Part 8

Have found no use for iodine, nitrate of silver or acid preparation of iron, which corrode and destroy instruments in the treatment of rectal diseases.

FISSURE, OR IRRITABLE ULCER.

Of all the diseases of the rectum, considering the apparent insignificance of the lesion, this heads the list as a pain producer. Fissure has characteristics peculiar to itself and I do not think, as is claimed, that its location, just above the muco-cutaneous junction or Hilton’s line, where the nerve supply is the greatest, explains these characteristics; neither do I think it of traumatic origin.

No other ulcer, wound or abrasion in the same locality produces the pain that identifies a fissure.

It might be compared to a rhagade or chap in the web between the toes or fingers. In its recent state it presents the appearance of a longitudinal tear of from three to five-eighths of an inch in length, looking raw and bloody, with ragged and somewhat everted edges; and may be complicated with polypi (Fig. 20), or a hemorrhoid occupy its base, called the “sentinel” pile.

It is aroused from its slumbers by a mechanical disturbance of the slightest nature, hence the name irritable. The act of defecation being followed by a dull, sickening, sometimes lancinating pain lasting three hours or more, incapacitating the subject from labor. The mere introduction of the finger may produce a deathly pallor and possibly syncope.

Ask the patient to extrude the parts, then gently pull down the mucous membrane and apply a ten per cent. solution of cocaine to the tract with a camel’s hair brush or silver canula attached to a hypodermic syringe; carrying the solution fully to the top of the fissure, which may be out of sight. If any unguent has been used about the fissure it should be subjected to a hot water irrigation before using the cocaine, as cocaine will not take effect on a greasy surface.

When the tract is sufficiently anæsthetized to introduce a speculum, apply on the end of a probe wrapped with cotton, 95 per cent. carbolic acid, and prescribe the following ointment for daily use:

℞ Acidi Salicyl. ʒ ss Vaselini ℥ ss

If unsuccessful after making two or three thorough applications of carbolic acid, inject into and beneath the bed of the fissure, in a sufficient number of places to encompass its length, possibly two, a few drops of the hemorrhoidal compound; and produce a slough. The object is to destroy the original ulcer and convert it into some other form that will heal. I have never seen a resulting sore from carbolic acid that was slow to heal.

A physician who had been a great sufferer from the effects of a fissure informed me that he had been etherized twice and the sphincters thoroughly stretched, and had submitted to incision three times, all of which had proved fruitless, and was finally permanently cured by the use of salicylic acid and vaseline.

PROLAPSUS RECTI.

A prolapse of all the coats of the rectum, amounting in some instances to complete invagination, is of such rare form, occurring mostly during infancy, that it might be considered practically out of the list of rectal ailments.

Prolapse of the mucous coat of the bowel is not an uncommon affection, and is a frequent complication of internal hemorrhoids. When the hemorrhoids are cured the prolapsus usually disappears.

It is natural for the mucous membrane at the lower end of the rectum, by its loose attachment to the muscular coat through the cellular layer, to roll down and become somewhat everted during the act of defecation. It is only when this condition becomes excessive and the protrusion so great that it does not return of its own accord, that it is called prolapsus of the first degree and treatment required.

Should it occur independently or persist after the removal of piles, a cure may be easily effected by the injection of from eight to ten minims of a ten per cent. solution of carbolic acid, beneath the mucous membrane in the cellular structure, at points where it is desirable to take up a fold. The needle may be introduced in a line with the axis of the rectum, varying from one-fourth, one-half of an inch or more from the muco-cutaneous junction, and even as high up as the upper margin of the internal sphincter.

This can be done while the membrane is prolapsed, or through the slot of a speculum. The latter is preferable on account of the sides of the slot limiting the distribution of the medicine. Anything that will excite an adhesive inflammation or a change in the cellular coat will have a similar effect.

The following preparation is effective:

℞ Acidi Salicyl. Sod. Bibor. ā ā ʒ i Glycerinæ ℥ i

Take six drachms of this preparation and add carbolic acid 40 minims.

If it be desirable to remove a thickened fold or bunch-like appearance of the mucous membrane, inject the same as you would piles, using the hemorrhoidal compound. It will slough off neatly and heal readily. It is peculiar of the injection of internal piles or of the same strength of medicine into or beneath the mucous membrane, that it tightens and takes up a slack of the membrane permanently, without apparent lessening of the calibre of the gut. It is also peculiar of the treatment and cure of internal hemorrhoids by injection, that no cicatrix, cicatricial tissue or contraction results, unless the operation has been extensive, involving both sides, and an active inflammation has been excited by extraneous causes.

RECTAL POCKETS AND PAPILLÆ.

Concerning the frequency of the diseased conditions to which the names rectal pockets and papillæ are applied, and their being such prolific sources of mischief as claimed by those who first caught up the craze and exaggerated the facts, a few brief comments may not be out of place.

That there are such morbid changes, and that they are more or less hurtful through reflex excitability can not be successfully disproved. That their appearance suggests the titles they have received is also undeniable. And the fact of their having been brought to notice in an irregular way, does not militate in the least against the existence of such affections, or the fitness of the terms used to designate them.

If it be true, as stated by enthusiasts on the subject of rectal pockets and papillæ, that they are frequently found in old, deep-seated, chronic diseases, where the presence of rectal trouble is never suspected by any local signs, we have, then, a sufficient reason to account for their having escaped the notice of specialists.

Andrews makes a labored effort, and with apparent success, to show that the so-called “pockets and papillæ” are normal structures. That the pockets are the sacculi Hornei (Fig. 22), which are little depressions situated just above and intimately connected with the verge of the anus, caused by the reticulated arrangement of bands of muscular and connective tissue, beneath a delicate mucous membrane and deepened by the corrugating action of the sphincter ani. That the papillæ are little dot-like prominences frequently found between the lower ends of the sacculi Hornei, and when somewhat enlarged resemble in appearance the carunculœ myrtiformes of the vagina. That these little papillæ, with their adjacent “pockets,” constitute the so-called “pockets and papillæ” of the itinerant.

I have seen just what Dr. Andrews very correctly describes, and will say, after carefully reading his explanation, I am fully convinced that he never saw what is meant by the discoverer of rectal pockets and papillæ. And further beg to say that the doctor must concede that there are others, who are not itinerants, capable of identifying a diseased surface when they see it, and pointing out its place of location.

It will be seen by a reference to the appended clipping, that Andrews has been making his microscopical dissections nearly an inch below where true rectal pockets are found. And I can conscientiously attest that true papillæ bear no resemblance, in the least, to his papillæ or carunculœ myrtiformes at the anal verge.