Presented by Dr, M. F. Decker COLLEGE OF OSTEOPATHIC PHYSICIANS AND SURGEONS LOS ANGELES, CALIFORNIA DISEASES OF THE RECTUM AND ANUS r? CHARLES B. KELSEY, M.D., SURGEON TO ST. PAUL'S INFIRMARY FOR DISEASES OF THE RECTUM ; CONSULTING SURGEON FOR DISEASES OF THE RECTUM TO THE HARLEM HOSPITAL AND DISPENSARY FOR WOMEN AND CHILDREN ETC., ETC. NK\V YORK WILLIAM WOOD & COMPANY 56 & 58 LAFAYETTE PLACE 1882 COPYRIGHT BY WILLIAM WOOD & COMPANY 1882. STEAM PRESS OF H. O. A. INDUSTRIAL SCHOOL, 187 & 189 E. 76th St., New York PREFACE. IN preparing the following pages for publication, I have endeavored to condense into convenient form, for both student and practitioner, as great an amount as possible of practical information concerning diseases of the rectum and anus. The advances which have been made during the past few years in tli is special branch of surgery have been very great. The whole pathology of malignant disease has been rewritten; and the close relations! iip of the so-called benign polypoid growths to epithelial can- cer has been worked out after careful study with the microscope. The operation of excision of cancerous growths in the lower part of the rec- tum has apiin become a legitimate surgical procedure, and what is bet- its range of applicability has been definitely determined. The advances in abdominal surgery, for which the present century will aluavs be fa: nous, have also had a bearing on diseases of the rectum, anl the operation of excision of cancer of the upper part of the rectum and the, .-i^moid flexure, through an incision made in the abdominal wall, lias brought within treatment a class of cases formerly beyond the reach of art. New methods of treatment of benign stricture have been devised as a substitute for colotomy. New methods of palliation in benign and malignant stricture have been devised as substitutes for the repul- sive operation of colotomy, and that operation bids fair in the imme- diate future to a>sunie deservedly a place of less prominence than it has occupied in the past. New and etTectual methods of curing h:em- IV PREFACE . orrhoids and prolapse without cutting operations have been added to the surgeon's resources. The advances have been due to the efforts of no one man or nation. The records of them are scattered through English, Continental, and American periodical literature, and many of them are practically beyond the reach of the busy practitioner. I have tried, therefore, as far as possible to condense what was pos- itively known within the following pages, and to reduce it to a form suitable for ready reference by student and practitioner, giving not only the results which have been reached by experiment and clinical experience, and which may be relied upon as the basis of practice, but in many questions marking out by foot-notes and references the way for any who may desire to go over for himself the ground which I have followed with no little difficulty. In addition, I have endeavored, whenever possible, to illustrate the subject under consideration by the reports of cases either from my own practice or that of others, knowing that a lesson is often conveyed to the student in this way better than by any other. My thanks are especially due to the librarians of the New York Hospital for their unvarying kindness and assistance, which has ren- dered my work a far from unpleasant one. CHARLES B. KELSEY. "THE MADISON," No. 25 MADISON AVE., CORNER OF 25TH STREET, NEW YORK, September, 1882. CONTENTS. CHAPTER I. PRACTICAL POINTS IX ANATOMY AND PHYSIOLOGY. PAGE Rectum. Position and Measurements. Curves. Divisions. Relations. \inis. 1'arts in Detail. Peritoneum. Relations to Three Portions of the Rectum. Distance iif Peritoneal Cul-de-Sac from Anus. Muscular Lay- er. Arrangement of Fibres. Submucous Layer. Mucous Membrane. Sustentator Tunica? Mucosse. Columnee Recti. Glands of Mucous Membrane. Muscles of the Rectum and Anus. External Sphincter. Internal Sphincter. Recto-Coccygeus. Levator Ani. Transversus Peri- nei. Ai terii -. Superior Ilaemorrhoidal. Middle Hsemorrhoidal. In- fcrinr Hamorrhoidal. Veins. Superior Haemorrhoidal. Middle Haemor- rhoidal.- -Interior Haemorrhoidal. Minute Anatomy of Veins. General ami Visceral Venous Systems. Nerves. Cerebro-Spinal and Sympathe- tic Nerve Supply. Tonic Contraction of Sphincter. Explanation of \\"anwer, or Invagina- tion. Fourth Variety: Imagination in the Continuity of the Bowel. Prolap>e of the Mucous Membrane alone. Cans.',. -Symptoms. Treat- ment: Palliative and Curative. 1'rolapse with Ha-morrhoids. Treat- ment by Injections. Cauterizat ion. 1 >>< -ript ion of Operation. Smith's Clamp. Dupuytren's OjM-ration. Prolapse of the Second Decree. Pa- thological Changes. Pi Peritoneum. Strangulation. Dangers in Fore 'Me Induction. Fatal Case of Reduction. Advisability of Reduc- ing Intlamed or (iangrenous Prolapse. Excision of Prolapse after tin- Format ion of a Slough. I >angers of Operation of Kxcision in Extensive Vlll CONTENTS. PAGE Prolapse. Operation by Elastic Ligature. Third and Fourth Varieties. Differences between Third and Fourth. Degrees of luvagination. Anatomical Appearances. Pathology. Relative Frequency. Symp- toms. Physical Signs. Acute and Chronic Forms. Diagnosis. Dif- ferential Diagnosis from Volvulus; from Stricture; from Internal Hernia; from Obstruction by Pressure from without the Bowel; from Foreign Bodies; from Peritonitis with Perforation. Treatment. Replacement by Manipulation; by Injections. Treatment by Puncture. Laparotomy.- Description of Operation 110 CHAPTER VIII. NON-MALIGNANT GROWTHS OF THE RECTUM AND ANUS. Polypus. Definition. Hypertrophy of Villi. Characteristics. Villous Tu- mor. Adenomatous Polypus. Fibrous Polypus. Structure; Character- istics. Symptoms of Polypus. Diagnosis. Diagnosis from Malignant Disease. Treatment. Vegetations. Definition. Description. Micro- scopic Appearances. Relation to Syphilis. Symptoms of Vegetations. Diagnosis. Treatment. Condylomata. Distinction between Condylo- mata and Vegetations. Description. Syphilitic and Non-syphilitic Con- dylomata. Benign Fungus. Gummata. Rarity and Literature. Ano- rectal Syphiloma. Definition of Fournier. Fibromata. Lipomata. Characteristics. Enchondromata. Cysts. Dermoid Growths. Charac- ters. Pilo-Nidal Sinus. Hydatids. Foetal Inclusions. Spina Bifida. Congenital Cysts ....-.., 1.35 CHAPTER IX. s NON-MALIGNANT ULCERATION. Varieties. Simple Ulcers. Generally due to Traumatism. Various Forms of Injury to which Rectum is Subject. Sodomy. Injury of Rectum in Labor. Ulcers due to Surgical Interference. Fissure or Irritable Ulcer. Nothing Distinctive in the Ulcerative Process. Characteristics of Irri- table Ulcer. Theories concerning this Form of Ulcer. Description. Herpes. Tubercular Ulceration. Distinction between True Tubercular Ulcer and a Simple Ulcer in a Tuberculous Person. Description of Each. Scrofulous Ulceration. Esthiomene. Rodent Ulcer. Dysentery. A Cause of Stricture. Venereal Ulceration. Gonorrhoea. Chancroids. Chancroidal Stricture. Discussion. True Chancre. Secondary and Ter- tiary Syphilitic Ulcerations. Diagnosis of Syphilitic Ulcers. Ano-rectal Syphiloma as a Cause of Ulceration. Ulceration Secondary to Stricture. Gangrene. Symptoms of Ulceration. Gravity of the Disease. Diag- nosis. Treatment. General and Local Measures. Treatment of Fissure. Fissure Complicated with Polypus. Treatment by Rest, Fluid Diet and Incision of the Sphincter. Local Applications 158 CHAPTER X. NON-MALIGNANT STRICTURE OF THE RECTUM. Stricture due to Changes in the Rectal Wall and to Pressure from Without. Spasmodic Stricture. General Division into Venereal and Non-Venereal CONTENTS. IX PAGE Strictures and into Fibrous and CicatriciaL Frequence of Syphilis in Connection with Stricture. Non- Venereal Strictures. Congenital, Dys- enteric, Traumatic, Varieties.- Stricture from Hypertrophy of Valves. Pathological Anatomy. Changes in Rectal Wall above and below the Stricture. Changes in Parts around the Stricture. Symptoms. Value of Flattened Passages as Symptom. Signs of Obstruction. Obstruction with Stricture of Considerable Calibre. Diagnosis. Dangers to be Avoided in Examination. Difficulty when Disease is Situated high up in the Bowel. Use of Bougie for Diagnosis. Treatment. Advisability of Anti-Syphilitic Medication. Palliative Treatment. Medicinal Treat- ment of Threatened Obstruction. Surgical Measures. Dilatation, Grad- ual or Sudden Rules for Gradual Dilatation. Divulsion, Dangers of, ami Methods of Performing. Treatment by Free Division. Description of Operation. Collection of Cases. Results of this Treatment. Com- parison with Colotomy. Cases from Author's Practice. Knife for Ope- ration. Excision of Non-Malignant Stricture. Colotomy. Restrictions to the Operation. General Considerations Regarding it. Treatment of Stricture High Up 181 CHAPTER XL CANCER. :.d Characters of Malignant as Distinguished from Benign Growths. Malignant, Semi-Malignant, and Benign Adenoma, Encephaloid. Col- loid. Melanotic Cancer. Osteoid Cancer. Age at which Cancer occurs. Symptoms Diagnosis. Treatment. Excision: History and Results of Operation. Conclusions Regarding Excision. Modes of Performing the Operation. Excision of Cancer of the Sigmoid Flexure. Palliative Treatment . 218 CHAPTER XII. I.MI'A'Ti I- I lis AND FOREIGN BODIES. Impacted Faeces.- Int- -tinal Concretions. Diagnosis and Treatment of Im- paction. Foreign Bodies Swallowed. Results which may Follow the Swallowing of a Foreign Body. Ulceration and Abscess. Foreign Bodies introduced } r Amini. Cases. Prognosis. Treatment. Dangers of Attempts at Removal. Laparotomy for Removal. Cases Successful . 252 HA 1'T 1. It XIII. ri:i Kin s ANL I 'runt us Generally a Symptom of .x.me other Disease. Description. Causes. -Delations of Internal Haemorrhoids, Fistula, Worms. Parasites, and Kiv.ema to Pruritus. Treatment of Eczema.- Herpes and Erythema. Constitutional Conditions causing Pruritus. De|>endeneo upon Consti- pation. Treatment of Constipation. General Treatment of Pruritus . 269 X CONTENTS. CHAPTER XIV. SPASM OF THE SPHINCTER, NEURALGIA, WOUNDS, RECTAL ALIMENTATION. PAGE Spasm without other Disease. Cases. Authorities. Symptoms. Treat- ment. Neuralgia. Cases. Diagnosis. Treatment. Wounds. Com- plications. Spontaneous Rupture. Treatment of Wounds. Alimenta- tion. Physiology of Absorption. Nutritive Enemata. Nutritive Suppositories 277 LIST OF ILLUSTRATIONS. FIGURE 1. Antero-posterior curve of the rectum, 2 2. Section of normal rectal wall, 8 3. Section of rectal mucous membrane, ...... 9 4. Rectal veins seen from without, 14 5. Rectal veins seen from within, 15 6. Nerves of the anus, 18 7. Third variety of congenital malformation, . . . ' . 32 8. Fourth variety of congenital malformation, .... 33 9. Fifth variety of congenital malformation, 34 10. Sixth variety of congenital malformation, ..... 35 11. Condition of bowel after colotomy, Hi 1-,>. Idem, 46 13. Enterotome of Dupuytren in i>osition, 47 14. Examining table, closed, .50 " 15. Examining table, opened, . 50 16. Lamp for rectal examinations, 51 17. Case for rectal instruments, ........ 52 18. Blunt-pointed bougie 55 19. Sharp-pointed bougie, 56 20. Bougie d boule, 56 21. Van Buren's rectal speculum, 58 22. Fenestrated rectal speculum, 59 ,':;. Bivalve rectal speculum 59 " 24. Rectal depressor, 59 ' 25. Endoscope, 60 2K. Thermo-cautery 63 27. Varieties of fistula, 78 28. Fistula with double track, 79 29. Idem, 79 :>0. Allingham's ligature holder, 84 31. Helmuth's ligature holder, 84 32. Author's fistula knife 86 33. Gorget, 86 34. Spring scissors, 35. Forceps for haemorrhoids, 107 :U>. Smith's clamp 109 :*7. First variety of prolapse, Ill :!?-. S< TOI id variety of prolapse, Ill 39. Third variety of prolapse 112 Xll LIST OF ILLUSTRATIONS. PAGE FIGURE 40. Rectal supporter, 115 " 41. Rectal polypus, 136 " 42. Villous polypus, 137 " 43. Microscopic section of villous polypus, 137 44. Glandular polypus, . . . . . . . . . 138 " 45. Vertical section of glandular polypus, 139 " 46. Vegetations around anus, 142 " 47. Condylomata, 147 " 48. Stricture of the rectum, 184 " 49. Rectal dilator, 200 " 50. Wales's dilator, 201 " 51. Knife for proctotomy, . . . . . . . . . 205 " 52. Cancer of the rectum Malignant adenoma (Stimson) . . 219 DISEASES OF THE RECTUM AND ANUS CHAPTER I. PRACTICAL POINTS IN ANATOMY AND PHYSIOLOGY. Rectum. Position and Measurements. Curves. Divisions. Relations. Anus. Parts in Detail. Peritoneum. Relations to Three Portions of the Rectum. Distance of Peritoneal Cid-de-Sac from Anus. Muscular Layer. Ar- rangement of Fibres. Submucous Layer. Mucous Membrane. Susten- tator Tunicaj Mucosae. Columnae Recti. Glands of Mucous Membrane. Muscles of the Rectum and Anus. External Sphincter. Internal Sphincter. Recto-Coccygeus. Levator Ani. Transversus Perinei. Arteries. Supe- rior Hsemorrhoidal. Middle Haemorrhoidal. Inferior Haemorrhoidal. Veins. Superior Haemorrhoidal. Middle Haemorrhoidal. Inferior Ha&- morrhoidal. Minute Anatomy of Veins. General and Visceral Venous Sys- tems. Nerves. Cerebro-Spinal and Sympathetic Nerve Supply. Tonic Contraction of Sphincter. Explanation of Wandering Pains in Rectal Dis- ease. Lymphatics. External and Internal Lymphatic Vessels. Physiology, Anatomy of the Third Sphincter. Valves of Mucous Membrane. Plica Transversalis Recti of Kohlrausch. Lack of Uniformity in Different Subjects. Physiology of Defecation. Explanation of Retention of Faeces after De- struction of the Sphincter. Conclusions Resulting from Study of Third Sphincter. THE rectum is the terminal portion of the large intestine extending 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 inva- gination and prolapse, which are due to straining at stool; and accounts also for the fact that, when denuded by the destruction of the surround- ing 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. 2 DISEASES OF THE RECTUM AND ANUS. The upper limit of the rectum is difficult to determine with accuracy, except from the fact that it is separated from the sigmoid flexure by a slight constriction which becomes more apparent when attempts are made at dilatation. From this upper point it gradually expands 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-posterior, the other lateral. The former is double. From above downwards it follows the curve of the sacrum and coccyx, being concave in front, and convex be- hind. When it reaches a point opposite the tip of the coccyx it suddenly reverses its direction, turns sharply backwards, 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 represented in an exaggerated form in Fig. 1, it is separated from the vagina in the female, FIG. 1. Exaggerated antero-posterior curve of rectum. 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, since, by it, an obstruction is formed to the downward course of the fasces. 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 the PRACTICAL POINTS IN ANATOMY AND PHYSIOLOGY. 3 ;ian 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 may be more or less twisted on itself like the sigmoid flexure. The sigmoid flexure may occupy an unnatural position, and the rectum* instead of commencing at the left sacro-iliac junction and curving towards the right, may commence at the right and curve toward the left. In one case, reported by Cruveilhier, 1 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 in the left side. Divisions. For convenience the rectum is usually divided into three portions, named first, second, and third, from below upward. The first 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 portion, which is the reverse of that next above, the finger should never be passed toward the sacrum, or even directly inward in making an ex- amination; but rather toward the pubes. Bearing this simple anatomi- cal point in mind will often save the patient much unnecessary suffering. The second portion is often described as reaching from the apex of the prostate to the recto-vesical fold of peritoneum; but, as the point of du- plicature 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 l>"int, 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 remem- bered, is convex backward, following the curve of the sacrum. The third portion extends from the third sacral vertebra to the left sacro-iliac syn- adrosis; its lower part is partially, and its upper, completely, sur- rounded by peritoneum; which, in the upper part, forms the meso-rectum attaching it to the sacrum. Relation*. The most important surgical relations of the rectum are on the anterior surface. The first portion is surrounded laterally and posteriorly by a bed of connective tissue, rich in $it 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 downward course. This intimate relationship with the urethra is often taken ad- vantage 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 'Anat. Path., AIIHT. Edition, 1&44. p. ::77. 4: DISEASES OF THE RECTUM AND ANUS. 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 connective and muscular, tissue; and the two cavities may easily be made to communicate by any morbid process or by a surgical pro- cedure. It was at this point that the trocar was plunged from the rectum into the bladder in the old operation of puncturing the bladder through the rectum; and Hyrtl 1 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 trigone of the bladder. A somewhat analogous case is reported in which a long slender calculus perforated the bladder and projected into the rectum, from which it was easily removed. 2 The prostate, when large, may project over the sides of the rectum, or the latter may receive the prostate in a kind of groove on its upper surface. The third, or upper portion, unlike the other two, has important surgical relations on every side. Posteriorly it is in whole or part covered with peritoneum; and is separated from the sacrum by the pyri- iormis muscle, the sacral plexus of nerves, and the branches of the in- ternal iliac artery. On its sides it is in contact with the adjacent convo- lutions of small intestine, and lower down, with the levator ani muscle and the connective tissue of the ischio-rectal fossa. In the male it is in relation, in front, with the posterior surface of the bladder, from which it 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 them 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 malposi- tions of the uterus may act directly upon the rectum. The vessels may be so obstructed as to cause haemorrhoidal troubles, or interfere with operations for their relief. The rectum 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 cancerous tumor when in reality the normal uterus alone is felt. The advantage of a rectal examination 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 in the male, and contains a great number of sebaceous follicles and muciparous glands. The skin 'Topog. Anat., ii., p. 103. *Gooch: Chirurg. Works, London, 1792, vol. iii., p. 216. PRACTICAL POINTS IN ANATOMY AND PHYSIOLOGY. 5 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 tlu- external and internal sphincter muscles; and also to the point at which many of the terminal filaments of the internal pudic nerve per- forate the gut. Both skin and mucous membrane at the anus are re- markable for the development of erectile tissue; the arteries coming from the inferior haemorrhoidal, and the veins being very numerous, winding, and twisted. The presence of this erectile tissue accounts for the habit of pederasty which will occasionally be referred to as a cause of rectal disease. It is a habit to which few are addicted in this country, but which is not uncommon in some other parts of the world. In America it is chiefly seen amongst the negro race and on shipboard amongst sailors who are on a long voyage. Among the latter it was a vice whose existence was well known and which was occasionally punished by the officers during the late war. The nerves are derived both from the cerebro-spinal and sympathetic systems, as will be shown later. After these general considerations of the position and relations 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 intes- tine, of four layers: an external or peritoneal; a muscular, divided into longitudinal and circular; a sub-mucous 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 surrounded by peritoneum, and has, beside, a fold of attachment to the anterior sur- face of the sacrum, known as the meso-rectum. 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 reflected 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 on to 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 peri- toneum parses directly from the sides of the rectum to the sacrum. Be- tween its two layers may be found some loose connective tissue, the hsemorrhoidal vessels and nerves, and the lymphatics. In passing from the limit of the meso-rectum behind, to form the cul-de-stf in front, the peritoneum covers more or less of the lateral and anterior surfaces of the middle portion of the rectum. As before men- 1 Hilton: Rest and Pain. Wood's Library of Standard Medical Authors, p. 166. 6 DISEASES OF THE RECTUM AND ANUS. tioned, the point at which the peritoneum leaves the anterior surface a the middle portion of the rectum to be reflected upon the posterior sur- face of the bladder in the male, or of the vagina or uterus in the female, varies in different subjects, and at different times in the same subject; and hence the differences in its distance from the anus as given in differ- ent works on anatomy. In new-born children the bottom of the cul-de- sac touches the upper edge of the prostate and approaches 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 enlargement of the prostate, it is carried still higher. In women it generally extends to the upper border of the poste- rior vaginal wall; so that the latter is separated from the rectum by peri- toneum 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 demonstrated on the cadaver by forcible injections of the bladder. The average distance from the anus of the point at which the serous coat leaves the anterior wall of the rectum is, therefore, very difficult to determine; and yet it is of the greatest importance in all surgical opera- tions on the part; since the fact of opening or not opening the peritoneal cavity may make all the difference between life and death in the result of an operation. Dupuytren gives the distance as seventy mm., and less when the organs are empty; Lisfranc gives six inches in the female, and four in the male, but does not state in what condition of the organs the mea- surements 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, 1 acting on the idea that the fold is not easily displaced downward by traction on the rectum, has experimented by filling 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 measurement of two and a half inches when the bladder and rectum are both empty, and an additional inch when distended. 4 Muscular Coat. In the fact that the muscular coat is arranged in two layers, an external longitudinal and an internal circular, the rectum resembles the other portions of the alimentary canal; but in the further arrangement of its fibres it resembles the oesophagus more closely than the intermediate portions. The fibres are spread out into two uniform 1 Cancer of the Rectum. London, 1880, p. 129. 8 The following authors give the following measurements: Malgaigne, male, 6-8 cm.; females, 4-6 cm. Luschka, 5.5-8 cm. Hyrtl, 8 cm. Lisfranc and Sanson, 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, 15.4cm. Esmarch: Die Krankheiten des Mastdarrns und des Afters. Pitha u. Billroth:Chirurgie, p. 7. PRACTICAL POINTS IN ANATOMY AND PHYSIOLOGY. 7 layers, and are not arranged in bands crossing each other in a basket net- work and leaving sacculi between the meshes. The longitudinal fibres are the direct continuation of the three longi- tudinal bands of the large intestine. Upon reaching the rectum, these blend into one continuous sheath which, however, 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 witli the peritoneum on to the posterior wall of the latter and thus form u firm band of union between the two organs, as has been particularly described by Dr. Garson. 1 They have been named by him the recto-vesical fibres. The ending of the longitudinal fibres is worthy of note. According to Homer, 1 when they reach the lower margin of the internal sphincter a part of them turn upwards between it and the external sphincter and nd for an inch or two in contact with the mucous coat into which they are finally inserted; having, therefore, an obvious influence in caus- ing 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 bun- dles of the external sphincter, and is inserted into the subcutaneous con- nective 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 lon- gitudinal 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 in- ternal 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 muscle will be described more fully later. Submucous Coal. The submucous tissue forming the bed upon whicli the mucous membrane rests is sufficiently lax to permit of consid- erable sliding of the mucous membrane on the muscular coat. In it the blood-vessels ramify, and from it perpendicular processes are given off which perforate both the internal and external muscular layers and are frially lost in the sheaths of the muscular fibres, or go entirely through the muscular layer and blend with the fibrous stroma of the surrounding 1 The Arrangement and Distribution of th- Muscular Fibres of the Rectum. Paper read before the Brit. Med. Ass. Reported in Brit. Med. Jour., Sept. 6th, 1879. * A Treatise on Special and General Anatomy. Vol. ii.,p. 40, Philadelphia, 1826. 1 Anat. des Menschen. Vol. ii.. Part 2, p. 208. 8 DISEASES OF THE RECTUM AND ANUS. 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. 1 See Fig. 2. Mucous Membrane. 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 particulars to suit its location and func- tion. 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 tissue beneath; and is so ample as to be gathered into folds at various points which are of considerable surgical and anatomical 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 sphinc- ter. These vertical folds have received the name of columnce recti, or columns of Morgagni; and Treitz states that they contain bands of mus- FIG. 2. Section of normal rectal wall (Cripps). cular fibres running longitudinally and terminating above and below in- elastic tissue. Kohlrausch" also describes a thin layer of longitudinal muscular fibres under the mucous membrane at this point and has named it the sustentator tunica mucosce; but most anatomists, with Henle, have failed to find anything more than the stratum of muscular tissue common to the whole mucous coat, and known as the muscularis mucosce. Between the lower ends of the columnce recti little arches are stretched from one to the other, forming pouches of skin and mucous mem- brane. These are more developed in old people, and may retain small pieces of hardened faeces or foreign bodies in their cavities, and thus give rise to suppuration and abscess. The mucous membrane may for the purpose of study be divided into three separate layers, the muscular, glandular, and epithelial. Fig. 3. 1 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. PRACTICAL 1'olMS IN AXATOMY AND PHYSIOLOGY. 9 The muscular layer (mnxcul(tris mucosce, sustentator tunica mucosai) is a layer of unstriped muscular tissue about 0.02 mm. thick, which is everywhere found in the deepest layer of the mucous membrane, extend- ing from the oesophagus to the rectum, but is more strongly developed in the region of the anus where it serves to hold the membrane in place and prevent prolapse. It consists of bundles running in some parts both lon- gitudinally 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 consists 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 regu- larity and set so closely together that the width of the intervening tissue Fir.. 3. Section of the rectal mucous membrane (Esmarch). 1. Follicles of Lieberkuhn. 2. Muscular layer of mucous membrane. 3. Submucous connective tissue and vessels ; with a soli- tary closed follicle, over which the tubular follicles are wanting. 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 respective measurements being: length, 0.35 mm.; diameter, 0.08 mm. These tubular depressions or follicles are lined with epithelial 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 contin- uous 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. Tin- intertnbular tissue consists of a fine trabeeular network, the meshes of which are very long in the vertical direction running parallel to the follicle (Cripp-). The follicles of Lieberkuhn are simply inverted villi and answer the same purpose of absorption. There are good reasons for the substitution of follicles for villi in this part of the canal, the former being less subject 10 DISEASES OF THE RECTUM AND ANUS. 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 Anus. The muscles which may 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 transversus perinei. External Sphincter. The external sphincter muscle is a thin layer of Toluntary fibres, about half an inch broad on each side of the anus, sur- rounding it in the form of an ellipse, and having a narrow pointed insertion anteriorly and posteriorly. It is situated immediately beneath the skin, and extends about two centimetres up the bowel where its upper limit may sometimes be seen by the white line already mentioned. It is divided into a superficial and 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. Be- tween the tendon and the bone is a bursa about the size of a pea bursa znucosa coccygea of Luschka. Anteriorly it is inserted into the central tendon of the perineum in common with the transversus perinei and bulbo-cavernosus, and in women with the sphincter vaginae. 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, the levator ani and ischio- coccygeus, as well as the peristaltic action of the bowel and the contrac- tion of the diaphragm. The superficial band of fibres acts only in puckering the skin. The nerve-supply comes from the haemorrhoidal branch of the internal pudic, and the haemorrhoidal branch of the fourth sacral nerve. Internal Sphincter. The internal sphincter is 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 thick- ness 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 it approaches the anus. It also is supplied by the haemorrhoidal branch of the internal pudic. Recto-coccygeus (Retractor recti, Trietz;" Tensor Fasciae Pelvis, Kohl- rausch). 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 ligament at the tip of the coccyx, and passing forward and downward, embrace the lower end of the rectum on 1 Specimen No. 1,288, Museum of College of Surgeons (Cripps). 5 Vierteljahrsschrift f. praktische Heilkunde. Prag, 1863, Bd. i., S. 124. Henle. Abbildung 2, 183. PRACTICAL POINTS IX ANATOMY ANI> PHYSIOLOGY. 11 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 coccyx 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 it a fixed point in defecation. Leva for Am. 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 pyriformis, behind, to the arch of the pubes in front. That part which is named ischio-coccygeus is usually described as a separate muscle, though in no way differing in function from the larger portion, and only distinguishable from it by its more tendinous 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 in- serted, also by aponeurotic fibres, into the border of the coccyx and lower part of the border of the sacrum. Owing to its tendinous origin and in- sertion, the greater part of the muscle is composed of aponeurotic fibres. It is in relation superiorly, by its concave surface, with the rectum; iuferiorly, 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 act together, to fix that bone and prevent its being thrown backward m defecation. It probably 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 portion of the pelvic diaphragm, is in its general shape an inverted cone, support- ing the pelvic contents in its cavity and allowing the rectum and prostate to pass through 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 attachment 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 the symphysis. This attachment will be found to vary somewhat in different dissections, being sometimes a little higher or a little lower on the bone, and sometimes on the cartilage between the bones. The muscular fibres may also be traced at times up- ward into the pelvic fascia above its junction with the obturator. From this extensive though delicate and in great part membranous 12 DISEASES OF THE RECTUM AND ANUS. origin, the fibres proceed downwards and inwards toward 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 concealed by the pubo-prostatic ligament or anterior fold of the recto-vesical fascia, from which they also sometimes take origin 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 interval, similar to those often found in other parts of this thin muscular sheet. The fibres which arise from the tip of the spine of the ischium are inserted into the side of the tip of the coccyx; while the fibres immedi- ately 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 posterior 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 upwards, 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 importance. Superiorly its surface is covered by the superior pelvic fascia which sepa- rates it from the peritoneum and pelvic organs. Its inferior surface is sepa- rated from the obturator internus muscle by the obturator fascia, and be- neath 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 contents. Again, it prevents the rec- tum from being protruded, and raises the anus and opens it; being in this respect the direct antagonist of sphincter. By inclosing 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 faeces at the same time. By inclosing the bladder, vesiculae seminales, prostate, and anus 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 impossibility of micturition, erections, and lancinat- ing pain due to spasmodic action of the muscle. It will often happen that after a complete paralysis by free division of both sphincter muscles in an operation iipon the rectum, the patient will still complain of a PRACTICAL POINTS IN ANATOMY AND PHYSIOLOGY. 13 sharp spasmodic pain at intervals just such a pain as is caused by spas- modic contractions of the sphincter. In such cases it is the levator ani which is at fault. The muscle also aids the longitudinal fibres of the rec- tum in their opposition to the dragging of the faeces; and the anal fibres also draw the rectum upwards and forwards, and compress it on the sides, and thus aid in the expulsion of its contents. 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 continuous, traversing the ante- rior extremity of the external sphincter. In such a case the two muscles form a continuous half ring the concavity of which is directed backwards and embraces the anterior part of the rectum, assisting powerfully in de- fecation by pressing the anterior against the posterior wall of the bowel in conjunction with the levator-ani (Cruveilhier). Arteries. The rectum is supplied with blood from five arteries, 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 mucous and muscular layers at regular intervals to the end of the bowel, where they communicate in loops opposite the internal sphincter, and anastomose with the terminal filaments of the middle and inferior hsemor- rhoidal arteries. The middle hseraorrhoidal arteries one each side are not constant in their origin, sometimes coming from the hypogastric or the inferior vesical, and sometimes from other sources. The inferior haemorrhoidul arteries also pairing are usually given off from the internal pudic near the point where it crosses the tuber ischii. They cross through the fat of the ischio-rectal fossaa and are distributed with the middle haemorrhoidal 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 portae; the other anal, returning its blood through the internal iliac. The first, or rectal circulation, is made up of the supe- rior lufimorrhoidal vein; the second, or anal, is made up of the middle and inferior haemorrhoidal veins; the middle receiving its blood from the anus and the inferior from the adjacent integument. The middle haemor- 14: DISEASES OF THE RECTUM AND ANUS. rhoidal 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 hasmorrhoidal is formed from two venous trunks, one on the anterior, the other on the posterior aspect of the rectum, 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 YHM. YKM. YHE FIG. 4. Rectal veins seen from without (Duret). 1 Amp., Rectal pouch. S. E., External sphincter. P., Skin at margin of anus dissected up and turned back. V. H. I., Internal haemor- rhoidal vein. V. H. M., Middle haemorrhoidal vein. V. H. E., External haemorrhoidal vein. form a true venous plexus. The inferior haemorrhoidal vein also has a plexiform arrangement at its origin, but its branches are situated be- tween 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 rectum proper 1 "Recherches sur la Pathogenic des Hemorrhoi'des." Arch. Gen. de Med., December, 1879. PRACTICAL POINTS IN ANATOMY AND PHYSIOLOGY. 15 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. 4 and 5. These veins make their ap- pearance suddenly by five or six branches which perforate the wall of the bowel about three inches from the margin of the anus. If the rectum be opened longitudinally and the mucous membrane dissected up to a suffi- cient 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; Fio. 5. 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. IV. Skin. II. I., Internal lutmorrhoidal vein. II. M., Middle haemorrhoidal vein. H. E., External hnemorrhoidal vein. and that they have already pursued quite a long course under the mu- cous membrane. They are formed by collateral branches, and especially by about a dozen primitive branches, which originate about half an inch above the anus and ascend in parallel and flexuous lines for several cen- timetres to unite into common trunks. Each of these little ascending brandies 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. 16 DISEASES OF THE RECTUM AND ANUS. 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 rudimentary branches of the external haemorrhoidal plexus. Many of these little communicating brandies between the external and internal haemorrhoidal systems pass through the substance of the exter- nal sphincter. It results from this, that when the external sphincter is contracted, the anastomosis between the two systems is prevented. Verneuil has laid stress upon the fact that where the internal or su- perior haemorrhoidal veins perforate the rectal wall from within out- wards, they pass through "muscular button-holes" surrounded by no fibrous tissue and having, 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 internal hsemorrhoids. 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 unite. The internal haemorrhoidal 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 vesiculae seminales. Nerves. 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, anastomos- ing with branches from the sympathetic. The muscular branches from the same nerves have already been spoken of in connection with the in- dividual muscles. The fifth sacral nerve also sends a small twig to the coccygeus. The posterior branch of the superficial perineal nerve from the internal pudic, supplies the skin in front of the anus; while the an- terior branch gives several small filaments to the levator ani. The inferior haemorrhoidal 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 sup- ply the skin over the coccyx and around the anus. PRACTICAL POINTS IN AN ATOM V AND PHYSIOLOGY. 17 According to a brief contribution of W. Krause,' the nerves end in the mucous membrane of the anus, in club-shaped bulbs, about 0.05 mm. in diameter, which lie under the bases of papillae. The tonic contraction of the external sphincter muscle is, in part at least, due to the influence of a nerve-centre located in the lumbar region of the spinal cord. 2 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 temporarily by shock or depression, proves that this centre is not lorat ed above the lumbar region. This nerve-centre is subject to various influences; and the sphincter may either be relaxed, or its tonic contrac- tion increased, by local stimulation, or by the influence of the will or emotions. Though the dependence of the sphincter for its tonic contraction 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 maintenance of a certain amount of tonic contraction, which could be inhibited and relaxation produced by stimulation of the mucous 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 rial 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 cere- brum.' 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* relates an instructive case 1 Esmarch, op. cit., p. 10. sius: Bull, de 1'Acad. Royal de Belgique, xxiv. (1867), p. 812. (Foster's Phy>i..l.-y. p. 387.) J Proc. Roy. Soc. (1877), p. 77. 4 Foster's Physiology, Phila., 1880, p. 388. 5 A lady consulted me, says Mr. Brodie, concerning a pain to which she had been for some time subject, beginning in the left ankle, and extending along the instep toward tlic 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 pro- truded externally when she was at the water-closet, at the same time that she lost from them sometimes a larger and sometimes a smaller quantity of blood. <>n n more particular inquiry, 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 faeces; and that, if she passed a day without any evacu- 2 18 DISEASES OF THE RECTUM AND ANUS. of pain in the foot over the distribution of the sciatic which was cured by curing prolapsing haemorrhoids 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. In the same way a fissure of the annus may cause pain in the lumbar and iliac regions; pain, loss of sensation, and cramps in the legs; and symptoms of bladder and urethral disease, besides more general nervous phenomena. See Fig. 6. 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 themselves by pain. This also explains how large masses of faeces may accumulate in the rectal pouch I * FIG. 0. Diagrammatic view of nerves of anus. (Hilton.) a, Ulcer on sphincter; 6, the fila- ments 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, transversus perinei. without causing suffering. Puncturing the bladder through the rectum is not a painful operation, and applications of strong acids to the mucous membrane will cause little suffering if the skin be properly protected. Exactly the opposite condition obtains at the anus, the extreme sensibility of which is well known. The pelvic plexuses of the sympathetic are placed one on either side of the rectum and vagina. Each is composed of prolongations from the hypogastric plexus above, uuited with branches from the sacral ganglia. ation at all, the pain in the foot never troubled her. Having taken all these facts into consideration, I prescribed for her 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 bedtime. 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. PRACTICAL POINTS IN ANATOMY AND PHYSIOLOGY. 19 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 to form a spiral tract down the gut. The folds are described ai -'milunar in form, with the convex border 22 DISEASES OF THE RECTUM AND ANUS. 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 inclosing 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 amusing 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 fully and so easily for the physiological emptiness of the rectum and fulness 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 the rectum to be normally empty, except just at the time of defecation, he believes that condition to depend upon the anatomical arrangement of the sigmoid flexure, joined with the narrowing 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 altogether 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 any- thing but natural, and nothing more or less than an attempt to exhibit natural appearances by placing the parts fn an unnatural situation such a situation, indeed, as is not known to be necessary for the exhibition of the valvulae conniventes or any other valves of the body. He meets the statement, that by the ordinary procedure of distending the rectum after removal from the body the valves are made to disappear, by the question, why, if such valves really exist, and if muscular fibres enter into their 1 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 longi- tudinal wrinkles, which are thicker 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 cellular tissue. Between these columns there are almost always to be found membranous semilunar folds, more or less numerous, oblique or transverse, of which the floating edge is directed from below upward toward the cavity of the intestine. These folds form a kind of lacunee, of which the bottom is narrow and directed downward." It seems evident that the sinuses of Morgagni are here referred to. PRACTICAL POINTS IN ANATOMY AND PHYSIOLOGY. 23 structure, they should not be discoverable at any time after death, or in any .state of the intestine a question very difficult of solution. Four years later, the voice of a New York surgeon is raised against these folds, and in almost the same language as O'Beirne's, though from an entirely independent stand-point. 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 faeces as Houston describes, though he has frequently met with accidental folds produced by the partial contraction of the bowel; and the proof that they are accidental is that, in the same subject, he has on different days found them to occupy different situations, but always they were unresist- ing and easily displaced by the extremity of 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 desiccation. Kohlrausch describes and figures one important fold, the plica transver- salis recti, which he locates at the same point as Houston's most constant one, projecting well into the lumen of the bowel from the right side. It forms rather more than a semicircle, 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 condition, inas- much 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 aays he has found in the empty state various folds of the mucous membrane, but that these have no determinate direction, 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 transversal is, or to Houston's chief valve. There is nothing to prove that they persist when the rectum is full; on the contrary, it is probable that they are effaced by the simple fact of disten- tion of the lattei, at least in great part. The name of valve is not, there- fore, applicable 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. Ilrnle 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 varirty, there is only one the plica tranversalis and this one is only present ;n a minority of subjects. 24: DISEASES OF THE RECTUM AND ANUS. Hyrtl describes two folds, both constant: one on the right wall lower down, and one on the opposite side. Eosswinkler also describes two- folds, but locates them on opposite sides to those of Hyrtl. There would be little profit in following these descriptions of differ- ent writers, each of them an authority on the subject treated, any fur- ther; * 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 thicken- ing of the muscular fibres, which can alone constitute a sphincter, from the projections 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 differences, 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 posterior 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 definite or constant situation, but may alter their shape with the 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 oc- casionally 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 examination 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 1 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., 1 ' Paris, 1815, t. iv., p. 377) probably all refer to the sinuses of Morgagni. PRACTICAL POINTS IN ANATOMY AND PHYSIOLOGY. 25 have often met this isolated development of some of the circular 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. Wlicn it exists, it is at a variable 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 >'Beirne has placed his superior sphincter at the junction of the rec- tum 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 con- sidered the physiology of the rectum to the existence of a third*sphinc- ter; and that Houston, in describing the valves of membrane, asserts t*b.at such an arrangement as he discovered was just the one which was a pos- teriori probable, and which best accounted for the accepted theories of the physiology of defecation. Nelaton, too, though he described the muscle 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 pos- sess. It is plain that each was led by a certain chain of reasoning to be- lieve 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 rec- tum, and the ability to retain both wind and motion after destruc- tion of the anus and its muscles. The force of this line of argument cannot be disputed, but were some other reasonable explanation found for these two facts than the existence of a third muscle, that muscle would soon be dropped from the descriptions of the anatomy 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 defeca- tion were simply as follows: The repeated descent of faecal masses causes the sigmoid flexure to become distended, and to ascend from its posi- tion in the cavity of the true pelvis into the left iliac fossa. "When this occurs, the flexure, in proportion to the rapidity and degree of its disten- tion, 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 movement, the contents are brought somewhat perpendicular to, and so as to press di- rectly upon the upper extremity of the contracted 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 ordinary respiration, or by the efforts of the flexure itself, in consequence of its muscular power being so inferior to that of the rectum; the faeces 26 DISEASES OF THE RECTUM: AND ANUS. are compelled to remain stationary until such time as the increased accu- mulation and distention produce a sense of uneasiness sufficient to call into action those great expulsive agents, the diaphragm and abdominal muscles. These muscles, instead of acting alternately, now act simul- taneously, 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 upon 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 passage. The nisus now ceases, but as soon as the rectum be- comes filled, it is aroused to make an expulsive effort by which its contents are driven or impacted into its pouch. Here they produce a great sense of weight and uneasiness in the perinaeum, an urgent desire to go to stool, and a still stronger nisus, by which the sphincters are forced open and dilated, and the final expulsion of. the faeces is effected. This rea- soning, it will be seen, is entirely based upon the normal empty and con- tracted state of the rectum, which O'Beirne not only states to be a clin- ical fact 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 liv- ing 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 muscle, 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 dur- ing the pauses between the peristaltic 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 contraction of the abdominal muscles, and a relaxation of the sphincter ani muscle. By the pressure of the abdominal muscles the contents of the descending colon are driven onward into the rectum, but the sigmoil flexuz*e itself is shielded by its situation from the direct force of this pressure, and a body introduced per anum 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 PKACIK AI. 1'oIXT.- IX AJf ATOMY AND PHYSIOLOGY. 27 or externally to the anus. This tonic contraction is due, in part at least, to the action of a nervous centre situated in the lumbar portion of the spinal cord. 3y the action of the will, by emotions, or by other nervous uts, 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 defe- cation. By these two alone the contents of the descending colon might be pressed onwards 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 in- crease in the peristaltic action of the sigmoid flexure itself. The order of events 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 arc driven against the sphincter. Through a voluntary 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 rec- tum are ejected. It should be mentioned that the one fact on which these physiological views rest, viz., the normal empty state of the rectum, 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 exam- ined; 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 loads to will be seen at once by the attempt of Bushe to explain the act of de- fecation, starting from the point that the faeces 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 expulsion. This sensation is, he believes, not due to the mere contact of faecal matter, for the latter generally accumulates in large quantities before the sensation is felt. Nor 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 sensation is felt and not attended to, it passes away, and does not return till the next accustomed period; and the longer it is unattended 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 conclusion! Nor is the cause of this 28 DISEASES OF THE RECTUM AND ANUS. periodically recurring desire to evacuate the bowel touched upon in the exposition given by O'Beirne; and this is the weak point in his argu- ment, 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 faeces in the lower bowel, ready to escape at any moment when the active watchfulness of the sphincter muscle is relaxed, or to prove that into our present understand- ing of the cause of the emptiness of the rectum a third sphincter muscle does not enter as a necessary element, but that the true explanation of the condition lies in the anatomy of the sigmoid flexure, which, by its large size, great capability of expansion, loose mesenteric attachment, and position, is peculiarly fitted to act the part of a reservoir. Nor does the phenomenon of retention of faeces after the destruction 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 ex- istence 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 ob- served 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 approaching evacuation, and this is what is gener- ally 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 arrange- ments, than an ability to absolutely prevent the evacuation which is about to take place. Of actual control there is little, because the sphinc- ter 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 sphinc- ter is abundantly equal, as every one has the chance to prove on his own person; and it is this ability to delay and postpone an evacuation of the bowels, rather than a constant action in preventing the escape of faeces which are ever ready to escape, which best expresses the true function of the muscle. After extirpation of the anus, this one element of natural defecation is destroyed, but several others are left. The 1 faeces tend to remain by their own consistence unless actively urged forward by the 1 The case was that of Fine, of Geneva, in 1797. " He formed an artificial anus, by which the fjecal matters escaped not continually, but once or twice a day only, and with a sensation of impending necessity which gave the patient time to make the slight preparations necessary to avoid soiling herself." Manuel de Med. Pratique " de Le Louis Odier, de Geneve. 2me ed., 1811. PRACTICAL POINTS IN ANATOMY AND I'HVSIOLOOY. 29 peristalsis of the bowel; and this peristalsis is not constant, but recurs periodically. The relative increase in the muscular elements in the rec- tum tends to keep it closed and empty until faeces are forced into it from abo in, the pressure of the faeces, owing to the S-shaped form of tlu- rectum, is not in the direction of the axis of the tube, but constantly he wall, and at the points of greatest curvature the resistance is greatly increased. To these let us add the contraction of the cicatrix after extirpation, and the natural redundancy of the mucous membrane which may block up the new anus by an actual prolapse, and we have the factors which account for the clinical fact so often seen. On the other hand, the constant escape of faeces, which at first almost always follows these wvere 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 described, are of the nature to form an obstruction to the passage of the faeces, 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 faeces, 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 personally been able to make, we are led to the following conclusions: 1. What has been so often and so differently 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 continence of faeces after extirpation of the anus, which necessitates the idea of the ex- istence of a superior sphincter. 5. When a fold of mucous membrane is found which contains muscu- lar tissue, and is Jinn enough to act as a barrier to the descent of the faeces, the arrangement may fairly be considered an abnormality, and is very apt to produce the usual signs of stricture. 30 DISEASES OF THE RECTUM AND ANUS. CHAPTER II. CONGENITAL MALFORMATIONS OF THE RECTUM AND ANUS. Separate Development of Rectum and Anus. Narrowing of the Anus or Rectum without Complete Occlusion. Congenital Stricture. Closure of the Anus by a Membranous Diaphragm. Entire Absence of the Anus, the Rectum Ending in a Blind Pouch at a Point more or Less Distant from the Perineum. Rectum Same as in Last Variety and the Anus Normal. Anus Absent and Rectum Opening by an Abnormal Anus at Some Point in the Perinea! or Sacral Regions. Cases. Anus Absent and Rectum Ending in the Bladder, Urethra, or Vagina. Cases. Rectum and Anus Normal, but Ureters, Uterus, or Vagina Empty into Rectum. Total Absence of Rectum. Absence of Large Intestine. Obliteration from Intra-Uterine Disease. Treatment. Operation Should Always be Performed and "Without Delay. Attempt Should First be Made to Establish an Anus in the Anal Region. Measurements of Pelvis at Birth. Use of Trocar not Justifiable. Useful Anus Seldom Obtained by Means of Incision Alone. Objections to Cutting Operation Without Plastic Operation. Proctoplasty. If Attempt to Establish New Anus in Anal Region Fail, Colotomy at Once to be Performed. Inguinal Preferable to Lumbar Colotomy. History of Colotomy. Callisen. Amussat. Descrip- tion of Operation of Colotomy. Dangers of Operation. The Inguinal Oper- ation. Description. Attempts at Establishing Anus in Anal Region after Colotomy Generally Unsuccessful. Cases. Closure of Artificial Anus. Operation of Dupuytren. Modifications of Dupuytren's Operation. THE study of embryology has revealed the fact that the anus and the rectum are developed separately. The anus is at first represented by a simple depression in the skin of the perineum which gradually extends in depth and advances to join the rectum. The rectum is developed in connection with the other abdominal viscera, gradually separates itself from them, and ending in a blind pouch, advances to meet the anal de- pression. At the proper time the two coalesce and the intestinal canal is complete. This process of development of either the rectum or anus may be arrested at almost any stage and the result will be one of the various malformations which are now to be described. These congenital malformations have been classified by different writers into various groups. We shall adopt in the following pages that CONGENITAL MALFORMATIONS OF THE RECTUM AND ANUS. 31 of Fapendorf ' which is the one followed by Bodenhamer, 1 Molliere, 1 and Esmarch. 4 1. Narrowing of the Anus or Rectum without Complete Occlusion. A congenital stricture of the anus, or of the rectum at a point more or less removed from the anus, has been occasionally reported. Serremone* 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 meconium. It is generally annular in form, resembling the contraction which would be caused by tying a tape tightly around the tube. There may be no symptoms caused by such a contraction, and the child may grow to adult life suffer- ing 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 rectum. 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 absence of free passage of meconium, dis- tention of the abdomen, and vomiting. The diagnosis is easily made by a digital examination should the symptoms be sufficiently marked to lead the attention of the surgeon to the rectum; for the stricture is generally near the anus and may be felt as a ring with sharp edges. The treat- ment consists either in dilatation or in nicking.* 2. Closure of the Anus by a Membranous Diaphragm. The mem- brane in these cases may be of greater or less firmness and thickness, and may be composed of skin or of mucous membrane. It is sometimes so thin as to bulge out with meconium when the child strains or coughs, and has been known to rupture spontaneously. This is the simplest of all the forms of congenital malformation of the anus, and, unfortunately, one of the rarest. It is easily diagnosti- cated by simple inspection of the parts; and the treatment consists in making a crucial incision through the membrane. The remains of the 1 " Dissertatio sistens observationes de ano 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. J "Train- (Irs Malailii-s . 27:5. Ashton, "Diseases of the Rectum." London. 1854, p. 27. DevUliers, Rev. Sled, de Paris, 1885. 32 DISEASES OF THE KECTUM AND ANUS. membrane, like those of the hymen which it strongly resembles, will shrink up so as not to cause trouble or deformity. 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 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 FIG. 7.-(Molli6re). 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. 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 pressure with one finger over the anus and the other hand on the abdomen. In females, valuable aid in diagnosis may be obtained by the introduction of a finger into the vagina. The use of a stethoscope over the anus, and of percussion on the abdomen, has 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 1 A. Copeland Hutchinson: 1826. Practical Observations in Surgery," London, CONGENITAL MALFORMATIONS OF THK RECTUM AND ANUS. 33 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. TJie rectum may be the same as in the last variety, and the anus be normal. The septum which separates the rectal and anal pouches in this case is generally within easy reach of the anue, and may be so thin as to per- mit a sense of fluctuation. In most cases, however, the septum is thicker, and is composed of cellular or fibrous tissue, lined both above and below by mucous membrane. It may be perforated, like the hymen, Fio. b. (MoUK-re). at some point, and allow of the slow dribbling of meconium. There may also be more than one septum. Voillemier' reports one case in which the rectum was divided in this way into four distinct compartments, the upper one containing meconium, and the others mucus. There is gen- erally little difficulty in the diagnosis of these cases, provided only a digital examination be made when the infant begins to show the effects of the obstruction; but the danger lies in the fact -of the normal anus, which is apt to allay suspicion as to the true nature of the difficulty. 1 1 Gaz. des Hop., 1846. * " Dr. H. G. Jameson, of Baltimore (Medical Recorder, vol. v., 1822, p. 290), divided two membranous septa, one above the other, with a button-headed bistoury, which In- j-.t". .! into the opening or ring of the septum,' and cut freely down toward the sacrum. This was done in, September, 1821. The patient got well. Roser (Arch, fur Physiol. Heilkunde, 1859, p. 12." mentions a circular valvular stricture an inch from the anus in a little girl of four, which he treated by division." Van Buron, " Lectures upon Diseases of the Rectum and the Surgery of the Lower Bowel." New York: D. Appleton & Co., 1881, p. 263, note. 3 34 DISEASES OF THE RECTUM AND ANUS. 5. TJie anus may be absent, and the rectum may open by an abnormal anus at any point in the penneal or sacral regions. When the rectum terminates in the glans penis, the labia, or at some abnormal point in the perineum, the lower portion of it is usually of a fistulous character, as shown in the plate, but lined by true mucous membrane; and the anus, whether in the perineum or at the base of the sacrum, or tip of the coccyx, is always narrow and insufficient for its purpose. A modification of this class of abnormalities is found in those cases where the rectum terminates in two openings at a greater or less distance from each other. FIG. 9. (Mollwre). Cruveilhier 1 reports a case of this nature, in which the fistulous pro- longation of the rectum ran subcutaneously in the scrotal raphe, and terminated at the glans penis. Mr. Morgan 3 has recently reported two modifiations of this species of deformity which are rarely met with, and are easily relieved. In the first, the anus was of the usual size and in the proper location ; but there was found to be a band of tissue passing from a point corresponding to the apex of the coccyx to the median raphe of the scrotum, with the posterior extremity of which it was continuous. The band was about three-quarters of an inch long, and was attached at both ends, the re- mainder forming a thick, free cord, which lay below the aperture of the anus, while from the centre of this band there ran a small branch of similar tissue, which was attached to the skin of the left buttock, and was about half an inch in length. 'The skin covering the central band 1 Anat. Pathologique du Corps Humain, t. i., Liv. i., Planche vi. 2 Three Cases of Unusual Deformity of the Anus. Lancet, October 2 3d. 1 3S 1 . CONGENITAL MAL1-ORMATION8 OF THK KECTDM AND ANUS. 35 exactly resembled that of the scrotum, shrinking and contracting upon stimulation, and it was so placed that any passage of faeces must cause it to be stretched, thus accounting for the pain attending each motion of the bowels. The second case was similar. The child was born with an imper- f orate anus, but the membranous septum, gave way spontaneously. The child, however, continued to suffer pain on defecation, and on examina- tion, there was seen a small, thick band passing from the median raphc of the perineum in front to the depression between the buttocks posteri- orly, and broadest behind. At a spot corresponding to the anus, on either side of the band, was a depression; that on the right was patent, and allowed a probe to pass into the anus; that on the left, though similar in appearance, proved to be only a cul-de-sac. Fia. lO.-(MolU6re). In a third case, there was a depression at the usual site of the anus, and the parts around were so far natural that the skin was pigmented and puckered, but there uas no communication with the rectum. The spot at which the faeces passed was in the median line half-way between this depression and the posterior commissure, but nearer the latter than the former. The opening was very small, and a probe passed up into it, showed an abundance of tissue between the passage and the vagina. The cure consisted in enlarging this abnormal opening posteriorly into the depression representing the natural one. Delans 1 reports an anal- ogous case in a well-nourished child aged four and a half years. There were two openings, one on each side of a median bridle, which was con- Soc. (U- Clururgi.-. March ^4tli, 1875. 36 DISEASES OF THE RECTUM AND ANUS. tinuous with the raphe in front and behind, and was composed only of skin and mucous membrane. Each opening seemed to be the natural one, but the one on the left was a cul-de-sac fifteen millimetres deep. The septum was excised, with what result is not stated. 6. The anus may be absent and the rectum may end in the bladder, urethra, or vagina. Of these varieties that in which the rectum opens into the vagina is the most common. In females the opening is seldom, if ever, into the bladder, but sometimes it is into the urethra. In males it is more often into the bladder than into the urethra, and in such cases the rectum may terminate either by a narrow duct running obliquely through the bladder and opening in the bas-fond between the orifices of the ureters, or by a free opening. The symptoms of this condition will of course vary greatly according to the location of the abnormal opening. When the commu- nication is between the rectum and bladder the fact will be shown by the mixture of the meconium with the urine, rendering the latter thick and greenish in color. The amount of meconium present will also indicate whether the opening is large or small. This condition is generally fatal from the development of cystitis, and from intestinal obstruction unless the condition be relieved by the appropriate surgical interference. 1 When the communication is tirethral in the male, the meconium will often escape independently of the act of urination. The prognosis is not as bad in these cases as in the vesical variety; several being recorded in which life has been preserved for a number of years. Gross* relates one case in a man aged thirty; and Bodenhamer cites several others in which children have lived three or four years. In the female the prognosis is more favorable than in the male, from the greater facility with which the meconium escapes. Where the abnormal opening is between the vagina and rectum, and is of considerable size, as it generally is, the prognosis is not necessarily grave. Women have been known to live to a good old age, even to reach one hundred years in the case of Morgagni, with this malformation, and to perform all the duties of wives and mothers without even being con- scious of anything abnormal (Fournier, 3 Eicord). 7. The rectum and anus are normal, but the ureters, uterus, or vagina empty into the rectal cavity and discharge their contents through it. This species of malformation is rare and is usually attended by other signs 1 As showing what the bladder and urethra may bear, however, Rowan's case is of great interest. In it defecation took place through the penis for two months without causing any signs of irritation, though the child was several months old, and the rectum was rilled with well-formed hard faeces. Australian Med. Journal, Mar., 1877. * A System of Surgery. Phila.. H. C. Lea, 1872, vol. ii., p. 657. . 3 Dict. des Sci. Med., t. iv., p. 155 CONGENITAL MALFORMATIONS OF THE RECTUM AND ANUS. 37 of imperfect development. It is not incompatible with life or with con- ception. 8. Total absence of the rectum. This variety differs only from the third in the amount of the rectum which may be absent. It may or may not be attended by an absence of the anus, but is usuaHy only one of the signs of arrested development. The blind pouch of the rectum may hang loose in the abdomen or pelvis; may be attached in the base of the sacrum, or to some of the adjacent parts; or may be continued down as a fibrous cord to the site of the anus. 9. Absence of the large intestine. This is also attended by an absence of the normal anus, the place of which is supplied by an abnormal opening in the umbilicus, or at some remote part of the body, as, for ex- ample, the side of the chest, or the face. With this abnormal opening the small intestine or what remains of the colon communicates. Thus far only arrests or excesses of development have been mentioned. The rectum and anus are, however, liable to certain diseases during fatal life which may result in narrowing or completely obliterating their cali- bre. Among these are enteritis and proctitis. Treatment. The treatment of the class of congenital contractions of the anus and rectum, and of the class of membranous septa, has already been referred to, and is exceedingly simple and generally attended by good results. The treatment of the remaining varieties, except the eighth and ninth which do not admit of surgical interference, may be guided by the following general propositions. 1. An operation should always be performed and performed without delay. There is little to be gained even by waiting for the rectal pouch to become distended with meconium, and there is much to be lost. If the obstruction be complete, death is a necessary result; being produced by peritonitis, by rupture of the over-distended bowel, or by a gradual wasting without acute symptoms. Even in cases where a certain amount of meconium makes its escape by a narrow orifice, and delay is not, therefore, as necessarily dangerous as in cases of complete obstruction, nothing is to be gained by delay, and an immediate operation may avoid a paralysis of the bowel from over-distention. ' 1 Cripps (Lancet, May 15th, 1880) has reported a most remarkable case bearing upon this point. The condition of imperforate rectum was diagnosticated on the third day, but operation was refused and the child taken from the hospital. Thirty days later she was brought back again apparently quite well; the abdomen was distended; food was taken well; but three or four times every day she vom- ited ftecal matter. In this case, the anus terminated in a blind pouch and a tro- car was plunged upwards through it. Only a little serous fluid escaped from the peritoneal cavity, and the child died of peritonitis. At the autopsy, the rectal ml -de-sac was found just above the anal pouch, but the trocar had penetrated the jx-ritoneal pouch between the two. There are two noteworthy points in the case. The first is the remarkable manner in which n;i tun- accommodated itself to the deformity; and the second is the ease with which the rectal pouch may be missed with a trocar. 38 DISEASES OF THE RECTUM AND ANUS. 2. If there be any chance of establishing an opening at the normal site of the anus, the surgeon should at first direct his attention to this pro- cedure. And, since in most cases it is impossible to tell that the rectal pouch may not be within easy reach from the perineum, it is generally good surgery to make a tentative incision at this point. Before attempting any operation on a child's pelvis, the surgeon should remember the exceeding smallness of the space in which he is obliged to 'work, even in its natural state; and also that the normal measurements may be decreased in any case of congenital malformation-. These normal measurements, according to Bodenhamer who made them on two new- born, well-developed, male infants, at full term are as follows : 1. From one tuberosity of the ischium to the other, one inch and one line. From the os coccygis to the symphysis pubis, one inch and three lines. From the os coccygis to the promontory of the sacrum, one inch and two lines. 2. From one tuberosity of the ischium to the other, one inch. From the os coccygis to the symphysis pubis, one inch and one and a half lines. From the os coccygis to' the promontory of the sacrum, one inch and one line. The means at the disposal of the operator for reaching the rectal pouch through the perineum and establishing a new outlet, consist in puncture, incision (proctotomy), and in the formation of a new anus by a plastic operation (proctoplasty). The operation by puncture consists in plunging a trocar through the perineum in the supposed direction of the rectum, for the purpose of establishing an outlet. It may be done without a preliminary incision, or after a careful dissection which has failed to reach the desired point. 3. The use of a trocar as an aid in finding the rectal pouch before or after incisions through the perineum, is not sanctioned by modern surgi- cal authority. It is a procedure attended with the greatest danger to the life of the patient, and when the rectal pouch is successfully reached, which is rare, the outlet thus made is of little use. The peritoneum, bladder, or uterus may each be wounded by the instrument with a fatal result; the opening made is not free enough to allow of easy escape of meconium; nor can such an opening be made to serve the purpose of rectum and anus by any subsequent dilatation. 4. The results of attempts to establish an outlet for an imperfect rec- tum by means of incisions alone through the perineum are not favorable as regards the production of a useful anus. The operation consists in cutting through the perineal tissues, stroke by stroke, until the rectal pouch is reached and opened. The incision should be longitudinal, and should reach from the scrotum to the tip of the coccyx. Should the fibres of the external sphincter be encountered beneath the skin, they may be carefully separated as near the median line as possible and drawn to each side. The direction of the dissection, CONGENITAL MALFORMATIONS OF THE RECTUM AND ANUS. 39 which it i? needless to say should be made with the utmost care, should be backwards towards the concavity of the sacrum iu the line which tht rectum normally follows. Additional safety may be secured by tht introduction of a sound into the male bladder or the female vagina. The finger is to be frequently used as a director in exploring for the rectal pouch, while the hand of an assistant makes pressure on the abdo- men. In this way the dissection may be carried to the depth of an inch or possibly an inch and a half, but at this point, if unsuccessful, it should be abandoned for fear of wounding the peritoneum. This operation, though it may be successful in allowing the escape of meconium, and in prolonging life, does not, in most cases, result in a useful anus for any great number of years. This is the experience of the greater number of writers upon this subject. Van Buren 1 says: " I have, in several instances, succeeded, by careful dissection, in reaching a fluc- tuating point of a blind rectal pouch, and in establishing a free outlet for the meconium, but in no case has it proved permanently useful. It has always been necessary to employ bougies or tents more or less con- stantly to keep the new canal from contracting, and the care, and pain, and trouble of fighting against the closing stricture, and the persistent tendency to obstruction and faecal accumulation, have invariably led to early death. At present, I know of no such case treated in this way, in which a permanently satisfactory result has been attained." Amussat,* Sir Benjamin Brodie, Velpeau," Benjamin Bell, 4 and many others, have borne testimony to the same effect. On the other hand, cases are occa- sionally seen where the result is more favorable, but they constitute a small minority of the whole. What the operation really accomplishes is the formation of a faecal fistula, with all the discomforts attendant upon such a condition. It was this difficulty, combined with the loss of two cases in which the operation had been performed from blood poisoning with jaundice, which Amussat considered to be due to thq absorption of meconium and faecal matter by the freshly-cut surface, which led him to abandon this operation, and to substitute in its place the one now to be described. Operation of Ammussaf. Proctoplasty. This operation is the same as the last, with the addition of two important features. In the first place, the rectum is drawn down and stitched to the skin ; and, second, to facilitate this, when necessary, the new anus is made either just at the tip of the coccyx, or that bone is exsected, and the anus made in the place it occupied. Where much of the lower end of the rectum is deficient, it may not be possible to draw the cul-de-sac down to the skin >Op. cit., p. 371. * " Observation sur une Operation d'Anus artificiel," etc. Gaz. Med. de Paris, N..v. -,Mh, 1835, p. 758. * " Nouveau Elements de Med. Operatoire," Paris, 1832. 4 " A System of Surgery." Vol. ii.. chapt. xix. Edinburgh, 1778. 40 DISEASES OF THE RECTUM AND ANUS. without more traction and dissection than it is safe to employ. In such cases, the excision of the coccyx, as originally recomended and practised by Amussat, 1 and more recently by Verneuil," besides adding to the chances of finding the rectal pouch, diminishes the distance over which the rec- tum must be stretched. Unfortunately, in the cases where the opera- tion is most needed those in which the rectal pouch is furthest from the skin the operation is not always practicable; and in other cases, the adhesions of the rectum to the bladder or vagina may be an insuper- able obstacle. In the latter class of cases, however, a new anus may be formed, and, if successful, the recto- vaginal fistula may be closed by subsequent operations. 5. In case of failure to establish a neiv anus in the anal region, colo- tomy should at once be performed. The teachings of different authorities will vary as to the propriety of first performing the perineal operation before resorting to colotomy, ac- cording to the views of each one upon the question of the desirability of colotomy. Some follow the rule I have laid down, that it is always bet- ter to attempt the perineal operation where there is a chance of its suc- ceeding ; others limit the latter operation to cases where the rectal pouch is known to be near the skin, and in all others turn their efforts at once toward the colon. The abdominal operation is obviously the only one where the rectum ends high up in the pelvis, and it is generally to be preferred in that class of cases where it opens into the bladder or urethra. 6. In the formation of an artificial anus, the left groin is the best site for 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, 3 in 1710, and the incision he recommended was simply " au venire " (in the abdomen) ; the design being to reach the sigmoid flexure. He never practised the operation which at present passes under his name that of opening the bowel in the groin, nor did the operation he proposed involve the idea of preserving the peritoneum intact. 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 opera- tion. In 1783, Dubois operated in the same way for imperforate anus, but the operation was unsuccessful, and the child died on the tenth day. ' Troisieme Memoire sur la Fossibilite d'etablir une ouverture artificielle sur la coon lombaire gauche sans ouvrir la Peritoine, chez les enfans imperfores. Paris, 1842. * Gaz. des Hop. de Paris, July 29th, Aug. 5th, 1873, pp. 604, 715. 3 Histoire de L'Acad. Roy. des Sci. de Paris, 1710, p. 36. CONGENITAL MALFORMATIONS OF THE RECTUM AND ANC8. 41 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 1797, Fine, of Geneva, mado ;in 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 1814, the operation was successfully 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 origi- nal 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 cer- tainly was in error; and on the whole he condemned the operation in the following words: 1 "The incision of the caecum and descending colon, which has been proposed, in this state of things (imperforate rectum) by means of an incision in the left lumbar region at the border of the qua- dratus lumborum, to establish an artificial anus, presents a very uncertain chance, and the life of the little patient can scarcely be saved; neverthe- less, the intestine may be reached more easily in this place than above in the iliac region." It is in reality to Amussat that the extra-peritoneal operation in the loin is due, and the operation which he described' is the one now in favor and the one usually spoken of as that of Callisen. 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 one-half inch posterior 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 anterior 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 in great part uncovered by peritoneum, being behind that membrane and in immedi- ate contact with the transversalis fascia. The patient should be placed 1 "Manuel de med. prat, de Louis Adier de Geneve." 2d Edit., 1811. Quoted by Carcopino, These, No. 197, 1879. Parallel entre 1'extirpation du rectum et 1'eta- blissement de 1'anus artificiel. 4 Edinburgh Med. and Surg. Jour., Oct. 1825, p. 271. 1 Carcopino. These. 4 London Med. and Physical Journal. 1821. * " Systema Chirurgiae hodiernae." t. i.. Haffinitp, 1818. " Quelques reflexions pratiques sur les retrecissements du rectnm." Gaz. Med. de Paris, 1839, No. 1. 42 DISEASES OF THE RECTUM AND ANUS. upon a hard pillow so 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 downwards and from behind forwards, 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 transversa- lis muscles, till the outer border of the quadratus is recognized; care being taken that as the incision grows deeper it does not also grow shorter, till when the bowel is reached the operator finds himself working in the small end of the funnel. If possible the outer border of the quadratus should be distinctly recognized before the transversalis fascia is divided, under which lies the colon moce or less enveloped in fat. "When dis- tended either artificially by air, or by the faeces, it is recognized either by the feel of the faeces or by its longitudinal muscular bands. When, on the other hand, it is collapsed (and Molliere 1 has called attention to the fact that it may be collapsed even in cases of prolonged retention, the accumulation being either above or below the point of operation), the patient may be turned on the back to allow it to fall into the wound, or pressure may be made on the abdomen by an assistant. Bryant recom- mends rolling the bowel partially forward after it has been seized, to bring its posterior surface into the wound, as an additional safeguard against wounding the peritoneum. When the bowel has been drawn well out to the surface of the wound, it must be secured in position before it is opened, in order that its con- tents may not escape into the abdominal cavity. This is best done by passing a couple of ligatures through it and the lips of the wound in the following manner. The needle is entered on one side of the incision and carried through the integument alone, and not through the whole thick- ness of the adominal wall, for the edge of the bowel is to be attached to the skin; it is then made to transfix the bowel and brought out at the opposite edge of the abdominal incision at a corresponding point. After two such sutures have been passed and intrusted to an assistant, the bowel may be opened by a longitudinal incision about three quarters of an inch in length, over the sutures which pass across its calibre. The middle of each suture is then drawn out of the bowel and divided. In this way four sutures will be in place; and after they have been secured, one may be inserted at each end of the wound in the bowel, and as many more along the sides as may be necessary for perfect coaptation. The sutures should be of strong silk. The operation may be modified with advantage by stitching the parietal 'Op. cit.. p. 596.' CONGENITAL MALFORMATIONS OF THE RECTUM AND A> 4',} and visceral layers of the peritoneum together with sutures passing down to the sub-mucous layer of the bowel, but not into its calibre. The wound may then be covered, and the opening into the bowel delayed for s*ix or eight hours for adhesions to occur. The immediate dange r in the operation of lumbar colotomy is that the peritoneum may be opened and death result from peritonitis, due not so much perhaps to the incision in the serous sac as to the escape of fluids into its cavity. It has also happened to good operators to open a coil of small intestine instead of the colon; or, by missing the latter at first on account of some change in its position, to become confused in the subsequent search and fail utterly in finding the desired part. Both of these most common accidents are best avoided by a close adherence to the rules which have been given. The list of mishaps in connection with this operation is a long and curious one. The wound is deep and it is more than probable that in many cases the accident which the operation is especially intended to avoid, and the avoidance of which is the one point in favor of the lum- bar over the inguinal incision a wound of the peritoneum is not avoided. The portion of the descending colon not covered by perito- neum varies greatly in extent in different cases; and during the operation there is no way of determining whether the serous coat is or is not under the knife. The kidney has more than once beenwoundet: at the bottom of the incision,' and as good an operator as Allingham* confesses to hav- ing opened the duodenum where it embraces the head of the pancreas, in an attempt to find the colon on the right side. In children the peri- toneal investment is more complete than in adults, and the operation is contra-indicated both on this account, and because of the greater mova- bility of the intestine. 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 114; Curling in 100 found it so located in 85; and Bourcart in 117 out of 150.' Inguinal colotomy is especially indicated in treating imperforate anus in children, in whom the mesocolon is so lax that the sigmoid flexure may wander even across the aorta into the opposite flank. He who attempts the extra- peritoneal operation in a child may consider himself fortunate if he finds the desired point at all; and when found it is so completely surrounded by peritoneum as to render a wound of the sac almost a certainty. The operation in the groin too is easier of per- formance, and when successful the resulting anus is more easily cared for by the patient. These facts, together with the decreasing fear of incising the peritoneum, have led some surgeons to advocate this operation not 1 Bryant, Amussat. 1 Op. cit., p. 230. 3 Guyon: Diet. Encyc. des Sci. Med., Paris, 1863. 4:4: DISEASES OF THE BECTUM AND ANUS. only in cases of adults where disease has encroached upon the sigmoid flexure, where it is particularly indicated; but in all cases for which the lumbar incision is generally chosen. The inguinal operation is in great favor among the French, the lumbar among the English. 1 An incision about two inches and a half long is made in the left groin parallel with Poupart's ligament, about half an inch above it, and well towards the lateral wall of the abdomen so far that the epigastric artery should not be seen in the operation. This incision is carried down to the peritoneum, each successive layer being divided on a director as is usual in operations on this part. Before the peritoneum is opened, all haemorrhage from the wound should be stopped and the cut rendered as dry and clean as possible. The peritoneum is then pinched up with for- ceps and nicked, a director is introduced, and the opening enlarged to the extent of an inch and a half. The descending colon should be in view immediately below the wound, and is recognized by the usual sign. When such is the case, the subsequent steps of the operation are compa- ratively simple; the incision into its wall and its union to the abdominal wound being accomplished in the same manner as already -described in the lumbar operation. But when such is not the case, the bowel must be searched for, and it may be necessary to enlarge the original incision. The following case from Molliere a illustrates very well the difficulties which may attend the operation in an adult under such circumstances. "An unfortunate woman was admitted to the hospital at night with symptoms of acute intestinal obstruction. The abdomen was greatly distended, but she asserted that it had been much increased in size for a long time previous. As death was imminent and punctures into the in- testine through the abdominal wall gave no relief, inguinal colotomy was decided upon. Scarcely was the incision made into the peritoneum before a quantity of ascitic fluid escaped, and an enormous, white, shiny, aponeurotic-looking tumor made its appearance. This tumor was some- what movable. The operator believing that he was dealing with ah ovarian cyst, and despairing of reaching the colon, made an incision into the small intestine from which escaped a large quantity of faeces. The autopsy demonstrated later that this tumor was itself the colon, greatly distended above a contraction caused by cicatricial bands in the pelvis. The patient had succumbed to a general tubercular peritonitis." 7. Attempts at establishing an anus in the anal region after the per- formance of colotomy are attended with great danger, and are generally unsucceseful. 1 For discussion as to the relative merits of the two operations the reader is referred to the following articles: Dupuytren, " Diet, en 30 vols.," Art. Anus Arti- ficiel; Videl de Cassis, These de Concours, 1842; Guyon, "Diet. Encyc. des Sci. Med.," Paris, 1863; Giraldes, " Nouv. Diet, de Med. et de Chir. prat.," t. ii., p. 633; Robert, "Bull, de 1'acad. Roy. de Med.," t. xxi., p. 931. 4 Op. cit. CONGENITAL MALFORMATIONS OF THK KECTUM AND ANUS. 45 Perhaps the best authority on this point is embraced in the experi- ence of Mr. Owen.' In two cases in which after an interval of three months he attempted to establish an anus in the natural position, the end was a fatal peritonitis due to the fact that the rectal pouch was com- pletely covered with peritoneum. Dr. Byrd* has more recently reported ;ise in which the operation was successful. The bowel ended in this case in a sort of cul-de-sac with an appendix, and the operation is de- scribed as follows. " By passing my finger into the bowel through the wound, I found that the calibre of the bowel easily permitted its passage for about three inches, when it suddenly narrowed, and from that point downward it resembled the appendix vermiformis. Into this narrowed portion was passed a small sound used for searching for stone in infants, and the end of it worked downward in the narrowed bowel toward the anus. To more easily meet the sound from below, an incision was made about two inches deep, up from the anus and back to the coccyx, large enough to permit the passage of the index finger. The sound was carried along until it could be felt only about one-eighth of an inch from the tip of the finger passed from below, when it would pass no further with ease. Force enough was then used to pass the sound through the intervening space, and the point was brought out at the anus. To the point of the sound a stout thread, running through a No. 10 Jacques catheter, was attached with a reef knot, and the sound was retracted, bringing the cath- eter with it. One end protruded from the anus, and the other from the artificial anus. To the end protruding from the artificial opening, a compress was tied, and by placing a bit of rubber dam under the com- press and drawing the catheter down, extrusion of the bowel was pre- vented, and some control was exerted over the faeces. The child was very much prostrated by the shock of this operation, but, by the second day, he had fully recover This plan of treatment was continued as follows: The author took "a piece of soft-rubber tubing about as large around as my little finger and one foot long. By tucking half an inch of one end up into the tube, it made a bulbous end somewhat larger than the rest of the tube; this end I fastened to the catheter, where it came out at the side, with a stout flax thread, and divw it down into the bowel by retracting the catheter. As I expected and desired, it caught against the shoulder of the narrowed Ix.wel, and by traction upon the catlieter, the mucous membrane was brought down in a fold in front of the bull), and covered the space that otherwise would have been filled with cicatricial tissue. To- 1 Surgery of Childhood. I'.rit. M.-.l. Jmr., IVbnmry -..'1st. 2sth; Mareh Uh. 1880. 1 Lumbo-Colotomy in the New-Horn for Relief of Im|*rforate Rectum, before the Tri-State Med Soc., St. Lmii.-. Ort :T>th. 1881. (Reprint.) 46 DISEASES OF THE KECTUM AND ANUS. day (about one month after the introduction of the rubber tube) I re- moved the tube, and find my little finger passes readily up the opening, which is covered throughout with mucous membrane." Unfortunately the history of this case ends at this point, the author expressing the hope that the artificial anus would close "without further operative interference, except the wearing of a well-adjusted pad," and being prepared to perform a further operation for its closure should it prove to be necessary. Kronlein ' also reports a successful case of this operation. 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 centimetres long. An attempt to reach the rectum by an incision through this pouch, resulted only in opening the peritoneum, as was shown by 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 oper- ation was again attempted, and the rectal pouch successfully united with 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. w i f 3 FIG. 11. FIG. 12. Condition of bowel after colotomy, showing septum and course of faeces (Packard). The attempt to re-establish an anus in the anal region originated with Demarquay, and involves, if it be successful, a subsequent attempt to close the artificial opening. This is an operation of great danger and one seldom successful. The difficulties consist in re-establishing the calibre of the bowel at the point where it is partially occluded by the for- mation of the artificial opening, and in subsequently closing this opening by a plastic operation. The danger is of fatal peritonitis. It is well known that in cases of colotomy, the side of the bowel opposite the opening becomes sharply bent upon itself, as shown in Figs. 11 and 12. The septum thus formed is composed of two layers, each consisting of the whole thickness of the intestinal wall, and it must be destroyed before the lumen can be re-established and the opening safely closed. Dupuy- tre:i's 2 original operation consisted first in compressing this valve by an instrument invented by himself, the action of which is shown in Fig. 13. 1 Berlin. Klin. Woch., 1879, No. 34-35. 3 Leons Orales de Clin. Chirurgicale. Paris, 1839, t. iv., p. 1. CONGENITAL MALFORMATIONS OF THE RECTUM AND ANUS. 47 This was applied and tightened so as at once to cause the death of the included portion. The subsequent steps in the operation consisted inclosing the artificial opening. His experience extended over 41 cases, 21 of which were done by himself and 20 by others. Three cases were fatal. Of the remaining 38 the operation was unsuccessful in 8, and suc- cessful in 29 in periods varying from two to six months. It is but proper to say that considerable doubt exists as to the reliability of this very favorable showing. Since his time, the operation of Dupuytren has been modified in vari- ous ways by different surgeons. Barker ' has recently reported a success- ful operation after a plan of his own, the essential feature of which con- sists in introducing into the bowel through the artificial anus, after the Fio. 13. Enterotome of Dupujrtren In position (Packard). projecting spur of the bowel has been removed in the usual way, a thin and flexible strip of rubber about one and a half inches long by five- eighths of an inch broad, in such a manner as to lap up against the in- ternal 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. 1 \ 1 Iin|ir<)Vfiii>>iit in I)ui>u\ tivn's Operation for Artificial Anus, and a Successful Case treated by it." Lancet, Dec. 18th, 1880. 4-8 DISEASES OF THE KECTUM AND ANUS. CHAPTER III. GENERAL RULES REGARDING EXAMINATION, DIAGNOSIS, AND OPERA- TION. Necessity for Physical Examination. Questions which may lead to Diagnosis. How to make Examination. Table. Lamp. Instrument Case. Position of Patient. Necessity for Enema before Examination. What may be learned by simple Inspection. Rectal Touch. What may be discovered by it. Bougies; Varieties; Author's Bougies. Rectal Specula: Van Buren's; Fene- strated; Bivalve; Objections. Colonoscope. -Stretching the Sphincter; Pro- per Method of Performing the Operation; Results. Difficulties of Diagnosis of Disease high up in the Rectum. Manual Examination. What may be Learned by this Method. Preparation of Patient for Operation. Assistants. Primary Anaesthesia. Thermo-Cautery. Haemorrhage. Rules for Con- trolling Haemorrhage. Cold. Styptics. Packing the Rectum. Treatment after Operation. Dressings. Necessity for Rest. Retention of Urine. Case of Fatal Retention. To one who has been trained in the habit of making a diagnosis before undertaking treatment it seems superfluous to insist 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 diagnosis, in whom, nevertheless, the merest inspection is sufficient to prove the exist- ence of much more serious, and often of incurable, disease. This is not due to ignorance, but to carelessness, to too great faith in the statements of the sufferers, and often to a false modesty on the part of the practi- tioner which leads him to accept such statements in lieu of a thorough examination. The following case illustrates many points in rectal diagnosis and may be as useful to others as it was to myself. CASE I. A young man appearing in perfect health was sent to me by Dr. N". M. Shaffer, of New Yorjc, for rectal trouble. He gave me a his- tory of constant discharge from the bowel and of some pain after defeca- tion, but the discharge was his chief trouble. On examination I discov- ered a fistula, but such an insignificant subcutaneous affair that I divided it on the spot, recomended a day's rest, and assured him that he would be entirely well in a week without further treatment. The fistula was well GENERAL RULES REGARDING EXAMINATION, DIAGNOSIS, ETC. 49 in a week, but the man was not. He still complained of discharge and some pain, though less than before. I made a second and more careful (.xamination and discovered a perfectly well-marked fissure just above the external sphincter. Once more I assured him that he could easily be cured, and I divided the base of the ulcer with a bistoury. The operation was thoroughly done, for I was a little chagrined at my former carelessness and wished to make sure of the cure. Theoperation was not followed by the slighest relief, and six weeks were passed in the vain hope of a cure. I then did what should have been done in the first place, and set myself deliberately to make a complete diagnosis. I etherized the patient, di- lated his sphincter, and made a thorough examination with artificial light. The fissure could be plainly seen and above it there was apolypus of con- M.lerable size which by its mobility had escaped me in the former exami- nation, and by its contact with the surface of the sore had prevented a cure. This was removed, but the man was not yet cured. The pain had all di -appeared, but the discharge from the bowel still remained in dimini.-hed quantity. I was about to despair, when he mentioned in the most casual way that he had had a good deal of itching at the anus for some time back, and an examination revealed a moist eczema which fur- nished the discharge. The skin disease had been there from the first, but as the man had asserted that it never troubled him, I had paid little atten- tion to it. This was easily cured and I ultimately had the satisfaction of seeing my patient well. Here then was rather an unusual combination of troubles a fistula, a fissure, a polypus, and eczema, and each one sufficient in itself to account for all the symptoms of which the patient complained. But all should have been discovered at the first examination, and the man should have been cured by one operation instead of three. Tin- 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 almost all diseases of this part and which infallibly points to trouble of some kind, but they do not tell what that trouble is. The pain of a fissure is, perhaps, diagnostic of the fissure, 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 at- tempts 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 fi-male, who have not yet come to the point which makes them willing to submit to an examination, have not yet reached a point which admits of treatment. 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 himself to be persuaded into " recom- mending something for piles " will sooner or later have a mistake in diag- 4 50 DISEASES OF THE RECTUM AXD ANUS. nosis laid to his charge, nor will the fact that he was moved by consider- ation for the patient's sensibilities save him from blame. I have often found that the best way to secure an examination in women who otherwise could not be brought to consent to it, was to re- sort to ether, with the understanding that whatever surgical procedure was thought advisable should be performed at the same time. In this way a patient's sensibilities may often be spared, while both diagnosis and treatment are included in one examination. FIG. 14. FIG. 15. Before, however, proceeding to make the physical examination which is inevitable, certain questions and answers may give the surgeon a pretty clear idea of what he is about to find. It is generally a good plan to allow an intelligent patient to tell his or her own history, and then to supplement it with appropriate questions as to the length of time since the trouble began; the character of pain when present, whether constant or intermittent, and increased by defecation; whether it comes with the stool, immediately or some time after, and its duration. The question of i.KAI, RULES KK(,Ai:iIN(r l.\ \ MIN ATI ON, DIAGNOSIS, ETC. 51 discharge should also be inquired into its quantity and character, whether blood, pus, or mucus; also whether there is any protrusion of any kind, and its character. The answers to these questions and to those which relate to the presence or absence of diarrhoea, constipation, and Fio. 16. Lamp for rectal examinations. incontinence, will generally give the surgeon a fair idea of the nature of the case before him. How, then, to proceed to make a rectal examination which shall be at the same time thorough and as free from pain as possible? T\vo things are necessary above all others a good bed or table and a good light. For a table, a strong, four-legged one, upholstered with hair and 52 DISEASES OF THE KECTUM AND ANUS. leather, answers every purpose. It should be hard, without springs, and about thirty inches in height. In place of this, any of the examining tables of the gynaecologists may be used. In my own office, I use a modifica- tion of the combined table and lounge of Dr. J. L. Little, which is rep- resented, closed and open, in Fig. 14 and Fig. 15. Its great advantage is that, when not in use, it answers as an ordinary piece of furniture, and when raised it provides a firm, hard operating table of convenient height. Either natural or artificial light may be used, but the latter is on some accounts preferable, being always at command, and easily thrown up the bowel or concentrated upon a particular point. To do this, a forehead mirror is requisite. The lamp which I have found most convenient is a modification of Tobold's, as 1 1 FIQ. 17. Case for rectal instruments, with sliding cover A A. represented in Fig. 16. The whole apparatus is easily moved to any part of the room, and is not cumbersome; and with the lens a very powerful illumination is always attainable. The instruments necessary are specula of various forms, bougies, a Davidson's syringe, ointment, cotton, sponge-holders, towels, basins, etc. ; and these should all be placed within easy reach of the hand. A con- venient 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 repre- sented in Fig. 17. The position in which the patient should be placed is a matter of some importance. For mere inspection of the anus and surrounding parts, the dorsal decubitus answers every purpose, and a digital exam- ination of the rectum may be made either in this posture or with the patient on the side. For a speculum examination or the passage of a t.KNKRAL BULE8 REGARDING EXAMINATION, DIAGNOSIS, ETC. 53 bougie, the patient should be placed on the side, with the buttocks well t-le vat '-d, the thigh which is uppermost strongly flexed on the abdomen, and the breast resting on the table. In this way, the weight of the abdominal contents falls upon the front wall of the abdomen, and, not upon the IK-MS, and the lumen of theoowel is not so firmly closed, nor .0 mucous membrane so firmly forced into the end of the speculum. Before commencing an examination, the bowel should be emptied, either by the natural effort of the patient or by an enema, and for this reason a water-closet in connection with the examining room is indis- pensable to the practitioner in rectal disease. In this way, the patient may come directly from the closet to the table with the parts in the best condition for inspection; and great additional confidence is acquired, specially ly women, that the examiner's frequent reiteration to "bear down '' will not be followed by untoward consequences. The point may seem trivial, but the fear of an accident will frequently, in women, result in a firmly closed sphincter, which no word of the surgeon can :vome, and a thorough examination cannot be made while the recta- l>ouch is filled with faeces. This is not merely a thing to be observed for the cleanliness of the examiner, for the act of defecation will bring internal hasmorrhoids and prolapse to the light, and may greatly assist in the diagnosis of other maladies. In examination with a speculum, it is indispensable to cleanliness. A simple inspection of the anus and adjacent skin and mucous mem- brane is often sufficient for a diagnosis, though it should never be trusted to alone. External haemorrhoids and internal ones when brought down by tlie use bf the closet or enema, external fistulas, ulceration, skin dis- -. many v.-nereal affections, pin worms, abscess, and fissure, may all re-cognized 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 ;t', and a retraeteil anus surrounded by a profusion of soft, fine hair, may also properly excite a suspicion either of grave rectal disease or of onstitutional affection which is causing emaciation. By using gentle force in pulling the anus open with the fingers, the mucous membrane may be everted to a considerable degree, especially if the patient can be brought to assist by an effort at bearing down. In this way a fissure may almost always be brought into view without the DM of a speculum of any sort, and the internal opening of the great majority of fistula- maybe reached, with a good view of the radiated folds and lacuna.-. Dr. Storer,' of Boston, has described a method of examining the 1 Lano t. May Mat, 54 DISEASES OF THE RECTUM AND ANUS. mucous membrane just within the anus, which is applicable only in women who have a lax sphincter. It consists in everting the mucous membrane by pressing it out of the anus by the index finger in the vagina. In a case in which the manoeuvre can be practised successfully and without too much pain, a small portion of the anterior wall of the rectum may be brought into view. The pessary of Gariel has also been used for the same purpose. It consists of a rubber ball, which is intro- duced empty into the rectal pouch, then inflated by means of a tube attached to it, and withdrawn with some force, the mucous membrane being prolapsed in front of it. But neither of these two procedures is of any great value. After having examined the anus in this way, the surgeon next pro- ceeds to the more difficult task of examining the rectum, an operation which may be done skilfully and almost painlessly, or awkwardly and with great suffering. The rectum may be explored either by the touch alone, or by vision alone, or by both combined. The former is the simpler and more painless method, and with practice may be made to afford all the information which can be gained by the two combined. To practise the rectal touch, the nail of the index finger should be well trimmed, and the finger lubricated with some tenacious oil. Olive oil is much better than vaseline, the latter being too easily rubbed off by the sphincter. The condition of the spincter 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 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 A lie use of ether, t/n 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 remain- ing fingers backward along the inter-gluteal 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. In this way three or three and a half inches of the rectum 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 vesiculae seminales and vasa deferentia. In other words, all that part of the bowel which is most subject to disease is brought within reach. i.KNKUAI. IK I.I-.- i:l.(r.vKDKN(r KXA MIX A 1 ION, DIAGNOSIS, ETC. 55 But after this is done the examiner may be no wiser than before, for \<> appreciate fully the condition of the rectum by the sense of touch alone requires a facility hi this method of exploration which most practitioners m-v.-r attain. In the majority of cases a digital examination will be made t-> dlSOOTer whether or not the patient is suffering from internal haemor- rhoids, and in the majority of cases also the examiner will be no wiser on this point after than before, for a soft internal haemorrhoid is a difficult thing to detect by the linger alone, being readily mistaken for the natural mucous membrane of the part, especially when the latter is abundant and gathered into folds, as it is apt to be. Ul iv rat ion 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 neces- sary by oft repeated examinations, to become perfectly familiar with the feel of the normal bowel. After this knowledge has been gained, a gentle sweeping of the ball of the finger over the whole inner surface of the G. TIEMANN & CO . Fio. 18. lower three inches of the rectum will detect any cnange in it, however slight. I wish it were possible to describe plainly the different sensations which are conveyed by the different pathological 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 examination, 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 followed 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 mi-t. with, and mo-; easily diagnosticated when encountered. The cervix or fundus of the nt-Tin. when pressing upon the bowel, may be distinctly felt with the linger in the rectum, and may deceive the unwary into a diagnosis of a new growth. The prostate may do the same. The differ- ent varieties of ulcerat ion have i-aeh 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. These are of all forms, sizes, and 56 DISEASES OF THE RECTUM AND ANUS. materials, and, in general words, the softer the instrument the better it is for examination. I much prefer the black rubber instrument, with the blunt point (Fig. 18), which may readily be bent into a circle in the hand, to all others in the market, and the same instrument comes with a sharp point (Fig. 19) which sometimes answers a good purpose. These G.TJEMANN. &CO. FIG. 19. instruments are made in twelve different sizes, and for the purpose of diagnosis the medium-sized is the best. The old-fashioned red, hard- rubber bougie is unnecessarily stiff and dangerous, and should be dis- carded, having no advantages over the softer ones either for the purpose of diagnosis or for that of treatment. The bougie a boule, made of hard- rubber with a flexible whalebone handle, is a favorite instrument with many. (Fig. 20.) FIG. For my own use I have had a kind of bougie made by Messrs. Stohl- mann, Pfarre & Co., which I prefer to all others, for the simple reason that it is softer and more flexible than any in the market. It is made of the same material as the red soft-rubber catheters, and differs from them only in size and in the thickness of its walls. With such an instrument one is pretty certain not to perforate the bowel, and for diagnosis it answers every purpose as well as the harder instruments. The better fitted a bougie is for pushing its way through a stricture the worse it is for rectal exploration. 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 GENERAL HULKS KkG ARDING EXAMINATION, DIAGNOSIS, ETC. 57 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 rectum, no matter what maneuvering 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 mure difficult operation than to pass one into the urethra, the triangular liniment in the latter being replaced by the curves, the folds of mucous nirinhrane, and the promontory of the sacrum in the former. Indepen- dent 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 rec- tum may often exist; and into the sulcus formed by this condition the point of the bougie may easily pass. For the sake of overcoming -e folds of membrane the most minute directions have been given as to how the bougie should be introduced and gently urged along each suc- cessive inch of the bowel 1 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 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 allow- able here more than in the similar operation on the urethra; and when an obstruction is met with the handle should be gently rotated, with- drawn, and again passed onward till by frequent repetitions of this manoeuvre it is made to pass. If this does not suffice, a Davidson's svringe 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 pass with ease. For measuring the extent of a stricture, an ingenious instrument has been devised by Laugier, which consists in attaching a thin rubber glove- tiiiL r < T to the end of a perforated bougie. This is passed up the bowel empty, and then in Hated and withdrawn till it reaches the upper limit of the obstruction. It is safer than the bougie a boule, for it may be allowed to collapse before being withdrawn, and all straining of the diseased tis- sues may thus be avoided. In case disease actually exists higli up in the bowel, the attempt to pass an instrument is full of danger. A patient may easily recover from a false passage made in the urethra, hut such will seldom be the case with the rectum, for hero when the instrument, leaves the bowel it enters the tirntmirum. To understand this danger it is only necessary to remem- tliat the bowel is generally ulcerated both above and below the seat 1 Houston: " Dublin Hosp. Reports," vol. v., 1830. 'Die Krankheiten des Mastdarmes und des Afters, Pitha und Billrotli's Chirurgie. 58 DISEASES OF THE KECTUM AND ANUS. of the contraction, and is sometimes weakened to such an extent 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 with- out 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 stric- ture high up ? I should hesitate long before doing so, and should make many careful attempts to pass the instrument at different times, resorting to injection if necessary, carefully exploring through the abdominal wall for induration, and watching for the usual signs of obstruction. There are one or two points worthy of remembrance in this connection. 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 firmly grasped, and the resistance to its with- drawal is equal to that encountered in introducing it farther. The feel- FIG. 21. (Van Buren). ing conveyed 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. Should it still be necessary for diagnosis, the speculum may be used and the inside of the rectum illuminated. I have postponed any refer- ence to this means of examination till the present, because it will gener- ally be found useful only after the others have been tried. The thorough use of the speculum involves, almost of necessity, the administration of ether and the stretching of the sphincter muscles; to try to use it with- out these adjuncts is almost to inflict useless pain upon the patient. I shall not attempt any description of the infinite number of instruments which have been invented for this purpose, or any judgment upon their relative advantages, but will merely say that the best vaginal speculum is still the best for the rectum that of Sims, with a groove where the blade joins the handle for the sphincter to rest in as suggested by Van Buren, Fig. 21. The fenestrated instrument, Fig. 22, is sometimes useful for inspecting the parts just within the anus; and a long vaginal cylindrical c.KNI :i:.\l. KL'LES REGARDING EXAMINATION, DIAGNOSIS, ETC. 59 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 .-mall portion of the inner surface of the bowel high up. But, after all been trk-il. none will be found better for any purpose than a small- FIG. -ii. bladed Sims's, and without ether all will be found eminently unsatisfac- tory. Almost the only other speculum besides Sims's which I have found of any practical value is the bivalve shown in Fig. 23, but the same objec- Fio. 83. tion applies to this as to all the others, that the redundant mucous mem- brane prolapses between the blades to such an extent as to render it almost useless, and that when the attempt is made to dilate the blades sufficiently to overcome this, the sphincter is immediately stretched to a painful extent. With any speculum the wooden depressor, shown in Fig. 24, may be found a useful addition. Fin. 84. Rectal Depressor (Van Buren). The idea of the endoscope has been applied to the rectum in the use of tl|p instrument shown in Fig. 25. It is of little, if any. practical value, 60 DISEASES OF THE RECTUM AND ANUS. however; its introduction beyond the point which can be reached by a long vaginal speculum being exceedingly difficult, and, in case of the dis- eases which it is supposed to enable the surgeon to see, not devoid of danger; and the mirror quite useless. It is almost useless to attempt to see within the rectum with any kind of a speculum without first overcoming the sphincter muscle, and the only effectual way of doing this is by stretching it. It is, therefore, my own practice to resort to this procedure in every case of doubtful character, nor was- 1 led to this practice without many trials of the various speculae in the market, all ending in disappointment. The stretching of the sphincter is in itself an entirely harmless proceeding, but one which neces- sitates the previous administration 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 sud- denly separating them till they touched the tuberosities on each side. In this way, the mucous membrane is often lacerated at one or more points, FIG. 25. Colonoscope of Bodenhamer. 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 funnel and gradually bore into the anus ; or to introduce two fingers, and make pressure on all sides of the opening till it becomes patulous. Instead of one or two seconds, this procedure should occupy five minutes, and should be done so gently as not to lacer- ate the mucous memb'rane. The dilatation should also be 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 temporary, and I have never 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 soreness in the part, but are never incapacitated for their usual duties. This stretching of the sphincters is a necessary preliminary in almost all operations within the rectum. "With the patient in the proper position on the side, under the influence rK.VERAL RULES REGARDING EXAMINATION, DIAGNOSIS, ETC. 61 of other, \viili the sphincter thoroughly dilated, and with a good reflected light, the lower four or five inches of the rectum may be thoroughly illuminated and examined. A couple of inches more may be seen by the ihe cylindrical speculum, with the patient standing and bending for- ward over the table, and assisting the examiner by straining down ; and in this way a stricture may sometimes be brought into view which could not be seen with the Sims's speculum alone. As a rule, however, a speculum will be found of very little use in the examination of stricture, but is chiefly available for obtaining a good view of other morbid processes affecting the rectal pouch and for making applications to them or performing operations for their cure. By its aid the different varieties of ulceration may be inspected and thus dif- ferentiated, the internal openings of fistulas may be located, and the whole rectal pouch may be brought into view. From what has been said it may readily be seen that the diagnosis of stricture above the reach of touch or vision is a difficult matter. So dif- ficult is it in some cases that no less an authority 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 profit- able business. In reality stricture above the rectal pouch is rare; when they exist they are usually malignant, for this part of the bowel is not subject to the influences which, by exciting 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 abdominal 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. 1 A hand which measures seven and a half inches in circumference can gen- erally be passed easily ; one measuring more than nine is unfit for the purpose. With a small hand there is no danger of permanent incontin- ence of fseces, but the sphincter should be dilated gently and gradually, rather than forcibly torn open. When the amis has been sufficiently dilated to allow the hand to enter 1 G. Simon, Ueber tin- kiinatliche Erweiterung des Anus und Rectum. Arch. f. klin. Chir., xv., 1, 1872; Dtsch. Klin. f. Chir.. Nov., 1882; W. J. Walsham, Some Remarks on tlif Introduction of the Whole Hand into the Rectum, St. Bartholomew's Hosp. Rep., vol. xii., 1876, p. 223. 62 DISEASES OF THE RECTUM AND ANUS. 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 more easily upon the female, 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 attended 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 comon 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 sometimes be discovered after all other methods of examination have failed ; but, as we have shown, the method is not always applicable, and the diagnosis of stric- ture 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 con- firmed sooner or later by the well-marked symptoms of intestinal ob- struction. Before attempting any 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 con- dition 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 on the morning of the day of the operation. After this the bowels may easily be confined for a week if desirable without inconvenience to the patient, and the passage of hard- masses of faeces over a wounded surface is avoided. GENERAL RULES REGARDING K\ A Ml NATION, DIAGNOSIS, ETC. 63 In all operations in which ether is used, three assistants will be neces- sary ami f. 7 _".. 70 DISEASES OF THE RECTUM AND ANUS. of the vagina in women; or the confession of intercourse with a diseased person, in men. The treatment of proctitis consists first of all in an endeavor to discover and remove the cause of the congestion, be it what it may. In the acute stage, the pain and tenesmus may be overcome by warm baths, and anodyne injections of starch-water with a few drops of laudanum. The bowels should be kept open by laxatives such as castor oil or pref erably.the saline cathartics in small doses. The patient should also be confined to the bed, and placed upon a diet chiefly of milk. In the chronic stage, astrin- gents are indicated; such as alum and tannin, and to these may be added suppositories of iodoform (gr. v.), and the same rules with regard to rest and diet should be observed. A1JCKSS A.M> FISTl'LA. 71 OHAPTEE V. ABSCESS AND FISTULA. Abscess divided into Superficial and Deep. Superficial Abscesses. Simple Fu- runcles; Causes; Characters; Results; Treatment. Suppuration of External Hsemorrhoid. Suppuration of Internal Haemorrhoid. Diffuse Inflammation of Subcutaneous Tissue, Causes; Symptoms; Treatment. Form of Incision. Deep Abscesses. Divided into Abscess of the Ischio-Rectal Fossa and of the Superior Pelvi-Rectal Space. Causes; Symptoms; Diagnosis. Dangers of Deep Abscess. Formation of Deep and Extensive Fistulas. Horse-shoe Abscess. Idiopathic Gangrenous Cellulitis. Reasons why Abscesses do not Heal Spontaneously. Prognosis. Treatment. Incisions and Subsequent Treatment of Deep Abscesses. Incontinence of Faeces. Relief of In- continence resulting from Operation. Fistula. Generally due to Abscess. Divided into Superficial and Deep. Complete Fistula. External Fistula. Internal Fistula. Description of Superficial Fistulas. How to Detect an Internal Opening. Location of Internal Opening. Descrip- tion of Track of Fistula. Symptoms of Superficial Fistula. Deep Fis- tula. Fistula with Numerous External Openings. Blind Internal Fistula. Ulceration of Rectum Causing Internal Fistula. Treatment. Spontaneous Cure. Advisability of Operation. Fistula in Relation to Phthisis. Contra- indications to Operation. Treatment by Cauterization. The Ligature. The Elastic Ligature. Galvano-Cautery. How to Pass Ligature. Incision. Description of Operation. Author's Knife for Fistula. Division of Deep Tracks. Treatment of Track running up the Bowel. Treatment of Blind External Variety; of Horse-shoe Variety; of Fistula with Numerous Exter- nal Openings. Dressing after Incision. Packing the Incision. Haemorrhage in Operation. Treatment of Blind Internal Variety. Incurable Fistulae. Treatment of Deep and Extensive Tracks. Fistula with Stricture. ABSCESSES in the region of the anus and rectum are best classified according to their anatomical location into superficial and deep. Of each of these there are several different varieties. Considering first the superficial variety, the simplest form will be found to be that which involves the skin of the margin of the anus alone, and which generally originates in one of the minute glands of the part. Such an abscess or furuncle, for it is really only a furuncle, may be due to traumatism, or to any irritation, such as the Us-o of improper paper after defecation, prolonged walking or horse-back riding, a menstrual dis- charge, or a discharge due to diarrhoea or dysentery. This form of disease is always distinctly circumscribed, is generally 72 DISEASES OF THE RECTUM AND AJSUS. about the size of an almond, is found by preference in robust persons r more often in men than in women , seldom in old people, and almost never in children. It generally goes on rapidly to suppuration, breaks spontaneously on the cutaneous surf ace,, and heals without the formation of fistula, though in cachectic or phthisical patients it may pursue a contrary course, the skin over it becoming thin and violet colored, and finally rupturing, leaving a permanent subcutaneous fistula. The treatment of such an abscess consists chiefly in the attempt to avoid the formation of a fistula, and the best means for accomplishing this end is an early incision as soon as suppuration appears inevitable. Eesolution is hardly to be expected, but it may be sought for by the use of laxatives, rest in the horizontal posture, and the application of a blad- der of ice. The incision should be large enough to allow of the free exit of pus, and after it has been made, the part may be poulticed for a day or two, and the abscess cavity then dressed with lint, care being taken to keep the lips of the incision separated. Another frequent cause of superficial abscess is the acute inflamma- tion and suppuration of an external haemorrhoid, which generally comes on after an attack of constipation and straining at stool, or may be due to the same causes as the last. The suffering caused by such a condition, as by the one last described, is out of all proportion to its apparent im- portance, and is sufficient to incapacitate a person of sensitive organi- zation from all accustomed duties. The remains of former external haemorrhoids are always liable to this accident, and by the proper abor- tive treatment, the inflammation may sometimes be overcome without suppuration. If, however, suppuration appears to be inevitable, a small sharp-pointed bistoury should be quickly passed through the little tumor. There is also a form of superficial abscess which lies nearer to the mucous membrane than the skin, and is due to the acute inflammation of an internal haemorrhoid, either just at the verge of the anus or within the sphincter. This is in reality a circumscribed phlebitis in a venous- pouch which is shut off from the general circulation. A circumscribed, tense, exquisitely painfultumor is formed, varying in size from a grape to an almond, which, after a few days of suffering, ruptures spontane- ously, and allows the escape of a small quantity of pus. Such an abscess, when within the bowel, is always liable, as will be shown later, to result in the formation of a blind internal fistula if left to its own course, and should, therefore, be treated by early incision. There is still another variety of superficial abscess, more serious in its consequences than those already described, for the reason that it affects the subcutaneous tissue and not the skin, and is diffuse and not circumscribed. The causes of this variety of abscess are the same as of those already mentioned, though traumatism plays, perhaps, a more important role. Falls, kicks, horse-back exercise, and violence in the ABSCESS AND FISTULA. 73 use of the syringe are its most frequent antecedents. Surgical inter- ference with the rectum, as in the removal of a haemorrhoid, may also be followed by this form of abscess, and it may arise from the perforation of the wall of the bowel just above the sphincter, by an ulceration of any kind, generally, however, that due to a foreign body. It has also been known to follow the suppuration of an internal haemorrhoid. The symptoms of this form of disease vary greatly in different cases. In cachectic persons, pus may form in large quantity, and break into the bowel without the knowledge of the patient, and a blind internal fistula may result. The diagnosis is generally easy. There will be the usual pain, tenderness, and swelling; and if the pain bo not too severe to admit of the attempt, fluctuation may be obtained by introducing one finger into the rectum, and making counter-pressure with the other hand outside. There is little use in hoping for resolution in an abscess of this kind, and all active attempts to cause it will be found to do harm, rather than good. The proper treatment is an early free incision. If the incision be made early, it may in itself have an abortive action, and under such circumstances it need not be very large. If pus has already formed, or the skin has begun to grow thin over the abscess cavity, the incision should be free enough to allow of the easy escape of the contents, for in this way only can the formation of a fistula be avoided. In such a case, drainage should be resorted to after the incision, and every effort should be made to secure healing from the bottom of the cavity. When the incision is made in the early stage of such a tumor as this, while the skin is yet hard and infiltrated, a free haemorrhage from cutaneous vessels is not uncommon, nor on account of its antiphlogistic action is it to be deprecated. Only when it has passed the bounds of safety need any steps be taken to arrest it, and this may always bo done by a careful stuffing of the incision with picked lint. A word of caution against opening such abscesses as these in the surgeon's office, and allow- ing the patient to walk home, may not be out of place; for a small artery may commence spurting at any moment during the active exercise. Deep Abscess. The deep abscesses of this region differ greatly from those already described, in their location, extent, and gravity. They may with advantage be divided into those of the ischio-rectal fossa and those of the superior pelvi-rectal space. 1 An abscess of the ischio-rectal fossa is generally bounded by the levator ani muscle superiorly, and by the skin below, with the rectum on one side, and the adjacent portion of the pelvis on the other. An aliscessof the superior pelvi-rectal space, on the other hand, originates in the lax connective tissue around the upper portion of the rectum above the levator ani muscle. It may assume vast proportions, blending 1 Richct: Traite d'Anat. Med. Chir. 74 . DISEASES OF THE BECTUM AND ANUS. laterally with the subperitoneal connective tissue of the iliac fossa, and burrowing in almost any direction in the true pelvis. The causes of deep rectal abscesses are various. Traumatism is per- haps the most frequent, and the injury is generally internal, rather than external, and is caused by the point of a syringe or a foreign body, rather than by kicks and falls. Foreign bodies, such as fish-bones, may pass entirely through the rectal wall, and be found loose in the cavity of the abscess they have caused. Such an abscess may also be due to the injury inflicted by the foetal head in parturition, and in such a case, the diagnosis may be difficult to make from a puerperal inflammation, due to blood poisoning and involvement of the lymphatics. They may also be secondary to diseases of the urinary organs, such as acute inflamma- tion of the prostate, or a rupture of the urethra, and extravasation of urine; and they may result from rupture, ulceration, or perforation of the rectal wall, in connection with stricture. This explains partly, though not completely, the frequent coexistence of stricture and numerous fistulae; for a stricture may act as the exciting cause of a deep abscess by the impairment of vitality and nutrition which it causes, as well as by producing a perforating ulcer above, as is proven by the fact that a great many fistulse have their internal openings below, and not above the constriction. Again, these abscesses may be due to a submucous inflammation, and production of pus, which first breaks into the rectum, and forms an internal fistula, and subsequently extends outwards, forming a large abscess; or they may be due to an acute phlebitis, or to faulty nutrition and a generally vitiated state. Finally, they may be in their origin entirely disconnected with the rectum, and due to disease of some neighboring part, or to necrosis of some adjacent bone of the pelvis or spine. Symptoms. In an abscess of the superior pelvi-rectal space the symp- toms are often obscure and far from characteristic. There is more or less vague pain in the pelvis and lumbar region, which is seldom intense and is generally increased in defecation. Fever may be entirely absent, is sel- dom continuous, and chills are only occasionally met with when pus is formed. In addition there is more or less headache and general malaise. An abscess of the ischio-rectal fossa may at its commencement be ac- companied by the same symptoms, but, later, the skin becomes hard, red, and oedematous sometimes over a large portion of the corresponding but- tock, the pain is very severe, and rectal touch impossible. The general symptoms are those of any acute inflammation. In abscess of the superior pelvi-rectal space, when the disease lias extended to the cellular tissue of the iliac fossa, immense collections of pus may form, and this may burrow in any direction. In men it generally follows the course of the bowel, in- volves secondarily the ischio-rectal fossa, and makes its way through the skin at some distance from the anus. In women it is more apt to pursue ABSCESS AND FISTULA. 75 a contrary direction and may appear on the surface in the region of the crest of the ilium or in the groin. An abscess of the ischio-rectal fossa may tend to discharge its contents upwards toward the superior perineal region, being less confined by fascia and muscle in this direction. In this way the prostate and urethra may be implicated, and the signs of re- tention of urine may be joined with those which point more directly to the rectum. The pus from such an abscess, in time, generally breaks on the cuta- neous surface and forms one or several permanent fistulous tracks. The pus from a pelvi-rectal abscess not infrequently makes its way into the rectum and is discharged with each act of defecation ; before the faeces when the opening is near the anus, after them when it is above the rectal pouch. It may, however, rupture into the vagina, bladder, uterus, or per- itoneum, but these internal openings are not the rule, but the exception, for the pus generally finds its way to the cutaneous surface, and fistulas result as with ischio-rectal abscesses. Either variety may cause fistu- lous tracks upwards into the true pelvis, downwards into the perineum, or outwards into the thigh. When the pus reaches the rectum it may bur- row for a considerable distance in the submucous connective tissue of the bowel, and separate the mucous membrane from its attachment before perforating it. In this way two large abscess cavities may be formed communicating with each other by a narrow orifice. What is now generally known as the horse-shoe abscess or fistula is due to the formation of an abscess in each fossa and the communication of the two behind the rectum through the substance of the sphincter muscle at its attachment to the coccyx. Such an abscess generally has one opening into the bowel and two on the cutaneous surface, though the latter may be single also. By manipulation the pus maybe made to cross from one fossa to the other imparting a characteristic sense of fluctuation. There is a form of gangrenous cellulitis which sometimes affects the ischio-rectal region. It is a rare disease, and is generally icliopathic. In it there is no pus formed, but the cellular tissue and the skin over it become necrosed and slough in large, black masses. The adjacent por- tion of the rectal wall may be involved and the rectum be laid open for a considerable extent. The disease is attended with fever and great pros- tration; the tendency to relapse and extension is marked, and the cavity left after separation of the slough closes very slowly. ' This form of dis- ease may be fatal. The reasons why abscesses in this region so seldom heal spontaneously are to be found in the anatomy of the part, and the fixedness or mobility of the walls of the abscess cavity. In the ischio-rectal variety the skin is 1 A Clinical Lecture on Idiopathic Gangrenous CellulitU :m>und the Rectum. Furneaux Jordan, Brit. Med. Jour., Jan. 18th, 1879. Also, Jackson, Brit. Med. Jour., Feb. 8th, 1879. 76 DISEASES OF THE RECTUM AND ANUS. hard, thickened and lardaceous; and from its rigidity cannot yield its position to allow of healing. The walls of the abscess higher up in the pelvi-rectal space, on the contrary, move with the varying fulness of the abdominal or pelvic organs with the incessant action of the levator ani, and with the fulness or vacuity of the abscess cavity, which depends on the intermittent discharge of pus through its small opening. Diagnosis. The diagnosis of these conditions should be made with great care, for on a correct appreciation of the extent of the disease will depend the prognosis and treatment; and this class of fistulae are not always proper cases for operation. A fistulous track communicating with a pelvi-rectal abscess may gene- rally be recognized by its length and by the amount of tissue between it and the bowel, which may easily be estimated with one finger in the rec- tum and a probe in the track. The probe does not approach the rectum, but either runs parallel with it, or recedes from it. The flow of pus from the opening is also apt to be intermittent and to occur at the time of defecation, being caused by the same muscular effort. Sometimes, when the cavity has not been recently emptied, a soft tumor may be felt by rectal touch, and pressure upon it may cause a flow of pus. With the pus bubbles of gas may also appear, but in a large abscess in the neighbor- hood of the bowel this is not a proof of an internal opening, but may be due merely to the proximity of the intestine. Prognosis. The prognosis is necessarily grave. In the beginning the patient is exposed to all the dangers of pyaemia, peritonitis, and phlebitis; and should the abscess go on to a favorable termination in an external opening, there is still the dread that it may at any time seek another opening toward the peritoneum with a fatal result. The imme- diate results being favorable, the ultimate ones may still be disastrous ; being those which always attend upon prolonged suppuration visceral complications, amyloid degeneration of the liver and kidneys, and tuber- cular deposits. In the comparatively small number of cases of pelvi-rec- tal abscess in which healing occurs, the patient still has to meet the results of extensive cicatricial contraction. These may be stricture on the one hand, or incontinence on the other; with the subacute inflammatory tendency which is always apt to attend upon a cicatrix at the anus and cause pain and uneasiness. In females especially, such a cicatrix may be the cause of grave trouble with the genito-urinary canal. Treatment. It may be considered as a rule to which there are few exceptions, that an acute inflammation in this region will go on to sup- puration; and hence that antiphlogistic measures adopted with a view to securing resolution are useless. Early incision is, therefore, the only rational treatment, and, where properly performed, this may result in cure without the formation of fistula. Allingham ' goes so far as to say 1 Op. cit , p. 16. AB8CE88 AND FISTULA. 77 that !>v this means he can almost guarantee that there shall be no fistula. The incision .-Inmlil radiate from the anus to avoid as far as possible the section of nerves; and should be free enough to secure the escape of pus, not only at the time, but while the abscess is healing. If there be bur- rowing in any direction, the incision should be prolonged to correspond; and the finger should be passed as far as possible into all parts of the cavity to break down all partitions. The wound should then be stuffed with lint wet with carbolized oil, and a drainage tube inserted. The secret of success will be found to lie in securing a free outlet for pus, and thus preventing burrowing. These abscesses should not be laid open into the rectum a point which is generally misunderstood in practice, because of the confounding of an abscess which which .may ultimately result in a fistula with fistula itself. The treatment is that of abscess, and not that of fistula, and is especially directed toward the prevention of fistula. Even should the abscess have already opened into the bowel, healing may still be secured by following this line of treatment, with suitable means for keeping the rectum empty, and a laying open of the lower end of the rectum may be avoided. After a fistula is fully formed and all attempts at closure have failed, the usual operation of dividing the track into the bowel may be necessary, but it should always be undertaken with the expectation of disastrous consequences to the retentive powers of the sphincters. Incontinence to a greater or less extent is almost sure to follow such a free division of both sphincters and of the bowel above them. Incontinence depends more upon division of the internal than of the external sphincter, and is more apt to follow a double division of the fibres than a single one. For this reason the surgeon should always en- deavor to leave a few fibres at least of the internal muscle in any opera- tion, and the incision should always be directly and not obliquely across the fibres of the muscle. It is also well to remember that incontinence is always more apt to result from division of the muscles in the female than in the male. Even when incontinence has resulted, the case may be capable of re- lief in this regard by an operation with the cautery, which will be described in speaking of prolapse. I have seen marked benefit in this sad condition result from this simple operation combined with the per- sistent use of a rectal bougie and such other measures as are calculated to increase the power of the sphincter, and I am much less inclined to despair of giving relief in these cases than formerly. In one case sent me by Dr. McCready, of New York, in which a considerable degree of incontinence resulted from an ischio-rectul abscess, this mode of treat- ment patiently followed for some months has almost entirely relieved the condition; so that where solid fteces at first escaped him there is now a 78 DISEASES OF THE RECTUM AXD ANUS. good degree of contractile power, and the patient is only troubled with an occasional discharge of the rectal mucus in small quantity. Fistula. A fistula which is not due to a perforation of the rectal wall from within is the result of a previous abscess, and, therefore, in enumerating the causes of abscess those of fistulae have also been given. Like the abscesses from which they arise, they may well be divided into superficial and deep; or into those of the anus, which are subcutaneous, and involve at the most only a few fibres of the external sphincter, and those of the rectum and pelvis, which open into the bowel at a higher point. Both the superficial and deep may also be divided into the com- plete, or those which open both on the skin and into the bowel; the ex- ternal, which open only on the skin, and the internal, which have an. opening only within the bowel (Fig. 27). Fia. 27. Varieties of fistula (Gosselin). A, anus; R, rectum; B, complete fistula; C. blind in- ternal fistula; D, blind external fistula. Superficial Fistula. On account of the special laxity of the sub mu- cous connective tissue in this region, already noticed, abscesses show little tendency to spontaneous closure, and fistula is the common result when left to their own course. In the subcutaneous fistula, the external orifice may be at some distance from the anus, or in the radiating folds. It may be so small as to escape the eye in a cursory examination, unless a drop of pus chance to be squeezed out of it by the pressure of the fingers in pulling open the parts; and when discovered, it may not admit the end of an ordinary probe. The surgeon should, therefore, always be provided with a probe of small size and of pure silver, which admits of being read- ily bent, for using in these examinations. The presence of more than one external orifice is rare in subcutaneous fistulae; and an internal opening will be found in the great majority of cases, if properly searched for. The only way to settle the question of the presence or absence of an internal opening in any doubtful case is by opening the anus with a speculum and injecting milk through the exter- nal orifice. In the vast majority of cases the milk will be found in the rectum, and the internal orifice will be found just within the external sphincter. ABSCESS AND FISTULA. tV 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 sub- stance. In some the internal opening will be found in the radiating folds entirely below the fibres of the sphincter, and in others it may be much higher up the bowel. 1 The internal orifice does not in all cases mark the superior limit of the fistulous track. This may run several inches up the bowel under the mucous membrane, when the internal orifice is just within the external sphincter (Figs. 28, 29). Fio. 28. Fio. 29. Fios. 28, 29. Fistula? with double tracks (Molliere). Fig. 28. AB, deep submuscular track resulting from an ischio-rectal abscess. AJ, submucous track running up and down the bowel. Fig. 29. DE, Subtegumentary and submucous fistula with internal and external opening. DF, deep submuscular track, having same internal, but separate external opening. The track of a fistula is sometimes straight, extending directly from one orifice to the other; in other cases a track, properly 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 either through 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 inflammation, 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 1 Kibes: Recherches sur la situation de 1'orifice interne de la fistule de 1'anus. Rev. Med., t. i., 1820. 80 DISEASES OF THE RECTUM AND ANUS. 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 gen- eral character of the case. The history of a slight abscess 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 history 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 foetid; sometimes containing faeces and gas. It is generally the stoppage of the dis- charge and the consequent 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 without causing the patient to seek relief. Deep FistulcB. Deep or submuscular fistulas differ greatly in their extent and gravity from those last described. In them the track is large and often double or branching, and the external opening may be far away from the anus. The whole perineum and gluteal region will some- times be found to be perforated by openings. In a case sent to me by Dr. E. "W. Taylor, of New York, I easily counted between twenty and thirty of these discharging points, and the whole perineum and sur- rounding region were hard, brawny, and infiltrated. The man, under the pressure of his sufferings probably, had become a confirmed opium eater and was in a deplorable plight. The track in some of these cases has been known to take a remarka- bly irregular course. Sir A. Cooper 1 mentions an autopsy where a fistula opened in the groin, followed the course of the spermatic cord, and ended in what seemed like an ordinary 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. Blind Internal Fistula. Fistulas 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 way. The abscess causing such a fistula may, however, be a small submucous one, and the symptoms will then be pain, spontaneous discharge of pus from the bowel, and subsequently 1 Lee. on Prin. and Prac. of Surg., with notes by Tyrell, t. ii., p. 326. ABSCESS AND FISTULA. 81 pain after defecation resembling that of a fissure. There is another, and perhaps more common class of internal list ul;e in which the opening is not the result uf tin- 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 investigations of Kibes, who believed that the internal orifice was always the first formed, but here he was undoubtedly in error. A circumscribed ulcer which shall perforate the mucous membrane and result in internal fistula may be due to several causes: to the inflam- mation of one of the lacuna? just above the sphincter from the lodgment within it of a particle of hard fseces; to rupture of an inflamed internal h:emorrhoid; to the application of strong acids to haemorrhoids; to oper- >us upon the rectum generally for haemorrhoids; and to the peculiar ulceration met with in tubercular patients, but not necessarily tubercular in its nature. Such a condition is a very painful one. The opening which may be lurire 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 ex- tensive 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. 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 some- times lined with healthy granulations, and that these may result in new tissue which shall close it; but this can never occur after the usual infiltrated tissue has once been formed, which is seen in all old cases. Allingham 1 relates several cases of spontaneous cure, and estimates the proportion in which it may occur as about one per cent. Setting aside these cases, we are at once brought to the question which will often be asked by the patient, and which the surgeon may not always be able to answer to his own satisfaction, whether or not it is always best, or even safe to try and cure a fistula. In certain cases of Bright's disease, cancer, cardiac and hepatic affections, etc., all sur- gical interference may be plainly contra-indicated; but the question is most apt to arise in connection with pulmonary affections. There can be little doubt that phthisical patients are especially predisposed to this affection, and the reason is probably in great measure a mechanical one, depending upon a loss of fat in the ischio-rectal fossa and a resulting 1 Op. cit.. i>. 24. 6" 82 DISEASES OF THE RECTUM AND ANUS. loss of support to the haemorrhoidal veins. From this there results a venous congestion and final dilatation or rupture of the vessels, which, with the cough and concussion, leads eventually to abscess. I believe it to be a safe rule to operate upon phthisical patients as upon others, being led by the idea that one exhausting disease 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. I have also yet to meet the first case which, under suitable and careful general and local treatment, refused to heal after the operation. There are several rules which should be carefully regarded in this class of cases, however. No cautious practitioner would think of operating either in a very advanced or a rapidly advancing lung trouble. Cough, when vio- lent and frequent, is also a decided centra-indication, interfering, as it does very certainly, with the healing of the wound. The following case will perhaps illustrate the line of treatment to be followed in a general way. CASE V. A theological student, aged twenty-eight, applied to me from a neighboring city for relief from a large subcutaneous abscess with an internal opening within the sphincter, and an external one at some dis- tance from the anus. The probe could easily be passed a considerable distance in every direction beneath the undermined skin. The discharge was very profuse. This condition had existed for several months; the patient was much reduced in weight, there was consolidation in the apex of one lung, with a history of phthisis and haemorrhages. The internal and external orifices were connected by an incision in- volving the external sphincter, and the abscess cavity was laid open for a distance of four inches along the perineum, and dressed with picked lint. After a fortnight's rest in his room, the patient being partially dressed most of the time, and spending his days on the lounge or easy chair rather than in bed, reparative action seemed to come to a stand- still, and with careful directions as to dressing the wound, I sent him off into the mountains. He reported at my office after an interval of three months spent in the woods, during which time he had frequently been on horse-back several hours at a time. The change in his general condition was very remarkable, he having gained nearly twenty pounds in weight. The abscess cavity was nearly, but not quite closed, and again he re- turned to the country, with the understanding that he should report in the city every fortnight. In just six months from the operation the wound was entirely healed, there had been no exacerbation in the lung troubles, and the patient was in better general condition than for years previous. In cases of fistula in phthisical patients, the sphincters should be AB8CB88 AND FISTULA. 83 interfered with as little a.* possible, as they are apt to be weak at the best The internal orifice is apt to be large and ragged, and the exter- nal may be the same. The tendency to undermine the skin is always marked, and the discharge is generally thin and watery. KISTIT.A. 89 fuse enough to cause the surgeon any uneasiness, and is almost always easily controlled by pocking the incision with lint, and making firm pres- sure with a compress held in place by a T-bandage. A free arterial ha-morrhage from a vessel well up the rectum may, however, be alarm- ing, and if not controlled by the admission of air or the application of ice to the part, the rectum must be tamponed. Fistula? of the blind internal variety can only be dealt with rationally by incision. A speculum should first be introduced and a silver director bent into the form of a hook passed into the orifice and brought down to the bottom of the track; with this as a guide the fistula may be opened into the bowel. The incision should always be continued through the sphincter and the anus, so that the wound may be properly dressed and drained; other- wise the operation will merely serve to convert a small internal opening into a larger one. An operation of this kind is always more apt to be followed by a concealed haemorrhage into the rectum than one fora com- plete fistula, and this should be guarded against by a careful plugging of the wound and by the application of dry persulphate of iron if necessary. The abscess in connection with a blind internal fistula may sometimes be detected by the induration which may be felt through the skin of the ischio-rectal fossa. In such a case, after the director has been passed into t he internal orifice, a counter-opening should be made into the abscess through the skin, using the director for a guide for the incision. In this way the blind internal variety is changed into the complete, and the usual operation of division into the bowel may be performed. After what lias been said of the origin and extent of abscesses of the superior pelvi-rectal space, it is evident that there may result from them a class of fistulae which are not to be operated upon by any of the methods we have described fistulae so deep and extensive as to centra-indicate all operative interference. And yet much may be done even in the worst cases of this kind, and by proper treatment some 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 comparatively 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 freely emptied. Through the drainage tube stimulating in- jections may be made, and the abscess treated as an abscess elsewhere would be, by rest and attention to the general health. A cure may some- timrs be effected in this way in a very unpromising case. Where the track has burrowed to great length, much may be accom- plished 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 ami tin- fun her extremity induced to heal while drainage is maintained from the middle opening by the use of injections or caustic applications. Should these means not succeed 90 DISEASES OF THE RECTUM AND ANUS. 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 divided with the ecraseur with good results. I have myself followed a track directly across the perineum and exposed the membranous urethra in the incision, dividing in the opera- tion the sphincters four different times. Such operations may sometimes be necessary to save life, but they maybe too great for the patient's powers of recuperation. 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 spontaneous closure, and if the stricture be nob relieved it will be of little avail to cut the fistula. Many awkward mistakes have happened to good surgeons by failing to detect this com- plication of diseases. HJ2MORRHOIDS. 91 CHAPTEEYI. HEMORRHOIDS. Definition. Division into External and Internal. Differences between the two Varieties. External Haemorrhoids. Pathology. Inflamed Haemorrhoids. Treatment. Means of Prevention. Palliative Treatment. Excision. In- ternal Haemorrhoids. Division into Capillary, Arterial, and Venous. Description of Capillary Variety, of Venous Variety, of Arterial Variety. Symptoms of Internal Haemorrhoids. Strangulation. Diagnosis. Treat- ment of Internal Haemorhoids. Palliative Treatment. Constitutional and Local Means of Palliation. Treatment of Strangulation. Curative Treat- ment. Haemorrhoids Associated with Uterine Disease. Symptomatic Haem- orrhoids. Radical Cure. Caustics. Dangers of Nitric Acid. Vienna Paste. Treatment by Carbolic Acid Injections; Cases and Cures. Advantages of this Treatment. Treatment by Ligature. Description of Operation. Operation with Clamp and Cautery. HEMORRHOIDS may be defined as varicosities of the anal or rectal Teasels. They may present themselves under various forms and condi- tions owing to changes in their substance; but the first step in their formation is always an enlargement and dilatation of the veins or arteries or both. Haemorrhoids, for convenience, may be divided into external and internal; and these may always be distinguished from each other, though both may exist at the same time in the same patient. An external haemorrhoid 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 internal haemorrhoid originates, on the other hand, within the rectum, 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 sphincter, and after long exposure outside the body it may become changed in character and appear- ance, 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. 92 DISEASES OF THE RECTUM AND ANUS. The distinction between an external and an internal haemorrhoid 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 impli- cated in each case. An external haemorrhoid is a varicosity of an external hgemorrhoidal vein, and is, therefore, an affection of the general venous circulation. An internal haemorrhoid is a varicosity of the middle or internal haemorrhoidal veins, which are parts of the visceral venous system. 'A glance at the venous anatomy of the rectum and anus (pages 14 and 15) will show the arrangement of these two sets of veins, and will also explain how, from the 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 hgemorrhoid belongs to one system or the other. For practical purposes, therefore, the first defini- tion is the better one an external haemorrhoid is one originating outside of the external sphincter, and an internal one is within that muscle. Other secondary differences which may arise from various causes in the development and location of the tumors will be considered later. External Hemorrhoids. A person of middle age who has not at some time suffered from an external haemorrhoid is indeed a great rarity, so common is this affection. In the majority 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 uni- versal 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. Out- side of these cases where a manifest cause exists, external haemorrhoids 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 and about equally. An external haemorrhoid may appear in two different forms which bear little resemblance to each other. The first is a small, round or elongated venous tumor; the second is a tag of hypertrophied skin, sometimes improperly spoken of as a condyloma. The second is formed from the first by changes soon to be described. The external haemorrhoid may arise in either of two ways, by the dilatation of a vein, or the rupture of a vein and the extravasation of blood into the adjacent tissue. The dilatation may not always be of the same character. In one case it may affect the whole calibre of the vessel, in another it may be in the form of a pouch springing out from one point in the circumference. A haemorrhoid resulting from the dilatation of a vessel is of gradual formation; but it sometimes happens, particularly after a violent straining at stool, that the patient will feel a peculiar H.KMOKRHOID8. 93 sensation at the anus, and an examination will reveal the presence of a tense, bluish, smooth tumor, the size of a pea or a grape, situated just at its verge. In this case, a previously dilated and weakened vein has suddenly given way, and the tumor is the result of the extravasation of blood. Such a bloody tumor as this will cause much pain and discomfort, preventing the patient from sitting down, or even from going round with any ease. It may be freely incised by transfixing its base with a small, sharp, curved bistoury and cutting outwards, the incision being in the direction of the radiating folds of the anus, and this operation is sure to give temporary relief, by allowing the escape of a small clot of blood and putting an end to the tension which is causing the suffering. If the surgeon undertake this method of treatment, there are one or two hints which may be of value. The incision itself is extremely pain- ful, and should therefore be done with a sharp knife of the form men- tioned; and it should be done instantaneously. Whatever deliberation is required, is better exercised before entering the knife. Again, care should be exercised to empty the clot entirely out of its bed, otherwise a small wound remains which will not readily heal, because the sac is pre- vented from contracting, and the patient is obliged to wear a bandage perhaps for a week or longer to keep from soiling the linen with a sani- ous 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 condition, as regards suffering, as before opera- tion. This is best avoided by placing a shred of lint in the cut. These, however, are untoward accidents which may attend an insignificant operation which usually gives relief to suffering, and allows the tumor to shrivel up and disappear except for a small tag of skin which may remain and form an external pile of the second variety. When left to its own course, a bloody tumor of this variety 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 cutaneous hsemorrhoid. Or the opposite course may be taken, and the tumor may show all the signs of an abscess, and finally rupture spontaneously with the discharge of a little blood and pus, 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 may be more or less febrile excitement; all of which will pass away the moment the tension is relieved. The treatment of such a case where the knife is not used will be described a little later. To return to the hsemorrhoid which is due to the varicose vein, but not to the extravasation of its contents. In such a case there may be one considerable dilatation which shall cause a smooth, round, bluish 94 DISEASES OF THE RECTUM AND ANUS. tumor the size of a pea or a grape ; or there may be a number of veins in- cluded in a new growth of connective tissue which shall constitute a dis- tinct, firm, haemorrhpidal tumor. For these dilated pouches are in them- selves causes of irritation, and are subject to irritation from without; and as a result an exudation takes place in their vicinity which finally ends in the production of new tissue. It is thus easily understood why on cutting into one external hsemorrhoid a single large clot will be ex- posed contained in a distinct sac; while in another, several smaller clots may be seen imbedded in the surface of the section, and why there is more or less connective tissue in the tumor. The formation of such a tumor is a gradual process due to the con- tinuous action of the primary cause and to subsequent irritation from with- out. It may go on with little pain and suffering, so little that the patient will hardly care to ask for relief ; and it may undergo a spontane- ous cure leaving in its place only an hypertrophied tag of skin. Gener- ally, however, during its course an attack of acute inflammation will be ex- cited at some time, and this is very apt to bring the sufferer into the hands of the surgeon. At such a time, if the inflammation has occurred in a fleshy pile the tag will be swollen, cedematous, and exquisitely sensitive. Suppuration may occur in it and a small marginal abscess and fistula be the result. Or, if the inflammation has attacked a sanguineous tumor, it will be found hard and swollen and painful to the touch. The patient will often say that he has tried to replace the little grape-like tumor with- in the bowel, but has been unable, though the pressure has caused it to disappear for the moment and has given a temporary relief. This is due to emptying the vein of its blood, but the blood returns the moment the pressure is removed. The pain is constant, often preventing sleep at night. The sufferer is unable to sit or stand and soon finds that he feels better in the recum- bent posture. A motion of the bowels is feared and therefore avoided as long as possible. When after two or three days of constipation the call can no longer be delayed, the pain is greatly increased. It is astonishing how much pain and constitutional disturbance such an apparently trivial thing may cause. Such as an attack in a sanguineous hgemorrhoid may terminate in three ways: by resolution, by induration, and by suppuration. In the former case the resolution may be complete especially when the inflam- mation has been of moderate intensity, and no trace of the tumor may re- main, or a cutaneous tag may be left to mark its former site. When the in- flammation assumes a chronic type, and the tumor becomes oadematous, and is still somewhat painful on pressure or during defecation, though not to such a degree as during the acute stage, the inflammation is said to have terminated in induration. Such a tumor is always liable on slight provocation to a fresh attack of inflammation. When suppuration HAEMORRHOIDS. 95 occurs, the tumor discharges its pus and then shrivels up and becomes a cutaneous tag. Treatment. The surgeon will seldom be called upon to treat a case of external haemorrhoids unless during an attack of acute inflammation; for at other times the annoyance caused by them is comparatively trivial. A cutaneous tag which is quiescent may as well be left undisturbed by the knife or scissors; for the removal of it will not infrequently cause an amount of suffering disproportionate to the benefit gained. The whole thought of the surgeon may then be turned first to the prevention and second to the relief of an attack of inflammation. The means of preven- tion are very simple and yet very effectual. They consist in the avoid- ance of excess in eating or drinking and in perfect regularity in defeca- tion; for inaperson affected with external haemorrhoids a single heavy meal at an unusual hour, an evening spent in smoking and drinking, or, worst of all, the neglect to have a motion of the bowels for a single day, will give rise to a sensation of heat, pressure, and itching about the anus, which warns him that trouble has commenced. Even under such circumstances the attack may be aborted by rest in the recumbent attitude, a light diet, abstinence from wine or liquor of any kind, and a laxative, preferably one of the mineral waters, repeated every night for three or four days. Should the attack go on and inflammation be actually excited, more active treatment will be required, and this may be either operative or medicinal. It is my own practice to try the latter first, and if it does not succeed, resort to the former. The medicinal treatment consists in keep- ing the sufferer on the bed or lounge, and applying a small bladder of pounded ice to the part. 1 This is generally very grateful to the patient and very effectual much more so than warm poultices or appli- cations of belladonna and opium; but should it not prove so, the latter may be tried. A good formula is equal parts of the extracts of bella- donna and opium smeared freely over the anus. In most cases the attack will subside after forty-eight hours of this treatment, and the use of a daily laxative; but should it not, a sanguinous tumor may be incised in the manner already described, and a cutaneous tag may be seized with a sharp forceps and quickly snipped off with the scissors. Ether is not generally necessary for this operation, which, though very painful, requires but a moment; and I have generally found that attempts at local anaesthesia with the ether spray were very delusive in this part of the body. If ether be employed at all, it is much better to take advantage of the primary anaesthesia produced by the first few inhal- ations, the patient holding the towel or bottle in his or her own hand. This is a favorite procedure of my own in this and many other opera- tions about the anus, and one which I cannot too strongly recommend. 1 Nothing is so convenient for this purpose or causes as little pain as the rubber baudruche. which may now b* procured at any druggist's. 96 DISEASES OF THE KECTUM AND ANUS. The only caution necessary in cutting off an external lisemorrhoid is to remove neither too much nor too little tissue. If too much be re- moved, the wound- will take a long time to heal, and if several tumors be removed, contraction to a disagreeable extent may follow; if too little, a tag of skin will still remain after cicatrization and shrinking, and, although this might be considered a matter of no importance in a male patient, I have seen ladies who did not so consider it. Internal Hcemorrhoids. External haemorrhoids were described as varicosities of the external hEemorrhoidal veins; and internal haemorrhoids may also be similarly defined as varicosities of the middle and superior haemorrhoidal veins, but they are more than this. An internal haamor- rhoid is often an arterial tumor, as well as a venous, and the arteries may be of large size. Occasionally one will be met as large as the radial. In describing these tumors, we shall follow the division laid down by Allingham into capillary, arterial, and venous. The capillary haemorrhoid is in reality an erectile tumor, composed of the terminal branches of the arteries and veins a'nd 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 naevus. They maybe situated high up in the rectum or low down by the sphincter; their surface is granular, and the membrane covering them is always of extreme thinness. This accounts for the chief symptom which distin- guishes them clinically from the other varieties the free arterial haemor- rhage 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 surface there is pretty sure to be a jet of arterial blood, comingper saltern. 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 " bleeding " most properly applies. In my own experience it is not as frequently met with as the varieties to be described later; and this prob- ably 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 capilla- ries become obliterated by the increase in the connective tissue, and the capillary tumor is succeeded by the arterial or the venous one. The one symptom of a capillary haemorrhoid 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 I HEMORRHOIDS. 97 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 disregarded, es- pecially in women who arc 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 constitutional symp- toms which may follow the daily loss of a considerable quantity of arterial 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 his case a single application of nitric acid to the bleeding surface worked a cure which has lasted for several years. The arterial hcemorrhoid. In this form of tumor the capillary net- work has disappeared and in its place is found a mass of freely anastomos- ing arteries and veins bound together by connective tissue. The arteries and the veins are tortuous, often varicose and dilated into sacs and pouches, and the arteries may be 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 firm to the touch and smooth; it is liable to inflammation, erosion, haemorrhage, and prolapse. The haemorrhage which occurs is arterial in character, and apt to be abundant. When the haemorrhoid has gained a sufficient size to become prolapsed in the act of defecation, the patient suffers the usual symptoms of the haemorrhoidal state. If the sphincter be not tight enough to strangulate the mass after it has come out of the body, the pain will not be very severe and the patient will return the tumor by a little gentle pressure and manipulation. The mini/* lunnurrhoid. This form of haemorrhoid may result from cither of those already named or it may arise de novo. It consists at first of a simple dilatation of the large veins beneath the mucous membrane of the rectum; later these veins undergo certain changes due to the hyper- trophy and induration of the mucous membrane and submucous connec- tive tissue, until finally a large, bluish, hard tumor is formed which is smooth to the touch, comes out of the body on defecation, and is covered by a mucous membrane which has assumed a partially cutaneous character from exposure. The three varieties of internal hemorrhoids thus described may all be present in the same person, and each be distinguishable from the other. In other cases the line of distinction may not Ibe so well marked. A venous lueniorrhoid mav contain a considerable number of arteries and 98 DISEASES OF THE RECTUM AXD ANUS. may bleed per saltern, and it is not certain that an arterial haemorrhoid is always a later stage of the capillary variety. But the three forms are well marked and-must be distinguished from each other in the matter of treatment. Symptoms. Usually the first symptom of internal haemorrhoids is the loss of blood during defecation to which reference has already been made. This may be present for a long time before any other symptom is no- ticed by the patient except perhaps an occasional feeling of discomfort in the rectum. Pain is absent until the tumor begins to descend within the grasp of the sphincter and appears at the anus at each act of defeca- tion. If the sphincter be firm and strong, the pain may be very severe and the tumor may become strangulated, but after the disease has existed for any great length of time, and especially in persons past middle life, there is apt to be aloss of power in the muscle which, though it facilitates prolapse, decreases the pain attendant upon it. In ordinary cases, the patient will reduce the tumors when they come down on defecation. They may, however, become 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 es- cape of blood from the over-distended vessels, the haemorrhoids may return of themselves 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 dis- charged. 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 haemorrhoid, even though it be far enough advanced to cause haemor- rhage 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-distended, 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 Van Buren's spec- ulum. Under these circumstances, it may generally be brought plainly into view. An examination in a case of internal haemorrhoids should never end at the finding of the tumor. An inch or so higher up there may be a stricture, malignant or simple, which has given no sign of its pres- ence except the haemorrhoids, and this is not a good thing to overtook. Treatment. The treatment of this most common and distressing malady may with advantage be considered under two different heads (a) palliative, (b) radical. (a) The palliative treatment of internal hcemorrhoids. In spite of H.KMORKHOID6. 99 all that the surgeon may say to his patient of the advantages of a radical cure, and the safety and facility with which it may be accomplished, he will still have many more chances in the way of palliation than will fall to him of using the knife. It is, therefore, of it advantage to know what can be done for a timid and reluctant sufferer without the knife; and, indeed, most patients may be made greatly more comfortable without any surgical interference whatever. The first thing to be done is to secure a daily natural evacuation of bowels, and this without medicine, if possible. The diet should be plain and abundant. Highly seasoned meats, gravies, salads, old cheese, etc., all alcoholic drinks, and anything approaching excess in tobacco, should be strictly interdicted. If the bowels do not act daily with this diet, and with regularity in the time of going to the closet, a laxative must be added, and this may be either in the form of a mineral water in the morning, or of a small dose of compound licorice powder at night. This powder may now be bought under that name at most drug stores. The formula is, however, appended for the convenience of any who may , ft Fol. sennse 2 parts. Had. liquiritiae 2 parts. Fruct. foeniculi pulv 1 part. Sulphurisdepurati 1 part. Sacch. pulv 6 parts. If the haemorrhoids are in the habit of coming down when the patient has a passage, he must accustom himself for a time to the use of a bed- pun, and to having his passages while in the horizontal position. This will be considered a very objectionable remedy by most; but it is one from which great benefit will be derived. The other treatment is local, and consists mainly in the use of nircnts and of cold. After each passage, the bowel should be injected with cold water. Even ice-water will do no harm. The quan- tity should not exceed four ounces, and if the case is one attended with bleeding, this will be found a most valuable means of combating that symptom. The number of astringents which have been recommended for under the circumstances we are now considering is very large. I shall content myself with naming one, the subsulphate of iron, which combines the advantages of all the others. This may bo applied in the form of an ointment ( 3 i. i.) to the haemorrhoids when prolapsed, or may be given in the form of a suppository (1 gr.) and allowed to remain in the rectum over night. It will In- found to act simply as an astringent, causing no pain, and destroying no tissue. By these means, when followed with care and patience, the worst case of haemorrhoids may be greatly improved, and wln.-n the sutleivr will not submit to curative treatment, or when, from any reason, opera- 100 DISEASES OF THE RECTUM AND ANUS. tive interference is contra-indicated, they should always be tried. Al- though they "are given simply as palliative measures, and should be considered as such, I have had some cases where, after a few weeks of this treatment, the patients believed themselves cured, and were, at all events, so far relieved as to disappear from observation. Treatment of strangulation. The practitioner may at any time be called upon to treat this complication of internal haemorrhoids, and the condition is an exceedingly painful one. He will generally find his patient in bed complaining that his piles are "down," and that he has been unable to replace them . The prolapse may have occurred at the time of defecation, or during a momentary mental excitement or physical effort. On examination, the anus will be seen to be surrounded with a mass of haemorrhoids which are swollen, congested, livid, and more or less cedematous, and any attempt to replace them will cause exquisite pain. This is an excellent opportunity for inducing the sufferer to submit to a radical operation, and should consent be gained, ether may be given, and the usual operation, by the ligature, be at once performed. The opera- tion, under these circumstances, does not seem to be contra-indicated, and I have never had occasion to regret performing it. But should an operation be refused, the mass must be reduced. The patient should be turned on the face, with a hard pillow under the pelvis to raise tho buttocks and allow of gravitation of the abdominal contents uway from the rectum. The mass should then be well smeared with olive oil, and a gentle effort made to reduce it by the taxis. This may sometimes be done by introducing one finger into the anus and exerting pressure with the others, gradually forcing the tumors, one by one, within the bowel; at other times, the mass may be replaced by a firm and continuous pressure, with the bulbs of all the fingers directly upon it, till the blood has been crowded back, and the diminished piles slip up together. Much gentleness is required for this manoeuvre, which is a very painful one under any circumstances, and one man may succeed where another would fail. At times, however, replacement by the taxis is impossible. Under such circumstances, it is a not uncommon practice to resort to leeches; and though I have never done it, I have seen it almost immediately suc- cessful with others; and the patient himself will assure you that, if the piles would only bleed, they could be easily reduced. It is better, however, to apply cold, and to leave the patient in bed on his face, with the buttocks raised. The cold should be in the form of an ice-bag, and this will almost certainly give relief to suffering, and sc. reduce the cedematous swelling as to render reduction possible on a second attempt. Should this also fail, there is nothing to do but to wait for the condition to subside under the use of cold and applications of belladonna and opium in the form of a soft ointment, with rest in the position named, and the administration of laxatives. After forty-eight hours of HEMORRHOIDS. 101 this treatment, the patient will generally succeed by himself in reducing the mass. (a.) Curative 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 haemorrhoids, as distinguished from those which are apparently idiopathic. Internal haemorrhoids may be symptomatic of disease in a number of the viscera. They often indicate structural changes in the wall of the ivctum itself 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 stricture, and not to the haemorrhoids. Again, they are often secondary to disease of the bladder, to enlarged prostate, or to stricture 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 disappear when these affections are cured. I was consulted not long since by a brother practitioner in regards to a very typical external sanguineous haemorrhoid the size of a large pea on the person of his four-year old child. The child had an adherent prepuce, and the pile was the result of the straining. The ordinary operation of circumcision cured the haemorrhoid. A man with enlarged prostate is never a very .hie subject for a surgical operation, and if such a man's haemor- rhoids can be rendered endurable by the palliative treatment already de- scribed, the better way will be not to use the knife. In women hsemorroids 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. The operator in rectal sur- gery may save himself much discredit, by postponing his operation for piles till his patient has been cured of a uterine misplacement or catarrh; for, as a rule, the co-existence of the latter diseases will prevent a favor- able issue to the operation. Either the wounds will not heal readily, or the haemorrhoids will speedily return. It will occasionally happen that a pregnant woman will suffer so severely from this complication as to de- mand surgical aid. Though it is better not to operate, except in a case where the haemorrhage or the pain render it unavoidable, still pregnancy is not an absolute barrier to surgical interference in this more than in many other affections. Haemorrhoids may also be symptomatic of disease of the liver, kidney, heart, or lungs. There are few liver affections which need prevent oper- ative interference in a bad case, but such interference should be preceded by general treatment pointing towards relief of tin- 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'oper- ation. Affections of the lungs, except in a very advanced stage, need DISEASES OF THE RECTUM AND ANUS. not prevent an operation. The condition which most positively stays the hand of the operator is that of albuminuria, whether dependent upon heart or kidney. Having decided to attempt a radical cure, the surgeon finds himself embarrassed with the number of operative procedures from which he may choose. It is safe to say that no one operation is the best in all cases, and I shall make no attempt even to enumerate all of those which have, at different times, been advocated, but shall describe several which are to be relied upon, and which, together, will cover every case. The Application of Caustics. Chief among the caustics used for this purpose are nitric acid, pure carbolic acid, and Vienna paste. The capil- lary hsemorrhoid may be cured by painting it once or twice with pure nitric or carbolic acid ; but large and old haemorrhoids are not curable by this means, though the haemorrhage from them may be stopped, and for a time they may cease to prolapse. When used upon a capillary .growth, a speculum must be introduced. If used in a case of large tumors, they must first be brought outside of the body, carefully dried, and then thoroughly covered with the acid, applied with a small stick. The end of a match makes an excellent brush. The tumors should then be well oiled and replaced. The application is not painful, unless the acid is applied to the wrong surface, viz., the skin. I have used this plan of treatment in many cases ; have seen an exhausting haemorrhage from a capillary tumor stopped forever by a single application, and have benefited old cases to an extent which con- vinced the patients they were radically cured in spite of my own skepti- cism; but it is never safe to promise anything more than temporary re- lief by this means. The capillary tumor is very likely to subsequently become the larger arterial one ; and the old and large haemorrhoid is more than likely to become prolapsed at some future date: so that I no longer use it in these latter cases when the patient will permit me to fol- low my own judgment. There is one danger in the application of a strong acid to an old pro- lapsing haemorrhoid, and that is, the occurrence of a profuse secondary haemorrhage when the slough separates. Such an accident is not com- mon, but it may be a fatal one, and it happens just often enough to worry the surgeon in every case in which he has employed this method in an old and debilitated subject. The Vienna paste is a much more powerful caustic than nitric acid, and its application to the surface of a hsemorrhoid is very painful. This and the amount of tissue destroyed by it are the two great objec- tions to its use. It has been employed to produce deep, linear, radiating cicatrices, each cicatrix running from the centre of the anus over the top of a prolapsed hasmorrhoid; and three or four such cauterizations will undoubtedly cure an ordinary case of piles; but the Paquelin cautery will HAEMORRHOIDS. 103 do it much better, and if the patient will submit to the latter, he will submit to something better still, and that is the ligature. '/'r>ntni>'>it ly Injection. The treatment of haemorrhoids by injection of certain substances, chief of which is carbolic acid, may now, I believe, be accepted as a surgical procedure of a certain definite value, and one worthy of a place among the recognized means of cure at our command. Originating as it did among the quacks, it has been looked upon with suspicion, and its adoption by the profession has been followed by the accidents which generally attend a new remedy before its applicability is fully understood; but this does not diminish its real value. The following four cases, selected from dispensary and private prac- tice in which this plan of treatment has been adopted, will illustrate some of its advantages and disadvantages. CASE VI. Male. Age, thirty-nine. This was an. ordinary case of prolapsing internal haemorrhoids of about six months' duration in an otherwise healthy man. The tumors were well developed, bled freely at each motion of the bowels, and were usually reduced by the patient with- out much difficulty. In the course of three months four injections of carbolic acid were made into four separate tumors. Only one of them was followed by any pain or soreness, and this not very marked in charac- ter; and after three months the man was discharged cured, there being no longer any bleeding or descent of the haemorrhoids at defecation. The man. who was a fireman, was at no time during the treatment un- able to attend to the active duties of the service. CASE VII. Male. Age, thirty-eight. In this patient anything like a cutting operation was out of the question. He had been a hard drinker for years, and was suffering from phthisis, cirrhosis of the liver, and albuminuria. The haemorrhoids were of long standing; the whole circle of mucous membrane prolapsed with them; and the sphincter had lost its contractile power. The man was under treatment three months, and during that time six injections of carbolic acid were made, and each one was followed by more or less pain and by sloughing of the haemorrhoid. The pain was not, however, so great as to counterbalance the relief the patient experienced from the cessation of the bleeding and the decrease in the protrusion, and the treatment was gladly persisted in by him, till in the end he considered himself as cured and ceased to attend. I have no doubt that in this case the sloughing of the tumor, which each time left a dirty sore after the introduction of the acid, was directly due to the patient's condition; but he was sustained with generous diet and suitable tonics, and, as I say, did very well much better than he would have done by any other plan of treatment which it was safe to try; and, but for it, I should have confined myself strictly to palliative measures. CASE VIII. Male. Age, fifty-two. General health excellent. Haem- orrhoids well-developed and prolapsing. Having had considerable experi- ence with this method of treatment by this time in dispensary practice, 104 DISEASES OF THE RECTUM AND ANUS. I ventured to try it in a private patient, and to promise an easy and painless cure. A single injection was therefore made, and for the first forty-eight hours there was little trouble; but at the end of that time I received a telegram from the gentleman that he was suffering great and constantly increasing pain he having left me on the day following the injection to return to his home in a neighboring city. I went to him and found, to my disgust, that the injection had in his case also caused a slough, and that he was suffering intense pain at each act of defecation. Suitable treatment with laxatives and anodyne suppositories was at once instituted, but his sufferings continued for many days, and he finally went off to the mountains where he remained till the ulceration had healed. Needless to say he refused to continue this " painless " method of cure, and I lost my patient and not a little reputation, the man being rich and influential. CASE IX. Male. Age, fifty-three. Also a private patient, and in. fair general condition, but with old and severe haemorrhoids and partial prolapse, and weakening of the sphincter. I was first called to see him in the night when he was suffering from strangulation of the entire mass, and a week later I began the use of the acid. This was fol- lowed very cautiously and with abundant intervals of rest after each injection, and in a very short time the relief was very apparent in the diminution of the size of the protrusion. There was no pain at any time during the treatment, and only a slight nipping sensation for an hour or so after each injection. In the end he was entirely cured, all haemor- rhage and protrusion of the tumors having ceased, though the anus was still surrounded by the redundant circle of half skin and half mucous membrane which remained from the former condition of prolapse. Here then was an old case of large prolapsing haemorrhoids in a pri- vate patient who would submit to nothing which he considered as surgical treatment, apparently cured without any pain, without any of the usual accessories of an operation, and without a single day's detention from his ordinary pursuits a result for which surgery has been waiting a long time. I say apparently cured, for the one doubt which remains in my own mind regarding this treatment is as to the permanency of the cure. This I have not as yet had time to test. I have seen nothing to make me doubt its .being permanent; and considering what Vidal has accom- plished with injections in cases of long-standing and extensive pro- lapse, I see no reason why it should not be permanent; but I have not as, yet had a chance to examine any of my own cases after an interval of years which is the only way of positively deciding the question. Beginning this plan of treatment, as I did, without very much confi- dence in it and with the fear of causing great pain and perhaps dangerous sloughing constantly before me, I can only say that the method is con- stantly growing in favor with me personally, and that the more I practise it the more confidence I gain in it. With solutions of the proper strength HAEMORRHOIDS. 105 the danger of causing sloughing of the tumors is very slight; and I am not at all sure in my own mind that once more surgery is not indebted to the quacks for a valuable discovery which may do much to modify the at present accepted plans of treatment of this disease. There are no objections to this method which do not apply equally to others. I have once seen considerable ulceration result from it in the hands of another, but I have seen an equal amount follow the application of the ligature; and I do not consider this as a danger greatly to be feared when injections of proper strength are introduced in the proper way. It is applicable to all cases; is especially adapted to bad cases; and may be used, as in the second case, where a cutting operation is inadmissible. It acts by setting up an amount of irritation within the tumor which results in an increase of connective tissue, a closure of the vascular loops, and a consequent hardening and decrease in the size of the haemorrhoid. Except when sloughing occurs, the tumors are not, therefore, removed, but are rendered inert so that they no longer either bleed or come down outside of the body. In cases in which the sphincter has become weak- ened by distention, the injections will also have a decided effect in con- tracting the anal orifice as do injections of ergot or strychnine in cases of prolapse. I have used this method of treatment now many times and, except in the third case reported here, have never had reason to regret using it, or to be dissatisfied with its results as far as I have been able to follow them. Although I should be very slow to advocate any one treatment of this affection to the exclusion of all others, I now often adopt this where Allingham's operation is declined by the patient, and as yet I have not known it to fail. Its advantages over all other methods, provided its re- sults prove equally satisfactory, are manifest to all. The patient is not terrified at the outset by the prospect of a surgical operation, is not con- fined to his bed, and is not subjected to any suffering. The cure goes on painlessly and almost without his consciousness. The method requires some practice and some skill in manipulation in getting a good view of the point to be injected and in making the injec- tion properly. In the first three cases reported, the solution employed was one part of pure carbolic acid to three of glycerin and three of water; in the last, the carbolic acid was decreased one-half and this is a better solution to use. The amount injected each time was about five drops. The instrument used was an ordinary -hypodermic syringe with a good 1 needle through which the solution would readily pass. When the tumor to be injected is prolapsed, the needle may be thrust into it without difficulty, and after the injection is made the tumor should be gently re- placed. If it be allowed to stay out of tin- anus for a few moments it will be seen to swell up and become black and hard with venous blood. There is seldom any haemorrhage from the operation, but occasionally a few drops of blood will follow the puncture. If the tumor is not protruded 106 DISEASES OF THE RECTUM AND ANUS. at the time of operation it may be seized with toothed forceps and drawn out and held while the injection is made. The injection should be landed as nearly as possible in the centre of the haemorrhoid, the needle being entered perpendicularly from the apex, and not passed upward under the mucous membrane in a longitudinal direction. If the acid be placed simply under the mucous membrane the latter will die and an ulcer result, but if placed more deeply the danger of an ulcer is much decreased. Used in this way and in the strength last indicated the acid will not be followed by any great amount of pain. Each injection should be followed by a day's rest in the horizontal position. No change need be made in the ordinary diet of the patient provided the bowels act regularly every day. Only one tumor should be injected at a time and I seldom repeat the injections oftener than once a week. It will sometimes be found necessary to inject the same tumor twice or three times when it is a large one. It will be observed that in the cases reported the length of time dur- ing which the patient was under treatment was in each case except the second about three months. I have no doubt that this could be much shortened, were it necessary; but where the patient is at no time confined to the house, time is of little consequence, and I seldom repeat the appli- cations oftener than once a week, preferring to see the full effect of each one before giving a second. Still, were there any reason for haste, I should not hesitate to shorten this interval, and I am led to believe that in the hands of the quacks the time is considerably shortened. I believe also that with them it is the custom to produce a sloughing of each tumor by the strength of the injection, and once or twice I have had patients come to me in this condition. But no such iise of the acid is necessary to effect a cure, and this result is one which I try very carefully to avoid. Treatment by Ligature. This is the method of treatment which has been brought to such perfection by Allingham, and which usually passes by his name. It consists in partially cutting through the haemorrhoid at its base, and tying the remainder. It is performed in the following manner. As in all operations on the rectum, the bowel should be thoroughly cleared by a cathartic on the previous day and by an enema just before operating. The patient may be placed either on the side or in the lith- otomy position; personally I prefer the latter. The sphincter should be carefully dilated, as already described, and this is a step of great practi- cal importance, as the securing of complete paralysis of the muscle will do more than anything else to prevent pain and spasm after the operation. In cases where the tumors were large and prolapsed readily, I have seen this step in the operation omitted as unnecessary by good surgeons; and I have seen a week of great suffering to the patient follow the omission. So important is this step in the operation for the relief of pain, that in II KMORHHOID8. 107 some cases in which the tumors, were so extensive and the sphincter so dilated that they could easily be 'removed without it, I have first cut off the haemorrhoids and then stretched the sphincter. It is rather a rever- sal of the regular order, but it illustrates the fact that stretching the mus- cle should not bo omitted. If the muscle is forcibly and suddenly torn apart by the operator, a fissure may result, and may require a subsequent operation for its cure after recovery from the original operation. The tumors being thus brought into full view by the introduction of a specu- lum, one is seized and drawn down with a toothed forceps. The selec- tion of a good forceps for this purpose is a matter of considerable import- ance. In my own operations, I use those figured below. The hold is firm and the handle sufficiently long for the hand of the assistant to bo out of the way of the operator in the subsequent steps. Fio. .Y>. Having secured a good firm hold on the tumor, the surgeon transfers the forceps to the left hand, and with a strong and long pair of straight scissors cuts the haemorrhoid away from its attachments for a certain dis- tance, beginning from below and cutting upwards. In this way the mass is entirely cut off except at its upper end, where the artery or arteries which feed it enter it from above. It is to prevent haemorrhage from these vessels that the ligature is applied instead of completely cutting off the mass; and this is done by the operator after transferring the forceps to the assistant. The ligature should bo of stout hemp, something stouter than ordi- nary ligature silk being necessary. The string should be tied very tightly, and after it is secured, the pile may be cut off to remove as much as possible of the dead tissue from the rectum. Each haemorrhoid is thus treated in succession, and after all are removed, a suppository of opium is introduced, and a T- ban dago tightly applied over a compress of lint and a napkin. The suppositories, which may bo repeated each night for two or three days, will serve to keep the bowels confined; and when the patient begins to experience a desire to go to stool, a laxative may be administered. There may or may not bo some pain when the bowels first move, and this will depend very much upon the thoroughness with which the alimentary canal has been emptied before the operation. I have seen as a result of neglecting this previous cathartic a female patient have to rid herself of a hardened mass of frecos of the size of an egg at the first motion of the bowels after the operation, and the suffering was simply 108 DISEASES OF THE RECTUM AND ANUS. atrocious. If there be a little blood with the first passage, it is a matter of no importance. The ligatures will generally come away about the end of the first week, and the patient should be kept in bed or on the lounge for a week longer. This in an active person Avill sometimes be difficult to manage; but no other course should be sanctioned by the surgeon, for the reason that when the ligature comes away, an ulcerated spot is left: and under certain circumstances, the most effective of which is active exercise, these little wounds may grow larger instead of smaller. In this way a case of internal haemorrhoids may be turned by an operation into one of ulcera- tion of the rectum, and the change is not to the advantage of the patient. One such case I have had in my own practice in a debilitated patient in poor general health; and a long course of careful treatment Avas necessary to effect an ultimate cure. Nothing has been said regarding primary or secondary haemorrhage, for the reason that it is not a complication to be looked for. When re- tention of urine occurs, as it often will, it must be met in the usual way. The diet for the first few days should be chiefly fluid. This operation, thanks to Mr. Allingham, is now so well and so favor- ably known, that but little need be said in addition. It is as safe as any operation in surgery, and by it the surgeon may promise his patient an absolute and permanent cure of his troubles in every case. This is saying a great deal, but not too much. It has been followed by fatal results but so has every other minor surgical operation ; and the chance of such a ter- mination is so slight that it need not enter into the calculation of the operator. Of all the operations for the cure of internal haemorrhoids it will be found the most satisfactory, the least liable to complications in its performance, and to unfortunate after-consequences. Once in my own practice after applying it to an old case of haemorrhoids with slight pro- lapse and almost completely surrounding the whole circumference of the anus with ligatures, I have been obliged to subsequently use a bougie to prevent a threatened contraction; but this I rather expected to be obliged to do at the time, and injurious contraction need not be feared in any ordinary case. I can confirm Mr. Allingham's statement that the opera- tion, when performed with a proper regard to minor details, is not fol- lowed by any considerable amount of suffering. I have had patients assure me that the first day following its performance was one of perfect comfort in fact of greater ease than any they had experienced for weeks previous. Operation with the clamp and cautery. This is generally known as Smith's operation, because he has advocated it so forcibly and practised it with such good results. He claims no credit for introducing it, however, this being due to Mr. Cusack, of Dublin, and his own originality has been chiefly spent in improving the clamp which is shown below. The operation consists in drawing down the tumor, embracing its M.KMOKKilOIl'-. 109 base in the clump, removing it with sharp scissors, and lastly applying the actual cautery freely to the cut surface. It is important to isolate the tumors well so as to compress them easily and completely, and in some cases where the haemorrhoid runs, as it were, abruptly into the hypertro- phied skin, Smith recommends the previous making of a slight groove with the scissors so that the compression of the neck of tumor may be the more effectual. The base should not be divided too close to the clamp lest there be not enough tissue left for the proper application of the hot iron. The latter is to be applied very thoroughly and slowly at a black heat; and the blades of the clamp may then be gradually released by the screw. Should any vessel not thoroughly cauterized bleed when the pressure is taken off, the clamp must be again screwed up and the cautery airain applied. It may be necessary to do this several times. This operation is claimed by Smith to be almost painless, provided the Fio. 36. cautery does not touch the skin and the clamp is fitted with the proper ivory protectors against the transmission of heat. Next to the operation by the ligature, it is the best of all the surgical procedures, but it is much better adapted to old cases of large prolapsing tumors than to those which are less developed, for the reason that there is more for the clamp to take hold of, and more left to cut off after the clamp is in position. I can hardly imagine h\v the operation can be painless, especially when a pre- vious cutting is done with the scissors, but I have not had a large experi- ence with it, and none at all without ether. With the iiu-aii.s ahvady enumerated every case of internal hemor- rhoids may be cured where a cure is desirable, or relieved when radical cure is out of the question, and I shall not, therefore, take the space necessary to describe the various others which either have been or are at present in favor; such as simple dilatation of the sphincters, the gal- vano-cautery wire, plunging the actual cautery into the substance of the hsemorrhoid, and cauterizing the skin of the anus in radiating lines to cause contraction. 110 DISEASES OF THE RECTUM AND ANUS. OHAPTEE VIE. PROLAPSE. Four Varieties. First Variety: Prolapse of the Mucous Membrane Alone. Second Variety: Prolapse of all the Coats of the Rectum. Third Variety: Prolapse of the Upper Part of the Rectum into the Lower, or Invagination. Fourth Variety: Invagination in the Continuity of the Bowel. Prolapse of the Mu- cous Membrane alone. Causes. Symptoms. Treatment: Palliative and Curative. Prolapse with Haemorrhoids. Treatment by Injections. Cauteri- zation. Description of Operation. Smith's Clamp. Dupuytren's Opera- tion. Prolapse of the Second Degree. Pathological Changes. Presence of Peritoneum. Strangulation. Dangers in Forcible Reduction. Fatal Case of Reduction. Advisability of Reducing Inflamed or Gangrenous Prolapse. Excision of Prolapse after the Formation of a Slough. Dangers of Operation of Excision in Extensive Prolapse. Operation by Elastic Ligature. Third and Fourth Varieties. Differences between Third and Fourth. Degrees of Invagination. Anatomical Appearances. Pathology. Relative Frequency. Symptoms. Physical Signs. Acute and Chronic Forms. Diagnosis. Differential Diagnosis from Volvulus; from Stricture; from Internal Hernia; from Obstruction by Pressure from without the Bowel; from Foreign Bodies; from Peritonitis with Perforation. Treatment. Replacement by Manipulation; by Injections. Treatment by Puncture. Laparotomy. De- scription of Operation. 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. 37. 2. Prolapse of all the coats of the rectum including, when the disease is of sufficient extent, the peritoneum. Fig. 38. 3. Prolapse of the upper part of the rectum into the lower or invagi- nation. Fig. 39. 4. Invagination in the Continuity of the Intestine. The same condi- tion as the third variety, only occurring in a part of the bowel furiher away from the rectum. 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 sub- mucous connective tissue. It is seen as an accompaniment of old cases 1'KoI.Al'SK. Ill of ha'inorrhoids, and its mechanism may be studied at anytime upon the horse in which it occurs naturally at the close of each act of defeca- tion. The second variety is an exaggeration of the first, in which, after the submucous connective tissue has yielded to its utmost, the whole thick- ness of the rectum begins to descend, and finally protrudes. It follows, of necessity, that after this protrusion has reached a certain length, the Fio. ST. First Variety of Prolapse (Molliore). Fio. 38. Second Variety of Prolapse ^Mullii- peritoneal coat must also descend outside of the bod\, and this condition is shown at a glance by reference to the plate. In both of these forms, the protrusion bc-ins tir-i at the part of the rectum nearest the anus. In the third form, the part of the rectum higher up is jiassid through that nearer the anus, and what is kno\vn as an invagination occurs. This condition must, of necessity, cause a sulcus or groove to exist between the containing and the contained portion; DISEASES OF THE RECTUM AND ANUS. 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 upon the point at which the invagination occurs; but in the variety under consideration, its bottom can generally be felt by intro- ducing the finger by the side of the protruding portion. In the fourth variety, this sulcus also exists, but its bottom cannot be felt, the point at which the inyagination has occurred being in the con- tinuity of the bowel, too far away from the anus. 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 sach 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 in- vagination, we shall consider each one in detail. Prolapse of the Mucous Membrane Alone. This is, perhaps, the most common of all the varieties of the disease when we take into considera- tion its frequent coexistence with haemorrhoids. It is found in children FIG. 39. Third Form of Prolapse (Bryant). most often between the years of two and four, and in adults it is more frequent in women than in men. Its causes are various. Among them may be enumerated the following: a. Those which tend mechanically to draw down the mucous membrane, such as haemorrhoids, polypus, vegetations, and tumors, b. Those which tend to weaken or to destroy the action of the sphincters, such as ulcerations or incisions, c. Those which cause muscular spasm, such as fissures, worms, dysentery, phy- mosis, cystitis, calculus, stricture of the urethra, and enlarged prosCate. d. Those which produce permanent dilatation and weakening of the sphincters, such as spinal paralysis, traumatism, chronic constipation, and sodomy. In this last connection, Molliere 1 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 1 Op. cit., p. 202. PROLAPSE. 113 sphincters may be attributed the frequent occurrence of prolapse in feeble and badly nourished children, e. Those which produce adema and swelling of the pelvic tissues, such as pregnancy, parturition, faecal accumulations, and hepatic lesions. In this connection also, Molliere 1 ill-tails an instructive experiment which may easily be repeated on the cadav.-r. He says: "On the cadaver of a young girl, I introduced under the mucous membrane of the anus a blow-pipe, and fastened it with a ligature. By practising insufflation, the air instantly spread in the sub-mucous 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 assure myself that only the mucous membrane had been raised up. It was then sufficient in this case to cause tumefaction of the sub- mucous 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 undeveloped sacrum in children, which, by its straightness, leaves the rectum comparatively unsupported. Symptoms. This first form of prolapse always comes on gradually and never suddenly. It may be partial or complete as regards the cir- cumference of the anus, being in some cases of haemorrhoids 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 toward the circumference. It is at first spontaneously reducible, or at least easily replaced by a slight pressure, and remains reduced till the next act of defecation; but as the amount of prolapsed membrane increases, the difficulty in reduction be- <-omes 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. Treatment. The first step in the treatment of prolapse of the rectum to which the surgeon will be called to attend will generally be to effect the reduction of the mass; after this has been accomplished, the treat- ment 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 ac- complished 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 re- 1 Op. cit., p. 199. 114 DISEASES OF THE RECTUM AND ANUS. duction 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 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 poultices 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 ac- complished. When by the action of the sphincter the prolapse has become gorged with blood and cedematous, 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 replaced. The palliative treatment is directed entirely toward diminishing the frequency and the amount of the prolapse, and in children 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 advantage; 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 ( 3 i. to f viii.) before it is returned. Another favorite wash is composed of the tincture of iron, xx. to xxx. 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. A rectal supporter may also be worn when the patient is up and about, and perhaps the best of these is the one made by Mathieu, and represented in the figure. After the bowel has ceased to come down with the act of defecation, an astringent injection may be given every night with advantage and allowed to remain in all night. The general health should be carefully attended to; tonics should be administered where they seem to be indi- cated; 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 spontane- ously at about the time of puberty; but in adults they are not at all likely to be so, and more radical measures will generally be necessary. Of these there are several which are effectual, and each of them has its supporters and advocates. PROLAPSE. 115 In cases of prolapse attending old internal haemorrhoids, the operation for the removal of the latter by the ligature may easily be extended so as to cure at the sumo time the former condition. And here a little careful discrimination may be necessary to distinguish between piles and pro- (1 mucous membrane. The piles are smooth, hard, and shiny tumors; the prolapse is soft and velvety to the feel, and generally surrounds the whole margin of the anus without being divided into dis- tinct tumors. In such a case, the proper course to pursue is to divide the prolapse into several sections with the scissors, and tie off each one exactly as though it were an internal haemorrhoid. I have several times performed this operation with the happiest results, both as to curing the piles and the prolapse; but caution must be exercised as to the amount of tissue removed, lest too great a degree of cicatricial contraction 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 car- Fio. 40. Rectal Supporter. bolic 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. At a meeting of the Therapeutical Society, December, 1879, reported in the Gaz. Hebdom., Jan. 2d, 1880, Dr. Ferrand related the case of a lady who had suffered three years from prolapse, the tumor being nearly the size of the fist, and descending even when she walked across the room, and causing great suffering. One gramme and twenty centi- grammes of a solution, composed of glycerin and water fia fifteen parts, ami alkaline hydrated extract of ergot two parts, was injected into the ischio-rectal fossa beside the prolapse. Considerable benefit resulted, and three other injections were practised at intervals of twenty days, ten aid a month, with the result of effecting a cure. The patient was seen after an interval of six months, and it was found that the prolapse \\as not reproduced even by such exertion as going up several flights of stairs. 116 DISEASES OP THE RECTUM AND ANUS. Vidal * also has recorded three successful cases of cure with ergotine.- The first was that of a man, aged thirty-nine, who had suffered for eight years. After five injections of fifteen drops of a solution of ergotine, at intervals of two days, the mucous membrane scarcely protruded at all. After the eleventh injection it only came down during defecation and returned spontaneously. The whole number of injections was twenty- two, and the man remained perfectly well four years after. The second patient, a female, aged sixty-four, was cured after twenty-four days' treatment, and remained well two years and a half after. The third patient, a female, aged forty-five, was cured in fifteen days by six injec- tions of twenty or twenty-five drops each. The solution used consisted of fifteen grains of Bonjean's ergotine dissolved in seventy-five minims of cherry-laurel water. The injections were made at the distance of one- fifth of an inch from the anus. Acute pain always followed, and con- traction of the sphincter lasting several hours. Several times an injec- tion of twenty-five drops of the solution caused spasm of the neck of the bladder and retention of urine. In no case did the injections produce any local inflammation or abscess. Dr. Vidal has more recently expressed himself as preferring Yvon's solution of ergot to Bonjean's ergotine, as causing less pain. The danger to be avoided in this method of treatment is the use of too irritating solutions, or solutions in too great quantity which shall excite a suppurative action and produce constitutional poisonous effects. Cauterization. In children in whom milder measures have failed, a -very effectual means of cure is the application of fuming nitric acid to the mucous membrane of the prolapsed part. The bowel should first be carefully wiped off with a towel or sponge, and the acid then applied by means of a small stick all over the mucous membrane, but not at all to the skin adjacent. After such an application the bowel should be replaced, a pad of lint firmly applied over the anus by means of broad strips of adhesive plaster, and the bowels confined by means of opium. Allingham speaks of stuffing the rectum with wool in addition, but I have always found the pad and straps sufficient when thoroughly applied, and the child kept on its bed. After three or four days the straps may be removed, and the bowels moved with castor oil. In a large proportion of cases, the cure will be found complete, though, in a few cases, I have seen a return of the disease after a few months." In any case, however, the benefit will be found to be very great, and should the disease return, a very careful search should be instituted for some existing source of irritation, such as polypus, phymosis, or calculus. In case of a recur- rence, a second application will be effectual in causing a cure. This treatment, though successful in children, is by no means so in 1 Paris Medical, August 28th, 1879. 8 Gaz. Hebdom., Jan. 2d, 1880. PROLAPSE. 117 adults. Allingham calls attention to the occurrence of deep sloughs in old persons with debilitated constitutions ; and, as a result of such a slough, he has seen an almost fatal haemorrhage. Stricture of the rectum may, without doubt, be caused by too free use of this remedy, but since it follows its abuse and not its proper use in appropriately selected cases, it can hardly be considered an objection. Linear Cauterization. In adults this is undoubtedly the best means at our command for dealing with this affection, and the best means of ap- plying it is that recommended by Van Buren, with Paquelin's cautery. The patient is at first etherized and placed in Sims's position. Van Buren reduces the prolapse, and applies the iron with the aid of a spe- culum. Allingham first applies the iron and then reduces the prolapse. In either case, from three to six vertical stripes should be made upon the mucous membrane, with the iron heated to a dull-red heat. The caute- rization should begin about three inches up the rectum, and end at the junction of the skin and mucous membrane. They should also be deeper at the end, where there is no danger, than at the beginning, where the bowel may be perforated. Van Buren recommends that the iron be bent at a right angle a short distance from the end, so that it may be the more thoroughly applied to the concavity of the rectum, and that, in mild cases, a small iron should be used, "no thicker than an ordinary firobe." Allingham, in bad cases, burns through the sphincter muscle at two opposite points, after reducing the bowel, and inserts a small pledget of oiled wool. By this burning through the sphincter, the patulous condition of the anus is overcome. The result of the operation is to decrease the circumference of the anal orifice, and, in this way, to effect a cure. The patient should be confined absolutely to bed till the wounds are entirely healed, so that a recurrence of the descent may be effectually avoided. For some time after the healing, and after the patient is allowed to be up and about, in fact, until the full effect of the operation has been ob- tained, a bed-pan should be used. The first operation, if thoroughly performed, will probably result in permanent cure. Should it not, it may be repeat i-d. The only danger in connection with it is the occur- rence of secondary haemorrhage when the sloughs separate, and of primary haemorrhage from large veins at the time of the application of the iron. To avoid this, Allingham recommends the choosing of points for cauterization which are free from large venous pouches, such as may be visible on the surface of the tumor. In old cases of extensive disease, the operation as thus described may not be effectual, and it may be necessary actually to produce a stricture at the anus to prevent recurrence of the trouble. There is, perhaps, no better means of accomplishing this than to apply the iron to the whole circumference of the anus, circularly, instead of in longitudinal stripes; but such an operation will seldom be called for. 118 DISEASES OF THE RECTUM AND ANUS. There is one other method of dealing with this affection, which, though not as. simple as the cautery-iron alone, is well worthy of trial, and that is Smith's operation with the clamp and cautery. We have already given a figure and description of the clamp and the operation in speaking of haemorrhoids, but the operation is even better adapted to cases of prolapse than to haemorrhoids, the mass being larger and more readily seized, cut off, and cauterized. Having thus described the most effectual means of dealing with this troublesome affection, it is scarce worth while to describe the various cutting operations by which pieces are removed either from the mucous membrane alone, or from the sphincter muscle, with the object of ac- complishing the same result that is more readily attained with the cautery iron. Dupuytren's operation consisted in removing three ellip- tical folds of skin and mucous membrane from the verge of the anus. The same idea has been more recently applied in Germany. * Robert and Dieffenbach cut out wedge-shaped pieces, and approximated the edges with deep sutures ; and the latter even went so far as to cut off the whole tumor an operation now seldom practised, except in slight cases, such as those accompanying internal haemorrhoids. 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 periy toneum also. It is probable that every prolapse of more than two inches in length may contain 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 in front 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, 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 connective 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. 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 first variety is seldom of long standing; while one of the second is generally so. The second generally 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 1 " Eine neue Methode der operativen Behandlung des Mastdarmvorfalls." Deutsche Med. Woch., No. 33, 1880. PROLAPSE. - 119 to the circumference, and the opening is circular and patulous. In the second, the orifice is slit-like and is drawn backwards by the attachment of the meso-rectum, or in females forward by the closer attachment to the vagina. The form of the tumor is conical, its walls are thick and linn, and when pressed between the fingers, the gurgling of gas in a con- tained loop of intestine may sometimes be detected, and a resonance may be obtained on percussion. If such a tumor be carefully dissected, the coats of the protruded vl will l)c 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 are- olar tissue will be seen to be infiltrated with albuminous deposit, and the muscular 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 of ten experienced in reduc- ing it and in keeping it reduced, in spite of the constant straining and desire for defecation which it produces. These changes in the mucous membrane may in rare cases result in the production of a foul, hard, bleeding, eroded mass, which may at the first glance strongly suggest malignant growth. The bleeding from a prolapsed rectum is commonly in the form of a general oozing, and applications of astringents may be necessary for its control. Strangulation is rare in infants and in feeble old people, but in a 3trong person the sphincter may be sufficiently powerful to produce such a result. A strangulation may be only temporary when met by the proper means, or it may continue long enough to cause ulceration and partial gangrene; the latter, however, is rare. When it occurs, it is pos- sible for it to end fatally from the contiguity of the peritoneum; but it more often results in a spontaneous cure of the prolapse, and in a cica- tricial stricture, the location of which will" depend upon the length of the prolapsed portion and the point at which the sphacelus occurs. 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 ad- dition of more or less incontinence of faeces in old cases; but the treat- ment is not the same in all respects; for certain measures which may be safe when a pro!ap->- contains no peritoneum may be fatal under the op- posite condition. In cases in which curative measures are out of the question, the hem- orrhages and the erosion-; maybe relieved by suitable applications, rest in bed, defecation in the recumbent posture, etc. Persulphate of iron is perhaps as u'"od an application to the bleeding sun'acr as any other; and weak solutions of nitrate of silver often have a good effect upon the ero- sions. The reduction of a prolapse of the second degree is by no means mple a mutter as that of the first. When the sphincter is tight and the tumor cedematous, it may be nearly impossible; and in old cases 120 DISEASES OF THE RECTUM AND ANUS. where the opposite condition of the sphincter obtains, it may be equally difficult to keep the parts within the body after placing them there. The latter may, however, generally be accomplished by the means already enumerated, and the reduction in obstinate cases may generally be ob- tained through the influence of anaesthesia. The dangers which may attend an attempt at reduction by taxis are well illustrated in the follow- ing case. CASE X. Complete prolapse of the rectum; rupture of the bowel during reduction. ' The case was that of a woman, aged forty-six years, who about twelve years before, a 'short time after a difficult labor, had begun to suffer from prolapse which came down daily at the time of de- fecation, and was easily reducible. She was seen by the doctor at a time when the tumor had been down nearly twenty-four hours and had resisted all the efforts of herself and female friends at replacement. She had passed a restless night and was much fatigued by her journey in an old cart, but had experienced no bad symptoms referable to the stomach or bowels. The doctor found at the anus a tumor larger than the fist, round, red, and covered with bloody mucous. The prolapse was directly continuous with the margin of the anus in such a manner as to render the introduction of a sound between them impossible. At the extremity of the tumor there was a rounded aperture which admitted the finger without obstacle. To accomplish the reduc- tion the woman was placed on the bed with the thighs separated; the tumor was seized in the palms of the two hands and the ends of the fin- gers, and a gentle circular compression was exercised in order to diminish its volume and cause it to go up by an operation similar to the taxis. The resistance being great, a few moments were allowed for rest, and after a quarter of an hour the same manoeuvre was repeated after having en- veloped the tumor in a cold cloth. " After a few moments I felt," says the narrator, " during a violent 'effort of the patient, the tumor distend under my fingers, and at the same time I heard a noise similar to that made by tearing parchment. At the same time the tumor suddenly dis- appeared of itself, and syncope, nausea, and a marked change in the ex- pression of the face supervened. When the patient came to herself she complained of severe colic. I then found outside of the anus a loop of intestine which I easily replaced, and on introducing the finger into the rectum I recognized at a consider- able height an irregular longitudinal rent the extent of which I was un- able to determine. I placed a tampon of lint over the anus and kept it in place with a T bandage and compress. I sent the patient to her home, ordering that nothing be disarranged. As the case was very serious, I requested a neighboring confrere to come and aid me with his advice. At our arrival, six hours after the accident, I found the patient sitting by 1 Condensed from report by Dr. Roche, Revue Med.-Chirurg., 1850. PROLAPSE. 121 the corner of the fire, without the dressings. Between the separated thighs were exposed, in the midst of the ashes, the large and a consider- able part of the small intestines, distended with gas, cold, and in several spots livid. The face was Hippocratic, the pulse thready and much accelerated, the voice feeble; and to this was joined colic and continual vomiting. After having placed the woman in bed and raised the intes- tines, the mass was replaced within the body, the former dressing was applied, and the woman died in a few hours." Two questions may arise in this connection. Should reduction be tried when the tumor is inflamed; and should it be tried in case of a circular slough? In answering the first question, the distinction must be made between a prolapse which is merely strangulated and one which is inflamed. The appearances may be much the same, but an old pro- lapse in an old person when found in this condition is much more apt to be inflamed than strangulated, for the sphincter muscle in such cases has generally lost the power of forcible constriction. The danger in re- turning an inflamed prolapse into the body is that the inflammation may extend and cause general and fatal peritonitis; and as a rule it is safer not to employ the taxis in such a case, but to put the patient in bed and treat it by local applications and rest till the acute symptoms have disappeared. In answer to the second question, Molliere 1 recommends extirpation of the prolapsed portion rather than its reduction when there is a circular slough, on the ground that no matter how radical such a step may appear at first sight, it is better than leaving the case to nature. For a circular slough means inevitably a cicatricial stricture; and if the prolapse be ex- tensive, a stricture situated high up in the rectum or sigmoid fluxure be- yond the reach of art. As preferable to this he recommends the complete ablation of the tumor with all the dangers which attend such a step. These dangers are easily understood to be haemorrhage, hernia of the intestines through the incision, and peritonitis. Each may be avoided where the surgeon is prepared beforehand for their occurrence, and Molliere relates one case where the operation was performed by himself with the hut iron, but the patient "died on the eighth day from the effects of the chloroform " so that ho was unable to decide on the value of the operation. Excision with the surgeon's eyes open to the fact that he is dealing with peritoneum may perhaps be done with success under such circum- stances. At all events it is a very different mat;< T I'nuu excision of this variety of prolapse under the impression that it is the one previously ribed, and contains no peritoneum, as the following cjise will show. Van Buren J says: "I have reliable information of a case in which the 1 Op. cit, p. 240. s Op. cit.. p. 60. 122 DISEASES OF THE KECTUM AND ANUS. removal of a ' compete prolapse ' of long standing, in a child, was quite recently undertaken by a hospital surgeon of mature years. The protest of a junior colleague led the operator to pass some deep sutures, in deference to a fear expressed as to the probability of intestinal protrusion, but he was confident that the tumor consisted of mucous membrane alone, and proceeded to remove it. Notwithstanding the deep sutures, protrusion of several coils of small intestine did occur, and the child died, in collapse, within twenty-four hours." In this form of the disease, the surgeon may find it better after mature deliberation not to attempt a radical cure, but to confine his efforts solely to palliation. The following case illustrates the danger of attempted removal of a part of the mass in an old and extensive prolapse. CASE XL "The patient was an elderly man who had a prolapsus as big as a cocoa-nut always coming down, and rendering his life a burden. He had already been operated upon twice by a hospital surgeon, but in vain. The patient was then sent to me, and, formidable as the case looked, I determined to undertake it. I applied the clamp deeply in three different directions. There was a great deal of bleeding and I had to apply the cautery over and over again before I could stop it; and then, just as I was finishing the operation, a most untoward event occurred severe vomiting, as the result of the anaesthetic, took place. The pro- lapsus was forced still further down; and before I and my assistants could return the parts, the violent action of the abdominal muscles was such that the weakened coat of the bowel gave way, and a knuckle of small intestine actually protruded through the rent thus made. I carefully returned this as soon as the vomiting ceased, and anxiously waited the result. Our house-surgeon, Mr. Newmarch, watched the patient with great care and treated him with great skill, keeping him constantly under the influence of opium, and locking up his bowels for several days. The result was not a single bad symptom of any kind. On the first action of the bowels there was no protrusion, nor afterwards; and as soon as the man was fairly recovered I removed three longitudinal folds of skin from the anus, so as further to tighten the parts. The man was completely cured. Now, the lesson this case teaches is this not to employ an agent which could cause vomiting; because, of course, in such a terribly severe case as this it is absolutely necessary to clamp deeply, and thus weaken the bowel. It was a most unlooked-for accident, not likely to occur again; in fact, it is hardly reasonable to expect to meet with another such a case for operation. I have, however, been called to cases as bad or worse, but where no operation could be recommended." ' Dr. Kleberg has utilized the elastic ligature in operating upon severe oases of prolapse : and, it may be, that if the mass has to be removed at 1 Henry Smith, Lancet, Mar. 15th, 1880. PROLAPSK * 123 all, the method he describes is the preferable one. The operation is per- formed a- follow-. l CAM: XII. Operation. On the previous day a dose of castor oil was siven, and on the morning before the operation an enema of luke-warm water was administered high up the bowel. Immediately before, a glass of wine and one grain of opium were given. After the patient had pressed down the gut as far as he could he was placed on the operating table in the Literal position with the pelvis raised and shoulders turned downward. Chloroform was then administered. In two cases Kleberg has operated without chloroform because the patients were in such a miserable condition that he was afraid to narcotize them thoroughly, and an incom- plete narcosis has all the dangers of profound anaesthesia and none of its advantages. After the chloroform, he says, " I carefully examined about the rectum at the junction of the skin and mucous membrane in order to discover the sphincter ani a procedure that was more difficult than one would think, because it had become so stretched and atrophied that I could only make it out by feeling under the fingers the coarser fibres running across the longitudinal axis of the bowel. Of anything like the normal muscle there was nothing to be discovered. An assistant, at this point, surrounded with all the fingers the pro- lapsus from above, the points of the fingers being directed towards the five end of the prolapsus, and pressed as hard as possible into the gut at a point perhaps half an inch below the supposed sphincter. Immediately in front of the ends of the assistant's fingers I then placed a good, fresh, unfenestrated drainage tube of rubber, one and one half lines in diameter, around the prolapsus, and drew it only as tight as seemed necessary to atop the circulation. The elastic ligature was brought' to the necessary tension by means of an easily-untied slip-knot of silk thrown under it. The assistant now had both hands free ; and from this time on the operation was performed under the carbolic spray. A few lines beneath the ligature I now made a longitudinal incision two inches long through the prolapsed gut, and in this way opened the sac formed by the drawing down of tlu- peritoneum. Then I seized the elastic ligature with the forceps and fixed it firmy. It was thus an easy matter to push back into the peritoneal cavity a protruding loop of intestine without the slightest bleeding taking place into the wound or any air entering the peritoneal cavity ; because the elastic pressure follows so rapidly all the movements that no opening can exist any where. After I had convinced myself that the peritoneal sac was empty, and that no imagination of the intestine was present, but, on the other hand, only that part of the gut which was to be removed lay in front of the ligature, I thru>t the largest size Luer's pocket trocar through the pro- 1 Ueber die Anwendung der elastischen Ligatur zur Operation sehr schwerer Fall.' von Prolapsus Recti. Arch, fur Klin. Chirurg., vol. xxiv., p. 840. 124 DISEASES OF THE RECTUM AND ANUS. lapsus, immediately below the elastic ligature, from before backwards, and passed through the canula two elastic drainage tubes of one and one- half lines in diameter, and, after removing the canula, tied them as tightly as possible, one on the right side, the other on the left. These knots were secured against slipping by means of the knot of silk. The first provision against haemorrhage the elastic ligature applied after Esmarch's plan was then removed and the prolapsus cut off with the scis- sors one inch in front of the permanent ligatures. After a few minutes* time, during which I kneaded the parts which still remained and lay above the ligatures thoroughly, and as far as possible removed the fluids from them; I covered the parts around the stump with cotton, and soaked that part of the prolapse which still remained above the ligature with a solution of chloride of zinc, dried it, squeezed the soft parts once more, thoroughly applied the chloride of zinc again, and then covered the whole with dry cotton-batting, giving the patient instructions to remove this as soon as it -became moist and to replace it with dry, and to give the air all possible access to the parts." No fever followed the operation, and the pain was bearable, with the aid of an occasional opiate. On the next day the parts had so far shrunk as to leave a concavity at the anus where before there had been a bulging. There was no bleeding, no peritoneal irritation, and only slight tenesmus. On the fourth day the first ligature cut out, and the second on the fifth. The rectum was irrigated twice a day with water and permanganate of potash, and on the seventh day a dose of castor oil was followed by a large evacuation while the patient was on his back without pain or haemorrhage. The passage, however, was involuntary. On the fourteenth day the wound was healed, the general condition of the patient excellent, and the evacuations regular but still involuntary. The sphincter at this time began to be appreciable, and there was no protrusion of the bowel, the patient going about and wearing a bandage. One month later he had control of solid faeces, but there was still a slight discharge of mucus ; and after another month he was entirely well. In this case the prolapse was about a foot in length and six inches in diameter. The mucous membrane was spongy, bleeding, excoriated, and ulcerated. The patient had been sick for two years, had been bed- ridden for two months, and was waxy pale. Another case by the same surgeon and the same method ended fa tally, but can hardly be considered a fair test of the dangers of the operation, on account of the exceedingly bad condition of the patient. Tliird and fourth varieties. These two forms of invagination will be described together because of the fact that they differ from each other not at all in their nature but only in extent and location. It will be ob- served that the word prolapse is now dropped and invagination substi- tuted which more aptly expresses the condition. The essential difference between the disease now to be considered and the forms already described PROLAPSE. 125 consists in the fact that while in the latter the bowel begins to slip down from i; s lowest portion at the anus, in the former the lowest portion at the anus remains in its proper position and the bowel from above is tele- scoped within it. fader these circumstances it isevident,as is shown in Fig. 39, that the affected portion of the bowel must consist of three differ- ent and distinct cylinders, an outer one which contains the other two, and two included portions, one of which is the entering and the other the re- turning bowel. When the upper part of the rectum becomes invaginated in this way within the lower, the included portion will appear at the anus as in the cases of prolapse already described, and a distinct sulcus may be felt by the finger between the extruded portion and the mucous membrane which is continuous with that of the anus. The bottom of this sulcus or the point at which the entering portion becomes directly continuous with that into which it enters may also be felt by the finger if it is low enough down; if not, it may be detected by the aid of a soft catheter. This is what is understood by the third variety of prolapse. When a portion of the bowel still further removed from the anus has become invaginated into that immediately below, the included portion may or may not descend sufficiently near to the anus to be felt by rectal touch, and the sulcus may not be apparent. This constitutes the fourth variety or what is now generally known as intussusception. It is evident that between a case of prolapse in which all the coats of the rectum appear through the anus, and in which a sulcus can be felt by the finger passed around the pro- truded portion; and a case in which the ileum is telescoped through the ilio-caecal valve and appears at the anus, the difference is one of degree and not of kind. Of this condition there are many degrees, and almost any portion of the bowel from the duodenum to the rectum may become invaginated into the portion next below. The caecum itself may be so loosened from its attachments as to follow the same course, and the orifice of the appendix vermiformis may be detected at the anus by the side of the orifice of the included bowel. In ?G3 cases of invagination collected by Bulteau, 1 220 were of the small intestine; 151 of the large; and 392 ileo-caecal. The mesentery of the two included portions is drawn in with tin in. and by its attachment and traction gives to them a curve the concavity of which is toward.- the point of attachment of the mesentery. For this iva-on the lower orifice of the included portion is not found in the axis of the containing portion, but turned toward some portion of its circum- ference, and is, therefore, often diHieult to detect by a digital examina- tion. 1 De 1'occlusion intestinale au point de vue du diagnostic et du traitement. These de Paris, 1878. 126 DISEASES OF THE RECTUM AND ANUS. The immediate effect of an invagination is to interfere with the pas- sage of faeces, but seldom to entirely prevent their passage, for the faeces do pass and in considerable quantity, forced down through the con- striction by the contraction of the healthy bowel above. Another immediate effect which is due to constriction of the blood- vessels in the included mesentery and in the walls of the included portion, is the transudation of serum and consequent swelling of the intestinal walls. By this means the serous surfaces become dark-colored, and the mucous surfaces become infiltrated; blood is effused between the mucous surfaces of the outer and middle layers, and lymph between the serous surfaces of the middle and internal layers, and after a time these become completely agglutinated. If the constriction be sufficiently severe, the included portions soon become gangrenous and slough away, the lumen of the bowel is again established, and a circular cicatrix is left. This is nature's method of cure, and though life is by it saved for a time, in the end the cicatrix thus formed may become a stricture which shall be more surely fatal than the condition from which it arose. The invaginated portion is at first of necessity short; but as the case advances, it may reach to several feet, and in one case 1 there is a reason to believe that about four yards of in- testine came away, piece by piece, per anum. The disease is twice as common in males as in. females, and is greatly more common in children than in adults. In adults the trouble will generally be found to involve the small intestine; in children, the large. An invagination of the small into the large intestine begins generally at the ileo-caecal valve, which with the vermiform appendix is carried up the ascending, and along the transverse colon, till it may finally reach the anus and protrude through it, the valve all the time remaining the lowest portion. In these cases only the inner tube is made of small in- testine, the middle and the outer consisting of the large. Strangulation is much more frequent where the outer layer is com- posed of the small than where it is composed of the large intestine; because of the greater tightness of the constriction. In the latter case the congestion may be only moderate in degree and the condition may last many weeks without gangrene or ulceration. This condition is known as chronic intussusception. If sloughing occur at all, it may happen at any time after the first week, generally, however, it occurs within three weeks, though it may be delayed for a much longer time. In one case 2 the separation of frag- ments of intestine extended over an interval of three years. In about one-half of the reported cases a favorable termination has followed spontaneous separation, in the remainder death has occurred 1 Peacock: Path. Trans., vol. xv. 2 Peacock, loc. cit. PROLA1 127 after a longer or shorter interval. Several pathological changes may occur. The peritonitis which serves to unite the serous surfaces of the contained portions may become general and cause death. The ensheath- ing portion may become ulcerated and perforated, allowing of the extra- ction of fseces. The ulceration may perhaps be due to the lateral -sure of the end of the contained portion against the side of the cylinder which contains it. ' Separation by sloughing leaves the upper end of the eusheathing portion united with the lower end of the healthy * 1, and results in complete amputation of the contained portion. avasation may also occur from a deficiency in this union at the time when separation occurs. The causes of invagination are not as yet perfectly understood. It is to understand how in the effort which the intestine makes to relieve if of a polypus or other tumor by its vermicular action, not only the growth itself may be extruded, but also the portion of the bowel to which it is attached; and polypus is one of the recognized causes of this condi- tion. But in the great majority of cases no such palpable cause is to be detected. Except in the case of a tumor it is probably always an accident of sudden occurrence dependent upon some violent action in that part of the bowel. A collection of gas causing an undue dilatation in one part of the intestine, combined with a violent movement of the abdominal muscles, and a peristaltic movement in the portion just above that which stended, might, it is easily understood, cause the accident. So, also, :lit any interference with, or undue violence in, the rhythmic action of natural peristalsis, by which the bowel in successive portions is first shortened and dilated by contraction of the longitudinal fibres, and then narrowed and elongated by the contraction of the circular fibres. Since the wave of peristaltic action is constantly passing from above down wards, it may easily happen that a narrowed portion may under unfavorable cir- cumstances be caught in a dilated portion just below, and, once engaged, the exaggeration of the condition becomes natural and easily understood. It is to such explanations as this that we have to look in the absence of any palpable cause. Symptoms. An invagination will cause a very different train of symptoms, according to the part of the bowel affected and the intensity of the constriction. As a rule, the symptoms are more acute and severe in invagination of the small intestine, and are more chronic in the large, because the constriction is more intense in the former than in the latter; but an invagination of the small intestine may approach in symptoms and chronicity to one of the large, and vice versa. Wherever the constriction be located, its first symptom is generally a sharp attack of pain in the abdomen, coming on suddenly, and often in the midst of perfect health. There is nothing characteristic in this Aitkeii: I'raet. of Med., vol. ii. 128 DISEASES OF THE RECTUM AND ANUS. pain. It may pass off after a few hours and again return; it may or may not be accompanied by vomiting at the start; it is sometimes relievable by direct pressure, and it is not at first accompanied by any tenderness of the abdomen. Change in the character of the evacuations is also a symptom com- mon to the disease in any part. After the onset there will still be a dis- charge of the contents of the bowel below the constriction, and a certain amount of faeces may still leak through the invagination. Instead of the natural passages, however, the appearance of bloody stools is a very com- mon occurrence, the blood coming, as has already been explained, from the congested and swollen mucous membrane of the outer and middle portions. There is also present at times a dysenteric discharge and a good deal of tenesmus. By careful manual examination, a tumor can generally be discovered in the abdomen, which may be characteristic enough to form a basis for the diagnosis; but this may be concealed by the presence of much fat, or by a general distention of the abdomen with gas. The tumor is cylindrical, and may be movable under the hand from its own peristaltic action, or it may be seen to change its position from day to day as the invagination gradually advances, and more and more of the bowel be- comes involved. The other symptoms depend in great measure upon the severity of the strangulation, and, as has been said, are more marked when the small intestine is implicated. In such cases, the symptoms rapidly in- crease in severity. There may or may not be considerable febrile action; the abdomen soon becomes tender to the touch; there is almost complete obstruction, or else only the passage of bloody mucus; the patient rapidly sinks, and the history ends either in death or in the slough- ing of the included part. The latter is shown by a re-establishment of the calibre of the bowel, and, therefore of the passages; by an abatement of all the worst symptoms, and finally by the appearance of larger or smaller pieces of gangrenous intestine in the passages. The existence and the early appearance of faecal vomiting have been given as points in favor of the diagnosis of intussusception of the small rather than of the large intestine, but they point rather towards complete obstruction than to the particular seat of the obstruction. In invagination of the large intestine, the general history of the case is that of a more chronic trouble. The pain is less severe and the par- oxysms separated by longer intervals; the faecal evacuations are larger, and the dysenteric symptoms are more pronounced; vomiting is variable, and after a time often stercoraceous. This state may continue for -several weeks before death results from gradual exhaustion or from the super- vention of acute strangulation. The history of a case of chronic inva- gination may at any time be cut short by the occurrence of a general PROLAPSE. 129 acute perionitis, and this is particularly apt to happen at the time of the separation of the slough. /)ni'!Ho*ift. In any case in which the invaginated portion descends near enough to the anus to be felt by digital examination, the diagnosis tsy to the surgeon of ordinary care and intelligence who has studied the symptoms which infallibly point in the direction of intestinal occlu- sion. But when such an examination has been made with a negative re- sult, beyond the fact that occlusion exists tho surgeon may be completely at a loss. Under such circumstances the differential diagnosis rests be- tween the following conditions: 1. Invagination; 2. Volvulus; 3. Stric- ture; 4. Concealed internal hernia; 5. Pressure from without the bowel by tumors etc. ; 6. Obstruction from foreign bodies, as calculi, indurated faeces, etc. ; 7. Peritonitis from perforation. It may be as well to state at once that in these cases the differential diagnosis will often be impossible, and then goon to throw what light upon the question modern science has made available. It is a good plan to divide all cases of intestinal obstruc- tion into the acute and the chronic. An acute case will generally be either an invagination, a volvulus, or an internal hernia. Duplay 1 also has called attention to the fact that a peritonitis from perforation may cause all the symptoms of an acute occlusion and has given the chief points in the diagnosis of that affection. In peritonitis the vomiting seldom be- comes faecal but remains bilious to the end; the constipation is less marked and the patient generally passes gas and liquid faeces or small quantities of solid matter; the tympanites is also less marked, and the coils of intes- tine are less pronounced; the pain begins with great severity atone point and extends over the whole abdomen (the same thing may happen in acute obstruction, but in such cases the other symptoms faecal vomiting, abso- lute constipation, absence of the passage of gasper anum are all equally severe, while in peritonitis they do not correspond in severity with the in- tensity of the pain); the temperature is elevated in peritonitis and normal or even less than normal in obstruction. Having then excluded peritonitis from perforation, the diagnosis in any acute case will rest between invagination, volvulus, and internal her- nia, [nvagination is indicated by the signs of partial occlusion, by the moderate tympanites, by the bloody stools mixed with mucus, the tenes- nuis. ;i'id tho presence of the tumor. The diagnosis between volvulus and internal hernia will generally be impossible except as the history may point to antecedent peritonitis, or to a hernia which has ceased to come down; <>r as the careful exploration of the abdomen by palpation and of the pel- \i> liy rectal and vaginal touch may show the existence of an induration or resistance limited to one point. In other words, in any acute ease of occlusion the existence of invagi- 1 Duplay: Du Tiuitt-iurnt Chirurgical tU> 1'Ocvlusion Intestinal. Arch. Geiil. de M. !., Dec., 1879. 9 130 DISEASES OF THE RECTUM AND ANUS. nation may be decided by the presence or absence of its peculiar symp- toms, and if excluded the diagnosis rests either with volvulus or internal hernia, but with which it may be impossible to decide. In a case of chronic intestinal occlusion, the diagnosis rests between invagination, occlusion by the pressure of solid or fluid tumors outside the bowel, stricture of the intestine, abnormal adhesions of the bowel, and obstruction by foreign bodies within the bowel, such as biliary calculi, indurated faeces, tumors, etc. The easiest of these to diagnosticate is that which comes from the pressure of a tumor without the bowel. Chronic invagination may be made out by the symptoms already given. For the symptoms of stricture, we must refer the reader to the chapter on that subject, and these symptoms are much the same whether the obstruction be due to a narrowing of the calibre of the bowel by a de- posit in its wall, or to the presence of a foreign body, or abnormal ad- hesions of the peritoneum which cause acute flexures and obstructions in its calibre. It will thus be seen that the differential diagnosis is shrouded in difficulty, and that the difficulty is rather greater in a case of chronic than of acute obstruction. A well-marked 1 case of invagination, whether acute or chronic, is, however, the easiest of all the forms of occlusion to distinguish, and the diagnosis can generally be made with sufficient approach to certainty to guide the surgeon in the selection of his plan of treatment. Treatment, It is evident that the treatment of the conditions we have been describing must differ in every particular from that of those previously described. When the invagination has occurred in the rec- tum, that is, when the upper part of the rectum has become telescoped into the lower, and has appeared as a prolapsed mass outside of the anus, the case may still be relievable by the methods of reduction and taxis. The mass must be replaced by a process exactly the reverse of the one by which it came down, the most dependent portion being first carried into the body, and the entanglement unfolded in this way. In a child, with the assistance of anaesthesia, the inverted position, and gentle manipulation with the fingers or possibly a soft bougie, this may some- times be accomplished where the point of constriction is low down near the anus. Prall ' reports a case where replacement was successfully accomplished by manipulation with the tube of a stomach-pump, though the mass could only 'just be felt in the rectum. In cases, whether of adults or children, where the constriction is still higher in the intestine, and manipulation with the hand or bougie is out of the question, various other mechanical means may be tried with a prospect of success. These consist in applying indirect pressure to the invaginated portion, and to the constricting part by means of copi- 1 Brit. Med. Journ., July 31st, 1880. PROLAP8K. 131 lypi of childhood and the latter as those of adult age a classifica- tion of little practical value. The mucous membrane, as has been shown, is composed of villi, of the follicles of Liebcrkuhn or tubular glands, and of occasional closed or solitary follicles. A polypus composed of an hypertrophy of the villi is well represented in Fig. 41. A polypus of this variety may reach the size of a pigeon's egg, it is soft to the feel, and has a shaggy or cauliflower surface. On section the cut surface is of grayish-red color, the substance of the growth homoge- neous, and the fluid which may be forced from it by pressure will be found to be full of cylindrical epithelium. A microscopic examination 136 DISEASES OF THE RECTUM AND ANUS. shows it to be composed of long fine papillae bifurcated at their extremities and covered by cylindrical epithelium. 1 Although the polypi are generally small, Dr. G-oodsall has reported a case from St. Mark's Hospital, 2 in which the tumor attained the size of an orange. It was rough and tuberculated on the surface, and was at- tached to the rectal wall by a pedicle long enough to permit of its extru- sion from the anus without pain. It was attended by a frequent, copious, watery discharge, but never by any very free haemorrhage at one time, and the patient showed no emaciation. Villous polypus (granular papilloma, Gosselin; villous tumor, Cur- FIG. 41. Rectal Polypus (Esmarch). ling; villous polypi, Esmarch; " peculiar bleeding tumor," Quain). Figs. 42 and 43. It is a question whether this form of growth should be classified with the polypi already described, or with the warty growths, whose descrip- tion is to follow. It consists of an hypertrophy both of the villi and of the follicles of Lieberkuhn, with a centre of connective tissue and generous vascular supply. According to the description given by Dr. A. Clark 3 of a specimen in the London Hospital Museum, the tumor is " essentially an outgrowth of dense areolar tissue, permeated by blood-vessels, and assum- ' Lucke: Die Geschwillste. Handbuch der allgemeinen und speciellen Chi rurgie. Pitha u. Billroth, p. 250. 9 Lancet, May 21st, 1881. p. 828. 3 Curling, p. 85. NON-MALIGNANT GROWTHS OF THE RECTUM AND ANUS. 137 ing a papillary form, the papilla? being flattened and curled so as to rep- resent hollow cylinders, and being clothed with layers of epithelium, the free layers being cylindrical." These tumors are very rare; they have the feel of a large warty poly pus with cauliflower surface; are of red color; bleed easily; are of rela- tively slow growth, existing in Gowland'a case several years. They adhere to the wall of the rectum by a pedicle, sometimes composed chiefly of mucous membrane, and at others large, short, and fleshy. Fio. 42. Villous Polypus (Bryant). The pedicle may be absent (Curling) ; and the growth will vary in struc- ture according to the proportion of its different elements. It may reach the size of an orange ' ; it is found only in adults or in old persons, and the symptoms aro the same as those caused by other polypi; viz., dis- charge and haemorrhage: but the haemorrhage is not a constant symp- tom, and varies greatly in frequency and amount in different cases. The adenomatous polypi, or those developed from the glands of the mucous membrane, are well shown in Fig. 44. 1 Syme: Diseases of the Rectum, 3d ed. , p. 82. 138 DISEASES OF THE BECTUM AND ANUS. These may be due either to an hypertrophy of the follicles of Lieber- kuhn or to an. hypertrophy of the closed follicles. They occur most fre- quently in young persons; are generally of the size of a small plum, rarely reach that of a pear, and yet Esmarch reports one weighing four pounds. 1 They are very vascular tumors, and, therefore, of reddish color; they are sometimes smooth on the surface, but oftener mammil- lated, like a strawberry, and are attached by a pedicle, most often to the posterior wall, but occasionally to the sides of the rectum, and at a point generally within reach of the finger, but sometimes higher up. They may indeed occur anywhere along the large intestine as high up as the ileo-caecal valve. The pedicle is generally large and short, and not long and slender as Fio. 44. Glandular polypus (Esmarch). in the case of the fibrous polypi soon to be described; but there are fre- quent exceptions to this rule, and these tumors will sometimes be spon- taneously expelled by rupture of the slender pedicle in defecation. The pedicle is also sometimes double (Smith). It consists of mucous membrane covering the vessels, which carry the blood to the tumor, and return it again an artery and generally two veins, but when the tumor is very large, sometimes two arteries and a collection of veins. Polypi which consist of an hypertrophy of the closed follicles -of the rectum are often found in considerable numbers. Fochier 2 removed sev. 1 Op. cit., p. 176-177. 8 Holliere, p. 362. Note. NON-MALIGNANT GROWTHS OF THE RECTUM AND ANUS. 139 eral hundred of them from a patient aged eighteen, and Richet 1 from v to a hundred in a man aged twenty-one. Van Buren * speaks of the same condition, adopting Broca's name of " polyadenomata." To this variety of polypus belong also certain cysts (closed follicles), distended by viscid and transparent fluid; and Bathurst Woodman has reported one such case in which the cyst was lined by a membrane similar to peri- toneum. On section, these adenomatous polypi are found to contain much vis- cid fluid, full of cylindrical epithelium and rudimentary glandular tubes. Under the microscope a vascular stroma of connective tissue will be Fio. 45. Vertical section of glandular polypus (Eamarch). found, in which there are enlarged glandular tubes sometimes branching at their extremities; and also cystoid spaces filled with reddish viscid fluid (Esmarch). The microscopic appearances of a section of such a polypus are shown in Fig. 45. The hard or fibrous polypus (sarcomatous polypus, Esmarch) which is composed primarily of the elements of the submucous connective tissue, is much rarer than the soft variety, and is most commonly found in adults, where it may be isolated or multiple. It is chiefly composed of fibrous 1 Traite Prat. d'Anat. Med.-Chirurg. 4th ed., Paris, 1873. *Op. cit., p. 103. DISEASES OF THE RECTUM AND ANUS. tissue, and resembles the uterine fibroid; but it may contain both mus- cular and glandular elements. When the glandular elements are filled with fluid which resembles glue, these tumors have been know as colloid, and when cysts are found filled with jelly-like substance, the name myxoma has also been applied. These hard or fibrous polypi vary greatly in their degrees of hardness to the feel, according to their turgescence and their composition. They may creak under the knife on section, and look very much like hyper- trophied and cedematous skin, or they may resemble the better-known nasal polypus in their consistence. The connective-tissue fibres are generally irregularly disposed, and cross each other in every direction, though a regular stratification, such as is seen in uterine myxomata, may be present (Esmarch). When seen in the rectum before removal, the surface is red from their vascularity, but after removal, they are pale, and generally smooth, though some- times uneven and irregular in surface, and covered with hypertrophied papillae. The mucous membrane is generally easily stripped off, though if there has been local inflammatory irritation, it may be firmly attached. The vascular supply is abundant, and distributed both to the substance and surface of the tumor. This accounts for their rapid development. The pedicle is generally very slight, and is formed mechanically by the traction of the growth on the mucous membrane beneath which it is located. It is composed, as in the soft variety, simply of mucous mem- brane and blood-vessels. There may, however, in a case where the pedicle has been formed by traction upon and prolapse of all the coats of the boWel by a tumor located primarily above the reflection of the peritoneum, be a peritoneal cul-de-sac within the pedicle. An hypertrophy and increased vascularity of the mucous membrane at the attachment of the pedicle has been noted in certain cases. If left to its natural course, the pedicle gradually becomes longer and more slender, and finally ruptures in the act of defecation, and in this way a patient may relieve himself of the growth. These tumors are benign in character, and when once removed, do not generally return at the same point. They may, however, recur, if not at the same point, at one very near it, and the same patient may be re- lieved of a succession of them. Symptoms. A rectal polypus may exist for many years, and give no sign of its presence. The two chief symptoms which it is apt to excite are haemorrhage and discharge. The haemorrhage may be a daily occur- rence, or may be present only at long intervals, and it may vary in amount from a few drops to a quantity which shall cause grave disturb- ance and alarm. When the mucous membrane covering the tumor has once become ulcerated, the haemorrhage Avill be frequent, and the dis- charge will be more or less foetid. The vessels are apt to bleed freely when opened, because of their being imbedded in fibrous tissue, and of NON-MALIGNANT GROWTHS OF THE RECTUM AND ANUS. their inability to contract. When the tumor is so high and the pedicle so short as to be beyond the grasp of the sphincter, there is no suffering, but after prolapse once begins to take place, the suffering may be very re. The sphincter may become dilated and relaxed, or the pedicle may be firmly grasped by it after the act of defecation, and a cure may It from the strangulation thus caused. The discharge from the rectum which a polypus may cause is some- times extreme in amount and constant, escaping not only at the time of defecation, but at frequent intervals between, and being of an excessively foatid character. This discharge may by its irritating qualities cause secondary congestion of the rectal mucous membrane, erosions around tlu- anus, vegetations, constant diarrhoea, andtenesmus; and joined with the loss of blood the condition of the patient may be easily mistaken for thai of chronic dysentery or even malignant disease. There are several points worthy of attention in examining a patient for this disease. It is a good plan, as suggested by Chassaignac, to first administer an enema of water before making the examination that the polypus may float freely in the distended rectum. The finger is, in the vast majority of cases, all that is necessary for the examination; and as Mollie're suggests, the examination should be made from above downwards and not, as is usually the case, from below upwards. In the former case, by passing the finger up along the anterior wall and withdrawing it along the posterior, the tumor may easily be caught in the descent after the pedicle has been put upon the stretch, while, in the latter case, it may easily be carried up the bowel and escape detection altogether. Diagnosis. Haemorrhage from the rectum in a child, with or without pain on defecation, generally means polypus; and it often means the same in an adult, though it will oftener indicate haemorrhoids. The secondary symptoms which seem to point to dysentery: the erosions and vegetations, must never cause the original disease to be overlooked. There is in fact but little difficulty in the diagnosis of a polypus in the vast majority of cases; but once in a while, where the attachment is broad and the pedicle not well marked, the question of benign or malignant growth may arise and be difficult to solve except by the subsequent history and development of the case. In the chapter on cancer, attention will be called to tli3 fact that the distinction between epithelioma and a benign polypus of the adenoid variety cannot always be made by the microscopic examination; and we here emphasize the fact that the diagnosis must rest rather upon the elinieal history and gross appearances than upon histological investiga- tion of the growtli when removed. In children, malignant disease is so rare that the chances are greatly in favor of benignity. Malignant growths, moreover, do not tend to spontaneous extrusion and are not pedunculated, and the presence of a pedicle is therefore greatly in favor of benignity. But given an adult with an adenoid polypus which has 142 DISEASES OF THE RECTUM AND ANUS. ulcerated and which is not pedunculated, and the diagnosis between it and malignant disease may be impossible, either by the microscope or the clinical history; for the ulcerated and bleeding tumor may cause a wasting and cachexia which strongly resembles cancer. A soft polypus may also be mistaken for an internal hsemorrhoid when no pedicle is present, but the point of attachment is different in the two cases. Treatment. The treatment of polypi is generally a simple matter, FIG. 46. Vegetations (Esmarch). and consists in their extirpation, after which they rarely return. There are two dangers to be considered; the first is that the pedicle, when a pedicle exists, many contain large vessels; the other is that it may con- tain peritoneum. The extirpation of a polypus, which has come down from its attachment in the sigmoid flexure, has been followed by death from wounding the peritoneum, at the hands of no less a surgeon than Broca. Where the pedicle is long and slender, the polypus may gener- WON -MALIGN ANT in the neighborhood of the rectum and anus may be of many varieties. Of the ilermoid, there are several recorded examples. At a meeting of the London Pathological Society, May 18th, 1880, Dr. r<.rt 4 showed a tumor he had removed from the rectum of a girl aired 1 Lipome de 1 anus simulant une hernie pt'-rincale. Aunales tie therapeutique, on., isu. * Pathologic des Tumeurs. Translation par Aronasohn, voL i., Chap. 14. 3 Bull, de la Soo. Aunt., s.-rond series, t. v., p. 6. 4 Brit. Med. Jour.. May OUtli. is*n. p. 811. 152 DISEASES OF THE RECTUM AND ANUS. sixteen. It was mainly composed of fibrous tissue inclosed in an integu- ment like ordinary skin, covered with long hair, and containing abundant involuntary fibre like that seen in the normal cutis. Growing upon it also was a well-developed canine tooth. The author refers to a somewhat similar case, recently reported in Germany, in which the tumor contained not only a tooth but brain substance. Danzell ' reports a case in a woman, aged twenty-five years, in whom a lock of brown hair, the size of the finger, protruded from the anus occasionally after defecation. In the front wall of the rectum, about two and a half inches from the anus, a hard tumor could be felt about the size of a small apple. This was extirpated by introducing the whole hand into the rectum after Simon's method, death following some months after from localized peritonitis. The hair growing from this tumor was from twelve to eighteen centi- metres long. The tumor itself, when extirpated, measured 4.5 cm. in length, 4 cm. in breadth, and 3. 5 cm. in thickness, and the microscopic examination showed the usual cyst-wall and contents. Perrin 2 gives an account of three cases of these tumors, which may be briefly extracted. CASE XIV. Woman, aged thirty years. First noticed small tumor at point of coccyx a few months after confinement. Tumor round, elastic, well defined, firmly adherent to point of coccyx, painless to the touch, but more sensitive at menstrual epochs, and when the patient was in sitting posture. At this time it was the size of a small nut, but a year later it had increased considerably, and extended from the anus to the sacrum; it gave a sense of fluctuation to the touch, and was unattached to the skin. Defecation painful. The sac of the tumor was extirpated after its steatomatous contents were emptied Avithout difficulty. It was adherent by fibrous tissue to the point of the coccyx, but not elsewhere. The examination after removal showed it to be about the size of a hen's egg, with the large extremity turned toward the anus. It was composed of an envelope and contents. The envelope was composed of two distinct layers; the outer, fibrous and elastic, and showing the elements of cellu- lar tissue under the microscope; the inner, thin, transparent, and resembling a very thin layer of cartilage. Under the microscope this transparent layer was composed of flattened, transparent, polygonal epi- thelial cells about one-fortieth mm. in diameter. The contents of the sac consisted of whitish matter, disposed in layers at the circumference, but mingled in a tallowy mass in the centre; seen under the microscope to be composed of epithelial cells filled with fatty matter. Cure. 1 Geschwulst mit Haaren im Rectum. Arch, fur Clin. Chirurg., 1874, p. 44? 2 De la Glande coccygienne et des tumeurs dont elle peut etre le siege. Stras- bourg, 1860, These No. 536. NON-MALIGNANT GROWTHS OF THE RECTUM AND ANC8. 153 CASK XV. Woman, aged twenty-seven years. This tumor had been growing for five years. It first appeared as a small tubercle about one- third of an inch in size, very hard and painless, at the left side of the coccyx. For tin- first three years it was painless, but during the latter h;nl caused more uneasiness when struck or pressed upon. After a tune the pain was increased, and became continuous with remissions and exacerbations, and the size began to increase, while the surrounding parts took on an inflammatory action. The pain followed the course of the sciatic nerve on the side of the tumor, and after a while it became impos- sible to lie on the back or to walk. At this time the tumor had increased to the size of a child's fist, and rested on the left sacro-sciatic ligament. The skin and subcutaneous tissue over it were healthy and not adherent. The tumor itself was hard and somewhat elastic, and adherent to the subjacent parts. The tumor having been completely separated by enucleation and dis- section from surrounding parts, was cut away with curved scissors, care being taken to cut the osseous portion as much as possible in a longitudi- nal direction. The excised portion presented a fibrous shell, like that of a cyst, containing in its upper part a caseous, grayish substance which increased in consistence in proportion as it neared the base, where it was of fibrous hardness and appearance, then became fibro-cartilaginous, and, at the base, where it was adherent to the bony outgrowth from the coc- cyx, it was almost cartilaginous. The interior of the tumor was perfo- rated with spaces inclosing a liquid matter resembling pus. Cure. CASE XVI. Man, aged twenty-four years. Fibrous cyst, size of a pigeon's egg, filled with liquid contents. Cure. Mollirre also reports one case of his own, in a young girl in whom the tumor, the size of a small almond, was covered by healthy skin. From these cases, the general characters of these tumors may be deduced. The are generally soft, pasty, and indolent, covered by healthy skin, to which they are not adherent, and firmly attached to the sacrum or coccyx. They occur most frequently in adults, and seldom attain any size larger than that of a hen's egg. They grow slowly for a longer or shorter time, until an inflammatory action is excited, when acute symp- toms supervene, and they demand attention. They may contain seba- ceous matter, hair, or teeth, and may be located either within the rectum, which is very rare, or in the ano-coccygeal region, which is more common. While speaking of tumors containing hair, etc., it may be well to refer to an affection which Dr. Hodges, 1 of Boston, has described under tin- name of " pilo-nidal sinus" (pilus, a hair; nidus, a nest ), and which has for some time been known in French literature by the name of the posterior umbilicus. The affection is simply a ball of hair and dirt in a 1 Boston Med. and Surg. Journal, Nov. 18th, 1880. 154 DISEASES OF THE RECTUM AND ANTT8. sinus between the anus and the tip of the coccyx. The sinus is a deep, symmetrical, -somewhat conical dimple of congenital origin, representing an imperfect union of the lateral halves of the body, involving the integument alone, in which, as life advances, short hairs and other particles accumulate. These, by their irritation, cause a purulent dis- charge from the fistulous opening of the cavity, and when the case comes under the observation of the surgeon, it is usually mistaken for fistula- in-ano. The hair being removed, the sinus closes by granulation. This sinus is never found in children, never in men who do not have a large amount of hair about the nates, and so rarely in women that the records of the Massachusetts General Hospital include but a single instance, and in this patient there was, for a female, an unusual growth of hair. For the development of the affection, there are necessary a con- genital coccygeal dimple, an abundant pilous growth (hence adult age, ' and almost of necessity the male sex), and insufficient attention to cleanliness. The affection is, therefore, met with in persons of the lower class, and in hospital, rather than private practice. Hydatids. The number of hydatid cysts of the pelvis which have been reported is by no means inconsiderable. F. Villard ' has collected thirteen of them in women, and the standard surgical writers mention their occasional occurrence. Bryant mentions removing a "basinful" of secondary cysts from one in this position. These swellings are to be recognized by their tense, globular, and elastic feel, and by the fact of their causing no symptoms except those due to pressure, except in cases of suppuration after the death of the entozoon. The cyst has laminated walls lined with a granular layer, and is usually surrounded by a con- nective tissue capsule formed from the part in which it is imbedded. It may be of any size, and contains a clear, watery, albuminous fluid, in which may be found parts of the entozoon. Fc&tal Inclusions. In these congenital cysts, any foetal structure may be found. They are not so rare but that several very complete studies have been made of them. Molk* gives numerous examples; Yerneuil ' has collected ten cases; and Paul 4 has written exhaustively on the sub- ject, his article being founded on a study of twenty-eight cases. That variety which is located in the sacro-perineal region is the most fre- quent of all. The sac is composed of three layers, cutaneous, fibrous, and serous. The skin is thinned from distention, is violet or bluish in color from congestion, and an inflammation or a spontaneous rupture may cause perforation of the sac, and the escape of the fluid contents. The 'Considerations cliniques sur les Kystes hydatiques du petit bassin chez la fename. Annales de Gynecologie, 1878, p. 101. 8 Surgery, p. 152, Ainer. ed. 3 Arch. Gen. de Med., 1855. 4 Etude pour servir a 1'histoire des monstrosites parasitaires de 1'inclusion foetal situe dans la region sacro-perineale. Arch. Genl. de Med., t. xx., 1862. NON-MALIGNANT GROWTHS OF THE RECTUM AND ANTJ8. 155 fibrous layer may be more or less resistant. It is sometimes composed of a simple hypertrophy of connective tissue, at others, it is aponeurotic in character. When the sac communicates with the spinal canal, this fibrous layer is a direct extension of the dura mater of the cord. The is hiu T is smooth, and covered by pavement epithelium, and to one side of it the included foetus will be found attached. This may also be a continuation of the arachnoid of the cord. These cysts contain a serous fluid and foetal contents in the form of an irnrular mass, hard and soft in spots. Any and every part of a foetus may be discovered in this mass. The tumor is ovoidal in shape, resembling an egg when small, or the scrotum when larger. The size is generally equal to that of the head of the foetus which bears it, but some- times equals that of the head at term, and may be larger. The tumor may be bilocular, its contents generally give fluctuation, and are irre- ducible except where there is a communication with the spinal canal. There is no pain unless inflammation has supervened. The diagnosis is generally made by discovering a hard mass of foetal elements in the midst of a serous cyst. When the cyst communicates with the spinal canal, the differential diagnosis between it and a spina bifida may be impossible. Such a cyst may cause death by obstructing labor, or by the develop- ment of a gangrenous inflammation after birth. As a rule, operations for their removal have not resulted successfully when undertaken during the first three years of life. One operation practised at a later date has, however, been crowned with success. Spina Bifida, Concerning this variety of cyst little need be said ex- cept as regards its diagnosis. It should be borne in mind that a tumor due to a deficiency of the spinal bones may be entirely within the pelvis, in which case it would present great difficulties in diagnosis. Such a case is the following. 1 CASE XVII. Woman, aged 36, single. The patient stated that ten years before, she detected a swelling as large as a goose egg in the right iliac region, her attention having been called to it by shooting pains through the abdomen starting from this point. The size of the tumor increased slowly, had once caused retention of urine, and now caused oedema of the right leg. The patient was cachetic and emaciated. . . . The abdomen was uniformly enlarged and tympanitic. On making a vaginal examination, the cervix uteri could be scarcely reached, situated us it was above the pubes, while a mass was felt behind in the cul-de-sac, extending to the right, apparently an ovarian cyst. But from a digital examination in the rectum it was evident that the rectum was pushed forward by a large, soft, fluctuating tumor behind it. which filled up the hollow of the sacrum to within a short distance of the anus. . . . 1 Emmet: Prin. and Prac. of Gynaecology, 1st ed.. p. 156 DISEASES OF THE RECTUM AND ANUS. The patient was placed under ether, and a fine trocar was introduced into the sac, about three inches beyond the anus, by which an ounce or more^of its contents were aspirated by Dieulafoy's pump. This fluid was serous in character, perfectly clear and limpid, resembling hysterical urine. It contained no albumen, and the microscope revealed nothing more than a few oil globules, which had, beyond question, been attached to the instrument before its introduction. Autopsy nine and a half hours after death. On opening the abdomen, the colon was so much distended as to fill the whole cavity, and reached to a level of the fourth rib, being filled with flatus and faeces. ... A cyst which contained some three quarts of fluid was found behind and to the right of the rectum, filling completely the cavity of the pelvis, and extending up to a line with the second lumbar vertebra. . . . The rectum was greatly constricted in its upper portion .... In attempt- ing to discover the attachments of the cyst in the hollow of the sacrum it was ruptured. The sacrum was removed, and a spina bifida found, the three lower bones of the sacrum being deficient on the right side. A funnel-shaped opening communicated directly with the spinal canal, from which projected portions of the cauda equina an inch or more in length. . . . Although the posterior portion of the bones were wanting, no external bulging of the sac could take place posteriorly in consequence of the dense ligamentous structures bridging it over. The diagnosis of spina bifida can generally be made by the reduci- bility of the tumor, the signs of pressure on the brain and spinal cord which are produced by pressure on the tumor, the fluctuation at the fon- tanelles, and the chemical character of the fluid which may be withdrawn for the purpose of diagnosis. The fluid of a spina bifida contains both sugar and urea as does that of the cerebro-spinal canal, and though both these substances may be found in cysts entirely independent of the cere- bro-spinal canal, they will always be found in spina bifida. There still remains a class of congenital cysts which are neither con- nected with the spinal canal (spina bifida), nor parasitical (containing foatal remains). These are often of large size at the time of birth, and may consist of a single cyst or be multilocular. They are generally attached by a pedicle near the tip of the coccyx, though the cyst or cysts may have prolongations in the perineum or the ischio-rectal fossae. The cyst-wall in these cases is fibrous, and when many cysts are present it sends prolongations between them. The integument covering it is thin and generally marked by large veins. The cyst is filled with a yellowish, tenacious, gelatinous fluid, transparent to light as is a hydrocele. It will be seen at once that the great difficulty in diagnosis lies between this form of cyst and a spina bifida, and though the diagnosis may not always be possible, it will generally turn upon the presence or absence of the signs of communication with the spinal canal when pressure is made upon the tumor. NON-MALIGNANT GROWTHS OF THE RECTUM AND ANUS. 157 The treatment of these growths is by extirpation. Injections of iodine, ctr., have in them the element of danger from prolonged and ex- tensivi' .suppuration. When extirpation is attempted it should be com- plete; and where the cyst is multilocular it should be followed into the ne um and ischio-rectal fossae if necessary, in order that no parts of it may remain to undergo subsequent development. 1 These cystic forma- tions, unless of sufficient size to cause death during labor, are not incom- patible with life. 1 Buueau: Bull, de laSoc. Med. de la Suisse roraande (Molltere). 158 DISEASES OF THE RECTUM AND ANUS. OHAPTEE IX. NON-MALIGNANT ULCERATION. ' Varieties. Simple Ulcers. Generally due to Traumatism. Various Forms of In- jury to which Rectum is Subject. Sodomy. Injury of Rectum in Labor. Ulcers due to Surgical Interference. Fissure or Irritable Ulcer. Nothing Distinctive in the Ulcerative Process. Characteristics pf Irritable Ulcer. Theories concerning this Form of Ulcer. Description. Herpes. Tubercular Ulceration. Distinction between True Tubercular Ulcer and a Simple Ulcer in a Tuberculous Person. Description of Each Scrofulous Ulceration. Esthiomene. Rodent Ulcer. Dysentery. A Cause of Stricture. Venereal Ulceration. Gonorrhoea. Chancroids. Chancroidal Stricture. Discussion. True Chancre. Secondary and Tertiary Syphilitic Ulcerations. Diagnosis of Syphilitic Ulcers. Ano-rectal Syphiloma as a Cause of Ulceration. Ulcera- tion Secondary to Stricture. Gangrene. Symptoms of Ulceration. Gravity of the Disease. Diagnosis. Treatment. General and Local Measures. Treatment of Fissure. Fissure Complicated with Polypus. Treatment by Rest, Fluid Diet and Incision of the Sphincter. Local Applications. THE many different varieties of non-malignant ulcers which are met with at the anus and within the rectum may best be classified, from the stand-point of etiology, into the following groups: 1. Simple. 2. Tuber- cular. 3. Scrofulous. 4. Dysenteric. 5. Venereal. 6. Those due to- stricture. 7. Those due to gangrene around the rectum. Simple Ulcers. These are almost always of traumatic origin, and the most frequent traumatism to which the rectum is subject is, perhaps, that arising from the presence and passage of hardened faeces. From this cause alone, or from this, combined with their extrusion from the anus, the surface of projecting haemorrhoidal tumors may become ulcerated for a considerable extent ; and, by this means, a fissure is often produced within the grasp of the sphincter. The latter I have known to happen on the first evacuation of the bowels after an operation for haemorrhoids (the bowels having been confined by medicine for several days), rendering necessary the usual operation for its cure at a subsequent time. Another frequent cause of direct injury is the presence of foreign 1 A part of this chapter and of the following one, on cancer, originally appeared in the American Journal of the Medical Sciences. Oct., 1880; April, 1881. AUTHOR. NON-MALIGNANT ULCEKA I I> >N. 159 bodies, either fish-bones, date-stones, etc., which have been swallowed, or larLvr substances whicli have been intentionally introduced per anum. The presence of such substances may eiite extensive ulceration which will lead to subsequent stricture. infrequent cause of direct violence to the rectum, and of subse- quent ulceration due to the direct injury, and independent of any vene- real disease, is sodomy, either attempted or accomplished. Burgeon' describes the rectum of an idiot, who for a considerable time had prac- tised this vice, as much dilated and infundibuliform in shape, the niu- C"iis membrane as blackish, swollen, and ulcerated in spots ; and the sub- mucous and muscular layers as hypertrophied to four or five lines in thickness. It is doubtful whether passive pederasty should be included among the causes of stricture, as the injury done does not generally reach to this i- x lent ; and, indeed, the anus is not often dilated to any such extent as in this case. Ligg 2 describes a deaf-mute, thirty-five or forty years of age, the victim of this habit, whose anus offered no trace of traumatisiifc. ami was well closed, being marked only by the absence of the radiating folds. The mucous membrane of the rectum also was nor- mal. This absence of the radiating folds, together with the presence of spermatozoa in the rectum or in the mucous discharge from it, are given a- the best medico-legal proofs of the vice. An injury to which women alone are subject, and which is believed liy many to go far towards accounting for the greater frequency of ulcer- ation and stricture in them than in men, is bruising of the rectal wall between the head of the foetus and the sacrum in parturition. Most of the standard authors mention such cases. An ulcer of the rectum is a not infrequent result of surgical interfe- rence with diseases of this part. Although in certain subjects a wound made by the surgeon may refuse to heal under the best of treatment, ulceration from this cause will generally be found to be due to careless r ignorant manipulation, rather than to the unfortunate constitutional te of the patient. Two cases occur to me now: one of a large ulcer, with hard and elevated edges, looking much like a true chancre, which resulted fmm tin- persistent application of caustics to a simple fissure; and another, of three separate ulcers which marked the former site of three internal lia-niorrhoids which had been removed by ligatures. The patient suffered only slight discomfort from the operation, and wa>- allowed to L r o to Ins business on the following day a thing which may sometimes be done with apparent impunity, but which should never be 'omitetianced by the operator. The application of nitric acid to prolapse is said to have been followed by disastrous ulceration and stricture, but such need nut !.e the case; nor 1 Bull, de la Soc. Anat., 1830, p. 80. Corr. Bl. f. schweiz. Aerate, No. 8, p. 71, Feb. 1st, 1879. 160 DISEASES OF THE RECTUM AND ANUS. is any such use of the acid necessary to effect a cure iu any case where its use is indicated at all. Prolapse is not, however, a rare cause of stric- ture, due to the strangulation and sloughing of the prolapsed portion, and to the subsequent cicatrization. Irritable Ulcer, or Fissure. An injury due to any of the causes already mentioned may, in certain persons, and when located at the verge of the anus, assume the characteristics of an affection which has been elevated into a separate class, and is known as fissure, or irritable ulcer. The irritable ulcer differs in no respect from other simple ulcers in the same locality, except in the fact of its irritability. There is nothing peculiar in the ulcer itself. It may be due to a slight rent in the mucous membrane from hard faeces ; to a congenital narrowness of the anal orifice and a naturally over-powerful sphincter, 1 to the irritation of a leucor- rhceal discharge in women; to an herpetic vesicle, or to the venereal sore which it so strongly resembles the soft chancre. Any sore which is fairly in the grasp of the external sphincter is apt to become an irritable or painful one; and a fissure may be painless at one time and, painful at another in the same person, or painless in one person and painful in another. For this reason G-osselin" has divided these ulcers into two distinct varieties, the tolerant and intolerant a classification which Molliere 3 still further improves by suggesting the words tolerable and intolerable. An ulcer associated with contracture, spasm, irritability, and sometimes with actual hypertrophy of the sphincter is what is known as an irritable one; and without this condition of the muscle it will not properly come under this classification. This contracture of the muscle may be temporary or permanent, and is due to the irritation of the sensitive nerve filaments on the surface of the ulcer by the passage of fasces, and to the reflex action excited thereby; and to many slighter causes such as laughing, coughing, sneezing, or posi- tion. It may even come on spontaneously in persons of a highly nervous organization, or with such slight provocation as to appear to be spontan- eous. There are two well-known theories regarding the causation of this little sore. According to Boyer, 4 the foundation of the trouble is a spasm, of the sphincter muscle, and the fissure is merely a secondary lesion due to the passage of fteces through the spasmodically contracted anus. Trousseau, 6 on the other hand, reverses the relation, and very properly, holding that the fissure exists first, and that the spasm of the sphincter and 1 Sarremone, These de Strasbourg, 1861, No. 555, Molliere, p. 134. 9 Diet, de Med. et de Chirurg. Prat., art. Anus. 8 Op. cit., p. 149. 4 Traite des Maladies Chirurg., T. x., p. 105. 6 Clin. Med., T. iii., art. Fissure. NON-MAI. I<. NAM 1 ULCERATION. 161 tlie resulting pain are reflex, being specially apt to occur in persons of neuralgic tendency, and being in many cases merely the local manifesta- tions of a general nervous state. Although these ulcers are generally stated to be due to an actual lace- ration of the mucous membrane, or to its abrasion from some irritation, they not unfrequently originate within the sinuses o'f Morgagni and a true fissure may be entirely concealed from view within one of these pouches, as in the following instructive case reported by Dr. Vance 1 which for brevity I will slightly condense. CASE XVI. A lady, aged 18, had suffered for more than a year from all the symptoms of fissure, had been frequently examined to no purpose, and was reduced to a very miserable state. On examination the integu- mentary folds were congested, thickened, and cadematous, doubtless as a result of constant scratching, but there was no trace of anything like a ti ure. The lining membrane was searched with the utmost care, but no lesion of any sort was revealed except slight hypertrophy of the sphincter. A - cond painstaking review of every part of the rectum gave the same result, and the author was about to abandon the hope of finding any local lesion, when as a matter of form, for there was no evidence of disease about them, he determined to pass a probe into each of the pouches. The probe could not be forced into the first one, and with the second he fared no better, but with the third, after an ineffectual attempt, the probe passed into the sacculus. Xo sooner had the probe entered, however, than the patient screamed with pain, and there was a spasmodic ictraction of the levator ani and sphincter muscles and the part was forcibly withdrawn from view. The site of the sacculus felt as if a buck-shot had been imbedded in the tissues, so hard and swollen was the part. A small probe-pointed teno- tome was carefully passed along the canal, and as soon as the sensitive point was touched, the handle was brought down and the edge of the knife made to sever the inner wall of the sacculus and expose the diseased point. This done, the cause of the suffering was revealed. On the left side of the anus, and at a point where there had been no unusual sensi- bility. an indurated ulcer had formed within one of the little pouches. When the sacculus was opened and the ulcer exposed, it seemed very much like an ordinary ti^uiv of the anus, but before cutting it open there was no evidence whatever, .save the symptoms the patient complained of, to indicate the existence of such a lesion. These ulcers are generally situated at the posterior commissure, but may be found anywhere on the anal circumference. They are generally single, but when of venereal origin there may be two or three. They are more common in women than in men, because constipation is more common in the former and because the skin is finer. They are confined to no age . and Surg. Reporter, An-, llth. 1880. 162 DISEASES OF THE RECTUM AND ANUS. and are by no means relatively rare in infants. They are generally oval in shape with their long axis vertical, and involve both skin and mucous membrane, being situated just at the junction of the two. In some cases they have the appearance of a simple erosion, in others of on old ulcer with grayish base and indurated edges which has involved the whole thickness of the mucous membrane and extended fairly down to the mus- cle beneath. In the majority of cases they are not attended by suppura- ration or the discharge of pus. They may exist for years without gain- ing in surface or depth . Allingham 1 has pointed out how commonly they are attended by small polypi situated at their upper end or on the oppo- site side of the rectum; and they will often be found in con junction with haemorrhoids and condylomatous tags, the dragging upon which in the act of defecation has seemed to me in some cases to account mechanically for a slight tearing of the mucous membrane. An eruption of herpes around the anus, similar to what is seen on the lips, may result after rupture of the primary vesicles in numerous small superficial ulcers of a reddish color and secreting a little pus. These may coalesce at their edges and form a serpiginous sore. They are apt to be accompanied by similar eruptions on other parts of the body, and must be carefully distinguished both from mucous patches and soft chan- cres. The ulcerations which result from acute and chronic eczema and from pruritus present no special characteristics. They are generally due to the injury inflicted by the nails of the sufferer. From what has been said of the etiology of these simple ulcers it is plain that they must present many variations in appearance ; yet the diagnosis of each from the other, and of the whole class from those which are to follow, will not generally be found difficult if proper atten- tion is given to the history, the appearance of the lesion, and its course. The disease is generally of a healthy type, and tends to self-limitation and spontaneous cure rather than to increase. The ulcerative action is generally superficial, and tends to extend on the surface rather than in depth. It is generally surrounded by the signs of reparative action, and with proper care will undergo cicatrization which when extensive will result in stricture. Tubercular Ulcers. There are two varities of ulceration met with in persons of the tubercular diathesis ; one due to the actual deposit and softening of tubercle, the other a simple ulceration containing no tuber- cular deposit, but modified in its course by the patient's general condition of malnutrition. The former may properly be called tubercular ulcera- tion, and the latter is better known as the ulceration of the tuberculous. The former is very rare. It may occur in the rectal pouch or indeed any- where along the course of the alimentary canal, but its favorite site is at 'Op. cit., p. 192. NON-MALIGNANT II.CKRATION. 163 the verge of the anus where it may exist before any general manifestation of tuberculosis. The characters by which such an ulcer may be recognized are its pale- .-urface covered with a small quantity of serum but devoid of healthy pus and appearing as if varnished; the absence of all surrounding inflam- mation and of the granulations which exist in a healthy sore; its ten- dency to spread in depth rather than on the surface; the absence of any marked pain: the regular outline ending abruptly in healthy skin; and above all its chronicity and the utter failure of all remedies to affect its steady course. The diagnosis may be confirmed by the microscope 1 and the disease is analogous to tuberculosis of the larynx which, however, has been studied much more thoroughly. Whether such an ulcer is ever a cause of stricture is doubtful, it being doubtful whether a truly tubercular ulceration in this place ever heals, or, in other words, results in the formation of contractile tissue. It is exceedingly difficult to induce them to take on a healthy reparative action; and if cicatrization begins, the process is generally incomplete, and the cicatrix easily breaks down. Sands, 1 however, relates a case of stricture in a boy aged eighteen due to tubercular deposit, both in the rectum and peritoneum, for which he performed colotomy, the deposit being on the anterior wall at the level of the pubic symphysis, and the rectum being so nearly occluded as not to allow of the passage either of an instrument or an injection. On autopsy, a portion of the small intes- tine seven feet long, was also found to be so narrowed as to admit of the passage only of a full-sized bougie, but the narrowing in both cases seems to have been due rather to the encroachment of the tubercular mass than to cicatrization and subsequent contraction. A tubercular ulcer starting in the wall of the rectum may end in per- foration and fistula (fistula with largo internal opening), and, as a matter of course, the usual operation in such a case would be followed only by ippointment. Such an ulcer has also been known to cause sudden death from haemorrhage in a child, aged four years, the subject of acute general tuberculosis. 1 1 In the excellent monograph of Pean et Malassez, Etude clinique sur lea 1*1' ''-rations anales, Paris, 1872, there may be found the history of a case of tins kind with tin- in icroscopic report and drawing of Cornil. Gosselin also gives a clinical lecture on :i similar case in the Gaz. Med. de Paris, Mar. '.27th, 1880, call- ing attention to the main joints in the diagnosis and treatment; and Allin.^ham speaks of cases in which the diagnosis was confirmed by Paget, and remarks parenthetically that the disease is not as rare as is generally supposed. Other literature on the subject may he found in Hal-rsln>n, On the Diseases of the Abdomen, London, 1862, p. 302 et sei. : in Mollier.-. Tnute iles Maladies < considered one of its varieties; but it is distinguished from it clini- cally by the fact that it does not infiltrate surrounding tissue, does not involve the lymphatics, and does not become generalized. It is the same disease met with upon the face, and is exceedingly rare at the anus, being seen only twice in four thousand consecutive cases at St. Mark's Hospital. According to the classical description of Allingham, it is found by preference at the vrr^e <>f the anus, ami extending from this point up- 1 See also Huguier, Mem A- -a 1. d" MeL, 1849; Harday, Scrofule et Scrofu- . j> MI; and I\'-au rt Malassez, op. cit. 166 DISEASES OF THE KECTUM AND ANUS. wards into the rectum. It is irregular in shape, and its edges end ab- ruptly in healthy tissue. Its surface is red and dry ; it destroys superfi- cially, attacking mucous membrane rather than skin, and undergoes rapid but only partial cicatrization under proper local and constitutional treatment. It never entirely heals, and is not to be included among the causes of stricture. It is at first generally mistaken for a late syphilitic manifestation, but is distinguishable from it by the powerlessness of all treatment to prevent its steady progress. It is one of the most painful of all the ulcerative affections of this part, and ends fatally, unless some other disease cuts short the history. It is best treated by complete exci- sion, and this, in one case of Allingham's, secured immunity for a period of four years during which the patent was under observation. Dysentery. In dysenteric ulceration, the diseased portion of the lower bowel becomes infiltrated with fibrinous exudation, and, as a result of the compression which this exercises, is necrosed and sloughs. When the slough is cast off, there results a loss of substance, and if this is superfi- cial, the membrane may regain its former state ; but, if deep, the usual callous cicatrix is produced in its place, and stricture is the result. The ulcers resulting from this proces vary much in size, location, and appearance. They may be minute circles, but are generally large, and, though their favorite site is the rectum or sigmoid flexure, they may be found anywhere in the large intestine. They may extend so as to coalesce and leave only islands of mucous membrane between the ex- tensive patches. The process usually involves only the mucous coat, but may extend in depth, and result in perforation and its attendant evils. The coats of the bowel may become sinuous abscesses, so that, on divid- ing the prominent portion of mucous membrane between two ulcers, several drachms of pus may escape (Habershon). Although all the symptoms of dysentery may result from ulceration due to other causes, as in Annandale's case,' there is no doubt that in this country the disease is one of the causes of chronic ulceration and stricture, and Habershon con- cludes that the disease is more common in our climate than is generally supposed. In the Medical and Surgical History of the War of the Rebellion, 8 " Dr. Woodward remarks that stricture resulting from dysenteric ulcera- tion seems to have been much rarer than might have been supposed, and that no case has been reported at the Surgeon -General's office, either during the war or since; that the Army Medical Museum does not con- tain a single specimen ; nor has he found in the American medical jour- nals any case substantiated by post-mortem examination which this con- dition is reported to have followed a flux contracted during the Civil "War. In the Amer. Journal of the Medical Sciences, for April, 1881, 'Brit. Med. Journ., 1872, p. 681. s Part ii., voi. i. . Med. Hist. NON-MALIGNANT ULCERATIN. 167 I published a case which I then believed came under that category, and the subsequent history of which has only the more convinced me of the correctness of the diagnosis. rreal Ulcers. Gonorrhoea of the rectum has already been spoken of under the head of proctitis. Without attempting to decide upon the specific character of the inflammation which may follow the contact of of gonorrhoeal virus, it may be well to call attention to the severity of that inflammation and to the fact that it may cause ulceration and, probably, subsequent stricture. During the height of the process, the rectum is hot, red, swollen and granular, and there is an abundant purulent dis- charge issuing from the anus, from time to time in clots. The irritation of this may cause erosions and fissures which may reach a considerable size; or a previously existing fissure may become inoculated in this way and spread in extent. Chancroids. One of the most frequent of all the superficial ulcera- tions at the anus is the soft chancre. It is said by Pean and Malassez to have constituted nearly one-half of all the ulcerations in this region ex- amined at the Lourcine in 1868. It is much more common in females than in males, constituting one in nine cases of chancroids in the for- mer and one in four hundred and forty-five in the latter. 1 To account for this greater relative frequency only two things are necessary: the frequency of accidental contact of the male organ in coition and the facility of auto-inoculation which is due to the proximity of the vulva and vagina. These ulcers are seen either on the skin around the anal orifice, or just within the canal, and show a decided tendency not to pass above the upper border of the internal sphincter. So marked is this trait that their existence in the rectum proper I as been denied, and the mucous mem- brane supposed to furnish no suitable ground for their inoculation. They may be single or multiple, may be situated at any point in the anal circumference, or may completely surround it. In one case of my own, the anus was completely surrounded by a group of these sores, and the ulceration extended from the posterior commissure backwards in the intergluteal fold its whole length, as far as the base of the sacrum, being superficial, however, in the whole of its course. In such a case the pain is apt to be severe; a careful examination is impossible without ether. and there is often free haemorrhage. The bleeding at the time of defeca- tion was the chief cause of alarm to the patient in the case mentioned. These sores have the same characteristics as the soft chancre m other parts of the body. The class of women in whom they occur is always an aid to the diagnosis, and if suspicion as to their nature exists, the test of auto-inoculation may always be tried. Sores of this variety tend to spontaneous cure with cleanliness, and, if ' Fournier : Diet, de Med. et Chirg. Prat. Art. Chancre, p. 7,\ 168 DISEASES OF THE RECTUM AND ANUS. necessary, with judicious cauterization; and no matter how completely they may have involved the anus or the skin around it, they seldom leave any traces of their former existence. On the other hand, the cure may be delayed even for months, and the sore may assume a chronic type, due either to the existence of other disease in the rectum, as haemorrhoids, or to a syphilitic or scrofulous taint in the patient. They may be complicated by a chronic oedema of the surrounding parts, and resemble the lupus exedens already mentioned, or by the gangrenous process known as phagedaena, generally of the chronic variety, and advancing in one place while healing in another. And now we come to the debatable ground upon which so much has been said and written, and about which much still remains to be learned. Do these soft chancres ever cause stricture of the rectum, and are they the most common cause of those grave strictures so often met in women who have had syphilis, and which are generally known as syphilitic? In the light of our present knowledge, and yet subject to such modifications of opinion as future experience may teach, we shall answer yes to the first of these questions, and no to the second. That a soft chancre may extend into the rectum and cause great destruction of tissue, cicatrize, and leave stricture, is beyond doubt. Van Buren 1 says, " I have certainly seen this in several cases, but only in women;" Bumstead and Taylor 2 speak in the same way; Molliere 3 says, " Nevertheless, the soft chancre of the rectum does exist, and has even been seen to assume frightful proportions in this deep region;" and Bridge's 4 case is generally considered as conclusive, though its authority rests much more upon the well-known character of the men who pro- nounced judgment upon it than upon its history as it stands recorded; for there is at least a strong suspicion of syphilis, and there is no account of the crucial test of auto-inoculation. Dr. Mason's 5 paper to prove the chancroidal nature of this kind of ulceration and stricture has this great advantage over the similar one of Gosselm," that he leaves the reader in no doubt as to what he means by chancroid, and unhesitatingly adopts the dualistic theory. That this is not the case in the latter article, the reader may readily convince himself by a careful perusal ; and, for my own part, I am unable to see where in this justly-celebrated article the non-syphilitic nature of the affection in question is taught, for the author leaves us in absolute ignorance as to which of the two at present well-known varieties of "chancre " is, in his Op. cit., p. 243. s " Venereal Dis.," Phila., 1879. s Op. cit.. p. 677. 4 Arch, of Dermatology, Jan., 1876. * Amer. Journ. of the Med. Sci. Jan., 1873 * Arch. Geul. de Med. , 1854. .-MALIGNANT ULCEKATION. 169 opinion, the primary cause of the stricture; and it is rather by inference than otherwise that his " chancre " is interpreted to mean chancroid. The idea left on the mind of the reader is not that the disease is not -vphilitic, but that it is neither ;i primary, secondary, nor tertiary man- ution of syphilis, as such are generally understood, but something developed in the neighborhood of the primary sore. Gosselin, though he comes nearer to it than had ever been done before, just missed enunciating the chancroidal nature of these strictures, though Bassereau had distinguished between the two chancres two years before. What he does assert is, that they are not to be considered manifestations of constitutional syphilis, but that they are of local Character, " due to a special modification of the vitality of the tissues contaminated by the virus of the chancre, comparable to the lengthening ami hypertrophy of the prepuce with contraction of its orifice, which follows a chancre on its under surface, in which the disease is evidently neither an oedema, nor a specific induration, nor a constitutional affec- tion, but a local lesion, due to the presence of the chancres, and con- secutive to the inflammation which they have caused." In the same -s of lesions, he places hypertrophy of the labia, condylomata, and other vegetations. The weight of the evidence, then, is decidedly in favor of the occa- sional causation of stricture by the chancroid. But that all of the many so-called syphilitic strictures are not due to this cause is rendered certain by the fact that many of them occur in women above the suspicion either of a chancre or a chancroid, and many more are developed late in tho course of true syphilis, but are not preceded by any ulceration, chancroidal or otherwise, at the anus, and have their starting-point well above the sphincter muscle. Of the true nature of these we shall speak later. Chancre. True chancre at the anus is not very uncommon. Though Pean and Malassez saw only one case at the Lourcine in 1868, they explain the fact by the slight local disturbance which the sore causes so slight that fhe sufferers do not seek treatment. They give the propor- tion in this place as compared to chancres in other parts of the body as one in sixty-eight, and as much more frequent in women than in men (one in thirteen in the former, to one in one hundred and seventy-seven in the latter). These are about the same figures reached by Jullien. In the female, a sore in tins locality is easily accounted for by accidental inoculation; in the male, it means sodomy. They are most likely to be mistaken for simple fissures, but have a hard, raised outline and indurated base, are less painful, and devoid of the healthy surface of the former. In any case of suspicion, constitutional treatment should be delayed till the diagnosis is completed by the appearance of general .- inptoms. Truo chancre within the rectum is very rare indeed. Kicord, 170 DISEASES OF THE RECTUM AND ANUS. Fournier, and Vidal de Cassis each report a single case, and in the latter the induration is said to have been so great as to cause stricture. ' Molliere carefully analyzes the evidence on this point up to date, and concludes that though a true chancre may exist within the rectum, it never causes stricture, for the reason that it does not produce any great amount of ulceration, and that the induration tends to spontaneous resolution, or, at least, rapidly yields to the influence of mercury. The difficulties surrounding the diagnosis of such a sore are manifest. Its mere appearance would scarce be conclusive, and in women, the absence of any other sore which might cause secondary symptoms would need to be absolutely proved a very difficult thing to do. Secondary and Tertiary Syphilis. One of the secondary manifesta- tions of syphilis is to be looked for at the anus and rectum the mucous patch, not an infrequent sign in the former locality, and one liable to assume ulcerative action from local irritation or inoculation with the virus of the chancroid. Generally, however, they are devoid of symp- toms, and disappear spontaneously without treatment, or simply with cleanliness and the use of an astringent wash. That the mucous patch may appear in the rectal pouch also is rendered probable from analogy with the fauces, and such cases have been reported; 2 but as they never form cicatrices, they must be counted out of the etiology of stricture. Tertiary syphilis. Well marked cases of tertiary syphilitic ulceration in the rectum such as are seen in the mouth and throat are seldom men- tioned; and yet that they may exist and may cause extensive destruction is not only probable from analogy, but clinically true. Smith 3 says, " I am strongly impressed with the view that stricture of the rectum is produced either directly by the specific ulceration in the part affected, or by contact of the discharge from the surrounding parts." A sentence of which the the last clause weakens the first, for the question is not whether ulcera- tion may be set up in the rectum of a syphilitic person by the irritation of a discharge from the surrounding parts, but whether there is such a thing as true tertiary syphilitic ulceration of the rectum. Curling 4 describes a case presented by the late Mr. A very 1 at a meet- ing of the London Pathological Society, 5 which he says clearly showed the connection of the lesion with syphilis. " Immediately within the anus, which was surrounded by a circle of vegetations, the ulcer com- menced extending three inches upwards, 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 muscular fibres of the intestine quite bare. The 1 Van Buren. 2 Molliere, p. 641. 3 Diseases of the Rectum. 4 Diseases of the Rectum, p. 112. 5 Trans. Path. Soc., vol. i., p. 94. NON-MALIGNANT ULCERATION. 171 patient died with numerous indelible marks of syphilitic eruption on the limbs and trunk." Paget 1 also describes a case very fully and gives the main points by which syphilitic ulcers may be distinguished from tubercular; he says " The whole mucous membrane is destroyed except one small patch which is thickened and opaque. The exposed submucous surface has a lowly- tuberculated, undulating, uneven appearance, and is thickened by infil- tration. In the early stages the tissue is soft, as it is from recent inflam- matory effusion or oedema; but as the infiltration organizes it hardens, becoming callous, with fusion of the mucous and submucous coats, and then contracts and thus brings about the stricture. The affection com- monly extends from the anus, as if by continuity with the excrescence (condylomata), to about five inches up the rectum; but it is rarely so marked in the lirst inch of the rectum as it is higher up." In the case spoken of, there were also ulcers in the colon which, as the patient died of phthisis, had to be carefully distinguished from tubercular disease. He says, " On the mucous membrane of all parts of the colon there are ulcers of regular round or oval shape, from one-sixth to two- thirds of an inch in diameter, with clean, sharply cut, scarcely thickened Bf, surrounded by healthy or only too vascular mucous membrane. Their bases are for the most part level, flat, or with low granulations resting on the submucous tissue, nowhere penetrating to the muscular coat, with no marked subjacent thickening or hardening. On some of t hem are ramifying blood-vessels; on some few there is at the centre of the base a small island of mucous membrane, giving to the ulcer an evident likeness to the annular syphilitic ulcer of the skin." In a few places tiny had coalesced so that the annular shape was less distinct. In the colon they were continuous with those in the rectum which Paget conjec- tures to have been originally of the same shape. The diagnostic marks are thus given: " These ulcers were limited to the large intestine and decrease in size and number from the rectum up- wards conditions which I think are never observed in tubercular disease. There is not a truce of tubercle, i. e., of circumscribed, crude, or softening tuberculous deposit, in the submucous or any other tissue of the intestine, none in a Fever's patch, or at the base or edge of any ulcer, or in the sub- peritoneal tissue below an ulcer. The shape and other characteristics of the ulcers are quite unlike those of intestinal tuberculosis; they are regu- lar; 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 undermined, sinuous, thickened, or brawny or infiltrated; the subjacent and intervening structures appear health \ except at the rectum. These ulcers are not grouped, and where by exten- sion or coalescence they have lost their first shapes they have acquired one M.-.I. Times and iich produce them operate chiefly in females. Age has little influence upon 188 DISEASES OF THE KECTUM AND ANUS. 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 deposit, syphilitic sclerosis, or dysen- tery; 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, excoriations, and warty growths, together with the failure of the general health, gastric and in- testinal disturbance, and wandering pains. The one sign of a stricture is the obstruction, and this may show itself in several ways, generally at first by alternate attacks of constipa- tion and diarrhcea. The constipation is mechanical, and is due to the accumulation of fasces above the constriction. The diarrhcea is secondary to the accumulation, which, in time, begins to act as a foreign body, set- ting 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 accumulation. 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 flattened, 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 irreg- ular spasmodic action of the sphincters, or to pressure from without 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 Intestine; its Diagnosis and Treatment," in the British Medical Journal for May 31st, 1879, Mr. Stephen Mackenzie wrote: '' The fact that full-sized, properly formed fasces are occasionally passed, of course shows that there can be no 1 " With regard to the lessened diameter of the faeces, just noticed, which must necessarily be the case whenever a permanently contracted state of the gut takes place; yet it has happened in some instances where that change had been ob- served, that, in a more advanced period of the disease, faeces of a natural size had occasionally passed. The knowledge of this circumstance I consider of some importance, inasmuch as, if properly attended to, it will prevent the practitioner from hastily concluding 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 Intestinal Canal, etc.," Bath, 1815. NON-MALIGNANT STRICTURE OK THE RECTUM. 189 organic strictuiv." Under criticism, he withdrew the statement in the issue of the sumo journal for May 15th, 1880, with the explanation that it was founded on his personal observation, which hud since been supple- mented and corrected by that of others. In a case which I recently 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 sufficient calibre to admit the ends of two fingers easily. She had never noticed any deformity of the faeces. While under the influence of ether, and after the sphincter had been very thoroughly dilated, an O'Beirne's tube was passed through the rectum, which was empty, into the sigmoid flexure, which was full. After rest- ing 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 dilata- tion, 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 mucous membrane, which were crowded into it from above. While remarking to those pres- ent 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 each violent effort the stricture was forced down to the anus, the membrane above it was crowded into it so as to greatly lessen its cali- l<:-c, and a flat passage was the result. When the effort was less violent, tlu re was still a passage, but the stricture having risen to its place, and not being so tightly filled with the mucous membrane, the passage was natural. The lesson 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 faeces may be re- formed in the rectum below, and be passed normal in size. At the bed- side 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 ob- struction will be manifest by abdominal palpation and inspection. The transverse and descending colon can be felt partially distended with masses of fjeces, and will bo dull on percussion, tender to the touch. >"ine\vhat movable, and pitting 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 190 DISEASES OF THE KECTUM AND ANUS. not occur without ample warning in this way. It is preceded by eructa- tions of fetid gas, the abdomen swells and becomes very tender on pres- sure, 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 seri- ous 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 strangulation pain, swelling of the abdomen, bloody passages, etc., and it may be caused by some in- digestible substance which has been swallowed and refuses to pass the stricture, or merely by hardened faeces or prolapse of the bowel above into the constriction. The following case is one of quite a large class: " The patient, a middle-aged woman, was admitted into St. Bartho- lomew's Hospital with symptoms of sudden obstruction. She stated that she had enjoyed good health up to the onset of the attack, nor had she previously been troubled with constipation. The attack commenced sud- denly while at work, and was followed by obstinate vomiting and consti- pation. The symptoms having existed for some days, and the case appearing urgent, while the sudden onset of the symptoms suggested mechanical strangulation, it was deemed advisable to open the abdominal cavity. This being done, Mr. Marsh felt a hard cancerous mass in the walls of the bowel, which caused the obstruction. The bowel was opened above the obstruction, stitched to the sides of the wound, the patient making a good recovery. ' There is one important element in the obstruction due to stricture, which must not be forgotten. It will sometimes happen that fatal ob- struction will occur even when, on post-mortem examination, the calibre of the stricture is found -to be large enough to permit the passage of the finger, showing that the obstruction 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 turning 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 excrementitious 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 1 Cripps, Cancer of the Rectum, p. 107. NON-MALIGNANT STRICTITKK <>F THK KECTUM. 191 tumor? The folds of the contracted part did not appear after death to have been sufficient for an entire stoppage of this sort." 1 Notwithstanding the statement that the folds of the part did not appear aft IT death to have been sufficient to produce the stoppage, it us th;it ;i prolapsed fold of mucous membrane is the only thing likely to give rise to it. In cases of advanced disease a spasmodic stricture (if such ever occurs) would seem out of the question, whereas partial or complete in vagi nation in this part is known to be of frequent occurrence. As shown by Rokitansky, 3 the paralysis above the stricture is also an un- doubted element in the production of the occlusion. Diagnosis. The first means of diagnosis in stricture is the examina- tion with the finger, and as the great majority of strictures 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 stric- ture, 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 determined to practise divulsion, this is one way to do it, but at present we are speaking of diagnosis, and forcible dilata- tion is not diagnosis, but a very grave surgical procedure. The finger should therefore be passed slowly up to the stricture, and unless the cali- bre admits of it without straining, it should not be passed further. The condition of the parts below may also be appreciated, the amount of in- duration 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 valuable where the stricture cannot be felt by the linger, 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 symptoms of stricture of bhe upper part of the rectum 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 1 Hunterian MS. Cases and Dissections, No. 59, in " Descriptive Catalogue," vol. iii., p. 98. From Mayo, op. cit,, p. 249. Manual of Path. Anat.," vol. ii., translated by Sieveking. 192 DISEASES OF THE RECTUM AND ANL't. the patient is much more apt to suppose himself suffering from chronic constipation and dyspepsia than from haemorrhoids. Pain in the abdo- men, not always localized at the left side, pain in the loins and down the legs, obstinate constipation and occasional diarrhoea, are the things usu- ally complained of, and in these there is nothing upon which to base a positive diagnosis. The faeces may never present any peculiarity, for the reason that they are accumulated in the rectal pouch below the obstruc- tion 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 and one calling for careful phy- sical 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 question by the use of bougies is altogether unsatisfactory and by no means free from danger. It is unsatisfactory because an obstruction will generally be encountered 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 dangerous because, with the ordinary rub- ber rectal bougies, a diseased 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 to 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 has two objectionable features. It is not at all an easy instrument to pass, and if passed through an ob- struction too much force is required for its withdrawal after the abrupt shoulder is in contact with the stricture. O'Beirne gives the following description of the way to pass his tube: " A gum-elastic catheter of the largest size was inserted 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 seconds, then relaxed and again became renewed. By first yielding 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 obstruction suddenly gives way, and the instrument passes forward, will be an anxious one for the surgeon, and the life of the patient may be sacrificed to desire for certanity 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 NOX-MALIONANT STRICTURK <>F THE RECTTM. 193 Davidson's 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 mucous membrane are drawn out of the way by the distention of the whole bowel and one great obstacle is eliminated. The next is the pro- montory 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. In certain cases information may be gained by the use of a long cylin- drical speculum with the patient bending over the table or chair and straining down to bring the parts into view. Fortunately, however, we are not limited to cither of these means for a diagnosis, for, if the stric- ture be cancerous and of any size the mass may be felt through the abdo- minal wall by careful palpation; and if not, and the symptoms warrant it, the sphincter may be stretched or incised sufficiently to allow of in- troducing the hand into the rectal pouch. Passing the whole hand into the rectal pouch, and then the finger into the sigmoid flexure as far as possible, is a very different affair from trying to pass the whole hand into the flexure, and is free from danger, because the distention by the hand is not carried to the point where danger is located at the reflection of the peritoneum. Though seemingly a much more serious matter, it is really safer than any forcible use of the bougies, and by it the diagnosis maybe rendered certain for all that part of the bowel at present under consider- ation. I know of no other way than this by which a stricture in the sig- moid flexure which cannot be felt by external manipulation can certainly be recognized. Treatment. The treatment of stricture of the rectum is both constitu- tional and local, medicinal and operative. The first question to be answered is as to the advisability of anti-syphilitic 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 stric- tures as syphilitic and indiscriminately uses mercury and iodide of potash will bo mistaken about as often as he who looks upon most of his cases as cancerous and therefore incurable. The general condition of a patient with a stricture is never up to normal, and an unnecessary course of medi- cation may do great harm instead of good. Cicatricial tissue, though the result of specific disease, is beyond the reach of specific treatment, but where the case can be seen earlv enough, 13 194: DISEASES OF THE RECTUM AND ANUS. much improvement can be gained by a thorough course of mixed treat, ment 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 oinment 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, how- ever, an irritating application and in cases of much ulceration and sensi- tiveness 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 stand- ing, but yielded to a considerable degree to the use of mercury and iodide of potash internally, with glycerin applied locally. Van Buren 2 has also seen good effects in a case of this kind from the use of the modified Zitt- man's decoction, in mild doses, guarded by bismuth, combined with in- unctions of the oleate of mercury. The following case taken from Zappula 8 is worth reproducing entire, proving as it is supposed to do that a syphilitic stricture which is so ex- tensive as to give rise to the diagnosis of malignant disease may be made to completely disappear by specific treatment. The author says: "The patient who is the subject of this case is one of my colleagues and an intimate friend, a man thirty-six years of age and of nervous tempera- ment. The family history is good. The patient has always enjoyed good health with the exception of some attacks of malaria, a gonorrhoea contracted in 1851, and some months after an ulcer in the balano-prepu- tial fold, which was followed by a painful adenitis in the right groin which, however, did not suppurate. The ulcer was of considerable size, lasted about forty days, and ended by healing under the influence of re- peated cauterizations. Nothing more is known of the character of that ulceration, and it is impossible to establish any connection between it and the disease under consideration. But it is certain that the patient used in inunctions more than one hundred grammes of mercurial ointment, and that an examination of the former site of the ulcer shows now no trace of its existence. " The first symptom of the present disease was pain which started from the right side of the anus, extended as far as the tuberosity of the ischium on the corresponding side, or sometimes took an opposite course, but always was confined to the ano-rectal region . The pain was of neuralgic character, intermittent, returning with more or less frequency, but always very severe and accompanied by the phenomena of spasm, Defe- 1 Le Progres Med., June 22d, 1878. 5 On Phantom Stricture, etc. The Amer. Journal of the Medical Sciences, October, 1879. 3 Annali universal! de Medicina, vol. ccxvii., p. 137. NON-MALIGNANT STRICTUPE OF THE RECTUM. 195 cation became a little less frequent, but was painless except once when there was a sharp pain about the anus. A fissure was suspected, and though it was impossible to discover it, a suitable injection of laudanum and rhatany was administered. "The pain disappeared from the ischio-rectal fossae, but symptoms of impaction followed which purgatives in large doses failed to relieve, and which on the contrary led to still more alarming accidents. It was under these circumstances that I first saw the patient on the 24th of September. He had suffered for one month and his condition seemed to be very serious. Three large faecal tumors occupied the left iliac fossa, the epi- rium, and the right flank. Severe colic starting from the left iliac fossa extended over the whole abdomen and reached to the anus. The abdomen was swollen and painful to the touch, and pain was also caused by pressure in the ano-ischiatic region where, however, no trace of or- ganic disease could be discovered. An examination of the anus led to the discovery of a stricture so tight that only the end of the little finger could be introduced without causing great pain. "Such was the group of symptoms the patient presented when I first examined him: retraction of the anus and probably of the rectum; abso- lute necessity of causing the disappearance of the obstacle to the exit of faeces and of exciting intestinal contraction. But it was impossible for me to know whether the contracture was due to ragades located immedi- ately within the anus, to the neuralgic symptoms described above, or to some neoplasm in the lower part of the rectum. Nevertheless I attacked the symptom of contracture by the method of Recamier, and it may be imagined how painful this proceeding was while the state of the sufferer did not permit me to give ether. However, during the operation I dis- covered an enormous dilatation of the lower portion of the rectum from which escaped a considerable quantity of glairy matter. Twice after wards I administered large doses of purgatives, but the patient vomited them almost immediately, and the abdominal meteorism increased. Then the vomiting became spontaneous, the fever increased, and the symptoms of strangulation became so intense that the life of the patient ned to me about to be sacrificed, when again, under the influence of two inunctions of croton oil on the abdomen, there followed a tumultuous expulsion of faeces. More than twenty hard, round, faecal masses came away and after ibis relief all went well. But the patient's ease only lasted a few days, for the faeces very soon accumulated afresh, without forming tumors, however; the passages were made with difficulty; and purpitives administered from time to time caused the expulsion of har- dened masses mixed with mucus and somet imes with blood. However, the Buffering continued, and wa- especially violent after the administra- tion of purgatives even in small doses; the abdominal pain became more and more severe; the ischio-rectal pain, together with the neuralgia which he had at the commencement, returned and resisted the most pow- 196 DISEASES OF THE RECTUM AND ANUS. erful local anodynes; but tho anal spasm did not return. Inspitc cf these frightful sufferings there was as yet little loss of flesh. " But the organism could not long withstand such sufferings and ema- ciation supervened; there was fever at irregular intervals always preceded by a chill, and a pale-yellowish tint to the skin. An examination of the rectum, which had been delayed on account of the repugnance of the patient, was extremely painful; but instead of finding as before a consid- erable dilatation of the lower extremity, I found the tissues soft and uneven, giving to the finger the sensation of folds and anfractuosities, in a way that without a speculum examination would have led one to be- lieve in the existence of condylomata and extensive destruction of tissue; but by the aid of that instrument I was able to prove that we had to deal with an hypertrophy of the mucous membrane which was mammillated. " This condition was found completely surrounding the rectum and reaching as high as the eye could see. The sensation which my finger experienced could not, therefore, be due to a duplicature of the hyper- trophied mucous membrane. A sound introduced into the rectum passed freely eleven centimetres, but, arrived at that point, it was arrested by an insurmountable obstacle, and caused great pain. A second examination practised about a fortnight later permitted me to observe a small tumor on the right side of the intestine four centimetres above the anus. This tumor was the size of a hazel-nut, spherical, smooth, somewhat elastic, and indolent even to pressure. It was absolutely immovable and did not seem adherent to the mucous membrane beneath which it lay. But all these details were very difficult to appreciate well on account of the hy- pertrophy of the mucous membrane and the irregularities of its sur- face. "The retraction of the rectum was then an evident fact, revealed not only by the rational symptoms, but by the physical examination and the hypertrophic thickening of the mucous membrane. But the diagnosis of the nature of the constriction still remained doubtful, for the data fur- nished by direct examination seemed insufficient. We were therefore re- duced to making a diagnosis by exclusion, and rejecting successively the valves of mucous membrane, strictures due to ulceration or simple in- flammation, excluding also the idea of a spasmodic or venereal stricture, tubercular stricture, polypus, and haemorrhoids, we were naturally led to the conclusion that we were dealing with a cancer. However, we had no pathognomonic sign on which to base this diagnosis; and the origin and evolution of the disease were not those of cancer, the march of which is slow and rarely takes such an exceptionally rapid course. Thus, hesitating to admit a cancer, I thought of syphilis. But it was neces- sary to know for certain whether our patient was suffering from syphilis. It was necessary to be able to establish by well-observed facts that a syphilis may remain latent nearly nineteen years without causing any species of manifestation. The emaciation, the coloration of the skin, NON-MAI. I.-.VANT STRICTURE OF THE RECTIM. 197 the daily fever, all seemed to indicate the presence of cancer, and to ex- clude the idea of syphilis. " However, the powerlessness of art in the presence of a hetero- plastic lesion determined me to attempt an antisyphilitic treatment which I commenced by administering large doses of iodide of potash. After twelve days of this treatment, the patient experienced relief of all the worst symptoms. The first to yield was the ischio-anal pain which for some time had been exceedingly severe. The anal tumor diminished little by little, the mucous membrane subsided, there were several normal passages, the colic became less frequent and less severe, and disappeared finally after some violent pain which the evacuation of a considerable quantity of hard faecal matter provoked. 'From that time the passages were daily and easy, the local symptoms became definitely better. The flesh returned, the fever disappeared, with it disappeared the yellowish tint of the integument, and at the end of three months the patient was completely cured." This case is also quoted by Molliere 1 in full, as proof of what may be accomplished by anti-syphilitic treatment in syphilitic stricture. He re- marks that one such case seems to him to pass all comment; and to prove what caution should be used in the diagnosis of organic disease. That nothing in fact was more improbable a priori than the syphilitic charac- ter of the lesions of this patient, and that specifics saved him from certain death. He asks: " Is not one authorized, in the presence of one such extraordinary fact, to lay down the absolute rule that iodide of potash should be employed in all neoplastic lesions of the rectum?" To my own mind the case conveys a very different lesson from the one intended. It seems to me to prove nothing with regard to the effect of internal medication in syphilitic stricture, and to be one more example of a diagnosis of stricture based upon the fact that a bougie met with an obstruction at a point beyond the limit of touch and vision. It may be a case of syphilitic stricture cured by treatment, but the history does not prove it. There are various means by which the comfort of these sufferers 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 administration of laxatives on occasion, and rest. The diet should con- jsist mostly of fluids, preferably milk. If milk is complained of, soups may bo substituted. A certain amount of farinaceous food mav 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. 1 Op cit , p. 30C. 198 DISEASES OF THE RECTUM AND ANUS. Many patients will assert from the outset that they cannot take milk, but nearly all can take it, and considerable quanities 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 medi- cation 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. Purgatives are always contra-indicated in stricture of any variety, because they cause straining and tenesmus, increase the- tendency to congestion and its consequences, and because where obstruc- tion actually exists or is threatened, they may do great harm by exciting violent peristaltic 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 pos- sible 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 way of general treatment before resorting to operation. Food 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. Norman 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 condi- tion, but the rationale of its operation is not understood. No purgatives should be administered, and the bowel should not be tapped with the aspirator. The dangers of this measure have already been pointed out. 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 inter- ference was either declined or contra-indicated, and they can never be dispensed with, though an operation be performed. The various surgical procedures at our command for overcoming stricture of the rectum may be considered in the following order: 1. Dilatation. 2. Division. 3. Colotomy. 1. 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 efficacious than medicated ones, and the improve- ment was then supposed to be due merely to the mechanical stretching of the part, and the instruments were introduced as often, and allowed to Ni'N-MAMGNANT STRICTURE OF THK RECTUM. 199 remain in, as long as possible, an idea still very popular. But as Syrne 1 pointed out, "it is the effusion of organizable matter in the cellular ure 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 frequently repeated, there will be a great risk of a using 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. Attempts at constant dilatation by means of bougies of any sort which shall remain permanently in place generally ilt either in failure or actual disaster. They are not well borne by the patient, and when their use is persisted in, in spite of the protest which nature is pretty sure to make, the rectum becomes irritable, the suffer- ing is greatly increased, and the patient is exposed to the risk of peri- tonitis and cellulitis. The dilatation should never be forced. A bougie should be chosen which will readily pass the obstruction without stretching, and if there be any doubt in the operator's mind as to the proper size of the instru- ment to be used, let one be selected which is too small rather than too large. The instrument should seldom be passed more than every alter- nate day, and once a week may be often enough. Little is gained by allowing it to rest for any length of time within the constriction. Practised in this way, much good may be done by this treatment. 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 iised under false pretences 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 submitted to a long course of supposed dilatation, and there is but one way of con- vincing 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 ulcerution, dila- tation by bougies is very apt to make matters worse instead of better, and in .such cases I seldom employ it in my own practice and have seen much suffering caused by it in the practice of others. This treatment by gradual dilatation, perhaps on account of the recent great advances which have been made, in the treatment of stricture, has, to a certain extent, been superseded by more radical measures. It is not long since a well-written article on rectotomy in one 1 Op. cit., p. 120. 200 DISEASES OF THE KECTUM AND ANUS. of our periodicals 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 need not always be done with a bougie; for the patient's own finger or that of a careful nurse is often better than any instrument. 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 recommended, on account of the uncertainty and difficulty of its application. 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. In years gone by, this treat- ment 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 described. Divulsion. The dilatation, instead of being gradual, may be sudden and complete. For this purpose, various instruments have been in- FJG. 49. vented, all of them with the idea of tearing open the constriction by the use of a considerable amount of force. One of these is shown in Figure 49. More recently, advantage has been taken of fluid pressure, and an instrument has been invented by Wales, which is shown in Figure 50. Of all the instruments for forcible dilatation, this is perhaps the best. There are now several cases on record where forcible stretching with the fingers, either with or without previous nicking with a knife, has been followed by immediate relief to obstruction and faecal accumulation. 1 What may be accomplished, by this method is well shown in the fol- lowing successful case from Smith. 2 "I was called by Dr. Vine to see a military officer, aged 40, who had returned from India in the most mis- erable plight. He had suffered for several years from chronic diar- rhoea, and had not got relief from any measures, and six months pre- viously he had been recommended by a medical board to go by sea to England. On his arrival at Southampton, on his way to Edinburgh, his native town, he was so ill that he determined to stop in London, and 'Smith, op. cit. Dr. J. M. Matthew; remarkably successful case of this kind. 2 Surgery of the Rectum. of Louisville, Ky., has recorded one NoN-MALIONANT BTRICTURK OF THE RECTUM. 201 win 11 he arrived there ho sent for Dr. Vine, who, on hearing his his- tory, at once suspected something wrong with his rectum, and making an Fro. 50. examination, found an obstruction. I was requested to see him, and I found the patient exactly in the condition of one suffering from strangu- 202 DISEASES OF THE RECTUM AND ANUS. lated 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 some relief were not soon; given, this gentleman would die. "In conjunction with Dr. Vine, I made a most careful examination, 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 stricture, more like a dimple than aught else. I was enabled to introduce through this a No. 10 gum-elas_ tic 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 chloroform, and I guided a long, straight, probe-pointed knife very 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 obstruction, 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 posi- tion. The abdomen became quite flat, and the patient became at once immediately relieved. No bad results followed this operation; in three days we commenced dilatation by bougies, and I was soon enabled to pass a full-sized rectum-bougie through the stricture. In a fortnight I took my leave of the patient, recommending Dr. Vine to pass the bougie daily. I heard a few weeks afterwards that the patient had gone to Edinburgh convalescent, and able to introduce the bougie for him- self." 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 pos- sess 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, peritonitis, and abscess. The relief ob- tained is not permanent, and the operation involves the subsequent use of gradual dilatation to preserve the calibre gamed. 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 en- tirely by the sense of touch with a straight, blunt-pointed bistoury passed along the left index finger 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 confined within the rectum, N-MALIGNANT STRICTURE OF THE RECTUM. 203 ami does not involve the sphincter; and it is generally performed with tin- knife in preference to the cautery or ecraseur. Regarding this operation, there is not very much to be said. It in- volves no new principle of treatment, and would seem to rank rather with the older procedures, such as nicking and dilatation, than as a sub- ite for colotomy. There have been many unpublished cases, espe- cially in New York, and I should 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 ex- ternal operation, it is probably 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. This muscle should at K-as.t be stretched as a primary step in the operation, and, when possible, a large drainage-tube should be left in. 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 ante- rior as well as posterior, the anatomical relations must be borne in mind, lest the peritonaeum in the female, or the bladder in the male, be wounded. The following case represents my entire experience with the operation, which I abandoned after once trying, being convinced of the advantages of the external incision, next to be described. CASE XIX. Mrs. , age twenty-six. This patient was a woman with a syphilitic history. The stricture was of eight years' growth, and had previously been treated both by nicking and by gradual dilatation. As a result of this treatment, she describes an attack of "inflammation of the bowels," which made her very dangerously sick. The stricture was two and one-half inches from the anus, was of just sufficient calibre to engage the end of the index finger, and did not involve more than one inch of the bowel, though there was the usual amount of ulceration above it. I divided the stricture by a single, deep, posterior incision, which did not implicate the sphincter, and the operation was followed by an attack of pelvic peritonitis, which very nearly cost the patient her life. This may have been due to the operation, or it may have been due to attempts at subsequent dilatation which was begun early and followed with perhaps t<"> great vigor; but it was certainly excited by the patient leaving her hod, going down-stairs, indulging freely in wine, and submit- ting to the embraced of her lover. Three months after the operation, I completely lost track of the case. At that time the calibre of the stricture was so much increased as to per- mit, of easy diirital examination of the parts above. The increased sixe seemed due entirely to a deficiency in the old cicatricial tissue at the point of incision; the rest of the circumference of the part having much 204: DISEASES OF THE RECTUM AXD ANUS. the same feel as before the operation. The act of defecation was much less painful, and her condition was altogether much better. I never counted the case as proving anything concerning the value of .the operation until a few months ago, and more than four years after its performance. In fact, I had little doubt that the contraction had re- turned, and supposed the patient had either succumbed to the disease or submitted to colotomy. At that time, however, the woman was in per- fect health and spirits, and since then I have thought better of the ope- ration. I would have given much for a rectal examination after so long an interval, but it could not be obtained. Other cases of similar operations have been reported in this country with equally good results. 1 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 recently advocated by Verneuil, Panas, and others. It may be performed in several ways, and with the knife, galvano-cautery, or ecraseur. ^The operations with the galvano- cautery and ecraseur were invented by Verneuil, 2 and have been practised 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 gal- vano-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. 1 Whitehead Old fibrous stricture: anterior and posterior incision with bis- toury, followed by dilatation. Two months later, much improved; passages large and natural; dilatation continued. Amer. Jour. Med. Sc., Jan., 1871. Lente Fibrous stricture and fistula; incision followed by dilatation. Three months later, much relieved, with prospect of entire cure by continuing the use of bou- gies. Amer. Jour. Med. Sc., July, 1873. Beane Probably syphilitic; incision both anterior and posterior, followed by use of dilators. Seven months after, cure of ulceration and of many bad symptoms, but tendency to recontractkm. Amer. Jour. Med. Sc., April, 1878. 9 Verneuil : Des retrecissements de la partie inferieure du rectum, et de leur traitement curatif ou palliatif par la rectotomie lineaire, ou section longitudinale de 1'intestin a 1'aide de 1'ecraseur. Gaz. des Hop., October 26th, 29th; November 7th, 9th, 12th, 16th, 19th, 1872. Traitement palliatif du cancer du rectum au moyen de la rectotomie lineaire. Gaz. Hebdom. March 27th, 1874. NON-MALIGNANT STRICTURE OK THE RECTUM. 205 Nelaton's method was the simplest of all, and was to introduce the left index finger as far as the stricture, and with this 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 incision. In performing the operation, I prefer the knife to all other methods of cutting, and have had one specially adapted for the purpose, which is shown in Fig. 51. 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 awkward 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 stric- ture is divided completely, as near as possible in the median line Fio. 51. posteriorly, and finally the incision is continued downwards and out- wards, growing deeper as it approaches the perineum, till finally all the soft parts are severed between the anus and the tip of the coccyx. In this way, a large triangular wound is made, the apex being within 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, but I have never seen so much as to make me prefer the ecraseur id- cautery operation in preference to the knife. The rectum should at once be j Kicked 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. This operation may be modified in various ways to fulfil any special indication. In extensive cancerous disease, I have sometimes made two such cuts, and taken out a considerable mass of the growth between them, merely for the purpose of opening the canal. 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 drainage and discharge in the most effectual of all ways, by furnishing a dependent gutter- 206 DISEASES OF THE RECTUM AND ANUS. 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 completely di- vided, and another great point is gained. The operation we are now considering, it should be remembered, is nothing 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 sphincter muscle in the sufferings accompanying severe cases of stricture and ulceration, and the relief which may be obtained by its simple division without interference with the stricture itself. In one case of VerneuiPs, for example, there was a stricture high up, and yet, under a mistaken diagnosis of spasmodic stricture 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 es- tablish the general principle, 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 effected 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 usually cause more or less uneasiness on the following day, unless the patient be under the in- fluence 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 suppuration 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 cleanliness, which may 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. The case which follows will give a very fair idea of what may be hoped for from this method of treatment : CASE No. XX. Mrs. , age 35, mother of one child- twelve years old. The patient has always suffered from obstinate constipation, and several years ago was relieved artificially of impaction of faeces. Her husband,, a physician, assures me that there is no venereal history, nor is there any reason to suspect any such. The symptoms of rectal trouble began six years after marriage, at which time she was operated upon for NON-MALIGNANT STRICTURE OF THE RECTUM. 207 large internal haemorrhoids. Soon after this she began to suffer with the usual symptoms of ulceration of the rectum. The examination revealed advanced ulceration of the whole circum- ference of the rectum, with a stricture about an inch and a half up, which just admitted the end of the index finger. In connection with the stric- ture there were two fistulae. For this condition the patient had submit- ted to the usual treatment by dilatation, but without relief. Her gen- eral condition was such as is usually seen in advanced rectal disease. She had lost flesh and appetite, and the suffering was extreme. What she most dreaded was an action of the bowels, so great was the pain at- tendant upon it. The operation which I have described was performed. One of the fistulas was also cut, but the other was left to the chance of sponta- neous closure, since it communicated with both rectum and vagina, and the usual operation for recto- vaginal fistula would have been necessary hud any interference been practised. The operation was attended with considerable haemorrhage, which was controlled by stuffing the rectum . with picked lint, after the ulcerated surfaces both above and below the stricture had been renovated by scraping them with the handle of a ealpeL The subsequent treatment consisted merely in absolute rest in bed and milk diet, with a dressing of the wound by the introduction of picked lint. No attempt was made at passing a bougie, and the stricture was left entirely to itself. The immediate effect of the operation was a most marked and satisfactory relief of the most painful symptoms. The passages were involuntary, but were painless and always preceded by a warning sensation, which gave the patient ample time to prepare herself. At the end of six weeks she had improved greatly in general condition, and was more comfortable than at any time since the trouble began. The passages were of normal shape and occurred painlessly once a day. They were under the control of the will, but there was incontinence of wind. In this condition the patient returned to her home in the West under the care of her husband. months later, she again came to New York for treatment, not from any return of the pain, but because of the discharge from the bowel, and the occasional annoyance which arose from the incontinence of wind. Her general condition was excellent, and, except for the two things mentioned, she would have considered herself in perfect health. An exami nation showed a very marked decrease and softening down in the stricture tissue; the wound made with the knife had never entirely healed, the patient having exercised freely and constantly while at home, and there were two distinct lines of liberation within the anus; one on the anterior surface, superfu ial, about half an inch broad and. an inch and a half long; the other, at the site of the cut behind, deeper, and running further up the bowel. Otherwise the old ulceration was entirely 208 DISEASES OF THE KECTDM AND ANUS. healed, and its site marked by a thin, shining bluish-white cicatricial surface. Attention was at once turned to the treatment of this ulceration. The patient was put upon almost absolute milk-diet, and after awhile was also confined absolutely to her bed. The remnant of the old incision was induced to heal by daily dressings of lint and balsam of Peru, and the ulceration above was treated by applications of bismuth, opium, nitrate of silver, balsam of Peru, iodoform, and oxide of zinc, alone and in com- bination. At the end of a couple of months she was so nearly well that attention was turned to the recto-vesical fistula. The openings into the rectum and vagina Avere both small, but there was a considerable abscess cavity in the recto-vaginal wall which discharged into each canal. This cavity was freely laid open into the rectum. At the end of three months the ulceration on the anterior wall of the rectum had entirely healed, that on the posterior wall had nearly healed, the incision had cicatrized, and the abscess cavity had closed except an exceeedingly fine and tortu- ous canal leading from the rectum into the vagina. The discharge from the rectum had practically ceased, and in this condition, which certainly warranted a prognosis of complete and speedy recovery, she returned to her home to continue the treatment for a few weeks longer till she should be entirely well. Two months later I again heard from her, and the report was most favorable. This case is certainly worthy of a careful consideration. When the lady applied to me, all the supposed resources of rectal surgery had been exhausted except colotomy. I do not think I exaggerate when I say that most surgeons would have at once decided in favor of colotomy, and would have been justified, of course, in so deciding, for colotomy is still the recognized mode of treatment in these cases. In my own mind, colotomy was always present as the dernier ressort, but having tried proc- totomy in several instances, and been more or less satisfied with its results, I determined to make this a test case. The result was most happy, and yet there is nothing exceptional in that result, though the great tractability of the patient, and her determination to do all that was asked of her, alone rendered it possible. In an analysis of cases made some time since, 1 1 found that in eighteen cases of non-malignant stricture treated in this way, all the patients were greatly relieved as to general health, or local condition, or both. In eight, kept under observation for a period of from three months in one case to four years in three cases, the cure was absolute, there being no return of the contraction, and in some a disappearance of all.indura- tion. A tendency to recontraction is mentioned in four, due in two to the fact that all of the stricture was not divided. Brief notes of some of these cases are given below. 1 External Rectotomy as a Substitute for Lumbar Colotomy in the Treatment of Stricture of the Rectum. The N. Y. Med. Journal, March, 1880. NON-MALIGNANT STRICTURE OF THE RKCTIM. 209 External Rectotomy with the Knife. 1. PANAS. Female, aged 33. Syphilitic stricture, very dense and painful; eight years' duration. Incontinence for three months after operation. Eighteen months later, described as completely cured. Oaz. des Hop,, Dec., 1872. 2. WHITTLE. Hard annular stricture, very close; one fistula. Oper- ation as for ordinary fistule. Haemorrhage troublesome and controlled hermo-cautery. Three weeks later, " general health completely re- stored and local condition greatly relieved." Lancet, June 1st, 1878. 3. PANAS. Woman, aged 40. Stricture probably syphilitic. Two previous operations by slight internal incision, and two attempts at cure by dilatation. Patient very feeble; suffering from abdominal distention; signs of approaching occlusion; ovarian tumor; diarrhoaa and vomit- ing. Operation followed by relief of pain and by great comfort; no ten- dency to return; vomiting and diarrhoea continued till death, some time after, from exhaustion. Post-mortem examination showed the complete success of the operation, and the division in the fibrous tissue. Qaz. des >., Dec., 1872. External Rectotomy with the Ecraseur, Galvano-CaUtery or Thermo- Cautery. 1. TRELAT. Ano-rectal syphiloma, of several years' duration, with great thickening, ulceration, and fistulae. Operation (kind not stated) five years before, unsuccessful. Galvano-cautery. Nine days after oper- ation, pneumonia and facial erysipelas. Death ia three weeks without local accident. Prog. Med., June 22d, 1878. 2. VERNEUIL. Stricture of several years' duration; great induration and tumefaction, and twenty fistulous tracts. Three operations; lir.-t, on one-half the fistulae; second, on remainder; and third, on the stric- ture with Scraseur. Four months later, " wound healed and functions of the rectum entirely re-established." Oaz. des Ho])., 1872, p. 1,028. 3. VERNEUIL. Previous syphilis; great constitutional disturlum-e: scrotum enlarged to three times its natural size by fistulous tracts, of which there were twelve. Ecraseur through one of the fistulas otlu i s operated on a month later. Two years later, parts had iv^aiiK-d tln-ir suppleness, and all traces of disease had disappeared. Loc. cit. 4. VERNEUIL. Patient in l>a\ every possible means; and that the incision may be only the first step in the cure. The stricture is easier to overcome than the ulceration which accompanies it. In the case given above, I succeeded ultimately by long and patient effort in curing that also, but it cannot be done in every case. In many of these cases the ulceration must be treated as ulceration with the same results, both good and bad, as usually attend the treatment of that most painful, obstinate, and often incurable condi- tion. But the chances of curing it, and at all events of relieving it, are infinitely better after the operation than before. It is understood that I do not advocate the operation in cases of dis- ease high up in the bowel, though it may be safely done at a considerable distance from the anus, and where an incision involving the anterior wall would be unjustifiable, for the anatomical reason that the peritoneum extends so much lower in front than behind. For other literature upon this subject, the reader is referred to the bibliography given below. BIBLIOGRAPHY. Panas: Du traitement des retrecissements du rectum par la rectotomie externe, Gaz. des H6p., December, 1872, p. 1,148. Muron, A.: Des retrecisseinents de 1'extremite inferieure du rectum, et de leur guerison par la rectotomie lineaire. Gaz. Med. de Paris, January 4th, 1873. Fochier, A. : Sur 1'application de la rectotomie lineaire aux retrecissements tres-etendus du rectum. Lyon Medicale, February 20th, 1876. Pinguet: Des retrecissements du rectum; appreciation des diverses methodes th.'-rapeutiques. These de Paris, 1873, No. 17. Tison: Nouvelles considerations sur la rectotoraie lineaire. These de Paris 1877. Turgis: Foreign Body in Rectum. Bull, de la Soc. de Chin, tome iv., No. 10, 1878, p. 789. Cerou: These de Paris, 1875, No. 390. 214: DISEASES OF THE KECTUM AND ANUS. Whitehead, W. R. : Case of Fibrous Stricture of the Rectum Relieved by In- cisions and Elastic Pressure, with Remarks. Amer. Jour. Med. Sc., January , 1871. Whittle, G. : Stricture of the Rectum Divided by the Knife. Lancet, June 1st, 1879, p. 788. Lente, F. D. : Report of a Case of Non-Malignant Stricture of the Rectum, and Remarks on the Surgical Treatment of this Disease. Amer. Jour. Med. Sc., July, 1873. Beane, F. D. : Case of Specific Stricture of the Rectum; Antero-Posterior Linear Rectotomy; Recovery; Remarks on the Operation. Amer. Jour. Med. Sc., April, 1878. Discussion sur les retrecissements du rectum. Bull, de la Soc. de Chir., Paris, 1873, p. 83. Verneuil, et al.: Rectotomie et colotomie (Soc. de Chir., Paris). Prog. Med., January 7th, 1882. Excision. The operation of excision, which is generally applied only to cancerous strictures and which will be fully described under that head, has also been applied to simple strictures; and, though I have never done it myself, I have seen a few cases which seemed particularly adapted to it. One such case is reported by Dr. Lowson ' in which the result was comparatively good, though no better than that obtained by proctotomy. The operation performed by him consisted in dividing the external sphincter posteriorly, so as to arrive at the stricture, pulling it down through this wound when possible, dividing the bowel above and below it, dissecting it out from its attachments, and uniting the two ends of the bowel by sutures. In this case there was considerable difficulty in the subsequent union of the parts, and after healing had occurred, there was considerable contraction, but the condition of the patient was greatly improved. Colotomy. This is the last resort of surgery in dealing with ulcera- tion or stricture of the rectum. In ulceration it may be a curative mea- sure; in stricture it is only palliative, and it should therefore not be undertaken till other measures have failed. It is intended to fulfil two important indications, the relief of pain, and preventing or overcoming obstruction, and we have already seen how both of these may be met in many cases by other means which, even when only partially successful, are much preferable. When none of the methods already pointed out serve to assuage the suffering, and when it is probable that the suffering is not due to an irritable sphincter muscle, or to pressure on neighboring nerves from the mass of the deposit, cancerous or otherwise (in which latter case cqlotomy cannot be expected to afford relief), and when none of the means already described for preventing or overcoming obstruction can be applied, colot- 1 Case of Stricture of the Rectum, treated by Excision of the Stricture. Lan- cet, April 12th, 1879. NON-MALIGNANT STRICTURE OP THE RECTUM. 215 omy may be resorted to. There is, however, but one class of cases 'in which obstruction may not be overcome by attacking the stricture itself, instead of the bowel above it, and that is where the stricture is too high to be safely reached by the knife, and where, even then, dilatation is too painful or too dangerous to be admissible. Judged by these rules, colotomy would be limited to a small propor- tion of cases. It would be tried after division of the sphincter and of the stricture had each failed to give relief in disease near the anus; and practically would be limited to disease high up in the bowel. Such re- strictions as these would greatly limit the number of operations especially in the United States, and I am not sure that this might not be done with advantage. We seldom see in the reports of this operation in current literature any other reason given for its performance than the mere ex- istence of obstructive or painful disease; and yet I doubt if the mere presence of a stricture of the rectum, malignant or benign, is a justifiable reason for the performance of this repulsive and serious operation. It has yet to be proved that colotomy delays cancerous growth, though it certainly prolongs life by diminishing pain and overcoming obstruction. But the relief to the pain may be and often is only partial, for a small amount of faeces which has passed the artificial anus may cause as much suffering and tenesmus as the natural quantity. In almost direct proportion as the operations of proctotomy and of partial or complete excision of strictures have become popularized and their advantages in suitable cases have become manifest, the operation of colotomy has been limited and the natural objections to it, both by patient and surgeon, have been allowed more weight in influencing the treat- ment. Especially is this the case in France, the birthplace of the opera- tion, and in Germany, while England, as represented by Allingham, is plainly following in the same course. In this country alone does coloto- my still hold its sway partly for the reason that its substitutes have never been so thoroughly tried here as on the other side of the water. It would be easy at the present time to collect a much larger table of cases of this operation than was accessible to Mason when he published his paper on this subject, hut I do not know that anything would be added to our general knowledge of the subject by such a labor. Allingham had operated at the time of his last edition twenty-seven times. His best result was obtained in a man with a scirrhous growth filling up the pelvis, in whom life was prolonged four and a half years after the operation. Another case, a woman, lived nineteen months, twelve of them in won- derful comfort. Only three of his patients died within a fortnight of the operation, one from phlegmonous erysipelas, another from exhaustion; and the third, in nine days, in whom there was complete obstruction at the time of the operation; and in whom paracen: abdominis was performed immediately after the colotomy; acute pleurisy being the imnmliatc cause of death. Curling has performed the opera- 216 DISEASES OF THE RECTUM AND ANUS. tion eighteen times with seven fatal results; two from chloroform, one from already existing peritonitis, another from peritonitis arising inde- pendently of the operation, but immediately succeeding it, one from pyaemia, and two from exhaustion, one on the sixth, and the other on the twelfth day. Bryant records fifteen operations of his own, four for vesico-intestinal fistula; two for pelvic tumor; and nine for stricture, cancerous and otherwise. Of these latter, one lived eighteen months in comfort, dying at last supposably of cancer of the liver; two lived two and four months respectively; one lived thirteen days, and two three days; in these cases the operation having been undertaken too late to prolong life. One died of peritonitis due to the operation, and three were alive at periods varying from one to three years. Bulteau 1 has collected one hundred and forty two cases of lumbar colotomy from the statistics of Doliger, Mason, Hawkins, and Heath. Of these ninety-two recovered and fifty died. These figures are about the same as those reached by D'Erckelens. 8 These figures show as well as would a more elaborate collection of cases the general results of the operation itself, the dangers which attend it, and especially the danger of postponing its performance till the patient is at the point of death. These patients sometimes sink with unexpected rapidity at Uie end, and when seemingly no worse than for weeks before are often very near death. In my own experience I have had a patient die in the night upon whom I intended to operate in the morning. Although an artificial anus is justly regarded as being only a substi- tute for death itself; and although many patients will deliberately choose the latter to the dangers and results of the former; it is astonishing how comfortable a patient may be with one where the retention of faeces is good. Bridge's case," in which the prostitute followed her customary avocation after its performance, is certainly an exceptionally favorable one, but it illustrates what may be done. Still we have Allingham's 4 testimony that " this operation, though doubtless it may prolong life, should not be resorted to without due consideration, because one cannot fail to see in many cases the remedy proves a most objectionable one; an opening in the left loin through which the faeces escape is very harassing and nothing but a great desire to live or the fear of immediate death would lead me to submit to such a proceeding. I presume after years the patients get used to the discomforts and loathsomeness of their condi- tion. My patients who have lived long seem to have had some pleasure in life; indeed, two women were married after the operation; but with all that I entertain repugnance to the operation greater than I formerly used, 1 De 1'occlusiou intestinale au point du vue du diagnostic et du traitement. These de Paris. 1878. Arch, fur Klin. Chirurg., vol. xxiii,, 1 Heft, 1878. 5 Loo. cit. 4 Loc. cit , p. 253. NON-M A.L1GX ANT STRICTURE OF THE RECTUM. 217 and latterly have mostly performed it as a last resource or for total ruction." The operation has already been described. A free discharge of faeces nuiy follow the opening of the bowel, or there may be only a slight escape of fluid. It is better for the patient that the evacuation should be post- poned till the edges of the wound have become agglutinated, as in this \vay the danger of extravasation is diminished. Morphine should be given hypodermically to keep the bowels as quiet as possible till cicatriza- tion is complete. Only the simplest dressings and perfect cleanliness are necessary in the way of local treatment. The sutures may be left in till they commence to cause suppuration. If the bowels are slow to empty themselves, an enema may be administered, or a scoop used through the new opening and a purgative may be given by the mouth. No change is necessary in the ordinary diet after the second day. The patient should be kept in bed for two or three weeks till cicatrization is complete, and then a pad must be arranged to cover the new anus and prevent leakage of faeces and prolapse of the mucous membrane. Bryant says some of his patients have found great comfort from the use of an india rubber ball with one of its sides cut away sufficiently to cover the new opening. It holds any little faeces which may come away, besides preventing the escape of flatus and serving as a pad. Annoying prolapse is not as apt to occur with the oblique incision as with the old vertical one, nevertheless, it may be expected in some degree, and the patient should be taught to exercise the greatest regularity in re- lieving the bowels early in the morning. Should faeces pass the artificial opening, as they are apt to do, they must be removed by enemata, for a very small quantity will cause great jiain and a constant demand for their removal. It will at once be seen that the treatment of a stricture high up in the rectum or in the sigmoid flexure must be conducted on entirely differ- ent principles from one within reach of the finger. In the latter case, the disease itself may be directly attacked with the bougie or the knife; m the former, both are nearly out of the question, and the surgeon is in reality limited to attempts at warding off the natural effects of the malady; in other words to preventing the occurrence of intestinal obstruction, and forming an artificial outlet for the contents of the bowel when obstruction Ls threatened. The medicinal means of pre- venting obstruction, and of overcoming it when actually impending, have already been referred to in the chapter on prolapse and invagina- t ion. In cases of cancerous disease, attention must be given to cleanliness ;K well after as before the operation, and this Is best secured by frequent injections of an unirritating disinfectant, as the permanganate of potash. In cases of non-malignant ulceration, the diseased surface may be treated after the operation as before. 218 DISEASES OF THE RECTUM AND ANUS. CHAPTER XI. CANCER. General Characters of Malignant as Distinguished from Benign Growths. Malig- nant, Semi-Malignant, and Benign Adenoma. Encephaloid. Colloid. Melanotic Cancer. Osteoid Cancer. Age at which Cancer occurs. Symp- toms. Diagnosis. Treatment. Excision: History and Results of Operation. Conclusions Regarding Excision. Modes of Performing the Operation. Excision of Cancer of the Sigmoid Flexure. Palliative Treatment. IN a general Avay it is undoubtedly true that new growths in the rec- tum, when benign, increase slowly, tend to grow away from the wall of the bowel, to form pedicles for themselves, and to project into the calibre of the canal, to remain movable, and not to involve surrounding parts; while with cancerous formations the tendency is just the opposite. In this way the diagnosis between a benign polyp and a cancerous nodule in the wall of the rectum is generally easy. But there is a class of tumors which occupy the border line between the benign and the malignant, in which the dignosis either clinically or with the micrscope may be difficult and even impossible. In fact recent careful study of these rectal tumors goes far to break down the lines be- tween the varieties which are usually drawn, and Cnpps,' who has done such careful 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. 52 with Fig. 45, 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 1 Cancer of the Rectum, London, 1880. Also Adenoid Disease of the Rectum. Trans. Path. Soc. of London, 1881. CANCKK. 219 marked pedicle, and projects into the cavity of the bowel, he says: ' In the more malignant varieties, the new growth frequently spreads as a thin layer between the muscular and mucous coats. In this form it often occupies several square inches of the bowel, while its thickness does not exceed a quarter of an inch. At first the mucous membrane lies intact over such a layer, but eventually it gives way by ulceration. This ulcer- ation sometimes begins at more than one point, so that the mucous mem- brane becomes honeycombed, and portious 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 pro- ceeding toward the centre, the growth is advancing towards the circum- ference. 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 process. The Fio. 52. Cancer of the rectum Malignant adenoma (Stimson). margin of the crater consists of the mucous membrane of the bowel, heaped up by the extending growth beneath it, tucking it over in such a manner as to overlap the healthy membrane. The border is at times so irregular as to represent a series of nodules rather than a continuous line." ison ' lias 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 portion-, must bo examined, as in carcinoma 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 epithe- lial elements, 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 character known as polyp 1 A Contribution to the Study of Cancer of the Rectum. Archives of Medi- August, 1879. 220 DISEASES OF THE RECTUM AXD ANUS. of the rectum or polypoid adenoma. The formation of a pedunculated growth with a tendency to isolation 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 degree 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 nmcosse remains unbroken until the young embryonal cells produced below it, in conse- quence 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 fasces lengthens its pedicle and tends towards its final separation. " On the other hand, if a broader area is occupied by the primary 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 by the partial pedunculation, into the sub- mucous tissue. Once established 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 innumerable 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 para- rectal tissue on the other. Here, too, the intensity of the process materially affects the rapidity of its extension, for if the proliferating connective 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 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 epithclioma, and this presents itself, here as elsewhere in the body, under two forms distinguishable with the microscope and clinically. The first (cancroid, lobulated epithelioma) 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 CANUKK. 221 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 epi- dermis, and only begins to ulcerate late in its course. It seldom 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. In the other variety (cylindrical epi- thclioma), 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 infil- trates 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 containing 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. .t to epithelioma, scirrhus, or hard cancer, is the variety most frequently met with in the rectum. It arises, not, like epithelioma, in the mucous membrane, but in the submucous connective tissue; there- fore in the early stages of its growth the membrane is found normal and movable over the hard mass beneath. When cut into it shows the characteristic, raw potato-like hardness of scirrhus, and there is no dis- tinct line of demarcation 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 the bowi-1 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 witli an irregular outline is formed in the midst of the hard cancer tissue, from which issues a fetid 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, 1 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." 1 It 1 Allingham. Molliere. 1 Moore, see Bryant's Surgery. 222 DISEASES OF THE RECTUM AND ANUS. spreads by infiltrating all the adjacent parts, eventually involving all the coats of the bowel, and extending both in surface and in thickness till, instead of appearing as a hard, movable spot under the mucous mem- brane, it involves a great part or the whole of the circumference of the rectum, inclosing 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 consideration the history of the case, it will often be impossible to distinguish between the gross appear- ances of scirrhus and those of simple fibrous stricture. I have now under treatment, at the Infirmary for Diseases of the Rectum, a case of stric- ture which I believe to be dysenteric in origin, in which the extent of the disease is fully as great as in any hard cancer I have ever met with, and yet which has been eighteen years in developing. Enceplialoid has its primary seat in the glandular tissue of the mucous membrane. It is inclosed m a capsule of connective tissue, from the internal surface of which spring trabeculae which divide the mass into lobules. On section, it may be comparatively firm or nearly fluid, and almost white or stained red with blood. It is often very vascular; large vessels may sometimes be seen on its surface, and large blood extravasations may be found in its interior. The name fungus haematodes 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 bo 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 diffused through it, giving it a milky hu->. 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 attain an immense size, fairly filling the pelvis. They quickly affect the neighboring lymphatics, and, when enucleated, speedily recur. The results of removal are, however, particularly favorable for a short time, as shown by the immediate improvement in the general condition of the patient, and the disappearance 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 sarcoma), the structure is essentially the same as in the last variety, except that the alveolar meshes are filled with a mucous, glue-like material, which m 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 very rare in this part, and appears in the shape of large, lobulated, fungus-like tumors, which are soft and easily broken down. Under the CANCER. 22:) 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 infil- trates the surrounding tissues, and secondary deposits will often be found in the neighborhood of the original mass, the whole tending to undergo cystic degeneration. The malignancy of these tumors varies in degree, some of them being comparatively benign; they do not always recur after removel, nor do they readily infect the lymphatics and era, 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. The following description of a case illustrates very per- fectly the general characteristics of colloid: CASE XXII. "The patient was an old woman, and the case was peculiar, in that the colloid material was contained in cysts of various sizes, pressed firmly one against the other, so that the disease might be called multiple cystic colloid degeneration. The anus was surrounded with a large number of tumors of unequal size, of which several, larger than the rest, were surmounted by smaller ones in such a way that the anus occupied the bottom of an extremely deep infundibulum. Two superficial liberations were to be seen at the margin of the anus. The finger recognized at a short distance above the anus an ulceration in the form of a zone, which was deep, had destroyed all the thickness of the rectum in a part of its circumference, and communicated with fistulous tracks, which penetrated into the substance of the diseased skin adjacent to the anus. The degeneration, which had given the rectum an enormous thick- ness, ceased abruptly nine or ten centimetres from the anus. Immedi- ately above, the rectum presented considerable hypertrophy in the muscular layer. This affection, which had all the characters of colloid degeneration, presented an arrangement in its upper two-thirds which I had never before met with, and which I will try and describe. Let one imagine a number of acephalocysts of unequal size (some of them as large as pigeons' eggs) squeezed tinnly one against the other, and held in a fibrous network, and one will have an exact idea of the change. Only these were not acephalocysts. The covering of each cyst was fibrous, very thin, and yet very strong : the matter contained in them exactly resembled currant jelly, on the surface of which had been deposited a cretaceous matter exactly similar to that which sometimes covers the excrement of birds. This cretaceous matter contained calcareous con- cretions. In the centre of the jelly-like substance, two or three blood- vessels were to be seen, similar to those which form in a hen's egg vessels without walls, ending in an enlargement of one extremity. The fibrous network in the midst of which these cysts were inclosed was evidently made up of the transformed coats of the rectum. I could 224 DISEASES OF THE RECTUM AND ANUS. recognize the longitudinal fibres of the rectum. There was also adipose tissue, an evident proof that the degeneration had not only invaded the rectum, but had developed at the expense of the adipose tissue of the pelvis. The lower third of the rectum presented no sign of a cyst, but an areolar tissue, with fibrous meshes, which occupied all the circumference of the anus; this tissue was filled like a sponge with colloid matter, which could easily be pressed out, and the tissue itself was approaching erosion or ulceration. The areolar and gelatiniform degeneration appeared to me to penetrate into the thickness of the skin of the anal region; while an extremely thin, almost epidermic, pellicle had resisted and covered the swellings on its surface. In the vicinity of the circular ulceration of the rectum, the colloid matter had not undergone degenera- tion, only it was permeated by an increased number of blood-vessels. Behind the rectum was a colloid alveolar mass, all the areolae of which contained blood-vessels. This mass had evidently been formed at the expense of the circum-rectal adipose tissue." 1 Cruveilhier draws this distinction between colloid and encephaloid. The colloid degeneration is not susceptible, as is the encephaloid, of inflammatory action producing gangrene; moreover, if the sanguineous centres are not absolutely foreign to it, it is certain that they are incom- parably 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 destruction by encroachment in successive layers; this encroachment, sometimes rapid when it occurs in the alimentary canal, permits of the re-establish- ment of the flow of faeces, temporarily interrupted by the undefined and often very rapid increase in the degenerated parts; so that, to the gravest signs of fecal retention, there sometimes succeeds a more or less, rapid separation, with or without diarrhosa. 1 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 distinguishing 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 ten cases only, which have been given in full in an exhaustive study by Nepveu, read before the Societe de Chirurgie (1880). 3 The cases are reported by the 1 Cruveilhier, Traite d'Anatomie Path. Gen., t. v., p. 67. 'Ibid., p. 69. * " Memoires de Chirurgie," Paris, 1880. < A. NX'EE. -'-.' following observers: Schilling, 1 Kopp, 1 Moore,' Maier,* Virchow,* Ash- ton/ Gross, 7 Meunier,* Gussenbauer/ and Nepveu." From the six of these cases which aro 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, one only in a woman. In the microspic 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 distinguish this form of disease from others, except that in one case the stools were colored black from mixture with the pigment 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, twice in the rectum above the sphincter, and four times at the anus. The size of the growth was generally considerable, surrounding 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 my 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 exceeded three years, but it wtu generally fatal in a much shorter time. The diagnosis is easy if the growth can be seen, and is sometimes assisted by the secondary black de- posits. In four cases the tumor was removed, but in none was the return long delayed. Osteoid Cancer. Either a sarcoma or a carcinoma in any part of the body may become ossified, and hence pathologists speak of osteo-sarcoma and osteo-carcinoma. It is rare that such a formation is found in any structure except bone or periosteum; and there seems to be but one case on record of bone-cancer of the rectum, which, because of its great rarity, I will quote in part: CASK X XIII. The preparation was removed from the body of a lady, 1 Mentioned by Eiselt, obs. v., Prag. Viertelj., Bd. 70 u. 76. * " Denkwurdigkeiten in der arztlichen Praxis," Bd. iv., Frankfort, 1838, pp. 805-313. M. dical Times, March, 1857. 4 Berichte iiber die Verhandlungen (U-r Naturforsehenden Gesellschaft /.i. burg, 1858, No. 30, p. 516. s "PathologiedesTumeure," Paris, 1867, t. ii., i>. 281, note. 6 Ashton, T. J., "Prolapsus, Fistula in Ano," etc., 3d ed., London, 1870, p. 162. 1 " System of Surgery." Phil.. 1*72. vol. ii.. p. 589. "Bull, de laSoc. Anat. de Paris," 1875, p. 792. "Ueber die Pigmentbildung in melanotischen Sarcomen und einfachen Melanomen der Haut." Virchow's Arch. f. path. Anat. u. Phys., Ixiii., 1875. 10 Op. cit. 15 226 DISEASES OF THE RECTUM AND ANUS. aged about fifty-four, who died January 18th, 1869, under the care of Mr. Collambell, of Lambeth. The history of the case pointed to the existence of disease in the rectum for about twenty years (during which time she had occasionally complained of pain, irregularity of the bowels, and a discharge of blood and mucus). . . . The specimen includes the whole pel- vic viscera. The rectum is laid open posteriorly, but rather on the right side, and shows a cancerous mass projecting into its interior at a distance of about four or five inches from the anus. The principal mass, of about the size of a walnut, is situated directly at the back, and occupies nearly the whole calibre of the rectum, but the disease involves, more or less, the entire circumference of the intestine upon a level rather above the larger mass. A small opening, large enough to admit a goose-quill, is found in the sigmoid flexure, about twelve inches above the cancerous growth, and communicates with a circumscribed abscess cavity within the peritoneum, above the pelvic viscera, and behind the pubes, and this again communicates with the rectum immediately belo\v the obstruction. At the time of the post-mortem this peritoneal abscess contained very little fluid, but what there was was pus discolored with fecal matter. There is also a large, foul, burrowing abscess, situated in the submucous tissues, almost completely surrounding the rectum at the seat of disease, communicating freely with its cavity and directly continuous with the intra-peritoneal abscess. When first laid open, the surface of the cancer generally presented a nodulated, red appearance, but the larger or posterior mass was rough- ened in its lower half by numerous sharp spicules of bone which pro- jected from its surface. The cut surface showed the growth involv- ing the thickened muscular coat as a hard, contracting mass and from its base firm fibrous bands ramified into the neighboring fat, just as from the base of an ordinary scirrhous tumor. That portion which pro- jected into the cavity of the rectum was softer, and its lower part was occupied throughout by numerous spicules of true bone. On the sur- face, the softer structures having sloughed away, the bony constituents were exposed. The growth did not extend to the sacrum, which was perfectly healthy, and the other bones of the pelvis were also free from disease. The other viscera were examined and appeared healthy. The lym- phatic glands were not carefully examined, but in the parts which were removed there was no glandular enlargement to be found. The ulceration in the sigmoid flexure seemed to be of a simple character; there was no evidence of malignant deposit elsewhere than in the ob- structed portion of the rectum. On examining the growth in the rectum it was found to be firm in the deeper parts, where it involved mucous and submucous tissues, but, nearest to the surface, where the spicules of bone were evident, it had the appearance and character, to the naked eye, of a fibro-fatty struc- 227 tuiv. In the dtvpests parts, however, where it was firmest, it had not any very irreat hardness. The parts involved in the ossification lay exposed in the rectum, and seemed, from their shreddy, softened appear- . to have IK i'n recently sloughing. Upon section, a quantity of juice was roadfly obtained, and showed under the microscope an immense number of free nuclei and cells of all shapes and of variable sizes, i hough the greater number were elongated or oval, and about half the size of the columnar epithelium of the neighborhood. There was a large quantity of molecular matter and oil, and the nuclei were indistinct. The solid portion of the growth was composed of cellular and muscular structures imbeded in a granular matrix. Bands and fibres, composed almost altogether of nuclei, ramified in the growth, and could be traced as continuous with the osseous portions. It appeared that the nuclei became darker, granular, and harder in outline as the examination was curried toward the ossified parts; the intervening matrix became more fibrous, and the processes of bone branched out into this. The bony spicules contained numerous lacunae, whose size was about that of the ordinary nuclei of the growth. They were of various forms, generally branching, and were arranged with no regularity, but in the manner usually found in adventitious bony deposits in tumors. The matrix was granular. The interest of this case lies chiefly in the fact of bone being found ramifying through parts of the structure; and that this bone was tin- result of ossification of the scirrhous growth seems evident from the manner in which it could be traced under the microscope. That it was not an original formation apart from the scirrhus must be admitted, for its histological characters show its definite relation to thg elements of the tumor, the lacunae replacing the nuclei, and the rest of the bone occupying the place of the intervening matrix. And a primary bone tumor in this tion is difficult to imagine. The occurrence of true bony deposit in iullary tumors is not altogether infrequent; but then it is found in the deeper parts, and is almost always in connection with some bone. In scirrhous growths, however, I do not find any mention of ossification occurring, except where starting from bone. I have no history of any case of any kind of tumor of the rectum in which bone formed an element of a primary growth. 1 These are the rarer forms of cancerous disease in the rectum and their recognition presents little difficulty. Most malignant growths are included under Cripps's classification of adenoma or under the older terms of epithelioma and scirrhus. Hecker* found twenty-one cases of vpithelioma in thirty-four cases of cancer. Cripps says, " I have failed to discover " (in the rectum) " any growths or tumors consisting entirely 1 Wagstaffe, " Trans, of the Path. Soc. of London," vol. xx., p. 176. * Schmidt's Jahrbucher, 1870. 228 DISEASES OF THE RECTUM AND ANUS. of the characteristic structure which pathologists designate 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 distinctive structures never form the entire bulk of the tumor; but I feel bound to state that with, perhaps, a more than average oppor- tunity 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. Allingham ' 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. Gowland, in a boy not thirteen ; Mayo *. speaks of one at the age of twelve, and Godin 3 of one at fifteen years ; and Quain* quotes one, reported by Busk, at sixteen. After the age of twenty the cases increase 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 consider- able 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 5 says : " I 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 tlfat just indicated and the anus is next in order of fre- quency 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 then elsewhere, and is more apt to be suddenly fatal on account of the increased liability to obstruction which the anatomical con- dition favors. The symptoms of cancer of the rectum may be classified as follows: pain; those due to contraction, to ulceration, to invasion of neighboring parts; and, lastly, the generalization of the disease and the cachexia. A cancer of the rectum may, and often does, begin so insidiously that its existence is not suspected by the patient till it has made irreparable 1 Diseases of the Rectum, London, 1879, p. 265. 8 Injuries and Diseases of the Rectum, London, 1833, p. 188. 3 Molliere : Traite des Maladies du Rectum et de 1'Anus, Paris, 1877, p. 580. 4 Proc. of the Path. Soc. of London, 1846-7. s Op. cit. CANCER. 229 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 membrane of the rectum proper which permits the exist- ence of extensive ulceration, the application of escharotics, and the per- formance of surgical operations without pain has been already referred to. <>n the other hand, cancer of the rectum is usually attended with great pain, and the suffering in itself may be made of great assistance in diag- nosis. 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 pressure of the glands, or by direct ex- tension of the original disease. 1 In the later stages of cancer the pain is often the most important symptom to be met by treatment. It may then be due to the irritation of faeces upon an ulcerated surface, to the involvement 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 astonishing to the surgeon to meet with an advanced case of scirrhus in which the calibre of the bowel is so nearly occluded as scarcely to permit the 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 disease is seldom profuse enough to be dangerous, through by frequent repetition it may become an important factor in the ultimately fatal result. The odor of the discharge is the same as that from a cancer of the uterus, and needs only once to be appreciated to be remembered. 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 indications for colotomy. The prostate and seminal vesicles in the male and the recto-vaginal sep- tum 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 1 Hilton: Rest and Pain, p. 163. 'Surgery of the Rectum, London, 1871. 230 DISEASES OF THE RECTUM AND ANUS. disease opened into the hip-joint, and Mollie're 1 another in which it in- vaded 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 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 sacrum 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. This im- plication of the lymphatics is sometimes shown by pressure effects at points quite remote from the original disease, as in the following case from my own case-book. CASE XXIV. J. B., aged, sixty, has always been strong and well until within a few weeks past, when he has been troubled with obstinate constipation. All he desires now is some "pills" to move his bowels. On closer questioning, he refers casually to the fact that he has consider- able pain in the right thigh, and some swelling in the right leg and foot, but " nothing to speak of." On examination, nothing was to be detected by rectal touch, but the pelvis at its upper part was partially filled by firm, nodular masses, which extended deeply down into the right iliac fossa. The patient had no conception of any trouble beyond constipation and "rheumatism," though the whole lower extremity on the right side was O3dematous. By careful diet and laxatives the threatened obstruction was avoided, and the man gradually sank with all the signs of the cancer- ous cachexia, and died three months from the first examination. Unfor- tunately no autopsy could be obtained. From what has been said, it is evident that there is little in the his- tory which the patient will give of cancer of the rectum to distinguish it from ulceration and stricture of any other variety, and that the diagnosis must chiefly rest upon a physical examination. To make such an exami- nation thoroughly, and yet safely, requires great care and gentleness, and, to properly interpret the conditions which may be found, no little experi- ence and knowledge. It requires many years of practice to reach the point Allingham has reached when he says : " There is something peculiar about the feel of cancer which the practised finger rarely mistakes even for simple indurated ulceration. I think it is many years now since I mis- took the one for the other." In the majority of cases the diagnosis may be made by the history and by 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 1 Op. cit., p. 565. < AN'CER. 231 disease is seen in its earlier stages, the hard, more or less distinctly circum- scribed new growth which' has infiltrated the wall of the bowel is diagnos- tic. The great difliculty is to distinguish 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 li not infrequently mistaken for cancer. When a soft friable mass of epithelioma is found seated on a hard, infiltrated 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 will show itself sooner or later either by examination through the abdominal wall, or by the signs of intestinal obstruction. In cases where the condition is more complicated and where secondary deposits in the liver, for example have begun to do their fatal work before actual obstruction has begun, these symptoms of stricture may all be obscured by the presence of others which shall more readily attract the eye. In a case which I now have under treatment, I had made the diag- nosis of cancer of the liver with ascites and great intestinal disturbance some time before my attention was called to the rectum, and it become evident by examination that the affection of the liver was secondary te malignant disease high up in the rectum, which was also gradually involv- ing the pelvic viscera. The greatest caution should be exercised in the examination for cancerous disease above the lower four inches of the rectum. Treatment. The treatment of malignant disease of the rectum is de- signed to be either curative or palliative. In a small number of selected cases a cure is, perhaps, possible, as with cancer of feeble malignancy in other parts of the body e. //., epithelioma of the lip. At all events, the disease may be removed, and its return delayed for many years. This fact, we believe, may be accepted as proved by a sufficient number of carefully examined cases, from which the chances of error in diagnosis and subsequent history have been eliminated. Cure can, however, only be effected by excision. All other means may be set aside as hopeless failures. 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 the height of its popularity. Like every other surgical procedur. that point of its history, it is perhaps also occasionally 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 1 Op. .-it., p. 166. 232 DISEASES OF THE RECTUM AND ANUS. figures. Out of a total of sixty-four cases, eleven died as a direct result of the operation; 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. No case is worth much in the consideration of a question such as this where the diagnosis has not been verified by the microscope in competent hands; for there are non-malignant growths of this part which, to the naked eye, strongly resemble cancer. We have then a remainder of thirty-four, in whom the disease returned in twenty; but of these twenty, several were operated on a second time for a re- currence of the growth, or possibly for a small nodule which had not been removed at the first operation, and after this second operation remained f i'ee. This leaves, however, a total of twenty-three out of sixty-four ope- rations 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 reappear for such a length of time is decisive. Some operators, however, report better re- sults 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 doubtful tumor of the pelvis." Yelpeau and Verneuil 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 gener- ally looked upon with suspicion. Allingham, 2 on the contrary, considers the partial removal 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 rec- tum 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 in- complete operation. With regard also to his ten cases of total extirpa- tion, he speaks very cautiously. He believes that a cure is very uncom- mon, 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. 3 Billroth 4 reports thirty- three cases. Thirteen died of the operation, and the remainder all died within two years, most of them of recurrence. 1 Diseases of the Rectum, ed. of 1876, p. 164. 9 Loc. cit., p. 277. 3 Molliere, Traite des Maladies du Rectum et de 1'Anus, Paris, 1877, p. 627. 4 Clinical Surgery. Extracts from the Reports of Surgical Practice Between the Years 1860-1876. By Th. Billroth, New Sydenham Society, 1881. CANCKK. 233 The deaths immediately following the operation were invariably due to retro-peritoneal suppuration, characterized by acutely septic symp- toms. Most of them died within from four to eight days. Since then, in certain cases, 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 pal- liative measure, and how do these results compare with those of lumbar colotomy? 4. What are the results as regards the subsequent condition of the bowel, and the control of the faecal evacuations? 5. What is the best method of its performance? For the purpose of arriving at a knowledge of what experience has already taught in this matter, I collected, a couple of years ago, 1 the re- 1 For the full literature of the cases upon which these conclusions are based, the reader is referred to the following bibliography: Agnew. Phil. Med. Times, June 23d, 1877. Allingham. Diseases of the Rectum, 3d ed., London, 1879. Briddon. Mod. Record, January 6th, 1877. Bushe. Treatise on Diseases of the Rectum, New York, 1837, p. 294. Byrne. Annals of the Anat. and Surg. Soc., May, 1880. Baumes. Bull, de 1'Acad. Roy. de Med., t. x., p. 936. Chassaignac. Traite de Fecrasement lineaire, Paris, 1856. Cripps. Cancer of the Rectum. Crosse (quoted by Mayo). Observations on Diseases and Injuries of the Rec- tum, London, 1833, p. 210. Curling. Observations on Diseases of the Rectum, London, 1851. Med. Times and Gaz., March 14th, 1857. Dennonvilliers. Gaz. des Hop., 1844. Desgranges (quoted by Molliere). Maladies du Rectum, etc., Paris, 1877, p. 627. Dieffenbach. Die operative Chirurgie, Leipzig, 1845. Dolbeau. These de Fumouze. Duplay. Gaz. Med. de Paris, 1872, p. 486. Dupuy. Bull, de la Soc. Anat., Paris, 1872. 2~ s. f xvii., p. 242. Emmet. Principles and Practice of Gynaecology, 1st ed., Philadelphia, 1879, p. 511. Ewart. Lancet, June 21st, 1879. Fenwick. Montreal Gen. Hosp. Reports, vol. i. Gay. Lancet, June 28th, 1879. Gosselin. Gaz. des Hop., 1879, p. 921. Holmer. Hospitals-Tidende, March 31st, April 7th, 14th, 1880. Holmes. Trans, of the Clin. Soc. of London, 1878, p. 113. Holt (quoted by Curling), op. tit. Keyes. Arch, of Med., August, 1879. King. Brit. Med. Jour., June 21st, 1879. Kumar. Wiener med. Woch., 1878, p. 1,070. Labbe. Gaz. des Hop., June 4th, 18th, 1880. Levis Arch, of Clin. Surg., February, 1*77 234: DISEASES OF THE RECTUM AND ANUS. ports of operations up to that time as far as they were then attainable. The list at that time included one hundred and forty cases. At that time I arrived at the following general conclusions concerning the opera- tion, and subsequent study of the question has led me in no way to alter them. 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 extensive disease. Regarding the question of radical cure, we find difficulty in establish- ing exact dates, and have to take into consideration the reputation of the reporter. We find, however, that in one hundred cases (deducting those immediately fatal, and seventeen which passed out of observation imme- diately 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 Albany, 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 Lisfranc. These de Pinault, 1829. Maisonneuve. Union Med , 1865. Also These de Cortes, 1860. Mandt. Revue Med., 1836, p. 264. March. Trans, of the N. Y. State Med. Soc., 1868; also Med. and Surg. Re- porter, June 9th, 1877. Mayo. Observations on Diseases and Injuries of the Rectum, London, 1833, p. 212. Moore. Med. Times and Gaz., March, 1857. Molliere. These de Carcopino, 1879. Nussbaum. Aerztlich. Intelligenzblatt, 1863. O'Hara. Phila. Med. Times, vol. viii. Paget (quoted by Cripps), op. cit. Peters. Arch of Med., August, 1879. Pital du Gateau. L'Experience, t. vi., p. 27. Polaillon. Gaz. des Hop., 1879. Post. Med. Record, July 31st, 1880. Recamier. These de Masse. 1842. Roddick. Montreal Gen. Hosp. Reports, vol. i. Schuh. Abhandlung cler Chir. und Operationslehre, Wien, 1867. Siebold (quoted by Curling), op. cit. Simon. Lancet, 1851, ii., 1882. Simon, of Rostock. Deutsche Klinik, 1866. Stimson. Arch, of Med., August, 1879. Terrillon. These de Carcopino, 1879. Van Buren. Arch, of Med., August, 1879. Van Derveer. Med. Record, September 20th, 1879. Velpeau. Nouveaux Elemens de Med. Operatoire, Paris, 1839, vol. iv., p. 814. Verneuil (quoted by Marchand). Etude sur 1' Extirpation de 1'Extremite In- ferieure du Rectum. Volkmann. Klin. Vortrage, March 13th, 1880. CANCER. 235 posed radical cure reported by his father passed out of observation at the end of one year. There are some other cases which have been in- cluded 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 tin- first year and are fatal within two. rhe oji'Tdfinn is chiefly valuable as a palliative measure and as such ' i npares favorably with colotomy both in prolonging life and relieving jxii n. 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 obtained, 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 whoso experience has led them to believe that life was rather shortened than lengthened by it. I'.y these it is claimed that in lumbar colotomy we have a safer method of relieving pain, and delaying the progress of the growth, and in both these ways prolonging life. American and British surgeons hold rather to this latter idea, while the French and the Germans favor excision. Excision can scarcely be judged in comparison with colotomy, being applicable properly only to an entirely different class of cases. In cancer I 'iir inches from the anus, colotomy or colectotomy are about the only means of relief. In cancer within four inches of the anus almost any other plan of treatment is preferable. This leads me to call attention to another point the operation of -ion as a palliative measure. In cases properly chosen, where the disease is not so extensive as to render its removal one of the capital sur- gical operations, we know of nothing better, 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 at- tention is called to the great improvement in general health, the loss of pain, ami tin- increase in strength. Patients go away believing them- selves radically cured, return to their employments, and are reported by the Kivnrh surgeons as "jut /;/'" th-im-iit (jut-rivs" a few weeks after the operation. It has been claimed 1 against this operation that even when a good immediate, result is ohtained, it may shorten life by hastening the return and final progress of the disease. Unfortunately, it is difficult to tell in any particular case how long a patient would have lived had the. disease been left to its course; but, accepting as a basis for comparison Alling- ham's estimate of the average duration of life in cancer of the rectum as two year we are justified in concluding that in all cases where 1 Labbe, Gaz. Hebdom., June 4th, ISth, 1880. 236 DISEASES OF THE RECTUM AND ANUS. life was prolonged more than one year and a half after the time of opera- tion (the operation generally being done late in the disease), this length of life may fairly be attributed to the surgical interference. This esti- mate 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 noth- ing 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 return of the disease within six months of the time of operation is reported, to discover whether, here also, there was any marked relation 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 rapidity of the growth before operation and the speedy return after removal. We can trace no connection between the time of the return and the extent of the disease removed when the removal has been complete; and the microscopic reports are too few for general conclusions to be drawn from them. I know of no writers, except Stimson and Holmer, who have made a careful study of the specimens excised, and have given the results; and, so far as the clinical reports of the German operators go, they would seem to give support to their practice of removing everything involved, no matter how extensive, in the hope that the local return may be long delayed. 3. Wlien the disease reaches above three inches from the anus, or in- volves neighboring parts so as to render its entire removal without injury to the peritoneum 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 extensive disease, open- ing the peritoneum, exsecting the sacrum when necessary to reach its upper limit, and removing the prostate and base of the bladder when they are implicated, balancing the risk of immediate death from the op- eration 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, they can hardly be considered other than exceptional, and a study of cases shows that the frequency of the fatal result is in direct propor- tion to the extent of the operation attempted. The rules for the selec- tion of cases laid down by Lisfranc were these: when the bowel is mova- ble, in other words, when the disease has not involved surrounding parts, the operation should be undertaken. When, on the other hand, the dis- ease is more extensive, and reaches higher, he leaves the question to be CANCER. 237 decided by future experience. I believe that experience has now decided it. In deciding for or against the operation, an examination of the glands in the hollow of the sacrum and in the loins is of great value, for these receive their lymph directly from the rectum, and may be en- larged, while those in the groin, which are supplied from the skin around the anus, may still be uninvolved. I shall not stop at this time to again discuss the question as to how much of the anterior wall of the rectum is uncovered by peritoneum, but must refer the reader to the chapter on anatomy. The height to which it is safe to go cannot be definitely stated for all cases, the reflection of the serous coat upon the rectum being at a variable point. Fochier 1 re- ports a case in which he used the 6craseur at twelve centimetres without harm, and Allingham,* who is always a safe guide, has seen all but the lower two inches of the bowel covered by peritoneum in a female, has opened into it in a male when not moro than three and one-half inches were removed, and has taken away fully five inches in a male without bringing it into view. There is an old rule for applying the trephine, that in every instance the operator should remember that some skulls are very much thinner than others, and he should act on the supposition that the particular point upon which he is operating is the thinnest part of the thinnest skull ever seen. Something of the same kind might be said of the peritoneum over the rectum; and everybody who has studied the anatomy of the part knows how various are the opinions of different authorities on this point. Nevertheless, a line of danger can be marked out, and that line is about three inches from the anus. It is true that more than this amount of the rectum has been removed without encountering the peritoneum, and it has been opened below this point; but I should not, for my own part, hesitate to try to remove three inches of the bowel fora a cancer, and I have refused to attempt to extirpate in an otherwise suit- able case because the disease passed this line. The index finger is a good guide. What is well within its reach in a hand of good length, it is safe to try to remove, provided it does not involve surrounding tissues to an :it which renders its complete removal impossible. Whatever may be said of the impunity with which the peritoneum may be opened in other parts of the body does not seem to apply here; for I have been able to find but three cases in which that accident was not followed by a fatal result. Unfortunately, the disease is but rarely seen at a stage when extirpa- tion is justifiable, that is when it is limited to a circumscribed spot within three or three and a half inches of the anus, when it is movable on the muscular coat, has not invaded the deeper tissues, and before there has been any glandular enlargement. 1 Lyon Med., February 20th, 1876. Op. cit., p. 275. 238 DISEASES OF THE KECTUM AND ANUS. 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 will often follow the extirpation of disease which is comparatively slight in amount. The three great dangers of the operation are peri- tonitis, pelvic cellulitis, and septicaemia. Hasmorrhage may fairly be dropped out of consideration, for the operation may, if desired, be rendered almost bloodless by the use of the ecraseur or galvano-cautery. 4. The operation is not followed by any annoying after-consequences which are of sufficient gravity to contra-indicate its performance. In a small proportion of cases, there will be complete incontinence, in a greater number there will be partial control over the evacuations, and in a majority the control will be sufficiently complete to prevent the occurrence of any annoying accident. Stricture to a troublesome extent is also rare, and when it exists, it may generally be overcome by the introduction of bougies. In one case reported by Verneuil, a special plastic operation was performed to relieve this condition, an account of which may be found in the work of Marchand. ' Regarding the best way of performing the operation, the surgeon has his choice of several. The first case of extirpation of the rectum of which we have any record was by Faget, in 1739, and was not for cancer, but simply a removal of the lower portion of the bowel, which had been completely surrounded and denuded by an abscess beginning in one ischio-rectal fossa, and subsequently extending into the other. From that time until 1826, the operation, as a means of treatment of cancer, will occasionally be found mentioned in surgical literature; generally, however, only in condemnation. In 1826, Lisfranc performed the first successful operation for cancer; and three years later, his student, Pinault, in a these reported nine cases, and gave to the procedure a permanent place in literature and practice. In 1833, Lisfranc himself embodied the same ideas in a paper read before the Acad. Royale de Medecine,* and from that time the operation became widely known. Since then, ife has had its advocates and opponents, and has been subject to many modifications in its performance. For a long time, it was coolly received by British surgeons, but within the past decade it has received a new stimulus from the Germans, and at the time of writing, it seems about to be fairly tried by the surgical world, and judged on its merits. Almost every surgeon whose name is prominently associated with the operation has had his own favorite way of performing it; and we shall, therefore, speak in detail only of those which have proved most acceptable, 1 Etude sur 1'extirpation de 1'extremite inferieur du rectum. Marchand, Paris, 1873. s Mem. de 1'Acad. Roy. de Med., 1833, iii., p. 296, CANCER. 239 and first of those described by Volkmarm in his Klinische Vortruge for h i:3th, 1880. He describes three different operations, depending on tin- 1 M at ion of the disease. The first is for the removal of a circum- scribed spot only. This is accomplished by dilating the anus, dragging d<>wti tin- disease, und excising it in such a way that the wound shall not ~e subsequent stricture. When the growth involves the anus, the edges of the wound are carefully brought together, stitched with catgut, ami a drainage-tube inserted between them. When the growth is entirely within the sphincter, the edges are brought together with equal , but the tube is inserted through a track made for it, which com- municates with the wound above, and perforates the healthy skin at a point outside of the border of the sphincter. When dilatation does not suffice, the anus is freely divided down to the coccyx, and this wound is subsequently carefully closed under the antiseptic precautions. I n the second class of cases where the growth involves the whole circum- ference of the bowel, but not the anus, the latter is divided forward into the perineum, and backward to the tip of the coccyx, when necessary, to give room for manipulation. The latter of these two incisions is carried as far into the bowel as the lower border of the disease, which is then removed. The mucous membrane above is stitched to that below, the pre- liminary incisions carefully closed, and a drainage-tube left in the posterior one. In the third class, where the disease involves all, or nearly all, of the anus and of the circumference of the rectum, the entire tube is separated and removed in a cylinder. The same preliminary incisions may be made as in the second class, and the anus is surrounded by a circular cut, which runs outside the sphincter. From this as a starting point, the dissection is carried parallel with the bowel till the upper portion of the disease is passed. By the use of knife, scissors, and fingers the bowel is completely freed, then drawn down to the anus, and cut off above the disease, the healthy upper end being stitched to the margin of the skin. In case the peritoneum is opened, the wound is at once \ stuffed with carbolized sponge, and afterward carefully closed with \ catgut. The coccyx and part or nearly all of the sacrum are removed when necessary to make room, as a preliminary step. The risk of haemorrhage is one of the great objections to this opera- tii.n, and later on we shall describe another procedure, which is pre- ferred by many, in A hich the knife is supplanted by other and bloodless instruments. It is no doubt true that the deep dorsal incision is the key to the operation, and greatly facilitates the securing of bleeding ves- sels; yet the lia-inorrhage may be so great as to impede the operator and endanger the life of the patient. It will be seen that, at every step in this operation, union by first intention is aimed at, and Lister's methods are carefully followed. If the elements of success in Lister- ism are, as I believe, cleanliness and drainage, these are certainly better 240 DISEASES OF THE RECTUM AND ANUS. met by a deep posterior wound, which is left open and syringed out fre- quently, than by carefully closing that safety-valve with catgut sutures and inserting a drainage-tube. It will also be observed that the bowel is always brought down and stitched to the free edge below. To do this much, dissecting is necessary, and but little permanent good is gained, as the stitches soon tear out. Maisonneuve described, in IS Union medicate of 1860, an operation which he named the precede de la ligature eztemporanee, and which dif- fers from the preceding in being almost entirely bloodless, although it differs little from the operation previously described by Chassaiguac, under the name Vecrasement lineaire. In the latter, the rectum is di- vided into two lateral halves by the chain ecraseur, and each half of the disease is then attacked in the same way and removed. In the opera- tion as done by Maisonneuve, a strong cord is substituted for the chain, and the disease is removed in the following manner. The skin and sub- cutaneous tissue are divided by a circular incision which completely sur- rounds the anus. The operator is provided with several strong curved needles, each of which is to be threaded through the point as often as' used, with a strong silk ligature about a foot in length. One of the needles with the ligature in its point is then passed from the external incision into the bowel above the growth, going wide of the gut to clear the tumor. The loop of string in the eye of the needle is seized within the rectum and drawn out of the anus, while the needle is drawn back out of its own tract. The result of this is a double uncut ligature, pass- ing from the point where the needle entered the external incision, out- side of the tumor, into the rectum above it, and then out of the anus; and this manoauve is repeated eight or nine times at points around the circumference of the anus equidistant from each other. A strong whip- cord or bow-string is the next requisite about two yards long and to this all the loops hanging from the anus are attached at points nine inches distant from each other. Each of the original ligatures is then withdrawn by the same course it entered, carrying a loop of the whip-cord with it. When all are drawn out, the rectum above the disease is sur- rounded by a series of loops of strong cord, and the ends of each loop hang out from the original incision. The ends are then attached to an ecraseur, and each loop made to cut its way out in turn. After all have been cut out, the lower end of the bowel and the diseased mass are of necessity completely separated from their attachments. The operation performed by Crippg is a modification of the two pre- ceding ones, and would seem to possess several advantages in facility of performance. The preliminary dorsal incision is made from within out- ward, by passing a strong curved bistoury into the rectum, bringing its point through the skin at the tip of the coccyx, and cutting all the in- tervening tissue. The buttock is then drawn away from the anus to put the tissues on the stretch, and a lateral incision made from the prelimi- CANCKK. -J4L nary 'cut behind, around the rectum to the median line in front. The of this incision, whether inside or outside the anus, will depend upon the location of the disease, and whether or not the anus is impli- <1. The cut itself should be made boldly, and deep enough to reach well into the fat of the ischio-rectal fossa. The forefinger in this incision will readily separate the bowel from the surrounding tissue, except at the attachment of the levator ani muscle, which should be divided with the knife or scissors. A piece of sponge is pressed into this cut to restrain the bleeding, while the opposite side is treated in the same way. The anterior connections give more difficulty, and the dissection in the male ded by having a sound in the urethra. The knife and scissors replace the finger in this part of the operation. When the dissection has been curried to a point above the disease, the bowel is drawn down and held while the wire ecraseur is passed over it, and the section made at the re- quired level. After this there may be free but seldom serious haemor- rhage. The vessels divided in the first steps of the operation all come from the wall of the bowel, and if ligatured when first cut, are again opened with the ecraseur. When the disease is located to one side of the bowel, the operation is modified accordingly. The preliminary dorsal cut is the same, and the nil incision is made on the affected side. At the farther end of this lateral incision, away from the dorsal one, a needle carrying a cord in its point is passed around the disease and into the rectum above it. The loop of cord is brought out of the anus, attached to the chain of the Ecraseur, and withdrawn as it entered. The chain is then made to cut its way out, and a rectangular piece of the rectum is thus included between two longitudinal incisions, one posterior with the knife and one lateral with the chain. In this rectangle is the cancer, and it is dis- sected upward from below, and separated above by again using the BUT. Instead of the chain or wire ecraseur, the wire of the galvanic cau- tery may he n-e recorded by Emmet. 1 The growth in the ease in which it was used was 1 Principles and Practice of Gynaecology, ed. 1879. 16 24:2 DISEASES OF THE RECTUM AND ANUS. an epithelioma the size of a hen's egg, situated on the posterior wall of the rectum an inch above the sphincter, with considerable surrounding infiltration. The sphincter was stretched, and the mass seized with a double tenaculum, and drawn well down by an assistant. "A steel grooved director, as the most convenient instrument for the purpose, was pushed through the skin in front of the coccyx and just behind the outer edge of the sphincter, into the cellular tissue of the pelvis, and then made to puncture the rectum, in healthy tissue, just beyond the upper edge of the tumor. The end was turned out of the gut, and pushed far enough forward to rest on the perineum while the other end was over the coccyx. Then a second director was pushed around from the outer side of the muscle on one side, through the cellular tissue into the rectum, across to the other side, through the cellular tissue and skin again to the opposite side of the muscle. So that the mass, with a portion of the rectum above, was now brought through the anus and fixed by the two directors, which had been passed behind the mass at right angles to each other, with their ends resting outside on the soft parts. The chain of an ecraseur was placed behind these two instruments and slowly tightened till the whole mass, as transfixed, was cut through along the course of the directors. By this means, I removed the entire sphincter muscle, about three inches of the posterior wall of the rectum, and about an inch and a half of the rectal surface of the recto-vaginal septum. The immedi- ate result was a most formidable opening in the connective tissue of the pelvis, about three inches in diameter and cone-shaped from below." Dr. Rouse 1 has recently called attention to a simple method of avoiding a wound of the sphincter, which is applicable to some of the slighter cases. A curved incision is made parallel with the outer border of the sphincter, and on a line with its outer limit. By introducing the finger through the rectum, the growth may be everted through this incision, and removed with the part of the rectal wall to which it is ad- herent. Perhaps the best of all the operations we have spoken of is the com- bination of the ecraseur and galvano-cautery knife, as used by Ver- neuil. But the operator is at liberty to choose from among them all the one he considers easiest of performance, and most free from the risk of haemorrhage or of wounding surrounding parts. A wound into the vagina, though always to be avoided when possible, may often be necessary in order fully to. remove the disease. When the fistula thus made is not too extensive, it may be closed immediately after the operation. If large, it must be left. A wound of the urethra in the male, when slight, is to be treated as though the patient had submitted to an external urethrotomy, by the frequent passage of the sound, to pre- vent contraction. When a large piece has been taken from the urethral 1 Lancet, Oct. 2d, 1880. CANCER. J t '. wall, a permanent recto-urcthral fistula is the necessary result, and the danger of fatal inflammatory action is greatly increased from the presence of the urine in the rectal wound. As for the cases reported by Xussliatim and others, in which the whole neck of the bladder, the iter part of the prostate, and the seminal vesicles have been remove:!, and the patients have lived for years in comfort, they are merely curiosi- ties of literature. That such a thing may happen has been proved, but that the operation should ever be undertaken in any case where such a result is necessary for the entire removal of the disease, has yet to be proved. It is with this operation much the same as with proctotomy by try- ing to save too much, discharge is impeded and life may be lost. Cases where the whole of the sphincter is removed, together with the skin of the anus, do better than those in which an attempt is made to save the sphincter and drain the wound with drainage-tubes. The operation of excision has, with the recent advances in abdominal surgery, also been applied to cancer of the sigmoid flexure and descend- ing colon. This operation to which allusion has already been made and to which Mr. Marshall 1 has very properly applied the name of "colec- tomy " has now assumed a definite place in surgery and marks another of the great advances of the present century. It dates from the time of Reybard of Lyons, 1 who in 1833 removed a tumor the size of an orange from the sigmoid flexure of a man aged twenty-eight years. In this case the tumor could be felt through the ab- dominal wall in the left iliac fossa, and the incision was made parallel with Pou part's ligament and the crest of the ilium. The tumor was drawn out through this wound and excised with three inches of the ad- joining intestine. The two ends of the bowel were stitched together and replaced within the abdomen and the abdominal wound was completely closed. There was considerable local trouble for a few days, but on the thirty-eighth day the wound had entirely healed and the natural pas- sages were restored. Death occurred ten months after from recurrence of the disease. This case wag subject to considerable discussion in the my, but was finally admitted as authentic. The operation thus inaugurated in 1833 has been modified in two essential particulars by subsequent operators, one in the choice of loca- tion of the incision, the other in the subsequent disposal of the ends of the divided intestine. Since the first case by Reybard, the operation has been performed at least seven times. Gussenbauer, of Liege, has done it twice. The first time in 1877' was upon a male patient aged forty-two years. The tumor which was asso- 1 Clinical Lecture on Colectomy, Lancet, May 6th, 13th, 1882. * Bull, de 1'Acad. de Med., vol. ix., 18l 3 Arch, ftirklin. I'hirurg., Bd. xxiii., 1879. 241 DISEASES OF THE RECTUM AND ANUS. ciated with the usual symptoms of obstruction could be felt in the left side, but an attempt was made to remove it through an incision in the median line of the abdomen. This incision proving insufficient, was en- larged by cutting laterally as far as the lumbar fascia. Another compli- cation arose from the attachment of the growth. to the small intestine which was opened, and fasces were allowed to escape into the peritoneal cavity. All the intestinal wounds were closed Avith sutures, the bowel was replaced within the abdomen, and the abdominal incision sewed up. In this case death followed in fifteen hours. Gussenbauer's second case was performed in 1879, ' and there had been no return of the disease two years later. Baum of Dantzic 2 operated between these two dates (1878) upon a. male patient, aged thirty-four years, in a case of doubtful nature. He first opened the small intestine to relieve the symptoms of obstruction, and seven days later he discovered the seat of the obstruction in the right hypochondrium. A second operation was then performed. The abdo- men was again opened, this time by a longitudinal incision over the tumor, two and a half inches to the right of the median line, and this, incision was afterwards enlarged by another running toward the right. The growth was situated at the junction of the transverse with the as- cending colon, and was removed together with a piece of the mesentery which contained an enlarged gland. The divided ends of the bowel were invaginated and united, the intestine replaced, and the abdominal wound closed. There was considerable discharge of faeces from this opening,. however, up to the time of death on the ninth day. The next case was by Martini, of Hamburg, 3 in 1879, and was per- formed with the deliberation and consequent success which arise from a certainty in diagnosis of the character and location of the tumor. The growth was situated in the sigmoid flexure and could be felt both through the abdominal wall and the rectum. The incision was made over the tumor, the intestine below was cut between double ligatures, the meso- colon was divided and the affected glands excised, and finally four inches of the bowel were excised together with the diseased mass and two inches breadth of mesocolon. After the removal of such a section it was impos- sible to approximate the divided ends of intestine. The rectal end was, therefore, invaginated upon itself, closed with sutures and allowed to drop into the pelvis. The upper extremity was attached to the incision in the abdomen to form an artificial anus. There were no bad symptoms and in a few weeks the man was able to'return to his business. Czerny, of Heidelberg, reported the next successful case in 1880, 4 in a 1 Ztschr. fur Heilk., Prag, 1880. 2 Centralblatt fur Chir., 1879, Bd. ii., p. 169. 3 Vierteljahrschrift fur Heilk., Bd. i., 1880. 4 Berliner klin. Woch., 1880, No. 45. CANCER. 245 female patient, uged forty-seven years. In this case also the growth could be felt through the abdominal wall on the left side and the diag- nosis was therefore positive. After opening the abdomen over the tumor, the bowel was found to In- implicated at two points, one at the transverse colon, and the other at the sigmoid flexure which curved upward to an abnormal degree and was involved in the same disease through a fold of the great omentum. Two and three-quarters inches of the sigmoid Ilex u iv. and four inches and a half of the transverse colon were excised and the cut ends of each portion were united. The peritoneum was \\ashed out, a drainage tube inserted, the abdominal incision closed ex- cept for the drainage tube, and the whole dressed antiseptically. For a time thero was a discharge of faeces through the abdominal wound, but this finally closed and the patient was well in four months. The return of the disease was, however, very rapid, and death was caused by it in about seven months after the operation. Billroth operated next in order, in 1881,' on a male patient twenty- eight years of age. The operation was done antiseptically, and the inci- wa> the usual one for left inguinal colotomy. The tumor involved the lower half of the sigmoid flexure, and there was considerable involve- ment of the adjacent mesentery and of the tissue behind the bowel. The upper section of the bowel was used for the formation of an artificial anus. The patient died in about thirty-six hours from incipient diffuse peritonitis. Bryant's case* is next in order, and is peculiar in the fact that the in- "ii was the usual one for left lumbar colotomy. This, in fact, was the operation attempted, but after the bowel had been opened, the obstruc- tion was found to be above the opening made. It was then determined to excise the disease, and this was successfully done through the original incision. The two ends of the bowel were attached to the wound, the upper in the usual manner for forming an artificial anus. The patient recovered, and was well at the time of the publication of the case. The disease constituted a cylindrical stricture of limited extent. Finally, Mr. Marshall's 3 case has just been published at the time of writing. The patient was a woman, aged forty-nine years, and no posi- tive diagnosis as to the seat of the obstruction could be made. The diffi- culties attending the diagnosis may best be gathered from his own descrip- tion. " The wasting and rapid ageing of the patient, although she took food tolerably well, suggested the presence of a malignant stricture, probably opitheliomatous; but it was difficult to say how far the symptoms wen- referable merely to the pain and vomiting which she had suffered; but, \Vi,-n. Med. Woch.. Man-h .'.th. 1881. 'Lanr.-t, V,,|. i.. 1882. I.-inr,.t. Mav C.tli. 13th. 1882. 246 DISEASES OF THE RECTUM AND ANUS. whatever the nature of the obstruction, its seat was obscure. The chro- nicity of the case pointed strongly to the large intestine, but the abdomen was not broad in shape; no tumor or scybala could be felt in either iliac fossa, or elsewhere along the course of the large gut, though both fossa& could be well examined under chloroform. There was no dulness in either loin to indicate a full colon, and no "colonic" note to show that the bowel contained gas. Rectal examination revealed nothing. The long tube passed one foot, and an enema of three pints was easily given, and seemed, from an accompanying diminution of resonance in the left flank, to have entered the descending colon. But as the patient was lying on the left side, it was possible that fluid contents had gravitated into the small intestines lying over the descending colon a source of movable dulness which, as remarked by Mr. Boyd, is often overlooked. The amount and uniformity of the abdominal distention were sufficient to prove that the obstruction, if in the small intestine, was near the lower end. If, however, the suspicion were correct that the cause of the ob- struction was an epithelioma, the probability of its seat being in the large intestine, somewhere beyond the caecum, was greatly increased." On account of the uncertainty in diagnosis, the incision in this case was an exploratory one in the median line, and the growth was found in the descending colon, between the lower end of the kidney and the iliac crest. As it was impossible to bring this part of the bowel to the median line, the first incision was abandoned, and a second one made over the tumor, parallel with the last rib, and one inch and a half above the poste- rior part of the iliac crest. The growth was cut out with the scissors, together with an inch of the bowel above and below, between double lig- atures. The open end of the upper section of the bowel was attached to the abdominal wound to form an artificial anus, and the lower end Avas left projecting from the lower and hinder part of the wound with the strong catgut ligature drawn tight upon it. The patient died of perito- nitis on the third day. Of these eight cases, one-half may fairly be said to have prolonged life, and the others have been fatal within a short time from peritonitis. As pointed out by Marshall in his instructive resume of the operation, the result undoubtedly depends in a great degree upon the certainty with which the diagnosis is made, or, in other words, upon the exact adapta- tion of the operation to the end to be attained. In most of the successful cases, the diagnosis as to the seat of the obstruction was made before the operation was begun, and in all of them only a single incision was neces- sary to reach the tumor. In three of the four fatal cases, two incisions were made one in the median line, and, subsequently, another to reach the disease. In this way the severity of the procedure was greatly in- creased. There seems to be little difference in the mortality whether the ends of the divided intestine be united and the abdominal wound closed; or CANCER. 247 one end be brought to the surface for the formation of an artificial anus. The latter is the simpler procedure; the former, when successful, ^ the better result. A great difference in the size of the two ends will some- t lines render their union difficult; the upper one being frequently hyper- trophied and dilated, and the lower contracted. The study of these cases leads plainly to the following conclusions: 1. In cancer of the descending colon, sigmoid flexure, and upper part of the rectum, when the disease is still movable, an attempt at its re- moval through the abdominal wall is justifiable. 2. In cases of obstruction where the symptoms point toward this part of the bowel as the affected part, even when the diagnosis is not certain, it may be well to make the exploratory incision in the left groin instead of in the median line, having in mind the possible extirpation of the dis- ease and the formation of an artificial anus. 3. In cases of intended colotomy also, it may be found possible, after the incision has been made, to substitute colectomy, and this constitutes another reason for choosing the inguinal to the lumbar incision in that operation, though, as in Bryant's case, colectomy may be done through the loin. 4. The operation of colectomy compares very favorably with colotomy in malignant disease, and while the latter may be the more suitable in an advanced case, the former may give better results when the disease is in its incipiency. The palliative treatment of malignant 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 situation at the outlet of the bowel. Among the first, we have pressure upon adja- cent 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 irritation caused by its direct implication in the cancerous growth, or by the passage over it of irritating sanious dis- charges 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 paroxys- mal 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 passage, diet, and the recumbent posture; b. Anodynes locally and by the mouth; c. Partial destruction of the growth by means of the curette, cauterization, or partial extirpation; tl. Division of the sphincter; e. Lumbar colotomy. The passages should be kept soft but not fluid, as any approach to diarrhoea always aggravates the suffering. This may be done partly by 248 DISEASES OF THE RECTUM AND ANUS. the choice of food, which needs to be regulated with great care on account of the tendency to gastric disturbance, more or less of which is always present; and by the administration of the mineral waters, which are generally sufficiently laxative for the purpose. Rest in the recum- bent 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 point of relieving suffering. This seems so plain a duty which the surgeon owes to his patient, that we need not stop to discuss any possible moral bear- ing it may have. If the agony of this incurable malady could always be relieved by the administration of opium, the question of operative inter- ference would arise much less frequently than it now does. But, unfor- tunately, the constant administration of this or any other narcotic will sometimes 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 applica- tion of chemically destructive agents or the actual cautery, and even by the partial excision 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. The dernier ressort of surgery for the relief of pain is lumbar colot- omy. "We have already attempted to limit the scope of this operation. In any case in which the suffering is due to the direct contact of faeces with the diseased surface, and is not due to a spasmodic action of the sphincter muscle, and cannot therefore be relieved by the permanent division and paralysis of that muscle, and is not due to the extension into and pressure of the disease upon neighboring parts, the operation may be tried. There may be such cases, but they are not common not nearly as common as is lumbar colotomy for cancer. Let it be remem- bered, however, that after colotomy fasces will still find their way to the tender point, and that the amount of suffering from a small mass of faeces may be as great as from the entire quantity. With regard to husbanding the sufferer's powers and prolonging life, much may be done by careful nursing and medication. 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 laxative as well as a tonic action. Cleanliness is best obtained by frequent washing out of the rectum with disinfecting fluids, as permanganate of potash and carbolic acid. 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 \\CKK. 249 ; ruction as such, it is well to remember that an exceedingly small outlet to the alimentary canal may, with proper care, be made to answer all the calls of nature. We see this constantly in cases of stric- ture both simple and malignant, where the finger cannot be forced through tlu 1 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 interference shall be postponed indefinitely. When, however 1 , obstruction is actually threatened, much may be done by the medical means already pointed out. When dilatation becomes nocessary, 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 are already numerous enough to serve as warnings for all future time. The best of all dilators in cancerous 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 may be better at once to make an artificial anus than to incur the 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 em- ployment, the patient will soon refuse to submit to its continuance; while, on the other hand, should the result be favorable, it may be em- < -mployed daily. The softest bougie is the best, and a candle often an- swers admirably. If dilatation be found too painful or ineffectual, as it sometimes will, recourse may be had to division or partial destruction of the cancerous mass. A double proctotomy may be done in case of malignant disease, and the section of the growth between 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 witli great facility and without danger. The latter operation is rather the preferable one. Relief both to pain and obstruction may sometimes be gained in this way by a partial destruction and extirpation of a cancerous growth, where its entire removal is out of the question, and its local return may expected with certainty. By such measures, the evacuations may be made less painful, the spasmodic action of the sphincter and the rec- tal tenesmus may be allayed, the cancerous look may for a time disap- pear, and the patient recover sufficient strength to resume the ordinary occupations of life. A growth maybe attacked in this way. either with the knife, cautery, 250 DISEASES OF THE RECTUM AND ANUS. finger or curette. Caustic applications ai % e 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 applica- tion of a paste of arsenite of copper, mixed with mucilage. The opera- tions for removing a part of the growth with the finger, 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 diseased tissue as possible torn and scraped away. Haemorrhage, 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 cautery. Allingham relates a case in which he entirely enucleated an immense encephaloid with his hand, with the happiest results. As a substitute for partial destruction of the growth in this way, the operation of crushing with an instrument similar to the enterotome of Dupuytren has been proposed. The proceeding is only applicable to a. certain class of cases, in which the stricture is annular and not too ex- tensive to be grasped by the instrument, and has no advantages over the other methods. There is no obstruction within four inches of the anus which may not be overcome by some one or other of these means. What, then, remains for lumbar colotomy ? Simply those above the reflection of the perito- neum. It will often be difficult for the surgeon to decide for or against colotomy in these cases. Two factors enter into the question: 1st, whether or not the patient is likely to survive the operation itself; and, 2d, if this is decided in the affirmative, whether sufficient is to be gained to pay for the risk. The general condition of the patient, the extent of disease as regards secondary deposits, and the amount of pain dne to de- fecation, all have to be taken into consideration. The operation may be indicated to relieve this pain when there is not much chance of actually prolonging life, and it may be indicated to prevent or overcome obstruc- tion where there is no great amount of pain. I am inclined, for myself, to limit the operation to those cases where the pain of defecation is great, and where the disease is still circumscribed, and should not for the choice between death from obstruction and death a few weeks later from exhaustion always have recourse to this extreme measure, but should rather trust to securing a comparatively -easy passing away of the patient under the influence of opium. Indeed, many patients will decide the question in this way for themselves when it is explained to them in all its- bearings. It is a curious fact that, by relieving the over-distention of the bowels by colotomy, the obstruction also will sometimes cease, and pas- sages will again pursue their natural course. Such a case is reported by CANCKK. 251 Goodhart, where three successive. operations for opening the colon above the strict uri- were resorted to to relieve obstruction, and after each one the passages were again restored to the natural outlet. 252 DISEASES OF THE RECTUM AND ANUS. CHAPTER XII. IMPACTED FAECES AND FOREIGN BODIES. Impacted Faeces. Intestinal Concretions. Diagnosis and Treatment of Impaction. Foreign Bodies Swallowed. Results which may Follow the Swallowing of a Foreign Body. Ulceration and Abscess. Foreign Bodies Introduced per Anum. Cases. Prognosis. Treatment. Dangers of Attempts at Re- moval. Laparotomy for Removal. Cases Successful. Impaction of Faces. The impaction of faeces may be due to several causes, but is most generally a symptom either of intestinal 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 they may follow a partial paralysis of the rectum from the long-con- tinued use of large enemata, or the pressure of the foetal head in child- birth. They may also be formed 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 encoun- tered in young and healthy men. Intestinal concretions may be composed entirely of hardened and stratified or clayey masses of fasces, or they may contain within them as a nucleus a biliary calculus, or indigestible substances 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 frequency of impaction during the famine in Ireland in 1846, when potatoes, and those of a very poor quality, were the only article of diet, is a well known historical fact. 1 In Scotland, where oat-meal is a favorite article of diet, faacal 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 cholesterin or of a biliary calculus coated with cholesterin. 1 For description of these cases see article by Dr. Papham in the Lancet. 1850. IMI'ACTKIJ FLECKS AND FOREIGN BODIES. 253 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. Tho symptoms t<> which it gives rise are generally 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 characteristic 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 reMilt of an overfilled and obstructed rectum. This diarrhoea is peculi- arly fa-rid in character, and th'e matters discharged may be entirely free from fc-eces 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 Allingham adds a peculiar ringing, barking cough, morning vomiting (particularly in women), and night-sweats. Of course errors in diagnosis are easy in such a condition as this, and a mass of fasces 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 beer, supposed diseased in these cases when a simple digital examination of i >e rectum, or in women even of the vagina, could not fail to make the diagnosis clear. Unfortunately for diag- nosis, the general practitioner is not fond of making rectal examinations, and these cases are not infrequently treated with, bismuth and opium as a consequence. The following instructive case was reported by Dr. Griffith. 1 In the autumn of 1876, I was hurriedly summoned to an old lady, who had within a few days of my seeing her met with a severe accident in the city, having been knocked down by a hansom as she was crossing vet. All her friends had given her up to die. She was so power- less to move, so prostrated, and so large a tumor, they stated to me, had made its appearance since her injuries. Her age (80) seemed to exclude all hope of recovery; and I was asked to see her more that it should not be said she hail died incapable of making her will and to witness her signature to it, than with any idea that I could benefit her. I examined the abdomen, and while doing so learned from her that she thought she hud been larger on the left side for some time before the accident. I found considerable enlargement of the entire abdomen from flatulent distention, and on the right side a tumor, hard and apparently 1 Fsecal Accumulations Stimulating Utero-Ovarian Tumors, Edinburgh Med- ical Journal. Mav. 1877. 254 DISEASES OF THE RECTUM AND ANUS. irregular, extending from the left hypochondriac into the left iliac fossa and passing a little way to the right of the median line. At first, I thought it might be enlarged spleen, or a left ovarian dropsy, or an extrauterine fibroid, which had been unnoticed, and was now observed, solely because attention was directed to the left side, where the patient had been struck by the vehicle. I could not at this, my first visit, make a very minute examination, owing to the extreme prostration and de- pression; but at my second visit, having in the interval built her up and cheered her all I could, I examined very carefully per vaginam, and with equal care explored by the rectum. I then came to the conclusion that there was neither ovarian nor uterine tumors, and that I had to deal with an accumulation of faeces even though the bowels were moved every day, as the attendant informed me, and that the accumulation had com- menced previous to her accident; forming, no doubt, the enlargement which she told me she had noticed before her injury, and which, as the accumulation increased, culminated in the enlargement I found. I swept out the bowels by free purgation, kept up for some days, while I sustained her with light and easily digested nutrients, allowing as stimu- lant only good tea and coffee. The next case is also from the same author: Mrs. G., aged twenty-five, mother of three children; the last being about four months old when I was first in attendance. I was called up to her on the night of 18th June, 1876, " as she was suffering acute pain in the left side, which she could endive no longer." On examining the abdomen, I found a hard, irregular, exceedingly tender tumor, from which she was enduring great agony, and which was almost as large as an infant's head. I made no further examination that night, contenting myself with ordering her one-half grain morphia suppositories, to relieve not only the pain, but likewise the tenesmus and the passing of mucus. The discharge from the bowels was quite fluid, but distinctly faecal, occasionally a scybalous mass making its appearance. Next day, the morphia having taken good effect, I examined with the finger by the vagina, but could make out neither ovarian nor uterine tumor; the sound in utero enabled me to make certain that there was no intrauterine growth; but movement of the uterus with the sound in the interior of it was attended with the movement of the mass, which I found lay outside the womb, yet connected to the left and upper portion of it in fact, attached to it. I gave it as my opinion that, whatever the mass was, it was outside the uterus, and was adherent to it, and that it was not ovarian. I did not, however, express the opinion at which I arrived after the above examinations and after thoroughly exploring by the rectum, viz., that it was a case of impacted and accumulated faeces, which, having set up great irritation, had occasioned inflammation, effu- sion of lymph, and matting or gluing of the bowel to the left and upper portion or cornu of the uterus, that organ being still enlarged, its invo- IMPACTED FAECES AND FOREIGN BODIES. 255 lution after delivery being not yet completed, probably owing to the irritation, inflammation, and subsequent adhesion to which I have referred. Taking this view of the case, I purged freely and continu- ously for some days, till at length, after the lapse of six weeks, I had the sfaction of hearing from my patient for I did not attend her contin- uously during this period that the tumor was all gone, and she was quite well; facts I verified by careful manipulation when she last visited me. The iodide of potassium had been combined with the aperients, as had also anodynes the former in hope of dissolving adhesions, the latter with a view to ease pain. I would add, to show the difficulties which sometimes behedge the diagnosis in these cases, that this patient had previously had pronounced to her by three medical men that operation alone (gastrotomy) could do her any good; and of this she had a mortal y that of a nail. I'pon the follow- ing day it was passed from the rectum, Hayed, and covered with a mucous substance. At another time three larire pennies were successively put to the same use, and Ilenrion found them later, scraped clean and mixed with f:er:il matters. !! continued this calling until 1820. At this time he swallowed some nails, and then a plated iron spoon ni.-;i:irin^ tiv.- and a half inches in length and one in breadth, for a moderate >um. lie died seven days later."' Napoleon relates a case of considerable historic, interest, where the ali- mentary canal was used for the purpose .,. l">tli. l"7-<. Al-tra.-t ->f Stmlsgaard'a paper read l.efore S,>c. de Chir., Paris, Oct. 9th. 1878. 262 DISEASES OF THE RECTUM AND ANUS. who introduced his hand, and had sufficient address to cure the good monk." ' A depraved sexual appetite has been mentioned as accounting 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 prob- able 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 depraved 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 Par- ker with regard to his father, whom he had brought into the hospital. After beating around the bush and manifesting considerable sharne 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 rec- tum, 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 dis- appeared 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 extraction. 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 pro- tect the parts with cotton. The most difficult part was the extraction of the glass, which was very irritating. It was done, but not without diffi- culty, by making it see-saw from side to side. Considerable haemorrhage occurred, which was arrested with sulphate of copper and alum. The man recovered in two weeks." 2 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 anything 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 1 Mem. de 1'Acad. de Chirurgie. 2 Amer. Journ. of the Medical Sciences, 1849, p. 409. IMI'ACTKIi K^CKS AND FOREIGN BODIES. 263 mentioned beer glasses, mushroom bottles, wooden pepper boxes, wine bottles of all kinds, lamp chimneys, and a part of the wooden handle of ;i baker's shovel twenty-two centimetres in length. A foreign substance may remain in the rectum for a considerable 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 constipation. However, he performed the manipulation so unskilfully that the piece of wood broke and remained partly within the rectum. All attempts made to remove 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 introduc- tion of a finger into the rectum did not demonstrate the presence of a foreign body, he restricted himself to combating the inflammatory symp- toms and pain (calomel, enemata, narcotics, leeches). On the eleventh day a purulent, sanguinolent, fetid fluid was evacuated, after which the patient felt markedly 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 neces- sity for more active treatment, Weigand contented himself with giving the patient from time to time two or three spoonfuls of castor-oil which always produced the discharge of a small amount of muco-sanguinolent At this time the lumbar and abdominal pains again appeared 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 31st day after the accident, after having taken three rifuls 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 ap- pearance, 0.1357 m. long, 0.027 thick, cylindrical, serrated at the broken end, and roughened on the cylindrieal surface; in fact it was the end of a pole with which bean-vines are propped. The patient recovered en- tirely without having been subjected to any further treatment " (Poulet). Prognosis. The prognosis in cases of foreign bodies will depend 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 1 Schmidt's Annalen, 113, *iv., p. 95, 1862. 264 DISEASES OF THE RECTUM AND ANUS. ability of the one in charge of the case. A little bungling in the treat- ment 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 suffering to confess. In this, way a week's valu- able 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 ingenuity. The one guiding prin- ciple 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 advisable 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 some- times render a body movable which before was absolutely immovable and thus open the way for its extraction. Having opened the way to the body, it may sometimes be removed by passing the whole hand into the rectum and seizing it. At other times forceps may be used with advantage and these may be of any shape which seems best to answer the purpose 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 rectum, which he had introduced a week previously in order to overcome, as he said, his obstinate constipa- tion. This vessel was a preserve jar, the handle of which was broken and the bottom 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 1 Journal de Chir., T. Hi., p. 177 (Poulet). IMI'ACIKI) F.KCKS AND FOREIGN BODIES. 265 excessive pains had compelled him to suspend his efforts. The upper part of the rectum was infolded and invaginated 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. D unit made the patient lie upon the side, and then, separating the in- testine from the walls of the vessel, he succeeded in seizing the latter -.vith 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 break- ing 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 introduce the extractors a large number of times. After all the pieces had been removed, Desault pushed back the inverted portion of the rectum by means of a cha'rpie tampon six inches long and two and a half in diameter, which he pushed in altogether after having covered it witli cerate. Below this were placed a large amount of charple, several compresses, and a triangular bandage which supported the whole dress- ing. 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 pro- truded when the patient went to stool, and such large tampons 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 ond in the hollow of the sacrum, the proper treatment consists in opening the abdomen and this should bo done after an attempt to remove it per ii.num has been continued a reasonable time, and before injury has been dune in such an attempt. It is not necessary to describe the operation of Liparo-entrrotomy 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, T. 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 peritoneal cavity by an incision near the umbilicus. The man recovered. The oldest known case 1 was reported by Realli in the Bull, dei Soc. Medich., and Gaz. Med., July, 1851, and is asfollows : CASK XXV. "On the 18th of December, 1848, a peasant was brought in the hospital of Orvieto in a condition of extreme weakness. Nine day-; previously, having hit upon the ingenious idea that, if he pre- vented the discharge of food he could limit the quantity to beswallowed, he introduced a piece of wood into the rectum; all his attempts at re 1 For this and many other interesting facts in connection with this subject the reader is rffrin',1 to Poulet's work on "Foreign Bodies in Surgery." Wood's Lihrnry of Standard Medical Authors, 1880. 266 DISEASES OF THE RECTUM AND ANUS. moval 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 com- pletely obliterating the intestinal cavity, and the patient being threatened with death from his atrocious sufferings, Kealli 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- incise 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. No faeces: were retained above the plug, but the mucous membrane was blackish, the peritoneal coat strongly injected, and the thickness of the intestinal wall markedly increased. 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 faeces, 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 alarming character. The evacuations from the bowels were again passed on the fifth day. Towards the fourteenth day, the wounds had cicatrized. Two years later, the health remained perfect." In a paper read before the Soc. de Chirurgie, 1 Studsguard, of Copen- hagen, reports the following similar case: CASE XXVI. " J. F., footman, aged thirty-five years, was admitted on January 10th, 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 anaesthetized 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 1 Bull, de la Soc. de Chir., 1878, p. 662. IMFACTKI) F.ECKS AND FOREIGN BODIES. horizontal ramus 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 de- scended 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 fill ire circumference was protected by sponges and compresses between the faeces, and the intestinal incision was closed by twelve to fourteen catgut sutures, according to Lambert'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 centimetres; the opening contained a notch, which was evidently of old date, about half a centinu'tiv 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 posterior 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 1 by Verneuil, and those- four, I believe, make up all the literature of the subject. CASK XXVII. A man, aged forty-five, had been in the habit of stopping up liis rectum to overcome an incontinence of fa-ces which had resulted from two previous attacks of dysentery. For this purpose, he 1 various large bodies, taking the precaution to tie to them a piece of cord, the ends of which were left hanging outside. Hut one day, he had no cord, and a cylindrical piece of wood, ten centimetres l once by soothing ointments, or lotions. A good ointment is the ordinar oxide of zinc made soft and applied gently, and one which is pretty cer- tain to allay itching is that made of chloroform ( 3 i.- f i.). 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: 3 Acid, carbolici 3 ss. Glycerinae f i. Aquae 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 obstinate case of this disease, but who are pretty sure at some time to have both knowl- edge and ingenuity taxed to the utmost, I will give one or two more for- mulae which have been found reliable. The following comes from Alling- lumi, and by it alone he has "seen a bad case cured in forty-eight hours." R Liquoris carbonis detergens (Wright's), Glycerinae aa 1 i. Pulv. zinci oxidi, Calamin. prep aa 3 ss. Pulv. sulph. precip 3 ss. Aquae purse ad 1 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 ointment made soft with vaseline or glycerin is also a good application, and the following lotion, also from Allingham, will often work well in allaying irritation: 272 DISEASES OF THE RECTUM AND ANUS. $ Sodae biboratis 3 ij. Morph. hydrochlor gr. xvi. Acidi hydrocyanic, dil 3 ss. Glycerinae 3 ij. Aquae ad vii j. M. This should be applied to the part four or five times in the twenty- four hours. Dr. Bulkley 1 has also recommended the following as being useful, and 1 have often found it so. $ Ungt. picis 3 iij. " bellad 3 ij. Tr. aconit. rad 3 ss. Zinci oxidi 3 i. Ungt. aquae ros 3 iij. M. 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 sur- faces by a layer of dry sheet lint or old muslin. These are the most palpable and perhaps also the most common 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 con- stipation be present, this must first of all be overcome, for this is in itself an efficient cause for the disease. The treatment of chronic constipation is by no means a simple matter. It may be begun with a purgative such as three compound cathartic pills, for the sake of opening the way 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 sugges- tions 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. 1 The Med. Record, December 18th, 1880. PRURITU8 AN I. 273 Deficient secretion is very apt to be associated with hepatic disturb- ance, ;mK THK 8PUINCTKK. 277 CHAPTER XI^. iSM OP THE SPHINCTER. NEURALGIA. WOUNDS. RECTAL ALIMEN- TATION. Spasm Without Other Disease. Cases. Authorities. Symptoms. Treatment. Neuralgia. Cases. Diagnosis. Treatment. Wounds. Complications Spontaneous Rupture. Treatment of Wounds. Alimentation. Physiology of Absorption. Nutritive Enemata. Nutritive Suppositories. SPASM of the sphincter without the presence of any other rectal affec- tion is undoubtedly rare. Its general character may perhaps best be shown by the citation of the following cases. (' V-.K XXVIII. Physician, aged twenty-eight. The patient was a man decidedly given to thinking about his own health, and though rally 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. CASK XXIX. Professional man. Age, thirty. In this case also the only symptom complained of was pain on defeca- tion, sometimes severe, sometimes slight. The history given pointed so strongly toward the existence of a fissure that I etherized the patient, fully expecting to cure him by' stretching the sphincter. He was entirely cured by stretching the muscle, but, to my surprise, a most care- ful examination revealed no disease; and, being dubious myself about the existence of spasm without fissure, the examination was a very thorough 278 DISEASES OF THE RECTUM AND ANUS. one. This patient was also a man of sedentary habits and of rather a nervoits character. The following case is taken from Syme, and is characterized by him as a remarkable instance of the affection. 1 "I was asked to see a gentle- man, about sixty years of age, who stated that, a few weeks before, after sitting out along 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 con- sulted 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 characteristic 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 complaint." With regard to this much disputed affection, a citation of authorities may be useful. Syme 2 believed that spasm existed as an independent condition without morbid change; that, though there could be no doubt that spasm and fissure frequently 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 con- tracted without any perceptible fissure or abrasion of the surface." Mayo describes spasm of the sphincter as a kind of cramp which often conies 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, consti- tuting, therefore, a permanent stricture, and generally combining both permanent and spasmodic contraction. The motions are passed Avith an effort and with pain, and all the common symptoms of stricture of the rectum are present. Allingham 3 says: "Spasm of the sphincter has been said to be the cause of impaction, but I have more often thought the reverse was the case; and the impaction the cause of the spasm. I must, however, 1 Diseases of the Rectum. Edinburgh, 1838, p. 138. 8 Loc. cit., p. 134. 8 Op. cit., p. 210. SPASM OF THE Sl'HINCTEK. 279 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 instances to such a degree that, when the patient lined, I have observed the anus protruded like a nipple, and an injec- tion returned in a fine stream as if coming out of a squirt. I have cer- tainly met with cases of idiopathic spasm of the sphincter usually in elderly, nervous, single women, and thcugh no impaction was present, costiveness was." Quain 1 concludes that "where pain, brought on by faecal 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) depends chiefly on the painful spasm of the sphincters; the fissure is only an acci- dent, as is proved by rhe existence of painful spasm without fissure, which, according to well-known surgical authorities, is found in propor- tion to the other of one to four." And, "the spasmodic constriction is the true lesion, and the fissure only an epipheuomenon." Sir B. Brodie 4 held the same views. The symptoms of spasm of the sphincter are pain on defecation 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 smart- ing in the urethra and constipation. The disease is generally attended by exacerbations 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 mind, a generally irritable nervous condition, and everything which has a tendency to irri- tate the rectum, or the parts around, will aggravate the complaint. It may easily be confounded with the affection next to be described, neur- algia, but is generally 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 pa- tient, in allaying any nervous extitement, in the administration of a cathartic to empty the bowel Vlien the spasm is present; and in ano- dyne injections, such as, for example, of twenty drops of laudanum in 1 The Diseases of the Rectum. London, 1854, p. 167. * Traite des Maladies Chirurg., etc., fourth edition, t. x., p. 139. 3 Lemons orales de Clinique Chirurg., t. iii., p. 284. 4 Lectures on Diseases of the Rectum. London Med. Gaz., vol. xvi., p. 26. 280 DISEASES OF THE RECTUM AND ANUS. an ounce of water. Suppositories may cause renewed irritation. Even in the more aggravated form, the disease will often yield to such mea- sures as this, but, if it does not, a cure may always be effected by forci- ble 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 retention of a bougie. Neuralgia. Neuralgia of the rectum is generally met with in nerv- ous people, especially females, such as are subject to neuralgia in other parts of the body. The following cases show its general character. CASE XXX. Professional man, age 49. 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 entirely 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 rested. 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 XXXI. Woman, aged 65, married. This patient had been treated for fissure, for ulceration, and for coccygodynia, and had refused to submit to excision of the coccyx. Her general health was fair, but there was decided gastro-intestinal disturbance. 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 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 sensitiveness to touch seemed to be lo- cated well within the sphincter, upon the posterior Avail 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 independent of the act of defecation. In cases of well-marked periodicity, 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 greatest 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 i WOUNDS OP" THK KKCi 281 this, local applications of cold water, ointment of belladonna ( 3 i.- 3 i.), and blistering over the sacrum maybe tried. Besides thi.s local t: incut, the case must be managed exactly as would be a case of neuralgia '.}\ any other part. The diagnosis from coccygodynia and from spasm must both be made with care. Wounds of the Rectum. Wounds of the rectum may be either con- tused and lacerated or incised. The latter most frequently result from surgical operations, 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 frequent 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 perforation of the bowel is abo*:e 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 un- complicated by the injection, the mere puncture may fhwl spontaneously. It is oblique from below upwards, and this greatly favors spontaneous healing without faecal extravasation. K- march has met with four cases of this injury, none of which were fatal though attended by much local trouble. Velpeau describes eight cases, six of which ended fatally. Passavant observed five cases, one fatal. Chomel has had two fatal results. There are two preparations in Bartholomew*! Hospital showing the results of this accident, one in a man, the other in a child ten years of age (Esmarch). les tli-.sp most common injuries, many others maybe enumer- ated. The person may fall upon a sharp body, as the point of an um- brella (Bushe 1 ), may be caught upon the horn of an animal (Gundrum; 1 Ashton), or may be impaled upon a spike (Esmarch*). 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 implanted as to require great force and an anesthetic for its removal. The rectum is not infrequently lacerated in child-birth, and although such wounds are generally of slight extent, Bushe 1 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 fa'ees, the rectal wall has given 1 Op. -it.. p. 80., * Detroit Lancet, Oct.. : Op -it . p. Op. cir.. p. 80. 282 DISEASES OF THE RECTUM AND ANUS. way. Mayo 1 relates 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 2 reports a similar case and Bushe 3 another. Such a rup- ture may be either vertical or transerse, 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 gun-shot wounds comes more properly within the scope of military surgery. They are always complicated with in- juries of other parts, and are generally fatal from extravasation of urine or f eeces. The complications which may attend a wound of the rectum have already been hinted at. They are haemorrhage, either primary or secondary; faecal infiltration; purulent infiltration; peritonitis; emphy- ssema; hernia; invagination; and later, stricture and fistula. When fasces are forced out of the rectum into the adjacent tissue, diffuse inflammation and gangrene will probably result, and the condition must at once be met by free incisions and free drainage, as has been described in the chapter on abscess. The danger of faecal infiltration may be lessened by a diet which shall prevent fluid passages, and by the free use of opium. A dilatation or a free division of the sphincter is also to be recommended, so that a free outlet may be accorded to the contents of the bowel. Emphysaema, as a result of a perforation, is generally confined to the perineum, but may be diffuse. 4 It is very apt to be fatal from diffuse inflammation and septicaemia, 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, however, be the rule. In some cases, such, for exam- ple, as laceration in child-birth, sutures may be at once applied. Alimentation by the Rectum. The fact that certain substances may be absorbed into the general circulation through the mucous membrane of the rectum has been abundantly proved by physiological experiment and clinical experience. The close anatomical resemblance between the inverted follicles of the rectum and the intestinal villi render an analogy 1 Op. cit., p. 13. '- Op. cit., p. 152. 3 Op. cit., p. 69. 4 Lancet, Jan., 1860, p. 89. ALIMENTATION BY THE RECTUM. 283 in function extremely probable without experimental proof; but such proof is easily obtainable. A solution of salt, in the proportion of one part to eighty of water, injected into the rectum will disappear com- pletely in the course of an hour so completely, that an evacuation at the end of that time will be found to contain no more than the usual 'juantity. ' The fluid extract of rhubarb may be detected in the urine in about an hour after being injected into the rectum by the characteristic red color caused by the addition of caustic potash.* Bouisson, 1 after injecting beef-tea into the rectum, found the lacteals charged with fluid. Savory, 4 in his experiments on the relative rapidity of this absorption by the stomach and rectum, found that strychnia in solution acts more quickly by the rectum, but that in powder the relation was reversed. Quinine should be given in larger doses by the rectum than liy the mouth, while chloral and belladonna are readily absorbed by the former. Curare, on the contrary, acts more quickly by the rectum (Cl. Bernard). Cubebs and copaiba both act equally well by the rectum ; and water charged with sulphuretted hydrogen gas is rapidly eliminated in the dog by respiration, as may easily be proved by the usual test with a salt of lead. The fact of absorption being admitted, the next question is as to the power of digestion before absorption, and upon this point there has been -iderable discussion of late, and much difference of opinion. The theory that the follicles of Lieberkuhn may take on a vicarious action, and secrete a digestive fluid under the stimulus of albuminous food plac.-d in contact with the epithelium has its upholders, but has never been absolutely proved.* A >;iuT theory is that food introduced into the rectum excites secre- tion by the gastric and intestinal follicles, and that, in the absence of food in the stomach the digestive fluids thus secreted pass down into the urn and there act upon the injected materials.* Still another theory is that, instead of digestive fluids descending to act ui)on the food, the latter ascends to be acted upon by the fluids in the small intestine, and is there fitted for absorption. 7 This theory has : Animal I'hcmi-t r\ . 'Smith: Supplementary Rectal Alimentation, and Especially ly Detibrinated Blcxxl. as Applicable t<> a Larire Range of Cases in which Nutritive Knemeta have been Kmpl.-yed. Read before the N. Y. Acad. of Med., February 20th, 1879. *Dict. Encyc., Art. Rectum. * Gaz. Ittd., i II. Stowell: Is Food Digested in the Rectum? The Medical Advance, January. 1879. A. Flint, Trans. N. V. A.-:i.l. ofM.-.l.. K. !.. J"th. 1ST'), ami " Cases Illustrative of Rectal Alimentation, with Remarks," Amer. Practitioner, Jan., 1878. 1 H. F. Campbell: Rectal Alimentation in the Nausea ami Inanition of Preg- nancy Intestinal Inhaustion an Important Factor and the true Solution of its Efficiency. Trans. Gynaecological Soc., 1879. 284r DISEASES OF THE RECTUM AND ANUS. grown out of certain facts which have recently come to light regarding the reversed peristaltic power of the bowel. Injected matters such as blood and milk colored with madder may be found on post-mortem ex- amination evenly distributed over the coats of the intestine fora consider- able distance above the rectum, and this is in itself a simple argument in proof of a reversed action of the bowel. But there are many stronger ones. Dr. Battey, in an article on the " Permeability of the entire alimen- tary canal by enema, with some of its surgical applications," 1 details some experiments of his own by which he succeeded, in the cadaver, in passing an injection from the rectum through the whole length of the digestive canal, and out of the mouth. He also gives certain cases in which what he has accomplished on the dead subject has been done by nature in the living patient. In this way he accounts for the undoubted fact that patients will often complain of tasting in the month a substance like castor-oil which has been administered by the rectum; and for the fact that the ingredients of an enema, or a suppository, have occasionally been actually vomited. Dr. Harris, of Milledgeville, G-a., 2 has recently re- ported a case in which clear beef-tea enemata were vomited after an operation for ovariotomy. Jaccoud records a case of faecal vomiting which occurred in his wards at the Lariboisiere, in 1867, in a young woman who was admitted with hysterical convulsions. For eight days this person, at least once, and sometimes twice, in the twenty-four hours, vomited veritable fasces, dense, solid, cylindrical, of a brown color, and with the normal faecal odor, coming evidently from the large intestine. Jaccoud witnessed the act himself, and so also did Dieulafoy, and he characterizes it as actual defecation by the mouth. Apart from the passing disgust which followed the act, the patient ate as usual, and continued in her ordinary health, except in the absence of normal action of the bowels. All possibility of deception seems to have been rigorously excluded. Within a fortnight the woman was seized with grave typhoid fever and died. Careful exam- 1 Virg. Med. Monthly, vol. v., 1878. NOTE. Dr. Battey makes a claim to priority in having established the " entire permeability of the canal to enema," which though no doubt perfectly just as fas as his own experiments go, is refuted in the Med. and Surg. Hist, of the War, Med., vol. ii., p. 836, foot-note, by the following references. A. Guaynerius: Tractatus de fluxibus. Cap. 2, Lyons Ed., 1534. History of a man who vomited suppository placed in the rectum. J. Matthias de Gradibus, Practicia de ^Egritudinibus stomaci. Cap. 5, de- vomitu, fol. 213, Venice E.I., 1502; History of girl who constantly vomited her suppositories even after they had been tied with a string to keep them in the rec- tum. Morgagni, references to numerous similar cases. 8 Quoted by Campbell, loc. cit. ALIMENTATION II V TMK KECTUM. 285 iiiation of the body disclosed no mechanical obstruction whatever in the intestinal canal. The ileo-caecal valve was normal. 1 By ..MI- of these tlireo explanations it is attempted to overcome the obvious physiological objection! to rectal alimentation which arise from the farts that albumen is not diffusible, or if so at all, only very slowly and in very small quantity; and that to be absorbed it must first be changed by digestion into albuminose. Another and very practical way of overcoming the obstacle has been suggested by Dr. Chadwick* which consists in placing the enema directly into the small intestine by means of an aspirator a procedure which might be considered as not unat- tended with danger. Michel 8 has found the obstacle insurmountable and has, therefore, come to a conclusion unfavorable to the absorption of the nutritive matter of the substances injected. The theoretical difficulty of the digestion of albuminoid substances has been practically overcome in a very simple manner which is nothing more or less than artificiallly digesting such substances, either before or after their administration, by mixing with them a certain quantity of pepsin or freshly prepared pancreas. Catillon 4 has performed the fol- lowing instructive experiments in this connection. He fed two dogs for two months with injections of eggs. The first had eggs only and lived with difficulty and with considerable loss of weight; the second had gly- cerin and pepsin mixed with the eggs and lived in an apparently normal manner, the weight and temperature remaining constant. After thirty- seven days the pepsin was stopped, when the animal began to lose weight and the temperature fell 3 Fahr. The conclusion is plain that for nu- trition the digestive ferments must be associated with the food, or in ; her words that they must be transformed into peptones. In another series of experiments the same author has demonstrated that the same result is obtained by peptones prepared artificially. There would seem to be no doubt, in the light of the abundant clinical evidence which has now been accumulated, that life may be supported indefinitely, without loss of weight, by the proper administration of properly prepared enemata. Flint* refers to one case in which life was so sustained for fifteen months, and in which the feeding had been mainly of this kind for live years. For the convenience of the practitioner, the following formulas for nutritive enemata have been collected. The first is the one used by 1 Van Buren: On Phantom Strictun , . tc. Amer. Journal Med. S<-i., October, - AIIUT. Journ. of OlwU-t., viii., Nov., 1875. Gaz. Hebdoni., 1879. 4 Meeting of French Asa. for Advancement of Science at Rheims, 1880. Attract in Brit. Med. Jour., Sept. 1Mb, 1880, p. 485. w York Med. Record, 1878, p. 56. 286 DISEASES OF THE KECTUM AND ANUS. Mayet 1 and approved by Brown-Sequard. 8 Take of fresh pancreas of the ox from one hundred and fifty to two hundred grammes, and of lean meat from four hundred to five hundred grammes. Bruise the pancreas in a mortar with tepid water at a temperature of 37 C. and strain through a cloth. Chop the meat and mix it thoroughly with the fluid which has thus been strained after separating all the fat and tendi- nous portions. Add the yolk of one egg. Let stand for two hours and administer at the same temperature after having cleansed the rectum with an injection of oil. This quantity is estimated by Brown-Sequard to be sufficient for twenty-four hours' nourishment and should be admin- istered in two doses. Where the pancreas cannot be readily obtained, the folio wing formula may be found useful. 3 To a basin of good beef- tea add one-half a pound of lean,, raw beef steak pulled into shreds. At about the temperature of the body add one drachm of fresh pepsin and half a drachm of dilute hydrochloric acid. Place the mixture before the fire and let it remain for four hours, stirring frequently. The heat must not be too great or the artificial digestive process will be stopped altogether. It is better to have the mixture too cold than too hot. Sometimes a little more pepsin may be needed which may be ascertained by stirring with a spoon. If alcohol is to be given, it should be added at the last moment. Eggs may also be added, but should be previously well beaten. This preparation is said to be well borne for a long time. The formula of the late Dr. Peaslee was as follows: Crush one pound of beef muscle fine, and add to it one pint of cold water. Allow it to macerate three quarters of an hour and then raise gradually to the boil- ing point. Allow it to boil two minutes and no more. The favorite in- jection of Dr. Flint is milk 3 ij., whiskey 3 ss., and the half of an egg. This he administers every three hours, day and night. But these simple enemata, no matter what their merits may be or may have been in the past (and we are inclined to wonder whether all attempts at alimentation before the admixture of pancreas was thought of, have been as useless as Catillon's experiments would indicate) are now generally replaced by those of artificially digested meat. In the year 1878, many experiments were made in New York with defibrinated blood as an enema, and the conclusions reached were em- bodied by Dr. A. H. Smith in the paper already referred to and were as follows : "1. That defibrinated blood is admirably adapted for use in rectal alimentation. J Gaz. Hebdom., Nov. 2ist, 1879. 2 Gaz. Hebdom., Nov. 14th, 1879. 3 Rennie: Case of severe cut throat; with some remarks on the administra- tion of nutritive enemata. Lancet, Oct. 23d, 1881. ALIMENTATION BY TIIK RKCTUM. 287 2. Tluit in doses of sixty to one hundred and eighty grammes (two to six ounces it is usually retained without any inconvenience, and is fre- quently so completely absorbed that very little trace of it can be dis- covered in the deject i 3. That, adminisiered in this way once or twice a day, it produces, in about one-third of the cases, for the first few days, more or less consti- pation of els. 1. That, in a small proportion of cases, the constipation persists, and even becomes more decided the longer the enemata are continued. 5. That iu a very small percentage of cases irritability of the bowels attends its protracted use. 6. That it is a valuable aid to the stomach whenever the latter is inadequate to a complete nutrition of the system. 7. Tiiat its use is indicated in all cases not involving the large intestines, and requiring a tonic influence which cannot readily be obtained by remedies employed in the usual way. 8. T4iat in favorable cases it is capable of giving an impulse to nutri- tion, which is rarely, if ever, obtained from the employment of other remedies. 9. That its use is wholly unattended by danger." However useful and nutritious these enemata may be, there is one practical objection to them which I have occasionally met with and have been unable to overcome. The sight of the blood, its administration, and its subsequent voiding are not calculated to impress the mind of a nervous and delicate lady pleasantly on the contrary, they sometimes excite the most profound disgust. No one form of enema should be continued for too long a time, and, as a rule, patients will be found to thrive the best upon an alternating diet of milk and egg, with preparations of beef and pancreas; alcohol being given as it is indicated. The rectum proper will seldom accom- modate more than six ounces of fluid, and this is the usual quantity for a:i enema: but the sigmuid flexure will hold much more than this; and fur myself, I much prefer what may 1>e call-.-d the colonic to the rectal method. in- injections are better retained, cause less irritation, may be given in larger quantity, and hence need not be so often re- peated. The best apparatus for this purpose is a small-sized, soft-rubber, flexible rectal bougie, the end of which will accommodate the smallest end- ;ho ordinary Davidson's syringe. This should be well oiled, and the fluid to be injected should be forced through it once or twice till it is well wanned, and tin; air is entirely forced out The tube is intro- duced into the .--igm'.ul flexure after the syringe has been connected. In this way, all over-distention of the rectum and consequent desire of the patient to immediately evacuate what has been administered is avoided. The enema should be administered slowly, and by the physician himself rather than the nurse or relative of the patient ; for the operation is one 288 DISEASES OF THE RECTUM AND ANUS. requiring judgment and skill, and on the success of the method depends the life of the patient in most cases. It is always well to empty the bowel by a simple enema before administering nutriment at least once a day. With proper care in using the syringe, the rectum and sigmoid flexure will generally be found to submit kindly to this method of treat- ment, but when once they become irritable, unless the injections can be intermitted for a day or so, and suppositories of opium be substituted, the treatment is practically at an end. In a few cases I have succeeded in re-establishing a tolerance by rest and careful treatment, but it is much better so to manage the case from the first that no irritation be excited. An enema, for this reason, should never be administered at a lower temperature than that of the body. Dr. Spencer 1 has described a suppository which he recommends in the place of enemata. It consists of the extracted product of artificially di- gested meat, from which the insoluble matter has been removed, mixed with a little wax and starch. Twenty ounces of meat thus prepared may be made into five suppositories, one of which .should be given every four hours. 1 Practitioner, Feb., 1882. INDEX. Abscess, boundaries of ischio-rectal, 73 causes of deep rectal, 73 classification of, 71 clinical history of superficial, course of pus in deep, 74 diagnosis of, 76 distinction between treatment of, and of fistula, 77 due to diffuse inflammation of subcutaneous tissue, 72 due to disease of urinary organs, 74 due to disease of neighboring parts, 74 due to foreign bodies, 73 due to perforating ulcer, 74 due to rupture of the rectum, 71 due to stricture of rectum, 74 due to submucous inflamma- tio:. due to suppuration of haemor- rhoi.l. 7-> early incision in, 76 following surgical operations, 73 horseshoe, 75 how to avoid the formation of listula in, 76 involving skin of anus alone, 71 not to be cut into the rectum. 77 of JU|M>rior pt'lvi-rvctal su;ic-, 73 of Uchio-rectal fo^ originating in cutaneous glands, 71 prognosis of, 76 19 Abscess, reasons for not healing sponta- neously, 75 results of deep, 76 rupture of, into neighboring organs, 75 symptoms of ischio-rectal, 74 symptoms of pelvi-rectal, 74 treatment of deep, 76 treatment of superficial. Absorption by the rectum, 283 Adenoma, malignant, 218 Adenomatous polypus, 188 Albumen, digestion in rectum, 285 Alimentation by the rectum, 282 Allingham, case of spasmodic stricture, 182 ligature holder, 84 on spontaneous cure of fis- tula, 81 on treatment of deep rectal abscess, 76 operation for haemorrhoids, 106 results of colotomy, 216 spring-scissors for fistula, 87 symptoms of ulceration, 174 Alveolar sarcoma, 298 Ainussat, operation for imperforate anus, 89 Ano-rectalsypliilonia. 149, 172 syphiloma, cause of stric- tnrf, 140 nyphiloma, definition of Fournier. 149 syphiloma, primary seat of, " 149 Byphiloma, use of anti-syph- ilitic treatment for, 149 290 INDEX. Anus, abnormal, 34 absence of, 32 congenital malformation of, 30 description of, 5 double, 34 erectile tissue of, 5 imperf orate, 31 imperforate, child living thirty days, 37 Arteries of rectum, 13 Baum, case of colectomy, 244 Benign fungus, 148 fungus, composition of, 148 fungus, haemorrhage from, 148 fungus, treatment of, 148 Billroth, case of colectomy, 245 report of thirty-three cases of excision of cancer, 23 1 Bivalve speculum, 59 Blood for rectal alimentation, 286 Bougies, how to pass, 57, 192 varieties of, 56 Boyer on fissure, 160 Bridge, case of colotomy, 216 Broadbent, on puncture for relief of ob- struction, 132 Broca, fatal case of excision of polypus, 142 Bryant, case of colectomy, 245 villous polypus, 137 Bulteau on invagination, 1.25 statistics of colotomy, 216 Bursa mucosa coccygea, 10 Byrd, case of formation in anus in nat- ural position after colotomy, 45 Calculus projecting into rectum, 4 Callisen's operation for imperforate anus, 41 Cancer, 218 age of patients, 228 causes of suffering in, 247 causes of mortality after exci- sion, 232 causing cedema of lower ex- tremities, 230 caustic applications in, 249 chances of radical cure by ex- cision, 234 comparative frequency of, in the sexes, 228 cure of, 231 Cancer, diagnosis of, 229 dilatation of, 249 distinguishing marks from be- nign polypus, 218 division of sphincter for, 248 examination for, 230 excision of, 231 excision of, as a palliative measure, 235 excision of, bibliography, 233 excision of, contraindications, 236 excision of, compared with colotomy as a palliative mea- sure, 235 excision of, dangers of opera- tion, 237 excision of, early history of, 238 excision of, how to perform, 238 excision of, history of opera- tion, 231 excision of, when justifiable, 237 extension into neighboring organs, 229 general character of, 218 generalization of, 220 generally painful, 229 haemorrhage from, 229 indications for colotomy, 248, 250 insidiousness of, 228 involvement of lymphatics in, 230 location of, 228 microscopic anatomy of, 219 mode of development, 220 of sigmoid flexure, excision of, 243 of sigmoid flexure, diagnosis of, 231 operation of crushing, 250 opium for, 248 osteoid, 225 palliative treatment of, 247 partial removal of, 248 peculiar feel of, 230 prevention of obstruction by, 248 proctotomy for, 249 reguiation of passages in, 247 results of excision, 232 IXDKX. 291 Cancer, secondary ulceration in, 229 secondary deposits of, 231 significance of pain, 229 symptoms of, 229 treatment of, 231 Carcinoma, melanotic, 224 Cartilaginous tumors (see enchondroma) < 'a u li flower excrescences, 143 . (!alv;iM<>-r:iutcry for tistula, 88 : .-IKHI^ rcllulitis, 75 rene f rectum after confinement, 17:? ( iariel, jM-ssary of, '>\ ( ilatulular ]x>lypus, 139 ( ;,iiiorrhy extravasation of blood, internal, diagnosis of, 98 internal, varieties of, 98 internal, method of cure liy carbolic acid injec- tions, 105 Internal, operation by clamp and cautery, 106 palliative treatment of internal. 98 suppuration of external, 72 suppuration of internal. 294 INDEX. Haemorrhoid, symptomatic, 101 symptoms of internal, 98 treatment by caustics, 102 treatment of external, by incision, 93 treatment by ligature, 106 treatment when strangu- lated, 100 treatment by injections of carbolic acid, 103 ulceration following ope- ration, 108 various operations for, 109 venous, 97 Hairy cyst, 152 Helmuth's ligature holder, 84 Herpes, 272 Hilton, white line between external and internal sphincters, 5 Horseshoe abscess, 75 Hodges, on pilo-nidal sinus, 153 Hydatids, 154 Inipaction of faeces, 252 of faeces, causes of, 252 of faeces, cases, 253 of faeces, dilatation of sphinc- ter for removal, 256 of faeces, diarrhoea caused by, 253 of faeces, errors in diagnosis, 253 of faeces, location of, 253 symptoms of, 253 treatment of, 255 Intestinal obstruction, treatment, 198 obstruction, mechanism of, 191 obstruction, coming on sud- denly, 190 obstruction, fatal when cali- bre of bowel is considerable, 190 concretions, 252 Invagination, 124 acute, 129 change in evacuations, 128 chronic, 128 diagnosis of, 129 degrees of, 125 Invagination, extravasation caused by, 127 frequency with which different parts are af- fected, 125 faecal vomiting in, 128 immediate effects of, 126, laparatomy for, 133 of large intestine, 128 pain in, 128 pathological changes in, 126 peritonitis caused by, 127 relative frequency of, 126 sloughing of included portion, 126 symptoms of, 127 taxis for, 130 treatment by injections' 130 treatment by puncture, 132 terminations of, 126 tumor caused by, 128 ulceration and perfora- tion caused by, 127 Imperforate anus, 31 anus, rules for treatment, 39 Incontinence of faeces, 77 of faeces, cure, 77 of faeces, treatment, 77 Incision of fistula, 85 Inflammation of rectum, 66 Inferior haemorrhoidal arteries, 13 haamorrhoidal veins, 13 Inspection of anus, 53 Instrument case, 52 Iodine as cure for fistula, 83 Irritable ulcer (see fissure) Ischio-coccygeus muscle, 11 Kleberg, operation for prolapse with elastic ligature, 122 Kohlrausch, plica transversalis recti, 23 case of stricture due to hy- pertrophy of valves, 184 Kronlein, case of attempt to re-establish anus after colotomy, 46 Lamp for rectal examinations, 51 Laparatomy for obstruction, 133 IXDKX. Iapan>-eMter"t,'ir.\ fi : 7 Levator ani, 11 ani, spasm of, 13 Licorice powder, compound, 99 Lieberkuhn, follicles of, 9 Ligament, anterior sacro-coccygeal, 7 pulx>-prostatic, 12 Lipomata, 15U cretaceous formations on, 151 as cause of invagination, 151 attached far up. 151 divided int') pedunculated and non-pedunculated, 150 study of by Virchow, 151 Little, examination table, 50 Lattre, operation of, 40 Lumbar colotomy. dangers in children, 43 nerve-centre governing sphinc- ters, 17 Lupus exedens, 164 exeden^. treatment, 165 Lymphatics of rectum, 19 Mackenzie, on the treatment of dysen- tery by injections of nitrate of silver, ISO" Malformations of rectum and anus, 80 Manual examination of rectum. 61 Marshall, case of colectomy, 245 Martini, rase of colectomy. 246 Mason, on chancroidal stricture, 168 Mathieu, re.-tal supporter, 115 Melanoma, -'. t analysis of cases, 225 cases and literature, diagnosis of. durati-.n ,,f. -j-jr, general cliara-ter ot location of, I malL'iiaii'-y <: Meao-rectum. 5 Middle hivmorrhoiilal arteries, 13 h;einorrlioi(lal veins, 13 Molk on fretal inclusions, 154 Molliere, ablation of prolapse. 1'Jl experiments in pro, lui -ing pro- lapse, 113 Morgagni, columns of, 8 sinuses of, 8, ~ Mucous membrane, glandular layer, 9 membrane, muscular layer, 9 membrane, valves of, 21 Muscles of rectum, 10 Muscularis mucosae, 8 Nerves of rectum, 16 Neuralgia of rectum, 280 Nilric acid for haemorrhoids, 102 Non-malignant growths, 135 stricture, excision of, 214 Nutritive suppositories, 288 enemata, 286 Operations, haemorrhage after, 63 preparations for, 62 retention of urine after, 65 Osteoma, 225 Osteo-carcinoma. _'"> Osteo-sarcoma, 225 Owen, attempt to re-establish anus after colotomy, 45 Packing the rectum for haemorrhage, 64 Paget, syphilitic ulceration, 171 Pain, anatomical explanation of, 17 Papilloma, granular, 134 Papillomata, 143 Paquelin's thermo-cautery, 68 Pederasty, 5, 159 Pelvis, measurements in children, 88 Pelvi-rectal abscess, 78 Perforation of bowel by foreign body, 259 Peristahi~. reverse, 284 Peritoneum, contained in prolapse, 118 in polypus 142 relations to rectum, 5 Peritonitis due to stricture. 187 from perforation. 129 Pitf's tail in rectum Pilo-nidal sinus. !.">:* I'lic-i trai: r,>lyar anal regions, 84 ending in blind pouch, 33 :ir in Madder, urethra, or vagina, 86 ending of longitudinal fibres, 7 excision of (see cancer) fixed position of, 1 haemorrhage from, 67 imperforate, 38 layers of wall, 5 length, 1 lymphatics of, 19 mucous membrane, 8 muscles of, 10 muscular coats, 6 normally empty state, 27 nerves, 16 operations upon, 62 ( >r examination, etc., 48 relations of different divisions, 3 submucous tissue, 7 I 4;il absence, 37 upper limit of, 2 \ariations in position, 3 veins, 13 Retention of urine after operation, 65 HI -tractor recti muscle, 10 Hi>< -lie, case of fatal rupture of prolapse, 130 Rodent ulcer, 165 ulcer, diagnosis, 166 Rupture c.f howel in prolapse, 120 of rectum causing abscess, 74 Sarcoma, alveolar. Sarcomatous polypus, 139 Scirrhus, 2',M extent. . rarity, 228 Scrofula, as cause of ul< -.-ration, 104 Secondary h;i-tm>rrha_:.-aft.-r nitric aci.l to h.-einorrlioids lir_> Sigmoid flexure, variations in position. 43 Smith, case of divulsion, 2:',l clamp for hifinorrhoids, 108 removal of severe prolapse, pjj Sodomy, appearance of rectum, 159 cause of ulcer.ition, 159 cause of vegetations, 144 medico-legal proofs, 159 Sodomy (see pederasty) Spasm of levator nni after operations, 13 of sphincter, 277 of sphincters associated with fis- sure, 160 of sphincters associated with im- paction. 279 Specula, varieties of, 58 Sphincter, dilatation, 60 external, 10 functions, 28 internal, 10 nerve control of, 17 third, 7, 19 Spina bifida. !."> bifida, diagnosis, 156 Stimson on cancer, 219 Storer, method of rectal exploration, 53 Strangulation of prolapse. 119 Stricture, attemptsat spontaneous cure, 186 bougies for detection of, li'.' cause of abscess, 74 cause of fistula, 187 cause of peritonitis, 187 cause of ulceration. 17',' congenital, 31 dangers in examination, 55, 57 due to pressure from without, 181 due to hypertrophy of valves, 184 due to gonorrhoea, 167 due to chancroid, 168 due to traumatism, 185 diet for, 197 difficulty in diagnosis when hi^h up, 58 following r 'inoval of hemor- rhoids. 108 general treatment, 197 how to m.MMire extent, 57 manual examination for diag- nosis, 62, 193 mechanism of production of flattened fivcea. 189 non-malignant. 1M non-malignant, alternate di- arrhoea and constipation, non-malignant, cause of, 181 298 INDEX. Stricture, non-malignant, change in wall of bowel capable of producing, 183 non-malignant, changes in bowel above and below. 186 non-malignant, constitution- al remedies for, 193 non-malignant, dangers of examination, 191 non-malignant, diagnosis of, 191 non-malignant, difficulty in diagnosis, 191 non-malignant, divided into venereal, non-venereal, ci- catricial, and fibrous, 183 non-malignant, pathological anatomy, 186 non-malignant, probable causes of when extensive, 188 non-malignant, symptoms, 188 non-malignant, treatment by dilatation, 198 non-malignant, usual seat of, 187 non-malignant, value of flat- tened faeces in diagnosis, 188 non- venereal, 184 spasmodic at anus, 181 spasmodic at rectum, 182 spasmodic, explanation of supposed cases, 182 sudden death in, 216 sigmoid flexure, treatment of, 217 syphilitic, but not ulcerative, 183 syphilitic, specific treatment for, 194 use of long cylindrical spec. ulum for examination, 193 treatment by division, 202 treatment by divulsion, 200 value of dilatation, 200 venereal, 183 venereal but not syphilitic, 183 Superior haemorrhoidal artery, 13 haemorrhoidal veins, 13 Suppositories, nutritive, 288 Sustentator tunicae mucosae, 8 Syme, treatment of fissure, 177 Syphilis and vegetations, 143 diagnostic marks of ulceration, 171 character of secondary ulcera- tion, 170 tertiary ulcerations, 170 late manifestations causing stricture, 183 Syphilitic stricture, 183 stricture, specific treatment* 194 Sympathetic nerves of rectum, 18 haemorrhoids, 101 Talma, autopsy on, 186 Tensor fasciae pelvis, 10 Thermo-cautery, 63 Third sphincter, 19 Transversus perinaei, 13 Tubercular ulceration (see ulcer) Tumor, peculiar bleeding (Quain), 136 Tumors, non-malignant, 135 Trousseau on fissure, 160 Ulcer, caused by applications to fissure, 159 caused by foreign bodies, 258 chancroidal, 167 dysenteric, 166 follicular, 164 of hsemorrhoid, 168 scrofulous, 164 simple, 158 tubercular, 162 tubercular, authorities on, 163 tubercu'ar, cause of fistula, 163 tubercular, cause of haemorrhage^ 163 tubercular, cause of stricture, 163 tubercular, characters of, 163 tubercular, course of, 163 tubercular, distinction between true tubercular and ulceration in a tubercular person, 162 tubercular, location of, 162 tubercular, treatment of, 164 venereal, 167 Ulceration, causing abscess, 74 caused by sodomy, 159 diagnosis of, 175 INDEX. JIM) Ulceratton, diet in, 179 division of sphincter for, 180 following operation for ha-morrhoids, 108, 159 from application of nitric acid to prolapse, 159 from childbirth, 159 from foreign bodies. 159 from hard faeces, 158 from surgical operations, 159 gravity of, 175 harm done by exercise, 179 local remedies for, 179 non-malignant, 158 non-tubercular, 164 occurring during the course of syphilis, 172 suppositories and enemata for, 179 syphilitic, diagnosis from tubercular, 172 syphilitic, cases of, 172 >\ tnptoms, 174 treatment, 176 treatment by absolute rest, 178 tnatment by large injec- tions of nitrate of silver, 179 within rectum, treatment of, 178 Valves of rectum, 21 of rectum, hypertrophy of, 29 Vance, rare case of fiscure, 161 Van Buren, op.-rution f r prolapse, 117 spasmodic stricture, 183 speculum, 58 Veins of rectum, 13 Vegetations, 143 causation, 144 due to sodomy, 144 relation to syphilis, 144 microscopic anatomy of, 143 Venereal stricture, 183 Venereal ulceration. 167 Vienna paste for haemorrhoids, 102 Vidal, cases of prolapse treated by in- jections, 116 Villous polypi, 136 tumor, 136 Virchow, on fatty tumors, 151 Vomiting of faeces, 284 Warts, 143 causing symptoms of fissure, 145 diagnosis, 140 due to pregnancy, 144 due to gonorrhoea, 144 due to leucorrhoaa, 144 mistaken for syphilitic condylo- mata, 145 nou-contagiousness of, 144 non-inoculability of, 144 powerlessness of specific treat- ment for, 144 symptoms, 144 treatment, 145 within n-ctum, 145 Wounds of rectum, 281 of rectum, complications, 282 of rectum, treatment, 282 Zappula, case of supposed syphilitic strii-tun- <-un-y antisyjihi- litic treatment, 194 from which it was borrowed. A 000 504 505 WI 600 K29d 1882 Kelsey, Charles B Diseases of the rectum and ami* WI 600 K29d 1882 Kelsey, Charles B Diseases of the rectum and anus MEDICAL SCIENCES LIBRARY UNIVERSITY OF CALIFORNIA, IRVINE IRVINE, CALIFORNIA 92664