in the inflammation it has caused." Three months later the following note appears : " The patient has had considerable sloughing of the tumors, following the injections of a thirty-three-per-cent solution, and has had one marginal abscess, leaving a subcutaneous fistula which has been cut. He is now in great measure relieved." In exactly four months from the beginning of the treatment the patient was dis- charged cured — that is, he considered himself cured, there being no more protrusion, except as the margin of the anus tended to roll outward, and no bleeding. Nine months after the first injection he visited me and still reported himself as having no symptoms. Eighteen months from the time treat- ment began the patient again reported with several haemor- rhoids, which were attached high up the bowel and had only recently begun to appear at the anus, and a few days later the following note was made: "Two injections (thirty -three per cent) without trouble. Yesterday, third injection of thirty-three per cent into a distinct tumor. To-day. slougli size of a silver quarter, irregular in shape, and in addition a marginal swell- ing size of a walnut. " The slough separated, cicatrization pro- HAEMORRHOIDS. 183 gressed slowly, and at the end of a month the patient went away, having no more hsemorrhoids, but in their place an un- healed ulcer, which seemed to be doing well and bid fair to be entirely healed in a few days. One year later he reappeared and reported that this ulcer had never entirely healed, but had gone on discharging and causing pain ever since. After several examinations I discovered three of the blind internal fistulse already described, and in addition two more large internal haemorrhoids. The patient having now been under treatment two and a half years, he was etherized and operated upon. The fistulge were laid open and the haemor- rhoids removed with the clamp, and the patient finally dis- charged cured. This is a very long way around to reach a very simple result. I have noticed that each of these flstulae were of the sub- mucous variety, running in the connective tissue between the milcous and muscular layers, as it might be inferred that they would be ; for the acid is deposited by the needle between these two layers, and the amount of sloughing it causes is not limited to the point at which it is introduced. It may perhaps be instructive to record one or two more cases. In June, 1885, I was called upon to treat an old gentleman, the mayor of a small town in Ohio, living in a high, cool, coun- try region, but much depressed with business losses and worry. He came to New York in the middle of the hot season and sub- mitted to treatment. The haemorrhoids were the worst which, up to that time, I had ever treated by this method. The sphinc- ter was much relaxed ; the tumors had been down for twenty- five years without being replaced, and were very large and vas- cular. There were three distinct masses, each about the size of a hen's egg. The case was not an attractive one, considering- the age and condition of the patient and the hot weather, but I undertook it. Into the largest of the three tumors I injected five drops of a fit" ty-per-cent solution. It was followed by a good deal of pain and loss of sleep for two nights, with some constitu- tional disturbance. On the third day, the pain of the first injec- tion having somewhat subsided, I injected five drops of pure acid into the second tumor, and had much less trouble than with the fifty-per-cent solution in the former case. After three days more I again injected the same amount of pure acid into the third tumor. Both of these last applications caused a distinct slough, with resulting ulcerated surface and free discharge of bloody 184 DISEASES OF THE RECTUM AXD ANUS. matter. After a few days more I returned to the first tumor, ■which liad not slouglied but simply become indurated, and in- jected five drops of pure acid into tliat. Tlie applications were all made within the space of two weeks. During this period the patient allowed his bowels to become constipated, and I had to clean them out with repeated copious enemata. There was at one time some vesical irritation and decrease in the amount of urine, whether from direct absorption of carbolic acid or from reflex irritation I do not know, and at the end of the treatment the patient was considerably reduced in strength — so much so that I put him upon the most nourishing regimen with bark and whiskey. Just as he seemed on the point of rallying I discovered a small abscess in the perineum, which was opened, and healed kindly, having no connection with the rectum. After recover- ing from this and gaining a considerable degree of health he went home to Ohio, and was immediately brought to bed with a second, larger abscess on the buttock. From this he also made a good recovery, and for one j^ear he had no rectal symptoms whatever, but at the end of that time, he informed me, bleeding had returned, and, though I have not seen him, I have little doubt that he is suffering again from the same tumors. ' This patient had his own way. He was not '' operated upon," but he would have had less suffering and less confinement if he had been. Moreover, he would have been radically cured. I can safely say that no operation I have ever performed with the clamp and cautery has caused the patient as much suffering or me as much worry as this one by injections. Let us now take another. A man of about sixty has had hae- morrhoids for twenty years. He is of sedentary habits and nervous, but with no other disease than the tumors. An exami- nation shows a very advanced case of long-standing trouble. The tumors can be divided into four chief ones — one posterior, one anterior, and one on each side ; but two of these are as large as hen's eggs, and the others only a trifle smaller. They spring from above the sphincter and are entirely covered by mu- cous membrane ; the sphincter is so relaxed that they protrude with the slightest exertion, and the patient has worn a rectal supporter for years. It is a beautiful case for the clamp, and fit for that only ; but at the outset I am met fairly by the not infrequent obstacle — *' no operation." Argument is useless ; he has heard of carbolic ' Previously rei)orte(l in part, N. Y. Medical Journal, Noveniher 14tli, 1885. HEMORRHOIDS " 185 acid ; in fact, his physician has sent him to me for that treat- ment, and it is that or nothing. Unwillingly I consent. An injection of thirty-three per cent is made posteriorly, and, with the usual caution and instruction, the patient goes home. Two days later he returns. He has had pain — yes, considerable; but he does not mind the pain as long as he can avoid " an ope- ration." Another injection of the same strength on the left side. It is four days before he again appears, and they have been passed mostly in bed, and he has used several suppositories ; but he is now better, and " if it is no worse than this he can stand it." The tumor injected last time is much smaller, but the posterior one, which was first attacked, is not much benefited, and five drops of pure acid are placed in its centre. Three days later he reports that he is beginning to be better, that there is less protrusion at stool, and he has left off his sup- porter. The last injection has not caused a slough, but a hard, inflammatory induration in the centre of the tumor. Another five drops of pure acid are injected into the same mass at a little distance from the hard spot, and he then tells me that ever since his last visit he has had considerable difficulty in passing water, which is high-colored and diminished in amount. Four days later, says he had no very severe pain after the last application, and straining at stool fails to bring down either of the tumors which have been operated upon. Another injec- tion of pure acid into the anterior tumor, the largest of them all. Three days later he reminds me that he is in a great hurry to go away on business, and is anxious to have treatment crowded more rapidly. He had no pain at all after last injection, and fears I did not get it in. The injection has again caused a hard lump of inflammatory induration, but no slough, and a decrease of about one-third in the size of the mass. There is still more work to be done on the first one, and another five drops of pure acid are injected into it, causing no pain at the time or after, as he tells me two days later. Thus far all had gone well, and three of the tumors had been treated without accident. An injection of pure acid was made into the last one, that on the right side. Three days later I am sent for to come to him. Before this he has come to me, but he has been in bed ever since the last injection. The urine has been very scanty and passed with difficulty; there is an enlarged and painful gland in the right groin, and a painful swelling at the verge of the anus on the right side, circumscribed, the size 180 DISEASES OF THE RECTUM AND ANUS. of an almond. Eleven days later, the patient being still confined in bed, the abscess at the margin of the anus was opened and a drachm or so of pus evacuated. A couple of days later it was found to have also opened spontaneously on the mucous side of the swelling, just within the sphincter. Ten days later this was healed. The patient had then been under treatment just forty days. He was much better. The tumors were all consid- erably reduced in size; they still protruded at stool, but went back spontaneously; and he promised to report again in a few days. He never did. In this case also the patient would have been much better off, both during the treatment and in the end, had he been ope- rated upon in my way instead of his own. In fact, it is a few such cases as this that have led me to lay down the invariable rule of practice to which I have referred — to select the mode of treatment which seems to me most appropriate, and never allow myself to be led into another which I do not think as good, sim- ply because the patient wishes it. These cases are the bad ones, and I would not convey the idea that all are like them. They illustrate exceedingly well all of the objections to this plan of treatment which I have ever encountered, except the single one of deep inflammation and suppuration. They may be enumerated in the following order : 1. Pain. 2. Ulceration. 3. Marginal abscess. 4. Fistula. 5. The impossibility of giving any definite prognosis as to the length of time necessary to effect a cure, or the amount of suffering the treatment will entail. 6. The fact that the treatment does not result in a radical cure, but that the tumors may reappear. There is still one other complication which may arise, and this is decided vesical symptoms, whether Tfrom carbolic-acid poisoning or merely from reflex irritation I have never been able to decide. I have seen the urine decidedly diminished, and great pain in passing it, after injections of the stronger prepara- tions, but I have never seen the typical train of symptoms fol- lowing carbolic-acid poisoning. It will be seen that none of these objections are vital. Any of the well-recognized methods of operation are attended by some pain, and occasionally by untoward accidents. I do not con- sider the operation by injection as dangerous to life, and I have HEMORRHOIDS. 187 never yet seen a fatal case, though several have been reported by Andrews ; and in all of my experience with the method I have never had but one serious complication — a single case of deep suppuration ; and even this I think can be avoided by the use of weaker solutions placed more superficially. There is still one point about which there should be no misun- derstanding. From all the information attainable, I believe that my experience with this method is about that of the irregular practitioners who thrive by it, and that the proportion of cures, without any pain or bad symptoms, obtained by them is practi- cally the same as my own. I have certainly tried all of the solutions ordinarily used by them, and some besides. The tinc- ture of iron and the fluid extract of ergot are two from which I hoped for better results, but neither seemed to possess any ad- vantages. From cases which have from time to time come to my knowledge, I know that abscesses, ulceration, and great pain are by no means unusual sequelae in the practice of these gentle- men. It is not long since one of this fraternity was forced by his patient to return the fee which had been paid in advance, after the patient had been confined to his house for several weeks with a deep abscess ; and only a few days ago I operated with the clamp upon a gentleman who had previously had a single injection made by one of these men, had been confined to his bed with it for a month, and had then abandoned the treat- ment. He had been particularly unfortunate, as he had subse- quently had a ligature applied by another practitioner, which, as he described it, " slipped on the fourth day," and he had then abandoned that treatment also. I believe I have now fairly stated the advantages and disad- vantages of this plan of operating upon haemorrhoids, and have put, as far as my own experience enables me, each reader in position to choose for himself whether he will use it or not, except in one particular. All of the patients I had supposed cured by this method, and upon whose cases I based my former favorable report, are now returning to be again cured by some more last- ing method. The relief afforded by this means seems to last about four years. The question, in fact, narrows itself down to this : On the one hand we have a method of treatment which is safe, certain, and practically painless, but which involves the administration of ether, the performance of what the patient dreads, a surgical operation, and a certain confinement to the house for a few days. On the other hand we have a method which avoids the 188 DISEASES OF THE RECTUM AND ANUS. ether, the surgical operation, and perhaps the confinement to the house, but which, in fact, involves fully as much of an operation as the other, only more quickly performed, and which is neither radical nor certain in its results. It is, in fact, this uncertainty as to the course of a case after an injection, and the fact that the operation does not result in a radical cure, even though it may be followed by serious complications, which keeps me from em- ploying this method oftener, rather than the complications them- selves or the possible dangers, I have never abandoned the idea that the patient should submit to the judgment of his physician as to his treatment, and I am not convinced that the surgeon should yield his preference for a method of treatment which long experience has proved to be as safe and certain as any ope- ration in surgery, to the foolish prejudices of a timid patient. As regards the comparative suffering caused by the two ope- rations, the clamp and the injections, it may be taken for a fact that any considerable number of cases will show greater pain spread over a longer time with the latter than with the former ; and all the patient actually gains in the most favorable case is the avoidance of a safe operation which he fears, while he sub- mits to an uncertain one which he does not fear because of his ignorance, together with a few days of liberty during which he would be better off in his room. Should the surgeon decide to employ this method, the follow- ing points ma}' not be useless : Use the weaker solutions in preference to the stronger. Never use it in any of the forms of external tumors already described. In cases of large, prolapsing, and long-standing disease, ex- pect pain and perhaps marginal abscesses. Be very cautious in prognosis as to the time the treatment will require and the amount of pain it will cause. In fact, it will generally be safer to acknowledge the uncertainty as to these two important points of the operation. Expect a return after about four years. The form of disease best adapted for this treatment is the tumor of moderate size, pendulous, and springing from the wall of the bowel entirely above the sphincter. Such may be re- placed within the bowel after the injection, and are very likely never again to be heard from ; and should sloughing occur in them, it will be attended by the minimum amount of suffering. The injection of haemorrhoids with carbolic acid, though ap- parently a simple and trivial affair, is to be regarded in the light HEMORRHOIDS. ISO of a surgical operation, and should not be undertaken by the practitioner until he has surrounded himself and the patients with all the safeguards at his command. The Clamp and Cautery. — After what has been said, the reader may be tempted to ask whether we possess any means of curing hsemorrhoids which is safe, certain, and free from com- plications, and I shall now try to answer that question in the affirmative. The operation with the clamp is generally known as that of Mr. Henry Smith, of London, and to him it owes its general in- FiG. 85.— Pile Forceps. troduction and acceptance by the profession, as does the liga- ture to Mr. AUingham ; though he claims no originality in the method itself, but only in some of its details. The essential idea of this operation is to seize the part to be removed, apply the clamp to its base, cut it off with scissors, and cauterize the stump. The clamp acts merely as a tempo- rary ligature to prevent bleeding during the operation ; and the Fig. 86- Author's Clamp. cautery is to prevent bleeding after the clamp has been re- moved. The instruments which are indispensable are therefore four in number — a hook forceps to seize the pile, shown in Fig. 85, the clamp shown in Fig. 86, scissors, and the cautery. The clamp is a modification of Mr. Smith's which I have had made for my own convenience, and the difference can be seen at a glance. Mr. Smith's instrument (Fig. 87) is armed with ivory shields to prcA^ent the possible effects of radiated heat, it has scissors handles, and the edges of the blades are smooth. In my own there are no shields, the handles are much larger, and the 100 DISEASES OF THE RECTUM AND ANUS. blades are now smooth and not serrated. I was led to abandon the ivory shields because I found them practically unnecessary and because they made the instrument more cumbersome. The handles were modified to give increased power and to avoid the general use of the screw for closing the blades. The edges were at first serrated to add to the crushing force ; but experience has convinced me that even with this amount of power the clamp is incapable of crushing the tissues to any extent, and I have dis- carded the serration for antiseptic reasons. I have placed it on a tumor, screwed it up to its greatest possible power, and left it in this condition for fifteen minutes. While it was in position the hsemorrhoid became cold and livid, but when the pressure was removed the vessels immediately filled up and the circula- tion was restored. It is for this reason that I say the clamp acts merely as a provisional ligature during the operation. In fact, Fig. 87.— Smith's Clamp. no force capable of crushing the tissues to the point of causing the occlusion of the vessels and the death of the parts can be ex- ercised without much greater mechanical power than this clamp possesses. Allingham's crusher will do it, but this is of the nature of a vise. There can be no bleeding while the clamp is in position, if the handles are firmly closed with one hand ; but un- less the cut surface has been thoroughly cauterized, there will be immediate bleeding on its removal. The advantage of the form of handle shown in my instrument over that of Mr. Smith is that an adequate pressure can be kept up for any length of time without the intervention of the screw, and by this fact the length of time consumed in operating is mucli diminished. The cautery is the most important of all the instruments, being the most delicate. The latest modifications of Paquelin's instrument leave little to be desired. If the operator prefer, he may use the galvano-cautery, and with a storage battery this is a very convenient form of instrument ; but I have not yet in HiEMORRHOIDS. 191 my own practice abandoned my old favorite for the newer in- vention. The Paquelin cautery is shown in Fig. 88, and may be obtained from Tiemann & Co., of New York, at a cost of about thirty dollars. Its beauty lies in its reliability and portability, and for these reasons I always carry it with me for operating at long dis- tances from home. Filled before starting, it can always be used on the following day, or after two days ; and should the opera- tion be very extensive, as in cases of cancer, it is only necessary to be provided with an additional ounce or two of benzine. The instrument merely requires to be properly understood and man- Paquelin's Thermo-Cauteiy. aged to secure perfeqt reliability, though I always carry an ex- tra platinum blade, to be secure against the temporary disabling of one, which generally is due to the lack of experience of an assistant. The scissors need only to be strong and moderately long, though a slight curve in the blades will sometimes be found an advantage. Various forms of forceps for bringing down hsemorrhoidal or other rectal tumors are shown in Figs. 89 and 90. Very little preparation for this operation will be found neces- sary in a healthy patient. When one in good health tells me his bowels are acting regularly, I have about abandoned the time- honored custom of deranging their action with a purgative just 192 DISEASES OF THE RECTUM AND AXUS. previous to this operation; and if they have moved on the morn- ing of the operation, all that is necessary is a simple enema of soapsuds an hour before the operation begins. If given an hour before, it will generally all be passed before the arrival of the surgeon. If given after the arrival of the operator, he stands a good chance of receiving a large portion of it in his lap and on his towels the moment he dilates the sphincter. Fig. 89. — Forceps for Ijriuging down Ha'inorrhoids. The operation is performed in the following manner : As a rule the patient is etherized, though, unless there is a good deal of tissue to be removed at the verge of the anus, the operation may be done with cocaine. Ether should be advised in almost every case, and cocaine only used as a substitute; for Fig. 90.— Lner's Hfemorrhoidal Forceps. although a tumor which is visible may be removed with the latter, it is difficult to thoroughly stretch the sphincter under its influence, and by omitting this two great advantages of ether are lost — the chance to thoroughly search the rectum, and the avoidance of the pain following the operation, which is secured in part by a complete paralysis of the sphincters. Many hae- morrhoids which are not visible at an ordinary examination will HEMORRHOIDS. 103 become visible after a patient has been etherized and his sphinc- ter dilated; and it is an awkward thing to assure a patient that he is radically cured because three or four perfectly visible tumors have been removed, and have him return in a few weeks with one or two more, which were overlooked at the operation simply because they did not crowd themselves into view. The tumors are next seized and removed one by one. Xo speculum is necessary for this, but if one be used a medium- sized blade of Sims's vaginal speculum, or the retractor shown in Fig. 22, will be found most convenient. The tumor is seized with the forceps and held by the left hand till the clamp is applied with the right. The forceps are next detached, the tumor cut off with the scissors (but not so short but that a good firm stump re- mains), and the cautery is then taken from the assistant, whose sole duty should be to have it always ready, and applied thor- oughly to the stump of the hsemorrhoid. No haste should be used in this step of the operation. The pedicle should be thor- oughly charred with the platinum at a dull red heat. When this has been done, the clamp may be loosened without being re- moved, to see if any vessel in its grasp is still inclined to bleed ; and if a bleeding point appear, it is again tightened and the cau- tery is again applied. Thirty seconds is an abundance of time for each tumor, and I have often done four to the minute — the greater part of this being devoted to the thorough application of the cautery. The secret of success in this operation is found just here. If all the cut surface is thoroughly cauterized while the clamp is on, there can be no hsemorrhage ; but if more sur- face is cut than is cauterized, haemorrhage may reasonably be expected and the operator is to blame. Thoroughly cauterize the entire incision and trust nothing to the clamp or to nature, is the advice I always try to impress most strongly on those study- ing this operation. When all the piles have been removed, the stumps will natu- rally retract within the sphincter and no dressing will be neces- sary. The thing most difficult for the unpractised operator to un- derstand is at just what point to apply the clamp ; and this can best be learned by experience, as it really constitutes the delicate point in the operation. There is no difficulty when the tumor is an internal one arising fairly from the mucous membrane above the sphincter, and not involving the skin of the anus. In such a case the clamp does not implicate the muco-cutaneous junction at the anus, and removing too little tissue will not leave un- 13 194 DISEASES OF THE RECTUM AND ANUS. sightly and annoying tags of skin, nor will removing more than is necessary result in cicatricial contraction to a serious extent. But where the margin of the anus tends to roll over, as is shown in Fig. 83, considerable experience is necessary to learn just how much tissue to include in the clamp. In such a case a groove should be made with the scissors in the cutaneous border for the application of the clamp, so that no skin may be included in its grasp. If this groove is made at the line of junction of mucous membrane and skin marked in the figure, painful tags of skin will certainly be left, which will cause subsequent annoyance and considerably detract from the success of the operation. If, on the other hand, all the protrud- ing mass be cut off, and the clamp be applied in the groove where the protrusion joins the anus, too great contraction is apt to re- sult, except in cases where, on account of a very lax sphincter, it is deemed advisable actually to reduce the size of the orifice. The endeavor must be to so draw the line between these two ex- tremes in an ordinary case as to leave no tags after cicatriza- tion, for these are always unsightly, generally annoying, and sometimes subject to a subacute inflammation which renders it desirable to remove them by a subsequent operation with cocaine. When it is necessary to divide the skin of the anus with the scissors before applying the clamp, there will be a little bleed- ing, which is easily stopped by a compress and bandage ; but when the clamp is used without any preparatory cutting, the operation is almost bloodless, and under any circumstances it is unnecessary to soil more than a single towel. This is a great desideratum in cases of enfeebled patients, besides enabling the operator to have his wounds perfectly dry without the use of any lint or other dressing. The operation with the ligature, as done by Allingham, by previously cutting away a part of the attachment of the tumor, is by no means bloodless, and unless the operator takes the risk of being called back after a few hours to stop the oozing of blood, he is apt to use considerable lint, and, having pressed it into the wounds, to leave it. This is a constant source of pain, and often it is practically impossible to remove it before the end of the third or fourth day, when it has become thoroughly loosened by the discharges. A rectum partly stuffed with lint, and containing three, four, or more ligatures around sensitive parts, is in a very different condition from one which contains no foreign substances, and HEMORRHOIDS. l-^o the wounds of which have been dressed in the most thoroughly antiseptic way possible with the cautery in the act of making them. One condition may be no safer than the other, but it is €ertainly much more comfortable. No dressing of any sort is necessary after the clamp opera- tion. If the patient seems to be doing well and complains of no untoward symptoms, the parts need not be examined for ten days, and all that is required is cleanliness to the wound. I formerly introduced an opium and belladonna suppository at the time of the operation, but have now abandoned even this. The bowels should be confined for forty-eight hours, and about thirty-six hours after the operation— in other words, at night of the following day— they should be encouraged to act by a slight laxative, either a pill or a saline. A single dose will generally be sufficient, and when the time comes for the bowels to move an enema of oil should be thrown up the rectum to facilitate the passage. In this way an almost complete clearing out of the rectum is secured on the second day. The patient dreads this first motion, but is agreeably disappointed, often being surprised that he has much less pain than his hsemorrhoids caused him in each passage before they were removed. The bowels may be treated in this way after Allingham's operation with great advantage, though his rule is to have them confined for a week or more. By the one method a compara- tively, and sometimes positively, painless evacuation is gained before the rectum has become loaded with solid matter. By the other, the pain which is sometimes and generally caused needs to be seen and felt to be appreciated. I have left my bed at night, roused my assistant, driven to an adjacent city, given ether, and unloaded a rectum on the seventh day after an ope- ration, in a delicate, nervous lady, after the rectal tenesmus had reduced her to a condition of unmanageable hysteria, in spite of trained nurse, repeated saline cathartics, and enemata of all sorts ; and one experience of this sort of unnecessary suffering will convert almost anybody to the other plan. An additional advantage of thus moving the bowels on the second day is that the rectum is cleansed of all blood and dis- charges, and that no special restrictions need be placed upon the patient's diet, while much headache and general malaise which follow the constipation produced by the daily use of opium are avoided. I have recently been tending a case where much trouble re- sulted from an unintentional departure from this rule. The 19tJ DISEASES OF THE RECTUM AND ANUS. usual operation was done with a simultaneous closure of a lace- rated cervix uteri, and at the end of forty-eight hours the usual laxative was given. I was told on the following day that it had acted nicely, and it was ordered to be repeated every night for the following week. Each day the patient was reported as doing well in this regard, though once or twice it was necessary to give two pills simulta- neously when th*e bowels seemed to be acting irregularly. On the tenth day the patient was up and about, preparing to leave the city for her home. On the eleventh she had an attack of in- testinal and rectal pain, and after a great deal of straining and suffering passed a very voluminous and hard passage with considerable blood. It was evident that the bowels had not been effectively moved since the operation, and the result of her efforts was a tearing open of the wounds and a further confine- ment to the house for nearly three weeks', each movement of t-he bowels being attended with some pain and bleeding. I do not wish to convey the idea that no pain follows this ope- ration, but I can honestly say that many patients have less pain on the day following it than they have suffered daily from their haemorrhoids for years before. I usually expect some of that annoying spasm of the levator which no stretching of the sphinc- ter can prevent ; and when this is present it will begin a few hours after the ether, and may last for the following day or two ; but it is not generally sufficient to prevent a good night's sleep, and it is often so slight as to cause no comment by the patient. It is very exceptional for any anodyne to be necessary, even on the first night after operating. Even this spasmodic contraction of the muscle is not always present. The length of time the patients are confined to the house of course varies. They are generally sitting up on the second day, or at most the third, and walking around the room tending to their own wants, the men smoking and reading, the women re- ceiving visits or sewing ; and one of the details about which the physician needs to be most strict is to keep the patient quiet in the house until the healing has so far advanced as to make ac- tive exercise safe. Many of my own cases come from a conside- rable distance and are anxious to return to their own homes as soon as possible. I usually aim to secure at least ten days, but I find they are very apt to depart at the end of a week, and occa- sionally five days sees them on their journey. I do not mean that this should be encouraged or recommended, for it is very much better that the patient should remain quiescent until the HEMORRHOIDS. 197 wounds are well advanced toward cicatrization ; but it shows better than anything else the general condition of the patient when there is no suffering which induces him to wish to stay in his room. The Operation of Excision, or Wliitehead's Operation. — This operation consists in amputating the entire " pile-bearing " re- gion of mucous membrane. An incision is made around the anus at the junction of the skin with the mucous membrane ; the latter, with the hsemorrhoidal tumors, is dissected upward till the upper limit of the haemorrhoids is passed, and then ampu- tated by a circular incision. The mucous membrane is then drawn down from above and stitched to the skin. Various .A%ri. i'\ \ \ \ \ \ Fig. 91. — 1, Muco-cutaneous junctioa, exaggerated; 2, liae of incision, a short distance from muco-cutaneous junction; 3, external sphincter muscle; 4, protruding pile. (Weir.) modifications have been made in the technique, all intended to facilitate the performance of a naturally difficult, tedious, and bloody operation ; but no essential change has been made in the guiding principle. After separating the mucous membrane at tlie anus by scis- sors all around, at one limited spot Weir ' carries the dissection deeper in an upward direction until the normal mucous mem- brane of the bowel is reached. From this point, by means of the finger-nail or with the end of a blunt curved scissors, the mucous membrane can be stripped from the external tissues down close to the circumferential initial incision about the anus, 'Med. Record, July 14tli, 1888. 198 DISEASES OF THE RECTUM AND ANUS. when any intervening tissues can be cut througii quickly with Fig. 9v. (Allingham.) the scissors. In this way, proceeding right and left, the separa- .^r:^.^.d.=^^x>L!kJ^ Fig. 9-3. (AlliiiKham.) tion of the bowel may be accomplished with decidedly increased HEMORRHOIDS. 199 rapidity and certainty. He has also dropped the introduction of the drainage tube, and he does not dust the surfaces with iodo- form, though he uses the usual sublimate solution of 1 to 5,000. He makes the correct point that piles invade the submucous connective tissue, and hence have to be cut through in the first steps of the dissection instead of being dissected off. The great point in operating is to make the circumferential incision, not in the line of junction between skin and mucous membrane, but in (Allinghani.) the mucous membrane itself inside the line of junction. In this way only can a stricture of the anus be avoided. (See Fig. 91.) Allingham, Jr.,' has discovered many disadvantages in the method, arising from the lax and irregular condition of the anus and the resultant trouble in separating the mucous membrane from the skin ; the time required in twisting the vessels if the case was a bad one ; and the length of the operation. He has tried to improve the method by the use of the instruments shown in the cuts. After the dissection of the mucous membrane has been ' The Med. Press, .June 2Tth, 1888. 200 DISEASES OP THE RECTUM AND ANUS. made, he varies the operation as follows : Opposite the position of any large pile he takes up the skin at D, Fig. 94, with a needle fitted with a medium catgut ligature. This he passes through the mucous membrane at C, and then around the stem of the pile. It is again returned through the mucous membrane at B, and lastly through the skin at A. Thus a loop is placed under the bowel, with the two ends coming out through the skin. The ligatures are then tied up just tightly enough to prevent haemorrhage when the piles are cut off. Each pile is treated in the same way. The drawn-out pile area still attached to the clamp is now to be cut off just in front of the ligature, and finally a few ligatures are put in so as to bring to the skin the mucous membrane between the piles. The operation is based by its inventor upon the following propositions, all of which appear to be at least open to discus- sion. He says : " During the first five years of my professional career I employed the ligature in the few cases of severe haemor- rhoids that came under my treatment. I operated according to the most approved method of that time, cutting through the skin and mucous membrane, and applying the ligature in the artifi- cially produced pedicle. The number of cases operated upon did not, perhaps, exceed a dozen ; nevertheless they were sufficient to convince me that the ligature by no means produced a radical cure. One of my patients returned almost as bad as ever, and the reports I heard of another were anything but satisfactory." ' This statement is so obviously open to criticism that it seems almost heartless to comment upon it. A young man in early practice operates a dozen times, and two of his cases are failures ! Older men operate thousands of times and never have a failure I Whatever else may be raised as an objection to the operation by ligature, this, we believe, is the first time it has ever been im- peached on the ground that it was not radical. Men have ob- jected to it because it caused pain, because it had been followed by untoward consequences, and because they believed a radical cure could be obtained l)y other preferable methods, but never because it failed to cure. The second proposition is better stated and less open to ob- vious criticism, but none the less, we believe, an error. The au- thor says : "After abandoning the ligature I adopted the clamp and cautery. . . . My experience, which exceeded fifty cases, re- sulted eventually in the conviction that it was decidedly inferior ' Brit. Med. .Jour., February 26th, 1887. HEMORRHOIDS. 201 to the ligature. The immediate risks I found to be greater and the failures by recurrence more numerous. Certainly it was more frequently followed by secondary hemorrhage, and I am acquainted with cases where the bleeding which is reported to have taken place must have been little less alarming after the use of the clamp and cautery than that which occurred in those days when htemorrhoids were unceremoniously excised and no pre- cautions whatever taken to arrest haemorrhage. These cases were operated upon by surgeons of recognized repute in this spe- cial method of treating piles. I consider that a plan of treat- ment which fails to compass that special end for which it was designed, and, in addition, has other obvious disadvantages be- sides the further objection of being somewhat difficult to under- stand and complex in execution, loses its position in surgery and must give place to other operations which involve less risk, give better results, and do not require any special surgical training. " Looking at this sweeping condemnation a little more closely, we find that the author, with an experience of fifty cases, found " the immediate risks to be greater and the failures by recurrence more numerous " than by the ligature. What immediate risks he found he does not state, but he heard of cases of secondary haemorrhage in the practice of others. What percentage of fail- ures he had he does not state, only that the results were worse than by the ligature. If by this is meant that while he failed in two out of a dozen cases with the ligature, he failed in a still greater percentage with the clamp, his results were indeed bad. How are we to compare his results with those of AUingham and Smith, who number their operations by these two methods by the thousands and never report failures ? Smith never speaks of any difficulty in understanding or practising the clamp operation, or of any particular "special surgical training" as necessary for its performance. Indeed, we know of nothing much simpler than to pinch up a pile with a clamp, and, after cutting off a part, burning the stump which remains. The author does not sufficiently particularize what "imme- diate risks '' he found to be so great. We never have heard of any immediate risk beyond the risk attending the administra- tion of an anaesthetic. ISTor does he tell what the additional "obvious disadvantages" were. We will not, however, argue the question. The author tried it and did not meet with suc- cess, while other men have practised it for a lifetime and found it perfectly satisfactory and eminently free from all the objec- tions which he raises. 202 DISEASES OF THE KECTUM AND ANUS. The third proposition is this : "I do not consider that any surgeon has a thorough concep- tion of haemorrhoids until he has performed the operation of excision. He may have dissected the cadaver any number of times with the special object of studying the structure of hae- morrhoids, but it is only on the living subject that dissection will reveal their true nature. It is these vivisections that have con- firmed my belief in the inefficiency of the ligature and clamp, and they have revealed also the cause of failure. In surgical literature we read of haemorrhoids as distinct individual tumors, but the vivisections I have referred to demonstrate that the en- tire plexus of veins surrounding the immediate interior of the gut is at fault. Without doubt the ha^morrhoidal condition is marked by special protuberances at certain points in the cir- cumference of the gut, and these, I find, have a pretty uniform position, owing, no doubt, to the regular disposition of the fibrous septa. But the essential fact remains that, though pos- sibly concealed by these masses, there are minute venous radi- cles behind and between the main tumors." We interrupt the author's remarks at this point merely to call attention to the fact that he has asserted something which no- body has ever denied — the veins of the rectum anastomose. He goes on to say that these small venous radicles ''are now as small as their larger neighbors once were ; but let the latter be removed by clamp or ligature, and the apparently insignificant A^einules will dilate and take their place, the very removal, per- haps, affording room for growth, and, whilst taking off external pressure, leaving the tension within increased. It is on the re- moval of these rudimentary piles that the permanence of the cure and the future welfare of the patient depend.'' The calling of a "minute venous radicle "' a "rudimentary pile " is, we believe, an entirely new and original pathological idea — very analogous to the assertion tliat the normal arch of the aorta is a rudimentary aneurism. The whole proposition seems to us rashly stated, unfounded in fact, incapable of proof, and unsupported by the clinical experience of the greatest au- thorities. In the first place, the author may argue as he will about the causes of his failures in operating by the two methods he con- demns. Other men who have i)ractised the operations longer, and are therefore greater authorities, do not fail ; and with them minute venous radicles do not develop into piles after they have operated. With them the removal of three or four sec- HEMORRHOIDS. 203 tions of the mucous membrane with the clamp or the ligature, and the substitution of firm cicatrices for hsemorrhoidal tumors, do not lead to the development of new hsemorrhoids by " af- fording room for growth," '"taking off external pressure," and " leaving the tension within increased." The question is not one for pathological discussion, or in any sense for argument ; it is one of clinical fact. Does the ligature operation or that with the clamp cure, or does it not ? On the negative we do not consider Whitehead's experience of twelve cases with the ligature and fifty with the clamp as any offset to the figures of Ailingham and Smith. Nor do we believe that those who are practising Whitehead's operation to-day are do- ing so because they have found the others to be unreliable. Both the ligature and the clamp will cure, but it is possible to imagine something better than either in certain particulars — something that will cause less pain, less confinement to the bed, less sympathetic vesical disturbance, and less danger of surgi- cal accident. This it was hoped carbolic-acid injections would supply, and, this hope proving unfounded, it is natural to try the next thing — excision. If this gave a more permanent cure than the older methods — which it does not — and if it were at- tended by less subsequent pain and' a more rapid recovery — which it is not — it would very soon take their place. Otherwise it will surely give room to the next properly attested method which is brought to the notice of the profession ; for if it has no great advantage in its results it will inevitably be carried out of practice by the inherent difficulty of its performance. The author speaks of the clamp operation as " being some- what difficult to understand " and as requiring "special surgical training." Its performance by a practised operator is a matter of seconds, not minutes. It is more rapidly done than the liga- ture, and both can be done in less than a minute — or could be before so much time was devoted to antiseptics. An operation such as these will not be abandoned for an elaborate dissection like Whitehead's until the latter has been proved to be in many ways preferable ; and we venture to say that this has not yet been done. Whitehead himself does not give results in suffi- cient detail to enable us to judge on the points necessary for a decision. He says : " I have now operated upon more than three hundred pa- tients without a death, a single instance of secondary haemor- rhage, or one case where any complication, such as ulceration, abscess, stricture, or incontinence of fseces, has occurred." 204 DISEASES OF THE RECTUM AXD ANUS. This is certainly a good result, but nothing exceptional, and certainly no better than can be shown by either the clamp or the ligature in other hands than his. The points upon which the merits of the operation must rest are not that it cures and fails to kill, but the amount of pain and constitutional disturbance it causes. He says ''the patient sits up on the fourth day, and is in condition to resume work within a fortnight *" ; that he rarely finds much pain after the opera- tion, and only occasionally uses the catheter. These are also good results, but not exceptional or confined to his method. On these points Weir ' has given some more accurate data from an experience of six cases. As the cases are well and clearly reported, we take this op- portunity for examining them, and through them the results of the method, rather closely. Regarding the first, it is stated that much less pain was ex- perienced after the operation than is often observed after the operation of ligation ; that on the eighth day the line of suture was completely healed, and a week later the patient was dis- charged from the hospital perfectly well, with a clean and well- shaped anus, only two sutures remaining attached to the skin, and these causing no trouble. In the second case the patient urinated voluntarily after the operation, the bowels moved without pain on the seventh day, and he was walking about on the twelfth. The stitches were removed, and he was discharged on the eighteenth day. In the third case the patient suffered a good deal of pain after operation, and the urine had to be drawn once, perhaps ; however, both these facts may have been attributable to the in- creased stretching and manipulation of an examination for a possible stricture. The bowels moved painlessly on the seventh day ; on the eighth the wound was found to have united .prima- rily, with the exception of a small area ; and on the thirteenth day he was up and about. In the fourth case there was no reaction whatever after ope- ration, there being no pain and the urine being passed volunta- rily. He was sitting up in bed on the third day, and about on the sixth. The majority of the sutures were removed on the tenth day. In the fifth case these particulars are not given, but in the sixth the patient was catlieterized during the first twenty-four hours ; the subsequent progress was painless; the patient was ' The Medical Record, .July 14tli, 1888. HEMORRHOIDS. 205 able to sit up in bed squarely on the affected part at the end of the third day, and was dressed within a week. Weir compares these results very favorably with those of the ligature method, and, we think, with perfect justice. The re- covery is quick, and the reaction, as shown by pain and diffi- culty in urination, is less. But with regard to the clamp and cautery method the same certainly is not true. It is now many months since I have used the catheter after an operation for hae- morrhoids — so many that I do not know if I possess such an in- strument ; and a case in which the patient is not able to report at my office in a week after operation is an unusual exception. Indeed, I have difficulty in keeping my patients under observa- tion after the first week. For exactly the reasons that Weir prefers Whitehead's ope- ration to the ligature I prefer the clamp to both. All three of them give the same satisfactory results in the end, but the clamp and the method by excision cure with less pain than the ligature, and the clamp operation is much simpler than that of excision, while possessing all its advantages. In addition to the objections which have already been for- mulated to Whitehead's operation I wish to add one more. The success of the operation depends 'entirely upon securing union of the adapted surfaces by first intention. Failure in this means bad stricture of the rectum ; and failure to get union by first inten- tion is nowhere more common than in this part of the body. A sufficient number of these cases are now on record in the prac- tice of the best hospital surgeons in New York to render this operation one of doubtful propriety while we have so many more reliable ones as we now possess. It is true that stricture may follow either the ligature or the clamp, but in the nature of these operations, consisting, as they do, in the removal of succes- sive segments of mucous membrane, sufficient strips of normal tissue are almost always left to prevent this accident, and a good operator will take especial pains to preserve enough mucous membrane to prevent closure of the anus by cicatrization. In Whitehead's operation the whole mucous membrane is dissected up and amputated, more being brought down from above to take its place. If this holds, all is well ; if it fails to unite by first intention, there is a wide ulcer completely surrounding the anus, and a stricture is the necessary consequence. The slight stricture which may result from either the ligature or clamp operation is easily curable by suitable treatment. I have also recently seen a case which illustrates another dan- •;!06 DISEASES OF THE RECTUM AND ANUS. ger of this method, and one which I had not thought likely to occur. The patient, a woman aged thirty-five, was operated upon eight months ago in one of our city hospitals for hsemorrhoids by Whitehead's operation. The anus now presents a peculiar ap- pearance, at first sight resembling a slight but complete pro- lapse. The incision in the operation had been widely outside the muco-cutaneous junction ; the mucous membrane had been drawn down to meet it and had united by first intention. Re- sult : a ring of excoriated mucous membrane, in half of its ex- tent fully an inch wide, surrounding the entire circumference of the anus, and ending, without any shading off, but suddenly and abruptly, in healthy skin. The woman suffers greatly, and I see but one thing to be done. I shall dissect up the mucous membrane till a point is reached inside the anus ; amputate it, and leave the wound to close by granulation over a bougie. The result will be a stricture of the anus, but one which I think can be controlled ; and a much less severe condition than the present one, which will certainly end in extensive ulceration and its attendant evils. CHAPTEE YIII. PROLAPSE AND INVAGINATION. Of prolapse of the rectum and invagination there are four •distinct varieties. 1. Prolapse of the Mucous Membrane Alone. — This, which is sometimes spoken of as "partial" prolapse, because only a part of the wall of the rectum is involved in the descent, is well represented in Fig. 95, Fig. 95.— First Form of Prolapse. (Molliere.) 3. Prolapse of all the Coats of the Rectum, including, when the disease is of sufficient extent, the Peritoneum. (Fig. 96.) 3. Pi'olapse of the Upper Part of the Rectum into the Lower, orllnvagination. (Fig. 97.) 4. Invagination in the Continuity of the Intestine. — The same condition as the third variety, only occurring in a part of the bowel further away from the anus. The first form is a mere everting of the mucous membrane of the lowest portion of the rectum, rendered possible by the laxity of the submucous connective tissue. It is seen as an accompani- 208 DISEASES OF THE KECTUM AND ANUS. ment of old cases of haemorrhoids, and its mechanism may be studied at any time upon the horse, in which it occurs naturally at the close of each act of defecation. The second variety is an exaggeration of the first, in which, after the submucous connective tissue has yielded to its utmost, the whole thickness of the rectum begins to descend, and finally Fig. 96.— Second Form of Pi-olap.se. (MolliOre.) protrudes. It follows, of necessity, that after this protrusion has reached a certain length the peritoneal coat must also de- scend outside of the body, and this condition is shown at a glance by reference to the plate. In both of these forms the protrusion begins first at the part of the rectum nearest the anus. In the third form, the part of fliiamH'^'- Fig. 97. - Third Form of Prolapse. (Bryant.) the rectum higher up is passed through that nearer the anus, and what is known as an invagination occurs. This condition must, of necessity, cause a sulcus or groove to exist between the containing and the contained portion ; and at the bottom of this sulcus the mucous membrane of one is directly continuous with that of the other. The depth of this sulcus must depend PROLAPSE AND INVAGINATION. 200 upon the point at which the invagination occurs, but in the variety under consideration its bottom can generally be felt by introducing the finger by the side of the protruding portion. (Fig. 98.) In the fourtli variety this sulcus also exists, but its bottom cannot be felt, the point at which the invagination has occurred being in the continuity of the bowel, too far away from the anus. This is known as intussusception, and is shown in Fig. 07. In the first three forms of the disease there is always a protrusion of a portion of the bowel through the anus ; in the fourth there may be no such protrusion, the lower end of the invaginated bowel being still within the rectum, or perhaps too far up the canal to be seen or felt. Having thus briefly defined the different varieties of prolapse and invagination, we shall consider each one in detail. R Fig. 98 —Showing the Commencement of the Formation of the Hernial Sac. lined by peritoneum and composed of all the coats of the rectum. H, Hernial sac Prolapse of the Mucous Memhrane Alone. — This is perhaps the most common of all the varieties of the disease when we take into consideration its frequent coexistence with hsemor- rhoids. It is found in children most often between the years of two and four, and in adults it is more frequent in woixien than in men. Its causes are various. Among them may be enume- rated the following : a. Those which tend mechanically to draw down the mucous membrane, such as haemorrhoids, polypi, vegetations, and tumors, h. Those which tend to weaken or to destroy the action of the sphincters, such as ulcerations or in- cisions, c. Those which cause muscular spasm, such as fis- sures, worms, dysentery, phimosis, cystitis, calculus, stricture of the urethra, and enlarged prostate, d. Those which produce permanent dilatation and weakening of the sphincters, such as 14 210 DISEASES OF THE RECTUM AND ANUS. spinal paralysis, traumatism, chronic constipation, and sodomy. In this last connection Molliere ' details a very interesting case from his personal observation in a woman suffering from vesico- vaginal fistula. Her husband, a brutish peasant, not daring to practise coitus in the ulcerated vagina of his wife, subjected her to unnatural intercourse daily for more than a year, with the result of producing a relaxation of the sphincter which showed itself by prolapse to an enormous extent and by incontinence. To this lack of tonicity of the sphincters may be attributed the frequent occurrence of prolapse in feeble and badly nourished children, e. Those which produce oedema and swelling of the pelvic tissues, such as pregnancy, parturition, faecal accumula- tions, and hepatic lesions. In this connection also Molliere ° details an instructive experiment which may easily be re- peated on the cadaver. He says : '' On the cadaver of a young girl I introduced under the mucous membrane of the anus a blowpipe and fastened it with a ligature. By practising insuf- flation the air instantly spread in the submucous rectal tissue, and the mucous membrane escaped from the anus. I repeated the same manoeuvre at another point of the circumference of the anus, with the same result. By dissection I was able to as- sure myself that only the mucous membrane had been raised up. It was then sufficient in this case to cause tumefaction of the submucous tissue to produce prolapse ; and, moreover, in this subject the anus was still firmly closed." /. To these causes it may be proper to add one anatomical one — the unde- veloped sacrum in children, which, by its straightness, leaves the rectum comparatively unsupported. Sjjmpto ins. —The first form of prolapse generally comes on gradually and seldom suddenly. It may be partial or complete as regards the circumference of the anus, being in some cases of hemorrhoids confined to one side of the aperture, and in others involving the whole circumference. It presents itself as a scarlet or livid mass (depending upon the state of contraction of the sphincter) projecting from the anus, covered with the natural secretion of the bowel, directly continuous with the skin on one side and with the mucous membrane on the other, and arranged in folds which radiate from the central aperture to- ward the circumference. It is at first spontaneously reducible, or at least easily replaced by a slight pressure, and remains re- duced till the next act of defecation ; but as the amount of pro- • Op. cit., page 202. - Op. cit., page 199. PROLAPSE AND INVAGINATION. 211 lapsed membrane increases, the difficulty in reduction becomes greater. At first also there is no pain, but after a time the act of defecation comes to be greatly dreaded by the patient, and the suffering continues till the tissue is replaced. Prolapse of the Second Degree.— As already said, the second variety of prolapse differs from the first in the fact that it is composed of the whole thickness of the bowel, and, therefore, when of sufficient length, of peritoneum also. It is probable that every prolapse of more than two inches in length may con- tain peritoneum : and it follows from the anatomy of the parts that the peritoneum will extend lower on the front than behind. In the peritoneal pouch thus formed there may be located coils of intestine, an ovary, or a part of the bladder. In this form of prolapse there is no groove or sulcus, as is shown by the figure, Fig. 99.— Prolapse composed of all the Coats of the Rectum. (Bushe.) and the absence of such a groove is, therefore, no proof of the non-existence of a fold of peritoneum in the tumor. It is a mistake to suppose that this second variety is not met with in children, for it is only an exaggerated form of the first, being the next step in the descent after the submucous connec- tive tissue has yielded its utmost ; and exaggerated cases of prolapse are often seen in children. It is distinguished from the first variety, first of all, by its size. (Fig. 99.) The first is never very large ; while the second, from the nature of the case, must be of considerable dimensions. Again, a prolapse of the second variety is generally of long standing. The second gen- erally follows the first, but a prolapse may be of this variety from the beginning, resulting, in such a case, generally from violent straining, and coming on suddenly. The first variety is not firm and thick to the feel ; the folds of mucous membrane radiate from the orifice to the circumference, and the opening 212 DISEASES OF THE RECTUM AND ANUS. is circular and patulous. In the second the orifice is slit-like and is drawn backward by the attachment of the meso-rec- tum, or in females forward by the closer attachment to the vagina. The form of the tumor is conical, its walls are thick and firm, and when pressed between the fingers the gurgling of gas in a contained loop of intestine may sometimes be de- tected, and a resonance may be obtained on percussion. It will generally be impossible to decide by physical exami- nation whether a prolapse of the second class contains perito- neum or not, unless the case be one of true rectal hernia in which the cul-de-sac of peritoneum contains a loop of small intestine or some of the pelvic organs. Such cases are rare, and the only safe rule is to act on the supposition that every prolapse not of the first variety may contain peritoneum, and act accordingly. If such a tumor be carefully dissected, the coats of the pro- truded bowel will be found enlarged, the mucous membrane will be seen to be thickened and dense in structure, especially at the free extremity, and it will also sometimes be found eroded and granular. The submucous areolar tissue will be seen to be infiltrated with albuminous deposit, and the muscu- lar layers will be hypertrophied. Owing to these changes, the bowel is actually increased in size and becomes too large to be retained in its proper place ; which explains the difficulty often experienced in reducing it and in keeping it reduced, in spite of the constant straining and desire for defecation which it pro- duces. These changes in the mucous membrane may in rare cases result in the production of a foul, hard, bleeding, eroded mass. The causes of the second variety are the same as of the first and need not again be enumerated. The symptoms also are the same, with the addition of more or less incontinence of faeces in old cases ; but the treatment is not the same in all respects, for certain measures which may be safe when a prolapse contains no peritoneum may be fatal under the opposite condition. A prolapse is apt to increase slowly in size as time advances. In children especially, it may at first cause little apparent dis- comfort. The bowel is usually replaced by the parent after defecation, and the condition is well borne till more or less in- flammation and erosion of the parts set in. Tlien each act of defecation is greatly feared. After a time the protrusion be- comes more frequent and remains down longer, till finally it is down most of the time. Then suddenly a change occurs and PROLAPSE AND INVAGINATION. 21} replacement is no longer possible. This will bring the case to the surgeon, and. he will find all the difficulties increased four- fold by the existence of one of two conditions — inflammation or .strangulation. When inflammation has occurred, there will be more or less febrile action and constitutional disturbance. The prolapse will be swollen, hard, and painful if the inflammation is in progress; if it has passed off, the tumor will be left larger and harder than before, from infiltration. The mucous membrane will be thick- ened, and may be eroded or ulcerated, and the difficulty of reduction is greatly increased from the changes which have oc- €urred in the tumor. Strangulation is rare in infants, but may occur where the tumor is large and the sphincter firm. It may Ibe temporary when properly met, or it may result in sloughing "which shall involve a whole or part of the tumor. It may re- sult in a cure by sloughing, or it may extend and cause death from peritonitis. When the sloughing involves the whole pro- lapse, it is also apt to cause a serious stricture. When it in- volves only the mucous membrane, it may cause just sufficient subsequent contraction to effect a cure. These changes are not apt to occur in the first form of the disease, and are generally confined to the second or third. The bleeding from a prolapse is not generally a very impor- tant matter. More or less of it occurs at stool, but seldom to a serious extent. It is more apt to be a general oozing than a free lisemorrhage. It would seem that there ought to be little difficulty in diag- nosticating this form of disease. The most common error is to treat a child for it and overlook the polypus which is the cause of it ; but this is generally the result of prescribing for what the pa- Tents call a "coming-down of the bowel/' without making any examination, and can hardly be called diagnosis. I have often seen large, prolapsing internal hsemorrhoids described by intel- ligent physicians as prolapsus, and this arises from a failure to justly appreciate the different nature of the two affections. Both are protrusions of the mucous membrane from the anus, it is true, but they do not resemble each other. They are often found associated, the prolapse being secondary to, and caused by, "the dragging down of the internal hsemorrhoids ; but even then they may easily be distinguished from each other. One is a new growth composed of connective tissue and blood vessels, covered by mucous membrane, and even when large is definitely and plainly circumscribed and more or less pedunculated. It is not 214 DISEASES OF THE RECTUM AND ANUS. a part of the natural rectum, but an adventitious formation which may be removed, leaving the rectum much as it was be- fore. Prolapse, on the other hand, is a part of the rectum itself merely misplaced. The mucous membrane is not changed ; there is no new element added ; it is not a circumscribed tumor, but a more or less voluminous mass of the rectal wall. They resemble each other very little, except that they occupy the same situation and are both covered by mucous membrane. In adults, an old, eroded, bleeding, and infiltrated prolapse may be mistaken for malignant growth, and I have seen two cases in which the difference could only be made out by most careful examination. But by far the most important point for the practitioner is to distinguish one form of prolapse from another, and particularly this one from the ones next to be described. Too much stress cannot be laid upon this point, for, although the disease is not at all an uncommon one, its pathological anatomy does not seem to be well understood. To the minds of many one prolapse is still very much like another, except that there may be a difference in size, and therefore in the amount of surface to be cut off or painted with nitric acid ; and until this idea is thoroughly elimi- nated there will still be an occasional case, not reported, in which it has borne its fatal fruit in the way of treatment. When it once begins to be understood that putting a clamp or knife to one of these protrusions may involve all the risks which would follow the ablation of an inguinal hernia, a great advance will have been made. Treatment. — The first step in the treatment of prolapse of the rectum to which the surgeon will be called to attend will gene- rally be to effect the reduction of the mass ; after this has been accomplished the treatment may be either palliative or curative. In children a prolapse may generally be reduced by laying the patient across the lap on its face and making gentle pressure on the protruded bowel with the fingers, which have been well oiled, or with a soft greased rag. If this cannot be accom- plished by a gentle taxis and without bruising the parts, the child should at once be etherized and a curative procedure adopted. It is scarcely worth while in a child to stop to try the various methods of reduction which have been recommended, where the taxis has failed, before resorting to this step. In an adult, however, ether and operative interference may both be declined, and the surgeon may have to tax his brain to accomplish the reduction without the aid of an anaesthetic. In PROLAPSE AND INVAGINATION. 215 such a case, after gentle taxis has been tried with the patient in the knee-elbow position and failed, cold should be applied while the patient remains on the face in bed with a pillow under the pelvis ; and this may be alternated with warm poul- tices and with plentiful applications of an ointment composed of equal parts of ext. of belladonna and ext. of opium. By these means, the most effectual of which is position, reduction may almost always be accomplished. When by the action of the sphincter the prolapse has become gorged with blood and oedematous, the surgeon is often tempted to resort to leeches. They will generally give relief, and may greatly facilitate reduction, but they are not free from the danger of a concealed haemorrhage within the rectum after the prolapse has been re- placed. Attempts at manual replacement must not be carried far enough to bruise the parts or set up inflammatory ac- tion. The palliative treatment is directed entirely toward diminish- ing the frequency and the amount of the prolapse, and in chil- dren a cure may sometimes be obtained by these means without resorting to surgical interference. The act of defecation is first to be regulated, and should be performed with the patient in the recumbent posture in bed, or while standing. One buttock may also be drawn aside so as to tighten the anal orifice, with ad- vantage ; and any source of irritation which produces frequent defecation and straining in the act must be removed. After the action of the bowels, if the prolapse has occurred, the bowel should be thoroughly washed with cold water and a solution of alum (3i. to sviij.) before it is returned. Another favorite wash is composed of the tincture of iron, twenty to thirty drops to four ounces of water. The patient should then be confined to the bed for some time, and pressure should be applied over the anus by a pad kept in place by a T bandage in the adult, or by a broad strip of adhesive plaster in children, applied so as to draw the buttocks into close apposition. If any palpable cause for the disease can be found it must be removed. I have cured a bad case in a child by doing away with the irritation caused by pin-worms, just as I have cured haemorrhoids by operating for phimosis. Calculus, phimosis, constipation, worms, and polypus must all be remedied if they are present. After the bowel has ceased to come down with the act of de- fecation, an astringent injection may be given every night with advantage and allowed to remain in all night. The general 216 DISEASES OF THE RECTUM AND ANUS, health should be carefully attended to ; tonics should be admin- istered where they seem to be indicated ; and if well borne, cod- liver oil may be used to fulfil the double indication of tonic and laxative. In children these measures may, as has been said, be curative, and, in fact, the disease often ceases spontaneously at about the time of puberty ; but in adults they are not at all likely to be so. After inflammation or partial strangulation has once occur- red, unless it has worked a cure by sloughing, it is almost use- less to hope for a cure by palliative treatment. The conditions have become changed ; the tumor is thickened and increased in size ; it has become too large for its former natural position in the pelvis, and acts as a constant source of irritation. Should radical operative treatment be decided upon, there are several effectual methods, each of which has its supporters and advocates. There is, in fact, one principle which lies at the foundation of the treatment of prolapse by operation. If the tumor be easily reducible, it may be retained in the body b}^ di- minishing the size of the anus. If it be not easily reducible, a part of it may have to be removed, the remainder reduced, and then the anus diminished to retain it. All plans of treatment are directed toward the accomplishment of one or both these things, and it remains only to choose between them. In cases combined with internal hsemorrhoids, the operation for the removal of the latter by either the clamp or ligature may easily be extended so as to cure at the same time the for- mer condition. In such a case the proper course to pursue is to divide the prolapse into several sections with the scissors, and operate upon each one exactly as though it were an internal hsemorrhoid. Caution must be exercised as to the amount of tissue removed, lest too great a degree of cicatricial contrac- tion result. Since beginning the use of injections in the treatment of haemorrhoids, I have also in some cases effected a cure of this form of prolapse by the use of carbolic acid in the same way as for piles. The idea of using carbolic acid for this purpose is, I believe, my own, and came naturally from my trials of the remedy in haemorrhoids ; but both strychnine and ergot have been used for the same purpose for some time. The acid should not be used stronger than a ten-per-cent solution. At a meeting of the Therapeutical Society. December, 1!c Co. 324 DISEASES OF THE RECTUM AND ANUS. over the anus, is very rare. Rollett ' reports a case due to direct inoculation from the penis to the rectum in a patient who was in the habit of introducing his finger into the bowel to provoke a passage. Tardieu has never observed a case, and Gosselin " saw only one at Lourcine in three years. In some experiments made by Boniere,' he found it very diffi- cult to inoculate the rectal mucous membrane with gonorrhoeal pus placed upon it through a tube, though the anus was easily affected. On the other hand, Requin * believes it almost sure to follow passive paederasty with a person suffering from the dis- ease. Individual cases will occasionally be seen reported, and most of the standard writers acknowledge its existence. ' In my own practice I have never had occasion to suspect its existence but once, and then I could not be positive ; the patient — a woman — denying any unnatural intercourse, and there being another explanation of the condition equally good. The diagnosis must rest upon the confession of the patient, the existence of the deformities which point to unnatural inter- course, the severity of the inflammation, and the microscopic examination of the discharge. In gonorrhoeal proctitis all the symptoms will be more severe and acute than in any of the simple varieties. The pain is more severe, the discharge very abundant and greenish in character, escaping with the stools and also by itself ; the finger introduced will at once detect the increased heat of the part, and a speculum examination will show intense redness and congestion. The mucous membrane is covered with thick discharge, bleeds readily when touched^ and the follicles are enlarged and discharge pus. Although a very severe proctitis may be caused by other causes than gonor- rhoea — such, for instance, as the prolonged use of drastic pur- gatives — the history of the development of the disease will be much more chronic. The irritating discharge from the anus may cause erosions and fissures, or previously existing fissures may become inocu- lated with gonorrhoeal pus and spread in superficial extent. The ' "Diet. Enc. (les Sci. Med.," article "Rectum." « Arch. Gen. de Med., 1854. * " Reclierchcs nouvelles sur la Blennorrhagie," Airh. Gen. de Med., April, 1874. 4 " f:iemcnts de Path. Med'.," t. i., p. 729. * Thiery : Presse Med. Beige, No. 26, 1882; Duninire : Philadelphia Medical Times, vol. xii.; Bumstead and Taylor ; Vidal. VENEREAL DISEASES OF THE RECTUM AND ANUS. 325 inflammation of the mucous inembrane of the rectum may be so :severe as to end in ulceration and loss of tissue. The treatment consists in rest in bed, hot sitz baths, anodyne injections of warm starch water and opium, and perhaps of a solution of nitrate of silver ( 1 or 2 grs. to 2 i-)- The diet should ~be of milk and fluids, and the bowels should be kept gently acting with salines. By this means a cure may generally be effected in a fortnight or three weeks. Chancroids at the anus may be caused by direct contagion or by auto-inoculation, and though they may be due to unnatural in- tercourse, their presence is no proof in itself of the vice. They are much more common in females than males, constituting one in nine of all cases of chancroids in the former, and only one in four hundred and forty-fi.ve in the latter. To account for this disproportionate relative frequency it is only necessary to re- member the possibility of accidental contact of the male organ in coition, and the facility of auto-inoculation due to the prox- imity of the rectum and vagina. They may be single or multiple, may be situated at any point of the anal circumference, and may cover a large extent of sur- face. They often extend upward between the radiating folds of iskin, and thus greatly resemble simple fissures ; or they may spread backward into the fold between the nates, following in extent the natural course of the discharge ; but they do not tend to spread upward into the rectum, or to involve the surface of the gut above the line of the sphincter. When they do so, which is rarely, they are of limited extent and well circumscribed. Their existence in the rectum proper has been denied by good observers, the mucous membrane there being believed to furnish no suitable ground for their inoculation. These sores at the margin of the anus have the same general characteristics as when located in other parts. The base is soft and covered with the same grayish pellicle, the edges are sharply punched, and the secretion is profuse. They tend to spontane- ous cure with cleanliness or with judicious cauterization, and are not very painful unless they are within the grasp of the sphincter, when they may cause the usual pain of fissure. Even w^hen they have extended upward in this way they still heal kindly, and almost spontaneously ; and no matter how completely they may have involved the anus or the surrounding skin, they seldom, when healed, leave any traces of their former existence. In certain rare cases they may be accompanied by an undue amount of ulceration, known as phagedsena ; and in certain 336 DISEASES OF THE RECTUM AND ANUS. patients with other rectal disease, or in whom the scrofulous or syphilitic taint is marked, they may assume a chronic type and the healing be delayed for a long time ; but even they may gene- rally be induced to heal with proper care. From this general description it is evident that only under very exceptional circumstances will a chancroid, even when phagedenic, extend far enough into the rectum, and cause suffi- cient destruction, and subsequent cicatrization and fibroid de- posit, to result in stricture. That it may do so we are almost forced to believe from the testimony of others ; but it is none the less a clinical fact that it seldom does do so, as all those having^ large experience with venereal sores will testify. Ulceration of the rectum, in my experience and that of others who have devoted special attention to the diseases of the rectum, begins ivithin the rectum proper, well above the sphincter, and not at the skin of the anus, except in some rare cases of lupus, tubercular disease, and rodent ulcer. In the old cases of syphi- litic stricture of the rectum, in which the anus is surrounded by tags of hypertrophied skin with ulcers between them extending upward into the gut, we have no proof whether the ulcers were present before the stricture or resulted from the stricture. The cases are always too old, the conditions too complicated, and the history too confused and imperfect for a positive opinion on this point. In any case of stricture of the rectum, venereal or not, there is generally ulceration below and above, and most fre- quently a circle of hypertrophied tags of skin around the anus, the adjacent surfaces of which are eroded and ulcerated. To assert that these ulcers are the original cause of the stricture is. to assert what has never been proved, and what it is obviously impossible to prove without very careful and prolonged observa- tion of individual cases. Gosselin is usually quoted as the authority for the idea that chancroid of the anus is the most frequent cause of ulceration, and of the so-called syphilitic stricture of the rectum. It is rather difficult to tell exactly what Gosselin did mean in his much-quoted contribution to this subject, but there seems very little ground for supposing that he intended to convey this idea. Although Bassereau had made the distinction between chancre and chancroid two years before, Gosselin's "chancre" still meant to him, indiscriminately, the hard chancre, the chancroid, and the mucous patch inoculated by the chancroid. What he asserts is, that these strictures are neither primary, secondary, nor tertiary manifestations of syphilis, as such are generally VENEREAL DISEASES OF THE RECTUM AND ANUS. 327 understood, but something developed in the neighborhood of the primary sore, comparable to hypertrophy of the labia or condy- lomata following the primary lesion. They are " due to a special modification of the vitality of the tissues contaminated by the virus of the chancre, comparable to the lengthening and hyper- trophy of the prepuce with contraction of its orifice which fol- lows a chancre on its under surface, in which the disease is evidently neither an oedema, nor a specific induration, nor a constitutional affection, but a local lesion, due to the presence of the chancres, and consecutive to the inflammation which they have caused." This opinion can certainly be made to teach the chancroidal nature of the affection only by a considerable exercise of the imagination. Nor can very much be said for the theory itself, except that it seems to be rather a doubtful way of accounting for a condition of doubtful etiology, and one which has never been accepted by the profession. Dr. Mason's ' paper is very much stronger than Gosselin's, in that he plainly asserts the causation of stricture to be the phage- denic chancroid. He says he has seen " constriction of the rec- tum follow, and that very shortly after the healing of chancroids has taken place." Van Buren says: ''I have also seen chan- croids at the anus become phagedenic and extend within the rectum, and have verified, at a later period, the existence of stricture of the rectum from the cicatrization, as there was every reason to believe, of this same ulceration." Bumstead and Taylor speak in the same way, and Molliere says: "Nevertheless the soft chancre of the rectum does exist, and has even been seen to assume frightful proportions in this deep region." Bridge's^ case is much relied upon to prove this point, though it is open to grave criticism. The woman had both stricture and ulceration at the time the case was first seen, and there is no positive proof that the ulceration was chancroi- dal and not syphilitic. The weight of evidence is thus seen to be decidedly in favor of the possibility of the causation of stricture by phagedenic chancroid, but that any large proportion of venereal strictures are caused in this way certainly cannot be accepted, and this is one of the points upon which further clinical evidence is espe- cially desirable. The diagnosis of the chancroid in this location will be easy ' Amer. Jour. Med. Sci., January, 1873. 2 Arch, of Dermatology, January, 1876 328 DISEASES OF THE RECTUM AND ANUS. by auto-inoculation, if the probability of its occurrence is only borne in mind, and the treatment has been sufficiently hinted at. Cleanliness, local application of astringents, and attention to the general health are all that is necessary when the sore does not extend beyond the radiating folds. There are two forms of phagedsena which may complicate a chancroid at the anus — the acute and chronic. The former is rare, and strongly resembles phlegmonous erysipelas following a wound, in that it may involve the tissues to a great extent, cause deep collections -of pus and destruction of tissue, and end fatally. The chronic is the one generally seen, and this may go on for a long time, healing in one spot while advancing in an- other. It is worthy of note that even after months of this pro- cess the sore still remains auto-inoculable. There are other complications of the chancroid which may render the diagnosis difficult. The sore may itself be inoculated with syphilitic virus and assume some of the characters of the hard chancre, especially the induration. In such a case the di- agnosis must rest in a great measure upon the combination of symptoms. The sore will present the appearance of the chan- cre, but the discharge will be more abundant than a chancre generally produces, and the pus will still be auto-inoculable. In addition, the glands in the groins will show the characteristic syphilitic induration. Molliere has pointed out that the combination of haemorrhoids and anal chancroid may cause certain peculiarities in the course of the latter. The sore may, after a time, lose its auto-inocula- bility, but still refuse to heal, the surface becomes red and vas- cular, the discharge sanious, and the sore is changed into a veri- table varicose ulcer. In the treatment of chancroids of the anus many points of difficulty may arise. The sore, from its position within the grasp of the sphincter, may be so painful that nothing can be done to it except by the surgeon himself, and only then by the exercise of the greatest care and gentleness of manipulation ; and al- though this pain may be at once relieved either by incising the ulcer or dilating the anus, both of these procedures involve a great risk to the patient of auto-inoculation. The bowels should, therefore, be kept gently open by the daily administration of a laxative which will cause soft but not watery passages. The ulcer must be touched two or three times daily with a weak solution of nitrate of silver (grs. v.- 3 i.) on a camel's-hair brush, and subsequently covered with a small pledget of soft lint VENEREAL DISEASES OF THE RECTUM AND ANUS. 329 gently laid into the fissure and pressed down with a probe. With a light touch this may be done without causing pain. Should the ulcer have extended upward to the upper edge of the sphincter, there may be such contraction of the muscle that this plan of treatment is impracticable, because all parts of the sore cannot be reached by the brush. In such a case ether or cocaine must be resorted to, a speculum introduced until every part of the ulcer is exposed, and the surface thoroughly cauter- ized with fuming nitric acid. The acid must be carried under the edges of the ulcer, and every point must be thoroughly de- •stroyed, for the operation will be positively injurious unless thoroughly done. Should the ulcer have reached such an extent of rectal sur- face as to render it doubtful whether by any means of exposure every point of it can be fully seen, it is better not to try cauteri- sation, but to be satisfied with astringent injections frequently repeated. These must also be made either by the surgeon or a thoroughly well-trained and skilful assistant, for no fresh wounds must be made by the point of the syringe, and no pain need be caused by its passage. A small glass point or a small soft-rubber catheter must be gently introduced on the side opposite the ulcer, and about four ounces of water thrown up and passed out to clean the surface of the sore. This should be followed by about two ounces of a solution of nitrate of sil- ver (grs. ij.- ^ i.), and this application should be repeated at least three times in the twenty-four hours. Phagedsena in the chronic f onn must be treated by destruc- tive cauterization, preferably with the Paquelin cautery, and every part of the ulcer must be completely destroyed. Subse- quently anodynes may be freely used till the eschar separates and a healthy granulating surface remains. In the acute form of phagedaena free incisions may be necessary in the fossae and •over the buttocks to let out pus and relieve tension, as well as the destructive cauterization of the sore. True chancre at the anus is not very uncommon, though it often passes unnoticed from the slight annoyance caused by it. In men its presence is very positive proof of paederasty, there being no chance of accidental inoculation as in women. When, therefore, Pean and Malassez give the proportion of one chancre at the anus to every one hundred and seventy-seven in other parts of the body in men, they also give some idea of the amount of unnatural vice existing in Paris. The same observers give the proportion as one in thirteen in women. JuUien gives a 330 DISEASES OF THE RECTUM AND ANUS. higher relative frequency — twenty-one of anus and perineum and four of the buttocks in eighty-two women. These sores are most likely to be mistaken for simple abrasions, or, when be- tween the radiating folds, for simple fissures. When typical in development they have the hard, raised outline and indurated base, but they are often mere erosions and strongly resemble the mucous patch. There is very little discharge, and what there is is not auto-inoculable. They tend to spontaneous heal- ing, but they may develop into mucous patches. Glandular en- largements in the groins should always be searched for, and in doubtful cases constitutional treatment may be delayed until the appearance of secondary symptoms. True chancre within the rectum has seldom been observed, though how common it may be as a result of unnatural inter- course will never be known, so little local and constitutional dis- turbance does it cause. Ricord, Fournier, and Vidal de Cassis each report a single case, and these are about the only ones re- corded. In that of the last named the induration is said to have been so great as to cause stricture — a statement which must of necessity throw doubt upon the diagnosis. The difficulties at- tending the diagnosis of such a sore are manifest. Its mere appearance would scarce be conclusive, and the absence of any other sore which might be followed by general symptoms would need to be fully established, which in a woman is a very delicate thing to do. The secondary manifestations of syphilis around the anal region are some of the syphilodermata, mucous patches, and condylomata. Mucous patches are very frequent and assume two distinct forms, the ulcerative and the vegetating. The latter begins as a slightly raised red papule, which may after a time become a. mere erosion or a distinct ulcer. They are generally multiple, and may be seated around the anus, within the radiating folds, looking exactly like simple fissures, or anywhere in the ano- perineal region. They are easily confounded with either chan- cres, chancroids, or fissures, and the differential diagnosis may be extremely difficult, and only to be made by the history and the results of treatment. The points to be sought for are the raised edges and the grayish pellicle, which are not found in simple fissures. The surface of a mucous patch sometimes becomes elevated by an upward growth of branching papillae, with production of connective tissue and dilatation of the blood vessels. When VENEREAL DISEASES OF THE RECTUM AND ANUS. 331: this development has reached a considerable extent, a cauli- flower appearance is the result, and what was at first a simple mucous patch may become a large, warty vegetation surrounded by other similar growths which have sprung up around the^ original lesion and which are due to direct auto-inoculation. These are known as vegetating mucous patches, vegetating con- dylomata, condylomata lata, syphilitic condylomata, etc.; and Fig. 118.— Syphilitic Ulceration of Colon. (Huiit.") a, swollen follicles with gummy infiltration;^. 6, commencing ulceration of follicle; c, ulcer showing submucous connective tissue; rf, ulcer ex- posing muscular layer. it [is to them, to the exclusion of other warty growths of non- syphilitic origin, and of tags of hypertrophied skin, whether syphilitic or not, that the name of condylomata should be lim- ited. The vegetating mucous patch is particularly common around the anus, and sometimes grows to a large size, nearly filling the intergiuteal cleft. The secretion is in the highest degree infec- :332 DISEASES OF THE RECTUM AND ANUS. tious, and is also auto-inoculable. The spreading of the growth, where it comes in contact with a moist surface, may be ac- counted for by direct auto-inoculation, and also by the general syphilitic infection, which, at this stage, is particularly apt to manifest itself in mucous patches at any point in the body which is both moist and irritated. These growths are therefore found most developed in fat people of uncleanly habits in either sex. The treatment is both general and local. Mercury is given for the syphilitic infection, of which these growths are the proof, and the sores themselves are treated by the application of calo- mel or iodoform in powder, by astringent washes, and the inter- position of pieces of lint between the warts and healthy parts to avoid further local contamination. Should the growths not yield rapidly to this treatment, they may be freely destroyed by acid. One point of great interest in connection with these syphilitic condylomata is that they very closely resemble (so closely that to distinguish between them by gross appearances may be impos- sible) another variety of warty growth which is often seen in the same place, but has nothing to do with syphilis, and may be entirely independent of any venereal disease whatever. Do mucous patches ever occur within the rectal pouch ? From analogy with the fauces alone it would probably be safe to answer in the affirmative ; but this is one of the points on which clinical evidence is especially to be desired. Molliere ' is the only observer with whom I am acquainted who has reported such a case. He describes a white, pearly, rounded plaque, in a subject evidently syphilitic, about one centimetre in diameter and five centimetres above the anus. It is known that any ulcerative lesion, often of a very trifling nature originally, may in the rectum, under the influence of the irritation of the faeces, assume considerable proportions ; and it has been assumed rather than proved that a mucous patch in the rectal pouch may in this way become the cause of destructive ulceration, subsequent cicatrization, and hence of stricture, so- called syphilitic. There is no clinical proof of this, as far as my reading goes, nor are we forced to accept any such theory, how- ever probable and plausible it may be, to account for the stric- tures and ulcerations of the rectum which arise during the secondary stage of syphilis. At this point we have to leave this question, with the others, ' P. 641. VENEREAL DISEASES OF THE RECTUM AND ANUS. 333 for future accurate clinical observation, only observing that, as Molliere points out, at no other part of the body are mucous- patches followed by retractile cicatrices. Of the existence of syphilitic ulceration of the rectal pouch, occurring in the late secondary or early tertiary stage of the dis- ease, there can be no more doubt than of the existence of the same condition in the fauces and trachea, where it is more easily dis- coverable and hence has been more often described. The ulcer is due to the deposit of syphilitic tubercle in the mucous mem- brane, which rapidly comes to the surface, disintegrates, and leaves a small, well-marked loss of substance, with clearly cut edges and yellowish, purulent base. When these ulcers coalesce- there is sometimes great destruction of tissue, and large cica- trices follow their healing. Their favorite seat is the lower part of the rectum, and when found in great numbers they will grad- ually decrease in frequency as the bowel is followed upward. This form of ulceration has been long recognized and has been thoroughly described, but better studied on the post-mortem table than in the consulting room. Curling ' describes a case presented by the late Mr. Avery at a meeting of the London Pa- thological Society, ° the history of which clearly shows the con- nection of the lesion with syphilis. '' Immediately within the anus, which was surrounded by a circle of vegetations, the ulcer commenced, extending three inches upward and occupying the whole of the internal surface of the rectum to that extent. The edges were rough and uneven above, and below soft and rounded ; the whole surface was smooth, exhibiting the muscu- lar fibre of the intestine quite bare. When she died she had numerous indelible marks of syphilitic eruptions on the limbs and trunk, and was suffering from sore throat." Paget," also, has given a clear description of the disease, with the points in differential diagnosis between it and tubercular ulceration. He says : ' ' The whole mucous membrane is de- stroyed except one small patch, which is thickened and opaque. The exposed submucous surface has a lowly tuberculated, undu- lating, uneven appearance, and is thickened by infiltration. In the early stages the tissue is soft, as if from recent inflammatory effusion or oedema ; but as the infiltration organizes it hardens, becomes callous, with fusion of the mucous and submucous coats, and then contracts and thus brings about the strictur^. The ' " Diseases of the Rectum," p. 113. "^ " Trans. Path. Soc," vol. i., p. 94. 3 Med. Times and Gaz., 1865, vol. i., p. 279. •334 DISEASES OF THE RECTUM AXD ANUS. affection commonly extends from the anus, as if by continuity with the excrescence (condyloma), to about five inches up the rectum ; but it is rarely so marked in the first inch of the rectum as it is higher up." ''These ulcers are limited to the large intestine, and de- crease in size and number from the rectum upward — conditions which, I think, are never observed in the tubercular disease. There is not a trace of tubercle — i.e., of circumscribed, crude, or .softening tuberculous deposit — in the submucous or any other tissue of the intestine ; none in a Peyer's patch, or at the base -or edge of any ulcer. The shape and other characteristics of the ulcers are quite unlike those of intestinal tuberculosis ; they are regular, with sharp, even, well-defined edges ; with level bases ; they are not excavating, nor do they extend through the submucous tissue ; their edges are nowhere eroded or under- mined, sinuous, thickened, brawny, or infiltrated ; the subja- cent and intervening structures appear healthy, except at the rectum. These ulcers are not grouped, and where by extension or coalescence they have lost their first shapes, they have ac- quired one altogether irregular, and have in no instance even tended toward that girdle-like shape, encircling the canal of the intestine, which is so characteristic in the large, coalesced tuberculous ulcer. Thus by negative as well as positive charac- ters these ulcers are clearly distinguished from the tuberculous, and, as I have said, there is no other form of intestinal ulcer to ■which they bear even a remote resemblance. " The amount of stenosis in these cases varies considerably. In some it is only such as is caused by the thickening of the surrounding structures ; in others extensive cicatricial contrac- tion will be found superadded, and with it the results of stric- ture of the rectum. This form of ulceration is, to my mind, entirely independent of any venereal lesion at the anus which may extend into the rectal pouch. It is syphilitic, and it belongs to a late stage of syphilis. It is, moreover, syphilitic ulceration of the rectum, and not of the anus, and it begins an inch or more above the ex- ternal sphincter. While some observers have sought to estab- lish that syphilitic stricture of the rectum was not syphilitic but chancroidal, and that it was due to an extension of an ulcer from the verge of the anus, the existence of this form of disease has not been denied, and it is to it that a certain number of syphilitic strictures are, I believe, to be attributed. This, of -course, is in direct opposition to the views of Gosselin and Ma- VENEREAL DISEASES OP THE RECTUM AND ANUS. 335 •son ; but those views have never been to any extent accepted, even by syphilographers, while those who have studied the dis- ease from the standpoint of the rectum are unanimous in reject- ing them. Cases similar to the following are not very rare in the practice of those who devote much attention to the rectum. Male, aged thirty-one, single ; has been under antisyphi- litic treatment at the Hot Springs for some time back, and was sent from there to me. Gives full syphilitic history, and has some brain symptoms, relieved by specific treatment. For past eighteen months has had symptoms of ulceration of the rec- tum, the usual diarrhoea, with mucous and bloody discharge, etc. Two weeks before coming to me two ulcers were found in the rectum above the sphincters, and were cauterized, with re- lief to pain. On examination under ether, and with the anus w^ell dilated, I discovered three separate and well-marked spots •of ulceration about two inches within the anus. One was poste- rior over the tip of the coccyx, the other two were on opposite sides of the median line in front. The ulcers were raised and distinct to the touch from the exudation under and around them ; the edges were distinctly marked, though not much indurated, and the bases a bright red and bleeding easily when touched. The treatment was entirely local, as the thorough course of mercurials already given evidently had not accomplished any- thing, though giving much relief to the other signs of syphilis. The ulcers were thoroughly cauterized with nitric acid, and sub- sequently treated by local applications of bismuth and iodoform, while the patient was confined to bed on absolute milk diet. In one month all rectal symptoms had disappeared. Six months later the patient still continued well in the rectum, but had a decided return of the brain trouble, for which he again visited the Hot Springs. For the past two years I have had under observation a case which illustrates very perfectly this form of disease in its more advanced stages. The patient is an intelligent physician, aged thirty-eight. He has a full syphilitic history and various indisputable scars •of the disease. Twelve years ago, while suffering from a tuber- cular syphilide, he first began to have the usual symptoms of ul- ceration of the rectum, and for this he had been under treatment for ten years before I saw him. On examination the lower four inches of the rectum, beginning within the anus and extending upward, was found ulcerated in its entire circumference, and in addition there was a free growth of fungoid granulation tissue 336 DISEASES OF THE RECTUM AND ANUS. covering much of the surface. The wall of the bowel was in- elastic and thickened, but there was very little contraction, and no stricture except what came from the partial closure of the calibre of the bowel by the fungous growth. The anus was partly surrounded by fleshy excrescences, and some of these were slightly excoriated on their anal surfaces, but the ulcera- tion proper did not begin till the sphincter had been passed. Antisyphilitic treatment had never been of the least value for this condition. At this time I strongly recommended the administration of ether, the thorough scraping of the diseased surface with a sharp spoon, and free application of strong acid to at least a. part of the surface ; this to be followed by the usual local and general treatment for rectal ulceration. But circumstances ren- dered this plan unavailable, and the patient disappeared for eighteen months. At the end of that time I again examined him, and found unmistakable stricture at two inches above the sphincter. The stricture presented all the characteristics usual in such cases, was of considerable extent, and admitted only a No. 8 bougie. This for a time was treated by dilatation. This, to me, is a perfect example of late syphilitic ulceration beginning within the rectal pouch and going on to the forma- tion of stricture. It will be noticed that in this case the anus was surrounded by fleshy excrescences, and that these were excoriated on the anal aspect. The presence of such tags is not to my own mind a proof of the syphilitic nature of the disease above, any more than is the excoriation upon and between them the starting point and origin of tlie ulceration within the rectum. Both the excrescences and the excoriations are explained by the irritating qualities of the discharge from the ulcerative process above, and will be found equally in tubercular or cancerous disease. This and one other are the diseased processes which explain the fact that in about fifty per cent of all strictures, not malig- nant, there is a full history of constitutional syphilis. Such a fact would not be disregarded in the study of the etiology of any other morbid process, nor should it be in this. If one-half of all non-malignant strictures occur in syphilitic patients, it is only fair to assume that syphilis has some causative influence. In the differential diagnosis of syphilitic from other forms of ulceration, the history is of great importance. The appearance 7f the sore is scarcely characteristic enough to warrant a posi- tive diagnosis unless all the facts of the case point in one direc- VENEREAL DISEASES OF THE RECTUM AND ANUS. 337 tion ; and the failure of antisyphilitic medication is of no nega- tive value, for the late manifestations of syphilis in the rectum often refuse to respond to either mercury or iodide of potash, though both should always be tried. Traumatism, whether sur- gical or other, and dysentery may both be easily eliminated, and the only remaining sore at all resembling the syphilitic ulcer is the tubercular one. The diagnosis between these two may be impossible where only one or two spots of ulceration exist in the rectal pouch ; but tubercular ulceration is not generally limited to the rectum alone, but rather tends to involve a con- siderable portion of the large intestine, being only more marked at the rectum. The other tertiary manifestations of rectal syphilis are neo- plastic in character. Circumscribed gummy deposits of greater or less extent have been quite frequently noted, and are scarcely as rare as would seem to be indicated by the statement of Four- nier that he had never seen a case. Other observers have re- ported isolated cases, and R. W. Taylor has recently given the notes of four. The deposit may occupy any part of the circum- ference of the bowel, and in one of Taylor's cases was located in the recto-vaginal septum, and had ulcerated through, causing a fistula. The diagnosis of such a tumor, with its attendant ul- ceration, offers but few difficulties, and the treatment is both local and constitutional. Instead of being circumscribed, this gummy deposit may in- volve the whole circumference of the bowel, and extend from the sphincter as far as the upper limit of the rectal pouch. This is what Fournier has described under the name of ano-rectal syphiloma, and what he believes to be the explanation of most of the cases of syphilitic stricture. For, although he recognizes that stricture may result from late secondary ulceration in the manner we have described, he believes that stricture from this cause is infrequent as compared with that produced by this dif- fuse deposit in the rectal wall. As described by him the disease commences as an infiltration of the rectal wall by this neoplasm. The deposit is entirely sub- mucous, and occurs by preference in the rectal pouch, and always encircles the whole calibre. It may also involve the anus, and may take the form of anal tags and tumors described when speaking of condylomata. At first it merely causes thickening and stiffening of the gut, so that it loses its dilatability, but there is no contraction and no ulceration until later. As the deposit increases in amount, 22 338 DISEASES OF THE RECTUM AND ANUS. the mucous membrane over it loses its vitality and becomes ulcerated, and the deposit itself finally degenerates into fibrous tissue, retracts, and causes stricture. This description of the gross appearances and general characteristics of syphilitic stric- ture will be recognized by all. Fournier was not describing any new affection, but simply, under a new name, " ano-rectal syphi- loma," endeavoring to give a complete history of the origin and development of the ordinary syphilitic stricture as seen by every practitioner ; and his description in many points corresponds with clinical experience. It must be admitted that in most cases of syphilitic stricture there is more infiltration of the rectal wall; more occlusion of the canal by hard masses of tissue ; more ex- tensive disease, in other words, than can easily be accounted for by mere cicatricial contraction ; and it seems exceedingly proba- ble that Fournier has more correctly described the true nature of the pathological process than any previous writer. He does not attempt to describe the initial stage of the deposit. To him it is simply a neoplasm which degenerates and contracts. The whole question evidently turns on clinical observation. Unfortunately I have never seen, in my own experience, a syphi- litic stricture in the early stage which he describes — an infiltra- tion of the whole calibre of the rectum for a considerable dis- tance longitudinally, but without any change in the mucous membrane covering it — and probably for the reason that he states, that in this stage the disease causes no symptoms. Syphilitic stricture, as generally seen, is just such a combina- tion of ulceration, infiltration, and contraction as he describes ano-rectal syphiloma to be in its more advanced stages. This affection is said by Fournier to be curable in its early stage (before degeneration and contraction have occurred) by specific treatment, but he has never seen but two such cases. Van Buren says that he also has seen the infiltration disappear under antisyphilitic treatment. In addition to these tertiary manifestations of syphilis, Mol- liere describes a stricture of the rectum due to a specific inflam- mation of the rectal tunics. He says that in these cases the muscular coat is replaced by connective tissue, which by scle- rosis causes atrophy of the muscular fibres. The origin of the trouble is in the muscularis, and not in the submucous connec- tive tissue as with the other forms of stricture. This is a form of disease which I have never seen. CHAPTER XII. NON-MALIGNANT STRICTURE OF THE RECTUM. For convenience of reference the following table of the differ- enfvarieties of stricture of the rectum has been prepared : STRICTURE OF THE RECTUM. Congenital. ] ^- Complete, ^ (3. Partial. f 1. Pressure from without 2. Spasm. 3. Non-venereal. Acquired. < 4. Venereal. . 5. Cancer. a. Dysenteric. 6. Inflammatory. c. Traumatic. d. Tubercular. 'a. Cicatricial. (From Chancroid. From Secondary and Ter- tiary Ulceration.) . Neoplastic. (Gummata. Ano- Rectal Syphiloma. Inflam- matory.) Congenital Strictures. — The congenital narrowing of the rec- tum, both complete and partial, which is sometimes seen, has been already described in speaking of the malformations of this part. Acquired Strictures. 1. Stricture due to Pressure from with- >out. — A tumor of any kind in the pelvis will not infrequently press upon the rectum so as to obstruct its calibre. An abscess in the ischio-rectal fossa may be accompanied by an amount of inflammatory deposit around the rectum sufficient to obstruct it, and a pelvic inflammation in women may be accompanied by an ■exudation which in the form of bands across the bowel shall partially close it, and at the same time lead to compensatory anuscular hypertrophy of the rectal wall. Medical literature is 340 DISEASES OF THE RECTUM AND ANUS. Fio. 119.— Stricture due to Plastic Exudation. 1, Anus. 2, Rectum. 3, Stricture laid open. 4, Abscess cavity communicating with rectumjby perforations above and below stricture, as shown by the probes. 6, A small ovarian cyst. NON-MALIGNANT STRICTURE OF THE RECTUM. 341 full of cases of this nature, and here it is only necessary to refer to them as a not infrequent cause of obstruction both of the rec- tum and of other parts of the canal. Fig-. 119 is from a specimen in my collection, in which the sigmoid flexure was in two places almost completely occluded by plastic exudation. 2. Spasmodic Stricture. — Much has been written in times past upon the question of spasmodic stricture of the rectum, but at present the condition is looked upon by the best authori- ties with great doubt, if not with absolute unbelief. Spasmodic contraction or stricture of the external sphincter is not an un- usual condition, and cases of it from my own practice and that of others will be reported further on ; but spasmodic stricture of the canal above this point has always been a matter of belief and assertion rather than of demonstration. AUingham upholds its existence, in connection with organic stricture, as a complication of the latter, and gives the follow- ing case as proof. He says : " There are, no doubt, many cases of stricture in which there is very little deposit and much spasm, and there are, on the other hand, cases where much obstruction -exists but very little spasm. A patient under my care at St. Mark's had a stricture so tight that I could not make the point of my little finger enter it ; on putting her under the full influ- ence of chloroform, I could get two fingers through without dif- ficulty." This case, if it be admitted, as it generally will be on so good authority, actually proves more than has ever been proved be- fore with regard to this question, and is about the only one which really proves anything. In my own practice I have seen this form of constriction, but never to such a marked degree as AUingham describes. I have already referred to the difficulty which often exists in passing a rectal bougie, from the natural conformation of the parts. It is upon this difficulty that nearly all the arguments for, and the supposed cases of, spasmodic stricture rest. When the bougie cannot be passed, a spasmodic stricture is supposed to be the cause. When, after numerous trials, by a lucky manipulation an entrance is effected, the spasm has been overcome. To this may be reduced nearly all the reported cases of this affection which from time to time have appeared in the writings of those who have devoted attention to the subject. Molliere, ' with his usual happy style, has gone very nearly to 'Loc. cit., p. 330. 342 DISEASES OF THE RECTUM ANI> ANUS. the bottom of this question. He says that at a not very remote period there flourished by the side of Ashton, Curling, and the surgeons of St. Mark's Hospital, certain specialists as expert in finding strictures in the rectum as are our laryngologists in dis- covering polypi in the larynx. These estimable practitioners gave themselves up to the daily exercise of dilatation by bougies, and to facilitate the practice one of them had invented a pair of pants of a special pattern, dressed in which novel livery his pa- tients came daily to have a sound introduced into the anus. This whole question of spasmodic stricture has been very ably discussed by Van Buren,' and if the reader wishes to fol- low it further he can scarcely do better than to consult that article. Uncomplicated spasmodic stricture of the rectum is a thing whose existence is not admitted by the best authorities, and which will seldom be found by a skilful examiner. It is, perhaps, too much to say that it never exists ; but a well-marked case of it within easy reach of the finger, which could be plainly detected by an ordinary examination, and which disappeared under chloroform, is what those who do not believe in its exist- ence are calmly waiting to see. Nevertheless, as my own chances of observation have in- creased I have come to have greater faith in the occasional ex- istence of this condition as a surgical curiosity, agreeing in this- with Ball, Cripps, and other later writers. This much I have certainly seen. On introducing my finger into the rectum of a nervous woman, I have found it tightly grasped not only at the anus but as high up as I could reach. Leaving it there for a few seconds and gently palpating for disease, I have felt the whole canal open up — balloon out, so to speak — and leave the finger in a patulous, open cavity. If this may happen over the lower four inches of the gut, why may it not happen anywhere, and to a more limited portion of the muscular wall ? I have also had a case more marked than this. The patient was a very nervous physician, worn out by suffering from rec- tal disease. His one chief symptom was pain in the rectum, caused by defecation and increased by the sitting posture, last- ing often for many hours after a movement of the bowels. On touching the skin near the anus in an attempt to draw the parts open for inspection, I found the pain was so intense as to cause him to cry out at the least touch. With much gentleness the finger was passed through the external sphincter, and met by a ' " On Phantom Stricture and other Obscure Forms of Rectal Disease," Amer, Jour. Med. Sci., October, 1879. NON- MALIGNANT STRICTURE OF THE RECTUM. 343 stricture at about an inch above — in other words, at the level of the internal sphincter or slightly above. A few days later he was etherized, and before giving the anaesthetic this condition was again verified both by myself and my associate, Dr. Gibbs. The ether was then given, and not till profound narcosis had been reached did the constriction disappear. The patient was found to be suffering from haemorrhoids, and an ulcer the size of a silver half-dollar, but quite superficial, over the internal sphincter. The cure of these was f oHowed by the relief of all symptoms. This was certainly a case of purely spasmodic stricture, but too near the anus to prove the point under discussion — spasmodic stricture of the rectum proper ; though if we may have spas- modic stricture of the unstriped muscular fibres of the internal sphincter, why may we not have the same an inch higher up ? 3. Non-Venereal Strictures, (a) Dysenteric. — Dysenteric stric- ture and ulceration have both been already described. Stricture due to this cause is, perhaps, more often multiple than when due to any other. (6) Inflammatory. — Proctitis, whether acute or chronic, when attended by sufiicient changes in the structure of the coats of the rectum, may result in stricture. There is another form of stricture which may be considered as on the dividing line between the congenital and the inflam- matory, and which consists in an enlargement and thickening of the folds of mucous membrane which are normally present in every one. Quain,' under the head of impaction of faeces, describes the case of a man, aged forty years, who died with a large accumu- lation which was evidently due to the presence of two crescent- shaped shelves of mucous membrane projecting into the rectum, one attached opposite the prostate and the other about four inches higher. Each of these was more than an inch in breadth, and into each the circular muscular fibres fully entered, while even the longitudinal layer dipped slightly inward at their bases. Kohlrausch also describes an analogous case, in which he made an autopsy on a criminal who had been executed. (Fig. 120.) He found an enormous dilatation of the rectum above the spot at which he locates the plica transversalis. At that point he discovered an undoubted stricture which, from its hardness and extent, he at first considered cancerous. It presented, however, nearly the same anatomical condition as the one just described ; 1 "Diseases of the Rectum," p. 273, London, 1854. 344 DISEASES OF THE RECTUM AND ANUS. the mucous membrane was sound and formed a considerable duplicature, the circular muscular fibre entered into this dupli- cature and formed a hard, hypertrophied, muscular ring several lines in thickness. The longitudinal fibres passed directly over the affected spot in this case, however, and were not unusually thick or firm, and the space left between the outer and inner muscular layers by the bending inward of the latter was filled with connective tissue. A stricture was in this way formed without degeneration of the mucous membrane — a condition, however, which led to no less serious results. Such a state furnishes in itself the ground for constant aggravation, for the longitudinal fibres passing entirely over the fold must, by each Fio. 120.— Longitudinal Section of Stricture of the Rectum at the Plica Recti Inferior- (Kohlrausch.) a, Mucous membrane; h, circular muscular layer entering into the fold of the stricture ; c, cellular tissue; d, longitudinal mu-sculiir layer passing over the stricture. contraction and by the necessary increase in their normal func- tion, augment the substance of the fold more and more, and thus decrease the lumen of the gut. Nelaton, indeed, has writ- ten that valvular retractions of the rectum are most often only an hypertrophy of his superior sphincter, and that the projec- tion formed by it into the cavity of the intestine is the point at which foreign bodies are most frequently arrested, as well as that at which invaginations in young children generally begin ; and in all these points he is borne out by Velpeau. ' Sappey ' ' Velpeau, " Anat. Chir.," 3d ed., p. 39, 1837. ' " Anat. Descript.," t. iv., p. 222. NON-MALIGNANT STRICTURE OF THE RECTUM. 345 says: " At the level of this band most of the organic contractions of the rectum are situated ; its study, therefore, offers no less interest in a pathological than in a physiological standpoint.' This idea of the pathological relations of the mucous folds and muscular bands in the causation of organic strictures may be traced through the works of Arnold, Tanchou, Hyrtl, and Houston, and has its foundation in the fact that, as these folds are the most subject to injuries, so they may be the most fre- quent starting point of those contractions of the rectum which a,re due to injuries, especially those from foreign bodies intro- duced per anum or swallowed, and from masses of hardened faeces, intestinal concretions, etc. (c) Traumatic. — A simple traumatism may result in stricture, either by causing ulceration and cicatrization or by exciting a chronic inflammation in the submucous connective tissue. Amongst these traumatisms may be enumerated operations upon haemorrhoids, applications of strong acids, the perform- ance of some surgical operations, foreign bodies, kicks and falls, and the injury produced by the head of the child at birth. (fZ) Tubercular Stricture. — There is no longer any doubt in my own mind that tubercular ulceration may result in narrow- ing of the canal, at least from induration and inflammatory deposit, if not from cicatricial contraction. I have seen this occur too palpably to be mistaken. 4. Venereal Stricture, {a) Cicatricial. — In the chapter on Ul- ceration, stricture has been frequently referred to as a not infre- quent consequence of that process, and the various forms of ulceration which by subsequent cicatrization were capable of producing this result have been mentioned. In a general way it may be said that any ulcer which destroys even the thickness of the mucous membrane to any extent will, when healed, leave a cicatrix, and if such a cicatrix be at all extensive it will by its contraction cause subsequent diminution in the rectal calibre. It has been shown that many of the more severe forms of rectal ulceration are of venereal origin. The venereal sores capable of producing a stricture are the chancroid and the later syphilitic ulcers. We shall leave out of consideration the true chancre and the mucous patch, for the reason that their influ- ence in the causation of stricture is still rather a matter of sur- mise than of proof, and the same thing may be said regarding gonorrhoea of the rectum. For a description of these ulcerative venereal processes the reader may again refer to the last chapter. 346 DISEASES OF THE RECTUM AND ANUS. (b) Neoplastic. — There is a class of venereal strictures whick are not primarily ulcerative, and therefore not cicatricial ;. these we have denominated neoplastic. In this class are to be placed the gummata ; the ano-rectal syphiloma, which differs from gummy deposit rather clinically than microscopically, both of which have already been described ; and a third late manifestation of constitutional syphilis, which is an inflamma- tion of the rectal wall. This inflammatory change may involve a large portion of the rectum. It begins in the muscular fibre, the interstitial tissue of which becomes filled with round cells which ultimately form a connective tissue, and this connective tissue by its hardening and consolidation finally causes the complete destruction of the muscular element. This is not to be confounded with the ano-rectal syphiloma, in which there is an actual deposit of large masses of new material in the rectal wall — masses which it may be very difficult to distinguish from cancer. In these various ways venereal disease, and especially syphi- lis, may result in rectal stricture, and this accounts for the fact that in about fifty per cent of all cases of stricture there is a syphilitic history. Pathological Anatomy. — In studying the pathological ana- tomy of stricture, there are several points to be observed, for changes will be found not only at the stricture itself, but both above and below it, and in the surrounding parts. From what has been said already, it will be inferred that a stricture which is not the direct result of a deposit of new ma- terial in the rectal wall will be composed either of cicatricial tissue, such as is found in other parts of the body, or else of con- nective tissue which is firm and dense and creaks under the knife on section. All the connective tissue in the rectum at the diseased point, whether submucous, subperitoneal, or intermus- cular, will be found to have increased in quantity, and this ac- counts for the increased thickness of the rectal wall. (Fig. 121.) The mucous membrane at the seat of stricture will generally be found destroyed, and replaced by granulation tissue on this, fibrous base, which bleeds easily when scraped. Above the constriction a process occurs which will be found to be almost constant. This begins by a dilatation of the bowel and an hypertrophy of the muscular layer, with, at first, a thickening of the mucous membrane. Later, the mucous mem- brane, due, probably, to the irritation of retained faeces, will show all the stages of ulceration, from simple congestion in NON-MALIGNANT STRICTURE OF THE RECTUM. 34? some points to a complete destruction in others, and an expo- sure of the muscular tissue beneath. This ulcerative process may extend for several inches up the bowel. The wall of the bowel above the stricture may be as thin as paper in spots, and at such points perforation is apt to take place. In a case re- ported by Goodhart, ' the changes of which we are speaking had gone on to actual gangrene, extending in spots along the trans- verse and descending colon, and were undoubtedly due to the intensity of the inflammatory action caused by the retained irri- tant matters. The bowel is also generally distended with ga& and faeces, and the latter are more often fluid than solid, though faecal tumors, with their well-known characteristics, will some- times be met. The dilatation above the stricture may reach an enormous, size, and may ultimately result in a cul-de-sac or pouch which Fig. 121.— Stricture of the Rectum showing Hypertrophy of the Connective Tissue. (Bushe.) will fill a large portion of the abdomen, and dip down below the point of constriction, and an ulceration in this pouch may result in its perforation and the establishment of a fistulous outlet for the faeces. Such an opening may be into the rectum, either above or below the stricture, or into the ischio-rectal fossa, with the necessary result of abscess. An opening may also be made into the bladder in either sex, and in females into any part of the genital tract. As showing what efforts nature is capable of making to over- come the occlusion caused by stricture, the following account of the post-mortem appearances found in the body of Talma, the tragedian, is of great interest. The whole history of the case may be found in Quain.^ ' Med. Times and.Gaz., February 28th, 1880. 2 0p. cit., p. 190." 348 DISEASES OP THE RECTUM AND ANUS. In the examination of the body the intestines were all found largely distended with air and fsecal matter. . . . The pelvis was filled with an enormous sac — the upper part of the rectum largely dilated. When the sac was raised a circular narrowing of the gut was discovered. This was the stricture. It was at the distance of six inches from the anus, and proved, upon close examination, to be wholly impervious. It was, in fact, a solid fibrous cord, but on the surface irregular, and having the ap- pearance of a purse, drawn tightly and puckered, with the strings tied around it. The great dilatation of the bowel at its lower end dipped down below the level of the stricture in the form of a de- pendent sac, in which was an opening about an inch in diameter, and from this opening issued a fluid, the same as that diffused through the abdomen. The rectum below the stricture was no more than the size of a child's intestine, and upon it, close to the stricture, was an ulcerated surface with a narrow opening, to which the edges of the aperture above the stricture had been adherent. A new communication, but an imperfect one, had thus been established between the two parts of the gut — severed one from the other by the stricture. But the connection had given way, doubtless in consequence of the violence of the ex- pulsive efforts, and thus the contents of the bowel had escaped a short time before death. The cellular tissue in the ischio-rectal fossae around a stric- ture may also become hard and lardaceous as a result of chronic inflammation ; and this change may extend to some distance from the original starting point along the sacrum, as high as the promontory, and into the subperitoneal tissue of the iliac fossae. Abscess is always liable to occur in the neighborhood of the stricture, probably from lowered vitality in the parts, and this accounts for the relative frequency of fistulae in this disease. These may be both numerous and extensive, and may make communications between the rectum and any of the adjacent •organs. For this reason a fistula should always lead the sur- geon to think of stricture and to examine for it. Allingham has also called attention to the frequent existence of a low form of peritonitis in connection with stricture, an in- flammation marked by tympanites, vomiting, and pain, espe- cially on walking or moving, and attended by thickening of the peritoneum and old and recent adhesions. Below the stricture the rectum may sometimes be found un- changed from its normal condition, but it will generally be ulce- NON-MALIGNANT STRICTURE OF THE RECTUM. 349 rated as it is above, or else there will be hsemorrhoidal tumors, excoriations, and vegetations and tags of larger or smaller size. These growths are the result simply of irritation of the dis- charge from the process above. Most strictures are located in the lower part of the rectum, and hence their presence is easily detected in the majority of cases. They are far more frequent in females than in males, because many of the causes which produce them operate chiefly in females. Age has little influence upon their frequency after the period of adult life. A stricture may or may not involve the whole circumference of the bowel ; and the contraction may be so slight as not to be apparent till the bowel is distended with the speculum, when a falciform band may spring out from one side. In more extensive disease there is still usually a passage for the faeces, but this may be very slight. The most extensive disease will be found to be due generally either to syphilitic de- posit, syphilitic sclerosis, or dysentery ; and in such cases the calibre of the bowel may be lessened for a space of several inches. Symptoms. — Where stricture is the result of ulceration, the signs of ulceration will at first mask those of the stricture, and the patient will complain of pain, discharge from the anus, ex- coriations, and warty growths, together with the failure of the general health, gastric and intestinal disturbance, and wander- ing pains. The one sign of a stricture is the obstruction, and this may show itself in several ways, generally at first by alternate at- tacks of constipation and diarrhoea. The constipation is me- chanical, and is due to the accumulation of faeces above the constriction. The diarrhoea is secondary to the accumulation, which in time begins to act as a foreign body, setting up a catarrhal inflammation, as a result of which sufficient fluid is poured into the bowel to soften the hardened mass, and large quantities are discharged, only to be followed by a fresh accu- mulation. It has often been asserted that a well-marked lessening of the rectal calibre must, in the nature of things, produce a change in the shape of the faeces, but this is not quite true. The flat- tened, tape-like stool is a sign of value when present, and should always lead to careful exploration; but it may not be present even in the worst cases of stricture, and it may exist without stricture, in the latter case generally being due to an irregular spasmodic action of the sphincters, or to pressure from without. 350 DISEASES OF THE RECTUM AND ANUS. the bowel. This point, to which attention was called by White * as long ago as 1815, has again recently been made the subject of discussion. In an able article on '' Annular Stricture of the In- testine : its Diagnosis and Treatment,*" in the British Medical ■Journal for May 31st, 1879, Mr. Stephen Mackenzie wrote: "The fact that full-sized, properly formed faeces are occasionally passed, of course shows that there can be no organic stricture." Under criticism, he withdrew the statement in the issue of the same journal for May 15th, 1880, with the explanation that it was founded on his personal observation, which had since been supplemented and corrected by that of others. In a case which I once saw in consultation with Dr. De Long, of Brooklyn, I had a long-wished-for opportunity to observe, in the presence of a number of physicians, the actual mechanism by which tape-like stools are produced. The woman suffered from a stricture one inch above the anus, which was of suffi- cient calibre to admit the ends of two fingers easily. She had never noticed any deformity of the faeces. While under the in- fluence of ether, and after the sphincter had been very thor- oughly dilated, an O'Beirne tube was passed through the rec- tum, which was empty, into the sigmoid flexure, which was full. After resting there a few moments it provoked a movement of the bowels. The stricture was instantly crowded down into view, appearing at the anus, and taking the place of the anus, which, owing to the complete dilatation, ceased to have any action and was simply a patulous ring. Through the stricture there came a long, tape-like evacuation, the mould which gave it its peculiar form being the stricture pressed to the surface of the perineum, and greatly lessened in calibre by folds of mu- cous membrane, which were crowded into it from above. While remarking to those present on the peculiar mechanism of its production, the straining ceased, the stricture rose, the mucous membrane was relaxed, and a passage of natural formation was the result. This alternation was repeated several times. At ' "With regard to the lessened diameter of the fteces, just noticed, which must necessarily be the case whenever a pernianeutly contracted state of the gut takes place ; j'et it has happened, in some instances where that change had been observed, that, in a more advanced period of the disease, fa'cesof a natural si/e had occasionally passed. The knowledge of this circumstance I consider of some importance, inas- much as, if properly attended to, it will prevent the practitioner from hastily con- cluding there is no stricture merely from an examination of the evacuations, when symptoms may otherwise indicate the presence of the disease." — " Observations on Stricture and other Affections occasioning a Contraction in the Lower Part of the In- testinal Canal," etc., Bath, 1815. NON-MALIGNANT STRICTURE OF THE RECTUM. 351 •each violent effort the stricture was forced down to the anus, the membrane above it was crowded into it so as to greatly les- sen its calibre, and a flat passage was the result. When the effort was less violent, there was still a passage, but the stric- ture having risen to its place, and not being so tightly filled with the mucous membrane, the passage was natural. The les- son to my own mind was this : that a stricture of large calibre might, as a result of straining, cause a passage of very small size ; and that to get this peculiar shape the stricture must be crowded down so as to actually take the place of the external sphincter, and be the last contracted orifice through which the soft substance is expressed. It is well known that, with the closest stricture high up, the fseces may be reformed in the rec- tum below and be passed normal in size. At the bedside but little importance is to be attached to the statements of patients concerning this matter. After a stricture has existed for a certain length of time, signs of obstruction will be manifest by abdominal palpation and inspection. The transverse and descending colon can be felt partially distended with- masses of faeces, and will be dull on percussion, tender to the touch, somewhat movable, and pit- ting on firm pressure. After an attack of diarrhoea, or after a brisk purge, these accumulations may disappear, only to form again in a short time. Generally complete obstruction does not occur without ample warning in this way. It is preceded by eructations of foetid gas, the abdomen swells and becomes very tender on pressure, the coils of intestine are visible through the abdominal wall, and their visibly violent peristalsis gives proof of the effort nature is making to overcome the obstacle. After a short time the patient is exhausted, and, unless surgical aid is given, dies. Complete obstruction has been seen to occur very suddenly, forming almost the first intimation of serious disease ; and this is more apt to be the case where the stricture is high up in the rectum or at the junction with the sigmoid flexure. It comes on with the usual signs of acute intestinal strangula- tion — pain,|swelling of the abdomen, bloody passages, etc. — and it may be caused by some indigestible substance which has been swallowed and refuses to pass the stricture, or merely by hard- ened faeces or prolapse of the bowel above into the constriction. There is one important element in the obstruction due to stricture which must not be forgotten. It will sometimes hap- pen that fatal obstruction will occur even when, on post-mortem examination, the calibre of the stricture is found to be large 353 DISEASES OF THE RECTUM AND ANUS. enough to permit the passage of the finger, showing that the ob- struction could not have been due merely to the contraction of the new growth. John Hunter remarked a fact of this sort, as is proved by the following account : "On introducing the pipe by the anus, it was found to come butt against one side of the upper part of the cavity of the tumor, where there was a bend in the passage ; but why a crooked pipe did not pass when attempted to be passed by turn- ing it to all sides I cannot conceive, or why a bougie which was slightly bent did not hit the hole is not easily accounted for; but, what is more extraordinary than either, why a clyster did not pass freely up ; or why did not the wind or soft excrementi- tious matter that did yet lay [sic] pass readily down, while I could pretty readily pass the end of my finger down from the gut above into the tumor ? The folds of the contracted part did not appear after death to have been sufficient for an entire stop- page of this sort." ' Notwithstanding the statement that the folds of the part did not appear after death to have been sufficient to produce the stoppage, it seems that a prolapsed fold of mucous membrane is the only thing likely to give rise to it. In cases of advanced dis- ease a spasmodic stricture (if such ever occurs) would seem out of the question, whereas partial or complete invagination in this part is known to be of frequent occurrence. As shown by Roki- tansky,^ the paralysis above the stricture is also an undoubted element in the production of the occlusion. Diagnosis. — The first means of diagnosis in stricture is the examination with the finger; and, as the great majority of stric- tures are confined to the lower portion of the rectum, this is in itself generally sufficient. It is the best and safest and least painful of all the means of diagnosis when properly executed, and yet it may be the immediate cause of death to the patient when roughly practised. There is an inborn tendency on the part of many, when the index finger comes in contact with a tight stricture, to bore through the narrow passage which is left and feel what is on the other side — a tendency to be struggled against and overcome. If the surgeon has deliberately de- termined to practise divuision, this is one way to do it; but at present we are speaking of diagnosis, and forcible dilatation is not diagnosis, but a very grave surgical procedure. The finger ' Hunteriaa MS. : " Cases and Dissections," No. 59 in " Descriptive Catalogue," etc., vol. iii., p. 98. From Maj'o, op. cit., p. 249. * " Manual of Path. Anat.," vol. ii., translated by Sieveking. NON-MALIGNANT STRICTURE OF THE RECTUM. 353 should therefore be passed slowly up to the stricture, and, un- less the calibre admits of it without straining, it should not be passed further. The condition of the parts below may also be appreciated, the amount of induration estimated, and a general idea formed of the nature and extent of the disease. In women the vaginal touch will generally be found of the greatest value and should never be omitted. As a rule all can be learned in this way that can be learned in any other where the disease is within reach of the finger, and nothing is to be gained by a painful speculum examination or the use of the bougie — means of diagnosis which, however valu- able where the stricture cannot be felt by the finger, are of little use for the lower four inches of the rectum. When a stricture is situated high up in the rectum or in the sigmoid flexure, the confidence in diagnosis which comes from actual contact of the finger with the disease is entirely lost, and there is perhaps nothing in the whole range of surgical diagnosis which requires more skill than the detection of stricture in this part, and nothing attended with more uncertainty. The symp- toms of stricture of the upper part of the rectum are not the same as when the disease is lower down, for the nerve supply is not the same nor is the sphincter muscle involved. For this reason the patient is much more apt to suppose himself suffer- ing from chronic constipation and dyspepsia than from hsemor- rhoids. Pain in the abdomen, not always localized at the left side, pain in the loins and down the legs, obstinate constipation and occasional diarrhoea, are the things usually complained of, and in these there is nothing upon which to base a positive diag- nosis. The fseces may never present any peculiarity, for the reason that they are accumulated in the rectal pouch below the obstruction and passed in the natural shape. They are apt to be lumpy and unformed rather than misformed, but they may be streaked with blood or slime, which is always a valuable sign a,nd one calling for careful physical exploration. A stricture in the locality in question must be examined for with the greatest care and gentleness, and the examination will often be negative in its results. The attempt to decide the ques- tion by the use of bougies is not always satisfactory and by no means free from danger. It is unsatisfactory to the general practitioner because an obstruction will generally be encoun- tered in trying to pass an instrument of any considerable size through this part of the bowel, and the passage of an instrument of small size, which is much easier, proves nothing. It is dan- 23 354 DISEASES OF THE KECTUM AND ANUS. gerous because, with tlie ordinary rubber rectal bougies, a dis- eased bowel may easily be ruptured with what may seem to the operator to be no more force than is justified in attempting to overcome the natural obstructions in this part of the passage. The bulbous-pointed bougie on the flexible stem appears a priori to be the most suitable for the exploration, but it is much more difficult to pass than the soft-rubber instrument. O'Beirne gives the following description of the way to pass his tube : " A gum-elastic catheter of the largest size was in- serted into the anus, and passed to the height of about two inches up the rectum, where its further progress was felt to be opposed by strong expulsive efforts, which lasted but a few sec- onds, then relaxed, and again became renewed. By first yield- ing somewhat to these efforts, and then taking advantage of the succeeding relaxation, the instrument was gradually passed to the height of seven or eight inches. At this point the resistance was sensibly felt to be much greater than at any former, but, instead of allowing it to yield, the instrument was pressed more firmly upward. Having steadily continued this pressure for about one minute, the resistance suddenly gave way, the tube passed upward as if through a narrow ring," etc. Even with the softest instrument, the moment when the ob- struction suddenly gives way and the instrument passes for- ward will be an anxious one for the surgeon, and the life of the patient may be sacrificed to desire for certainty of diagnosis. A bougie intended for this purpose should always be hollow, and the opening at the lower end should be of a size to admit the small tube of a Davidson syringe, which should be fitted to it before the attempt to pass it is begun. Then, with a basin of warm water close at hand, the bougie may be introduced, and at the first obstruction the bowel should be filled with water until it is moderately distended. In this way the folds of mu- cous membrane are drawn out of the way by the distention of the whole bowel, and one great obstacle is eliminated. The next is the promontory of the sacrum, which is much more easily passed by a soft than by a stiff instrument. Without these precautions, and sometimes with them, the inexperienced examiner will find a stricture in the rectum of nineteen persons out of twenty, no matter how healthy they may be ; and for this reason it is seldom safe to rest the diagnosis of stricture on the fact that a bougie cannot be made to pass. Moreover, a bougie of good size will often pass a stricture small enough to produce great trouble. NON-MALIGNANT STRICTURE OF THE RECTUM. 355 In certain cases information may be gamed by the use of a long, cylindrical speculum, with the patient bending over the table or chair and straining down to bring the parts into view. But the best method in a doubtful case is a careful bimanual ex- amination under ether. Passing the whole hand into the rectal pouch, and then the finger into the sigmoid flexure as far as possible, is by no means free from danger ; still, with a small hand the diagnosis may be rendered certain for all that part of the bowel at present under consideration. I know of no other way than this by which a stricture in the sigmoid flexure, which cannot be felt by external manipulation, can certainly be recog- nized, except exploratory laparotomy. Treatment. — The treatment of stricture of the rectum is both constitutional and local, medicinal and operative. The first question to be answered is as to the advisability of antisyphilitic medication. In recent cases where syphilis is to be suspected this should never be omitted. It is well to exercise caution in this matter, however, and the cases in which the patient should be submitted to this form of treatment should be carefully chosen. The practitioner who considers the majority of strictures as syphilitic, and indiscri- minately uses mercury and iodide of potash, will be mistaken about as often as he who looks upon most of his cases as can- cerous and therefore incurable. The general condition of a patient with a stricture is never up to the normal, and an un- necessary course of medication may do great harm, instead of good. Cicatricial tissue, though the result of specific disease, is be- yond the reach of specific treatment, but, where the case can be seen early enough, much improvement can be gained by a thor- ough course of mixed treatment, and a gummatous deposit or a syphilitic sclerosis may be checked. Mercury and iodide of potash should both be given, neither being relied upon alone. Mercury in the form of an ointment or the oleate may also be administered by the rectum, and the full constitutional effects of the drug may be gained in a very short time by this method ; it is, however, an irritating application, and in cases of much ulceration and sensitiveness it may not be well borne. M. Trelat ' has seen good effects follow internal medication in cases of ano-rectal syphiloma, though Fournier speaks so positively as to their uselessness. He gives two cases in which the disease was of long standing, but yielded to a considerable 'Le Progr^s Med., June 22d, ISyS. 356 DISEASES OF THE RECTUM AND ANUS. degree to the use of mercury and iodide of potash internally, with glycerine applied locally. Van Buren ' has also seen good effects in a case of this kind from the use of the m.odified Zitt- man's decoction, in mild doses, guarded by bismuth, combined with inunctions of the oleate of mercury. There are various means by which the comfort of these suf- ferers may be greatly increased without recourse to operative treatment ; and since in many cases the surgeon is limited to these means in his efforts to afford relief, it is well that they should receive careful attention. The most effectual of them will be found to be a careful regulation of the diet, the adminis- tration of laxatives on occasion, and rest. The diet should con- sist mostly of fluids, preferably milk. If milk is complained of, soups may be substituted. A certain amount of farinaceous food may also be allowed, such as toast, crackers, and mush ; but milk is the basis of the diet, and the other things are only intended to make that diet endurable. Many patients will as- sert from the outset that they cannot take milk, but nearly all can take it, and considerable quantities of it daily for an indefi- nite period, if a little care is exercised in its administration. The bowels should move daily without straining. Should any medication be necessary to secure this daily evacuation, a mild laxative will be found all-sufficient. The mineral waters, or Rochelle or Glauber's salts, answer every purpose. One of the most grateful ways to these sufferers of moving the bowels is to administer an enema of warm water through a long tube which will reach above the stricture. Purgatives are always contra- indicated in stricture of any variety, because they cause strain- ing and tenesmus, increase the tendency to congestion and its consequences, and because where obstruction actually exists or is threatened they may do great harm by exciting violent peri- staltic action in an already weakened and ulcerated bowel. The opposite condition of diarrhoea is more difficult to meet and often cannot be controlled by direct medical treatment, depending, as it does, on the ulceration associated with the stricture. It is best met by diet, rest in the recumbent posture, and bismuth with morphine. The general strength of these patients is to be supported in every possible way, and in all of them where it can be borne cod-liver oil will be found to answer a good purpose. When obstruction actually exists, much may be done in the ■ "On Pbantom Stricture," etc., The Americau Journal of the Medical Sciences, October, 1879. NON-MALIGNANT STRICTURE OF THE RECTUM. 357 way of general treatment before resorting to operation. Food by the mouth should be almost absolutely suspended ; opium should be given in large doses to allay the peristaltic action of the intestine, and large poultices covering the abdomen will be found to give great relief to the suffering. Dr. ISTorman Kerr has derived great benefit from the administration of the extract of belladonna in doses of one or two grains at short intervals, in this condition, but the rationale of its operation is not under- stood. No purgatives should be administered. By these means, combined possibly with gentle dilatation, the life of a patient may be prolonged in comfort. I have often been agreeably surprised at the happy results of such measures, where operative interference was either declined or contra-indi- cated, and they can never be dispensed with though an opera- tion be performed. The various surgical procedures at our command for over- coming stricture of the rectum may be considered in the follow- ing order : 1. Dilatation. 2. Division. 3. Colotomy, Dilatation. — This may be either gradual or sudden, partial or complete. The use of bougies for gradual dilatation is an example of a good practice originating in false ideas. It was first adopted with the idea of destroying the stricture by the effect of medicinal substances applied in this way ; experience, however, soon proved that simple bougies were not less efiica- cious than medicated ones, and the improvement was then sup- posed to be due merely to the mechanical stretching of the part, and the instruments were introduced as often and allowed to remain in as long as possible — an idea still very popular. But as Syme ' pointed out, "it is the effusion of organizable matter in the cellular texture of the part which causes the stricture, and it is the absorption of this deposit which removes the disease. The bougie, by its pressure, excites the action of absorption ; and if the pressure be too great, too long continued, or too fre- quently repeated, there will be a great risk of causing more than sufficient irritation for the purpose, and of inducing again the very condition it is desired to counteract, the consequences of which must be a confirmation and increase of the disease." The rules which should guide the surgeon in this method of treatment are now well understood and generally admitted. The dilatation should be intermittent and not constant. At- tempts at constant dilatation by means of a bougie of any sort which shall remain permanently in place, generally result either ' Op. cit., p. 120. 358 DISEASES OF THE RECTUM AND ANUS. in failure or actual disaster. They are not well borne by the patient, and when their use is persisted in, in spite of the pro- test which nature is pretty sure to make, the rectum becomes irritable, the suffering is greatly increased, and the patient is exposed to the risk of peritonitis and cellulitis. The dilatation should never be forced. A bougie should be chosen which will readily pass the obstruction without stretch- ing ; and if there be any doubt in the operator's mind as to the proper size of the instrument to be used, let one be selected which is too small rather than too large. Such an instrument may be left in for three or four hours each day, or, as is a favorite practice with me, may be put in when the patient goes to bed, and left in all night. Practised in this way, much good may be done by this treat- ment. The patient may be greatly relieved and made very comfortable ; but it must be continued indefinitely. For this reason, I suppose, it is not infrequently used under false pre- tences in cases of hypothetical stricture in hypochondriacal patients ; and most of the reported cases of cure will be found reported by the laity. It has happened to me more than once not to be able to find any stricture after a patient had sub- mitted to a long course of supposed dilatation, and there is but one way of convincing the patient under such circumstances. It consists simply in passing a full-sized instrument its whole length into the bowel. In cases where the stricture is associated with much ulcera- tion, this, too, must be treated by suitable applications while the dilatation is continued. The trjeatment by gradual dilatation alone has to a certain ex- tent been superseded by more radical measures. It is not long since a well-written article on rectotomy in one of our periodi- cals was begun by the statement that the treatment of stricture by dilatation was acknowledged to be a failure. This is by no means the case. The measure may not be curative, but it is, perhaps, as valuable a palliative as is at the command of the surgeon. It is applicable to all strictures, malignant or benign, which are within reach of the anus. When the disease is high up it is not free from danger, and can scarcely be recom- mended, on account of the uncertainty and difficulty of its ap- plication. I have said that this treatment by gradual dilatation was not curative and must be continued indefinitely. I have seen no exceptions to this rule, though many of them are reported. NON-MALIGNANT STRICTURE OF THE RECTUM. 359 In years gone by, this treatment and that of forcible dilatation or divulsion were about the only means of dealing with this affection. Now we have better ones, which will shortly be de- scribed. Divulsion. — The dilatation, instead of being gradual, may be sudden and complete. For this purpose various instruments have been invented, all of them with the idea of tearing open the constriction by the use of a considerable amount of force. There are now several cases on record where forcible stretch- ing with the fingers, either with or without previous nicking with a knife, has been followed by immediate relief to obstruc- tion and faecal accumulation.' What may be accomplished by this method is well shown in the following successful case from Smith:'' "I was called by Dr. Vine to see a military officer, aged forty, who had returned from India in the most miserable plight. He had suffered for several years from chronic diarrhoea, and had not got relief from any measures, and six months previously he had been recom- mended by a medical board to go by sea to England. On his a,rrival at Southampton, on his way to Edinburgh, his native town, he was so ill that he determined to stop in London; and when he arrived there he sent for Dr. Vine, who, on hearing his history, at once suspected something wrong with his rectum, and, making an examination, found an obstruction. I was requested to see him, and I found the patient exactly in the condition of one suffering from strangulated hernia; he was constantly vomiting, complaining of pain, and the countenance was anxious, and he was much emaciated; the abdomen was immensely distended, and it was clear that, if sojne relief were not soon given, this gentleman would die. " In conjunction with Dr. Vine I made a most careful exami- nation, and I found, on introducing the finger into the bowel as far as possible, that it met with an obstruction, but after some time I discovered what appeared to be the opening of the stric- ture, more like a dimple than aught else. I was enabled to in- troduce through this a No. 10 gum-elastic catheter, and through this instrument some faecal matter and air came. I was thus made to see that I had got beyond the stricture. " On the following day the patient was placed under chlo- roform, and I guided a long, straight, probe-pointed knife very 1 Smith, op. cit. Dr. J. M. Matthews, of Louisville, Ky., has recorded one re- markably successful case of this kind. "^ " Surgery of the Rectum." 360 DISEASES OF THE KECTUM AND ANUS. carefully along the side of my left index finger, and fortunately got- its point into the orifice of the stricture. I nicked this on either side, and then got the point of my finger into the obstruc- tion and dilated the orifice as much as I could, whereupon an enormous quantity of faecal matter was emitted, deluging the bed and placing myself and my assistants in a most unenviable- position. The abdomen became quite flat, and the patient be- came at once immediately relieved. No bad results followed this operation ; in three days we commenced dilatation by bou- gies, and I was soon enabled to pass a full-sized rectum-bougie through the stricture. In a fortnight I took my leave of the pa- tient, recommending Dr. Vine to pass the bougie daily. I heard a few weeks afterward that the patient had gone to Edinburgh convalescent and able to introduce the bougie for himself. " In spite of a few such successful cases as the one above, this^ method of treatment has but few upholders, because it has been found to possess no advantages over more gradual dilatation, and to be in itself by no means devoid of danger. The dangers are haemorrhage, laceration and rupture of the bowel, peritoni- tis, and abscess. The relief obtained is not permanent, and the- operation involves the subsequent use of gradual dilatation to preserve the calibre gained. Even when applied to the lower three inches of the bowel, the operation is rough, uncertain^ and unsurgical, and above this point it is scarcely admissible. Nevertheless it has occasionally served a good purpose, and a few happy results are recorded in cases of linear contraction. Division of the Stricture. — The practice of nicking a linear stricture in two or three places as a first step in the treatment by dilatation is a good one and generally devoid of danger. It can usually be done entirely by the sense of touch, with a straight, blunt-pointed bistoury passed along the left index fin- ger as a guide. The operation of internal proctotomy consists in dividing the whole of the stricture tissue in the median line either anteriorly or posteriorly. It is called internal because the incision is con- fined within the rectum and does not involve the sphincter, and it is generally performed with the knife in preference to the- cautery or ecra.seur. Regarding this operation there is not very much to be said. It involves no new principle of treatment, and would seem tO' rank rather with the older procedures, such as nicking and dilatation, than as a substitute for colotomy. There have been many unpublished cases, especially in New York, and I should NON-MALIGNANT STRICTURE OF THE RECTUM. 361 probably express the general feeling of the profession were I to say that it is not looked upon with very great favor. Though at first sight it might appear less serious than the external operation, it is the more dangerous of the two — the sphincter preventing the free discharge from the wound and increasing in this way the liability to pelvic inflammation. The danger of haemorrhage is not very great when the incision is confined tO' the median line, but, should there be trouble from this cause, the advantage of a free external wound in controlling it will at once be manifest. When the cut is anterior as well as poste- rior, the anatomical relations must be borne in mind, lest the peritoneum in the female, or the bladder in the male, be. wounded. External proctotomy involves not only the division of the stricture, but of all the parts below, including the anus. This is the operation usually accredited to Nelaton, and more re- cently advocated by Verneuil, Panas, and others. It may be performed in several ways, and with the knife, galvano-cau- tery, or ecraseur. The operations with the galvano-cautery and ecraseur were invented by Verneuil,' and have been prac- tised by him more than by any other surgeon. The operation, as performed by him, consists in passing the left index finger through the stricture as a guide, and then plunging a trocar from a point in the median line, just in front of the tip of the coccyx, into the rectum, on to the tip of the finger above the stricture. After drawing out the trocar a fine bougie is passed through the canula into the rectum and brought out at the anus. Removing the canula, the bougie is replaced by the chain of the ecraseur, and the operation is com- pleted. The same section may be accomplished by repeated strokes of the galvano-cautery or thermo-cautery knife. Both these measures are intended simply to prevent haemorrhage, and have no other advantage over the knife, and by any of the methods all of the stricture tissue and the parts below may be divided. Nelaton's method was the simplest of all, and was to intro- duce the left index finger as far as the stricture, and, with this ^Verneuil: " Des retrecissements de la partie iaferieure du rectum, et de leur traitement curatif ou palliatif par la rectotomie lineaire, on section longitudinale de rintestin a I'aide de I'ccraseur," Gaz. des Hop., October 26tli, 29th ; November 7tli, 9th, 12th, 16th, 19th, 1872. "Traitemeat palliatif du cancer du rectum au moyen de la rectotomie lineaire," Gaz. Hebdom., March 27th, 1874. 362 DISEASES OF THE RECTUM AND ANUS. as a guide, to pass in a blunt bistoury and divide all the soft parts below the stricture as nearly as possible in the median line. By pulling open the lips of this incision, the stricture ■comes plainly into view and may be divided by a second in- cision. For this purpose I employ the knife shown in Fig. 122. It is ■simply the lithotomy knife of Blizard, made heavier in the back and at the handle; for with an ordinary bistoury there is great risk of breaking the blade in the midst of the stricture tissue, which is often as hard as cartilage, and thus having an awk- ward accident. The blunt point on the end of the blade is a great convenience in passing the knife along the index finger, avoiding, as it does, all risk of wounding the operator. The best position for the patient is the lithotomy position, and the whole incision may be made at one stroke. The blade should be passed fairly through the stricture before the cutting is begun, .then the stricture is divided completely, as near as possible in the median line posteriorly, and finally the incision is Fig. 122.— Proctotomy Knife. continued downward and outward, growing deeper as it ap- proaches the perineum, till all the soft parts are severed between the anus and the tip of the coccyx. In this way a large triangu- lar wound is made, the apex being Avithin the rectum, above the stricture, and the base at the skin, and all the stricture tissue is •completely cut through. There will generally be a free gush of blood when the cut is made, and the rectum should at once be packed in the manner already described, without waiting to try any other method of stopping the bleeding. This is a precaution which should never be omitted. It is this haemorrhage, and the trouble of removing the lint with which it is almost always necessary to stuff the rectum, which has led some to operate with the thermo-cautery. The bleeding is absolutely nothing, and the wound is dressed by its ■own eschar, thus saving much distress to the patient. It may be asked. Why should so large an incision be made, and so much tissue be divided below the actual disease ? The answer is simple. In the first place, this incision provides for free NON-MALIGNANT STRICTURE OF THE RECTUM. 363 drainage and discharge in the most effectual of all ways, by fur- nishing a dependent gutter- shaped opening which cannot become closed. This is better than any number of drainage tubes, and it is this alone which makes the external operation a safer one than the apparently slighter internal incision. In the second place, by this incision the sphincter is com- pletely divided and another great point is gained. The opera- tion we are now considering, it should be remembered, is no- thing less than a substitute for colotomy in the same class of severe cases for which that operation is generally considered the only relief. One point which is exceedingly well brought out by a study of these cases is the important part played by the sphinc- ter muscle in the sufferings accompanying severe cases of stric- ture and ulceration, and the relief which may be obtained by its simple division without interference with the stricture itself. In one case of Verneuirs, for example, there was a stricture Mgh up, and yet, under a mistaken diagnosis of spasmodic stric- ture at the anus, the sphincter was cut through with the galvano- cautery, while the real cause of the trouble was untouched, and yet there was entire relief from suffering. The same experience has been repeated often enough to establish the general princi- ple that free division of the sphincter is not only a justifiable therapeutic measure for the relief of the pain attendant upon either benign or malignant stricture or ulceration, but is often the best means at the surgeon's command for allaying suffering. By the external operation, then, the obstruction is divided, and one great cause of suffering is abolished, and both are ef- fected by the same stroke of the knife. The after-treatment of the incision is very simple. When the rectum has been tightly packed with picked lint, it will usu- .ally cause more or less uneasiness on the following day, unless the patient be under the influence of opium. For this reason I generally remove enough of it on the following day to give the patient ease, and the remainder is allowed to remain until sup- puration has commenced. It may usually all be picked out by the third or fourth day without causing any pain. The subse- quent treatment of the incision itself consists wholly in cleanli- ness, which rhay be obtained by gently syringing the part with warm water and a little carbolic acid. 'No particular attention need be given to regulating the passages. The first one after the operation will often be the only comfortable one the patient has experienced for years, and, unless there is some special reason for interference, they may be left entirely to nature. 364 DISEASES OF THE RECTUM AND ANUS. At the suggestion of Weir I have come to adopt a modified operation in these cases. Internal proctotomy exposes to great danger of periproctitis, and external proctotomy involves pro- longed convalescence from delay in closure of the external in- cision through the sphincter — a delay sometimes of months. Weir's idea was, after an internal division, to run a drainage tube from the bottom of the cut out at the tip of the coccyx, to leave it in for three or four days till the danger of periproctitis had passed, and then to remove it. I have done this in several cases with good result, and it is the method I now prefer. Regarding the operation of proctotomy from every stand- point, I have been somewhat disappointed in it. I have never seen in my own practice any of the perfect cures reported by its advocates in France. True, it greatly shortens the treatment by dilatation, and it gives immediate relief to obstruction, but it is not curative and is only preparatory to the subsequent con- tinuous use of the bougie. In malignant disease, as a substitute for colotomy, I have abandoned it, having had two fatal cases. In non-malignant strictures of the less severe form I always employ it, and follow it after a few weeks with systematic dilata- tion with the short bougie, left in several hours. Although I cannot say I have ever seen the induration of a stricture entirely disappear, I have by these means, combined with topical appli- cations to the ulcerated surface and the prolonged administra- tion of the tincture of arbor vitse, made several of my cases so comfortable that they no longer consider themselves as uncured and have abandoned all treatment. Indeed, my success has been something of a surprise to myself, and has led me to give a much more favorable prognosis in these cases than I did in the early years of practice. Excision. — The operation of excision, which is generally ap- plied only to cancerous strictures, and which will be fully de- scribed under that head, has also been applied to simple stric- tures. I have done it in a few cases and have been satisfied with the results. There is but one other means of dealing with non-malignant stricture — colotomy. In the ordinary run of cases this will not be necessary, but in some of the more severe forms, those at- tended by much ulceration, fistulpe, etc., where the patient's strength is gradually giving way under the pain and loss of sleep caused by the frequent movements of the bowels, this is the proper line of treatment. After colotomy some of these cases will heal, and the artificial anus may be closed by opera- NON-MALIGNANT STRICTURE OF THE RECTUM. 365 tion. I have some cases, now in very fair health, who were very near the point of death when this operation was performed. In stricture involving the anus only, and extending not more than five cm. into the rectum, the following operation is recommended by Esmarch : ' Fig. 123.— (Esmarch.) The anus is divided in the median line front and back, as shown in Fig. 123. The mucous membrane is dissected up in front and behind Fig. 1S4.— (Esmarch.) until it can be drawn into the outer angle of the skin incision, as shown in Fig. 124. The mucous membrane is then sutured to the free edges of the skin incision, with the result shown in Fig. 125. This operation is particularly adapted to strictures of slight 1 L. c, p. 124. 366 DISEASES OF THE RECTUM- AND ANUS. extent due to contraction of the skin of the anus — such as might be caused by burns or by too free removal of skin in the operations for hsemorrhoids. It is successful in that it draws down healthy mucous membrane to take the place of cicatricial tissue. Fig. 125.— (Esmarch.) In another class of cases the injury to the lower part of the rectum may have been so extensive that to'dissect up and dra"w down sufficient mucous membrane to transplant into the anus. Fig. 120.— CEsmarch.) # # would be attended by danger. These are cases in which more or less extensive periproctitis has resulted in contraction. In them the skin around the anus must be drawn into the orifice to- NON-MALIGNANT STRICTURE OF THE RECTUM. 367 supplement the mucous membrane, instead of vice versa, and for this Dieffenbach has recommended the following operation : An incision is made front and back, as in the former case, but extending only as far outward as the margin of the anus. ;;?;^ ir ^# Fig. 127.— (Esmarch.) (Fig. 126), and this is joined by a semilunar incision anteriorly and posteriorly, as shown in Fig. 126. The flaps of skin included in the semilunar incisions are next Fig. 128.— (Esmarch.) carefully dissected up from the cellular tissue, as shown in Fig. 127, drawn into the anal incision, and sutured, as in Fig. 128. Within the last few years a new method of treating stricture- of the rectum has come in vogue — that by electrolysis — and it 368 DISEASES OF THE RECTUM AND ANUS. may be worth while to add. my testimony to that of others re- garding it. I have tried it extensively, and, I believe, according to the most approved methods. As far as ahsorption of the stricture goes, I have found it a delusion and utterly valueless. By a combination of dilatation and cautery action I have known it ,to do good, but with either the ordinary bougie or a knife I can do much better. CHAPTEE XIII. CANCER. In a general way it] is undoubtedly true that new growths in the rectum, when benign, increase slowly, tend to grow away from the wall of the bowel, to form pedicles for them- selves and to project into the calibre of the canal, to remain movable, and not to involve surrounding parts; while with can- cerous formations the tendency is just the opposite. In this way the diagnosis between a benign polyp and a cancerous infiltra- tion of the wall of the rectum is generally easy. But there is a class of tumors which occupies the border line between the benign and the malignant, in which the diagnosis, either clinically or with the microscope, may be difficult and ■even impossible. In fact, recent careful study of these rectal tumors goes far to break down the lines between the varieties which are usually drawn; and Cripps,* who has done such care- ful and valuable work in this department, is inclined to group nearly all of them under the single head of adenoma, holding that all are primarily affections of the glandular element. The true nature of the growths may perhaps best be gleaned from a comparison of Fig. 129 with Fig. 107, the latter being a benign polypus, and the former a malignant growth, but both being adenomata. According to Cripps, the names malignant, semi-malignant, and simple adenoid will cover both the benign and cancerous growths of this part of the body, except possibly the form of colloid. Generally, but not always, it is possible to distinguish between them both clinically and microscopically. After speaking of the innocent growth, which is soft, has a fairly marked pedicle, and projects into the cavity of the bowel, he says: " In the more malignant varieties, the new growth fre- quently spreads as a thin layer between the muscular and mu- cous coats. In this form it often occupies several square inches of the bowel, while its thickness does not exceed a quarter of an ' " Cancer of the Rectum," 1889. 24 370 DISEASES OF THE RECTUM AND ANUS. inch. At first the mucous membrane lies intact over such a layer, but eventually it gives way by ulceration. This ulcera- tion sometimes begins at more than one point, so that the mucous membrane becomes honeycombed, and portions of the subjacent growth may even sprout through it. The destructive process not only destroys the mucous membrane over the surface of the growth, but after a while the new growth is itself destroyed by ulceration. While destruction is proceeding toward the centre, the growth is advancing toward the circumference. In this way a crater-like mass of disease is produced, the centre of which consists of dense fibrous tissue belonging to the muscular coat of the bowel, which appears for long to resist the ulcerative pro- cess. The margin of the crater consists of the mucous mem- brane of the bowel, heaped up by the extending growth beneath it, tucking it over in such a manner as to overlap the healthy Fig. 129.— Cancer of the Rectum— Malignant Adenoma. ( Stimson.) membrane. The border is at times so irregular as to represent a series of nodules rather than a continuous line." Stimson ' has also made a careful study of these growths. He says: " If it is admitted that cancer of the rectum is essentially a glandular or epithelial affection, one having its origin in the mucous membrane, the borders of the growth, as being the freshest, most recent portions, must be examined, as in carcino- ma of other organs, for evidences of primary changes and mode of development. These changes consist of hypertrophy of the mucosa by hypertrophy and hyperplasia of its epithelial ele- ments, together with an abundant development of embryonal connective tissue between the tubules. They are the same as those found in a variety of neoplasm of recognized benign cha- 1 " A Contribution to the Study of Cancer of the Rectum," Archives of Medicine, August, 1879. CANCER. 371 racter known as polyp of the rectum or polypoid adenoma. The formation of a pedunculated growth with a tendency to isola- tion in the one case, and of a flat growth with a tendency to spread laterally and into the underlying tissue in the other, may be explained partly by mechanical causes and partly by the de- gree of intensity of the changes in the submucous connective tissue. If the primary change occupies a limited area upon a natural fold of the mucous membrane, and if the muscularis mucosae remains unbroken until the young embryonal cells pro- duced below it, in consequence of the neighboring irritation, have had time to develop into adult fibrous tissue, the natural retraction of this new tissue narrows the base of the fold, giving it at once a polypoid form and opposing by its greater density a stronger barrier to the extension of the epithelial formation in this direction. The pedicle once formed, the neoplasm increases in the direction open to it, that is, into the lumen of the canal in all its diameters, and the dragging to which it is subjected by the constantly recurring passage of the faeces lengthens its pedi- cle and tends toward its final separation. " On the other hand, if a broader area is occupied by the pri- mary change, or if the processes are more intense and rapid, the pedunculation is absent or less perfect, and the epithelial growths of the mucosa break through immediately, or after an interval spent in overcoming the greater resistance offered hj the partial pedunculation, into the submucous tissue. Once es- tablished in that region, the spread of the disease is easy and its ultimate generalization a question only of time. "The second and final barrier to generalization is presented by the muscular coat of the intestine, but it is a barrier in which are many gaps, large ones along the lines of the vessels, and in- numerable small ones in the fine meshes of connective tissue which separate the muscular bundles and are continuous with the submucous tissue on one side and the pararectal tissue on the other. Here, too, the intensity of the process materially af- fects the rapidity of its extension ; for if the proliferating con- nective tissue, which is most easily implicated while it is in the formative stage, is allowed time to reach its full development, to become fibrous, it forms, as it were, a second line of defence capable of offering a certain resistance after the first line has been carried." With a full appreciation of the importance of the conclusions which Cripps has reached, it may still be well, in a work of this kind, to call attention to some of the clinical characters of some 372 DISEASES OF THE RECTUM AND ANUS. of the different forms of malignant disease as found in this part of the body. Of all the varieties of true cancer, the one most frequently met with is epithelioma, and this presents itself, here as else- where in the body, under two forms distinguishable with the microscope and clinically. The first (cancroid, lobulated epithe- lioma) contains the characteristic onion-like nests of squamous epithelium, and is the same form so commonly seen in the lip, though rarely about the anus. It has its point of origin at the anus, and not within the rectum, and begins as a hard, dry, warty nodule. It is slow in progress, covered at first with firm epidermis, and only begins to ulcerate late in its course. It sel- dom spreads far up the rectum, but tends rather to involve the integument, which it may destroy to an extent similar to that sometimes seen in the same variety of disease about the face. This form of disease is rare. In the other variety (cylindrical epithelioma) the cells are columnar, and the growth resembles in minute structure the mucous membrane from which it springs. This variety, on the contrary, chooses the rectum proper for its development, and is found above the internal sphincter. It is easily distinguished from the former, but not so easily from a scirrhus which has begun to ulcerate. It is softer than the other, more vascular, and therefore more prone to bleed and undergo extensive degeneration and ulceration, and it rapidly infiltrates surrounding tissues. Early in its course it is movable on the subjacent tissues, but it is seldom seen by the surgeon at this stage. At a later period it presents itself as a soft, friable mass seated on a hard, infiltrated base ; ulcerated in spots, the edges of the ulcers being hard and raised. At this stage the growth will yield on pressure the well-known cancer juice con- taining cells and nuclei, and it may be difficult to distinguish it •from a tumor which began in the submucous tissue as a hard mass and subsequently underwent degeneration. Next to epithelioma, scirrhus, or hard cancer, is the variety most frequently met with in the rectum. It arises, not. like epi- thelioma, in the nnicous membrane, but in the submucous con- nective tissue ; tlierefore, in the earh^ stages of its growth the membrane is found normal and movable over the hard mass be- neath. When cut into it shows the characteristic raw-potato- like hardness of scirrhus. and there is no distinct line of demar- cation between it and the adjacent tissues. From the original tumor are often seen, and sometimes felt, hard fibrous bands spreading out in various directions, generally longitudinally in CANCER. 373 the bowel — the processes or claws from which cancer takes its name. These tumors may soften down in parts and slough or ulcerate away. When ulceration has begun, a cavity with an irregular outline is formed in the midst of the hard cancer tissue, from which issues a foetid discharge mixed with more or less blood and pus. Although a large part of the growth may die in this way and be discharged, the steady increase in the disease is not checked. Indeed, the growth often seems to be most rapid in the bed of the part which has been destroyed. This form of cancer is said to be most apt to show itself first on the anterior wall of the rectum, near the prostate,' and '"to increase most on the side of the chief arterial supply, and in that toward which, by lymphatics and veins, its constituent fluids most easily filter."" It spreads by infiltrating all the adjacent parts, eventually involving all the coats of the bowel, and ex- tending both in surface and thickness till, instead of appearing as a hard, movable spot under the mucous membrane, it involves a great part or the whole of the circumference of the rectum, enclosing it in a dense, contracting sheath. The hardness and contractility of this form of disease are the chief clinical facts upon which a diagnosis rests ; and yet, leaving out of consider- ation the history of the case, it will often be impossible to distin- guish between the gross appearances of scirrhus and those of simple fibrous stricture. Encephaloid has its primary seat in the glandular tissue of the mucous membrane. It is enclosed in a capsule of connective tissue, from the internal surface of which spring trabeculse which divide the mass into lobules. On section it may be com- paratively firm or nearly fluid, and almost white or stained red with blood. It is often very vascular ; large vessels may some- times be seen on its surface, and large blood extravasations may be found in its interior. The name fungus hsematodes has been applied to a variety of this disease in which, after the capsule has burst, the mass has protruded. The material composing it may resemble brain tissue (from which it is named), or it may be more spongy and shreddy, like placenta. On squeezing a section of the tumor a large amount of juice may be obtained, and this, when thrown into a vessel of water, is uniformly dif- fused through it, giving it a milky hue. This is given by Paget as an exceedingly valuable rough test of the nature of the growth. These cancers are rapid in their increase, and may ^ Allingham, Molliere. * Moore. See " Bryant's Surgeiy." 374 DISEASES OF THE. RECTUM AND ANUS. attain an immense size, fairly filling the pelvis. They quickly affect the neighboring lymphatics, and, when enucleated, speed- ily recur. The results of removal are, however, particularly favorable for a short time, as shown by the immediate improve- ncbent-in the general condition of the patient and the disappear- ance of the cancerous cachexia. The extreme softness of the tumor, and the deceptive sense of fluctuation imparted to the finger, may cause a mistake in diagnosis, which may be avoided by the use of the aspirator, or even the hypodermic syringe. When the fluid thus obtained is examined under the microscope, it will be found to contain cells and nuclei, with more or less blood. In colloid cancer (alveolar cancer) the structure is essentially the same as in the last variety, except that the alveolar meshes are filled with a jelly-like material, which in its most natural state is glistening, translucent, and pale yellow. This variety of cancer has its origin in the follicles of Lieberkiihn, or the crypts which surround the rectum. It is not ver}'" rare in this part, and appears in the shape of large, lobulated, fungus-like tumors, which are soft and easily broken down. Under the microscope the mucous contents of the alveoli will be seen to contain cells of various forms, the most characteristic being large, round, and flat, with a nucleus and concentric laminae. The growth rapidly infiltrates the surrounding tissues, and secondary deposits will often be found in the neighborhood of the original mass, the whole tending to undergo cystic degene- ration. The malignancy of these tumors varies in degree, some of them being comparatively benign ; they do not always recur after removal, nor do they readily infect the lymphatics and viscera, being in this respect about on a par with epithelioma. The term colloid is used without much exactness, being applied to almost any growth which consists in part of large, cellular spaces filled with glue-like material. Cruveilhier draws this distinction between colloid and en- cephaloid. The colloid degeneration is not susceptible, as is the encephaloid, of inflammatory action producing gangrene; more- over, if the sanguineous centres are not absolutely foreign to it, it is certain that they are incomparably rarer in colloid than in the cancerous degeneration, properly so-called, where effusions of blood are so often met with — apoplectic centres sometimes so large as to conceal the true nature of the morbid tissue. Colloid alveolar degeneration shows only one mode of de- struction — by encroachment in successive layers; this encroach- CANCER. 375 ment, sometimes rapid when it occurs in the alimentary canal, permits of the re-establishment of the flow of faeces, tempora- rily interrupted by the undefined and often very rapid increase in the degenerated parts ; so that to the gravest signs of faecal retention there sometimes succeeds a more or less rapid separa- tion, with and without diarrhoea. ' Melanotic carcinoma, or black cancer, is by some classed among the true cancers, and by others among the sarcomata. It belongs to the class of soft or medullary cancers, and its dis- tinguishing feature is the development of pigment. Whatever may be said of the microscopic characters of melanoma, it is clinically a very malignant growth, running a very rapid course, and very likely to become generalized. Its clinical history, as relates to the rectum, is to be studied from eleven cases only, ten of which have been given in full in an exhaustive study by ISTepveu, read before the Societe de Chirurgie (1880).^ The cases are reported by the following observers : Schilling," Kopp,* Moore," Maier,° Vircho^w," Ashton,' Gross, ^ Meunier," Gussen- bauer," ISTepveu,'" and Ball.'' From the seven of these cases which are reported with an approach to completeness, several facts of interest are to be gathered. The age of all of the patients was advanced, ranging between forty-five and sixty-four years. Five were in men, two only in women. In the microscopic examinations which were made in five of the cases, the tumor is in every case described as a sarcoma. There is nothing in the symptomatology to dis- tinguish this form of disease from others, except that in one €ase the stools were colored black from mixture with the pig- ^ Cruveilhier : " Traite d'Anatomie Path. Gen.," t, v., p. 69. ^ '' Memoires de Chirurgie," Paris, 1880. ^ Mentioned by Eiselt, obs. v., Prag. Viertelj., bd. 70 u. 76. * " Denkwiirdigkeiten in der arztlichen Praxis," bd. iv., Frankfort, 1838, pp. 505-313. 5 Medical Times, March, 1857. ^ Berichte iiber die Verhandlungen der Naturforscheudeu Gesellschaft zu Frei- burg, 1858, No. 30, p. 516. ' "Pathologic des Tumeurs," Paris, 1867, t, ii., p. 281, note. ^ Asliton, T. J. : "Prolapsus, Fistula in Ano, etc.," 3d edition, Loudon, 1870, p. 163. ^ " System of Surgery," Philadelphia, 1872, vol. ii., p. 589. "^ Bull, de la Soc. Auat. de Paris, 1875, p. 792. " " Ueber die Pigmentbildung in melanotischen Sarcomen und einfachen Melano- men der Haut," Virchow's Arch. f. path. Anat. u. Phys., Ixiii., 1875. '* Op. cit. i«Brit. Med. Jouru., October 12th, 1885. 376 DISEASES OF THE RECTUM AND ANUS. ment — a point which might aid in diagnosis were the tumor so high up as to be out of sight. In rectal examinations it was also noticed that the finger was colored in the same way. The location of the disease was once in the sigmoid flexure, three times in the rectum above the sphincter, and four times at the anus. The size of the growth was generally considerable, sur- rounding the bowel and projecting into its cavity. Sometimes it was firm enough to cause tight stricture, at others ulcerated and broken down in parts. The course of the disease is marked by secondary deposits in the adjacent glands or in the viscera, while the original growth may spread in neighboring organs, and by ulceration cause a foul discharge mixed with blood and pigment. To these may be added the usual signs of incontinence and obstruction. The duration of the disease in no case ex- ceeded three years, but it was generally fatal in a much shorter time. The diagnosis is easy if the growth can be seen, and it is sometimes assisted by the secondary black deposits. In five cases the tumor was removed, but the return was not long de- layed. This form of cancer, though rare in man, is said to be relatively much more frequent in the horse. Most malignant growths are included under Cripps' classifi- cation of adenoma or under the older terms of epithelioma and scirrhus. Hecker ' found twenty-one cases of epithelioma in thirty-four cases of cancer. Cripps says : '' I have failed to dis- cover" (in the rectum) "any growths or tumors consisting en- tirely of the characteristic structure which pathologists desig- nate as scirrhus or medullary cancers, or as belonging to the various varieties of sarcoma. Considering the eminence of many careful observers who have applied such names to these growths, it would be quite unjustifiable to assume that such dis- tinctive structures never form the entire bulk of the tumor ; but I feel bound to state that, with perhaps a more than average opportunity of examining such growths from the rectum, I have been unable myself to discover tumors composed entirely of the distinctive features appertaining to these diseases." Cancer of the rectum, like cancer elsewhere in the body, generally occurs in middle life or old age. There are, however, some interesting exceptions to this rule. AUingham " reports a case of encephaloid in a boy of seventeen, under his own care, and another (variety of cancer not stated), under the care of Mr. ' Schmidt's Jalirblicher, 1870. * " Diseases of the Rectum," London, 1869, p. 265. CANCEK. 377 Gowland, in a boy not thirteen ; Mayo ' speaks of one at the age of twelve, and Godin ^ of one at fifteen years ; Quain ' quotes one, reported by Busk, at sixteen ; and Despres * reports an epithe- lioma in a child of six. After the age of twenty the cases in- crease rapidly in number. With regard to the relative frequency in the sexes, different statements will be found in the works of different writers, according to the experience each has had, and considerable reasoning has been indulged in to explain why the disease should be more common in the one sex than in the other. In a collection of one hundred and seven cases, I have found fifty in males and fifty-seven in females. The locality in which the disease first appears varies. Quain^ says : "1 have most frequently met with the lower margin of the deposit at the distance of from two to three inches above the orifice of the bowel. The part between that just indicated and the anus is next in order of frequency as the seat of the disease, and to this succeeds the lower end of the colon." This perhaps, expresses the facts of the case as well as they could be stated in a few words. The upper limit of the rectum, where it joins the sigmoid flexure, is a common site of the disease, and here it runs a more rapid course than elsewhere, and is more apt to be sud- denly fatal on account of the increased liability to obstruction which the anatomical condition favors. The symptoms of cancer of the rectum may be classified as follows : pain ; those due to contraction, to ulceration, to inva- sion of neighboring parts ; and, lastly, the generalization of the disease and the cachexia. A cancer of the rectum may, and often does, begin so insidi- ously that its existence is not suspected by the patient till it has made irreparable progress. This will be the case particularly when the disease is well up in the bowel beyond the reach of the sphincters. The slight sensitiveness of the mucous mem- brane of the rectum proper which permits the existence of extensive ulceration, and the application of escharotics and the performance of surgical operations without pain, has been al- ready referred to. On the other hand, cancer of the rectum is usually attended with great pain, and the character of the pain may be of great assistance in diagnosis. ^ "Injuries and Diseases of the Kectum," London, 1833, p. 188. "^ Molliere : " Traite des Maladies du Rectum et de I'Anus," Paris, 1877, p. 580. 3 "Proc. of the Path. Soc. of London," 1846-47. ^Gaz. des Hop., November 2d, 1880. = Op. cit. 378 DISEASES OF THE RECTUM AND ANUS. Attention has been called to the point in diagnosis that the existence of pain or cramp in the lower extremity in cancer of the rectum is a bad sign, suggesting a direct encroachment upon some of the neighboring nerves, either by implication and pres- sure of the glands, or by direct extension of the original disease. ' In the later stages of cancer the pain is often the most impor- tant symptom to be met by treatment. It may then be due to the irritation of faeces upon an ulcerated surface, to the involve- ment of the anus in the ulceration, or to direct pressure on adja- cent parts, and each of these is to be met by a different and appropriate treatment. The symptoms directly referable to contraction of the bowel are often slight, and differ in no way from those caused by the simple, fibrous stricture of the same part. It is often astonish- ing to the surgeon to meet with an advanced case of scirrhus in w^hich the calibre of the bowel is so nearly occluded as scarcely to permit tlie passage of the end of the finger, and yet in which the patient has never had sufficient uneasiness to call for a direct rectal examination. The haemorrhage from an ulcerated rectum in cancerous dis- ease is seldom profuse enough to be dangerous, though by frequent repetition it may become an important factor in the ultimately fatal result. Above the contraction there often develops an ulceration which is not to be confounded with the breaking down of the cancer itself. When the cancer itself once begins to break down and ulcerate, its extension is limited by no tissue of the body. The bladder may be opened and a permanent fistula result, in which case the passage is generally from that viscus into the rectum ; but the opposite may be the case — and the pain caused by the entrance of faeces into the bladder and their discharge through the urethra is one of the best of all the indi- cations for colotomy. The prostate and seminal vesicles in the male and the recto-vaginal septum in the female may each be destroyed ; in fact, any part near the disease may be implicated. Smith' has recorded a case in which the disease opened into the liip joint, and Molliere ' another in which it invaded the soft parts in the loin. There are two sets of lymphatics which may be involved in malignant disease of the rectum, one coming from the anus > Hilton: " Rest and Pain," p. 163. "^ " Surgery of the Rectum," Loudou, 1871. ••*0p. cit., p. .065. CANCER. 379 and going- to the glands in the groin ; and one coming from the rectum proper and going to the glands in the hollow of the sa- crum and lumbar region. The proper place, therefore, to feel for glandular involvement in disease within the sphincter is along the spine, deep in the pelvis— a simple point which may decide the surgeon for or against operative interference. From what has been said it is evident that there is little in the history which the patient will give of cancer of the rectum to distinguish it from ulceration and stricture of any other vari- ety, except that when a patient of middle age complains of bloody and mucous discharges and difficulty in defecation, ^>vhich have come on within a short time, and is at the same time losing flesh and strength, the examiner's suspicions should be aroused. The diagnosis must rest chiefly upon a physical examination, however, and to make such an examination thor- oughly, and yet safely, requires great care and gentleness, and to properly interpret the conditions which may be found, no little experience and knowledge. In the majority of cases the diagnosis may be made by the history and l3y physical examination with the finger alone. Cancer in this locality is a disease of rapid growth, and when a patient says that stricture has existed any considerable number of years the idea of malignancy may be abandoned. Something also may be learned from the general appearance of the patient, but most of all from the digital examination. When the dis- ease is seen in its earlier stages, the hard, more or less distinctly circumscribed new growth which has infiltrated the wall of the bowel is diagnostic. (Fig. 130.) The great difficulty is to distin- guish between an advanced case where the rectum is partially occluded by hard masses of disease, and an old case of stricture and ulceration which is not malignant. This may sometimes be impossible except by the microscope, and syphilitic disease of the rectum is not infrequently mistaken for cancer. When a soft, friable mass of epithelioma is found seated on a hard, infil- trated base which is ulcerated in spots, the edges of the ulcers being hard and raised, the diagnosis is also easy. Cancerous stricture of the sigmoid flexure, or of the upper part of the rectum above the limit of digital examination, is the most difficult to diagnosticate, and may sometimes escape the most thorough search. It may also end fatally from acute in- testinal obstruction before it has caused sufficient symptoms to make its existence suspected ; for this part of the canal is very movable, easily forced out of its natural relations, and subject 380 DISEASES OF THE RECTUM AND ANUS. to complete occlusion by an amount of new growth which lower down in the rectum would cause only slight difficulty in defeca- tion. I know of no other means of diagnosis in these cases than those already described under non-malignant stricture at this point ; but the experienced examiner, if he suspect malig- nancy, is much more cautious than with non-malignant disease in the use of the bougie, for he knows how easily a cancerous stricture will tear and cause sudden death. In cases where the condition is more complicated and where secondary deposits — in the liver, for example — have begun to- Fig. 130.— Cancer of the Rectum. (Agnew.) do their fatal work before actual obstruction has begun, the symptoms of stricture may all be obscured by the presence of others which shall more readily attract the eye. In one case I had made the diagnosis of cancer of the liver with ascites and great intestinal disturbance, some time before my attention was called to the rectum, and it became evident by examination that the affection of the liver was secondary to malignant disease high up in the rectum, which was also gradually involving the pelvic viscera. Treatment. — The treatment of malignant disease of the rec- tum is designed to be either curative or palliative. In a small CANCER. 381 number of selected cases a cure is, perhaps, possible, as with cancer of feeble malignancy in other parts of the body — e.g., epithelioma of the lip. At all events, the disease may be re- moved, and its return delayed for many years. This fact may 'he accepted as proved by a sufficient number of carefully exam- ined cases, from which the chances of error in diagnosis and sub- sequent history have been eliminated. Cure can, however, only be effected by excision. The operation of excision, which, after being fully described and ably advocated by Lisfranc in 1830, was allowed to fall into disuse, has again, within the past few years, become popular. It would probably be a waste of time to inquire to whom the credit of reviving it is due. Cases of its occasional performance are scattered through the surgical literature of the rectum from the early part of the century to the present, and just now it is at the height of its popularity. Like every other surgical pro- cedure at that point of its history, it is perhaps also occasion- ally done when it were better to be content with less radical measures. As a result of a careful search among the statistics of this operation, Cripps' gives the following figures : Out of a total of sixty -four cases, eleven died as a direct result of the ope- ration, six from peritonitis, one from cellulitis, and four from accidents incident upon any surgical interference. In the fifty-three cases of recovery, the subsequent history is unknown in sixteen, and in three more the diagnosis was so doubtful as to exclude them from the list. We have, then, a re- mainder of thirty-four, in whom the disease returned in twenty; but of these twenty, several were operated on a second time for a recurrence of the growth, or possibly for a small nodule which had not been removed at the first operation, and after this second operation remained free. This leaves, however, a total of twenty-three out of sixty-four operations in which the disease had not returned after an interval varying from a few months to over four years — a limit reached in three cases. This is certainly an encouraging result for this disease, and the fact that undoubted cancer may be removed and not re- appear for such a length of time is decisive. Some operators, however, report better results than these, and some have not been so successful. Curling " gives one case of removal of an epithelioma in which there had been no return in the rectum after seven years, though for one year there had been •' ' a doubt- ' Op. cit., p. 166. - " Diseases of the Rectum," ed. of 1876, p. 164. 382 DISEASES OF THE RECTUM AND ANUS. ful tumor of the pelvis," Velpeau and Yerneuil each report cases in which the cure has seemed permanent, and Chassaignac gives several in which there had been no return after six years. Dieffenbach's thirty cases in which the patients lived many years without a return are generally looked upon with sus- picion. Allingham,' on the contrary, considers the partial re- moval of the circumference of the bowel as unsatisfactory. In all of his thirteen cases in which he was able to follow the progress of the case for one year, there was either a return of the growth in the rectum or the glands in the groin became affected, and there ensued disease in the internal organs. In four cases the disease did not return in the bowel, but in the inguinal glands, proving that it was not due to an incomplete operation. With regard also to his ten cases of total extirpa- tion he speaks very cautiously. He believes that a cure is very uncommon, and not generally to be expected, and he does not commit himself even on the question of the prolongation of life. The mortality, as a direct result of the operation, is generally about twenty-five per cent.^ Billroth ' reports thirty-three cases. • Thirteen died of the- operation, and the remainder all died within two years, most of them of recurrence. The deaths immediately following the operation were invari- ably due to retro-peritoneal suppuration, characterized by acute septic symptoms. Most of them died within from four to eight days. Since, then, we are justified in expecting recovery from the- operation itself , and such a length of life as would not result were the disease left to its natural course, we may ask: 1. What are the dangers and what is the mortality of the operation? 2. In what class of cases is it applicable? 3. What are its results, as a curative and as a palliative measure, and how do these results compare with those of colotomy ? 4. What are the results as regards the subsequent condition of the bowel, and the con- trol of the faecal evacuations? 5. What is the best method of its performance? For the purpose of arriving at a knowledge of what experi- ence has already taught in this matter, I collected, several years ago, the reports of operations up to that time as far as they were ' Loc. cit., p. 277. « Molliere : " Traite des Maladies du Rectum et de I'Anus," Paris, 1877, p. 627. ^"Clinical Surgery: Extracts from the Reports of Surgical Practice betweeni the Years 1860-1876." By Th. Billroth. New Sydenham Society, 188L CANCER. 39,3 then attainable. The list at that time included one hundred and forty cases, and I arrived at the following general conclusions concerning the operation, which subsequent study of the ques- tion has led me in no way to alter. 1. Although there have been a few cases of excision in which the cancer has not returned in a number of years, such a result is so rare as not to justify the exposure of the patient to the risk of immediate death which attends the attempt to remove very extensive disease. Regarding the question of radical cure, we find difficulty in establishing exact dates, and have to take into consideration the reputation of the reporter. We find, however, that in one hun- dred cases (deducting those immediately fatal, and seventeen which passed out of observation immediately after operation) we have five cases of reported permanent cure, in which there had been no return for at least ten years. Three of these are reported by Volkmann, and two by Velpeau. March, of Al- bany, has been credited with another case of radical cure, but the author is much indebted to the present Dr. March for a letter stating that the case of supposed radical cure reported by his father passed out of observation at the end of one year. There are some other cases which have been included in the category of permanent cures — cases in which the disease had not returned in four or five years — but the great majority recur within the first year and are fatal within two. 2. The operation is therefore of great value as a palliative measure, and as such it compares favorably with colotomy both in prolonging life and relieving pain. The treatment of cancer of the rectum by excision has not yet been accepted by the surgical world as a substitute for other measures, even in cases best adapted for the operation, although it cannot be denied that a radical cure has sometimes been ob- tained, and that in many other cases life has been prolonged beyond what could have been hoped for by any other .means of treatment. It is no less true that the operation is one of great danger, and that there are not lacking those whose experience has led them to believe that life was rather shortened than lengthened by it. By these it is claimed that in colotomy we have a safer method of relieving pain and delaying the progress of the growth, and in both these ways prolonging life. Excision can scarcely be judged in comparison with colo- tomy, being applicable properly only to an entii*ely different class of cases. In cancer above four inches from the anus. 584 DISEASES OP THE RECTUM AND ANUS. colotomy is about the only means of relief. In cancer within four inches of the anus other plans of treatment may be prefer- able. In cases properly chosen, where the disease is not so exten- sive as to render its removal one of the capital surgical opera- tions, we know of nothing better as a palliative measure, and this fact cannot fail to be deeply impressed upon the reader of these cases. The statement that all suffering was relieved is almost invariable. In almost every case attention is called to the great improvement in general health, the loss of pain, and the increase in strength. Patients go away believing them- selves radically cured, return to their employments, and are re- ported by the French surgeons as " parfaitement gueries" a few weeks after the operation. It has been claimed ' against this operation that even when a good immediate result is obtained, it may shorten life by hastening the return and final progress of the disease. Unfor- tunately, it is difficult to tell in any particular case how long a patient would have lived had the disease been left to its course ; iDut, accepting as a basis for comparison Allingham's estimate of the average duration of life in cancer of the rectum as two years or less, we are justified in concluding that in all cases where life was prolonged more than one year and a half after the time of operation (the operation generally being done late in the disease), this length of life may fairly be attributed to the surgical interference. This estimate is manifestly a small one, for ;a study of the cases makes it evident that many who did not [live eighteen months after the operation yet gained a considerable length of comfortable existence ; and there is notliing to prove that in any case the operation hastened the natural course of the disease. I have carefully searched the record of cases in which a re- turn of the disease within six months of the time of operation is reported, to discover whether here also there was any marked Telation between this result and the nature or extent of the disease at the time of operation ; but it is especially at this point that the table fails us. A proper answer to this question involves not only a careful report of the extent of the disease, but a microscopic study of its character, and such data are given only in a relatively small proportion of cases. I believe, however, that the cases show a marked relation between the 1 Labbe: Gaz. Hebtlom., Juue4th, 18th, 1880. CANCER. 385 rapidity of the growth before operation and the speedy return after removal. 3. When the disease reaches above four inches from the anus, or involves neighboring parts so as to render its entire removal questionable, the operation is contra-indicated. The Germans have apparently no limits to the applicability of this operation. They perform it in cases of the most ex- tensive disease, opening the peritoneum, exsecting the sacrum when necessary to reach its upper limit, and removing the pros- tate and base of the bladder when they are implicated, bal- ancing the risk of immediate death from the operation against the chance of radical cure or prolonged immunity from return. Conservative surgeons will hesitate long before accepting this view, for, although very satisfactory results have been obtained in such cases, a study of cases shows that the frequency of the fatal result is in direct proportion to the extent of the opera- tion attempted. The rules for the selection of cases laid down by Lisfranc were these : when the bowel is movable, in other words, when the disease has not involved surrounding parts, the operation should be undertaken. When, on the other hand, the disease is more extensive and reaches higher, he leaves the question to be decided by future experience. I believe that ex- perience, in spite of the favorable reports from the German ope- rators, will ultimately decide in favor of inguinal colotomy in this class of cases. Although there is a very evident relation, which is shown by a study of the statistics of the operation, between the extent of the operation attempted and the favorable or unfavorable results obtained, a fatal result may follow the extirpation of disease which is comparatively slight in amount. The three great dan- gers of the operation are peritonitis, pelvic cellulitis, and septi- roportion of cases; that the dangers are great and the results as to comfort very unsatisfactory; and yet that in pro- perly selected cases — those seen early — much good may be done CANCER. 399- by operation, and in those seen late an astonishing amount of lower bowel may be extirpated without an immediately fatal result. The operation of excision has, with the recent advances in abdominal surgery, been applied to cancer of the sigmoid flex- ure and colon. Kendal Franks ' has recently collected fifty-one cases, from which he draws the following conclusions: 1. The operation rarely effected a cure. 3. As a palliative measure it was justi- fiable and frequently demanded. 3. Recurrence generally took place in the liver or mesenteric glands, and gave an easier death. 4. The mortality after immediate suture of the gut, and after the formation of an artificial anus, is nearly the same. 5. Im- mediate suture is preferable to the formation of an artificial anus. 6. The death rate has been reduced in the later cases, and a further reduction may be anticipated. In the discussion following the paper, Bryant said his first impressions on reviewing the whole number of cases were against the operation. In malignant disease of the lower bowel we had to choose between colotomy, colectomy, and tiding the patient down hill, and he thought the conclusion was in favor of colotomy, which gave comfort to the patient, prolonged life, and gave all the benefit colectomy seemed to do. On looking over the table it appeared that only one of the fifty-one cases was cured; there were direct failures in forty per cent, and indirect failures in the others. The operation was, therefore, dangerous and could not be recommended. Treves also spoke to the same effect. The operation was simply palliative and not curative. Only one case of the series presented no recurrence after four years; and yet cases of can- cer which had been colotomized commonly lived three or four years. For six years he had not seen a case in which he would have dreamt of removing the colon for malignant disease. There was a remarkable difficulty in uniting certain parts of the colon. The transverse part and the sigmoid, being covered by peritoneum, were easy, but in the c?ecum it was almost impossi- ble, the non-peritoneal surfaces declining to heal, and in many cases an abscess formed outside the gut. Weir has collected and analyzed thirty-five cases with the following result: In all save one the disease involved the large intestine, and in an additional case the operation was aban- doned, only a small piece being removed for microscopic exami- 1 Lancet, March 2d, 1889. 400 DISEASES OF THE RECTUM AND ANUS. nation. Five of the cases done during acute obstruction all died of shock. In thirty-three cases there was a mortality of 51.5 per cent, only a little greater than that resulting from excisions for other causes than cancer. Aside from the shock, ten died within forty-eight hours and four died of peritonitis from the escape of faeces. To Weir's table the case of Penrose, Med. Neivs, December 15th, 1888, should be added. It was one of cancerous obstruction of the descending colon, treated by colectomy and by subse- quent successful closure of the artificial anus. PaUiative Treatment. — The palliative treatment of malig- nant stricture of the rectum is in many points the same as of non-malignant. The relief of pain is perhaps a more marked indication in most cases. The pain depends on two classes of causes — those which make cancer a painful disease wherever met with in the body, and those which are due solely to its situa- tion at the outlet of the bowel. Among the first we have pres- sure upon adjacent parts and involvement of neighboring organs and nerves ; and among the second, the passage of faeces over an ulcerated surface, and spasm of the sphincter muscle from ir- ritation caused by its direct implication in the cancerous growth or by the passage over it of irritating sanious discharges from the sore. From this it is easy to understand why cancer is in one person attended by excruciating suffering, while another may hardly be conscious of its presence ; and why the pain is in some paroxysmal and particularly aggravated by a movement of the bowels, and in others dull and constant, radiating through the loins and down the thighs. For the relief of this symptom we have at our command : a. Regulation of the passages, diet, and the recumbent posture ; h. Anodynes locally and by the mouth ; c. Partial destruction of tlie growth by means of the curette, cauterization, or partial extirpation ; d. Division of the sphincter ; e. Colotomy ; /. Electrolysis. The passages should be kept soft but not fluid, as any ap- proach to diarrhoea always aggravates the suffering. This may be done partly by the choice of food, which needs to be regu- lated with great care on account of the tendency to gastric dis- turbance, more or less of which is always present ; and by the administration of the mineral waters, which are generally suffi- ciently laxative for the purpose. Rest in the recumbent posture is a means of palliation of great value, sometimes giving more relief than anodynes. These latter may be given both by the mouth and in enemata, and if possible should be pushed to the CANCER. 401 point of relieving suffering. Tiiis seems so plain a duty which the surgeon owes to his patient that we need not stop to discuss any possible moral bearing it may have. If the agony of this incurable malady could always be relieved by the administration of opium, the question of operative interference would arise much less frequently than it now does. But, unfortunately, the constant administration of this or any other narcotic will some- times cause gastric and mental disturbance harder to bear than the disease. By using the finger-nail, a curette similar to the one used in the uterus, or a scoop such as is used for submucous uterine tumors, the pain may in some cases be greatly relieved by a removal of a part of the growth when of the soft variety. The same may be done by the application of chemically destruc- tive agents or the actual cautery, and even by the partial exci- sion of the mass, merely as a means of relief and where there is no question of cure. I have already called attention to division of the sphincter muscle as a palliative measure in the treatment of rectal disease, and all that was said regarding the treatment of benign stricture applies equally well to cancer. With regard to husbanding the sufferer's powers and pro- longing life, much may be done by careful nursing and medica- tion. Milk is by far the best diet, and cod-liver oil in small doses the best medicine where it can be borne, for it has a laxa- tive as well as a tonic action. Cleanliness is best obtained by frequent washing out of the rectum with disinfecting fluids, as permanganate of potash, carbolic acid, and chloral. The means of overcoming obstruction in malignant disease are also much the same as in benign stricture, and to what has already been said on that subject we must again refer the reader. Before commencing to treat the obstruction as such, it is well to remeniber that an exceedingly small outlet to the ali- mentary canal may, with proper care, be made to answer all the calls of nature. We see this constantly in cases of stricture, both simple and malignant, where the finger cannot be forced through the obstruction, and yet there is no retention; and in such cases, by the judicious administration of laxatives, life may be made so comfortable that the question of surgical inter- ference shall be postponed indefinitely. When, however, ob- struction is actually threatened, much may be done by the medi- cal means already pointed out. When dilatation becomes necessary, it should be of the gentlest kind. The cases of fatal accident from perforation of the bowel where the coats have been weakened by ulceration 26 402 DISEASES OF THE RECTUM AND ANUS. are already numerous enough to serve as warnings for all future time. The best of all dilators in cancerous disease is the finger, either that of the patient or the nurse, passed daily, and none of the mechanical means with which we are acquainted equals this for safety and comfort. When the disease is beyond the reach of the finger, a bougie must be used, but the dangers are greatly increased, and it will be better at once to make an artificial anus than to incur the S.TIEM/^NN &C0 Fig. 138. — Simon's Sharp Scoop. risk of fatal accident which the use of a bougie high up the bowel certainly entails. The frequency with which the bougie may be used will depend upon the result of its trial. Should much irritation, tenesmus, or haemorrhage follow its employ- ment, the patient will soon refuse to submit to its continuance; while, on the other hand, should the result be favorable it may be employed daily. The softest bougie is the best. If dilatation be found too painful or ineffectual, as it some- times will, recourse may be had to division or partial destruc- FiGS. 139, 140.— Rectal Hooks. tion of the cancerous mass. A double proctotomy may be done in case of malignant disease, and the section of the growth be- tween the two incisions be removed, in this way opening once more the calibre of the bowel and overcoming the obstruction. I have performed this modified operation with great relief, and I have also found that, after making a single free division of the cancerous mass, large pieces adjacent to the cut could be excised with great facility and without danger. CANCER. 40a Relief both to pain and obstruction may sometimes be gained. in tiiis way by a partial destruction and extirpation of a cancer- ous growth, where its entire removal is out of the question and its local return may be expected with certainty. By such mea- sures the evacuations may be made less painful, the spasmodic ac- tion of the sphincter and the rectal tenesmus may be allayed, the- cancerous look may foratime disappear, and the patient recover sufficient strength to resume the ordinary occupations of life. A growth may be attacked in this way either with the knife, cautery, finger, curette, or electrolysis. I have not been well satisfied in several cases with a modified operation which con- sists in first dividing the stricture posteriorly, together with the parts between the disease and the skin, with the cautery knife, next removing considerable portions, if they can be isolated, with the wire ecraseur, and finally resorting to the sharp scoop of Simon (Fig. 138). In these operations the hooks shown in Figs. 189, 1-40 will be found very useful. By these means com- bined a large portion of the disease may be removed, and the lumen of the bowel may be almost completely re-established : and yet I cannot recommend them, having had one case of nearly fatal secondary hsemorrhage and two fatal cases of proctoto- my. If any operation is to be done it should be either colotomy or extirpation, and the mortality of these will be less than that of partial operations. Caustic applications are of no use, except in cases where a fungous mass has protruded from the anus. This may at times, be removed, with great advantage to the sufferer, by the appli- cation of a paste of arsenite of copper mixed with mucilage. The operations for removing a part of the growth with the fin- ger, scoop, or curette may give great relief in the soft varieties- of the disease. The sphincter should first be thoroughly dilated, the anus held open with a speculum, and as much of the dis- eased tissue as possible torn and scraped away. Hsemorrhage, of course, is to be expected, but this is less where the growth is boldly attacked in its deeper parts than when the surgeon is timid and attacks merely the superficial portions, and may be controlled either by plugging the wound with lint and styptics, or by the actual cauter}^ Allingham relates a case in which he entirely enucleated an immense encephaloid with his hand, with the happiest results. As for electrolysis in cancerous as well as other strictures of the rectum, all that can be said for it is that with a sufficiently strong current tissue may be destroyed. CHAPTEE XIY. THE FORMATION AND CLOSURE OF ARTIFICIAL ANUS. The indications for the performance of laparotomy, with or without the formation of an artificial anus, which are most fre- quently met in connection with rectal surgery, are : 1. Congenital malformations. 2. Intestinal fistulae. 3. Severe ulceration of the rectum. 4. Cancer. 5. Intestinal obstruction. The rules governing the attempt to form an artificial anus in the perineum in cases of congenital malformation have been sufficiently dwelt upon in the chapter devoted to that subject, bailing to find the rectum through the perineum, or, from care- ful study of the case, deeming it best not to make the attempt, the rule is to form an artificial anus in the left groin. Attempts at establishing an anus in the anal region after the performance of colotomy are attended with danger and are gen- erally unsuccessful. Perhaps the best authority on this point is embraced in the experience of Mr, Owen, ' In two cases in which after an interval of three months he attempted to es- tablish an anus in the natural position, the end was a fatal peri- tonitis due to the fact that the rectal pouch was completely cov- ered with peritoneum. Dr. Byrd ' has more recently reported a case in which the operation was successful. Kronlein ' also reports a successful case. A child six days ■old had had no evacuation of the bowels since its birth. The anus was extremely narrow and ended in a pouch 2.5 cm, long. An attempt to reach the rectum by an incision through this pouch resulted only in opening the peritoneum, as was shown ' " Surgery of Childhood," Brit. Med. .Tour., February 21st, 28th, March 6th, 1880. ^ " Lumbo-Colotomy in the New-Born for Relief of Imperforate Rectum." Read Ibefore the TriState Med. Soc, St. Louis, October 25th, 1881. (Reprint.) •Berlin Klin. AVoch., 1879, Nos. 34 and 3.'5. THE FORMATION AND CLOSURE OF ARTIFICIAL ANUS. 405 Dy a free discharge of peritoneal fluid. The bowel was then opened in the left groin, and the child lived and thrived. When the child had reached the age of seven months, the rectal pouch could be distinguished, and the original operation was again at- tempted and the rectal pouch successfully united with the lower one. At the close of the report a stricture existed at the place of union, but the larger part of the faeces were already evacuated by the perineal opening. The attempt to re-establish an anus in the anal region origi- nated with Demarquay, and involves, if it be successful, a sub- sequent attempt to close the artificial opening in the groin. Recto-vesical fistula, when not due to malignant disease, may be curable by local operation, but communication between the bladder and the intestine at any point, whether cancerous or in- flammatory, is best treated by colotomy. Cripps,' by his study of sixty-three cases, has found the proportion of inflammatory to cancerous to be forty-five to nine — figures which greatly im- prove the prognosis if colotomy be performed. In these cases it is of the utmost importance to determine as nearly as possible the location of the opening in the bowel before the operation, lest a left inguinal colotomy should chance to give an artificial anus below the point of communication ; and here again Cripps's monograph furnishes the only available statistics. In sixty-three cases the communication was with the rectum in twenty-five ; colon in fifteen ; small intestine in twelve ; unas- certained in six. The rectum was the part implicated in nearly half the cases, and generally at its middle portion. The colon was involved in fifteen cases, and in eleven of these the communication was with the sigmoid flexure. "From these statistics two facts of great importance are established: the one, that communications with the large bowel are about twice as common as those with the small bowel ; the other, that in all the cases of communica- tion with the larger intestine the opening existed either between the rectum and bladder or between the sigmoid flexure and the bladder, so that every one of them would have been relieved by a left lumbar colotomy. The practical importance of this cannot be overrated, for it gives a decided answer to the ques- tion, On which side shall colotomy be performed ? Indeed, there is not a single case amongst the whole number in which there would have been any advantage in opening the right rather than the left colon. The small intestine alone was ' " The Passage of Air and Ffeces from the Urethra." J. & A. Churchill, 1888. 406 DISEASES OF THE RECTUM AND ANUS. involved in twelve cases only, while in five cases there was a double communication in both the large and small bowel.'' AVith our present knowledge it is not always possible to de- cide whether the opening is in the large or small bowel in any individual case. There are two points on which the answer may depend. When by thorough examination, with an anaesthetic if necessar}', disease is found b}' rectal examination, it is fair to assume that the opening is in the immediate vicinity of the disease found. Help may also be furnished by examination of the food passed by the urethra. If it be ill-digested, the fact points to. ail opening in the small intestine, more especiall}' if the evacuations by the rectum consist of tlioroughly digested material. If fragments of perfectly formed faeces are passed with the urine, the inference is that the opening is in the rectum or sig- moid flexure ; and the same inference may be reached from the fact that no fsecal matter finds its way into the bladder when the patient is constipated, but only when the bowels are loose. In these cases, then, left inguinal colotomy is strongly indi- cated ; the only substitutes for it being cystotomy or laparotomy with the hope of closing the communication, neither of which offers as good a chance of prolonging life. The cases of severe, non-malignant ulceration of the rectum, •with or without fistulse, which are incurable by topical treat- ment, offer a third indication for the formation of an artificial anus. These ulcers are generally either tubercular, syphilitic, or chancroidal, and many of them are as incurable as though they were cancerous. They are generally, after a certain time, associated with stricture, and the patient is worn out by chronic intestinal obstruction joined to the exhaustion occasioned by the ulceration with its pain and tenesmus. These cases are beyond the reach of cure either by local applications of any sort or by internal medication. Neither acids, scraping, nor burning will do any good after the disease has become of large extent, and "the internal use of antisyphilitic remedies is worse than use- less. The disease may have been syphilitic at its commence- ment, but after it has existed for a few years antisyphilitic treatment will not cure it and will consequently exhaust the powers ^f the patient. Colotomy in these cases will prolong life indefinitely by re- lieving obstruction if it exists, and by allowing the rectum to become quiescent by giving another outlet for the foeces. Ul- cerations which have resisted all local treatment will heal by THE FORMATION AND CLOSURE OF ARTIFICIAL ANUS. 407 this means ; and should they not heal, will cease to exhaust the patient by pain, tenesmus, and loss of sleep. It is better to admit freely the limitations of our art in these cases, and advocate boldly the only remedial measure in our power, than to go on trying ineffectually to cure old and incur- able ulcerations of the rectum by local treatment. In cancer of the rectum the indications for colotomy are very clear, and there seems to be a growing tendency to earlier ope- ration, though in this surgeons will differ according as they have greater or less faith in certain other palliative measures. Here we have to consider extirpation complete or partial, proctotomy, and electrolysis, as well as colotomy, and to judge between them all which is best. A safe rule may, I think, be formulated thus : Cases of can- cer which are unsuitable for extirpation should be submitted to colotomy as soon as the symptoms of stricture become well marked. Had we any proof that colotomy done still earlier than this would prolong life by retarding the growth of the can- cer, as I believe to be the case, the rule would be still further modified to the point of operating on all cases unsuitable for ex- tirpation as soon as the diagnosis was made; and there are some facts which indicate that this will soon be accepted as the pro- per line of practice. The result of my own study and experience is tending more and more to convince me of the advantages of early operation as the best treatment for all cancers of the rec- tum, except in the few cases which can be completely extirpated early in their growth. In delaying operation till the signs of stricture become well marked, a life may be lost. In stricture high up in the rectum, fatal obstruction may be almost the first sign of the stricture. My own experience makes me cautious in advising delay, unless the disease is well within reach of the finger, so that the extent of the contraction can be clearly appreciated. In one of my cases no diagnosis was made till after fatal obstruction led to an autopsy, the disease being a small annular cancer in the sig- mioid flexure. In another, in which the diagnosis was clear and the disease extended far up the rectum, the patient died of ob- struction while we were trying to arrange a convenient time for a colotomy. I have myself been an advocate of almost any line of treat- ment in these cases in preference to colotomy, for the natural objections to this procedure have been very great in my own mind. I have therefore done more proctotomies and excisions 408 DISEASES OF THE RECTUM AND ANUS. than colotomies, and have fought acute and chronic obstruction from this disease with medical rather than surgical means, often with success that compared favorably with that of colo- tomy. I have warded off threatened fatal obstruction again and again by means other than colotomy, till the patient has finally succumbed to either exhaustion, generalization of the disease, or an intercurrent affection; and have in such cases felt that I had avoided a deformity which I naturally shrank from inflicting. But this prejudice has passed away, as it becomes more and more evident how comfortable a patient may be after colotomy, how little annoyance the artificial opening may cause, and to what an extent life may be prolonged ; and I now advise and practise the operation much more frequently than formerly, simply because I better appreciate the good it may do. Proctotomy, dilatation, electrolysis (by electrolysis I mean destruction of the growth, not absorption) are all means of great value in preventing obstruction in cancer; but none of them prevent the exhaustion which comes from the perpetual irrita- tion of faeces at the disease. Colotomy does both, with no more danger and much more efficiently. I cannot but think that the objections to this operation in the minds of the laity, as well as many of the profession, are more aesthetical than practical and should be discouraged. Colotomy is not a pleasant idea, but the idea is worse than the fact, and, whether pleasant or not, it is the duty of the surgeon to prolong life as long as possible. The only other cases, directly connected with the rectum, in which it may be necessary to create an artificial anus, are those of acute or chronic intestinal obstruction depending upon pres- sure by tumors or upon the constriction caused by bands or masses of plastic exudation in the pelvis. In the formation of an artificial anus the left groin should be chosen for the site of the operation. The colon may be opened either in the loin or groin, and on either the left or right side. There is some uncertainty in the early history of colotomy, and some ambiguity of terms which is apt to mislead. The idea of an' artificial anus was first proposed by Littre ' in 1710, and the incision he recommended was simply " aii ventre" (in the abdomen) ; the design being to reach the sigmoid flexure. He never practised tlie operation wliich at present passes under his name — that of opening the bowel in the groin — but the ope- ration he proposed did not involve the idea of preserving the ' " Histoire de I'Acad. Roy. des Sci. de Paris," 1710, p. 36. THE FORMATION AND CLOSURE OF ARTIFICIAL ANUS. 40& peritoneum intact, and to this point the surgery of the present day has returned. About the year 1770 Pillore, of Rouen, actually performed the first operation of this nature by making an opening into the caecum in a case of cancer of the rectum which caused complete obstruction. The patient survived twenty-eight days, and death was not due to the operation. In 1783 Dubois operated in the same way for imperforate anus, but the operation was unsuc- cessful and the child died on the tenth day. In 1793 Duret, of Brest, opened the sigmoid flexure of a child two days old, and this child lived to adult age. In 1794 Desault practised the same operation without success, and in 1707 Fine, of Geneva, made an artificial anus in the arch of the colon for cancer of the upper part of the rectum, which was also successful, the woman living three months and a half. ' In 1S14 the operation was success- fully performed for cancer of the rectum by Martland ; ^ in 1817 by Freer, of Birmingham ; ' and in 1820 by Pring.* In many of these cases the original operation of Littre was modified to suit the operator ; but in none of them was any attention paid to wounding the peritoneum. An undue prominence seems to attach to the name of Callisen in connection with the operation in the left loin. There was nothing original in his choice of location, nor did he bring out the idea of operating without wounding the peritoneum. He believed that the intestine could be more easily reached from this point than any other, in which he certainly was in error ; and on the whole he condemned the operation in the following words:* "The incision of the caecum and descending colon, tuhich has been proposed, in this state of things (imperforate rec- tum), by means of an incision in the left lumbar region at the border of the quadratus lumborum, to establish an artificial anus, presents a very uncertain chance, and the life of the little patient can scarcely be saved ; nevertheless the intestine may be reached more easily in this place than above in the iliac re- gion." It is in reality to Amussat that the extraperitoneal operation ' "Manuel de med. prat, de Louis Adier de Geneve," 2d edit., 1811. Quoted by Carcopino, These No. 197,1879. "Parallel entre I'extirpation du rectum et I'eta- blissement de I'anus artificiel." ■•'Edinburgh Med. and Surg. Jour., October, 182o, p. 271. ^ Carcopino. These. ■^ London Med. and Physical Journal, 1821. * " Systema Chirurgiae hodiernge," t. i. Haffinite, 1813. 410 DISEASES OF THE EECTUM AND ANUS. in the loin is due, and the operation which he described ' is the one that until recently has been most in favor and the one usu- ally spoken of as that of Callisen — lumbar colotomy, or the ope- ration of Amussat. Lumbar Colotomy. — Against the operation of lumbar colo- tomy there have always been several serious objections. It is a difficult operation to perform, and as usually done involves a great risk of opening some part of the alimentary canal not in- tended. The ground on which it was advocated, that by it the colon could be reached behind the peritoneum, was often false, for the peritoneum was frequently wounded in the attempt to reach the gut. The anus thus formed was awkwardly placed for the patient, so that he could exercise but little care over it without assistance. The operation of closing the fpecal fistula thus formed was a very difficult one. In children the loin ope- ration presented still greater difficulties, for the undeveloped state of the colon renders it much more difficult to find than in •adults, it presents many variations in position, and the relatively large size of the kidney greatly decreases the space in which the operator is obliged to search. In the child, too, the descending colon is almost completely surrounded by peritoneum. In fact, the lumbar operation owed its popularity entirely to the false dread which so long existed against incising the peritoneum. This dread, and the surgery based upon it, have fortunately be- come things of the past. Nevertheless the lumbar operation is applicable to cases of disease of the sigmoid flexure and of the colon in which the inguinal incision would be below the disease, and for this rea- son it will never pass entirely out of practice. The guide to the descending colon is the outer border of the quadratus lumborum muscle, and the guide to the outer border of the muscle is a perpendicular from a point half an inch pos- i;erior to the middle of the crest of the ilium, or to a point half an inch posterior to the middle of a line drawn from the ante- rior superior to the posterior superior spinous process. This point should first of all be accurately determined and marked with ink or iodine, for the edge of the muscle cannot easily be felt in many subjects. The descending colon is here sometimes uncovered by peritoneum to a considerable extent, being behind that membrane and in immediate contact with the transversalis fascia. The patient should be placed upon a liard pillow, so ' "Quelques Reflexions pratiques sur les Retrecissements du Rectum," Gaz. Med. de Paris, 1H39, No. 1. THE FORMATION AND CLOSURE OF ARTIFICIAL ANUS. 411 that the loin may be brought into prominence, and the operator should stand at the back of the patient. The incision should cross the edge of the quadratus obliquely from above downward and from behind forward, beginning at the left of the spine below the last rib, and extending four or five inches. In this way the middle of the outer border of the muscle will correspond to the middle of the incision, and the large branches of the spinal nerves will not be severed. The incision is then carried carefully down, layer by layer, through the latissimus dorsi, external and internal oblique, and trans- versalis muscles, till the outer border of the quadratus is recog- nized; care being taken that as the incision grows deeper it does not also grow shorter, till when the bowel is reached the opera- tor finds himself working in the small end of the funnel. If Fig. 141.— Lumbar Colotomy. possible the outer border of the quadratus should be distinctly recognized before the transversalis fascia is divided, under which lies the colon more or less enveloped in fat. This inci- sion should not be more than three inches in length, for by limiting it to this extent the operator is in a manner compelled to come down upon the point required at which the colon is most likely to be reached, and great weakening in the abdomi- nal wall and consequent prolapse are avoided, and considerable sphincteric power may be gained. Having reached the gut, great care must be used in selecting "the piece to be opened, for it is an easy matter to incise the duodenum instead of the colon. ISTo piece of intestine should be opened till the longitudinal bands in it have been clearly recognized. If this can be done to the operators satisfaction 412 DISEASES OF THE RECTUM AND ANUS. without wounding the peritoneum, so much the better, but otherwise it is much safer to incise the serous membrane, pass^ the hand into the abdomen, and make sure that the colon and not the small intestine is being operated upon. This should, I think, be the general rule in the operation, for in most cases it is very difficult to make sure of the longitudinal bands before the peritoneum has been opened. In a certain proportion of cases the ascending and descend- ing colon will be found destitute of mesentery, and hence un- covered by peritoneum for a portion of the posterior wall, as shown in Fig. 143. This proportion is given differently by dif- ferent investigators. Treves places it at seventy-four in one hundred cases on the right side and sixty-four in one hundred on the left. Allingham, Jr.,' finds it to be eleven out of sixty on the right and ten out of sixty on the left. Combining the results of the two sets of dissections, we have eighteen and one- Fig. 142.— Colon without Mesentery. (Allingham.) third out of one hundred on the right side, and sixteen and two- thirds out of one hundred on the left, or a much smaller propor- tion than has generally been supposed. In other words, in only about seventeen cases in one hundred can either the ascending or descending colon be opened without first incising the perito- neum. In a certain other proportion of cases represented by Fig. 143^ the ascending and descending colon have a short mesentery, or,, in other words, are completely covered by peritoneum, so that they can neither be seen nor reached without opening the perito- neal cavity. This proportion, according to the same authorities, is eighty-one and two-third cases in one hundred on the right side, and eighty-three and one-third in one hundred on the left. In still another set of cases represented by Fig. 144 there is a long mesentery, allowing of free motion of the colon from one 'British Medical .lournal, April 28th, 1888. THE FORMATION AND CLOSURE OF ARTIFICIAL ANUS. • 413 side of the spine to the other. These cases show how impossible it may be to reach the bowel without incising the peritoneum and introducing the hand into the abdomen. When the gut has been found it should be stitched to the edge ■of the skin by sutures passing through the serous and muscular coats before opening the bowel. These should be about a quar- ter of an inch apart. It is better to delay opening the bowel for Fig. 143.— Colon with short Mesentery. (Allingham.) at least forty-eight hours, unless the obstruction is so severe as to render the opposite course necessary. It is of great importance in this as in inguinal colotomy to make so sharp a spur in the posterior wall as to prevent the passage of faeces into the distal end past the artificial anus. If Fig. 144. — Colon with long Mesentery. (Allingham.) the bowel can be drawn well out of the wound, this may be ac- complished by passing a suture underneath it, drawing it tight, and securing it to the edges of the incision. The suture may be passed through the mesentery close under the bowel, if the me- sentery can be reached; otherwise it may be passed through the muscular coat of the gut. Failing to do this, the bowel should be drawn well out of the wound, so that in the undistended gut 414 DISEASES OP THE RECTUM AND ANUS. at least two-thirds of its calibre shall be outside of the line of sutures. In this way a sharp bend and a good spur are secured. Inguinal Colotomy. — The operation in the left groin is to be preferred in all cases except those mentioned where the disease is in or above the sigmoid flexure. It is attended by no greater danger than the lumbar operation, and in other respects has many advantages. It is easier of performance; the anus is so situated that the patient can better care for it and secure clean- liness; it is more easily closed by a subsequent operation; it allows the terminal portion of the gut to be more easily cleared of any fsecal matter which may collect in it; and it permits of attempts to establish an anus in the perineum in those cases in which the operation has been performed for imperforate anus in children. This operation permits also of considerable choice in the part of the sigmoid flexure to be opened. The opening may be made low down toward the rectum or high up toward the colon — so high that only a few inches of the gut shall intervene be- tween the opening in the groin and the place that would be occu- pied by one in the loin. (Fig. 145.) The operation in the right instead of the left groin has been advocated to meet the frequently found abnormality in the posi- tion of the flexure in children. It is well known that in them the flexure is relatively much longer and much more loosely attached by its mesentery than in adults. In one hundred and thirty-four autopsies on children of less than two weeks of age, Giraldis found the sigmoid flexure on the left side in one hun- dred and fourteen; Curling' in one hundred found it so located in eighty-five; and Bourcart in one hundred and seventeen out of one hundred and fifty. ^ It would seem from this that the ab- norinality is not sufficiently frequent to indicate a change in the site of the incision, especially when the ease with which the flexure can be found and brought to the surface, no matter in what part of the pelvis it may be, by the incision in the left groin, is considered. In performing this operation, as in all laparotomies, it is un- necessary to say the strictest antisepsis should be observed. The wall of the abdomen should be scrubbed with soap and a stiff brush, and then carefully shaved together with the sym- physis. After all loose hairs have been wiped away the parts should be again washed with ether, and subsequently with bichloride, 1 : 1000. The abdomen should next be covered with ' Op. cit., p. 230. * Quyon: " Diet. Euc. des Sci. Med.," Paris,, 1863. THE FORMATION AND CLOSURE OF ARTIFICIAL ANUS. 415. towels wet in warm bichloride solution, 1 : 3000, till only an opening- five or six inches long and three or four wide is left for the incision. The incision which I have adopted, and which gives perfect satisfaction, is the one advised by Cripps. (Fig. 145.) An imaginary line is drawn from the anterior superior spine to the umbilicus. An incision two and a half or three inches long is. made to cross this at a distance of an inch or more from the- spine. Drawing the skin tense towards the median line, as he recommends, till the transversalis fascia is exposed, is a very useful point, for by so doing the opening is made somewhat, valvular, thus aiding in sphincteric power. Before opening the- Fig. 145. peritoneum on the director, all oozing from the cut surfaces, should be dried by pressure with a towel. Immediately on dividing the peritoneum the finger of the- right hand, first carefully cleansed, is passed into the abdomen and the first presenting coil of gut is drawn out. In many cases this will prove to be the sigmoid fiexure, and can easily be recognized by the longitudinal bands of muscle and the ap- pendices epiploicce. Should it prove to be small intestine, it is slipped back and the finger passed more deeply into the pelvis for another loop. Any mistake in opening small for large bowel in this location seems to be entirely unnecessary, and, in fact, but little trouble is experienced in bringing the large bowel to the surface at once, even if it does not crowd itself out through the wound. 416 DISEASES OF THE RECTUM AND ANUS. Cripps suggests passing two provisional sutures through the bowel at this stage of the operation, to act as leaders and subse- quently serve as a guide for opening the gut. (Figs. 146, 147.) Fig. 146.— rCripps.) 1 prefer, however, to at once pass a long harelip pin under the gut in the following way. (Fig. 148.) Entering it through the skin on one side a quarter of an inch from the edge and at Fig. 147.— (Cripps.) about the junction of the middle and lower thirds of the wound, it is next passed through the peritoneum on the same side, then through the mesentery of the gut at a correspondingly low point THE FORMATION AND CLOSURE OF ARTIFICIAL ANUS. 417 of the exposed coil, then through the peritoneum of the opposite side, and finally through the skin again. In this way a very sharp spur is formed and the gut is so securely fastened in the wound that there is no possibility of its becoming detached. The gut is next stitched to the skin with half a dozen sutures of black thread on each side and one in each angle. The needle used should be round and half-curved. The suture should in- clude first the edge of the skin, then the visceral layer of peri- toneum, then the serous and muscular layers of the gut, and should be tied and the ends cut short. About fourteen of these will completely shut off the cavity of the abdomen so that the gut may be opened at once, should the severity of the symptoms render it necessary. When the suturing is completed about two-thirds of the calibre of the gut should be outside the line of sutures. ? Fig. 148.— Harelip Pin in Colotomy. If possible, it is better to postpone opening the bowel for a couple of days at least, and cover the wound first with protec- tive, then with a pad over the gut, and on this bichloride gauze, cotton, and an obstetrical bandage. The protective next the gut is important, as it prevents the matting together of all the parts and dressings by the free effusion of lymph. Even a few hours are sufficient to give union of the serous surfaces by effusion, how- ever, sufficient to prevent oozing into the peritoneal cavity, and I seldom care to wait longer than the end of the third day, being ready to open the gut much sooner should it seem advisable. Slight scarification of the peritoneal surfaces with a needle be- fore joining them with the sutures will promote more rapid union. The gut is opened by piercing it with a sharp-pointed bis- toury, introducing a fine pair of toothed forceps, seizing the edge, and excising a considerable piece with scissors, paring 27 418 DISEASES OF THE RECTUM AND ANUS. the bowel well down to the line of sutures. This procedure is not attended by any pain, and ether is unnecessary. When the bowel has been opened the appearance of a double- barrelled gun shown in Fig-. 149, with the lower orifice smaller than the upper, becomes evident. The sutures may be left to find their own way out, but the pin should be taken out as soon as union is secure. The open- ing is dressed merely with a piece of sheet lint and vaseline, and pad and bandage. By the end of the tenth day the patient is generally up and about, and is convalescent in two or three ■weeks. In a case recently operated upon in the height of acute obstruction with incipient general peritonitis, the bowels were Fig. 149.— Opening in Inguinal Colotomy. working naturally twice a day at the end of the second week, and the patient walked into my office, much to my surprise, on the seventeenth day. I have had one patient, operated upon for intestino-vesical fistula of cancerous origin, leave the hospital for his home, a hundred miles away, on the fourteenth day. In the after-treatment of the opening I have found nothing much better than a dressing of greased sheet lint, a pad of cot- ton, and a wide elastic bandage. I generally have a truss, ex- actly similar to the ordinary truss for hernia, with a hard-rub- ber bulb to fit the opening, made for each case; but most of the cases make little use of it, and are perfectly comfortable with- out the increased pressure it affords. THE FORMATION AND CLOSURE OF ARTIFICIAL ANUS. 419 With regard to this operation there are a few general consid- erations which are worthy of notice. It is not in itself a dangerous operation when performed as here described and before the patient has become exhausted by obstruction. When done early, as soon as the symptoms of stricture are manifest, the danger of peritonitis is very slight and the mortality correspondingly small; but when delayed till the patient is at the point of death, the mortality reaches to thirty or forty per cent. I recently operated on an old gentleman on his eighty-first birthday. The case had been seen six months before, and the family told that '' eventually" a colotomy would be necessary. When I operated he was in a very feeble condition, and the pro- priety of the attempt to prolong life was left entirely to the de- cision of his physician, his family, and himself. The operation was completed in exactly seventeen minutes, and, though at- tended by the least possible amount of shock, the patient very nearly passed away on the table. He lived, however, till the gut had been opened forty-eight hours after, and two large f secal evacuations had taken place through the artificial anus twelve hours later, and then sank quietly and died on the third day. All that can be said of such a case is that an attempt to prolong life and end suffering failed — not that the operation in any way hastened the end. The operation should be regarded not as a last resort, to be performed at the very close of life and perhaps after fatal ob- struction has set in, but as a measure calculated, when used early, to delay the course of malignant disease and to add years of comfortable life to the patient; while in non-malignant dis- ease it is often curative. In cases of intestinal obstruction the surgeon has his choice between laparotomy and enterostomy, and the choice must be made with great care. Opening the abdomen, finding and re- lieving the cause of the obstruction, be it band, diverticulum, concealed hernia, or invagination, would certainly seem better surgery than to open the first presenting distended coil of intes- tine, with the probability that it may be above the disease, and the hope that the cause of obstruction may take care of itself, and leaving the abdomen without a search. And yet, as Curtis * has shown, much to the surprise of the profession at large, the ^ "The Results of Laparotomy for Acute Intestinal Obstruction," Trans. Med. Soc. State of New York, 1888; and "Enterostomy for Acute Intestinal Obstruc- tion," Med. Rec, September 1st, 1888. 420 DISEASES OF THE RECTUM AND ANUS. choice between the two operations may depend entirely on the strength and general condition of the patient. After studying both operations carefully he reaches the following conclusions : " 1. The mortality for laparotomy is 68.0 per cent ; the mortality for enterostomy is 48.7 per cent. 2. In enterostomy 4.8 per cent of the sixty-two cases died because the operation did not relieve the constriction: but even in laparotomy 5.8 per cent of the three hundred and twenty-eight cases died from the same cause. 3. Enterostomy restores the natural passage for the faeces in 60 per cent of the cases which recovered : while even laparotomy pre- serves it in only 79 per cent of the recoveries. 4. Laparotomy is therefore so very little better than enterostomy that, in conside- ration of its greatly increased risk, it is indicated only when the patienfs condition is so good that he can bear the shock, and when the intestines are not so greatly distended as to offer a serious obstacle to a thorough exploration of the abdomen. 5. Under all other circumstances enterostomy should be performed, and, if necessary, this can be done without an anaesthetic. La- parotomy may be resorted to later to remove the cause of ob- struction and to close the artificial anus. 6. Whichever ope- ration may be chosen, it is necessary to operate early, for every delay greatly increases the risk of failure.'' In doing an enterostomy under these circumstances the in- cision should be the same as that for left inguinal colotomj^ and the parietal peritoneum should be stitched to the skin in the same manner. The first presenting distended loop of gut is then fastened into the opening very much as described in that ojjera- tion. The operation is more difficult, however, than a simple inguinal colotomy, for the loop of gut may be the size of the arm and may protrude, if there be much abdominal distention, in a manner which will add greatly to the difficulty. It must be handled as gently as possible, and kept in place by soft towels wet in warm antiseptic solution till the sutures are passed. A considerable section of the distended gut should be outside of the wound when the operation is completed — a piece at least an inch and a half long by the same in breadth — and only a few hours at the most may be allowed to elapse before the gut is incised and the edges pared down to the skin. In laparotomy for obstruction the site of the incision has first to be decided. The rule is to make the incision as near as pos- sible over the cause of obstruction when, as in cases of tumor, this can be located, and in all others to cut in tlie median line- THE FORMATION AND CLOSURE OF ARTIFICIAL ANUS. 4:-Zl Weir ' has discussed at length the relative advantages of a short incision, such as is used in ordinary ovariotomy — from two and a half to five inches long below the umbilicus — and a free lay- ing open of the abdomen by a cut from seven to twelve inches in length. The objections to the short incision are that by it, unless the seat of difficulty be very apparent, it cannot be found without a prolonged search, which is often disastrous to the pa- tient. An incision large enough to admit even the whole hand, as Weir points out, only allows the operator to use the sense of touch, and in a case of obstruction this is particularly unsatis- factory and often decej^tive ; while a larger incision past the "umbilicus permits both sight and touch and may save much time in unavailing search. The proper rule is by a short incision below the umbilicus to search for the most common causes of obstruction in the neighborhood of the caecum and the hernial openings, and, failing to find the disease, to enlarge this cut up- ward past the umbilicus till the intestines may be fully drawn out through it and all parts of the abdomen inspected. The time consumed in a laparotomy is one of the chief factors in its result, and is much more important than the length of the inci- sion, while the free exposure of the abdominal contents in the search for the obstruction is likely to do less harm than a pro- longed search with the hand in the dark. The old rule for finding the obstructed point in the bowel was to begin at the caecum, and if this was found distended to search toward the rectum, but if undistended to search toward the stomach, for it is plain that the distended gut lies above the ob- struction. In the former case the search was short; in the latter a coil of undistended gut was selected as a starting point and traced upward inch by inch to the obstruction. This course, as again shown by Weir, is full of uncertainties. In the first place, it is no easy matter to decide whether the colon is or is not dis- tended as a starting point ; and in the second, it is impossible to tell, after starting with a loop of undistended small bowel, whether it is being followed upward or downward, toward or away from the obstruction. According to Rand ' the first point of small intestine which presents is to be drawn out of the wound and held taut. The hand is then to be passed backward to the spine, guided by the mesentery. If the bowel is held in its true direction, the hand passed down on the right of it will be guided 1 " On the Technique of the Operations for the Relief of Intestinal Obstruction," Med. Record, February 11th, 1888. 2 Br. Med. Jour., December 22d, 1883. 432 DISEASES OF THE RECTUM AXD ANUS. by the mesentery to the right side of the spine, and can be passed up and down along the right side of the mesenteric attachment at the vertebra. But should the upper end, as held by the ope- rator, be in reality the lower end — in other words, should the piece be held in the wrong direction — the hand passed to the right of it will follow the twist of the mesentery to the left side of the spine, and vice versa. This rule, though anatomically cor- rect, is also of little use in practice, and the operator may easily spend many minutes of valuable time in tracing the undis- tended gut in the wrong direction, only to find himself at last at the stomach instead of the caecum, and under the necessity of retracing his steps. Under all the circumstances, therefore, if the obstruction be not manifest after a short search through a small incision, it is better to enlarge the cut, turn the gut out of the wound first on one side and then on the other, and find the seat of disease, whether it be in the intestine itself or in the abdomen. In this way only can a thorough search be made and the necessity for puncturing or incising the gut to diminish its size obviated. In handling the gut it should be covered with a soft towel wet in warm salicylic acid solution 1:1000, and exposed as little as possible. If it be kept out of the abdomen for any length of time, the towel should be changed every few minutes and the gut gently irrigated with the same solution. In replacing the intestine, if difficulty be experienced, the simple device practised by Czerny, of enclosing the mass m a towel and tucking the edges into the abdomen while the first sutures are introduced, is a great help. As the wound is gradually shortened from above downward, the towel may be drawn down and out. The su- tures should include the w^hole thickness of the abdominal wall, with the peritoneum if possible; but, as Weir has shown, the peritoneal edges may not be accurately approximated, as the coils of the intestine come in contact with the incision and after a few hours shut it off from the general peritoneal cavity by adhesions. In all cases of obstruction, no matter what the variety, if after laparotomy it is found impossible to remove the cause, the rule is to form an artificial anus and leave the question of re- section to a future date. Resection in the midst of obstruction is an almost fatal operation, while secondary resection and clo- sure of an artificial anus give a much better chance for the patient. In cases of cancer of the upper part of the rectum or descend- THE FORMATION AND CLOSURE OP ARTIFICIAL ANUS. 433 ing colon, the operation of resection may be followed by the es- tablishment of an artificial anus with both ends of the gut in the wound, by a circular enterorrhaphy, or the establishment of an intestinal anastomosis. If the patient's condition permit, there is no objection to com- pleting the whole operation at one time by the establishment of an intestinal anastomosis, provided the colon above can be drawn down to the rectum; but on account of the amount of tis- sue removed it may be impossible to do this, or even to attach both ends to the wound. The incision may be made over the disease. If this be in the sigmoid flexure, it may be either parallel with Poupart's liga- ment or extend from the umbilicus to Poupart's ligament. Enterorrhaphy. — The loop of intestine to be operated upon, should be drawn well out of the abdominal wound, and a flat sponge, previously carbolized or soaked in warm Thiersch ' so- lution, placed in the abdomen under the incision to keep back the coils of small intestine and prevent any contamination of the abdominal cavity by blood or faeces. While the exposed gut is covered with warm antiseptic towels, pieces of tape a quarter of an inch wide, carefully prepared by previous soaking in bi- chloride, should be tied above and below the part to be excised. The gut should then be cut across at right angles to its axis, and a triangular piece of mesentery to correspond excised as shown in Fig. 150. The bleeding mesenteric vessels should be tied with catgut, and the contents of the gut thoroughly pressed out be- tween the tapes. The divided ends of the gut should next be thoroughly washed with antiseptic solution. The object of excising a triangular piece of mesentery to cor- respond with the excised piece of gut is to prevent kinking and strangulation of the gut after union has occurred. The edges of divided mesentery are first to be united with catgut sutures about a quarter of an inch apart from each other, and the edges of the gut at the mesenteric attachment should be carefully approximated at the same time. In suturing the gut, Wyeth, in his successful case, employed three sets of sutures. 1. A suture through the mucous mem- brane alone, or Czerny's suture. 2. One through the peritoneal coat alone, or Lembert's suture. 3. One piercing the peritoneal coat and passing along with the muscular layer, coming out on the free divided edge of the gut, which he calls the intermediate suture. ' Thiersch solution : Boric acid, gr. iv.; salicylic acid, gr. i.; water, 3 i. 424 DISEASES OF THE RECTUM AND ANUS. When the gut is cut across, the muscular layer retracts, car- rying the peritoneal with it and leaving the mucous to project about an eighth of an inch. The Czerny suture unites the mu- cous membrane and the submucous connective tissue, and is a a Fig. 150.— Resection of Intestine. (Wyeth.) inserted as is shown in Fig, 151. It gives great additional strength to the union of the cut surfaces. The Lambert suture, . . Peritoneal layer. . . Muscular layer. . .Mucous membrane. Fig. 151.— Schematic, a, LemVierfs, and h, Czerny's sutures. (Wyeth.) shown in the same figure, unites the peritoneal surfaces, passing only slightly into the muscular layer. Fig. 152 shows the result of passing and tying these two sets of sutures, the free edges of the raucous membrane being turned inward and the knot of the Czerny suture remaining within the lumen of the gut. The THE FORMATION AND CLOSURE OF ARTIFICIAL ANUS. 495 intermediate suture is shown in Fig. 153 witli the others. It is used merely to strengthen the line of union. In suturing the gut a round, fine, straight needle should be used, threaded with fine, black, iron-dyed silk, and kept in a 1 : 3000 sublimate solution. For passing the sutures Wyeth gives the following rule : "In commencing the sutures, first insert one Czerny suture just over the mesenteric or attached border of the intestine, and tie this, the knot, of course, coming within the lumen of the gut. The needle should pass from "within through the mucous layer at a distance of about three- FiG. 152. — Schematic. Showing the inversion of the peritoneal layer by tying Lembert's suture, and of the mucous membrane by Czerny's suture. (Wyeth.) sixteenths of an inch from the free border, out along the free border of the same end, and, being carried across to the oppo- site end, should be made to enter below the muscular and mu- cous layer, and to emerge through the mucous layer three-six- teenths of an inch from its cut edge. A Lembert suture should be next inserted just at the edge of the mesenteric attachment, as follows : The needle is made to enter the peritoneal coat one- eighth of an inch from the edge, and passing between the serous . . Peritoneal layer. x/^iSiSSj E! ■ ■-, ^^»;^SS^< ^^Sl!5i'" Muscular laver ■'lill l'lliKliiliiiiiillillllW (illllliMlilMilBllliili^ • ■•^"-^uscuiai layer. ^■~^ . . . Mucous membrane. Fig. 153.— Schematic. Showing the route of the intermediate sutures. (Wyeth.) and muscular coats, is again brought out through the peritoneal layer about one-twenty-fifth of an inch from the edge. At a point exactly opposite, the same stitch is passed through the peritoneal layer of that side for the same distance, and this thread is tied. In knotting all these sutures it is a wise precau- tion to use the double or friction knot for the first tying, for by so doing there is no danger of the suture slipping and the parts separating as the second turn is being made. A second Lem- bert suture should now be inserted on the other side of the mesenteric attachment, and an intermediate suture passed 426 DISEASES OF THE RECTUM AND ANUS. between these, through the substance of the mesentery and down into the strip of intestine, which here is uncovered by perito- neum. Extra care must he taken to see that this part of each end of the cylinder is in perfect coaptation. The sutures are now inserted for the remainder of the opposing surfaces. The Lembert and intermediate sutures alternate through the entire circumference, and should be one-eightli of an inch apart. The mucous or Czerny sutures should be from one-fourth to three- eighths of an inch apart. The relative proportion of these sutures is shown in Fig. 154. It is evident that, while the Czerny suture is tied leaving the knot within the cavity of the intestine for the first part of the operation, the last few threads must be tied leaving the knot embedded between the mucous and muscular layers of the wall. In applying the sutures the plan followed was, first a Czerny, then a Lembert about over this, next an intermediate, another Lembert, and after this a. Fig. 154.— Schematic. Section of intestine, showing the proportion of each form of suture, and their distance apart. I, Lembert; i, intermediate; c, Czerny suture. (Natural size.) (Wyeth.) second Czerny suture, and so on. In other words, it was neces- sary to insert the mucous suture before the superficial sutures had quite reached that point. All the threads should be cut off close to the knot." Instead of this elaborate suturing it is much better to use continuous sutures, one to the mucous membrane and two to the gut, for by this means much time may be saved. The appearance of the gut after the operation is finished is shown in Fig. 155. In doing this operation time is of the utmost importance, and the operator, if circumstances permit, should familiarize him- self witli the technique by frequent performance on the cadaver or on live dogs. Wyeth's successful case took four hours in the performance, notwithstanding that he had previously operated ten times on the cadaver. After completing the line of suture, additional strength and THE FORMATION AND CLOSURE OF ARTIFICIAL ANUS. 4:2: security may be gained by enwrapping the bowel at the point of union in a piece of Avholly or partially detached mesentery, as has been recommended by Kraussold ' and Senn ; " and for safety, the line of junction may be fastened by a thread to the abdomi- nal wall near the incision, so that it may be brought at once to light should subsequent symptoms demand it. Intestinal Anastomosis. — Thanks to the labors of Dr. Senn, many of the operations upon the intestines may now be com- pleted at one sitting, in which it was formerly necessary first to establish an artificial anus, and subsequently submit the patient Fig. 155. — Showing the Line of Sutures in the Mesentery and Around the Intestine. (Wyeth.) to all the dangers of a second laparotomy to close the opening thus made. This applies to many cases of obstruction, to hernia with gangrenous gut, to fsecal fistula, and to resections from any cause. The operation he has devised consists briefly in making an opening in the gut above and below the disease, or in the sides of the two terminal portions after a resection, in ap- proximating these two openings by sutures, and allowing the flow of faeces to establish itself by this new channel. The two ' Sammlung Klinischer Vortrage, No. 191, s. 23, 1881. ^ " Experimental CoQtribution to Intestinal Surgery," Lancet, October 8tb, 1887. 428 DISEASES OF THE RECTUM AND ANUS. openings are held in apposition by rings introduced into the lu- men of the gut — one through each opening. To the rings threads are attached, about six to each ring, and these are threaded and brought through the intestinal wall from within outward about a quarter of an inch from the edge of the incision, which should be longitudinal and at least an inch and a half long. After these have been tied in pairs, and the two openings have been ap- proximated in this way, the adjacent peritoneal surfaces should Fig. 156.— Apposition Ring of Catgut. (Abbe.) be still further secured by a row of sutures entirely surround- ing the site of the anastomosis. In Senn's experiments the rings were made of decalcified bone, but a soft-rubber catheter may be cut into sections and strung on catgut, which when ab- sorbed will allow of loosening and evacuation of the rubber, or a ring of catgut such as Abbe has employed (Fig. 15G) may be used. Abbe has suggested that after resections the ends should be applied to each other, so as to allow of intestinal paristalsis in the natural direction through the artificial opening ; other- THE FORMATION AND CLOSURE OF ARTIFICIAL ANUS. 420 wise a sharp angle has to be turned in the passage of the fseces from the proximal to the distal portion. In resections also the two cut ends should be turned and stitched over by a continuous, suture. If, in spite of the precautions of the operator, the use of flat Plate within the in- testine above seat of obstruction. Perforated decalci- fied bone plate. Fig. 157.— (Senn.) Sponges in the abdomen, the torsion of bleeding vessels, closing the lumen of the gut above and below the point to be opened,. Fig. 158.— (Senn.) I etc. , blood or fseces escape into the abdominal cavity, the wound should not be closed till the peritoneum has been washed out either with simple warm water previously boiled or with a so- lution of salicylic acid 1:1000. TTeither bichloride of mercury nor carbolic acid should be used for this purpose. The same must be done should purulent peritonitis be found to exist on 430 DISEASES OF THE RECTUM AND ANUS. opening the abomen— in fact, when there is any reason to fear that anything septic may remain in the cavity after closing the wound. Fig. 159— (Senn.) Closure of Artificial Anus. — The operation of closing an ar- tificial anus is rather a more difficult and dangerous one than that of forming the opening in the first place. Fig. 160.— Condition of Bowel after Colotomy, .showing Septum and course of Faeces. (Packard.) In the ordinary operation of closing a colotomy opening, the spur, if there be one sufficiently marked to be likely to produce obstruction, must be removed. In the old operation of Dupuy- Fig. 161.— Enterotome of Dupuytren in Position. (Packard.) tren ' this was done by compressing it with a forceps made for the purpose till a slough was produced. The spur is shown in ' " Le9ons orales de Clin. Cbir.," Paris, 1839. THE FORMATION AND CLOSURE OF ARTIFICIAL ANUS. 431 Fig. 160, and. the enterotome of Dupuytren in position in Fig. IGl. The spur is composed of the entire thickness of two layers of in- testinal wall. His idea was to apply sufficient pressure at once to cause the complete closure of the blood vessels and subsequent sloughing. He therefore passed one blade into the upper opening, the other into the lower, brought them into contact on each side of the fold, and screwed them tightly together. This is perhaps the most difficult part of the operation. It is not always easy even to find the lower opening through the artificial anus, which is small and liable to be filled up with prolapsed mucous mem- brane ; and after having introduced this blade of the forceps it is by no means easy to tell exactly what is within the grasp of the instrument when it has been secured. Dupuytren's rule was to determine the course of the two segments, pass one blade into each for an inch or more, and then bring them together. What- ever form of instrument is used, the blades should cover a considerable surface, should fit one into the other to secure the destruction of the tissue, and should be separate to facilitate their introduction. The feeling in more recent times has been in favor of starting with a moderate degree of pressure which will secure adhesive inflammation around the part and shut off the general peritoneal cavity, and, after a few days, to increase the pressure to a point which secures the death of the part. The in- strument must be left on till it comes away of itself, usually about a week, and the pressure should be increased from time to time. The instrument will sometimes be very well borne, at others it will excite considerable constitutional disturbance with signs of obstruction, and it may set up fatal peritonitis. It is best, therefore, to attack the spur by successive advances rather than to seize and compress the whole at once. In some cases this primary destruction of the spur may be dispensed with — cases in which it is of such small size as to offer no considerable obstacle to the passage of fseces beyond the artificial opening. In such the bowel may be closed at once. The closure of the orifice may be accomplished in seve- ral different ways. The operation of Malgaigne consisted in dissecting up the edges of the gut without passing beyond the adhesions to the abdominal wall, turning the edges into the lumen of the bowel back to back, and uniting the opposing serous membranes by suture — closing the opening in the skin by a subsequent operation. The operation of Denouvilliers con- sisted in dissecting up the mucous membrane alone and turning 432 DISEASES OP THE RECTUM AND ANUS. it into the lumen of the bowel in the same way. Barker ' has reported an operation, the essential feature of which consists in introducing into the bowel through the artificial anus, after the projecting spur of the bowel has been removed in the usual way, a thin and flexible strip of rubber about one inch and a half long by five-eighths of an inch broad, in such a manner as to lap up against the internal orifice, and to secure this in position by a single wire stitch at each end passed through the abdominal wall. The object is to allow the rubber to remain till the fistula is closed by paring and suturing its edges, and then by cutting the wires to allow it to pass down the bowel. In the case recorded, the rubber answered the purpose of preventing the escape of faeces very perfectly for the first few days, after which there began to be leakage, and it was removed. The fistula, however, went on to complete closure. Another successful operation is the one performed by Dr. Byrd and described by him as follows : ' "The eperon was destroyed with an enterotome made of steel wire bent into the shape of a pair of tongs, with the blades having fenestrated openings that more tissue could be enclosed within their bite. This was applied by passing a blade into each end of the bowel about two inches. The spring of the instrument caused sufficient inflammation to secure surround- ing adhesions to a certainty, and the pressure being reinforced in three days with a strong India rubber band over the blades, an ulcerative process ensued which caused the eperon between the blades to disappear." " The eperon having been destroyed, I operated for the clo- sure of the artificial anus in the following manner : The skin on either side of the opening was caught up in a fold in such a manner that the top of the folds met easily over the opening in the bowel ; an incision along the top of these folds, which was about three-quarters of an inch from the opening in the bowel, was then made through the skin and superficial fascia, and ex- tended so as to form an ellipse enclosing the opening. That portion of the skin next the opening was then dissected up from the outer side, leaving it attached at the inner side to the open- ing in the bowel ; it was then inverted and turned into the bowel. This procedure brought the raw surfaces in apposition, 1 Lancet, December 18th, 1880. • "Excisions of Portions of the Alimentary Canal covered by Peritoneum," by William A. Byrd, M.D., Quincy, 111. Reprint from Transactions of the American) Medical Association. THE FORMATION AND CLOSURE OP ARTIFICIAL ANUS. 433 and threw skin into the bowel so as to form a continuation of the mucous membrane. The skin on either side of this ellipti- cal raw surface was now brought together by passing two stay sutures, with a shot and shield, back about an inch from the cut edges, and making traction. This brought the edges to- ci C: gether and made them rise from the abdomen like an inverted V. Where the skin met at the apex of the V, it was fastened with catgut suture. The portion of the skin in the intestine was shaped like a V, and that outside had its apex immediately Fig. 165— (McBurney.) above the apex of the lower one. By this procedure fully an inch and a half of raw surface was brought in contact over the opening in the bowel, thus almost insuring sufficient adhesion, while the V-raw surfaces of the skin that was inverted into the bowel acted as a valve, and were held in apposition by the pres- 28 434 DISEASES OF THE RECTUM AND ANUS. sure of the contents of the bowel. There was some oozing of fecal matter, for a few days after the operation, from the cor- ners of the wound, but these slight openings closed readily by applying pressure with a sponge, and she is now in excellent health, perfectly recovered.'" More recently Szymanowski's operation for the closure of urethro-perineal fistula has been applied to the closure of artifi- cial anus — in one case very successfully by Parker Syms, of New York. The steps in the operation are as follows: A single straight incision is made, from A, three-quarters of an inch in front of, to B, three-quarters of an inch behind, the fistula (Fig. 162). This incision passes through skin and super- ficial fascia, and closely skirts the right side of the fistula. The edge of this incision is raised, and, working with a small blade to the patient's right side, the skin and fascia are undermined until a pocket is formed including the area A C B F, the right edge of the pocket being indicated by the dotted line A C B. On the opposite side, a curved incision, A D B, is then made, the greatest width of the flap thus marked out being three-quar- ters of an inch to one inch. This flap must be generous and should include a good pad- ding of fascia, as, when it is lifted, the shrinkage is great. Before lifting the flap a thin layer of skin is removed from its surface. This is best done with small curved scissors, the super- ficial layer of skin being rapidly chipped off. The freshening process is carefully extended over the entire area A D B F, excepting over a surface a little larger than the fistula, and immediately next to it. The flap A D B is then dissected up close to the median line and inverted, its attached edge acting as a hinge and as a me- dium for blood supply. Five or six fine catgut sutures are passed through the skin at different points a little beyond the dotted line A C B, into the pocket, then through the free edge of the flap, and then back into the pocket and out through the skin. Five or six loops are thus formed, by drawing upon which the flap is closely drawn down to the bottom of the pocket, and the free ends of the loops are tied. (See Fig. 165.) Two or three sutures of catgut are now passed with a curved needle through the upper surface of the inverted flap so as [to firmly bind it to the parts beneath. Sometimes with interrupted and sometimes with a continuous catgut suture the free^edge, A F B, is now securely fastened to the edge A D B. THE FORMATION AND CLOSURE OF ARTIFICIAL ANUS. 435 It will be seen that none of these methods involve the open- ing of the peritoneum. Dupuytren's statistics covered forty-one cases, twenty-one of which were done by himself and twenty by others. Three cases were fatal. Of the remaining thirty- eight the operation was unsuccessful in eight, and successful in twenty-nine in periods varying from two to six months. In more recent times the statistics of Heiman,' Korte,^ Hoe- nel,' and Palloson give for the enterotome the following re- sults : In ninety-five cases sixty complete cures, twenty-six cases of persistence of the fistula, and nine deaths, four of which could be directly attributed to the operation. In sixteen cases treated by the enterotome and subsequent plastic operations, ten were completely cured, in three the fistula persisted, two were unsuccessful, and one died of erysipelas. With the 'bolder surgery of to-day so great care is not used in avoiding the peritoneum, and in cases of faecal fistula, or artifi- cial anus without spur sufficient to prevent the passage of faeces, the operator would have little hesitation in freeing the edges, whether the 'peritoneum was opened or not, turning them into the lumen of the bowel back to back, and closing the orifice by Lembert's suture. The statistics- of this operation are, accord- ing to Palloson, in twenty-nine cases, eighteen cures and eleven deaths — five from peritonitis, three from obstruction, one from collapse, and two from pneumonia. According to Hoenel, in forty-three cases there were twenty-five cures, two failures, and sixteen deaths. These figures all apply to old cases of artificial anus or faecal fistula, and are better than those which result from operations on recent cases ; for, as pointed out by Hache," in the operation for the immediate closure of a faecal fistula resulting from a gangrenous hernia, for example, we must add to the dangers inherent to the operation itself the danger of collapse, of general peritonitis, of secondary perforation of the intes- tine^above the adhesions, of stercoreal abscess, and inanition. Kocher ' lost all of his seven cases either of inanition or di- arrhoea ; Morse " lost three out of seven of peritonitis or col- 1 Dtsch. Med. Wocli., 1883, No. 7. 2Berl. Klin. Woch., 1883, No. 50. 3 Arch. f. Klin. Chir., 1887, xxxvi., fasc. 2. "Le Bull. Med., May 27tli, 1888. ^ " Corresp. be. fiir Schweize Aertze," 1886, No. 5. « Wien. Med. Woch., 1883, No. 15. 436 DISEASES OF THE RECTUM AND ANUS. lapse ; and Korte ' in thirty cases lost sixteen immediately and six after a few days. These figures are deceptive, many of the cases being opera- tions on strangulated hernia with fresh faecal fistula while the patient was suffering from the attendant shock. In all such cases the rule now would be to form an artificial anus by bring- ing the two ends of the gut to the surface after resecting what was necessary ; or, better still, to resect and establish an intes- tinal anastomosis at one operation. Reichel's statistics (quoted by Weir) show thirty-seven resections for artificial anus, with only two deaths. In fistulse of the pyo-f secal variety the surgeon has to deal not only with a fascal fistula, but an abscess sometimes of enormous extent. These may arise from an abscess around the intestine which has opened into it as well as upon the surface, or they may originate in an ulceration and perforation of the gut. They generally have their starting point around the caput coli in a typhlitis or perityphlitis, and if left without operative interfer- ence are more apt to point in the loin than anteriorly. In dealing with this complicated and very grave condition the first effort should be directed to the abscess cavity, and this should be thoroughly opened up and drained, and by every pos- sible means made to heal. The fistula is thus changed from a pyo-fsecal to a simple fsecal one, and the opening in the gut may then be attacked with some hope of cure. If it be small it may close by simple cauterization of its edges, or it may be sutured by Lembert's suture. If larger, and there is sometimes consid- erable destruction of the intestine, the surgeon may have to choose between enterectomy with anastomosis or anastomosis alone. Should the perforation be in the caput coli, enterectomy will be out of the question, and a union of the healthy gut above and below the diseased part may be the only resource. ' Loc. cit OHAPTEE XY. CONSTIPATION AND F^CAL IMPACTION. It may be stated as a general rule that a person in health should have one daily evacuation from the bowels. And yet to this rule there are many exceptions; for some people in perfect health go to the closet both night and morning, and others but once in forty-eight hours, three days, or even longer. Usually at a certain hour in the twenty-four, which in a healthy person is fixed and invariable, there is felt a desire to relieve the bow- els, caused by a physiological process carried on without the knowledge or will of the individual. Simply from the force of a habit which has existed for years, or from the effects of a rou- tine mode of life — such as a morning meal taken at the same hour every day, and composed of the same articles of food — the muscular layers of the bowel begin a gentle rhythmic contraction which forces the solid faecal residue contained in the sigmoid flexure down into the rectum, where its mere presence excites a desire for its removal. Thus far the process of defecation is purely involuntary ; but beyond this it is under the control of the individual, and he may yield to this call of nature or disre- gard it and pay the penalty. A sensible person, having regard to his health and comfort, will promptly regard the hint that nature is ready to do her part in unloading the economy of its refuse, and will allow no light matter to interfere with the regu- lar, daily morning evacuation of the bowels. Should, however, the individual resist this hint of nature, and by a voluntary exercise of the will prevent the escape of faeces, the desire soon passes off ; the mass is returned by reverse peri- stalsis to the sigmoid flexure, there to remain till nature repeats the call, or till a succession of bad symptoms forces the patient to seek relief in medicine. It is a curious question how long a person may go without any evacuation of the bowels and without seeming to suffer any very severe consequences ; and remarkable cases are on record, usually in women in the lower walks of life. Some of the fol- 438 DISEASES OF THE RECTUM AND ANUS. lowing cases, taken from Johnston,' are almost incredible, but those in which the time is reckoned by months may easily be believed. Thus: In the Amer. Jour. Med. Sci., 1846, p. 260, there is a case reported lasting three months and twenty-two days ; in the " Diet, des Sci. Med.," t. vi., p. 257, one by Renan- din of four months ; in the A7ne7\ Jour. Med. Sci., October, 1874, p. 440, one by Strong of eight months and sixteen days ; in the Bull, des Sci. Med., t. x., p. 74, one by Valentin of nine months ; in the London Med. Gaz., vol. xi., p. 245, Staniland reports one of seven months ; in the "Dublin Hosp. Reports," vol. iv., p. 303, there is one of eight months ; Inman, in the Half-Yearhj Ahs. Med. Sci., vol. xxxi., p. 275, reports one of two years ; De- villiers, Jour^ de Med., 1756, t. iv., p. 257, reports another of two years ; Chalmers, Med. Gaz., 1843, vol. xxi., p. 20, reports one of three years ; and, finally, in the reports of the Phila. Med. Mu- seum, 1805, vol. i., p. 304, there is one reported in which the pa- tient went fourteen years without an evacuation of the bowels. The causes of constipation are manifold. The first and sim- plest is one already hinted at — ignorance and carelessness on the part of the individual. Women suffer more than men be- cause a false sense of modesty leads them oftener to neglect the call of nature, and because their habits of indoor life and lack of exercise lessen the force of the peristaltic movements of the bowel. Again, the condition of pregnancy leads often to a state of constipation while it lasts; and frequent repetitions of it are apt to render this chronic from a loss of muscular tone in the parts concerned in defecation. The habits of life and the occupation of the individual are often the cause of his trouble. Brain work at the expense of physical exercise; over-eating and physical inertia; the necessity for sitting long in one posture (tailors, shoemakers, etc.) ; im- proper nutrition or lack of nutrition — anything which lessens the physical powers — may fairly be put down as a cause of this condition. For the same reason old people and infants are more apt to suffer than the young and middle-aged, because of the general lowering of vitality and the absence of muscular strength. Perhaps as common a cause as any is the habit of using laxa- tives in the form of pills or mineral waters; and this acts as does the habit of constantly whipping a horse — he soon expects to be whipped before he goes. This habit is the direct result of the universal dissemination of the now exploded idea of bilious- ' Pepper's " System of Medicine," vol. ii., p. 646. CONSTIPATION AND FAECAL IMPACTION. 439 ness — a hypothetical condition which every patient takes pride in discovering and treating with cathartics in his own person and his friends. Many other causes might be dwelt upon at length — the use of drugs, especially opium and perhaps also tea ; the loss of fluids from the body by certain exhaustive diseases; the lack of sufiicient fluid with the food; and the use of food of too concen- trated a quality and containing too little refuse matter. Constipation is often also a symptom of gastric or intestinal indigestion, both in children and adults; and in the former it is sometimes due to the anatomical formation of the sigmoid flex- ure, which in them is relatively much longer and more convo- luted than in adults (Jacobi). It is also an accompaniment of spinal disease, leading to paralysis. Recently a case of this kind consulted me, not so much for the constipation as for the painful secondary effects of the condition from which he was suffering. About a year before he had received a severe injury to the spine, ending in complete paralysis below the waist, and for several months his bowels never moved, and were only kept open by manual clearing out of the rectum. Latterly they have begun to show some signs of returning pow- er, so that by large enemata and various mechanical means he succeeds in getting relief. But the result of these efforts and of the prolonged constipation has been to so loosen the attach- ments of the rectum that the mucous membrane is completely everted. In other words, he is suffering both from constipation and prolapsus. A cause of constipation of more especial interest to the sur- geon is the existence of any affection of the rectum or anus which renders the act of defecation painful — so painful that an infant will cry when placed on the pan, and will exert all its powers (and very successfully) to prevent a passage, and an adult will postpone the act as long as possible. A prominent physician, who was under my care some years ago for fibroid tumors of the rectum, assured me that the act of defecation caused him such acute suffering that he always avoided it as long as he possibly could without being positively sick; and then, when he could postpone it no longer, was in the habit of administering chloroform to himself on the closet to deaden the pain. The most common of these affections which tend directly to cause constipation on account of the suffering they give rise to in defecation are piles, fissures, ulcers, and fistula ; but one 440 DISEASES OF THE RECTUM AND ANUS. other cause which must never be forgotten in an obstinate case is the possibility that the bowel may be congenitally malformed in such a way as to render easy and complete evacuation im- possible. There may be a congenital narrowing of the intestine two or three inches above the anus, which, as life advances, shall make itself more and more apparent in the way of difficult evacuation. There is also a spasmodic contraction of the sphincter muscle Avhich may be due to a congenital narrowness or may be ac- quired in adult life, and which will render defecation so painful that obstinate constipation is but the natural consequence. This is sometimes the result of fissure, and at others a purely ner- vous affection without fissure. A painful affection of this kind may very soon establish a vicious circle which it may be difficult to break. First the pain causes a voluntary constipation; then the passage of hard, large masses of faeces does mechanical injury to the diseased parts and renders them worse ; and in this circle the patient travels till complete loss of health and serious disease is the result. Constipation is not only a symptom of disease, as in the cases enumerated, but is also a disease per se, attended by its own train of consequences. When long-continued it leads to certain changes in the bowel and adjacent parts. It is thus the most frequent cause of piles, fissures, ulceration, and abscess. Pro- lapse of the bowel is often caused by this condition, and cases of actual rupture from straining, with fatal consequences, have been reported. In addition to these results, which, being external, neces- sarily attract the notico of the sufferer, other changes are often produced internally of which he or she may be entirely uncon- scious. The natural result of turning the large bowel into a re- servoir for solid faeces is to cause dilatation of its calibre and paralysis of its walls. In this way it may assume vast dimen- sions, filling the entire abdominal cavity and pressing all mov- able organs out of their natural position. The amount of faecal matter which may accumulate in the large intestine, in cases of chronic constipation, is simply enor- mous. The whole abdomen may be practically filled with it. In one case fifteen quarts of semi-solid faeces were removed on autopsy; and in another the weight of the collection found in the bowel was twenty-six pounds. ' ' Chelius, Heidelberg Med. Ann., 1838, vol. iv., p. 55. (Johnston.) CONSTIPATION AND F^CAL IMPACTION. 441 The obstruction caused by a mass of impacted fseces may end fatally, as in the following case from Bristow.' It was " that of a little girl, eight years old, whom I saw casually only during life, and of whose history I obtained, after her death, some not very perfect details. She had long suffered from tendency to constipation ; and it was stated that she had occasionally gone as long as three weeks without passing an evacuation. At the time of her admission into the hospital there had been no relief to the bowels for seven weeks. She was then pale and thin, had a large, tense belly, without pain or tenderness, a clean tongue, and a poor appetite. She had a ' strumous ' look and was sup- posed, I believe, to be suffering from abdominal tubercle. She became gradually more and more emaciated and anxious-look- ing, while the belly grew larger and more tense. She never had any distinct abdominal tenderness, but suffered at times from colicky pains, and often (especially toward the close of life) com- plained that she was so full that she felt as if she would burst. During the last week or two the tongue became somewhat foul, and she had frequent vomiting, but never of stercoraceous mat- ter. She passed but little urine, and that was high-colored ; she sank gradually from exhaustion, and died exactly three weeks after admission. Amongst other kinds of treatment adopted was the use of purgative medicines and of purgative injections ; and the medical man in attendance on her was led to believe that they had acted. There is no doubt, however, from subsequent inquiries, as well as from what was observed after death, that he was deceived. At the post-mortem examination the form of the distended intestines was distinctly impressed on the tense and thin abdominal walls, and on opening the abdomen the enormously enlarged colon was at first alone visible. The disten- tion began at the caecum and extended to within two inches of the anus, where it ceased abruptly. In the greater part of its extent the bowel measured from nine to ten and a half inches in circumference, the greatest amount of distention being mani- fested in the sigmoid flexure. The muscular walls were hyper- trophied from the ascending colon to the lower end of the sig- moid flexure ; and in the latter situation (where the hypertrophy was greatest) they measured one-eighth inch in thickness. The mucous membrane seemed healthy in the greater part of its ex- tent, but it presented some congestion here and there, and at distant intervals large patches in which there were groups of small, circular, shallow ulcers. The bowel contained no flatus, ' "Diseases of the Intestine and Peritoneum." 443 DISEASES OF THE RECTUM AND ANUS. but was completely full of thick, semi-solid, olive-green colored, faeces. These were more solid in the rectum than elsewhere, and immediately above the anus formed an indurated, conical lump. The small intestines were also considerably distended.'' The treatment of chronic constipation is by no means a sim- ple matter. It may be begun with a purgative such as three compound cathartic pills, for the sake of opening the v/ay for future treatment ; but here the administration of purgatives should end, for their repeated administration is calculated to do harm rather than good, by substituting an occasional over-action for the daily one which indicates a healthy state of the intestinal tract. The following suggestions may be found of use in the treatment of this condition, which is one that must be overcome at the commencement of the treatment of any rectal affections with which it may be associated. Constipation may be due to deficient action of either the small or the large intestine, and this deficient action in either case may be the result either of deficient secretion or deficient nerve power. Deficient secretion is very apt to be associated with hepatic disturbance, and is marked by dull headache, bad taste in the mouth, viscid secretion from the buccal glands, etc. This is a condition pretty sure to be aggravated by cathartics, for the reason that the temporary increase in secretion which they cause is followed by a corresponding decrease, which serves only to make the patient worse than before. For the purpose of in- creasing the natural secretion of the small intestine, the fruits containing citric acid, such as oranges, and other fruits, such as figs and apples, when the patient can digest them, all serve a good purpose. Water is also an excellent remedy, and two tum- blerfuls of it taken in the morning will often be very beneficial. To it maybe added a slight saline, which decreases its capability for absorption ( 3 ss.-O. i.), and therefore increases the peristal- sis ; and the addition of a single grain of quinine is said to greatly increase the effect.' This treatment, if patiently per- sisted in for a few weeks, will generally be followed by a good result. Deficient innervation will be found in most cases of consti- pation in old people, people of sedentary habits, and those who have little exercise. It is generally attended by deficient action of the skin and a sallow complexion. In such cases water will be found only to weaken the digestive power, unless it can be ' Thompson, New York Medical Record, May 5th, 1877. CONSTIPATION AND F^CAL IMPACTION. 443 <;onibined with a different mode of life and abundance of out- door exercise. Cold bathing-, however, cold against the spine and abdomen, plenty of exercise in the open air, and nux vom- ica, will generally be found to give relief. In constipation dependent upon the large intestine, the trou- ble will generally be found to be due to deficient innervation rather than to any lack in the secretion. It is best treated by keeping the rectum empty, by nux vomica, or belladonna in doses sufficient to cause dryness of the throat, and by electri- city. The latter should be in the form of the faradic current; one pole being* placed over the spine and the other passed up and down along the track of the colon. Infantile constipation may be due, as pointed out by Jacobi, to the disproportionate length of the sigmoid flexure. In chil- dren it is not unusual to find two, or even three, flexures in the lower part of the colon, in which the fseces may remain until they become hard and friable, and when such an anatomical formation is associated with a deficiency of the intestinal se- cretion a very obstinate constipation, and even impaction, may result. Dr. Eustace Smith ' has thoroughly summarized the other •causes of habitual constipation in children as : First. Improper feeding. An excess of starch or of any arti- cle which overtaxes the digestive power may burden the ali- mentary canal with a large, undigested residue, and thus set up a costive habit. By such means a mild catarrh of the intestinal mucous mem- brane is excited and maintained. There is an excess of mucus, and the fsecal masses, rendered slimy by the secretion, afford no sufficient resistance to the muscular contractions of the bowel, so that this slips ineffectually over their surface. Second. Dryness of the stools. Even in the youngest infants the evacuations may sometimes be seen to consist of small, hard, round balls, like sheep's dung. This form of costiveness is generally due to insufficiency of fluid taken. The food is made too thick, or the needs of the system in the matter of water are overlooked. But whether the constipation be due originally to excess of mucus or deficiency of fluid, it cannot continue long without affecting injuriously the peristaltic movement of the bowels. As the colon grows accustomed to be overloaded, the intestinal contents can no longer exert a suf- ficiently stimulating influence upon the lining membrane, and 1 Br. Med. Jour,, July 7th, 1888. 444 DISEASES OF THE RECTUM AND ANUS. the muscular contractions begin to flag. If the infant be badly nourished, this languor of muscular contraction may be aggra- vated by actual weakness of the muscular walls ; and as, under these conditions, the bowel is apt to be over-distended by accu- mulation of its faecal contents, the expulsive force at the dispo- sal of the patient is seriously impaired. Constipation due to the above-mentioned causes is often made more serious by the infant's own efforts to delay relief. A baby whose motions are habitually costive knows well the suffering which undue disten- tion of the sphincter will entail, and often yields to the desire to go to stool only when it is no longer possible to resist. The pain is sometimes aggravated by the formation of little fissures, and the violent action of the sphincter, set up by their presence, forms an additional impediment to free evacuation. The form of constipation due to mild intestinal catarrh is- common enough in young infants. This is owing, no doubt, in great measure to over-abundant feeding with starchy matters, or to the giving of cow's milk without taking due precautions to insure a fine division of the curd. When constipation is due to this cause, our first care must be to protect the child's sensi- tive body so as to put a stop to the series of catarrhs. To do this it will not be sufficient to swathe the belly in flannel. The legs and thighs must also be covered, for so long as a square inch of surface is left bare the protection of the child is incomplete. The infant's diet must next be regulated with due regard to its powers of digestion. Excess of starch must be corrected, and it is best to have recourse to one of the malted foods. A certain variety in the diet is of importance in all cases where the diges- tive power is temporarily impaired. In addition to the regulation of diet and clothing, the bowels should be regularly stimulated by manipulation. The sluggish- ness of peristaltic action may be very materially quickened by judiciously applied frictions. The nurse should be directed to rub the child's belly every morning after the bath. She should use the palm of the hand and ball of the thumb, and, pressing gently down upon the right side of the abdomen, carry the hand slowly round in a circular direction, following the course of the colon. The frictions may be continued for five minutes. In ob- stinate cases the child may be placed upon the bed, and the bowels gently kneaded with the thumbs placed side by side, the movements following the course of the colon. In addition to the above-mentioned general treatment, more special measures may be necessary. These may be divided into CONSTIPATION AND F^CAL IMPACTION. 445 suppositories and enemata, and medicines given by the mouth. The time-honored piece of castile soap for a suppository is recommended, and the now popular enema of thirty or forty drops of pure glycerine. Large enemata of soap and water should be used only rarely, as great dilatation of the rectum and permanent loss of muscular tone are very apt to follow their con- tinued use. For the permanent cure of habitual constipation, remedies given by the mouth are greatly to be preferred, but strong pur- gatives are worse than useless. The aim should be to find the smallest dose which will awaken a normal degree of peristalsis, and to give this dose regularly so as to excite a habit of daily evacuation. The daily dose is most efficient when combined with a remedy which tends to give tone to the muscular coat of the bowel. For this purpose a useful draught is composed of half a drop of tincture of nux vomica, combined with ten drops of tincture of belladonna and twenty of infusion of senna, made up to a fluidrachm with infusion of calumba. This should be given at first three times a day before food, and subsequently reduced to twice and then to once daily. The liquid extract of cascara is useful in many cases, especially when combined with tincture of belladonna. Twenty, thirty, or more drops of cascara ex- tract, with ten of tincture of belladonna, may be given with a few drops of glycerine every night. When the motions are drier than normal, a saline may be given in addition to the liquid already recommended to be added to the diet. The saline may be combined with small doses of nux vomica and quinine. For a baby of five or six months, five to ten grains of sulphate of sodium maybe given, with a quarter of a grain of quinine, half a drop of tincture of nux vomica, and a minim of aromatic sulphuric acid, in a teaspoonful of water, three times a day before food. If the remedy has been well chosen, its quantity may soon be diminished, and finally it may be discontinued. An adult patient should first of all be instructed to have a regular time for the daily evacuation, and the best time for this purpose is immediately after breakfast. The time being fixed, the patient is to go to the closet whether the desire for a passage be present or not, and pass a certain time upon the commode. I generally recommend the time immediately after the morning meal for this purpose, because the breakfast itself often acts as a stimulant to this function, especially in those in the habit of taking a morning cup of coffee. If the patient be a man in the 446 DISEASES OF THE RECTUM AND ANUS. habit of smoking, the first few whiffs of smoke often act in the same way; and there are many men to whom the morning- cigar or cigarette is an essential to the daily evacuation. In such a case it must be a very decided opponent of the weed who would object to its continuance in moderation. If the plain cold water taken in the morning has no effect, the mineral waters may be tried in its place with great advan- tage; and the patient may select the one most agreeable to the taste and which most effectually accomplishes the desired end. The morning meal may consist of whatever the patient most de- sires, but a dish of oatmeal or coarse cracked wheat and milk should always be an essential part of it. A laxative bread may be made of equal parts of coarse Scotch oatmeal, whole wheaten flour, and coarse ordinary flour, with yeast or baking powder. This may be eaten once or twice daily. ' I have almost always found that where perfect regularity in the daily life with regard to eating and exercise can be estab- lished, the function of defecation will also be performed regu- larly, provided the diet be plain and rather coarse in quality. To have a copious, well-formed evacuation, it is necessary, first of all, that the diet should be composed of substances which leave a considerable quantity of waste, and chief among these are the coarser grains and the vegetables. In women a certain regulated amount of daily out-door exercise should be insisted upon, in spite of all excuses and professions of disability. If necessary, this may be small at first, and gradually increased ; and in a woman who has lost the habit and perhaps almost the power of walking, considerable tact and firmness on the part of the physician may be required to carry out this part of the treat- ment, but it will be found to be care well spent. In addition to these dietetic and hygienic rules, certain medi- cation may and often will be found necessary. This should be of the mildest possible kind which will accomplish the object. A pill which I have found to act very effectually and plea- santly under these circumstances is made after the following formula: 5t . Pulv. aloes soc gr. iss. Ext. nucis vom gr. ss. Ext. belladonnse gr. i M. I W. H. Taylor, Lancet, May 31st, 1879. CONSTIPATION AND F^CAL IMPACTION. 447 One of these should be taken at bedtime, and will generally be followed by an easy passage on the following morning. If this does not work satisfactorily, various other remedies may be substituted, amongst the best of which is the compound licorice powder, the rhubarb and soda mixture, or the dinner pill ; the object being to find one among the many laxative preparations which, without causing pain or diarrhoea, will give an easy and natural evacuation of the bowels once every day. The use of enemata for chronic constipation should not be commenced till all other means have failed, for the reason that when once the bowel has become accustomed to this form of stimulus it will be found very difficult to discontinue its use. In some cases, however, their employment may be a necessity, and they are always much less harmful than purgatives. Instead of the ordinary enema of soap and water, the introduction of a harmless foreign body into the rectum will sometimes excite peristalsis. Small fragments of soap or of candles are preferred by many for this purpose to fluid injections. In cases where enemata have lost their power from prolonged use, my own practice is to resort to the use of a long rectal tube two or three times a week; but this should not be trusted to the patient for fear of accidents. Most patients will find it impos- sible to introduce them easily, and will not care to make the at- tempt. With a long flexible tube of small calibre a pint or more of water may easily be thrown into the sigmoid flexure and co- lon, and the bowel be thoroughly emptied. Impaction of Fceces. — The impaction of faeces may be due to several causes, but is most generally a symptom either of in- testinal atony in old people or of some paralytic affection such as locomotor ataxia. It not infrequently occurs in women as a result of the entire neglect of the function of defecation, for which they are perhaps unjustly celebrated ; and it may follow a partial paralysis of the rectum from the long-continued use of large enemata, or the pressure of the foetal head in childbirth. It may also result as a consequence of a painful affection, such as a fissure, which renders each act of defecation an agony to be avoided by every possible means. The disease is generally one of old people, of hysterical girls, and of careless women ; but it has been seen in children, and as a result of improper diet may occasionally be encountered in young and healthy men. Intestinal concretions may be composed entirely of hardened and stratified or clayey masses of fseces, or they may contain within them as a nucleus a biliary calculus, or indigestible sub- 448 DISEASES OF THE RECTUM AND ANUS. stances which have been hastily swallowed, such as peach pits, cherry stones, etc. Molliere calls attention to the presence of magnesia, which favors the aggregation of faecal matters, and which also may act as the nucleus of a scybalus ; and the fre- quency of impaction during the famine in Ireland in 1846, when potatoes, and those of a very poor quality, were the only arti- cle of diet, is a well-known historical fact. ' In Scotland, where oatmeal is a favorite article of diet, fsecal accumulations are said to be of frequent occurrence. Certain other drugs besides magnesia, such as chalk, sulphur, and powdered cubebs, have been blamed as the cause of intestinal concretions. Intestinal calculi have been seen which were composed of pure choles- terin, or of a biliary calculus coated with cholesterin. The usual location of a mass of impacted faeces is the rectal pouch, but it may be situated anywhere between the caecum and this point. The symptoms to which it gives rise are gene- rally sufficiently well marked to enable the practitioner to reach a correct diagnosis if he be on his guard. The pains which it causes will generally be obscure and may be located anywhere in the abdomen or in the lower extremities ; and the signs of disturbance in digestion are not in themselves sufficiently marked for diagnosis, but the one symptom which is charac- teristic is diarrhoea. Just as the practitioner has to learn that incontinence of urine may be a sign of a distended and not an empty bladder, so he may have to learn by a disagreeable error in diagnosis that a diarrhoea is sometimes a result of an overfilled and ob- structed rectum. This diarrhoea is peculiarly foetid in charac- ter, and the matters discharged may be entirely free from faeces and consist entirely of mucus. In some cases there may be an approach to a daily natural evacuation. The act of defecation is always attended by straining and pain as the faecal ball is pressed down against the perineum and rises again when the muscular effort ceases. To these symptoms AUingham adds a peculiar ringing, barking cough, morning vomiting (particu- larly in women), and night sweats. Besides these we see cold- ness and swelling of the feet from pressure on the pelvic and abdominal veins ; varicose veins in the legs ; varicocele ; shoot- ing pains in the legs, groins, and loins from pressure on the sacral nerves ; seminal emissions, jaundice, and albuminuria from pressure. Of course errors in diagnosis are easy in such a condition as ' For description of these cases see article by Dr. Papham in the Lancet, 1850. CONSTIPATION AND F^CAL IMPACTION. 449 this, and a mass of faeces in the colon may be mistaken for any and every sort of tumor in the pelvis or abdomen. Liver, spleen, stomach, uterus, and ovaries have again and again been supposed diseased in these cases, when a simple digital ex- amination of the rectum, or in women even of the vagina, could not fail to make the diagnosis clear. Unfortunately for diagno- sis, the general practitioner is not fond of making rectal exami- nations, and these cases are not infrequently treated with bis- muth and opium as a consequence. The treatment of impaction is simple, and consists first of all in the entire removal of the mass. In cases of paralysis, where the accumulation has not been allowed to reach any very great amount, and the scybala are small and not very hard, this may sometimes be accomplished by the use of injections with a long tube and the assistance of the finger of the operator. In women very effectual aid may be rendered under similar conditions by pressure from the vagina, by which small masses may be extruded one after another, each with a certain amount of pain, but without laceration of the mucous membrane at the anus. This plan of treatment will often constitute one of the regular duties of the attendant upon a case of paralysis — a dis- agreeable duty which must be attended to at certain regular in- tervals. In cases of longer standing, however, these means may be entirely inadequate, and all injections, no matter what their sup- posed solvent virtues, will be of no avail even if they are not at once ejected. In such cases the operation of breaking up and removing the mass must be begun by the administration of ether and dilatation of the sphincter. This accomplished, the mass may be attacked with the fingers, an iron spoon, a pair of litho- tomy forceps, or scoop, and removed piece by piece. When this has been done, an injection may be administered through the long tubs and more matter will generally come down from the sigmoid flexure. The impacted mass is often as large as the fist, and sometimes as a foetal head, and the amount in the sigmoid flexure and colon may be much greater, though not as hard, so that at a single sitting an enormous amount may be removed. After such an operation as this, the patient must be treated by injections and a daily laxative, as described in speaking of constipation, till the over-distended rectum has recovered its tone. This may require a considerable time. 29 CHAPTEE XYI. PRURITUS ANI. Pruritus ani — itching at the anus — is generally a symptom of some other disease, such as hgenwrrhoids or eczema, but it is often present in a marked degree when no cause for its existence can be discovered. It is an exceedingly painful and annoying affection, and one which will often tax the powers of the surgeon to the utmost for its cure. It is met with in both men and women, and seems to be dependent upon no particular general state, being found in rich and poor, the overfed and underfed^ the professional man of nervous constitution and the laborer, alike. The disease is marked by an itching at the anus which is more or less constant, but is generally worse after the sufferer . has become warm in bed at night. The itching causes an at- tempt at relief by scratching, and the scratching, though it may be controlled during the day, is generally practised uncon- sciously during sleep to an extent which causes laceration of the skin. The itching in bad cases, even when constant, is marked by exacerbations and remissions, and may cause an amount of suffering which is simply unbearable. The disease is attended by certain changes in the appearance of the parts. The skin becomes thickened and parchment-like (Fig. 16G) or else eczematous and moist from exudation. It may be red from the scratching, or there may be quite a characteris- tic loss of the natural pigment of the anus. In the latter case the skin becomes of a dull-whitish color, and this will oftener be noticed where the disease is of long standing and severe. The exudation may be very marked where the itching is slight, and may be attributed by the patient to trouble within the rectum instead of to its real source. Associated with the changes in the skin it is not at all uncommon to find one or several fissures. Causes. — The cause of pruritus may sometimes be easily discoverable, and in such cases a cure rapidly follows its re- moval. For example, pruritus is often a symptom of internal PRURITUS ANI, ' 451 haemorrhoids, and is easily and effectually cured by their re- moval. Again, it is often a symptom or complication of a fis- tula with a small external opening, such as may easily be over- looked in a cursory examination, and is cured by the ordinary operation and the consequent cessation of the discharge upon which it depends. It is often dependent upon the presence of the oxyu7^is vermicularis in the rectum, and in every case these should be carefully looked for. If they are present they may generally be seen like small pieces of white thread between the radiating folds at the margin of the anus, especially at night when the itching begins. They may generally be eradicated by certain simple measures, the best known of which is an enema of lime water, or of carbolic acid, 3 i. ; glycerine, i i. ; and water,. X Fig. 166.— TMckened Condition of the Skin in Pruritus. (Esmarch.) |vij., injected after each passage. Turpentine and tincture of iron may be used for the same purpose, and are both very effectual ; but the parasites are much more easily removed in children than in adults, and I have had one case which was ex- ceedingly intractable, and in which I have never been able to keep the worms from returning for any great length of time. A single examination should never be considered as proof of the absence of this parasite in an obstinate case of pruritus. Instead of a parasite located within the rectum, pruritus is occasionally easily accounted for by the presence of pediculi. In such a case the diagnosis and cure are alike easy. Again, the parasite may be vegetable instead of animal, and the itching may be due to the disease known as eczema margi- 453 DISEASES OF THE RECTUM AND ANUS. natum. In this case the diagnosis will rest upon the finding of the spores, under the microscope, in the epidermis scraped from the edge of the affected spot and moistened with glycerine. The most effectual remedy for this condition is a wash of equal parts of sulphurous acid and water frequently applied with a soft cloth, and gradually increased in strength, if necessary up to the pure acid, which latter is, however, generally a painful ap- plication, and one which will readily blister. The acid, even when diluted to a considerable extent, will blister if covered with a cloth. Strong tincture of iodine applied with a brush is also an effectual remedy in eradicating the plant. Pruritus may also be dependent upon other skin diseases, among which chronic eczema is perhaps the most common, and this is to be treated exactl}^ here as elsewhere in the body, first by general measures directed to the constitutional state, and second by local applications. The congestion and the thicken- ing of the skin must first be remedied, and for this purpose very hot water, compound tincture of green soap, and if necessary a solution of caustic potash, may be applied. The water, to be of any use, must be as hot as the fingers can bear, and should be applied to the part with a soft cloth and held there till it begins to cool. This may be repeated half a dozen times, but all rubbing should be carefully avoided both during the applica- tion and in drying the parts after it. This is a favorite remedy with most dermatologists; it should be used just before going to bed, and is often in itself sufficient to insure a good night's sleep. If there be thickening of the skin from effusion, a stronger application than hot water will be necessary; and for this the compound tincture of green soap is a good remedy, or the so- lution of potash (gr. v.- § i.) or liquor potassse may be resorted to with caution. The formula for the compound tincture of green .soap is the following : ^ . Saponis viridis, Olei cadini. Alcohol fifi 3 i. M. It is a much stronger preparation than the simple green soap, and also a much more disagreeable one, but it is very effectual and should be well rubbed into the part once a day. These rem- edies should be followed at once by soothing ointments or lo- tions. A good ointment is the ordinary oxide of zinc made soft and applied gently, and one which is pretty certain to allay PRURITUS ANI, 453 itching is that made of chloroform (3i.-3i.)- This soon loses its power by the evaporation of the chloroform, and should on this account be kept in a wide-mouthed glass bottle, tightly corked, and should be frequently renewed. Another favorite application, and one which is very generally effectual, consists in a lotion of carbolic acid. The formula is : l^' . Acid, carbolici 3 ss. Glycerinse 1 i. Aquse I iij- M. This may be applied at night, and if found to be too strong may be diluted by the patient. In a more dilute form it may also be continued for a considerable time after all symptoms have ceased. For the sake of those who have never encountered an obsti- nate case of this disease, but who are pretty sure at some time to have both knowledge and ingenuity taxed to the utmost, I will give one or two more f ormulse which have been found re- liable. The following comes from AUingham, and by it alone he has " seen a bad case cured in forty-eight hours ": 5. Liquoris carbonis detergentis (Wright's), Glycerinse aa 3 i. Pulv. zinci oxidi, Calamin. prsep aa | ss. Pulv. sulph. prsecip 3 ss. Aquae purse ad 3 vi. M. The part affected is to be thickly painted over with this once or twice a day and allowed to dry. The white precipitate oint- ment, made soft with vaseline or glycerine, is also a good appli- cation, and the following lotion, also from AUingham, will often work well in allaying irritation : 15. Sodse biboratis 3ij. Morph. hydrochlor gr, xvi. Acidi hydrocyanici dil 3 ss. Glycerinae 3 ij- Aquae ad 3 viij. M. This should be applied to the part four or five times in the twenty -four hours. Dr. Bulkley ' has also recommended the following as being useful, and I have often found it so : 1 The Medical Record, December 18th, 1880. 454 DISEASES OF THE RECTUM AND ANUS. IJ . Ungt. picis 3 iij. " bellad 3 ij. Tr. aconit. rad 3 ss. Zinci oxidi 3 i. Ungt. aquae ros 3 iij. M. The following prescription lias also been very efficient in my hands. I am indebted for it to Dr. Salisbury : ^ . Menthol 3 i. Simple cerate 3 ij. Oil sweet almonds 1 i. Carbolic acid 3 i. Pulv. zinci ox , 3 ij. M. Apply morning, noon, and night, after cleansing the parts. An ointment of chloral and camphor, a drachm of each to the ounce, is also at times effectual in allaying itching. There are two other skin diseases, either of which may be the cause of pruritus — herpes and erythema. Herpes at the margin of the anus is the same as when seen on the lips. In the latter case it heals spontaneously, in the former a dressing may be necessary. This may consist simply of a dry powder such as zinc or bismuth, or of one of the lotions already mentioned. Erythema will be found chiefly in fat people, where it is due to contact of the opposing cutaneous surfaces. It also is best treated by the application of dry powders, and by separating the opposed surfaces by a layer of dry sheet lint or old muslin. These are the most palpable, and perhaps also the most com- mon, causes of pruritus, but there are many cases in which the cause is not so easily discoverable, because it is a constitutional and not a local one. Where no local cause can be detected, a careful inquiry must be instituted with regard to the patient's general health and habits. If chronic constipation be present, this must first of all be overcome, for this is in itself an efficient cause for the disease. Another not infrequent cause of pruritus is derangement in the function of the liver. This may or may not be associated with constipation. It must be treated by general dietetic mea- sures, the dilute mineral acids, occasionally by doses of podo- phyllin, active out-of-door exercise, and cold and friction ap- plied to the hepatic region. In women uterine disorders must be looked for and cured before very much will be accomplished in PRURITUS ANI. 455 the treatment of pruritus ; and in women also the urine must be examined for sugar in obstinate cases, for diabetes will some- times give rise to incurable pruritus. In case none of these causes can be found to account for the itching, errors of diet must be searched for, and corrected when found. Anything like excess in smoking or in alcoholic drinks will keep up the disease, and in men these habits must be care- fully regulated if indulged in at all. The disease will sometimes be encountered in stout, full-blooded persons who live well and perhaps incline to the gout, and who show no other signs of dis- order. In such, active exercise and plainer living, with cold bathing of the part at night and morning, and the use of a lotion of carbolic acid, will often effect a speedy cure. On the other hand, the disease may be present in exactly the opposite class of persons, the overworked and worried professional or busi- ness man, and it is in this class of cases alone, where the itching seems to be purely a nervous symptom, that arsenic is indicated. It may be combined with quinine and cod-liver oil, and carried up to its full physiological effect. As a relief for the intolerable itchings at night, Allingham recommends the introduction of *' a bone plug shaped like the nipple of an infant's feeding bot- tle, and with a circular shield to prevent its slipping into the bowel." Its benefit is explained by the pressure it exerts upon the terminal filaments of the blood vessels and nerves of the anus. In this way, then, the physician must undertake the cure of a case of pruritus ani ; and not by the administration of any single lotion or ointment to allay the itching, which is but the symp- tom of some local or general condition. In every case the cause must be found and removed if success in the treatment is to be gained. I know of no disease of the rectum or anus in which there is a better chance for the practitioner to show his general knowledge and skill. If a case be undertaken in this way, and the treatment be intelligently followed by both doctor and pa- tient, a cure may generally be effected ; sometimes in a very few days, but at others only after prolonged effort and many discouragements. The prognosis should, therefore, be guarded at the outset, lest the patient be led to expect a too speedy relief; and in some cases, in spite of the best of care, the disease will frequently return, and the patient can scarcely at any time con- sider himself as perfectly cured. CHAPTER XVII. WOUNDS AND FOREIGN BODIES. Wounds of the rectum may be either contused and lacerated^ or incised. The latter most frequently result from surgical ope- rations, and may be intentionally inflicted, as in the operations for fistula or for the removal of tumors; or the result of accident, as in the operation for stone. Contused and lacerated wounds are generally the result of accident, and perhaps the most fre- quent cause of such an injury is the perforation of the bowel with an enema tube, a bougie, or a urethral sound. The gravity of this accident will depend upon two factors — whether the per- foration of the bowel is above the peritoneum, and whether the enema has been deposited in the perirectal tissues. The latter complication will be followed by abscess and peritonitis, and will result either in death or in stricture and fistula. If the wound be uncomplicated by the injection, the mere puncture may heal spontaneously. It is oblique from below upward, and this greatly favors spontaneous healing without faecal extrava- sation. Dr. Achilles Nordmann, of Basel, has published a description of twenty-five bowel lesions due to the administration of ene- mata. They include three complete perforations, and ulcers and wounds of various depths and sizes. The causes of these wounds seem to have been the use of defective instruments, ig- norance of the anatomy of the rectum, catching the transverse folds on the end of the tube, extreme irritation of the mucous membrane of the bowel, and obstructions caused by such condi- tions as a foetal head, an enlarged prostate, or a misplaced uterus. As a rule, these lesions are to be found on the anterior wall from one to seven centimetres from the anus. They are not always easy to diagnosticate, as other foreign bodies or caustics may produce similar appearances. Tubercular or hsemorrhoidal ulcers may be mistaken for them. A perforating wound gene- WOUNDS AND FOREIGN BODIES. 457 rally results in serious periproctitis, which may end fatally, or in stricture. Esmarch has met with four cases of this injury, none of which were fatal, though attended by much local trouble. Vel- peau describes eight cases, six of which ended fatally. Passa- vant observed five cases, one fatal. Chomel has had two fatal results. There are two preparations in St. Bartholomew's Hos- pital showing the results of this accident, one in a man, the other in a child ten years of age (Esmarch). Besides these most common injuries, many others may be enumerated. The person may fall upon a sharp body, as the point of an umbrella (Bushe '), may be caught upon the horn of an animal (Gundrum," Ashton), or may be impaled upon a spike (Esmarch"). Thompson* describes the case of a man, aged eighteen, who stated that he had fallen about four feet, in a sit- ting posture, on to the end of the upright shaft of a smithes hammer, which he described as having entered his seat for a considerable but unknown distance, and requiring some amount of force in its removal, which was accomplished by a fellow- workman. He had very little pain at the time of the accident, and walked about a mile to the infirmary without much trouble. On examination only some slight bruising was found around the anus, with a little blood-stained mucus. Per rectum nothing was detected. The abdominal walls were quite flaccid. Ex- aininations caused no pain. He complained, however, of a slight, continuous, aching pain just above the pubes. Soon after ad- mission he passed both urine and faeces, the former normal, the latter soft and streaked with blood. Some hours later he passed another motion, with a considerable quantity of clotted blood ; the suprapubic pain also became more intense, but the abdomi- nal walls still remained flaccid. The face was very pale, the pulse rather weak, and the extremities cold ; but the patient ap- peared to be in good spirits, answered questions readily, and did not feel unwell. He remained in this condition until midnight, when the abdominal pain became more severe. Symptoms of collapse gradually came on, and he died at 8 a. m. At the ne- cropsy, on the same morning, the peritoneum was everywhere found intensely injected, and in part presented a thin layer of lymph. There was a marked laceration in the recto-vesical pouch 'Op. cit.,p. 80. '^ Detroit Lancet, October, 1879. ^Op. cit., p. 43. ■"Lancet, December 3d, 1887. 458 DISEASES OF THE RECTUM AND ANUS. a little to the right of the middle line, which led into a triangular opening in the wall of the rectum about three inches from the anus ; this aperture was triangular, its base measuring one inch and a half, its sides an inch each. At the brim of the pelvis, on the right side, was a laceration of the peritoneum covering the psoas, with bruising of the subjacent muscle. The mesenteric glands were enlarged and inflamed. The abdominal cavity contained a small quantity of hard faeces ; there was also found a piece of cloth corduroy two inches long and one inch and a half in breadth, corresponding in texture to the patient's trousers and to an aperture in their seat. In such cases the accident may be immediately fatal from collapse, and the wound in the rectum may be complicated by a wound of the peritoneum or of any of the adjacent organs. The body which has done the injury may also be so firmly im- planted as to require great force and an anaesthetic for its re- moval. The rectum is not infrequently lacerated in childbirth, and although such wounds are generally of slight extent, Bushe ' relates a case in which the child's head was passed through the anus. It has also happened that in a violent effort to expel a mass of hard faeces the rectal wall has given way. Mayo ' re- lates one such case in a woman of forty, in whom the rupture was in the recto-vaginal septum, about two inches within the bowel. Ashton ' reports a similar case, and Bushe ' another. Such a rupture may be either vertical or transverse, will be marked by sharp pain at the moment of the accident, and will be followed by a discharge of blood. It is doubtful whether it ever occurs without previous disease of the wall of the bowel. The consideration of gunshot wounds comes more properly within the scope of military surgery. They are always compli- cated with injuries of other parts, and are generally fatal from extravasation of urine or faeces. The complications which may attend a wound of the rectum have already been hinted at. They are haemorrhage, either jjrimary or secondary ; faecal infiltration ; purulent infiltration ; peritonitis ; emphysema ; hernia ; invagination ; and later, stric- ture and fistula. When faeces are forced out of the rectum into the adjacent tissue, diffuse inflammation and gangrene will ' Op. cit., p. 80. - Op. cit., p. 13. 3 Op. cit., p. 152. *0p. cit., p. 69. WOUNDS AND FOREIGN BODIES. 459 probably result, and the condition must at once be met by free incisions and free drainage, as has been described in the chap- ter on abscess. The danger of fsecal infiltration may be less- ened by a diet which shall prevent fluid passages, and by the free use of opium. A dilatation or a free division of the sphinc- ter is also to be recommended, so that a free outlet may be ac- corded to the contents of the bowel. Emphysema, as a result of a perforation, is generally con- fined to the perineum, but may be diffuse.' It is very apt to be fatal from diffuse inflammation and septiciBmia due to the putrid nature of the gas, and is to be met by free incisions. Wounds of the bladder or urethra communicating with the rectum are to be met by providing for the free issue of the urine. This may be done by catheterism, by aspiration, or by free division of the sphincter. Where none of these complications exist, a fresh wound of the rectum may close by first intention, and an effort should always be made to secure this by rest in bed, by emptying the bowel, and keeping it empty by frequent washings with water, and by the use of opium. Healing by granulation will, how- ever, be the rule. In some cases, such, for example, as lacera- tion in childbirth, sutures may be at once applied. As Ball points out, the proper method of treatment for punc- tured wounds low down in the rectum is free incision through the sphincter up to the wound to allow of drainage. Of gunshot wounds of the rectum during the Civil War, Otis ' collected 103 cases, with a mortality of 42.7 per cent ; in 34 of these the bladder also was wounded, with a mortality of 41.17 per cent. Foreign Bodies ivhich have been Sivallowed. — Medical litera- ture is full of curious cases in which foreign bodies have been swallowed, either accidentally or by design, and have in some cases passed the full length of the alimentary canal and been safely voided with the fseces, or in others have become entangled in the mucous membrane and given rise to much trouble. Every practitioner is familiar with cases of peach-stones and coins which have been accidentally swallowed, and knows how gene- rally such substances take care of themselves and cause no symptoms after once passing the oesophagus. Much larger sub- stances, such as whole or partial sets of false teeth, and the vari- ' Lancet, January, 1860, p. 89. ^ Ashhurst, " Encyclopoedia of Surgery," vol. ii., p. 199. Quoted by Ball. 460 DISEASES OF THE RECTUM AND ANUS. ous things with which performers in travelling shows entertain an audience, may also be passed in safety. To show what nature is capable of in this line, it may be well to enumerate the substances which were swallowed and safely voided by a certain lunatic now become famous. The patient stated that she had been swallowing nails, etc., and a dose of castor oil brought away two pieces of faience one or two centi- metres long and about the same breadth, two nails, and a pebble. During the following six weeks she passed nineteen large pointed nails, a screw seven centimetres long, numerous fragments of glass and china, a piece of a needle, two knitting needles, frag- ments of whalebone, etc., amounting in all to three hundred grammes. During all this time the patient ate and drank as usual, and seemed in ordinary health. ' Prof.'Agnew " saw in the dissecting room of the Philadelphia School of Anatomy a female subject, afterward learned to have been insane, in whose intestinal canal from jejunum to rectum were found three spools of cotton partially unwound ; two roller bandages, one of them two and a half inches wide and one inch thick, the other was partially unrolled, one end being in the ileum, the other in the rectum ; a number of skeins of thread, a quantity being packed tightly in the csecum ; and finally a pair of suspenders." Prof. Gross records the " case of a man who swallowed a bar of lead, ten inches long, upward of six lines in diameter and one pound in weight, whilst performing some tricks of legerdemain," which was removed by gastrotomy and the patient recovered in two weeks. He also mentioned another case in which a tea- spoon was swallowed whilst the patient was in a paroxysm of delirium, which was removed from the ileum by enterotomy. re- covery taking place in a few weeks. "" It would be beyond the scope of a work such as this to at- tempt to deal with the whole question of foreign bodies in the alimentary canal, and the accidents which may attend them. In a general way, the prognosis is good unless the foreign body be a very ragged one or a large, sharp one like a fork ; and the treatment consists in giving a diet, like bread and fruit, which will cause copious stools, with little drink, and the avoidance of exercise such as walking. If complications arise, they must be treated on general surgical principles ; and at the present day no patient would be allowed to die from the effects of a foreign 'Lancet, 1866, vol. i., p. 2B. * Randolph Winslow : Maryland Medical Journal, March, 1880. WOUNDS AND FOREIGN BODIES. 461 substance in the stomach or intestines without a surgical opera- tion for its removal, provided only the diagnosis were clear. The complications which may attend the detention of such substances in the rectal pouch just above the internal sphincter are ulceration with perforation, haemorrhage, and abscess. Ul- ceration may be caused by the pressure of a large body, and may cover a considerable space ; or it may be caused by the pressure of the sharp ends of a smaller body, in which case the spots of ulceration will be smaller, and may be located at two opposite points in the rectum. As a result of ulceration, there will be more or less pain, purulent discharge, and perhaps also a sharp hsemorrhage from the erosion of a vessel. When perforation of the wall of the bowel has occurred, inflammatory action is almost sure to be excited in the surrounding parts, and this may vary greatly in its extent and gravity. If the injury be above the point of reflexion of the peritoneum, it may cause either a localized or a general peritonitis. A general peritonitis caused in this way will be fatal, as it is also generally accompanied by more or less extravasation of faeces. A circumscribed perito- nitis with formation of an abscess is a less fatal complication. Under these circumstances the usual signs of pelvic abscess will be present — fever, pain on pressure, tympanites, painful defeca- tion and urination — and by careful examination a tumor may be discovered, either through the rectum or at the bottom of the iliac fossa. Such cases, when the tumor is on the right side, are often mistaken for cases of perityphlitis, but the tumor is not in the same location ; it is deeper and nearer the median line. Such an inflammation may terminate in resolution, provided the cause be discovered and removed ; but the usual termination is in suppuration, and the pus, if not removed by the surgeon, may find its way into the general peritoneal cavity or into the bladder or rectum. Abscesses of the superior pelvi-rectal space have already been described, and those which are due to foreign bodies in the bowel do not differ from them in general char- acters. When the focus of inflammation is located below the reflex- ion of the peritoneum, the prognosis is less grave. Phlegmon- ous abscess may form in the ischio-rectal fossa, and must be treated according to the rules already laid down ; but here the difficulty is well within the reach of the surgeon, and a cure may confidently be looked for by proper care. Foreign Bodies Introduced per Anum. — A classification of these cases is useless. The foreign bodies mav be introduced 462 DISEASES OF THE RECTUM AND ANUS. through traumatism ; by the patient in an honest endeavor to relieve himself of piles or prolapse ; by the surgeon for the pur- pose of relieving rectal disease. They are often introduced in a spirit of revenge or of trickery : and most often of all they are lost in the practice of an unnatural vice. Edward II. is said to have met his death by having a red-hot iron thrust into the rec- tum. '-We seized the king,"' said one of the murderers, "and threw him forcibly upon the couch, and, whilst I kept him there b}^ the assistance of a table, with a pillow on his face, Gurney inserted through a horn-tube a red-hot iron into his bowels.'^ (Gross, vol. ii., p. 627.) The case of the prostitute into whose rectum the students of the University of Gottingen introduced a pig's tail, butt end first, is as follows: "Some students had formed the plan of playing a practical joke on a prostitute; they determined to push into her anus a frozen pig's tail. They cut the hairs very short in order to make them sharper and rougher, then dipped it in oil and for- cibly introduced it into the woman's anus, with the exception of a portion, three fingers' breadth in length, which remained outside. Several attempts were made to extract it, but, as it could only be withdrawn against the hairs, the bristles pene- trated the mucous membrane and gave rise to excruciating pain. In order to relieve it various oily remedies were given by the niouth, and the attempt was made to dilate the anus with a speculum in order to extract the tail without violence, but it was unsuccessful. Severe symptoms developed — violent vomit- ing, obstinate constipation, very high fever, and intense pains in the abdomen. Marchettis was summoned on the sixth day. This physician, having been informed of what had happened, invented a very simple and ingenious device. He took a hollow reed, one end of which he prepared so that he could easily intro- duce it into the anus, and completely enclosed the pig's tail in this reed, in order to withdraw it without pain. For this pur- pose he attached to the tail, by the end which projected from the anus, a stout wax thread which he passed into the reed. With one hand he pushed this form of canula into the rectum, and held the cord with the other to prevent the tail being pushed in still further. He succeeded in completely enclosing the tail, and promptly relieved the patient." ' A punishment for adultery among the Greeks is said to have been the introduction into the rectum of a peeled radish cov- ' Hevin, p. 339. WOUNDS AND FOREIGN BODIES. 463 ered with hot ashes ; and cases in which patients have fallen upon sharp and fragile objects, such as the wooden pickets of a fence, which have broken off and remained in the rectum, are on record. The list of foreign bodies which have been lost in the rectum by ignorant persons, in attempts to check a diarrhoea or to pre- vent the descent of piles or prolapse, is a very long one, and in- cludes such substances as bottles, sticks of wood, and round stones, some of them of a size relatively enormous; and the use of the rectal pouch by criminals for the purposes of concealment is well known to the police. In the Museum of Anatomy and Pathology at Copenhagen is a longish, oval, flat stone, about six and three-quarter inches long, two and a half inches wide, one and a half inches thick, and weighing nearly two pounds, which a patient in Bornholm introduced into his rectum to prevent prolapse, from which he had for a long time suffered. The stone was extracted by a sur- geon, Frantz Dyhr, in 1756.' A little case with a very ingenious housebreaking and other thieves' instruments was found by Dr. Closmadeuc at the ne- cropsy of a man in the prison at Vannes. The man had died of acute peritonitis, from which he had suffered seven days. During his illness a hard, rather large body was felt in the left side of the hypogastrium ; he said that it was a piece of wood containing money, which he had introduced into the rectum ; this, on exploration in the meantime, was found empty. On section, the case, which was cylindro-conical in form, lay in the transverse colon, with its apex directed toward the cgecum : it was of iron, and was wrapped in a piece of lamb's mesentery ; it weighed about twenty-three ounces, was about six and a third inches long and five and a half in circumference, and contained thirteen tools and some coins." "A monk, desiring relief from a severe colic from which he was suffering, was advised to introduce into the rectum a bottle of Hungary water, in the cork of which there was a small open- ing through which the water gradually distilled into the intes- tine (these bottles are usually long). He pushed it so far that it entered the rectum altogether, whereat he was greatly aston- ished. He could neither have an evacuation nor receive an enema ; inflammation and death were apprehended. A mid- ' Bull, de la Soc. de Chir., 1878, p. 660. - London Medical Record, December 15th, 1878. Abstract of Studsgaard's paper read before Soc. de Chir., Paris, October 9th, 1878. 464 DISEASES OF THE RECTUM AND ANUS. wife was consulted in order to see whether she could introduce her finger and extract the bottle, but she was unable to do it. Forceps, a ripping iron, and anal speculse were useless. It could not be broken ; this would have been more disastrous, as the pieces of glass would have wounded him. Finally a little boy, eight or nine years old, was found, who introduced his hand and had sufficient address to cure the good monk.*' ' A depraved sexual appetite has been mentioned as account- ing for the presence of many foreign bodies. It is known that sexual orgasm may be excited by stimulating the reflex power of the rectum, and it is probable that at the moment when the orgasm is at its height the body used to produce it is allowed to escape from the hand and is lost within the bowel. This is a habit which will never be acknowledged by its victims, but which may often be assumed to exist by the surgeon in de- praved patients. The bodies used for this purpose are generally smooth, long, and round, such as glass bottles and pieces of wood. The following case is one in point, and the age of the patient is suggestive, for this vice is said to be more common in old men than in others — men whose physical powers have not kept pace with their desires. " On the afternoon of March 1st, 1848, a young man consulted Parker with regard to his father, whom he had brought into the hospital. After beating around the bush and manifesting con- siderable shame and embarrassment, he stated that his father, named Loo, who was sixty years old, had passed the previous night in a house of prostitution. Overcome by drink and opium, the old debauchee conceived the strange notion of pushing a goblet, two and a half inches in diameter and three and a half inches long, into the vagina of his partner. During the night, while Loo was completely intoxicated, the woman attempted to revenge herself. She carefully introduced the bottom of the goblet into the rectum, placed the end of the opium pipe, which was a foot and a half long, into the goblet, and pushed it into the rectum. The goblet disappeared and had been retained twenty-four hours. A piece of the edge, about half an inch long, had been broken off by the friends in attempts at extrac- tion. The glass was firmly fixed, and it was very difficult to pass the finger between it and the rectum. Parker, determining to break it, employed a cephalotribe and removed it in pieces, taking care to protect the parts with cotton. The most difficult part was the extraction of the glass, which was very irritating. ' " Mem. de I'Acad. de Chirurgie." WOUNDS AND FOREIGN BODIES. 465 It was done, but not without difficulty, by making it see-saw from side to side. Considerable haemorrhage occurred, which was arrested with sulphate of copper and alum. The man re- covered in two weeks." ' It would be interesting to enumerate the foreign bodies which have been removed from this part of the body, and the list would be startling from the strangeness of the different articles; but enough has been said to indicate that almost any- thing, from a conical stone to a club or a coffee cup, may be encountered by the surgeon, and to indicate the size of the body which the sphincter will allow to pass. Among them may be mentioned beer glasses, mushroom bottles, wooden pepper boxes, wine bottles of all kinds, lamp chimneys, and a part of the wooden handle of a baker's shovel twenty-two centimetres in length. A foreign substance may remain in the rectum for a con- siderable time and finally be expelled spontaneously, as in the following case reported by Weigand.' "A farmer, aged sixty-eight years, of a robust constitution, but somewhat stupid, introduced into the anus a cylindrical piece of wood for the purpose of relieving his obstinate consti- pation. However, he performed the manipulation so unskil- fully that the piece of wood broke and remained partly within the rectum. All attempts made to rem.ove the foreign body failed; two days later he suffered from abdominal and lumbar pains, dysuria, and constipation. Weigand, being consulted by the physician, recognized the symptoms of enteritis. As the in- troduction of a finger into the rectum did not demonstrate the presence of a foreign body, he restricted himself to combating the inflammatory symptoms and pain (calomel, enemata, nar- cotics, leeches). On the eleventh day a purulent, sanguinolent, foetid fluid was evacuated, after which the patient felt remark- ably relieved; but it was impossible to discover any trace of the piece of wood. Weigand then expressed serious doubts as to whether a foreign body was really contained in the rectum: but as the patient resolutely maintained that he continued to feel the piece of wood, renewed search was made, until the finger, being introduced far in, encountered a rough, hard object which it was impossible to seize for want of proper instruments. As circumstances did not indicate a necessity for more active treat- ment, Weigand contented himself with giving the patient from ' Am. Journal of the Medical Sciences, 1849, p. 409. 2 Schmidt's Annalen, 113, iv., p. 95, 1862. 30 466 DISEASES OF THE RECTUM AND ANUS. time to time two or three spoonfuls of castor oil, which always produced the discharge of a small amount of muco-sanguinolent faeces. At this time the lumbar and abdominal pains again ap- peared more frequently, and, on the other hand, the patient's former appetite being gradually restored, he walked about and attended to light domestic duties. On the thirty-first day after the accident, after having taken three spoonfuls of castor oil, he stated that he had an intense desire to go to stool, when, in addition to blood and pus, the piece of wood made its appear- ance, 0.1357 m. long, 0.027 thick, cylindrical, serrated at the broken end, and roughened on the cylindrical surface; in fact it "was the end of a pole with which bean vines are propped. The patient recovered entirely without having been subjected to any further treatment.'' (Poulet.) Prognosis. — The prognosis in cases of foreign bodies will de- pend greatly upon their size and nature. A long body like a piece of wood may go so far up the bowel as to do fatal damage before its removal ; and a fragile body like glass may cause fatal injury in the attempt to remove it. Again, the prognosis depends in great measure upon the surgical ability of the one in charge of the case. A little bungling in the treatment may at any moment change a case which promises well into a fatal one. Finally, much will depend upon the length of time during which the body has remained in the rectum: and it is not very uncommon for patients who have met with an accident in the practice of this secret vice to conceal the real nature of the trouble, which they well understand, till they are forced by suf- fering to confess. In this way a week's valuable time may be lost and a fatal amount of injury be done. Treatment. — Each case of foreign body must be treated by itself, and besides a few general principles which apply equally to all cases, the surgeon will be left entirely to his own ingenu- ity. The one guiding principle should be to avoid doing fresh injury in the attempt at removal. Only the smaller and least friable of bodies can be removed without a previous dilatation of the sphincter under ether, and in most cases it will be advis- able to incise the anus in the median line down to the tip of the coccyx as a preparatory measure to all treatment. This step will sometimes render a body movable which before was absolutely immovable, and thus open the way for its extrac- tion. Having opened the way to the body, it may sometimes be re- moved by passing the whole hand into the rectum and seizing "WOUNDS AND FOREIGN BODIES. 467 it. At other times forceps may be used with advantage, and these may be of any shape which seems best to answer the pur- pose intended, including the obstetric forceps, which have been found useful in many cases. If a bottle has been introduced •with the mouth downward, a string may be secured around the neck for the purpose of traction : but, unfortunately, in almost all cases the position will be reversed. In cases of long bodies the lower end is not infrequently firmly wedged in the hollow of the sacrum — so firmly as to resist all efforts at dislodgment. Under such circumstances fatal injury may easily be done by the operator by persistence in the attempt. Above all things the surgeon must avoid breaking such a substance as a cup, for experience has proved that, after this has happened, removal without causing great injury is almost impossible. Certain complications may at any time arise in the treatment of these cases, one of which is recorded by Desault.' A man, aged forty-seven years, entered the Hotel Dieu on April 17th, 1762, in order to have a crockery vessel extracted from his rec- tum which he had introduced a week previously in order to ■overcome, as he said, his obstinate constipation. This vessel was a preserve jar, the handle of which was broken and the bot- tom detached. It was conical in shape and three inches long; it had been introduced by the smaller end, which was two inches in diameter. When the patient presented himself at the hospital he had already made efforts to extract the foreign body, but an escape of blood and the excessive pains had compelled him to suspend his efforts. The upper part of the rectum was infolded and in- vaginated in the vessel, and formed a very hard tumor which filled it completely. The surrounding parts were inflamed, and this fact rendered the extraction more difficult. Desault made the patient lie upon the side, and then, separating the intestine irom. the walls of the vessel, he succeeded in seizing the latter with a strong extractor, which he pushed up as far as possible, and which was held by an assistant. By means of this point of support, and with another extractor introduced in the same manner, he succeeded in breaking the vessel and in extracting it in small pieces without wounding the rectum. The operation was neither long nor painful, though it was necessary to intro- duce the extractors a large number of times. After all the pieces had been removed, Desault pushed back the inverted por- ^ Journal de Chir., t. iii., p. 177. (Poulet.) 468 DISEASES OF THE RECTUM AND ANUS. tion of the rectum by means of a charpie tamipon six inches long- and two and a half in diameter, which he pushed in altogether after having covered it with cerate. Below this were placed a large amount of charpie, several compresses, and a triangular bandage which supported the whole dressing. The dressing was renewed twice a day on account of the relaxation, which did not cease till the sixth day. Then the intestine no longer protruded when the patient went to stool, and such large tam- pons were not required. They were discontinued entirely after the tenth day, when the ruptures had cicatrized, and the man left the hospital entirely cured two weeks after the operation. In cases where a long body has become firmly wedged into the lower end in the hollow of the sacrum, the proper treatment consists in opening the abdomen, and this should be done after an attempt to remove it jjer anuiii has been continued a reason- able time, and before injury has been done in such an attempt. It is not necessary to describe the operation of laparo-entero- tomy in this connection. The incision may be made either in the median line or in the groin. In the " Surgical History of the War of the Rebellion," vol. ii., p. 322, there is a history of one such operation performed upon a sailor who had introduced a stone five and a quarter inches long by three wide. The colon had been perforated, and the stone was removed from the peri- toneal cavity by an incision near the umbilicus. The man re- covered. The oldest known case ' was reported by Realli in the Bull, de Soc. Medich. and Gaz. Med., July, 1851, and, being the one which has served as a guide for all subsequent ones, we give it in full : Case. — Foreign Body. — "On December 18th, 1848, a peasant was brought to the hospital of Orvieto in a condition of extreme weakness. Nine days previously, having hit upon the ingeni- ous idea that if he prevented the discharge of food he could limit the quantity to be swallowed, he introduced a piece of wood into the rectum ; all his attempts at removal only served to push it in still further. The finger could only touch the end of the object, and it was firmly fixed in such a manner as not to yield to any tractions which could be made upon it with such a slight purchase. "After the failure of all attempts at removal, the foreign body completely obliterating the intestinal cavity, and the pa- ' For this and many other interesting facts in connection with this subject the reader is referred to Poulet's work on " Foreign Bodies in Surgery," Wood's Library of Standard Medical Authors, 1880. WOUNDS AND FOREIGN BODIES. 469 tient being threatened with death from his atrocious sufferings, Realli decided to operate. After having cut the abdominal walls on the left side, he could distinctly feel the stake in the descending colon. He desired to push it down to the anus, but the attempts proved unsuccessful, and he was compelled to in- cise the intestine. Only after this was done could he remove the body, which was ten centimetres long and more than three centimetres in diameter at the base. The point was rounded and very soft. ISTo freces were retained above the plug, but the mucous membrane was blackish, the peritoneal coat strongly injected, and the thickness of the intestinal wall markedly in- creased. " The wound in the intestine was united by a suture, which was applied according to Jobert's plan. The lips of the wound in the abdomen were united by means of an interrupted suture. Cold and then iced applications were made over the operated region. Two doses of castor oil were administered. There was a purulent discharge from the anus. During the first few days the tumefaction of the walls of the intestines prevented the advance of fseces, and caused meteorism and vomiting. Three bleedings, two applications of leeches, and a few doses of castor oil put an end to these symptoms, which had acquired an alarm- ing character. The evacuations from the bowels were again passed on the fifth day. Toward the fourteenth day the wounds had cicatrized. Two years later the health remained perfect."' In a paper read before the Soc. de Cliirurgie,' Studsgaard, of Copenhagen, reports the following similar case : Case. — Foreign Body. — ''J. F., footman, aged thirty-five years, was admitted on January lOtli, 1878, to the Copenhagen Hospital, and left cured on April 16th, 1878. The night before entering he had introduced an empty mushroom bottle into the rectum, the neck of the bottle being uppermost, in order, as he stated, to relieve a rebellious diarrhoea, and on the morning of January 10th he was obliged to call a physician, acute pains being experienced in the abdomen. " He was ansesthetized with chloroform, but the bottle, which, previous to the narcosis, had been felt in the rectum, slipped further up. He was exhausted by the passage and the increasing pains ; vomiting of mucus. The bottle could be felt through the somewhat tense abdominal wall along the median line on the left side, the bottom being near the horizontal ramus 1 Bull, de la Soc. de Chir., 1878, p. 662. 470 DISEASES OF THE RECTUM AND ANUS. of the pubis. In the evening, profound narcosis and posterior linear rectotomy ; the hand was introduced as far as the third sphincter, which was not forced, on account of its resistance. The bottle was then pressed from the outside down into the pelvis, but it descended in a loop of the intestine in front of the rectum. Immediately afterward antiseptic laparo-enterotomy through the median line, by an incision ten centimetres long, commencing at the umbilicus. A loop, which was thought to be the sigmoid flexure, was extracted, and the bottle was then slowly removed through an incision four centimetres long^ which was made upon the orifice and upper part of the neck. The entire circumference was protected by sponges and com- presses between the faeces, and the intestinal incision was closed by twelve to fourteen catgut sutures according to Lembert's method, the peritoneal surfaces having been freely washed. In order to be on the safe side, the sutures were tied with three knots ; the intestines were then introduced, and the abdominal wound united with eight silk sutures tied alternately with knots and the figure of eight. The operation lasted an hour. " The bottle was seventeen centimetres long, the diameter of the bottom was five centimetres, that of the neck three centi- metres ; the opening contained a notch, which was evidently of old date, about half a centimetre long and presenting cutting edges. The recovery occupied a long time, and the prognosis was uncertain for a very protracted period, on account of a local peritonitis with abscess formation, which I incised both upon the median line and through the rectum, upon the pos- terior wall of which it projected. Gas began to pass two days after the operation ; from the ninth day on, he had spontaneous evacuations, which were well formed and contained no traces of pus." One other case of this kind has been placed on record ' by Verneuil. Case.— A man, aged forty-five, had been in the habit of stopping up his rectum to overcome an incontinence of faeces which had resulted from two previous attacks of dysentery. For this purpose he used various large bodies, taking the pre- caution to tie to them a piece of cord, the ends of which were left hanging outside. But one day he had no cord, and a cyl- indrical piece of wood, ten centimetres long and about eight in diameter, escaped into the upper part of the rectum and could neither be forced down nor reached with the finger. All the ' Prog. Med., May loth, 1880. WOUNDS AND FOREIGN BODIES. 471 efforts which were immediately made by a physician of the place only forced the body further from the anus. In this condition the patient entered the service of M. Ver- neuil. There were few signs of retention, but the finger could not be made to reach the foreign body ; only with the hand on the abdomen could it be felt in the left iliac fossa. It was so high that linear proctotomy could give no assistance, and there- fore laparotomy was decided upon. The plan of operation was the following : Through a small abdominal incision to search for the sigmoid flexure, in which the body was probably lodged; to draw the sigmoid flexure outward, and, if healthy, to incise it, remove the body, sew up the gut and replace it in the abdo- men. If, on the contrary, it was diseased, to stitch it to the abdominal wall and make an artificial anus. But the foreign body was so fixed in the upper part of the rectum, with its long axis from behind forward, as to be immovable, and by reason of this immobility of the rectum the former plan of operation had to be abandoned. Fortunately, it was possible to dislodge the body from this fixed position, and M. Lucas Championniere, who at that mo- ment practised the rectal touch, received it upon the end of his finger. While an assistant fixed the body by pressing on the abdomen, M. Verneuil endeavored to seize it with the forceps of Muzeux or to fit it with a gimlet, but without success. Linear proctotomy was then resorted to, and M. Yerneuil succeeded in moving the body with one of the blades of a lithotomy forceps, bringing it down, and seizing it with another pair of strong for- ceps. The instrument slipped many times on the bark of the wild-cherry wood, and it was only after many long and painful attempts, practised with a very defective stock of tools, that the foreign body was finally withdrawn. It was followed by a discharge of very foetid fsecal matter and a little blood. The result of the operation, thanks to the precaution taken during the manoeuvres and the treatment subsequently employed, sur- passed all expectations. The abdominal wound healed by first intention under Lister's dressing, and a soft-rubber catheter, kept permanently in the rectum, through which chloral was in- jected every two hours, prevented any complications in tliat part. Case, — Removal of a Stone from the Peritoneal Cavity; Re- covery.' — John S., sailor, aged forty-one, had been in the habit of crowding either a belaying pin or an eight-ounce bottle into the ' " Boston City Hosp. Rep.," 1882. 472 DISEASES OF THE RECTUM AND ANUS. rectum to relieve a retention of urine, which was of a spasmodic nature, and which recurred frequently. June 13th, 1870, not having any bottle, he obtained a pebble, five inches long by three Fig. 107.— Stone removed from Peritoneal Cavity. Natural size. in width, and weighing two pounds, and, having greased it, he applied it to the anus and sat upon it. Suddenly the stone slipped into the rectum above the sphincter, and although the WOUNDS AND FOREIGN BODIES. 473 patient could touch he could not remove it. A physician was called, who endeavored to pull it out with wire loops, but the more he tried the farther the stone receded from the anus. A Fig. 168.— Stick removed from Rectum. Natural size. final effort was made by causing* the captain's boy to pass in his hand "up to the shoulder"; he could reach the pebble, but could not draw it down. The patient was then brought to Bos- 474 DISEASES OF THE RECTUM AND ANUS. ton, and Dr. Thorndike called June loth. He found him suf- fering from peritonitis, indicated by tympanites, pain, high pulse and temperature, vomiting, and brown tongue. The pa- tient having been etherized. Dr. T. passed his hand into the rectum ; he could feel the stone high up in the abdominal cavity, but his hand and arm were so cramped by the want of space that it was impossible to seize the foreign body. An in- cision, five inches long, was then made, parallel with the outer border of the left rectus muscle, extending upward to a point two inches above the umbilicus ; the peritoneal cavity was opened, and the stone found lying among the intestines just below the stomach. (Fig. 167.) The bowels were highly con- gested, but not adherent to each other. The aperture through which the stone escaped from the intestine was about eight inches above the anus. The external wound was closed with six silk sutures. "The patient had a thin, yellow dejection three days after the operation. No blood ever came from the rectum. The vomiting, hiccough, tympanites, and pain gradually subsided, and he got out of bed in twelve days." Fig. 1G8 represents a willow stick introduced by the patient five years before "to relieve constipation." A recto-vesical fistula had been formed, and the stick had become encrusted with phosphates.' These five cases indicate with sufficient clearness the general rules which should guide the practitioner. The operation is applicable only to bodies high up in the rectum. The point of incision may be in the median line, over the sigmoid flexure in the left loin, or over what seems to be the most prominent point of the foreign body, wherever that may be. If the intestine is healthy, it may be closed and returned into the body ; if not, an artificial anus should be made at the point of incision. It is worthy of note that all of the cases thus far recorded have ended in recovery. Note. — Other cases of this sort are as follows : Russell, G. — Case of intestinal obstruction caused bj'^ a wine bottle ; removal hy abdominal section ; death. British Medical Journal, May 28th, 1881. Gentiliio-M.me. — Corps etranger du rectum deplace et arrete dans I'S iliaque ; ex- traction par I'abdomen, suture de Tinte-stin ; gueri.son. Union Med., Septembre, 1881. BiLLRcrn. — Foreign body in the sigmoid flexure ; laparotomy ; enterorrhaphy ^ death. Wiener Med. Woch., Nos. 3, o, 7, 1881. In this case the foreign body (a pencil seven centimetres long) had been in the bod}' three weeks, and the patient was in collapse from perforation at the time of the operation. ' Cnuumcr, Omaha Clinic, October, 1888. OHAPTEE XVIII. SPASM OF THE SPHINCTER— NEURALGIA. Spasm of the sphincter without the presence of any other rectal affection is undoubtedly rare. Its general character may perhaps best be shown by the citation of the following cases. Case. — Spasm of the Sphincter. — Physician, aged twenty- eight. The patient was a man decidedly given to thinking about his own health, and though generally well, not at all robust. He came to me complaining of a sense of discomfort about the rectum, accompanied by difficulty in defecation. The discomfort seldom amounted to actual pain, and he had noticed that when he was away on his summer vacations he was always better and in fact perfectly well. Nevertheless the trouble in defecation had increased so markedly during the past few months that he was fully convinced that he was suffering from actual stricture. An attempt at digital examination caused the most exquisite suffering, forcing the patient to cry out in agony, and yet there was entire absence of any lesion. The treatment was based upon the fact which he had himself noted, that when his general condition was improved the local trouble ceased ; and the patient was cured by purely general measures looking toward the building up of the system. Case. — Spasm of the Sphincter. — Professional man, aged thirty. In this case also the only symptom complained of was pain on defecation, sometimes severe, sometimes slight. The history given pointed so strongly toward the existence of a fis- sure that I etherized the patient, fully expecting to cure him by stretching the sphincter. He was entirely cured by stretching the muscle, but, to ray surprise, a most careful examination re- vealed no disease ; and, being dubious myself about the exist- ence of spasm without fissure, the examination was a very thorough one. This patient was also a man of sedentary habits and of rather a nervous character. The following case is taken from Syme, and is characterized 476 DISEASES OF THE RECTUM AND ANUS. 'by hini as a remarkable instance of the affection:' '* I was asked to see a gentleman, about sixty years of age, who stated that a few weeks before, after sitting out a long debate in the House of Commons, he had felt extreme difficulty in evacuating the bowels, having previously for several years experienced more or less uneasiness from this source : that he had consulted a physician and surgeon in London, who prescribed laxatives without affording relief ; and that his complaint had continued so as at length to confine him to bed. I proposed an enema, which was at once objected to on the ground that the anus would not admit the smallest-sized tube. Suspicion being thus excited, the anus was examined and found to present the char- acteristic features of spasmodic stricture. Having explained my views of the case, I gently insinuated the narrow sheath of a bistoury cache, which I happened to have with me, and then expanding the blade, withdrew it so as to make an incision on one side of the orifice. A copious stool immediately followed, and the patient was at once completely relieved from his com- plaint. " With regard to this much-disputed affection, a citation of authorities may be useful. Syme ' believed that spasm existed as an independent condition without morbid change ; that, though there could be no doubt that spasm and fissure fre- quently existed together, it was not reconcilable with the facts met with in practice, that spasmodic stricture was always of secondary origin and dependent upon the fissure. He says : " In a considerable number of cases I have found the sphincter firmly contracted without any perceptible fissure or abrasion of the surface." Mayo describes spasm of the sphincter as a kind of cramp which often comes on suddenly, sometimes at night during sleep. The paroxysms may occur daily or two or three times a year ; and the attack may come gradually and cause uneasiness for two or three days, and then pass away, or its coming and going may be sudden. He says : " There are cases in which the disease produces long-continued and permanent suffering ; in which the anus becomes permanently contracted and hardened, constituting, therefore, a permanent stricture, and generally combining both permanent and spasmodic contraction. The motions are passed with an effort and with pain, and all the common symptoms of stricture of the rectum are present." ' " Diseases of the Rectum," Ediuburgh, 1838, p. 138. *Loc. cit., p. 134. SPASM OF THE SPHIXCTER — NEURALGIA. 477 Allingham ' says : '' Spasm of the sphincter has been said to- be the cause of impaction, but I have more often thought the re- verse was the case, and the impaction the cause of the spasm. I must, however, acknowledge that spasm is often the cause of the constipation which is the forerunner of impaction. In impaction, spasm of the sphincter always exists ; in some in- stances to such a degree that, when the patient strained, I have observed the anus protruded like a nipple, and an injection re- turned in a fine stream as if coming out of a squirt. I have cer- tainly met with cases of idiopathic spasm of the sphincter, usu- ally in elderly, nervous single women, and though no impaction was present, costiveness was." Quain ^ concludes that *' where pain, brought on by fsecal evacuations and continuing after them, happens to be present, the fault — the morbid condition — is not in the sphincter, but in the skin or mucous membrane covering it, and that the division of the muscle is not required in order to remove the patient's suffering." In other words, that spasm is always dependent upon fissure. Boyer ' treats of " constriction with fissure" and " constriction without fissure." Dupuytren' says : " The gravity of this affection (fissure) de- pends chiefly on the painful spasm of the sphincters ; the fissure is only an accident, as is proved by the existence of painful spasm without fissure, which, according to well-known surgical authorities, is found in proportion to the other of one to four." And, •' the spasmodic constriction is the true lesion, and the fis- sure only an epiphenomenon." Sir B. Brodie ' held the same views. The symptoms of spasm of the sphincter are pain on defe- cation and for a time after; more or less uneasiness about the anus, especially when sitting; fulness in the perineum; often more or less trouble with the bladder, as shown by frequent micturition, sometimes attended by smarting in the urethra and constipation. The disease is generally attended by exacerba- tions and remissions. A digital examination of the anus is always painful, and the contraction may be so great as to leave hardly a trace of the anal orifice. Any anxiety or distress of J Op. cit., p. 210. 2 " The Diseases of the Rectum," London, 1854, p. 167. ^ "Traite des Maladies Chirurg., etc.," fourth edition, t. x., p. 139. "• " Le9ons orales de Clinique Chirurg.," t. iii., p. 284. * "Lectures on Diseases of the Rectum," London Medical Gazette, vol. xvi., p. 26. 478 DISEASES OF THE RECTUM AND ANUS. mind, a generally irritable, nervous condition, and everything which has a tendency to irritate the rectum or the parts around, will aggravate the complaint. It may easily be confounded with the affection next to be described, neuralgia, but is gene- rally distinguishable from it by the marked dependence of the pain upon the act of defecation, which is not seen in neuralgia without spasm. The treatment consists in attention to the general health of the patient, in allaying any nervous excitement, in the adminis- tration of a cathartic to empty the bowel when the spasm is pre- sent, and in anodyne injections, such as, for example, twenty drops of laudanum in an ounce of water. Suppositories may cause renewed irritation. Even in the more aggravated form the disease will often yield to such measures as this, but if it does not a cure may always be effected by forcible dilatation of the sphincter under ether. If the patient will not submit to this, the next best thing will be found to be the introduction and re- tention of a bougie. Neuralgia. — Neuralgia of the rectum is generally met with in nervous people, especially females, such as are subject to neuralgia in other parts of the body. The following cases show its general character. Case. — Professional man, aged forty-nine. The patient was slight and pale from sedentary habits, but was generally well. Thirteen months before consulting me he was operated upon for fissure, and after the operation he had for some time been en- tirely well, but he now has what he describes as a dull, wearing pain in the rectum, coming on while at his daily work, lasting a longer or shorter time, sometimes all day, but generally passing away after he has reached his home and become quiet and rest- ed. He has noticed that the pain has a direct connection with the state of his general health, and that when he is away from his work and rusticating he is entirely free from it. The pain is no greater at the time of defecation than at any other, and is never so severe as to be unbearable. A careful examination of the part failed entirely to show any lesion. Case. — Woman, aged sixty-five, married. This patient had been treated for fissure, for ulceration, and for coccygodynia, and had refused to submit to excision of the coccyx. Her gen- eral health was fair, but there was decided gastro-intestinal dis- turbance. The pain of which she complains has been present for about eighteen months. She suffers chiefly when sitting, sometimes finds it impossible to lie upon her back, and is apt SPASM OF THE SPHINCTER — NEURALGIA. 479 to have a sharp twinge when she starts suddenly from her chair. The pain is no worse at defecation, is not increased by pressure upon or movement of the coccyx, and is entirely unconnected with any lesion of the rectum or anus. The greatest sensitive- ness to touch seemed to be located well within the sphincter, upon the posterior wall of the bowel. There was enlargement of the womb and misplacement. From these cases, which are both good examples of mild forms of the affection, it is evident that the disease may vary greatly in its severity. In some persons it will cause the same suffering as the most intense neuralgia elsewhere. The pain is apt to be paroxysmal, but may be continuous, and is indepen- dent of the act of defecation. In cases of well-marked periodi- city a malarial element should be looked for, and the disease may be a manifestation of the gouty diathesis. In the former case, quinine, and in the latter colchicum, may be of the great- est service. In all other cases the treatment will often be found unsatisfactory, and is to be conducted on general principles. The first care should be for the general health, the second for the regularity of the bowels, and after this local applications of cold water, ointment of belladonna ( 3 i.- i i.), and blistering- over the sacrum may be tried. Besides this local treatment the case must be managed exactly as would be a case of neu- ralgia in any other part. The diagnosis from coccygodynia and from spasm must both be made with care. I have come to be very cautious as to the diagnosis of pure neuralgia of the rectum without first making a careful exami- nation under ether, so many are the lesions which, though diffi- cult to detect and slight in themselves, may cause pain. Those most frequently found will be erosions of the mucous mem- hrane, pockets, and small internal fistulae. Il^DEX Abbe's apposition rings, 428 Abscess, 100 cases of deep pelvic, 109 ischio-rectal, 103 of superior pelvi-rectal space, 105 Adeno-papilloma, 267 Air cushion, 64 Anatomy of rectum, 1 Ano-rectal syphiloma, 337 Anus, anatomy of, 5 artificial, 404 Artificial anus, 404 closure of, 430 Benign fungus, 280 Buggery, 319 Cancer, 369 diagnosis, 379 electrolysis in, 403 extirpation, 381 palliative treatment, 400 symptoms, 376 treatment, 380 Canula for packing rectum, 69 Cautery, Paquelin, 68 Chancre at anus, 329 Chancroids of anus, 325 Clover's crutch, 65 Cocaine in rectal surgery, 71 Colectomy, 399 CoUoid, 374 Colotomy, history of, 409 in cancer, 407 inguinal, 414 in non-malignant ulceration, 406 lumbar, 410 Condylomata, 278, 331 31 Congenital malformations, 73 treatment, 405 tumors, 284 Constipation, 437 Curves of rectum, 1 Cysts, 283 Defecation, physiology of, 24 Divisions of rectum, 3 Dysentery, 304 Eczema ani, 454 Electrolysis in stricture, 367 Encephaloid, 373 Enchondroma, 282 Enema, apparatus for, 45 Enterorrhaphy, 423 Epithelioma, 372 Erythema of anus, 454 Esthiomene, 301 Examination by hand, 59 Excision, AUingham's method, 388 Bardenheuer's method, 392 Kraske's method, 390 Levy's method, 397 Fibromfata, 280 Fissure, 295 in children, 297 treatment, 304 Fistula, 115 blind internal, 118 director for, 129 faecal, 151 horseshoe, 130 incontinence after, 139 operations for, 124 recto-labial, 134 recto- vesical, 148, 405 varieties, 116 with phthisis, 123 482 INDEX. Foetal inclusions, 286 Foreign bodies in rectum, 459 Fungus, benign, 280 Gangrenous cellulitis, 98 Gonorrhoea of rectum, 323 Greek-love, 819 Gummata of rectum, 337 Haemorrhage after operations, 69 Haemorrhoids, 152 bad results of injecting carbolic acid, 181 diagnosis of, 168 external, 153 external cutaneous, 159 internal, 163 operation by clamp and cautery, 189 reflex symptoms, 167 treatment, 169 treatment by cocaine, 174 treatment by electrolysis, 158 treatment by injection, 158 treatment by ligature, 176 venous, 165 Hernia, internal rectal, 252 into rectum, 235 varieties of rectal, 255 Herpes of anus, 454 Houston's valves, 24 Hydatids, 286 Impaction, 447 Incontinence following fistula, 139 Instrument case, 63 Instruments for office, 62 Intestinal anastomosis, 427 Intussusception, 225 Invagination, 223 treatment of, 283 Levator ani, 14 Ligature bottle, 66 Light for examinations, 47 Lipomata, 281 Lymphatics of rectum, 22 Malformations, congenital, 73 Melanotic carcinoma, 375 Mucous patch in rectum, 330 Muscles of rectum, 12 Nerves of rectum, 17 Neuralgia of rectum, 456 Paederasty, 319 Paquelin cautery, 68 Periproctitis, varieties of, 97 Peritoneum, relation to rectum, 6 Phagedaenic ulceration, 329 Pilonidal sinus, 285 Polypus, 263 diagnosis, 273 fibrous, 269 glandular, 265 symptoms, 272 treatment, 273 villous, 265 Pouches of rectum, 10 Prolapse, cauterization of, 217 first degree, 210 inflammation of, 213 palliative treatment, 215 removal of, 222 second degree, 211 treatment by injection, 217 treatment of, 214 treatment when associated with haemorrhoids, 216 with circular slough, 221 Pruritus ani, 450 Rectal bougies, 51 depressor, 57 hernia, 235 masturbation, 319 pouch, size of, 60 Recto-coccygeus muscle, 14 Recto- vesical fistula, 405 Retractor recti muscle, 14 Rodent ulcer, 302 Sacculi of rectum, 10 Scirrhus, 372 Scrofula, 300 Senn's apposition plates, 427 Sigmoid flexure, anatomy of, 3 Sinus, pilo-nidal, 285 Skene's rectal irrigator, 46 Sodomy, 319 INDEX. 483 Spasm of sphincter, 474 Specula, 55 Sphincter, external, 13 internal, 14 third, 24 Spina bifida, 288 Stricture, benign, 339 congenital, 339 diagnosis, 352 dilatation, 357 division of, 360 divulsion, 359 dysenteric, 343 -electrolysis for, 367 excision of, 364 from pressure, 339 high up, examination, 61 inflammatory, 343 non-venereal, 343 pathological anatomy, 346 spasmodic, 341 symptoms, 349 treatment, 355 Stricture, traumatic, 345 tubercular, 345 venereal, 345 Superior pelvi-rectal space, 106 Syphilis, secondary, in rectum, 330 Szymanowski's operation, 434 Tensor fasciae pelvis, 14 Ulcer, irritable, 295 Ulceration, catarrhal, 293 non-malignant, 291 symptoms, 305 syphilitic, in rectum, 333 traumatic, 291 treatment, 318 tubercular, 298 Vegetations, 274 Veins of rectum, 17 Venereal diseases of rectum, 317 "Wounds of rectum, 456 COLUMBIA UNIVERSITY This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the rules of the Library or by special ar- rangement with the Librarian in charge. 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