Part 148

Thus it is seen that the rectum and anus have vascular and nervous supplies of considerable diversity and importance.

Congenital Malformations.

The simplest form of congenital malformation in this region consists in an anus of insufficient size for the natural demands of the system, but in no other manner abnormal. The most frequent variety of imperforate anus is where complete occlusion is effected by the common integument or by two cutaneo-mucous flaps, which owing to defective development remain united without forming a raphé or perceptible line of union. The rectum is not involved, and when the child strains the contained meconium causes bulging of the part, which disappears under slight pressure, but reappears when again free. In other cases the occluding tissue is very firm, dense, with a disposition to pucker or form rugæ. The sphincter muscle is rarely perfect, and though an artificial anus may be made, years may elapse before the child can control the evacuation. In conjunction with an imperforate anus the colon may terminate in a cul-de-sac, or it may communicate with the urethra, the bladder, or the vagina.

{880} An imperforate rectum has been known to discharge at the umbilicus, upon the face, under the scapula, upon the penis or the anterior part of the scrotum. Sometimes, though very rarely, a common cloaca has been found, as in fowls, common to the rectum and to the genito-urinary organs; and still more rarely the rectum has opened in abnormal sites upon the perineum and upon the buttocks.

The anus may be entirely absent. The rectum may be entirely absent or it may be incomplete, terminating at various distances from the anus. These malformations of the bowel may be associated with a perfect anus, or with any of its imperforate forms, or with a fecal fistula. In occlusion of the rectum the offending structure is in some cases a hymen-like fold of mucous membrane, which, during straining, can be recognized by the finger as a fluctuating protrusion; while in others it consists of a mass of dense fibrous tissue which extends upward from an inch to an inch and a half: in the former there is always found a normal anus; in the latter there is either no trace of anus or one in a more or less rudimentary state. In those cases where the rectum is entirely absent the intestine terminates either in a cul-de-sac or a fecal fistula; very rarely the rectum is replaced by a fibro-ligamentous cord or band which springs from the colon, and, descending toward the bladder, blends with the connective tissue of the part. In the latter the pelvis is always in an imperfect state of development, being much contracted in its lower diameters, and the anus is absent; and Rokitansky and Curling lay stress upon the non-development of the pelvis as a diagnostic guide in determining the absence of the rectum. The passage of a sound into the bladder or vagina is a procedure of some diagnostic value, as if its point impinges directly against the sacrum it may be presumed that no rectum exists. If the malformation is of such a character that the fecal matter can find no exit, a train of symptoms ensues analogous to those seen in the adult affected with intestinal obstruction: the infant cries and is constantly restless, refuses food, vomits, the abdomen distends, and death speedily ensues. A remarkable exception to this rule was the case mentioned by Bodenhamer of a child with absence of the rectum who was not operated on until three months after birth, and who was apparently in perfect health. At the operation the intestine was found three inches from the surface, and the child made a good recovery.

Although the statistics of this class of malformations are somewhat contradictory and confusing, it is safe to state that more male than female children are so afflicted.

The prognosis in the large majority of these cases is grave, for unless the operator can see or feel the fluctuating protrusion, or can recognize it after a very slight exploratory incision, he is working totally in the dark and in close proximity to the peritoneum. Hemorrhage, peritonitis, pelvic cellulitis, and septicæmia diminish the chances for recovery. Indeed, the majority of these cases are scarcely amenable to surgical treatment.

{881} PRIMARY DISEASES OF THE RECTUM AND ANUS.

Prolapse and Procidentia of Rectum and Anus.

These conditions obtain most frequently at the two extremes of life, infancy and senility, but have a very different causation in each. Prolapse of the bowel may be partial or complete--partial when a portion of the mucous membrane is extruded, and complete when the entire rectum appears outside the anal orifice. A predisposing cause in infants is found in the mobility of the bowel--in the fact that it and the sacrum are much less curved than in the adult, and the abdominal viscera are more voluminous: this, associated with the undeveloped state of the muscular system, causes the weight and strain to act directly and forcibly upon the sphincters, and the extrusion takes place. It is often excited by allowing children to sit for a length of time upon the chamber-vessel. It is frequently caused among children by the presence of vesical calculi, by Oxyuris vermicularis, diarrhoea, constipation, dysentery, polypi, and by the long-continued acts of coughing and crying.

In adults and the aged it may be caused by loss of tone of the anus and rectum in chronic diarrhoea and dysentery, or from the energetic action of drastic cathartics, by urinary calculi, the long-continued use of enemata, chronic cough, diarrhoea alternating with constipation, stricture of the urethra, prostatic hypertrophy, tenesmus due to the presence of polypi, and by the pressure of a pelvic tumor. It may accompany procidentia uteri and hemorrhoids. An incomplete, reducible prolapse consists of two or more overlapping plications of normal-looking mucous membrane, sensitive but painless. In these cases there is provoked a hyperplasia of much-elongated connective tissue in the submucous space which undergoes serous infiltration and causes an oedematous condition of the part. In a complete prolapse the entire rectum--all of its component layers--is protruded through the anus. In a recent case the folds of the gut are well marked, but in one where the bowel has remained in this abnormal condition for some time the submucous tissue becomes charged with inflammatory deposit which effaces the plications and causes the bowel to become pale, hard, dry, and tough; and finally pigmentation occurs and the part assumes somewhat the character of true skin. These vary greatly in size, from the slightest protrusion of mucous membrane to a tumor the size of a melon. Usually they are reduced with ease, but their reappearance is occasioned by the slightest tenesmus.

In old age the soft parts of the floor of the pelvis and the anal sphincters lose to a great extent their tone and contractile vigor, and the rectum, also participating in this change, is often unable to withstand the increased thrust of the diaphragm and the compression of the abdominal muscles during defecation; which act frequently demands more exertion on account of a tendency to constipation in advanced life.

In these long-standing cases of senile procidentia it is a matter of experience, verified by post-mortem dissection, that the fibres of the sphincters and of the levatores ani muscles are flattened, pale, and stretched beyond the possibility of contraction, while the entire perineum is in a state of atrophy.

{882} Polypi of the Rectum.

There are two varieties of these--the gelatinoid or soft, and the fibroid or firm. The latter is of rare, the former of common, occurrence, especially in children under the age of twelve years. The fibroid polypus is only found in adults, and is composed of dense connective-tissue elements and blood-vessels. The gelatinoid or soft polypi are also partly composed of connective tissue and vessels, but much finer than in the other: they contain hypertrophied follicles and are covered with spherical epithelium. They resemble nasal polypi, but are more dense. These growths are not malignant in character, but are very troublesome, as they are almost always pedunculated, the stem being from half an inch to four inches in length, which admits of the descent of the tumor within the grasp of the sphincters during defecation, and frequently admits of its escape from the anus. Their presence is not free from danger, as they are very vascular, bleed readily, and are sometimes detached by the breaking of the pedicle during defecation. They frequently bleed spontaneously. The presence of these abnormal growths teases the rectum and brings on tenesmus and frequent desire to go to stool; the feces are flattened, and with them escapes a quantity of glairy red mucus which has been compared to thin currant-jelly. When caught in the grasp of the sphincters they often bleed profusely, and especially is this the case with children so affected. The presence of these bodies is accompanied with a sense of weight and uneasiness in the bowel. They may be single or multiple; they may be round, reniform, oval, fusiform, or irregular; they may be smooth or villous. In size they vary from that of a marble or cherry to that of a small hen's egg, and they are usually found about three inches above the anus, but they vary in position from a point just within the sphincter to one six inches up the rectum. Their presence is usually diagnosticated without difficulty, or, if any is experienced, a digital exploration will reveal them. A child with functional disturbances of the bowels accompanied with frequent hemorrhages should be examined for polypus. One of these growths sometimes unpleasantly complicates a case of hemorrhoids.

A rectal polypus is an adenoma, consisting of dilated glands of Lieberkühn imbedded in connective tissue, also containing nerves and blood-vessels, and is covered with the epithelium of the bowel.

Hemorrhoids, or Piles.

These are usually fibrous when situated below, or vascular when situated above, the sphincter ani muscle. They are conveniently known as external and internal piles, but in some instances it is impossible to say whether these tumors are external or internal. In either variety they are due to an abnormal state of the blood-vessels, and especially of the plexus of superior, middle, and inferior hemorrhoidal veins disposed around the lower extremity of the rectum immediately above the internal sphincter muscle. The inferior mesenteric and internal iliac veins receive a large portion of the blood from this plexus, so that a very free intercommunication exists, around the lower portion of the rectum, between the general {883} venous system and that of the liver. It should be borne in mind that these veins are destitute of valves, and are situated in a very dependent part, which is normally in a high degree of functional activity.

External hemorrhoids are found at the very verge of the anus, and, when not irritated or inflamed, appear like movable, dependent plications of hypertrophied skin. They appear either singly or in groups, but it is nothing unusual to find five or six of them together, and they are not infrequently associated with the internal variety. These pendulous tabs of integument are very prone to inflammation, and they then become exquisitely tender, painful tumors, which vary in size from that of a small pea to that of a pigeon's egg. That portion of the tumor presenting toward the anus is covered with mucous membrane; the other is covered with integument; the former is dark-colored, due to engorgement of its vessels. These, being composed internally of tortuous, dilated veins which have totally lost their normal resiliency, bleed freely on section, but after a time they undergo the following changes: the over-distended vein, of which each is mainly composed, either becomes obliterated by the encroachment of inflammatory deposit or its walls give way and the contained blood escapes; its serum is absorbed, and the tumor now consists of a blood-clot, the remains of a vessel, inflammatory lymph, a hyperplasia of connective tissue, mucous membrane, and integument. It undergoes a still further change by absorption, and remains a permanent pendulous teat of cutaneous and connective tissue, bearing no trace of vascular channels.

On account of the extremely sensitive nature of the mucous membrane and skin of the anus, an inflamed condition of these tumors entails an amount of suffering very disproportionate to their size: there is torture in the act of defecation, constant tenesmus, spasm of the sphincters, a sense of weight and heat in the perineum, and sometimes a swollen, very painful, condition of the raphé, which stands out like a cord.

Occasionally there is a total inability to urinate, combined with a frequent desire to do so. When an attack such as this ends in suppuration of the tumor a radical cure is effected, but a marginal ulcer of the anus sometimes follows. An unclean and neglectful habit provoking constipation, sexual incontinence, over-indulgence in highly-seasoned food or in stimulating beverages, exposure to cold and wet, and the straining attendant upon dysuria, will provoke an attack. No age or sex is exempt from this affection (Gross). It is claimed that before puberty females are more subject to it than males; after that age the reverse obtains, except during pregnancy.

Internal hemorrhoids are round, oval, or sometimes cylindroid-shaped tumors covered by mucous membrane; they are smooth, granular, or rough to the touch, much less sensitive and painful than the inflamed external variety, and are situated within the rectum it may be an inch or two above the internal sphincter muscle. They occur in groups or scattered over the surface of the bowel. In structure they are soft, spongy, vascular tumors composed of dilated and tortuous blood-vessels, the veins predominating over the arteries, their interstices scantily supplied with connective tissue, and their covering is of mucous membrane. In color they are dark red, but when compressed and strangulated by the sphincters they assume a dusky purple hue. After long exposure they take on a pseudo-cutaneous appearance.

{884} The columns of the rectum are the seat of the cylindroid pile, which is brighter in color and much more arterial in its structure than the ordinary variety, and bleeds very freely. Anything which causes stasis and accumulation of blood in the hemorrhoidal plexus of veins predisposes to this very common affection. Constipation is the usual cause; and among others may be named diseases of the liver which cause portal obstruction, pelvic tumors causing engorgement from pressure, the gravid uterus, labor, prostatic hypertrophy, urinary calculi, stricture of the urethra, stricture of the rectum, and rectal tumors. Among other causes are horseback-riding, the erect posture, violent cathartics, seat-worms, dysentery, diarrhoea, dyspepsia, and a sedentary life, with a diet of rich, stimulating food.

These piles do not usually cause much suffering; they vary in size from that of a pea to that of a pigeon's egg, and cause a sense of weight and stuffing in the bowel; but when they are large and numerous they cause severe pain, tenesmus, difficult defecation, spasm of the sphincters, and prolapse of the anus. When the patient is at stool the tumors are forced down and protrude in a bunch, surrounded and constricted by a collar of prolapsed mucous membrane: under these circumstances the tortuous and dilated vessels of which they are composed give way and free arterio-venous hemorrhage takes place. In some cases this happens at every stool, the patient losing from a few ounces to a half pint of blood almost daily until alarmingly depleted. Usually, the protruded piles are easily restored after a motion of the bowels, and so remain until the next one occurs; but in other cases of longer standing and of more gravity the sphincter loses all tone and the piles remain constantly prolapsed. This affection is very chronic, and the subject of it has to regulate his life with the greatest care, as the least unusual effort or excess may provoke an exacerbation. Excepting in the worst cases the general health is not materially impaired. They occasionally become so strangulated as to slough off, which effects a cure, but this is accompanied by grave constitutional disturbance. The disease is rather rare before the age of puberty, but is very common in both sexes in adult life, and is frequently associated with fistula, polypus, fissure, or carcinoma of this region. In females suffering with piles a free hemorrhage from them sometimes takes the place of the menstrual flow. The presence of internal piles causes a sense of weight and fulness and the sensation of a foreign body or of feces remaining in the rectum, with troublesome and obstinate itching about the anus. These symptoms, with the occurrence of hemorrhage from the rupture, erosion, ulceration, or abrasion of the dilated vessels, render the diagnosis easy. Should the piles not protrude, they can readily be made to do so by directing the patient to sit and strain over a vessel containing hot water. If the piles do not appear, a digital examination should be made. Indeed, it would be better to make one in every case of this kind.

About the margin of the anus the superficial veins are prone to great dilatation, and when presenting form masses of a bluish color, often very dark, covered partly by mucous membrane, partly by integument. These are also commonly known as piles.

{885} Dilatation of the Rectal Pouches, or Physick's Encysted Rectum.

This is an uncommon disease, generally occurring in those advanced in years, and consists of an hypertrophy, and sometimes of an inflammation, of the natural rectal sacs. These pouches are quite small in early life, and enlarge gradually as age advances, this condition being favored by the lodgment in them of extraneous substances, such as indurated fecal matter, inspissated mucus, the seeds of fruit, and other undigested masses. Constipation, so usual with the old, predisposes to this affection, as it keeps the bowel distended with hardened feces. The pouches vary much in size, the largest of them admitting the end of a finger. The disease is insidious and slow, but is capable of producing intense suffering should inflammation, suppuration, or ulceration attack them. Sometimes as many as a dozen are involved.

The symptoms, which are rather misleading than suggestive of the disorder, are a sensation of weight and uneasiness just within the anus and uneasy sensations in the rectum, distressing itching, and, after a time, pain following defecation and lasting often for hours. The pain, which is aching and burning in character, is not confined to the parts affected, but radiates down the thighs, toward the back, and into the perineum. An increased secretion of mucus always exists in these cases, but the discharge of purulent matter is uncommon, and its presence indicates the existence of very active inflammation.