Part 44

Patients affected with hemorrhoidal swellings,—the action of whose bowels is irregular, and in whom the vessels about the anus are congested,—are peculiarly liable to inflammation and abscess in the rectum or its neighbourhood, from the application of cold or wet to the surface, particularly that of the lower part of the body. Ascarides often produce violent irritation in the extremity of the rectum, both in children and in adults; and the morbid excitation is communicated to the bladder, as will afterwards be noticed. Not unfrequently the inflammation is induced by a foreign body, either lodging in the cavity of the bowel or imbedded in its coats—as hardened feculent matter, alvine and biliary concretions, bones of small animals, needles, pins.

Effusion often takes place into the loose cellular tissue round the bowel, with hard swelling, followed by unhealthy and extensive suppuration. Rigors generally precede the formation of matter, and violent fever almost always attends, abating, along with all the painful feelings, on evacuation of the fluid. Still the discharge continues, and the patient is kept uncomfortable and unhappy. Resolution can very rarely be produced; suppuration is the almost uniform termination of the action, and in persons of bad habit this sometimes occurs in these parts without any assignable cause, and without previous warning. The purulent collections are often very extensive, both externally and internally, the integuments are all undermined, and in some cases it is difficult to ascertain the depth of the abscess, even with the aid of a long probe.

Owing to the loose nature of the texture surrounding the gut, abscesses near the anus often attain a great size, and extend deeply before there is much external indication of their existence; a hardness is felt on pressing the fingers deeply by the side of the tuberosity of the ischium; this is at first obscure, but gradually becomes more developed; and at last a small dark red spot appears, indicating that the matter has approached the surface, and is most superficial at that part. But the surgeon should not wait for the pointing here, as the matter may burrow much previously, and abscess form in the substance of the sphincter, or exterior to it. If the matter does not cause ulceration of the coats of the intestine, and escape into its cavity, pointing takes place, and the pus is discharged externally, in general through a small opening. The matter is of a very offensive odour. The external aperture, and even the whole cavity of the abscess, may be at a distance from the gut, but in most cases the matter is close to it: its coats are denuded, and often ulcerated through. The surrounding degree of induration, the quantity of contained matter, the extent of the cavity, and the situation of the opening, vary almost in every instance.

Cases occur of induration, often very extensive, in the neighbourhood of the anus, on one or both sides, with dark discoloration of the integuments, and burning pain. The affection resembles carbuncle. The precursory symptoms are soon followed by partial suppuration, and extensive sloughing of the cellular tissue. At first there is excitement of the system, but symptoms of debility, and flagging of the vital powers, soon present themselves—irregular pulse, delirium, disordered stomach, hiccough, vomiting, and cold extremities. The disease is one of great danger, and the patient can be saved only by free and early incision, and the judicious employment of stimulants.

In some instances the inflammation is merely superficial, seated merely in the integuments, and followed by slow collection of matter.

It is indeed seldom that a cavity formed by abscess near the anus fills up entirely, however large and free the opening into it may have been. The parietes contract, but the hardness around is not entirely dissipated; the opening may close for a little while, but is soon found again discharging, and may continue to do so for months or years. A sinus is thus formed. Fresh collections and openings, either externally or internally, are apt to occur, with extensive induration of the cellular tissue, and disease of the gut. Instead of a single sinus, a number of collateral ones are formed, all running into the main canal, like branches to a common-sewer, or by-lanes opening into one spacious street. The disease is one of frequent occurrence amongst females; and often from a false sense of delicacy its existence is not declared till it has advanced to a state of truly horrible perfection.

Fistula is generally the consequence of abscess in the cellular substance near the anus. By the term is understood a sinus or track, with narrow orifice and hard parietes, discharging thin gleety matter. If the track extends from the cavity of the gut to the surface, flatus must often pass through the narrow and tortuous canal, and, from a peculiar noise being produced by its passage, the name of Fistula has probably been adopted. The term cannot be properly applied to recent cavities of abscesses, but only when their sacs have contracted, their lining has become callous, and their discharge thin and almost colourless.

The fistula may be one of three varieties—blind external, blind internal, complete. The first denoting that the sinus opens externally, but does not communicate, either at its origin or elsewhere, with the cavity of the bowel. The second, that it communicates with the bowel, but does not open externally. The last, that it both communicates with the bowel and opens externally. Some contend that fistulæ are always complete, that they commence from within, and that the internal opening is always at one particular point; but such, according to my experience, is far from being the case.

Fistulæ occur in children, though rarely; generally in people advanced in life. The cavity of the sinus, after long continuance, becomes coated with an expansion resembling mucous membrane, and secretes a discharge of mucous character.

In every case, it is necessary that the surgeon should ascertain, as accurately as possible, the extent and nature of the fistula; and, with this view, examination with the probe is requisite. The probe is introduced into the canal, when the fistula is an external one, and directed through its windings, so as to discover its direction, length, and divarications; the guidance of the instrument is facilitated, and the information augmented, by the forefinger being placed in the rectum. Sometimes all the by-paths cannot be detected, until the orifice of the canal is enlarged. When the fistula is complete, the probe, entered at the external extremity, can be passed into the bowel so as to be felt by the finger in the rectum; but it must be remembered that the internal opening is not always at the inner termination of the sinus, but often seated more externally—the cellular tissue being destroyed to a considerable extent above it, so as to form a large unhealthy abscess, communicating with the main track of the fistula. But the gut may not be opened into, though denuded to a large extent, and forming part of the walls of the sinus; and in some instances, the sinus may not come within a considerable distance of the bowel.

An internal fistula is more difficult of detection. The symptoms leading to a suspicion of its existence are—puriform discharge from the bowel, increased on going to stool, and then accompanied with tenesmus; pressure on the side of the anus, causing pain, and sometimes an augmentation of discharge; and in many instances hardness, deeply seated, is felt. On introducing the finger into the rectum, the aperture in the coats of the bowel is perceived, or a part of the bowel feels more boggy and tender than the rest; through this point a curved probe, introduced along the finger, may be passed into the sinus, and being then directed downwards, reaches the outer extremity of the canal, causes the integuments to project, or is readily felt from the surface. The internal opening is usually immediately within the sphincter, seldom higher. The discharge, in general, is rather profuse, the bowel is very irritable, desire to evacuate it is frequent, and the feces are often tinged with blood. There is a sensation of itching about the fundament, the heat of the parts is felt by the patient to be increased, he is unable to bear pressure there, and sits on one buttock: in most cases the bladder sympathises considerably. The giving way of the bowel may be produced by ulceration commencing in the mucous membrane, but is more frequently the result of inflammatory action in the surrounding cellular tissue. The aperture is the seat of acute pain when pressed upon, and during evacuation of the bowel. Great light is thrown on such cases by the use of a proper speculum. But its introduction can seldom be borne in cases of inflammation, abscess, or recent fistula. In ulceration of the coats within the sphincter it is useful. Considerable information can certainly be obtained by the finger; but to the sense of touch, however acute, it is better, when admissible, to add that of vision. The speculum, made of silver or steel, and having its internal surface highly polished, is introduced gently into the anus, and expanded fully; and by changing the situation of the instrument, and holding a light so as to illuminate the interior, the surface of the bowel for five or six inches above the anus can be examined accurately, as if it were an external part of the body.

Simple indurations and contractions of the lower part of the bowel follow long-continued irritation and inflammation of its parietes. The part is not an uncommon seat of stricture, and sometimes the bowel is constricted at two or more points near each other; frequently the stricture is extensive and firm, in other cases it is narrow, consisting merely of a thin band. It is often complicated with fistula; if so, the internal aperture is immediately above the stricture, and is caused by ulceration; abscess sometimes forms above the stricture, destroys the coats of the bowel at that point, burrows around, and not unfrequently points at a great distance from its origin; or sloughing and ulceration may take place in the coats of the bowel, and feculent matter be discharged through the opening of the abscess. In females, the vagina may be opened into in consequence of unhealthy suppuration in the cellular tissue, between that organ and the gut.

The existence of stricture is in general readily ascertained by examination with the finger; its most common situation is here shown; the medical practitioner must not suppose that every obstruction, however slight, to the passage of a bougie into the bowel is owing to organic disease; the top of the sacrum naturally projecting forwards on the commencement of the rectum, in some degree opposes the entrance of any large body, and this circumstance is laid hold of by the unprincipled or ignorant; the patient is very often declared to labour under stricture of the bowel, when none exists. Some practitioners discover stricture in almost every patient with disordered digestion; the whole digestive apparatus is certainly thrown into disorder by obstruction in the lower part, but this obstruction is fortunately rare. In cases of tight stricture, the bowels are distended with feces and flatus; and if evacuation is not procured vomiting ensues, followed by enteritic symptoms, as in strangulation of the higher bowels. The gut above the stricture is always more or less dilated.

The symptoms which lead the surgeon to suspect the existence of stricture, are—difficulty in voiding the excrements; a long time occupied in the evacuation, with pain and much straining; small thin portions of feculent matter coming away, when the matter is consistent; discharge of puriform fluid, mixed with a slimy mucus; itching and heat in the parts; and irritability of the urinary organs.

Strictures of the urethra and rectum often coexist, as exemplified by the following case:—A middle-aged man, when in Holland, laboured under a very deep and extensive fistula in ano. Sinuses were divided in all directions, and some healed; one, however, remained open, leading towards the gut from near the tuberosity of the ischium on the left side. He was desired to keep this open by means of bougies, which, as many were used, he manufactured himself out of cloth and plaster. On one occasion a portion passed deeply, and could not be extracted; but his alarm at this occurrence was appeased on being told that the foreign body would be absorbed. His condition at that time was very miserable; and inflammation was often excited in the parts, with fresh collections of matter. At the same time, he laboured under stricture of the rectum and urethra. He applied to me fifteen years after the commencement of the disease. Then the most troublesome symptom was a constant itching in the perineum, and round the anus, preventing sleep, and causing much excoriation from involuntary scratching; besides, he was annoyed by seminal emissions, and frequent desire to make water. I first divided a small internal fistula, and some time afterwards operated on a large complete one; in the latter instance, a foreign body was felt deep in the wound, the incision was extended, and a large portion of bougie, firmly impacted, was with some difficulty withdrawn. Some days after, other portions of bougie were extracted along with numerous hairs; and these continued to be discharged for many weeks. The symptoms were much relieved. An occasional itching remained, but disappeared after the cure of a very bad stricture in the urethra. He recovered perfectly from the complication of diseases.

Schirro-contracted Rectum, a malignant and truly horrible disease, may be the consequence of inflammatory action, or of neglected stricture. The neighbouring parts are involved in cartilaginous induration; the surface of the bowel is lobulated and ulcerated, its cavity is contracted, and the discharge is profuse, sanious, bloody, and putrid; there is frequent desire to void the contents of the gut, but in general nothing but flatus and puriform fluid is evacuated; when feces do pass, dreadful pain is excited, and continues for some time. The difficulty of voiding feculent matter becomes greater and greater, frequent attacks of ileus occur, and in one of them the patient expires. During the progress of the disease, the functions of the bladder become disturbed; change of structure in it and in the vagina takes place; and frequently the cavities of the rectum, bladder, and vagina are laid into one by inveterate and malignant ulceration. The affection is more common in females than in males, and rarely occurs in young persons. The countenance has the sallow hue peculiar to carcinoma, and in the advanced form of the disease becomes still more cadaverous from profuse discharge of matter and frequent hemorrhage.

The cellular tissue, anterior to the rectum, is liable to become the seat of tumour. Malignant medullary formations occasionally form here, causing most distressing symptoms; by displacing the bowel they may obstruct its canal, and simulate stricture or schirro-contraction.

Prolapsus Ani. Folds of the lining membrane of the lower portion of the rectum are apt to protrude during evacuation, as already mentioned, in those labouring under hemorrhoids. These are readily replaced, and the painful feelings relieved, if the attempt be made before swelling and engorgement of the vessels and cellular tissue take place. Protrusion, however, is sometimes to a great extent; the sphincter is relaxed, and the lower part of the bowel is retained within it with difficulty; indeed there is often more of the lining membrane of the gut without the sphincter than within it. The mucous lining becomes insensible, thickened, and white; and the patient is subject to attacks of inflammation, with additional swelling, excoriations, and ulcers of the parts. Slight protrusion is very common, and patients who have long laboured under it are in the habit of reducing the bowel after every stool, in the intervals wearing a supporting bandage. They are subject, however, to constant uneasiness, and more or less puriform discharge from the parts; often there is a flow of blood while at stool; the health is undermined, and comfort diminished; all exertions are gone through with difficulty, and undertaken with reluctance. During exertion protrusion is almost certain to occur, and apt to be increased. The part most commonly prolapsed in time becomes hard, thick, and in a measure insensible; and new folds appear on extraordinary straining at stool, in coughing, or any exertion of the abdominal muscles.

Tumours occasionally grow from the coats of the rectum, and are of various consistence. They may be either vascular, or deposited in consequence of increased vascular action, and afterwards increased by addition of solid matter. They are to be removed either by ligature or incision, according to their situation, nature, and attachments.

Foreign bodies may lodge in the rectum—as bones, portions of hard indigestible meat, &c., introduced by the mouth—or clyster-pipes, bougies, &c., which have been passed up per anum. From being the source of constant irritation, and obstructing the functions of the part, they demand removal. Alvine concretions are now rare; they are usually situated in the caput cæcum coli, sometimes in the sigmoid flexure, or in the arch of the colon; they may descend into the rectum, and lodge there.

Children are sometimes born with the anus imperforate, the extremity of the rectum being covered merely by integument, or the bowel terminating an inch or two above the usual site of the anus; or the rectum may be wholly deficient. In the last case, the colon may end in a blind sac at the fundus of the bladder, or it may open either into that viscus or into the vagina.

Treatment of Affections of the Rectum.—In the treatment of hemorrhoids, the cause should be removed if possible; and this may suffice for the cure. When the tumours are recent and small, they may be made to disappear by the use of astringent ointments or decoctions, as of galls, kino, oak-bark, and by sedulous attention to cleanliness of the part. In inflamed tumours, blood may be extracted by leeches or punctures, and hot fomentations afterwards used. Recent hemorrhoids are sometimes got rid of at once by the puncture of a lancet, by which a clot of grumous blood is discharged, with immediate subsidence of the swelling, and abatement of pain. When constriction of the internal tumours or folds of bowel by the sphincter has occurred, the tumour should be replaced if possible. In irritability of the sphincter, a bougie is sometimes used with advantage; and incision of the muscle, by which rest is afforded to the parts, will often effect a cure, after the failure of all other means: this is essential when rugged ulcers or fissures occupy the orifice; the division may be made on either side, certainly not in the mesial line. In most cases, the tumour must be got rid of by the knife or ligature. When the piles are internal, removal by ligature is to be preferred; the patient being made to strain, and thereby bring the tumours as low as possible, a ligature is placed round the base of the swelling, provided its form conveniently admits of it; otherwise the base is pierced by a fixed needle armed with a double ligature, the separate portions of which are applied tightly to the corresponding parts of the base. This operation is very inconsiderately and indiscriminately employed. It can only be warrantable when the tumours are so large as to obstruct the orifice so perfectly as to prevent evacuation, unless they are extruded. Before proceeding to this measure, the bowels should be emptied by mild and repeated purgatives, and afterwards all stimuli should be avoided. It is imprudent to apply ligature to several tumours at once, for serious consequences will most probably ensue, inflammation of the bowel, obstinate constipation, and general excitement. Excision of such piles is contraindicated by the risk of profuse hemorrhage. The bleeding is into the cavity of the bowel, a coagulum is there formed which encourages the flow; and from this cause, and the peculiar situation of the bleeding point, it is with difficulty arrested. When the tumours are external, ligature may certainly be adopted; but here there is no objection to the use of the knife, and excision is much less painful and more speedy. The tumours, along with protruded portions of the mucous lining of the rectum that cannot be reduced, and are changed in structure and function, are readily taken away by the rapid stroke of sharp curved scissors. Or they may be laid hold of and stretched, and their base divided by one or more sweeps of a bistoury. The removal of these tumours, or of a portion of the loose fold of skin or altered mucous membrane which occupies the sphincter in the direction of the bowel, is in general followed by a cure of the prolapsus. The sphincter now acts fully, and on the cicatrisation of the open surface contraction of the tissues occurs to such an extent as to produce a permanent cure without interference with the internal parts. Should hemorrhage follow upon the removal of external tumours or folds, the surgeon has it completely under command. Pressure by a large graduated compress is generally sufficient.

In inflammation of the rectum, the exciting cause often is not discovered; when detected it should be removed without delay. In simple inflammation of the part with violent fever, general bleeding may be required; and in all cases blood should be abstracted locally and freely. Leeches are to be applied to the verge of the anus, and the lower part of the perineum, and hot fomentations afterwards used. Internal antiphlogistics are at the same time not to be neglected. In retention of urine, or great irritability of the bladder, in consequence of the affection of the rectum, the perineum should be leeched and fomented, perhaps, also, the lower part of the abdomen; the use of the catheter should be avoided if possible. When induration takes place in the cellular tissue by the side of the anus, or in the perineum, suppuration must in all probability occur, and poultices, with occasional fomentation, are to be used, though only for a short time; for, as already mentioned, pointing of the matter is not to be waited for in this situation; incision must be had recourse to early, in order to prevent bad consequences. Leeching is sometimes used here, as in purulent formations in other parts, from gross ignorance of the real state of matters; and sometimes their use is continued after fluctuation is distinct, and until the pus begins to ooze through the leech-bites; such is very useless and very dangerous practice; in most cases the internal parts are extensively destroyed before the matter comes spontaneously to the surface.

In the carbunculous state of the cellular tissue, near the rectum, with extensive infiltration, dark integument, and a tendency to sloughing, an early and free opening must be made wherever matter is suspected to have formed, however deeply seated, and in whatever quantity, and whether the parts are indurated or not; nothing but mischief can result from delay. When the cellular substance is destroyed, the incision must be proportionally extensive, to afford a free exit for slough as well as matter. During the suppuration which follows, the system will require good support, and most probably a free administration of stimuli.

It has been recommended that, in abscess extending along the gut, the cavities of the bowel and abscess should be at once laid into one by incision. I have done so, but always found the cure to be tedious. It is better that the matter should first be evacuated through an external opening, that the painful symptoms and constitutional disturbance should be allowed to subside; and that after the cavity has contracted, and the extent of the sinus has been ascertained, the operation should be performed. In the operation the knife is now employed; but in former times the ligature and cautery were in constant use. The old surgeons supposed that there was something malignant in the hardness and callosity attending this disease, and were not contented with opening the cavities, but endeavoured to dissect out the whole parts; and, if foiled in this, they finished the work with a red-hot iron. Indeed the practice of excision was recently in vogue in the Parisian hospitals.

But the operation for fistula has been much simplified. The bowel is generally so much separated from its connexions as to be incapable of again adhering, or of furnishing granulations; and, though capable, healing is effectually prevented by the frequent motion of the parts caused by the action of the sphincter and levator of the anus. One side of the cavity is fixed, whilst the other is in motion. It becomes necessary to lay the cavities of the bowel and of the fistula into one. This can generally be effected with great ease; a salutary degree of excitement follows the use of the knife, rest to the parts is procured, the edges are allowed to retract and adhere to the opposite surface, and the wound heals quickly from the bottom. The surgeon, in his operative procedure on these parts, must use both hands equally well, otherwise he must vary his position, and often put his patient in a very awkward predicament, more particularly if a female. The patient is placed in a stooping posture, with the legs unbent, or kneeling on a chair, and resting his arms on its back, the fundament being turned towards the light. The surgeon inserts the finger, well soaped and oiled, into the rectum, and with the other hand insinuates a curved probe-pointed bistoury into the sinus, using the instrument merely as a probe. Having reached the extreme depth of the canal, the direction of the instrument’s point is changed so as to apply its cutting surface to the coats of the bowel, at that part. The instrument on being thus passed into the bowel is fixed by the finger, and by drawing both outwards, the coats of the bowel and the parts intervening between them and the sinus are divided. All collateral sinuses extending towards the perineum and buttock must be freely divided, for they cannot be expected to contract otherwise. Such is all that is necessary in the generality of cases; but it is evident that the steps of the operation, and the extent and number of incisions, must be varied according to circumstances. A great part of the affected bowel may be pulled down by a director before being cut, as is sometimes done; but the practice is useless and painful. Should hemorrhage take place, it may be restrained by stuffing the wound gently with lint; if this fail, the bleeding vessels are to be secured by ligature; but this is seldom necessary. The bowels should be well cleared out before the operation, so that two or more days may pass over without the parts being required to perform their functions; and, if the bowels are naturally loose, opiates may be administered. Afterwards copious evacuation is to be procured by enemata or gentle laxatives. It is necessary to prevent the external part of the wound from adhering, until the whole has contracted equally, and begun to be filled up by granulations from the bottom; and with this view a piece of lint is interposed between the margins. Stuffing the wound daily with large dossils of lint, smeared or not with irritating ointments, is attended with much pain, and certainly impedes the cure. The dressing should be simple and light, and introduced with gentleness and care. The first should be allowed to remain undisturbed till spontaneously discharged along with the feculent matter. In the greater number of cases, a second interposition of dressing is all that is required. In all cases, dressing should not be continued long; but as the cavity gradually contracts, discharging laudable pus, and becoming coated with healthy florid granulations, the interposed pledgets should be daily diminished, and soon omitted entirely. If the surgeon continue long to stuff the wound it cannot contract, will become callous as before, and a fistula will be reproduced. Injections into the wound, or the application of lint soaked in a gently stimulating lotion, are often beneficial in promoting contraction. But, as already stated, most fistulæ get well after proper incision, with but one or two dressings, and without any after application excepting abundance of soap and water. During the cure, the general health must be kept vigorous, and the state of the bowels strictly attended to.

In ulcer of the mucous lining, with irritability of action in the bowel, injections of tepid or cold water are useful, by removing irritating matters from the part. By means of a speculum ani the ulcer can be readily exposed; it maybe touched occasionally with the nitrate of silver, in substance or solution, or, if very indolent, with a solution of the bichloride of mercury. When the irritation is very great, and the lower part of the bowel frequently in a state of spasmodic action, the sphincter may be divided so as to allow the parts to remain quiet; and anodyne suppositories or soothing enemata will then be used with much greater advantage than previously. To obtain reparation of breach of structure in any part, rest is a principal part of the treatment; and in the case of the rectum and other mucous canals it is preëminently required.

Strictures of the rectum are treated by bougies of wood, plaster, or elastic gum, introduced at intervals, and gradually enlarged. The bougie should be smooth in the surface, and rounded at the point; also slightly curved, so as to suit the figure of the bowel; and with a narrow neck, so as to remain without the irritation caused by distention of the sphincter. At first it should be of such a size as can without much difficulty be pushed past the stricture, and, as this relaxes, the size of the instrument must be proportionally increased till it completely fills the bowel when dilated to the natural calibre. The bougie may at each time be retained from a quarter of an hour to an hour, according to the feelings of the patient. Suppositories and enemata are at the same time employed; the latter to clear out the lower bowels, the former to allay the irritation which accompanies the disease, and which may be increased temporarily by the bougies. When the stricture is callous, and will not yield by dilatation, it may be divided with the knife, and notched at various points of its circumference; and, when the parts have begun to granulate, recourse to the bougie will soon effect a cure. When fistula and stricture coexist, both are got rid of at once by the usual operation for the former, and by the after treatment peculiar to each.