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A TREATISE ON

DISEASES OF THE ANUS
RECTUM, AND PELVIC COLON

JAMES P. TUTTLE, A. M., M. D.

TROFESSOR OF RECTAL SrRGERY IN THE NEW YORK I'OLYCI.INIC MEDICAL SCHOOL

AND HOSPITAL, VISITING SURGEON TO THE ALMSHOUSE

AND WORKHOUSE HOSPITALS

• • I • ■*

It » > > *

WITH EIGHT COLORED PLATES AND
THREE HUNDRED AND THIRTY-EIGHT ILLUSTRATIONS

IN THE TEXT

NEW YORK
D. APPLETON AND COMPANY

I 902

• • :.••...:

Published August, 1902

T3fe>

PREFACE

Within the past decade the field of rectal surgery has been greatly
broadened and its methods changed through improved instruments, asep-
tic technique, and a wider knowledge of pathology. The lively interest
t^iken by the profession in this branch of medicine and the little atten-
tion paid to it in the undergraduate schools have resulted in the estab-
lishment of special clinics for teaching and treating rectal diseases.

This book is practically the outcome of twelve years' conduct of one
of the first and largest clinics of this kind. The opinions expressed
herein are therefore based upon a clinical experience derived from a
large number of actual cases. Such an ex[)erience teaches that no one
method succeeds always, and that the practitioner should be conversant
with many in order tliat he may have resources in reserve for all emer-
gencies. Therefore, while relating my own practices and opinions, I
have also given those of other operators, so that the reader may have as
complete a knowledge of the subject as possible.

Much space has been devoted to examination, diagnosis, and local
treatment, because these are the subjects which the general practitioner
needs most to know. The non-operative treatment of each disease is
first described, together with the class of cases in which it will prob-
ably be useful; but when such measures are likely to prove futile I have
not hesitated to say so.

The book has been written during an active practice, and almost
every opinion expressed therein has been put to the test. I am sensible
of its imperfections, but should it prove useful to the many physi-
cians who have honored me by attendance upon my clinics or assist in
the dissemination of knowledge upon these important subjects, I shall
be amply repaid for the nights of labor it has cost.

I take this opportunity to express my appreciation of the generous
assistance afforded me in the work by I)rs. S. T. Armstrong, George II.
Wellbrock, F. ^f. Jeffries, ^fr. Jl. J. Hopkins, and the publishers, who
have been patient, kind, and courteous. To them and all the friends
who have aided me by suggestions and encouragement I extend my sin-
cere thanks.

James P. Tuttle.

42 West Fiftieth Street, New York.

• • •

CONTENTS

CHAPTER I

EMBRYOLOGY, ANATOMY, AND PHYSIOLOGY

PAOB

Definitions of the parts — Embryology — Anatomy — The perina^um — Ischio-rectal
foss*T — The anal canal — The rectum — The mucous membrane — Submucous
layer — Muscular wall — Serous coat — Vascular supply — Nerve supply —
Lymphatics — Retro-rectal anil superior pelvi-rectal spaces — Relations of
the rectum — Sigmoid flexure or pelvic colon — Physiology .... 1-46

CHAPTER II

MALFORMATIONS OF THE ANUS AND RECTUM

Malformations of the anus — Entire absence — Abnormal narrowing — Partial
membranous occlusion — Complete obstruction by a membranous diaphragm
— Anal opening at some abnormal point in the perina'um or sacral region —
Malformations of the rectum — Entire absence — Rectum arrested in its
tlescent, the anus being normal — Rectum oj)ening into some other viscus —
Other organs, such as the ureters, vagina, or uterus, oi)en into the rectum
— Treatment — Results of operations for imperforate anus .... 47-93

CHAPTER III

EXAMINATION AND DIAGNOSIS

Historical examination — Digital examination — Instrumental examination of the

rectum — Anaesthesia in rectal examination — Examination of fa*ces . . 94-138

CHAPTER IV

CATARRHAL DISEASES OF THE RECTUM AND SIGMOID: PROCTITIS AND SIGMOIDITIS

Simple catarrhal inflammation — Acute catarrhal proctitis — Chronic proctitis and
sigmoiditis — Hypertrophic catarrh — Atrophic catarrh — Specific catarrhal
inflammations — Dysenteric proctitis and sigmoiditis — Diphtheritic proctitis.

139-166
CHAPTER V

CHRONIC COLITIS, MUCOUS COLITIS, MEMBRANOUS COLITIS

Secondary membranous colitis — Ulcerative colitis — Follicular colitis . , 167-192

CHAPTER VI

TUBERCULOSIS OF THE ANUS. RECTUM, AND PELVIC COLON

Perianal tuberculosis — Miliary varietv — Ulcerative variety — Anal tuberculosis—
Lupoid ulceration of the anus — Verrucous ulcerations of the anus — Tuber-
culosis of the rectum and sigmoid — Hyperplastic tuberculosis . . , 193-212

vi THE ANUS, RECTUM, AND PELVIC COLON

CHAPTER VII

VENEREAL DISEASES OF THE ANUS AND RECTUM

Gonorrhceal proctitis — Chancroid of the anus— Chancroidal ulceration of the
rectum — Phagedenic chancroid — Complications — Syphilis — Anal chancres —
Rectal chancres — Secondary manifestations — Tertiary lesions — Hereditary or
congenital syphilis of the anus and rectum 213-

CHAPTER Vin

NON-SPECIFIC ULCERATIONS

Ulcerations of (he perianal region — Traumatic ulceration — Herpetic ulceration —
Eczema of the anus — Rodent ulcers — Ulcerations of the anal ccrywi/^Simple
ulcers — Traumatic ulcers — Ulceration of the rectum and sigmoid— Spec'ml
ulcerations — Specific ulcers — Catarrhal ulceration— Varicose ulceration —
Hffimorrhoidal ulcers— Follicular ulceration— Strictural ulceration— Carci-
nomatous ulceration — Ulceration from Bright's disease — Diabetic ulceration

—Hepatic ulceration— Trophic ulceration— Marasmic ulceration , . 258-

•

CHAPTER IX

FISSURE IN ANO — IRRITABLE ULCER — INTOLERABLE ULCER

Shape and location of ulcers — Etiology — Pathology — Symptoms — Reflex symp-
toms— Xon-operative treatment — Operative Treatment — Results of dilatation
— Methods of incision — Excision — Submucous fissure — Complications of
fissure 291-J

CHAPTER X

PERIANAL AND PERIRECTAL ABSCESS

Superficial abscess — Tegumentary abscess — Subtegumentary abscess — Ischio-rectal
abscess — Profound abscess — Retro-rectal abscess — Superior pelvi-rectal ab-
scess— Diffuse septic periproctitis — Idiopathic gangrenous periproctitis . 319-3

CHAPTER XI

FISTULA

Definition — Classification — Frequency — Etiology — Diagnosis — Anatomical charac-
ter— Origin — Tubercular fistula — Operations in tubercular fistula — Prognosis
— Pathology — Treatment — Xon-operative methods — The ligature — Fistulot-
omy— Operative methods — Instruments necessary — Incision — Excision — Ex-
• cision with immediate suture — Complex fistula — Primary, secondary, and late

complications — Incontinence of fa?ces — Treatment of incontinence . . 353-4S

CHAPTER XII

COMPLICATED FISTULA

Fistulas originating in bone disease — Fistulas connecting rectum with other
organs — Urinary fistula — Recto-vesical fistula — Recto-urethral fistula — Rec-
to-genital fistula 421-45

CONTENTS vii

CHAPTER XIII

STRICTURE OF TDK RECTUM

PJkOB

Stricture of large caliber — Congenital strictnre — Neoplastic stricture — Spasmodic
stricture — Inflammatory stricture — Diffuse inflammatory stricture— Cicatri-
cial stricture — Perirectal stricture — ^Pathology of stricture — Tubercular stric-
ture— Syphilitic stricture — Etiology — Symptoms — Latent period — Ulcerative
or inflammatory stage — Obstructive period — Diagnosis — Examination — Hec-
tometers— Laparotomy in — Malignant stricture — Trtatment — Dietary and
medicinal: local and operative — Gradual dilatation — Rapid dilatation or
divulsion — Electrolysis, cauterization, and raclage — Proctotomy — Excision —
Proctoplasty — Lateral entero-anastomosis — Colotomy — Resume . . 455-516

CHAPTER XIV

COXSTIPATIOX, OBSTIPATION, AND F^CAL IMPACTION

Definition — Defecation — Reverse peristalsis — Etiology — Predisposing causes —
Exciting causes — Ijocal and mechanical causes — The influence of Houston's
valves — Malformations — Enteroptosis — Acute flexures — Spasm of tlic sphinc-
ter— Extra-intestinal obstruction — Diagnosis — Acute constipation — Symp-
toms— Diagnosis — Treatment — Chronic constipation — Symptoms — Reflex and
constitutional effects — Mental and nervous symptoms — Treatment — Medic-
inal, local, and operative — Valvotomy — Fifcal impaction — Symptoms — Diag-
nosis— Treatment 517-567

CHAPTER XV

PRURITUS AN I

Rsscntiiil pruritus — Characteristics — Local causes — Reflex causes — Constitutional
causes — Treatment — Constitutional, local, and operative .... 568-581

CHAPTER XVI

n.IMORRnOIDS — PILES

Predisposing causes — Exciting causes — Nomenclature — Classiflcation — External
?t(fmorrhoids — Symptoms — Treatment — Internal h(emorrhoids — Pathology —
Symptoms — Preventive treatment — Palliative treatment — Operative treat-
ment— Dilatation — Cauterization — Electrolysis — Injection method — Ligature
— .Submucous ligature — Clamp and cautery — Crushing — Excision — Limited
excision — Accidents and complications following operation — Recapitula-
tion 582-666

CHAPTER XVII

PROLAPSE OF THE RECTUM, PROCIDENTIA INTESTINI RECTI

Incomplete prolapse — Etiology — Symptoms — Treatment — Complete prolapse —
First degree— Second degree — Third degree — Symptoms — Etiologj- — Pathol-
ogy— Treatment — Reduction — Reduction in gangrenous conditions — Cauteri-
zation— Sigmoidopexy — Rectopexy — A mputation — Complications of ])rolapse

— Rupture of hernial sac in prolapse 667-710

viii THE ANUS, RECTUM, AND PELVIC COLON

CHAPTER XVIII

BENIGN TUMORS OP TU& RECTUM

PAOS

Connective-tissue type— Muscular type — E[)ithelial type — Bolypus — Seat and
manner of development — Histology — Course and symptoms — Diagnosis —
Treatment — Fibroma — Enchoi^roma — Lipoma — Myoma — Lymphadenoma —
Myxoma — Adenoma — Simple adenoma — Symptoms — Treatment — Multiple
adefiomata — Etiology — Dist ribution of — Con f onnation — Color — Consistence —
Condition of the mucous membrane in — Symptoms — Diagnosis — Histology —
Malignant transforniAti(m in — Treatment — Villous tumor: Papilloma — Etiol-
ogy and development — Symptoms — Diagnosis — Treatment — Cystoma — Simple
cysts — Dermoid cysts — p]xtra-n»ctal dermoids — Postanal dimples — Sacro-coc-
cygcal tumors — Angeioma — Verruca — Fungus of the rectum — Hydatids —
Jlypertrophied anal papill(B 711-759

CHAPTER XIX

MALIGNANT NEOPLASMS— (ARt'INOMA AND SARCOMA

Carcinoma — Seat of the disease — Etiology — Heretlity — Age — Sex — Occupation —
Previous diseases — Histological types — Epithelioma — Adenoid cancer — Medul-
lary cancer — Scirrhous cancer — Colloid cancer — Symptoms — Lines of exten-
sion— Diagnosis — Treatment in general — Results — Statistical tables — Causes
of death following extirpation — Indications and contraindications to dif-
ferent methods of treatment — Palliafif*e treatment — Irrigation — Drugs —
CuretUige — Cauterization — Colostomy — Entero-anastomosis — Sarcoma — Form
— Number — Characteristics — Site — Course — Histology — Etiology — Symptoms
— Diagnosis — Treatment — Prognosis 760-801>

CHAPTER XX

EXTIRPATION OF THE RECTUM

Preparation of the patient — Perineal methcnls — Sacral methods — Abdominal
methods — Combined methods — Vaginal method— Prolapse after — Inconti-
nence— Stricture — Functional complications — Conclusions — Choice of methoil
—Statistical table 810-85S

CHAPTER XXI

COLOSTOMY — COLOTOMY — ARTIFICIAL ANUS

Mortality from colostomy — Statistical table — Lumbar colostomy — Inguinal or
abdominal colostomy — Teinjwrary colostomy — Methods of fixation of the gut
— Closure of artificial anus — Permanent colostomy — Author's method —
Colostomv on the right side 859-893

CHAPTER XXII

FOREIGN BODIES IN THE RECTUM AND SIGMOID FLEXURE

Bodies which have been swallowed — Enteroliths; coproliths; fa*cal stones —
Bodies introduced for the relief of certain symptoms — For purposes of con-
cealment— By accident — Symptoms — Diagnosis — Complications — Prognosis
—Treatment 894-914

CONTENTS ix

CHAPTER XXIII

WOUNDS, INJURIES, AND RUPTURE OF THE RECTUM

PAOI

Characters of — Causes of — Prognosis — Symptoms — Mortality from — Treat-
ment 015-921

CHAPTER XXIV

NERVOUS OR HYSTERICAL RECTUM

Insane rectum — Neuralgia of the rectum — Irritable rectum — Morbid sensibility
of the rectum — Reflex irritation — Nerve affections — Rheumatism and gout in
— Insensitive rectum — Treatment 922-929

CHAPTER XXV

RECTO-COLONIC ALIMENTATION

History of — Indications for — Principles and methods — Selection of materials in —
Methods of administering— Formuho 930-937

Index 939-961

LIST OF ILLUSTRATIONS

FIGURE PAGE

1. Development of intestinal tract (SchSflfer) 2

2. Development of rectum (Schaffer) 3

3. Divisions of anal canal (Stroud) 4

4. Divisions of the pelvic outlet 5

5. Dissection showing muscular arrangement at pelvic outlet, perineal triangu-

lar spaces, and ischio- rectal foss»T 6

6. Normal anus in repose 8

7. The anal canal 0

8. Longitudinal section of anal walls, showing arrangement of muscular fibers 10

9. Female perinteum (Kelly) 11

10. Levator ani muscle 12

11. Levator ani muscle (Cripi)s) 13

12. Cast of rectum (Quenu and Ilartmann) 16

13. Cast of rectum (Quenu and Ilartmann) 16

14. Cast of rectum and anal canal (Quenu and Hartmann) 16

15. Cast of rectum and lower looj) of sigmoid (Martin) 16

16. Cast of rectum (Quenu and Ilartmann) 17

17. Cast of rectum and anal canal (Quenu and Ilartmann) 17

18. Arrangement of circular muscular fibers of rectum 19

19. Diagrammatic illustration of chief aggregations of circular muscular fibers

in rectal wall 19

20. Dissection by ^lartin, showing fan-shaped arrangement of circular muscular

fibers 21

2L Arrangement of longitudinal muscular layer of the rectum (Lamier) . . 22

22. Showing reflection of peritonaMim from rectum on to the pelvic walls . . 23

23. Illustrating usual location of Houston's valves 25

24. Inferior and middle valves of Houston 27

25. Abnormal development of valves of Houston 28

26. Inferior mesenteric artery giving off sigmoidal branch and terminating in

superior ha'morrhoidal 29

27. External and middle ha^morrhoidal veins arising from the anal canal and

lower end of the rectum ; also branches running upward to form superior

hjemorrhoidal veins 31

28. Vascular supply of lower end of rectum (partly schematic) .... 82

29. Spinal nerves of the rectum and anus 84

30. Lymphatics of anal and perianal region 35

31. Showing connection between perianal and inguinal lymphatics ... 35

32. Exaggerated retro-rectal cellular space 37

33. Line of attachment of the mesosigmoid 41

34. Intersigmoid fossa, showing left sigmoidal artery 43

35. Complete absence of the anus 50

xii THE ANUS, RECJTUM, AND PELVIC COLOX

PIOURX PAOB

86. Membranous occlusion of the anus 5^

37. Partial membranous occlusion of the anus 54

38. Anus opening at tip of coccyx 56

39. Complete absence of the rectum, the colon ending in a large dilatation and

the anus being normal 57

40. Case in which rectum failed to reach the anus 58

41. Case in which tlie rectum descended posterior to anal canal .... 58

42. Fibrous cord leading from the anus to the arrested rectum .... 50

43. Rectum descending i)osterior to the anus and the latter opening into the

vagina (Amussat) 60

44. Atresia ani vesical is 62

45. Atresia ani urethralis 64

46. Atresia ani preputialis 65

47. Atresia ani vaginalis 66

48. Malformation in which the |>eritoneal cnl-de-sac extends Wlween the blind

ends of the roctum and anus 76

49. Commode for oHice use 09

50. licft lateral or Sims's [wsture 100

51. ^Exaggerated lithotomy position 101

52. Incorrect knec-c^hest posture 102

53. Correct knee-chest posture 102

54. Patient held in knee-chest posture by straps and bands 103

55. Patient held in knee-cliest posture on Martin chair 104

50. The Little office-lounge closed 105

57. Electric head-light 113

58. Kelsey's rectal speculum 114

59. Conical bivalve rectal speculum 114

60. Gant's operating rectal siK'Culum 115

61. Sims's rectal speculum 115

62. O'Xeill's rectal sixjculum 115

63. Author's conical fenestrated speculum 115

64. Van Buren's rectal simjcuIuiu 116

65. Pratt's rectal retractor 116

66. Mathews's rectal s[)eculum 117

07. Kelly's proctoscope 117

68. Kelly's set of instruments for examining the rectum and sigmoid . .119

69. Kelly's rectal curette 120

70. Kelly's rectal scoop 120

71. Kelly's sphincter dilator 120

72. Tuttle's modification of Kelly's sigmoidoscope 121

73. Laws's pneumatic proctoscope 122

74. Laws's proctoscope with aperture in window for therapeutic applications . 122

75. Tuttle's pneumatic proctoscope 123

76. Tuttle's long sigmoidoscope with flexible obturator giving the instrument

the Mercier curve 124

77. Tuttle's silver probe 126

78. Tuttle's rectal spoon 126

79. Tuttle's dressing-forceps 127

80. Alligator forceps for use through proctoscope 127

81. Wales's soft-rubber rectal bougie 128

82. Rectal bougie k boule 129

83. Tuttle's rectal irrigator 144

LIST OP ILLUSTRATIONS xiii

FIOrSK PAOK

84. Hypertrophic catarrhal proctitis ; specimen showing increase in depth of

tubules and intertubular substance

85. Atrophic catarrhal proctitis ; specimen showing atrophy and exfoliation of

epithelial cells and decrease in intertubular substance

86. Linear and stellate ulcerations on Houston's valves seen in a patient with

amoebic dysentery

87. Transverse section of inflamed follicle

88. Gross appearance of mucous membrane in follicular colitis (Delafield and

Pruden)

88 A. First tier of sutures in valvular colostomy (Gibson) ....

88 B. Last tier of sutures in Gibson's method

88 C. IxDUgitudinal section showing results of infolding by Gibson's method

89. Perianal tubercular ulcer surrounding external opening of a fistula .

90. Tubercular ulceration of the rectum with submucous fistula

91. Transverse section of tubercular ulcerof the rectum, showing elevated cen

ter and undermined edges

92. Tul)ercular ulcer of the rectum

93. Tul>ercular ulceration of tlie rectum . . ....

94. Tubercular ulcer encircling the sigmoid

95. Tubercular stricture and ulceration of the sigmoid ....

96. Photomicrograph of tubercular ulcer of the rectum ....

97. Tubercular ulcer with spud introduced beneath the undermined edge

98. Multiple perianal chancroids

99. Photomicrograph of gumma from the rectum

100. Impacted faeces in cavity of follicular ulcer

101. Fissure in ano

102. Irregular fissure or irritable ulcer of anus

10:}. Fissure with sentinel pile in syphilitic child

104. Fissure pnxluced by rent in a crypt of Morgagni

105. Perineuritis in chronic fissure (Quenu and Ilartmann)
100. Intrafascicular neuritis in chronic fissure (Quenu and Ilartmann)

107. Eversion of anterior fissure by finger in the vagina ....

108. V-shaj)ed incision for fissure at the posterior commissure of the anus .

109. Intramural or submucous abscess of the rectum

110. .4. is<*hio-rectal abscess; /?, superior pel vi-rectal abscess

111. Bilateral isc-hio-rectal abscess o|)ening into rectum |)osteriorly .

112. Ischio-rectal and retro-rectal abscesses communicating with each other

The rectum is dissected off and drawn forward ....
llil. Ischio-rectal and submucous abscesses communicating

114. Is<.*hio-rectal and submucous abscesses connected by tract through the

nmscles.

115. Retro-rectal abscess

116. Blind external fistulas

117. Blind internal fistulas, ^l, subtegumentary ; ^, subaponeurotic

118. Complete subaponeurotic fistulas, showing irregular tracts .

119. Subtegumentary fistulas. ^, blind external ; i?, complete .

120. External opening of subtegumentar)' fistula

121. Subtegumentary fistula almost surrounding the anus ....

122. Straight tubular fistula passing directly through external sphincter

Drawn from post-mortem dissection

123. Tract of urinary fistula which simulated the ano-rectal variety .
124- Outline of tortuous ano-rectal fistula

147
152

162

188

188
191
192
192
195
207

207
208
208
208
209
210
210
221
245
281
292
293
294
295
297
297
301
311
329
331
332

333
334

335
340
353
354
354
355
365
368

369
369
370

xiv THE ANUS, RECTUM, AND PELVIC COLON

PIQURC PAOK

125. Transverse section of tubercular fistula (photomicrograph) . . . 375

136. AUingham's ligature-carrier 380

127. Ligature passed through fistula and securiHl 381

128. Fistula in which the internal opening (A) is in a different quadrant from

that in which the abscess cavity {B) is nearest the rectal wall, and show,
ing how perforating the wall at the latter point and incising the gut
down to the anus by ligature or knife will leave a part of the pathological

tract untouched 383

129. Mathews's fistulotonie 384

130. Clover's crutch 386

131. Brodie's probe- pointed grooved director 387

132. Artery forceps 387

133. T-shaped haemostatic forceps 387

134. Needles for rectal surgery (actual size) 388

135. Wyeth's needle-holder 388

136. Grooved director piisscd througli fistulous tract and showing how passing

a bistoury along the gnwve and cutting outwanl will divide the sphinc-
ter obliquely 380

137. Fistula laid open outside of sphincter so that the latter can be cut squarely

across 390

138. First step in excision of fistula 392

139. Removal of a fistula threaded ujwn a probe 393

140. Methotl of introducing the sutures after excision of fistula . . . . 394

141. Final step in closing fistula 895

142. Rectal portion of fistula closed by flap of mucous membrane . . . 396

143. Y-shaped blind internal fistula 399

144. Director passing thn^ugh internal and external openings of fistula and

leaving part of tract untoucheil 400

145. Fistulous tract passing through external sphincter 401

146. Subtegumcntary fistula involving ischio-rectal and retro-rectal spaces . 402

147. Long fistulous tract opening near the greater tro<*hanter .... 403

148. Tract of horseshoe fistula operated on in September, 1901 .... 405

149. Dumb-bell fistula 406

150. Results of operation in preceding civ^c 406

151. 1. Oblique incision of sphincter, which is frequently followed by inconti-

nence. 2. Transverse incision not likely to result in same . . . 413

152. On the left is shown the separation and lengthening of the muscle (1 to 2),

due to oblique incision. On the right is seen the vicious union of the
fibers and the line of incision for repairing the muscle . . . .414

153. Old method of repairing sphincter 415

154. Chet wood's operation for fiecal incontinence — first step . . .417

155. Chetwood's operation — second step 418

156. Recto-urethral fistula. 1. Tract running downward and backward, prob-

ably originating in urethra. 2. Tract running downward and forward,

probably originating in rectum 426

157. Rectum, perinaeum, and urethra inciseil to expose recto-urethral fistula . 434

158. Recto-urethral fistula and wound in the rectum closed. The incision in

the urethra anterior to the fistula is left open 435

159. Final step in operation for recto-urethral fistula 436

160. Resection of the urethra for recto-urethral fistula 437

161. Recto-vesico-vaginal fistula. The fistulous tract indicated by the dotted

line passed around the cervix and not through it 440

LIST OP ILLUSTRATIONS XV

riorRx PAOB

162. Laaenstcin's operation for rccto-raginal fistula 452

163. Closure of recto-vaginal fistula, showing mucous flap brought outside of

rectum and sutured to the skin 453

164. Longitudinal section of stricture of the rectum 464

165. Stricture of the rectum due to prostatic inflammation. A, perforation of

the rectum ; B^ cavity in which lemon-seeds were found ; C\ inflamma-
tory hyperplasia ; Z), peritonaeum 467

166. Stricture complicated by recto-vaginal fistula 474

167. Stricture of the rectum causing procidentia 484

168. Bougie arrested in diverticulum surrounding a stricture .... 489

169. Bodenhamers bulbous rectal bougie 490

170. Crede's rectal bougie 496

171. Sims's rectal dilator 499

172. Durham's rectal dilator 500

173. Multiple stricture of the rectum 505

174. Trocar for insertion of female segment of Murphy button in Bacon's

oj>eration for stricture of the rectum 510

175. lateral entero-anastomosis (Bacon), ^l, mesorectuni 511

176. Clamp introduced through stricture and anastomotic opening in order to

widen the caliber of the gut in Bacon's operation 512

177. Diagrammatic illustration of acute flexure between the sigmoid and rec-

tum 523

178. Malformation of the sigmoid flexure 536

179. Acute flexure of the sigmoid on the rectum 537

180. Adhesion of sigmoid to the rectum, causing acute flexure at their junction 538

181. Inflammatory ailhesion of the appendix, binding the sigmoid to the ante-

rior surface of the sacrum and preventing its rising out of the pelvic

cavitv 539

182. Rectal electrode 555

18^3. Testing resistance of valve with Martin Ilook (Hemmeter) .... 558

184. Fixation and incision of valve after Martin's method (Heinmeter) . . 559

185. Martin's knives 560

186. Pennington clip for cutting rectal valves and the instrument for apply-

ing it 560

187. Pennington clip applied • 561

188. (Jant's clip for cutting rectal valves 561

189. Rectal valve after incision by Martin's method (Hemmetcr) . . . 562

190. Re<*tal valve after operation by Pennington's clip 562

191. Kelsey's rectal scoop 565

192. Pruritus ani 570

lOii. Prolapsed internal ha?morrhoid with condyloma attached .... 606

194. Mixed ha?morrhoid 611

105. Hard-rubber pile-pipe 616

196. Mathews's rectal divulsor 619

197. Gant's syringe for injecting haemorrhoids 628

195. Transfixion and ligature of ha^moiThoid 632

199. Ligation of ha»morrhoid after Allingham's method 633

200. Subcutaneous ligature of a ha?morrhoid 636

201. Tattle's hiemorrhoidal forceps 638

202. Pile seized with ha?morrhoidal forceps 638

203. Methrxi of applying the clamp after the ha^morrhoid is dragged down . 639
304- Gant's hoemorrhoidal clamp 640

xvi THE ANUS, RECTUM, AND PELVIC COLON

FIOURK

205. Haemorrhoidal clamp

206. Modified Paquelin cautery (Kennedy's)

207. Groove cut into muco-cutaneous tissue into which the clamp fits

208. Stump of excised hemorrhoid held by clamp

209. AUingham's hajmorrhoid crusher

210. Allingham's forceps for use in crushing operation

211. Smith's hemorrhoid crusher

212. First step in modified Whitehead operation for hemorrhoids

213. Second step in modified Whitehead operation

214. Third step in modified Whitehead operation

215. Modified Whitehead operation completed

216. Earle's forceps

217. Earle's operation

218. Limited excision of hemorrhoids

219. Exstrophy of mucous membrane following faulty Whitehead operation

220. Strangulated hemorrhoids

221. Incomplete prolapse of the rectum

222. Complete procidentia recti — first degree

223. Complete i)rocidentia recti — second degree

224. Complete procidentia recti — third degree

225. Complete prolapse of the rectum, showing circular arrangement of the rugie.

226. Rectal hernia or archocele

227. Delorme's operation for procidentia recti

228. Delorme's oi>erHtion completed, showing reduplication of rectal wall .

229. Infolding of the gut in Peters's operation for procidentia recti .

230. Attachment of the gut to the abdominal wall in Peters's operation .

231. Rectopexy for procidentia recti — the incision

232. Rectopexy — the gut inverted and brought through the incision ; the su-

tures passed through its muscular walls

233. Rectopexy — the sutures out through the tissues on each side of the sacrum

234. Rectopexy — the operation completed

235. Rectal hernia protruding through the anus

236. Rectal hernia, same case as Fig. 235, protruding through vagina

237. Myxoma, rectal polyp

288. Ladinski's rectal snare

239. Fibroids of the anus and rectum. Drawn from photograph taken before

operation, 1894. Nine distinct tumors were removed ....

240. Myxoma (Stengel)

241. Multiple adenomata of the rectum

242. Hypertrophic folliculitis of rectum and colon (Lilienthal's case) .

243. Lympho-adenoma

244. Pai)illoma with cylindrical epithelioma (Quenu and Hartmann) .

245. Schematic illustmtion of rectal papilloma

246. Papilloma of rectum

247. Villous polyp of the rectum (Ball)

247 A. Congenital postanal fissure. 247 B. Congenital postanal dimple. (Mar-

koe and Schley. Am. Jour, of Med. Sci.. May, 1902) ....

248. Ilypertrophied anal papille

249. Epithelioma

250. Adenoid cancer

251. Medullary cancer

252. Scirrhus of intestine

LIST OP ILLUSTRATIONS xvii

PAGE

253. Colloid cancer of large intestine 771

254. Rectal specimen forceps 773

255. Medullary carcinoma of the rectum 775

256. Scissors employed for obtaining specimens of rectal growths . . . 781

257. Lateral entero-anastomosis 797

258. Entero-anastomosis with complete elimination of the fiecal current from

the diseased area 798

259. Anastomosis of the ileum with the rectum for carcinoma of the sigmoid

and ileum 799

260. Round- and spindle-celled sarconm 803

261. Melanotic alveolar sarcoma 804

262. Line of incision in perineal proctectomy by Allinghain's method . 815
263 Second step in Allingham's method (Mathews) 816

264. Perineal extirpation of the rectum (Qu^nu's metliotl) 816

265. Perineal extirpation — loosening rectum from anterior perineal rhaphc . 817

266. Perineal extirpation 818

267. Perineal extirpation — tlie peritoneal pouch laid open 819

268. Perineal extirpation 820

269. Perineal extirpation completed 821

270. Kraske's 823

271. Ilochenegg's 823

272. Bardenheuer's 823

273. Rose's 823

274. Von Ileinecke's 823

275. Levy's 823

276. Rydygier's 823

277. Ilegar's 823

278. Extirpation of the rectum by the sacral route— first step in the bone-flap

operation 824

270. Sacrum removed to expose rectum and otlier pelvic organs (partly

schematic) 825

280. Second step in bone-flap operation 826

'/^\, Third step in bone- flap operation 827

282. Fourth step in bone-flap operation 828

283. Fifth step in bone- flap operation. The growth has been resected and the

ends of the intestine have been sutured together 820

284. Sacral anus, made in bone-flap operation when it was impossible to estab-

lish aperture in normal position • . . 830

285. Final step in bone-flap operation 831

286. Rectal carcinoma involving vaginal wall 832

287. Incision in vaginal extirpation (Murphy) 833

288. Separation of rectum from vaginal walls (Murphy) 834

289. Rectum laid open and cut across below neoplasm (Murphy) . . . 835

290. Resection of involved area in vaginal extirpation of the rectum (Murphy) . 836

291. Restoration of gut in vaginal extirpation of the rectum (Murphy) . . 837

292. Closure of peritonwum and vaginal wound after vaginal extirpation of the

rectum (Murphy) 838

293. Colorectostomy (Kelly) or invagination of colon through a slit in the

anterior wall of the rectum 839

294. Method of widening the caliber of the gut after colorectostomy . . 840

295. Result of colorectostomy for carcinoma as seen through proctoscope five

years after operation 841

xviii THE ANUS, RECTUM, AND PELVIC COLOX

FIOURK PAOB

296. Abdomino-anal extirpation of high rectal cancer— enucleation of diseased

portion through abdominal route 843

297. Abdomino-anal extirpation. Sigmoid is brought down through everted

rectum and sutured after method of Weir 844

298. Final steps in abdomino-anal extirpation. Peritoneal cavity closed, intes-

tinal tract restored, and drainage-tube ftxed in retro-rectal space . 845

299. Exposure of hemorrhoidal and sigmoidal artery in abdominal extirpation

of the rectum 849

300. Line of incision in lumbar colostomy 864

301. Lumbar colostomy 864

302. Lumbar colostomy completed 865

303. Incision in inguinal colostomy 870

304. Inguinal colostomy 871

305. Inguinal colostomy, rrii)ps*s method 872

306. Inguinal colostomy, Crijips's method. Final sutures in place . . . 872

307. Cross-section after colostomy by Allingham's method 874

308. Ooss-section after colostomv bv Kelsev's method 874

309. Inguinal colostomy, Bodine's method 875

310. Enterotomy after colostomy by Bodine's meth(xl 876

311. Inguinal colostomy (Mathews's method) 876

312. Cross-section after colostomv bv Mavdl-Rcclus method .... 877

313. Temporary inguinal colostomy 877

314. Temporary inguinal colostomy. Gut supported on rod and sutures in

position 878

315. Incision for o[>oning the gut in temporary inguinal colostomy . . . 878

316. Dupuytren's cnterotome 879

317. Xelaton's intestinal clamp 879

318. CoUins's long clamp forceps 879

319. Murphy button open 880

319a. Murphy button closed 880

320. Senn's decalcified bone-plate 880

321. Laplace's forceps for intestinal resection 880

322. O'llara's clami)s 881

323. Isolation of diseased portion of gut by O'llara's method .... 881

324. Disea.'^ed portion excised and edges of peritonroum brought together

(O^Hara) 881

325. Sutures introduced over forceps (O'llara) 882

326. Sutures tied and forceps ready to be withdrawn (O'llara) .... 882

327. Gut seized for lateral entero-anastomosis, by O'llara's method . . . 882

328. Lateral entero-anastomosis (second step in O'llara's method) . . . 883

329. Ijateral entero-anastomosis completed (O'llara's method) .... 884

330. Closure of artificial anus by plastic method 885

331. Closure of artificial anus by plastic method completed 885

332. Cross-section after extra-peritoneal closure of artificial anus . . . 886

333. Ligature thrown around proximal loop of gut in colostomy in order to

secure faecal control 887

834. Witzel's method of colostomv 888

335. Bailey's method of permanent colostomy 889

336. Braun's method of permanent colostomy (Bryant) 890

337. Weir's method of permanent colostomy (Bryant) 890

338. Permanent colostomy (author's method) 891

339. Permanent colostomy completed by author's method 892

DISEASES OP THE
ANUS, RECTUM, AND PELYIC COLON

CHAPTER I
EMBRYOLOGY, ANATOMY, AND PHYSIOLOGY

For tlie purposes of our discussion the following anatomical divi-
sions will be observed:

The anus is that portion of the intestinal tract which extends from
the margin of the true skin to the free borders of the semilunar valves
of Morgagni.

The rectum is that portion of the intestinal tract which extends from
the free borders of the semilunar valves to a point about opposite the
third sacral vertebra, where the gut becomes entirely surrounded by
p^^ritonivuin and the lower end of the mesentery is attached.

The pelvic colon or sigmoid flexure is that portion of the intestinal
tract which extends from the third sacral vertebra to the lower end of
tlie d<\-»cending colon at the external border of the left psoas muscle.

This division differs from that ordinarily given in works on anatomy
and text-books on diseases of the rectum, but it gives definite limits to
all three portions, and confines the term rectum to the immobile por-
tion of the canal comprised between the points where the mesentery
ceases above and the mucous membrane ceases below.

Embryology. — The sigmoid and rectum, like the upper portion of
the ah'mcntary canal, are developed from the hypoblast and mesoblast
of the oMim; the anus is developed from the epiblast. In the develop-
ment of the embryo, after the formation of the neural canal and the
folding in of the three layers of the blastoderm, which forms the head
and produces a cavity known as the " foregut," there appears a pro-
trusion at the posterior blind end of the enteric groove, creating the
so-called " hindgut," or rudimentary rectum.

Soon after the formation of the neural canal, the mesoblast is
divided by cleavage into two layers, one of which follows the hypoblast
1 1

THE ANUS, RECTUM, AND PELVIC COLON

and the other the epiblast, and the s^paee U'tween tliem gradually en-
larges to form tlie ctelum or pleuro-peritoueal eavity.

From the hypoblast the mueous membrane, and probably the sub-
mueous tissue develop, while the inner layer of the mesoblast forms the
muscular, peritoneal, and glandular portions of the gut (Sehalfer).

To the sixth week of gestation the large and small intestines are
one cavity, and of nearly an uniform caliber, with the exception of the

lower portion of the hindgut, whicli
even at this early period is more ca-
pacious than any other })ortion of
the intestinal tract except the stom-
ach. About the sixth week the
vermiform appendix is developed;
from this time tlie colon, sigmoid,
and rectum grow more rapi<lly in
circumference than the '* foregut/*
or small intestine, and, extending
downward, more and more n(*arlv
approach the outer layer of the
mesoblast and the epiblast at the
lower portion of the embryo
(Fig. 1).

The blind end of the hindgut,
in close apposition with the lower
end of the s])inal column and orig-
inally connected with the neurenter-
ic canal, forms what has been called
the cloaca, in that it receives at this
period through the allantois the se-
cretions of the urinar}' and genital
a, notochord : 6, hypophysiH : c biicMiuct ; rf, organs as well as tliosc of the in-

tonffue ; r, pcnuanent kidney ; /, cloaca ; .

jjf, aiiua ; h, hcxuuI proniineuce ; i, tail; j, testinai Canal.

cttcum coli: t, truchea; Mttr>'»x; m, pun- About the eighth weck of gCSta-

crea.; n, section of n.andibular arch;o, ^j^j^ ^j^^ ^j^^^^ j^ divided, how we

commencing lung ; p, Mtomach. .

do not clearlv understand, into two
parts; the anterior forms the uro-genital organs and the posterior the
enteron or rudimentary rectum. Imperfection in this division causes
many of the abnormalities of the rectum.

The urinary and generative organs develop from the inner layer of
the mesoblast^ some of the cells from which differentiate into a cord
in which a lumen is formed, the so-called Wolflian duct, which has its
posterior opening in the cloaca or hindgut, and thus connects the two
systems. In normal development this duct closes, and the connection

Fio. 1. — Development of Intestinal
Tract (Schaffer).

EMBRYOLOGY, ANATOMY, AND PHYSIOLOGY

between the urinary and alimentary tracts becomes obliterated about
tJie twelfth week of gestation. It will be noted later that this commu-
nication sometimes persists and forms one of the types of malforma-
tions of the rectum. With such intimate relationship in deTclopment,
one is not surprised to find these or-
gans closely related in symptomatology
and disease.

During the development of the rec-
tum from the hypoblast and niosoblast
there is going on an invagination of
the epi blast or ectoderm, which is
called the proctodeum (Fig. 2). This
invagination increases until the outer
and inner layers of the nu'soblast are
pressed together and absorbed, nnd the
epiblast of the proctoda.>tim and tiie
hypoblast of the hindgut approach
each other, and form a double sa'ptum
between the rectum and the procto-
dn>uni or embryonic anus. Testut and
Waldeyer state tliat the layers of the
mcsoblast are not present at this
pf>int; that the hindgut or enteron and
proetodasum are separated by two
epithelial layers, the one belonging to
the hypoblast, the other to the epi-
blaiit. The existence of fibrous tissue
in this siPptiim, in cases in which the
latter has not been absorbed, would
indicate that the absence of the mcso-
blast at this point is not at all uni-
form. The absorption of the septum
renders the conjunction of the rectum
anil anus complete, and leaves a nar-
row zone that indicates the transition
from mucous to muco-cutaneous tis-
sue, which has been termed by Stroud
the "pecten" (Fig. 3). This zone '"""■'hii'i*""-
marks the lower limits of tlie rectum and the upper margin of the anus.

The conjunction takes place generally at a point slightly in front
of the posterior end of the gut, and thus leaves a cul-de-sac which, as
has been said, is connected with the neurenterie canal. This cul-de-
sac and connecting canal are largely absorbed during fcetal life, leaving

FlO. 2. — DETKLOPHmXT OT RlCTL'H

(Schiifferj.
scctiuii of mandibular arch : t, hyp-
ophyBiB, behind it the reiuuiuB of (he
phuytiitval BKptuiii; e, coinmoncing
lang; d, at'imuchi e, livvr: /, yolk
sulk: g, Woltniin duet; A. blind po^

4 THE ANUS. BBCTDM, AND PELVIC COLON

till.' Loccvgcal gland or ^land of Lusclika, which is situated just in front
of the coccyx and remaJDS in adult life. Sometimes imperfeet absorp-
tion leaves a congenital posterior rectocele. It is from the remains of
this posterior cul-de-sac and communicating canal that dermoid cysts
and other teratoid tumors of tlie recto-coecj-geal space develop.

It will be seen from this brief and incomplete account of histo-
genesis that the rectum proper is a development of the liypoblast and
niesoblast in common with the rest of the colon; that its muscles and
submucous layer are from the inner layer
of the niesoblast, and that it logically and
practically ends with the serrated uiar^'in
of the pectcn or free borders of the semi-
lunar valves. It is also apparent that the
anus, with all its surrounding muscles,
cells, and faicia', is a development of the
epiblast and outer layer of the mesoblast,
and histologically includes all that por-
tion of the intestinal tract below the upper
margin of the pecten.

As will be seen farther on, the mem-
branes, the glands, the blood and nerve
supply all undergo a more or less abrupt
change at this point, and the diseases
which we encounter in the two portions
are almost as distinct. It is necessjiry,
therefore, to understand exactly the lim-
itations of the anus, rectum, and sigmoid,
and also to describe them separately.
They are discussed consecutively from below upward, because this is the
order in which they are met in examination and treatment.

The bony outlet of the jmiIvis comprises a somewhat diamond-shape
space, which an imaginary lino extending from the anterior border of
one tuberosity of the ischium to the other divides into two triangular
spaces. The anterior one is known as the uro-genital triangle, and the
posterior as the rectal triangle (Fig. 4). For convenience of descrip-
tion these triangles are further divided by a line drawn from the sym-
physis pubia to the tip of the coccyx into the right and left anterior
and posterior quadrants. The uro-genttal triangle is in close relation
with the anus and rectum, and contains important genito-nrinary
organs.

The rectal triangle contains the anus, rectum, and surrounding tis-
sues. The anatomy of the parts included in these two spaces must be
thoroughly understood in order to practise rectal surgery succeBsfully.

pectcn; rf, anuL pufiillu ;
IXKkct: /, IVIIkHliiiuonHB; .
dentaCa: h, ruotal glutidit.

S.A., riithl Btilyrior ymiclniiit;
E.P., riglil poBlcriorquadraut
B.A. BoJ L.A., nnvgenilal ti

A., lolV Dtilurlor quiulnilil ;
.P., letl poBterior quudnmt ;
igle ; B.P. and L.P., nicUd

EMBRYOLOGY, ANATOMY, AND PHYSIOLOGY 5

The Perinsam. — Tlie [tcriiiwum is the space comprised in the uro-
[ genital triangle. It is bounded by the anus behind, the scrotum in
I front, and tlie rami of the ischii upon the sides, and is occupied by vari-
"mportant structures. Superlidally it is covered by the skin, in
[ the central line of
I which there runs a
[ rhaphe continuous
ETith the central
I rhaphe of the scro-
Etum. and ending ut
I the margin of the
I anus. There is noth-
I in^ peculiar in this
I cutaneous layer, cx-
I tejJl that in the ceu-
K:4ral rhnplie there are
■few glandular constit-
P-flentf and very few
liliair follicles, Im-
nediately beneath the
kia is found the su- "■"-»■"■

•erficia] fascia of the periniiniin, which is continuous with the superficial

II over the body. It is not attached to the bones or umscles, but

8 with the deep fascia, at the orifices; beneath this is found the

ii'riicial perineal fascia, called also Colles's fascia, which is continn-

Mvu» with the dartos of the scrotum in front, attached on each side to the

^sami of the pubes and ischii, and stretched across the posterior border of

e perineal space in a line slightly anterior to the tuber ischii. In front

f the anus this fascia dips down around tlie posterior border of the

ransversue periniei muBcles, to be attached to the free border of the

tiangular ligament (deep perineal fascia). The tatter structure is a

lense, fibrous membrane .■stretched across tlie anterior portion of the

lelnc floor. It is divided by anatomists into superficial and deep layere.

jilt-riorly it arises from the superior pubic ligament, is attached later-

■ to the rami of the pubea and ischii a little deeper than the ems

lie. Posteriorly it is stretched across the perineal space, just above

> transversus perina'i muscles, and is continuous with the posterior

iJcr of the superficial fascia ; while its attachment anteriorly is above

of the superficial fascia, their posterior borders are conjoined, and

c two thus enclose a wedge-shaped space anterior to the anus. 'In this

e are situated the accelerator urinie, transversns perinsi, and the

rtor penis muscles, the corporis spongiosum, the perineal arteries

i nerves, and the bulbous urethra containing Cowper's gland?. This

THE ANUS, KECTUJJ, AND PELVIC COLON

}

■wedge-shaped space is divided into two triangular spaces by the atta
itit-nt of tlie two walls in the center to the rhaphe of the perineal be
and the accelerator urins muscle (Fig. 5). These spaces comiiiu
eate anteriorly through a tract of cellular tissue at the juncti
of the scrotum and Ihe i>erin[euni. They are tilled with oellu
tissue, in which the blood-vessels and nerves of the generative oi'gt
ramify.

The transversus [jeriniei muscle crosseB the posterior border of t
perineum from one tuberosity of the ischium to the other; the ace

crator urinJE muscle runs through the center of the space, being coverei
by the superficial fascia, and these, together with the external sphinctei
nnd the sphineter vaginal in women, unite in a common fibrous eentei
called the perinea) body, just in front of the amis. The deep and super-
fipial fascire thus enclose important organs connected with the
genital tract, and form a barrier between them and Ihe rectum.

iBchio-iectal Fouae. — Back of these perineal spaces, and separated
from them hy the wedge-shaped border of the perineal fascifc and the
IniDi^vcrsus perina'i muscles, are situated the ischio-rectol spaces which
practieiillv surround the lateral nnd posterior portions of the anus and
rectum. They measure from before backward 5 to 8 centimeters O to ^J

EMBEYOLOGY, ANATOMY, AND PHYSIOLOGY T

inches), from side to side 2^ to 3^ centimeters (1 to If inch), and in
depth from 4 to 10 centimeters (1^^ to 3^^ inches), according to the
size of the subject (Fig. 5).

Each fossa forms an irregular, wedge-shaped or cuneiform space,
its base being directed downward. Each space is enclosed by the peri-
neal fascias and the transversus perinagi muscle in front, the levator ani
muscles above, the obturator fascia?, the obturator internis muscle, the
ischium and the sacro-ischiatic ligaments externally, the rectum and
the anus internally, the gluteus maximus muscle, the sacro-sciatic
ligaments and the coccyx posteriorly, and the skin and superficial fas-
cia below. The fossa? are connected posteriorly bv a zone of cellu-
lar tissue between the fibers of the levator ani muscle and the ano-
coccygeal ligament. These spaces are filled by fat and cellular tissue,
in which ramify the blood-vessels and nerves of the lower end of the
rectum and the perineal branch of the fourth sacral nerve. The fat
in these spaces is supported by a network of connective-tissue bands
which divides them into numerous compartments that coinnmnicate
with each other through the lymphatics and the blood-vessels. It is
owing to these divisions that one often finds in oj)erating upon ab-
scesses here that he has to deal with multiple cavities instead of one large
excavation. The deepest portion of the spaces lies close to the rectum.
This explains the fact that in large abscesses in this region the highest
point is always nearest the rectal wall. Although these fossae are
crossed by numerous blood-vessels and nerves, none of them is vitally
important surgically, for the entire cellular tissue may be destroyed
without any serious damage to the nene or blood supply of the adja-
cent organs.

Above the levator ani muscle are situated the superior pelvi-rectal
and retro-rectal spaces, but these can be better understood after the anus
and rectum have been described.

The Anns or Anal Canal. — The anus is usually described as a simple
orifice at the lower end of the intestinal tract, but practically it embraces
all that ])ortion of the tract below the true mucous membrane. It is
situated in the middle of the pelvic outlet just back of the imaginary
line drawn between the tuberosities. In women it is slightly farther
fon\'ard than in men, the distance from the coccyx measuring in the
fonner 2o to 30 millimeters (1 to 1^ inches), and in the latter 20 to 25
millimeters (J to 1 inch). In a condition of repose it appears as an
antoro-posterior slit (Fig. 6). The skin around it is slightly pigmented
and drawn into folds by the contraction of the sphincter muscle. Em-
bedded in this skin, chiefly posteriorly, are sudoriparous glands called
circumanal glands, some sebaceous glands, and a few hair follicles, from
which issues a short stumpy growth of hair. All of these decrease as

THE AMOS, I

the ccniriil portion of llie anus \s approachwi, and disappeur altogether
wlierc the skin changes into muco-cutaaeous tissue.

Behind the anus there is a smooth, dense ridge of -.kin extending
to the posterior surface of the coccys, eaUed the anal rhnphe; id front
of it is the ]>eriiieal rhaphe
proper, which has been
alirady descril)ed. Aa the
center of the anus is ap-
proached the skin loses
its corneous character,
firadually changing loln
iLiueo-culaneons tissue,
which is finally trans-
formed into mucous mem-
brane at the upiJcr end of
the anal eannl.

Dimeiisiiiitg. — The anal
canal is limited by the
true skin helow and the
free borders of the semi-
lunar valves or the ano-
rectal line of Testut
(Traits d'anatomie hu-
niaine, vol. iv. p. 234).
It measures from 16 to
24 millimeters (| to 1
>u. i;-n..i.vn: Am- IV );i-.ru™, inch) in length. lis cir-

cumference varies from
3 eentiiiielers (1^ inch) in normal condition to 1.5 centimeters {Ti-ff
inches) in disease, following injury or vicious practiecs. The average
anus will admit a cylinder of (i5 millimeters in circumference without
rupturing the mucous membrane.

The walls of the anal canal are composed of muco-cutaneous, fibro-
celliilar, and muscular layers. The muco-cutaneous layer is smooth,
shiny, and glossy. It contains few glands and blood-vessels, but it is
richly endowed with terminal nerve-ends. It is covered in its lower
portion by stratified, squamous epithelium, which undergoes a gradual
transformation until it ends in the typical colunmar epithelium of the
mucous membrane at the upper margin of the linea deatata or ano-
rectal line. This irregular border limits the upper end of the anus,
and forms the central floor of the rectal ampulla. The dentations are
slightly elevated above the surface of the adjoining mucosa, and form
an irregular ridge between the rectum proper and the anal canal. They

EMBRYOLOGT, ANATOMY, AND PHYSIULOGY 0

I van* in nnniiicr from fire to eight, and assume the foi-iii of papilla at
I their suminitp. Audrcwa (Diseases of the Rectum, 1895, p. 303) con-

■ siders these papilla: the normal tactile organs of the rectum endowed
I villi a special recta! sense. Stroud, however, states that they are ab-

jiurmal structures growing from the tips or faces of the indentations.
B found in ihem epidermal, dermal, and amyelinic nerve-fibers. Tliey
e absent, or at least not noticeable in the large majority of ciij-es; but
when they are well developed thoy produce many reflex disturbances
which are accounted for by their abundant nerve supply (Fig. T).

In the upjwr portion of the muco-cutaneous tissue one finds a few

Bjn«gular, tubular glands analogous to those seen in the rectum. Stroud

!«lte them aecidcntui glands, but Hermann considers them as simple

mucous crypts. About -1 to 5 millimeters (-^ of an inch) below the

o-rectal lino there
s a piKirly defined lini:
depression wbicli
U'ks the lowoi' I 111
f the internal ^plmir-

■ ter, and is known ■■>■<
Hilton's white I j i ic
In many cases tlii> i-^

filiDost imperceini''!"
I ili« eye, bul ir ■ i
idwayebemade <<iir
loucb, as it markr. iia
^ncture between the
inlenial and external
phincter muscles.
r*« Fibro-Tfllular
— Beneatli the

nnco-cutaneous tissue, and separating it from the muscular layer, is a
1 fibro-cellular layer of the anal canal. Above Hilton's white line
1 layer is chiefly cellular, below this point it develops into a thin
r of connective tissue continuous with the superficial fascia eover-
g the ischio-rectal foss^. It is closely attacheil to the muco-eutaneous
I muficular layers, thus uniting the two and preventing any great
lovemcnt of one upon the other.
The Muscular Layer. — The anal canal is surrounded by the external
liphiDrk-r, some fibers of the levator ani, the longitudinal muscular fibers
f the rectum, and a few of the circular fibers comprising the lower por-
tioD of thr internal sphincter. The external sphincter forms the chief
Binseular wall of the anal canal. A few interlacing fibers of the levator
i and the longitudinal muscles of the rectal wall pass down between

iind «urDiouDted by p,

THE ANUS, RECTUM, AND PELVIC COLON

its fibers and around its lower margin to be attached to the deeper lay-
ers of the skin, and thus comprise a portion of the muscular wall. The
arrangement of these fibers will be seen in the illustration (Fig. 8).

The External Sphincter Muxcle. — The external sphincter is com-
posed of voluntary or striated muscular libers, and from a surgical point
of view is the most important muscle of the rectum. It arises from the

ir nuiMuliir Blwrt of innwtin

■■iiJiuB ill intoniiii -pliinctc

below

J?. lonKitudinal

jlur flbois a( iiut penetrating

.-stumal spliincler; C. fiber*

of leva

crMilr Iti upper portion, and <i

yarn ti

ited to gut -KtO.

rcxwed ilannward: A fxtcmul

spliincter.

posterior surface of the coccvx ami the fibrous layer of the skin over
this repion, passes forward to the posterior commissure of the anus,
whore its parallel fibers divide to surround this aperture, and reuniting
at the anterior commissure, pass forward to be inserted into the perineal
body. It. is composed of a superficial and deep layer. The fibers of
the superficial layer are circular and entirely surround the anus (Fig.
5). The fibers of the deep layer are parallel, and simply separate and
apply themselves to the anal portion of the rectum to the height of 1 to

EMBRYOLOnT, ANATOMY. AND PHYSIOLOGY

L 2 centinictcrs (| to ^ of an incli). In women it is continuous in front
I witb tile fibers of the sphincter vaginie (Fig. 9). Inside of the external
I sphincter the fibers of the levator aiii, the longitudinal muscles, and the
•ruul sphincter, which form a jinrt a! tlie walls of llie anal canal,
I gre found.

Erect, rlil.

THE ANUS, HECTFM, AND PELVIC COLON

Ita anterior fibers pass downward and backward around the pros
gland to unite witii the fibers of the opposite side beneath tlie neck of
bladder ; the middle fibers pass downward and inward around the reel
some being attached to the sides of this organ, and interlacing at t
lower ends with the fibers of the external sphincter, while others u
posteriorly and pass backward to be inserted on the anterior surface
the coccyx. The posterior fibers pass downward and backward, and
inserted upon the aides of the coccyx and lower part of the aaeniin.

Dniwn frolu dias«clion by Ihi

Crippa (Diseases of the Rectum, p. i)) states that this muscle cross
the rectum at right angles, and thus encloses this organ in the narn
angle of a V-shaped muscular formation, in consequence of which i
only action is to constrict the rectum (Fig. 11). Upon this auaton.
cal construction he has based his ingenious theory of spasmodic stri
ture. Numerous dissections have failed to show any other arrang
ments than illustrated in Fig. 10. Viewed from below, the muscle a;
pears as an inverted dome, and the contraction of its fibers not on!
lifts hut also constricts the rectum and anus. Ita fibers are not uniform,
spread out, but are collected in small handles, the spaces between thei
being occupied by fibrous tissue.

EMBnYOLOQY, ANATOMY. AND PUYSIOLiXJY

Iscliiti-cocci/i/fus J/u*[7f.^ADatimiists deforibe tLe posterior fibers
jof the levator ani as a distinct musdo under the aiiove name. The por-
[lion Sd described arises from the rami and spine of the ischiuiii and
com the border of the eacro-ischiatie hgamcnt, and passes downward,
fard, and backward, to be inserted by aponeurotic fibers upon the
of the coccyx and last sacral vertebra. This portion of the muscle
R somewhat more fibrous than the anterior portion; its function seems
I be that of pulling the coccyx forward. It forms the floor of the
bIvib posterior to the
Ktuin.

The author sees no
»son for describing it
separate muscle,
IDd therefore when ref-
i is made to the
ir aui in this book
entire muscular
or floor of the
bItis will be meanl.

Rfet»-fi>rry<jtus Mus-
\b. — Under this name,
llid also under the
toit^ tensor fasciie pel-
B (Kohlrauseh) and re-
ictores recti (Treitz),
fiai bands of un-
trifved muscular fibers
been described,
which are said to arise
fmm the coccygeal liga-
ment near the tip of the
rwccTX, and pass forward
aud downward, finally
blending with the longitudinal muscular fibers of the rectum aud the
pelvic fascia around the anus.

lieliilions of tlif Anal Canal. — According to the foregoing descrip-
tions, the relations of the anal canal are as follows: Anteriorly it is in
relation with the perineal body, the deep layer of the superficial peri-
neal fai^cia, the posterior iiorder of the triangular ligament, and the
nnt<:Tior fibers of the levator ani muscle; laterally with the perianal
fasci», which separate it from the isohio-rectal fosss. and with the ex-
tvntal sphincter muscle; posteriorly it is in relation with the esternal
■pbincter, the levator uni, and the ano-coccygea! ligament.

: B, bliuldvt

VAT.1K Asi Mum ui ((.'rii>|)B)
; C, aDacfx ; R, rectiun ; ."f, fj
LA, luvntcir aiii tiiUHvIc

iipliy«.

14 THE ANUS, RECTUM, AND PELVIC COLON

The blood-ves*sels, nerves, and lyuiplmtics of the anus are so inti-
mately connected with those of the rectum proper that it is deemed
advisable to describe them all together.

THE RECTUM

The rectum, as defined, comprises that portion of the intestinal
canal between the semilunar valves of Morgagni and the attachment of
the mesentery opposite the third sacral vertebra. Treves first advocated
this division. It gives to the organ (iefinite limits ; it separates the
mobile from the immobile i)orti{m of the gut; it marks the line wliere
the course of the blood supply changes ; it indicates the point where
the three longitudinal muscular bands of the colon si)read out and be-
come more or less equably distributed around the gut; and, finally, it
marks a point at which there is always a decided narrowing in caliber,
indicating the juncture of the rectum with the pelvic colon.

According to this division, that jwrtion of the rectum which is ordi-
narily called the superior or first portion is included in the sigmoid flex-
ure under the term pelvic colon, and justly so, as it corresponds in every
anatomical detail with the other loops of this organ.

Course and Direction. — The name rectum would imply that the
organ is straight, but such is not the case. Beginning in the hollow of
the sacrum, it follows the sacro-coccygeal curve downward, being first
directed backward, then forward, and finally backward again at the anal
canal. It thus forms a double antero-posterior curve, the concavity of
which is directed forward in the superior portion and backward in the
lower or prostatic portion. It begins ordinarily opposite the center
of the sacrum, passes outward to the right beyond the central line, and
then again to the left, thus making two lateral curves as it descends.
These curvatures are not marked, and they are of no great practical
importance. The antero-posterior curvatures are well marked, how-
ever, and indicate the direction in which the finger or instruments
should be directed in introducing them into the organ. They are more
marked in some individuals than in others, and may be greatly in-
creased by tumors, displaced uteri, or pelvic adhesions.

Above the third sacral vertebra the sigmoid begins: the canal may
turn to either the right or left ; the angle may be sharp or obtuse,
and there is no way of accurately determining this except by ocular
inspection.

Divisions. — The rectum may be divided into two portions — the in-
ferior or prostatic portion, and the superior or sacro-coccygeal portion.
The inferior portion is very short, and extends from the ano-rectal line

EMBRYOLOGY, ANATOMY, AND PHYSIOLOGY 15

or upper border of the crypts of Morgagni to the summit of the prostate.
The superior portion extends from the summit of the prostate to the
middle of the third sacral vertebra.

Some writers subdivide the upper portion of the rectum into peri-
toneal and infraperitoneal portions. This division, however, is im-
practical, inasmuch as it is impossible to determine the lower limits of
the peritoneal covering. Numerous divisions and subdivisions are con-
fusing, and the author prefers to study the organ as a whole.

Dimensions. — The length of the rectum is 10 to 15 centimeters (3\f
to 5||^ inches) in men, and 9 to 13 centimeters (3f to 5 J inches) in
women. This varies according to the size of the individual, and is some-
what greater in old people than in young. These measurements are less
than those ordinarily given, on account of the fact that they do not
include the first or superior portion of the rectum in the old divisions.

The diameter is very difficult to obtain in the living subject. It
measures when empty 10 to 20 millimeters from before backward, and
30 to 40 millimeters from side to side. When distended, or removed
from the body and spread open, its measurements vary greatly, and
sometimes assume enormous proportions. Sappey has reported a case
in which the gut measured 34 centimeters (132 inches) in circumfer-
ence at its widest point. From the chapter on Foreign Bodies in the
Rectum one will gain some idea of the extent to which the organ may
be dilated.

The circumference varies in the different portions of the organ^
being on an average 6 to 10 centimeters in the prostatic portion, 12 to
20 centimeters in the widest portion of the ampulla, and 10 to 14 centi-
meters in its upper or narrow portion. Numerous instances have been
recorded in which these figures were gn^atly exceeded. Quenu and
Hartmann, after having excised and split open a large number of recti,
give the following average circumference: Anus, 5 to 9 centimeters;
rectal ampulla, 13 to 16 centimeters below and 8 to 10 centimeters
above; the tubular portion, or the last loop of the sigmoid according
to our division, 10 to 12 centimeters.

Conformation. — When the rectum is empty, the anterior walls are
pressed backward by the pelvic contents, and thus come in close ap-
position with the posterior walls. Thus there is formed a lateral slit
or flattened canal, much wider from side to side than from before
backward. When distended with gas, liquids, or solid substances, the
organ assumes an irregular cylindrical shape. It is often wider from
side to side than from before backward on account of pressure by the
pelvic organs, or through adhesive bands which prevent its being dis-
tended as much in the antero-posterior direction as in the lateral. The
irregular shape of the organ will be appreciated by referring to several

illustrations (Figs. 12 to 17) of casta made by filling the organ with ]
ter of Paris, paraffin, and other such substances.

In c-orlain casps of utmiy, or wlitTO tlio rectum has been greatly
teink'd, it a.-^^uriifs a \\t\ Lrr(.';,iLliir shape, the satculj resolving tli

Fio. U.— CauT of Rectom AM) Anal Cabal, Fiu. 1B.-

Slinwintt liTBguliir eurvtM in ftiraier. Loc

(Qui;nu nnd lUrtuiunii.)

EMBRTOLOGY, ANATOMY, AND PHTSIOLOGV

i into true Jivertituli. In other cases, espeeiiiHy when; IhiTi; baa
a [irotrat'tod recliti?, the orfj^an asaunies ii cylindrical or tuEiular
lape, with slight variation in ealilwr from the apex of the prostate
iBpwairrl. This eimilitjiin is the iiormul oiil' in children, and is said by

Oally to occur once in every six adults. This pro[)ortion, however,
Bppears to the author to be largely overestimated.

Tlie Mteriiul surface is irre^darly convoluted, hut lesa so than the
moid flexure. The grooves which mark its contour correspond with
e of Ihp mucous folds or Houston's valves internally.
atomiciil Strvcture. — The walls of the i-eetiini are composed of
r layers or cnats. From wilhin outward Ihiy comprise the mucous,
• Sabmucons, the muscular, and the serous Iniers.

. Kncous Hembrane. — Tht. mucous membrane of the rectum
El from that of the upper colon m thai it is thicker, darker in color,
J vascular, and more mobile, being attached to the muscular wall
gh a loose, lax, submucous tissue, which allows it to slide in all
ions. It in characterized by a great development of tubular and
laroiis glands, together with many closed follicles and an ex-
MJvely vascular apparatus. Throughout its extent it is thrown into
' horizontal folds, some of which correspond with the valves of
Bouslon. In its lower portion it is gathered into longitudinal folds,
locstitating the columns of Morgagni, between the bases of which are

18 THE ANUS, EBCTUM, AND PELVIC COLON

found the semilunar valves or cr}'pts of Morgagni, the free borders of
which mark the limitation of the rectum above and the anus below.

Structure of the Mucous Membrane. — The membrane is composed of
three layers: the epithelial, glandular, and muscular. The epithelial
layer consists of a layer of columnar cells throughout the rectum proper.
This changes, however, into stratified polyhedral and prismatic layers in
the transitional zone at the lower end of the organ. Below the epitheli-
um there are numerous closed follicles; between these follicles are the
glands of Lieberkiihn, which practically compose the substance of the
mucous membrane.

Tlie glands in the rectum, chiefly Lieberkiihn's follicles, differ some-
what from those in the upper portion of the colon in containing more
goblet or mucus-secreting cells. The glands are tubular and are very
close together, the intervening tissue measuring about one-sixth the
diameter of the tubes.

Tiie cells lining the tubules are arranged at right angles to the
cavity, and are continuous with those covering the mucous membrane
between the tubules. The arrangement of these tubules is similar to
that of a honeycomb, the division between any two forming a commoii
wall for each of them.

The intertubular tissues are composed of a fine trabecular network,
the long meshes of whiclr run parallel to the tubules, forming, accord-
ing to Cripps and Testut, lyni])h-i>aths. ]*ractically, the Lieberkiilm
follicles are nothing more than inverted villi. They are said to be
inverted on account of the solid condition of the material with which
they come in contact, but their function remains the same as that of the
villi — viz., the absorption of the fluid contents of the bowel. The ab-
sorption takes place through the epithelium or through the intervening
spaces, more probably through the former.

At the lower end of the rectum are found numerous compound
racemose glands, called by Schiiffer anal glands. Here and there be-
tween the Lieberkiilm glands are found small nodules of lymphoid
tissue, which are said to possess a very feeble vitality. These have no
mouths or openings connecting them with the cavity of the rectum, and
no connection with the lymphatics, so far as has been discovered.

The muscular layer of the mucous membrane, called the muscu-
laris mucosa, is somewhat more developed in the rectum than in the
other portions of the colon. Kohlrausch (Anat. u. Physiol, der Beck-
enorgane, Leipzig, 1854) described these fil)ers imder the name of
sustentator tunicje mucosa*. Treitz states that the fibers are specially
developed in the columns of ^[orgagni, but other anatomists have failed
to establish this fact. The exact functions of these minute fibers are
not known.

EMBRYOLOGY, ANATOMY, AND PHYSIOLOGY

1!)

Sabmncons Layer. — The submucous tissue of Ihc rectum consists in

I Imisc, alveolar n-lwork of elastif tissue and connective-tissue cells.

3t is thicker unj more elastic than at any other portion of the intestinal

sdh!, and thus allows a greater mobility of the mucous membrane

»ve it. In this tissue ramify the blood-vossels, nerves, and lymphatics.

1 certain diMrases it becomes greatly hypertrophied, and may become

itirely transformed into fibrous tissue.

Ifaicttlar Wall, — The muscular coat of the rectum is composed of

1 circular and longitudinal fibers. The circular libera compose the inter-

IKBi or KUTTIH.

nl layer. This layer is irregular in its distribution, the fibers being

regated at different levels upon one part of the cireumference and

ipnad out at the other (Figs. 18, 19). The chief aggregation of fibers

B at the lower end. where they go to make up the internal sphincter.

(• muscular filx'rs throughout the rectum arc separated by connective-

Kue fibers arrangjnl parallel to them. This arrangement apparently

ytatits for the rapid development of the connective-tissue strictures

I inflamed conditions.

ImUrnai Sfihincter. — This muscle, composed of an aggregation of

r fibers, begins about 4 centimeters above the anal margin, and

r increases in thickness until it reaches the ano-rectal line, after

20 THE ANUS, RECTUM, AND PELVIC COLON

which it thins out again and disappears about the middle of the anal
canal (Fig. 8). Its width from above downward averages 1 to 3 cen-
timeters (f to 1^ incli). Its thickness is so variable that no accurate
measurement can be given. Its lower fibers are below and within the
grasp of the external sphincter, from which it is separated by a narrow
zone of connective tissue (Fig. 8).

A depressed zone, not always perceptible to the eye but appreciable
by digital touch, Jiiarks the line of division bc»tween these two muscles.
The internal sphincter is purely an involuntary nmscle, but it is looked
upon by many surgeons as the most important factor in fa»cal continence,
and in the production of constipation.

The Third Sjthinrtrr. — Aggregations of cin*ular fil>ers at different
levels of the rectum luive Iwen the cause of nuu-h controversy. Velpeau
(Traite d'anat. chir., 1S;3T, p. 39) says: *' Xelaton described a muscle
which he called the superior sphincter, and which is situated about 4
inches above the anus, about the s])()t where strictures of the rectum
are generally observed. It is formed of fibers which are both aggregated
and fan-shaped. lU depth in front is about six to seven lines, while
posterior and on the sides it is spread out to about 1 inch." Velpeau,
while denying some of the functions attributed to the muscle, confirmed
Nelaton's (lescri])tion, and (losselin (Arch. gen. de med., 1854, p. GG8) de-
scribed this aggregation as dividing the up])er and middle portions of
the rectum.

Hyrtl (Topog. Anat., p. KJv^) described this aggregation. He
frankly confessed that his <lissections failed to confirm its uniform j)res-
ence, but, reasoning from ])liysi()logical ])henomena, claimed that there
was a true circular sphincter entirely surrounding the rectum at this
point. His claims have not been verified by Sa])])ey (Traite d'anatomie
humaire, p. 212). C'hadwick (Transactions of the American (iyna'co-
logical Society, vol. ii, 18TT), Lamier and Testut {op, ci7., vol. iv, p. 211)
have all practically verified Xelaton's statement. There are also similar
aggregations above and below this point (Fig. 20). It is generally con-
ceded that these aggregations of circular fibers occur at the base of Hous-
ton's valves, and that the muscular fibers extend into the la vers of these
valves. O'Beirne (Xew Views of the Process of Defecation, Dublin,
183:5) descril)ed the aggregation found at the juncture of the sigmoid
and rectum as the third sphincter, and attributed to it a most important
role in the act of defecation. Dissection has demonstrated the existence
of an aggregation of circular fibers on the concave surface of the gut at
this point, the fibers of which spread out upon the sides and convexity
(Fig. 19). It is claimed that the action of such a muscle will constrict
the gut at the point where the fibers are concentrated, and this muscular
constriction can be easily demonstrated through the modern proctoscope.

EMBRYOLOGY, ANATOMY, AND PHYSIOLOGY

If rom the casta made of the rectum and microscopic esamioation of the
tintestinal walls, it has been shown that there exist at every flexure of
Ithe rectum and colon an aggregation of circular fibers proportionate to
I the acuteness of the flexure ; that in the rectum these aggregations are
f situated opposite the insertion of the valves of Houston, and, finally,
I the chief aftgregations occur about 3 inches above the margin of the
■mis and at the junction of the rcc-
tnm and sigmoid. Assuming that
a perfect ring of aggregated circu-
j lar fibers is necessary to the forma-
I tion of a sphincter, it must be ad-
llDitted that there is no anatomical
f conforruation above the internal
■ aphincter to which tliis term can
' be applied. On the other hand, if
sider the semicircular aggre-
JgatioHE as sphincters, one must ad-
Kinit not only a third but a fourth.
* flfth, and even more sphincters.
Such a nomenclature would be con-
fusing, and therefore these aggre-
j^HgatioDS should be called the semi-
^^■circular muscles of the rectum,
^^Hand the term third sphincter
^^VahouKI be discarded.
^H LongUwiinal Museular Layer.—
^^P Outside of the circular fibers is the
longitudinal muscular layer of the
rectum. This layer is a continua-
tion of the three longitudinal mus-
cular bands of the colon which coalesce at the juncture of the rectum
and Higmoid, and spread out. forming a distinct coat around the rectum,
, somewhat thicker in front and behind than upon the sides. This layer
^^■iB divided by anatomists into external, middle, and internal portions.
^^H The external fibers pass downward and are inserted into the superior
^^Hpelvic fascia covering the upper surface of the levator ani muscle. The
^^pniddlc fibers mingle with those of the levator ani, and are attached with
^Htfaem 10 the rectal wall. The internal fibers pass downward, together
^Viritb some fibers from the levator ani between the two sphincters, and
ire inserted in the superficial fascia surrounding the anus. Goodsall
and Miles state that these fibers can be seen to pass between the deep
and superficial layers of the external sphincter muscle. The arrange-
t of these fibers in the upper portion of the rectum is very irregular,

THE ANUS, BBCTtDI, AND PELVIC COLON

as will be seen from the illustration {Fig. 21) taken from Lamler.
Sometimes they dip into the flexures of the gut, and at others thej pass
over the same.

Outside of the longitudinal muscular layer
in the lower portion of the reetum the walls
are ruenforced by the fibers of the levator ani
muscle.

SeroDB Coat. — Beginning at the lower
point of the pclvie peritoneal cul-de-sac, the
peritomeuni covers the anterior surface of the
rectum, and, pa.ssing upward and backward
in an oblique line, finallv invests the entire
cirt'uraferonce of the organ at about the level
of the third sacral vertebra. As this coat
passes upward it is reflected externally upon
the sides of the pelvis, thus forming the lat-
eral supports of the rectum (Fig, 22), At
the level of the third sacral vertebra the two
folds of peritonaeum imite posteriorly to
form the pelvic mesocolon or mesorectum.
Anteriorly the serous coat is reflected ujwn
the bladder in males and the utenis in fe-
iHiml libera luales.thus fonuing the recto-vesieal or Doug-
las's eul-ile-sac. These culs-de-sar contain the
sigmoid flexure, loops of small intestine, and
sometimes tlie ciecum, vermiform appendix,
and the ovaries. The depth to which they
extend upon the anierior surface of the rec-
tum varies in individuals and under different
circumstances. With the bladder and rectum empty, they extend to
within a centimeters of the margin of the anus; but when these organs
are distended this distance may be increased to 9 or even 12 centimeters
(4J inches). Tlicy are about 1 to 2 eentimetcrs nearer the anal mar-
gin in women than in men. In cases of procidentia with rectal hernia,
or where the perinauini has boon injured during childbirth, the cuU-de-
sar sometimes approach verj- near the perineal surface. In one case
the cvl-de-sac was 8ei)arate<l from the pcrinfeTim by only the thickness
of the external sphincter muscle. These variations are rendered im-
portant by the fact that the cvk-fle-sar, when extending abnormally low,
may be easily penetrated in operations upon the anterior wall of the
rectum.

Columns of Morgagni, PiUars of Glisson, Columns of thf Rectum.
— The mucous membrane at the lower end of the rectum is gathered

RmcTiiM (Lmiiior).
a,i,cd, (tmovoB of recUl cylin-

iritudliiiil hand nrifiu); lii purt
from oirculur filjcre; Ip. foo-
hhapoii 1>audd aiiauig front
both rnuM'Ular lurcn; y, fw<.
ciculiu KpliltinK ntf (mm Idd-
gitudinal bundle. (. ('.

EMBBTOLOGT, ANATOMY. AKD PflYSIOLOGT

[ iogether into longitudinal folds designated by the above names. They
; rendered more prominent by the eontraetion of the sphincter, and
I obliterated b}' dilatation of the canal. The base of each column joins
[ irith the dentate margin, forming the upper limit of the anus, and is
I continuous at its outer angle with the adjacent semilunar valve. The
\ top of the column gradually spreads and loses itself In the smooth mu-

A, B, superior pelvl-rcclul aprncan : C, D, Uuhlo-rectRl fanex.

i membrane of the rectal wall. They vary in number from five to

reive, and measure from base to apex 10 to 12 niilliineters (about J

a inch) (Fig. 7). They are composed of raucous and submucous tissue,

md contain, according to Treitz, some muscular fibers which act in

brcrcoming the eversion which takes place at the time of defecation.

The grooves between these columns gradually deepen from above

bDwnward, and end in the semilunar valves. Testut (op. cit., vol. iv, p.

2^) slates that in these grooves are found irregular elevations caused

f dilatation of the subjacent veins.

Semilunar Valve*, Crypts of Morgagtii, Anal Pockets. — The rectal

nncous membrane ends below in an irregular festooned border com-

»sed of small folds stretched across from the base of one rectal column

24 THE ANUS, RECTUM, AND PELVIC COLON

to another, their concavity being directed upward. The upper border
of these folds comprises the so-called ano-rectal line. Behind these folds
the membrane dips down and forms little pouches of variable depths,
which are called the crjpts of Morgagni or anal pockets. The folds
themselves are termed the semilunar valves of the rectum. The epi-
thelium covering these folds gradually changes from the stratified poly-
hedral form to the typical columnar epithelium of the rectal mucous
membrane. The free borders of the valves are concave, and their ex-
tremities are continuous with the angles of the rectal columns. They
vary in number from five to twelve, as do the rectal columns, and meas-
ure in width from G to \2 millimeters. In depth they measure upon an
average 3 to 5 millimeters. In some cases there is scarcely any depres-
sion, while in others a veritable sinus exists behind the valves (Fig. T, B).
They are said to be deeper and more apparent in early life than in old
age, but they are often quite marked in adults. They are almost in-
variably absent at the anterior and posterior commissures of the rectum,
but there is generally a well-developed crypt upon each side of these
points. Those in the anterior circumference are less accentuated than
those situated posteriorly. This fact has Ixvu utilized by Ball to ex-
plain why fissures occur so much more frequently just to one side
of the posterior anal commissure than at any other point. Occasion-
ally small masses of faecal matter or foreign bodies are arrested in these
little pockets and produce much local and reflex irritation; such acci-
dents are comparatively rare, although certain irregular practitioners
have made great capital out of them, and ascribe almost every dis-
ease of the intestinal canal to these pockets. The function of these
valves is practically unknown. They have been considered as reservoirs
for the mucus or lubricating material of the rectum, but frequent ex-
aminations at periods remote from defecation have failed to demon-
strate any accumulation of mucus in them. Moreover, their epithelial
lining contains no mucus-producing cells, which indicates they do not
secrete the material. They are best seen in the living subject by the use
of a conical fenestrated speculum, into which is introduced a small lar-
yngeal mirror. On the margin of these valves are seen the small papillae
which have been described in connection w4th the anal canal.

The Valves of Houston or the Rectal Valves. — The mucous mem-
brane of the rectum above the crypts of Morgagni is thrown into irregu-
lar horizontal folds, most of which entirely disappear when the organ is
distended. At three or four points in the organ, however, these folds
become more prominent when the gut is distended, and extend out into
its cavitv in a crescentic form.

Houston (Dublin Hospital Reports, 1830, vol. v, p. 158) first de-
scribed these folds as valves of the rectum. They vary in number from

EMBBYOLOGY, ANATOMY, AND PHYyiOLOGY

e to five. Ordinarily there are three, termed the superior, the middle,

il inferior valves of the rectum. The middle one is the most constant.

s from the right anterior quadrant of the rectal wall about 6 to 0

mtimeters {23 inches to 3^ inches) above the margin of the anuB.

jCoblrauscb described this fold ua the "plica transvcrsalis recti," but

e is no occasion to confuse the reader by introducing any new nomen-

ire. j\s Testut says, the name originally applied to them by Iloua-

" is rendered sacred by long usage," Aa described by Kohlrausch,

E5tut, Otis, and others, this middle valve varies in height according to

e depth of the peritoneal rul-de-sac, being always just below ihe latter.

The inferior valve is located upon the left posterior quadrant 25 to

0 millimeters (1 to 1^ inclies) above the margin of the anos, and the su-
wrior valve is located

1 the same quadrant,
iightly more to the

^wde. at 0 to 11 centi-
meters {3i to4t incli-
es)above the anus(Fig.
1 23), At the juncture
f the rectum with the
mid, opposite the
bird sacra! vertebra,
P^ere is always a ivell-
Ideveloped fold or valve
f which more nearly oc-
[■cludes the caliber of
I the organ than either
J Of the others. This
Italve was originally
^iescribed by O'Beime,
who attributed to it
the function of main-
taining the fsBcal mass
I in the sigmoid flexure
mtil just before the
■criBis nf defecation,
fit is situated some-
lirhat anterior, and to
l.tiie right or left side,
lACcording to the di-

yrection of the flexure of the sigmoid upon the rectum. It is more
arkcd in those cases in which this flexure is acute, and in such cases
I'Obscnres any view of the sigmoid through the rectum.

26 THE ANUS, RECTUM, AND PELVIC COLON

The rectal valves protrude into the cavity of the organ to variouR
extents. They are attached to the wall of the gut from one-third to
one-half of its circumference; they are crescentic in shape, and present
for consideration two surfaces, a free border, a base, and a central body.
The superior surface of each valve appears as a smooth, inclined plane,
slightly depressed in its center. In abnormal conditions this depression
may become quite marked and capable of retaining fseeal ^r foreign
substances. The inferior surface of the valve corresponds to the supe-
rior, being more or less convex, according to the concavity of the latter,
and is se])a rated from it ])y the mucous membrane and tissues which com*
pose the ])ody of the valve. The free bonlers of the valves are crescentic
in sha])e, clearly defined, and directed toward the cavity of the rectum.
In the normal condition they are usually thin, flexible, and easily pushed
aside. Owing to the arrangement of the valves at diflTerent levels, these
edges overla]>])ing give to the rectum, when dilated and viewed through
the proctosco])e, an a])])earanc(» somewhat like a turbine wheel (Fig. 24).
The bases of the valves where they join the rectal wall are convex, and
considerably thicker than the free border; they are ordinarily opposite
one of the grooves in the external rectal wall, as shown in the casts, but
this arrangement is not invariable. Their attachment to the rectal wall
is not u])on a horizontal plane, but slightly higher on one side than on
the other, thus furnishing a sort of inclined plane, which contributes to
the easy passage of the fan-al material over them. As Houston stated
in his original paper, the valves consist of two folds of mucous mem-
brane separated hy cellular tissue and muscular fibers. The mucous
membrane covering them differs in no wise from that covering the rest
of the rectum in normal conditions. The structures composing the
bodv of the valves hetween the lavers of mucous membrane have been
minutely described by Martin (Philadel])hia Medical Journal, 1899),
Pennington (Journal of the American Medical Association, Decem-
ber, 1900), and more recently by Testut (Traite d'anatomie humaine,
1901).

Martin claims to be the first to have discovered fibrous tissue
in the valves, and has based an elaborate theor}' of constipation upon
their abnormalities. Pennington removed a large number of recta from
children and adults indiscriminatelv, and submitted them to Prof. Wil-
liam A. Evans for examination. The latter demonstrated the presence
of these valves in each individual case ; he located the most prominent
one just below the level of the peritoneal cul-de-sac, and the next most
prominent, ''that which contracted the caliber of the gut chiefly" at
the juncture of the rectum and the sigmoid, just as we have described
above. The muscularis mucosa was found to be more prominent in the
valves than elsewhere ; the submucosa was composed of loosely arranged

KMBHYOLOGY, ANATOMY, AND PnTSlOLOOY

[onnective tissup, quite vascular, devoid of iymph elements, and almost
wiw as thick as elsewhere in the rectal wall. The circular muscular
Mt vas found to dip well into the valves, and measured from two to

foiir times as thick here as elsewhere. The longitudinal muscular fibers
were found to bo very irregular in their behavior, sometimes passing

28 THE ANUS, EECTUM, AND PELVIC COLON

OYor tbo depressions formed by the entrance of the circular ULers inti
valves, and sometimes dipping into these grooves. This is in harr
with the observationB of Laiiiier referred to in describing the h
tudinal muscular coat of the rectum.

Evans describes numerous unusual conditions and abnormal dev(
ments in the valves. While these minute studies of the anatomical ai
tiire are interesting, they have no practical value for the surgeon bej
confinning the statements of Houston that the structures are not sir
mucous folds, but true valves conijio.sed of mucous membrane, cell
and fibrous tissue, and possessed of circular muscular fibers. It
singular fact that in none of
examinations thus far made ha
been shoivn that the peritona
dipped into the groove at the 1
of the valve. The illustration ('
25) shows the extent to which tl
vtilvea may develop, together w
their oblique attachment to the i
tal wall.

The function of tliese valvei
to support the fwcal mass in
passage througSi the rectal ear
and, being so arranged as to presi
to the mass an inclined plane pfl
ing circularly around the rectu
they impart to it a rotary or coi
screw motion by which it is dep-
iled from one valve upon the upj
surface of the valve below un
it reaches the anus. Martin a
Pennington have experimented
introducing lubricated cotton -ba
into the sigmoid flexure, and ha
observed their passage downwa
through the rectum by the aid ■
the proctoscope. They state th:
the balls slip from the sigmoid into the rectum and lodge again
the first valve; they are then carried by a rotary motion downwai
and forward to the middle valve, and then by the same motion th(
are deposited posteriorly upon the lower valve, and finally from th:
valve upon the internal sphincter or into the mouth of the instrumei
through which they were observed during the process. Thus, appai
ently, gross and microscopical anatomy and clinical observations all ten

EMBETOLOGT, AXATOMT, AND PnYSIOLOGY

» confirm more and more Houston's original claims as to the existence
] tunctioiiii iif these valves.
VaBcnlar Supply. — Arteries. — The rectum receives its blood supply
mm four sources ; the superior, middle, and inferior hiemorrhoidal, and
e middle sacrul arteries.

The superior hcfmorrhoidal artery is the temiinnl division of the in-
rior mesi-nlcric which has its origin in the aorta just below the nephritic
artery. It descends in front and slightly outside of the right internal
iliac, and is embedded in the two folds of the mesentery. At about the
k'vel of the pnimontory of the suerum it gives off the sigmoidal artery
(Fig. 2i'-} whiLh supplies the lower portion of the sigmoid; it passes

Fib. SB.— IxrHBiuR Uebentuuo

O of lutUT to tllO

witli Dilddlo tueniorrhoida] nrlery.

mward between the folds of the mesoroctum, and divides about the

il of the second piece of the sacrum into two, sometimes three divi-

I, which pass, one upon the right and one upon the left side of the

; the left branch is distributed to that aide and to the anterior

(face of tile gut, the right branch is distributed to the right side and

DRterior surface of the gut, About 4^ inches above the margin of the

a these vessels penetrate the muscular wall of the gut, after which

J diride into numerous branches, and descend to the lower limits of

i rectuin, where they terminate. The trunks of the vessels run more

B parallel with the long axis of the gut, and their capillary divi-

30 THE ANUS, RECTUM, AND PELVIC COLON

sioiis pass around the intostine, frwiy anastomosing with one another.
Tlu'V also anastomose witli branches from the middle ha»morrhoidal and
middle sacral arteries.

The middle Juvmorrhoidal artery is extremely variable in its origin.
It generally arises from the hypogastric artery, but may arise from the
internal iliac or the prostatic. Jt is situated above the levator ani mus-
cle, and passes through the superior jHilvi-rectal spaces, distributing some
branches to the anterior surface of the rectum, to the seminal vesicles
and prostate in men, and to the vagina in women. It supplies the leva-
tor ani muscle, and furnishes a distinct anastomotic circulation with the
superior lucmorrhoidal artery, which in cases of injury to the latter ves-
sel would afford an adecpiatc circulation to the lower end of the rectum.

The inferior h(nnurrhoidul artery arises from the internal pudic and
crosses the ischio-rcctal fossii obliquely from the posterior poriion of
its outer wall; it divides into a number of branches which supply the
lower j)()rtion of the levator ani, the external and internal sphincters,
the skin, and su])erficial fascia around the anus. The branches of one
side anastomose with those of the other, and with branches of the mid-
dle luemorrhoidal artery. They also anastomose in a very mild degree
with the lowest branches of the superior luemorrhoidal artery.

The middle sdvnd nrlerif arises from the posterior portion of the
aortn at its bifurcation, and descends along the middle line in front
of the sacrum, terminating in a minute branch which supplies the gland
of Luschka; it gives oif branches which pass through the cellular tissue
to supj)l\ the posterior surface of the rectum. Its branches anastomose
with the branches of the superior luemorrhoidal and the lateral sacral
arteries.

Veins. — The veins of the rectum correspond in name and course to
the arteries, but they return the blood through two entirely different
channels — viz., the portal vein and the inferior vena cava. The internal
or superior liaMuorrhoidal veins collect the blood from the rectum proper
and empty it through the mesenteric vein into the portal circulation.
The middle and external hannorrhoidal veins (Fig. 27) and the middle
sacral veins collect the blood from the external surfaces of the rectum
and anus and empty it into the general circulation through the vena
cava. The internal ha?morrhoidal plexus forms the venous supply of the
rectum proper. The a no-rectal line marks the beginning of these veins
above and the external veins below. This line, as Otis has happily said,
provides a sort of watershed hetween the two circulations of such low
altitude that under certain conditions it does not interpose a sufficient
barrier to prevent an intermingling of the two streams. The two sys-
tems are connected at this point through anastomotic branches which
are so narrow in early life as to be almost imperceptible.

EMBRTOLOQY, AKATOMY, AND PHYSIOLOGY

Cripps {op.cit., p. 2fi) ya.vs he hns tie in onst rated thiit the interna]
emoirfaiiidRl plexus can not be injected through the iline veins, but
1 be injected tlirough the inferior mcBenteric vein, nnd the blood
rill not pass on into the external veinK, so Ihnt if anv cumTnunicatinn
Exists between the two systems it mu'^l hr p\-i>u-i-\rA liv valvis, (Jueiii;
lod Tcstut have both
lemonst rated the ox-
of valvea in
pliese anastflmotie
i in the adult, and
has in part con-nlm.

the

veir

■I «M

■ipps, but thev suii''
inferior hivin-
'hoidal plexus can
Injected thrnnfrh
the inferior mescni. rii
veins. The autln'r li:i.-
lemonfitrated the fan
,t the external plox-
can be injected fnmi
inferior niesi>ii-
tcric veins in old siili-
jeets who have autlLTi'd
from constipation and
iiii-mnrrhoidAl disease.
Indeed, the communi-
cation between these
^tcans is often
tpartmt to the naked
ejre in operations upon
ntixed hiemorrhoids, and it is no longer ncecssary in the light of siieh
positive facts to further discuss this question of anastomosis.

Just above the uno-roctul line in the submucous tissue there are
s small venous sacs or pools (Fip. 28), bulbous or elliptical in
', and each about the size of a grain of whent. These little pools
FDund the rectum, some at a liigher and some at n lower level, nnd
ractically form the beginning of the internal ha'morrhoida! plexus.
teret (Archiv. g^n. de niM., December, 1879 and 1885) states that
luae little pools are arranged like clusters of grapes in the columns
f Morgagni. The dissection made by the writer, however, shows that
ley entia'ly surround the rectum, and are not particularly aggrcf^ated
a the columns. From these pools the small veins proceed in all direc-

THB ANUS. RECTUM. AND PELVIC COhOS

tions to form an intricate network of vosbcIs surrounding the rectum.
Above the margin of tlie internal sphineter they unite to form larger t
trunks, which approach the arteries, and wilh them penetrate the mu»- ]

cnhir wall of the put : the venous trunks unite above this point to font

I LOWIK ESD OK RkoTIU (1'aI

■liicli iuluniul liu.-uiorrlioiJnl plui

Lthe inferior mesenteric vein which empties into the portal circulation.
These veins are without valves.
Vemeuil has advanceil the ingenious theory that the contraction
of the longitudinal muscular fibers, at the points where the vessels per-
forate the rectal wall, serves to sugply the place of tlie valves, and inci-

EMBRYOLOGY, ANATOMY, AND PHYSIOLOGY 33

dentally ho claims that the spasms of these muscles, causing obstruction
in the veins, have a potent influence in the production of internal haemor-
rhoids. It is impossible to confirm or deny this theory, as the facts are
not demonstrable.

The middle haemorrhoidal veins arise from the anterior surface of
the rectum above the levator ani muscle, the seminal vesicleg and the
prostate in men, and the vaginal wall in women. The capillaries unite
into larger trunks and follow the course of the arteries through the
pelvi-rectal spaces, and empty sometimes into the hypogastric and some-
times into the ischiatic veins, but always finally into the general circula-
tion through the vena cava.

The external haemorrhoidal veins originate in the small anastomotic
capillaries in the anal canal ; they become more or less dilated as they
pa.*is outward over the border of the external sphincter, but immediately
narrow down and unite with the subcutaneous capillaries of this region
to form trunks which empty into the external pudic vein, through which
they are connected with the general circulation.

The Nerve Supply of the Anns and Rectum. — The anus and rectum
receive their nerve supply both from the great sympathetic and cerebro-
spinal systems. The rectum proper is largely supplied by the sympa-
thetic system ; it receives branches from the mesenteric, sacral, and
hypogastric plexuses. It also receives filaments from the third, fourth,
and fifth sacral nerves. The nmcous membrane of the rectum becomes
less and less sensitive from below upward, thus indicating the absence
of sensitive fibers in this portion of the gut, a fact which has been cor-
roborated by microscopic and anatomical research.

The nerve supply of the muscular apparatus of the anus and rectum
arises from the intricate plexuses formed by the second, third, fourth,
and fifth sacral nerves (Fig. 29). The filaments from these nerves
unite, separate, and reunite so often that it is impossible to determine
the exact origin of any of the final trunks of distribution. According
to Morestin, Langley, Anderson, and Testut, the levator ani receives its
three filaments from the third and fourth sacral nerves. The first two
filaments are distributed, one to the posterior or ischio-coccvgeal por-
tion, and the other to the anterior or levator ani proper; the third fila-
nH*nt passes beneath the muscle and gives off branches to its lower sur-
fa(t\ and ])asses onward to supply some small filaments to the superficial
surface of the external s])hincter.

The external sphincter muscle receives its nerve supply from three
sounds : two filaments from the branches formed by the third, fourth,
and fifth sacral nerves extend transverselv across the ischio-rectal fossa,
and distribute themselves to the middle portion of the muscle and
to the perianal cutaneous surfaces; a filament which comes off from the
3

THB ANUS, RBCTUH, A^l

internnl |iLi(]ic, just before its division into terminal branches, sup-

■ pliea the anterior portion of the muscle, and is called the anterior

■ sphinclrrian nerve; while a filament coming off from the fifth and
H Bixtb sacral nerves passes down into the hollow of the eaerinn lietween
W the levator ani muscle and the recto- coecygeus ligament, and finally
B reaches the posterior

siijierficial surface of
the external sphincter.
Morei^Iin calls this the
lesser sphincterian
nerve. j\ll these fila-
ments posse.s^ both
sensitive and motor
fibers, and with them
are distributed fila-
ments of the sympa-
thetic nerve. The cen-
tral origin of the nerve
supply of the anuB and
rectum is said to be
locateil alwiit the level
of the first lumbar ver-
tebra. This center is
practically the same as
that of the genito-uri-
nary apparatus, which
fact accounts in a lai^
measure for the vari-
ous reflexes between
the two systems. The
Fin. ay.— MriHAL Nkbvks "f t»e iih ti u asi, Am's. inhibitory center of
this nerve supply ia
situated iu the brain, but the exact location is unknown.

Lymphatics of the Anns and Rectmn.^Tiic lym])hatics of tlio anus
and rectum are very difficult to demonstrate by dissection. Occasionally
cases have been found in which the vessels and glands have become in-
flamed and thickenc'l, and thus the seat and course of these particular
vessels have been traced. Quenu (Bull, de la Soei^t^ anatomic, Paris,
1893, p. .3!)9) has shown that these organs are supplied with three sets of
lymphatics practically corresponding to the arterial supply. The sacral
or superior plexxis of the lymphatics originates in the submucous and mu-
cous portions of the middle and upper rectum posteriorly. They follow
the course of the vessels, the lympliatic ganglia lying in close a

e apposition J

^H^ EMBRYOLOGY, ANATOMY, AND PHYSIOLOGY 35 H

^^I'lrith the ha'morriioiiijil vpins. Betwei^n tho rw-funi anil tlio anterio

^^p Burfaoes of the sacrum and coccyx is found ii chain of lymiiliatics which |

^^1 exteDds upward in tho

^^H,celtular tissue boUteon
^Vthe folds of Ihc 1.1,'.-

^^^BC^H^^

^^Kenten-, and tluis

3B(«iw / ^MBl^ "1 1 -,^

^^Bcoanected with ilic

^^B^^S 1 ffiT^^t. *^r

^^■prevertebral lymphat-

^^^^^1 jirt ^ Y

^^Bic ^^'stetn.

.J^^^^^d^^ \ MM

^H The middle ha-ni-

^^^^K^B^' M^ f

^^Hbrrhoidal vessels are

^^^^^Bp' J^ /

^ ^HHKfK-A /

^^B chain of lymphatics

Hk ^^^^^R^h/n -^f

^^H vhit-h follows their

J-^-^S^m^ -^

^^B course and ends in the

i/7 ^^BK*^"^ \

^^B 1)r[ingiistric lymphatic

^^B plexiis. These lym-

^^B phatic« originate in

■

^^^tfie anterior portion p,,, ^^

— LtMPiiATicis 01 An*l ash Pkhianal Heoii-k,

^^Btif tbf- rectum, and.

■

^^Lttfising outward above the levator ani muBCle between the rectum and

■

^^Blfr*?fWW« M ^ °^B and along the circular vaginal veins in the

^ — ^'

Quenu says it appears

from his dissections

^M .^^^^M

that the middle por

^B / _^^^H

tion of the rectum ia

connected with the

^^^^ta^^^hj^^^^^^^^H

lymphatics of bull

^^^^^^^^^^^^^^^^^r^^^l

the sacral and hyi>o

^^^^^^pP '^^^

gastric plexuses.

^^^^^^^Rflk

The lynipliatics o

^^^^^^Ha^

the anal and periaua

^^TgJ^^B^B^^ -^

region ar^ very nu

j/: ^^^^^^V^^^

merous. They ni-e

^' ^^^^B ' J m.

connected by anasto

^^^K X .^^

iiiotic branches wit!

l^^BBi^^^

the lower lymphatic

of the rectum. Theydo
not follow the course

^_^

r... ... >,...-,,. t„^S..I,.« KEI.t^S I'.K,.^... AN..

^^^H of the externiil ha'mor

^^Btioidal veins very closely, bnt ramify beneath the skin, the chief branche

^^B|)a^Gio? forward and iijward between the scrotum and the thigh, an(

^H^^^k

36 THE ANUS, RECTUM, AND PELVIC COLON

finally unite with the inguinal lymphatics (Figs. 30, 31). It has not been
demonstrated whether or not this chain is directly connected with the
inferior chain of the lymphatics below Poupart's ligament. The im-
portance of the lymphatic system about the anus and rectum will be
appreciated when we come to study the subject of infectious and malig-
nant diseases of these organs. Clinical experience corroborates the ana
tomical studies of Deaver, Quenu, and Moreau (Bull, de la Societe de
biologic, 1894, p. S12) with regard to the origin and distribution of the
lymphatic system.

Retro-rectal and Superior Pelvi-rectal Spaces. — To comprehend the
relations of the rectum one must thoroughly understand the cellular
spaces surrounding it. That jmrtion of the organ below the peritoneal
attachment and above the levator ani is surrounded in its entire course
by a cellulo-fibrous layer, in which ramify the blood-vessels, nerves, and
lymphatics before they penetrate the walls of the organ. This layer
fonns a complete sheath to the rectum, and extends from the perito-
neal fold down to the 8uj)erior surface of the levator ani muscle. It is
longer behind than in front. The fibrous portion of this sheath is out-
side of the cellular, and originates in the fascia* lining the true pelvis;
it passes off from the pelvis in a double layer at the points where the
lateral sacral arteries diverge, and the inner layer attaches itself more
or less firmlv to the sides of the rectum at about the middle of its cir-
cumference. These folds represent the lateral ligaments of the pelvic
rectum, as described bv Jonnesco and Ombredanne, and are the chief
supports of this portion of the organ. The outer layer of this fascia
proceeds along the border of the sacrum and is attached to this bone.
Between these layers posteriorly, separating the rectum from the sacrum,
is a comparatively thick eel lulo- vascular area which extends to the su-
perior fascia of the levator ani below, and upward between the layers
of the mesorectum, thus becoming continuous with the prevertebral
cellular layer of the abdominal cavity (Fig. 32). This cellular space is
termed the retro-rectal space, and has been compared by Ombredanne to
the prevesical space of Retzius.

Anteriorly the rectum is also surrounded by a cellular space above
the levator ani muscles, which is separated from the retro-rectal space
by the latero- rectal ligaments which we have just described. This space
separates the rectum from the bladder, prostate, and seminal vesicles in
men, and from the broad ligaments and uterus in women. It is bounded
in front by the prostato-peritoneal aponeurosis, which contains a cer-
tain number of muscular fillers. This aponeurosis is closely attached to
the prostate, passes loosely over the seminal vesicles backward, and is
attached to the sides of the rectum along with the latero-rectal liga-
ments. It is also attached to the anterior wall of the rectum, thus divid-

BMBEYOLOGY, ANATOMY. AND PHYSIOLOGY 37

ing this anterior cellular space iuto two portions. The spnces thus

formed are more closely connected with the genito-urinary apparatus

than with the rectum, although they form the anterior boundary to the

Utter oi;gan. They

are knoHHi as the su- [<*; *

perior pelvi - rectal

spaces (Fig. 22). It is

in them that abscesses

originating In the

prostate, seoiinat veei-

eles, uterus, and broiid

ligament often devcl-
It is not prt'tend-
[ ed that the division
] between the retro-
' rectal and pelvi-rectal

8pac«s is BO firm that

it can not be bmk>'n
I do»'n, or that abseess-
) developing In one
[ may not penetrate the
I other. Aa a rule, how-
lever, those developing
I .in the retro-rectal
Kipace trill burst iuto
I the tsehio-rcetal fossa
F or burrow out through

the obturator foi'amen

before they invade

the anterior spaces; and those developing in the superior pelvi-rectal
[ ^wces will burrow upward and forward, often opening in the inguinal
I legion or through the abdominal wall before they invade the retro-rectal
I space. Tliese spaces are separated from the i sol lio- rectal foBste by the
P levator ani muscle and its limiting fasciif. The ischio-rectal fosea>
r which surround the anna and lower portion of the rectum have been
Ideecribed in the preceding pages.

The Selationi of the Bectnm. — The rectum is in relation at its dif-
I ierent levels with the various organs and tissues of the pelvic cavity.
^ The lower or prostatic portion is in relation anteriorly with the prostate
i membranous urethra in men, and in womun with the vaginal wall,
if rectum turns backward at its lower end, and the uro-gonital or-
a forward, the space left between the two comprises the uro-gcnital
B or perineal body. I^aterally this lower portion of the rectum

I
I

EMBRYOLOGY, ANATOMY, AND PHYSIOLOGY 39

part of the organ also receives a certain amount of support from the infe-
rior mesenteric arteries and the fibrous sheaths which surround them.

The Sigmoid Flexure or Pelvic Colon. — This loop of the large intes-
tine, termed also the omega loop, and by French writers the pelvic
colon, begins above at the termination of the descending colon near the
outer border of the left psoas muscle, and comprises all that portion
of the intestinal canal between this point and the upper termination of
the rectum opposite the third sacral vertebra.

As ordinarily measured in situ, it is about 19 inches in length, but
when removed from the body and stretched out upon its mesentery this
length is considerably increased.

It originates in the left iliac fossa, passes downward for 2 inches
parallel to the external border of the psoas muscle; it then crosses
transversely to pass into the pelvic cavity, which it occupies for the
greater portion of its extent; passing across this cavity from left to
right, and slightly upward, it reaches the lower margin of the right iliac
fussa ; from this point it passes downward, backward, and inward along
the anterior surface of the sacrum to its junction with the rectum. It is
attached to the posterior wall of the abdomen and pelvis by a peritoneal
fold called the mesosigmoid, which is continuous with the mesocolon, but
is much longer than the latter, thus giving the sigmoid greater mobility
than any other portion of the large intestine. This mobility explains the
great variation in its situation, direction, and relations, as described by
ditferent authors.

The sigmoid is divided into four portions : The first portion is verti-
cal ; the second is transverse; the third forms a long loop with its con-
cavity directed upward when the sigmoid occupies the pelvis, and down-
ward when it is lifted up into the abdomen; the fourth is irregularly
curved, and descends into the hollow of the sacrum, downward, backward,
and inward.

From this description it will appear that the sigmoid joins the rec-
tum from the right side of the pelvis instead of the left, as is held by
most authors. For a long time the author has taught and demonstrated
the fact that the intestine at the juncture of the rectum and sigmoid
turns to the right quite as frequently as to the left. The anatomical and
clinical studies of Testut, Schifferdecker, Jonnesco, Treves, and others
prove that this is in reality the most frequent disposition.

The walls of the sigmoid are composed of four layers, the mucous,
submucous, muscular, and serous.

The Mucous and Submucous Layers. — The mucous and submucous
layers differ in no wise from those of the rectum, except that the solitary
follicles are less frequent, and the membrane in its entirety is not quite
so thick as in the lower organ.

40 THE ANUS, RECTUM, AND PELVIC COLON

The Muscular Layer, — The muscular layer consists of circular and
longitudinal fibers. The circular fibers are distributed around the sig-
moid much more etjuably than around the rectum. While there are cer-
tain points or flcAurtvs in the gut where aggregations of these fibers take
place uj)on one side, these aggregations never c»ompletely surround the
gut, nor are they ever so marked as to produce any idea of a sphincter
muscle.

The longitudinal libers, arranged at first in three bands as in the de-
scending colon, gradually assume the form of an anterior and a posterior
band, which spread out as they approach the recto-signioidal juncture,
and form a more or loss complete layer around the gut.

Serous L(ii/rr. — The perit(meal layer of the sigmoid flexure surrounds
the gut .similarly to that of the small intestine, and its folds, coming in
contact with each other posteriorly, form the mesosigmoid or ilio-pelvic
mesocolon. This mesentery is quite short in its iliac portion, but rapidly
becomes longer, reaching its maximum about the middle portion of the
l)elvic loop, where it again grows shorter, and finally terminates at the
juncture of the sigmoid with the rectum. The lower portion of this
mesenterv, as alreadv stated, is called the mesorectum.

The line of insertion of the mesosigmoid into the pelvic and abdom-
inal walls may be descrilx'd as follows: Beginning above at the exter-
nal border of the psoas (P'ig. 33), it follows this line downwanl to a
point about 2 to 3 centimeters (J to 1^^ inch) above the crural arch;
here it crosses the ])soas muscle from left to right, and turning upon
itself follows the internal border of the muscle upward and inward as
high as the fifth or fourth lumbar vertebne, where it again bends down-
ward and inward, crossing the right common iliac arterv% and reaches the
median line on a level with the sacro- vertebral juncture. From this
point it descends in the median line as far as the third sacral vertebra,
where it ends. Sometimes the attachment of the mesosigmoid extends
across the middle line, passing over the fifth lumbar vertebra almost to
the internal border of the right psoas muscle, and then turns downward
and inward, following the anterior surface of the sacrum to the begin-
ning of the rectum. Between the two layers of this fold there is a thin,
cellular layer, through which the blood-vessels, nerves, and lymphatics
of the intestine pass.

In a certain number of cases the mesosigmoid, after turning down-
ward at the lumbosacral juncture, passes toward the left until it reaches
the sacro-ischiatic symphysis, and then turns backward toward the
median line of the sacrum. It is this distribution which led to the first
descriptions of the rectum as beginning at this point. Such an ar-
rangement, however, is far from being the most frequent one.

Intersigmoid Foi(sa, — When the sigmoid is turned upward one sees

EMBRYOLOGY, ANATOMY, AND PHYSIOLOUV

t the point nliere the mesogigmoid crosses the iliac artery a circular

rifice, lU to 15 millimeters in diameter, which leads into a funnel-shapi'd

\l-de-sae called the intersigmoid fossa (Fig. 34).

This cul-de-i'tic whs first |iiiint<'d out hv H'-nsinj; and Rnsor. It is

gitiiated at the [Jurifliil iii>rrlinn ui' llu> LUi-nsi^iiinid ami ;i little to the

left of the median line. Its direction is obliqnely upward, and from left
lo right in the line of the iliac artery. Its depth varies from 3 to 6 cen-
timeters (1ft to 2g inches), but occasionally it extends much deeper.
Around this orifice are situated the iliac artery below, and the niesen-
ipric or three Figuinidal arteries above and at the sides. It is an impor-
tant guide, therefore, in pelvic operations to indicate the location of
these vessels.

The sigmoid when empty ordinarily falls down in the recto- vesical
i-pan; or Douglas's cul-de-mc, and occupies the pelvic cavity for the

4i THE ANUS, RECTUM, AND PELVIC COLON

i^n'iittr |M.rti«»n of its extent. Under such cireumstancos it forms an
acute tltxun* at its juncture with the rt^rtum.

\Vh»n ili-^teniliHl with pis or faei-al material it rises up in the abdom-
LUdl v;i\ity a> hi^h as the umbilicus, sometimes to the transverse colon,
i>r ♦n>'n t"» the diaphragm; its distal end being carried across into the
riirht iliac f«»'*.«»a, >t ra ijrhlens t)ut this angle between it and the rectum,
md '.'nKluiVs a ct»mpiiraiively straight channel through the two organs.

Whent-vt-r Ity adhesive Iwnds, tumors, or any other conditions the sig-
m«^:'l •*- i-rt^wnird fn>m rising up in the abdominal cavity, and thus
>tra '.;:::: vr.ini: out this tiexun*, a mechanical difliculty in the passage of
t;i^ ,i! !v,i:t*na! will K* presented : as will Iw seen later on in the chapter
u>^r. r.n<!::^uit»n. this eomlition of affairs is not at all rare.

;^ >*■'; >• — 11^^* sigmoid tlexure reciMves its blood supply from
i\\'. ^.j:r..':.I artrries. branches of the inferior mesent^jric artery; they
run v.rvv;"ar!\ around the gut and anastomose with the colonic arteries
4Nn- ,.r..' :ho sujH'rii>r lueiuorrhoidal arteries below (Fig. 34).

l> \ •.:!- :"«^!l.>w prartieally the same course as the arteries, and empty
x:wr ■ \^^'*x\ :uto the portal circulation through the inferior mesenteric

V\\r arTiTic> «Mitcr tiie mesocolon at the sides of the intersigmoid
••^^-^i, ;;!'..: any injury at tiiis j)oint during oi)erative procedures or
thr-^vu.. :'ro!,»nirrd prc>surt» from uterine tumors mav be followed bv
C^iv^r^ v.r .'f the ^iirnioid.

/"• .V';v< i.f the ^^^/;;/*>l(/. — The nerves of the sigmoid are of the
s\:v.:>a:''.t!iv variity, with the exception of a few fibers of the sensory
:\;h\ \\!;uii are derive*! from the lumbar and saicral plexuses and dis-
:r:^\::is; upon the posterior wall of the gut.

/i *.: Nv o^ the Siipnoid. — Owing to the great mobility of the sig-
V ^ : :*t \un^ its n»lations an» very various. In its upper or iliac portion
:: > :r. n^aiion anteriorly with the abdominal wall, or separated from
:*',*■ ^;»v.'f ^\ loo]^> «^f small intestine. Posteriorly it lies upon the iliac
v:>v'o a^ul fasiia, then upon the psoas muscle and left iliac vessels,
: aV. ;;-.s»n the last lumlmr vertebra, and finally upon the right psoas
v'\>v!o ;r.^'. the anterior surfacv of the sacrum. In its course across the
IX >•> :: :> mi n^lation anteriorly with loops of small intestine, with the
>\u:v:i r '.n men. and with the uterus, ovaries, and fimbriated extremities
of : ^ :v/:vs in women. Adhesions In^tween the latter organs and the
-»;:*" ^\: ATx^ by no means uncommon, and account for a great deal of the
va V. >» ■.■..!-. «iMnen suffer from constipation and intestinal accumulation

*»^ '. r «v.;My the sigmoid lies almost entirely in the pelvic cavity,

A • ' X :*\*T\ fort^ called the pelric colon. Under such circumstances

, ^ V. ?y*At;on anteriorlv and below with the bladder in men, and

EMBBVOLOQY, ANAT0M7, AND PHYSIOLOGY

with the uterus in wonion. Posteriorly it is in relation with the reeliini
aud anterior surface of the sacrum in both sexes. Above it ia in relation
with the loops of the small intestine whith rest upon it.

When the orgim is mui-h distended hy gas or ftecal matter it rises
into the abdominal cavity, ;iiid is thert.' jiracticallj surrouuded by loops

!"'&-

^x^/W

w^I

'«i

^«r

1 :■' -t !■

Vv M

Fin. Bi— ISTEltBCOMOlIJ I
ShoKlDX \c\\ siglDoidDl 111

I of aninll intestine and the abdominal wail ( Eugle, Medieinische Woehen-
I'Khrift. \'iennii, 1857, p. 047; Jacoby, American Journal of Medical Sci-
^caees, 1S7^; and Bouchard, Th^se, Paris, 1863).

Pbynolog;. — The anus, rectum, and sigmoid, while forming a por-
ti «f the alimentary tract, take no part in the processes of digestion.
"be sigmoid and rectum are storehouses for the fiEcal material after the
pof digestion is complete. They are provided with a system of

44 THE ANUS, RECTUM, AND PELVIC COLON

glands or tubules which absorb from the mass whatever fluid or nour-
ishing substances are left in it.

The functions of the anus consist in furnishing an exit for the fiecal
material and in controlling its discharge except at opportune moments.
In normal conditions this exit is wide enough to admit of the passage
of well-formed masses, and capable of closing sufliciently to retain abso-
lutely fluid materials. It is governed bv both voluntary and involuntary
muscles. Normally the aperture is closed, but this closure may be ren-
dered much more linn and resisting by voluntary action when exigencies
recjuire it. The organ relaxes and oj)ens through the inhibition of sphinc-
teri(; contraction ordinarily governed by will-power. It seems to be con-
trolled by two centers: one in the s})inal cord and the other in the brain.

Physical and anatomical experiments and a study of lesions of the
cord show that the reflex center of the anus and rectum is located
in the cord nearly opposite the base of the first lumbar vertebra in the
ver}' tip of the cord or conus medullaris.

The inhibitory center is situated in the brain. Injury to the choi*da
and more ])articularly to the conus is therefore followed by incontinence,
while injury or disease above this region results in constipation.
'* Faeces or air in the rectum excite the lumbar center and cause two
effects — contraction in the wall and relaxation of the sphincter. This
process can be controlled by the will to a considerable extent, although
we are still ignorant of the precise mode in which the voluntary influ-
ence is exerted. But if the volitional path in the cord is interrupted
above the lumbar centers, the will can no longer control the reflex pro-
cesses; as soon as the fteces irritate the rectum they will be expelled by
the reflex mechanism. If the damage to the cord involves the sensory
tract, the patient is unconscious of the action of the bladder or bowel.
If the sensory tract is unaffected, the patient is aware of the process,
but can not control it. It is often said that there is permanent relaxa-
tion of the sphincters, but this is true only when the lumbar centers are
inactive or destroyed. In this condition evacuation occurs as soon as the
urine or faeces enter the bladder or rectum. The urine escapes continu-
ously instead of being expelled at intervals. The condition is less
obvious in the case of the rectum, because there is no such continuous
passage of faeces into the rectum as there is of urine into the bladder.
We may, however, distinguish between the two states of the rectum by
the introduction of the finger. If the lumbar center is inactive, there
is a momentary contraction due to local stimulation of the sphincter,
and then ])ermanent relaxation. If, however, the reflex center and
motor nerves from it are intact, the introduction of the finger is fol-
lowed first by relaxation and then by gentle, firm, tonic contraction '*
(Gowers, Diseases of the Nervous System, vol. i, p. 246).

BMBRYOLOGY. ANATOMY, AND PHYSIOLOGY 45

The functions of the rectum and sigmoid are practically the same.
They are both receptacles or reservoirs for the faecal material after it
has passed through the intestinal canal. The material is softer and more
fluid in the sigmoid than in the rectum ; it is also more constantly pres-
ent in the former. It is not true, however, as is frequently stated, that
the rectum is always empty except just before the period of defecation.
It nearlv alwavs contains more or less faecal matter. The writer has
made many examinations with regard to this fact, and, except in cases of
impaction, he has never found a case in which the rectuin was empty
and the sigmoid well filled with faecal material. They both act as reser-
voirs, and a certain amount of faecal material is always present in them.

The theory and processes of defecation, together with O'Beirne's
doctrine of retro-peristaltic action by which the fivci\\ mass is lifted back
into the sigmoid after it has once entered the rectuin. will all be dis-
cussed in the chapter upon constipation, as they bear directly u])on this
subject. It is sufficient to state here that after a great many ocular ex-
aminations of the rectum and sigmoid, the author has never seen a case
in which the fa?cal matter, having once entered the rectum, has been
lifted back into the sigmoid flexure.

Owing to their glandular apparatus, both the rectum and sigmoid
act as absor])tive and secretive organs. The longer the t\Tcal mass re-
mains in them, the drier will it become through the absorption of its
fluid materials by the Lieberklihn follicles. This absorptive action of
the rectum is nuule use of by physicians for the stimulation or nour-
ishment of patients when feeding by the stomach is ini])racticable. Cer-
tain medicinal substances seem to enter the circulation much more rap-
idly through this route than through the stomach. As examples, we may
mention cocaine, Ix^lladonna, hyoscyamus, and opium. Whether absorp-
tion takes place through the blood-vessels, or through the epithelial cells,
or through the intercellular substance between the individual cells, is
not clear. Cripps (op. cit., p. 16) doubts the existence of the intercel-
lular substances, and says that " it is highly probable absorpticm takes
place through the epithelial cells themselves. Possibly the nuclei of
the columnar epithelium may be the means of taking nourishment into
the l)ody by escaping into the retiform tissue between the glands, and
thus l)ecoming lymphoid cells. According to this view, the columnar
epithelial cells lining the rectal follicles have a far higher function than
that generally assigned to them by physiologists, and instead of being
employed in a simple secretion of mucus, they are in reality the parents
of leucocytes of the body." This theory is interesting, and its author
has produced some microscopic evidence in its favor, but the necessarily
slow processes of such absorption are not in keeping with the rapid entry
into the circulation of certain substances when introduced into the rec-

40 THE ANUS, RECTUM, AND PELVIC COLON

turn. Considt'ring the large capillary and vascular supply of the rectum,
it seems more probable that absorption takes plaw through these, and
that the absorbed fluid enters direct Iv into the circulation. The secre-
tory functions of the rectum and sigmoid consist in secreting mucus in
greater or less (piantity, which lubricates the fanral mass when dry, and
thus facilitates its passage with the least possible friction. The amount
of mucus secreted depends upon the dryness and irritating <|ualities of
the faecal material. In normal conditions it is bart»ly |)erceptible, but
in cases of chronic constipation or acute catarrhal inflammati(m. it be-
comes greatly exaggerated, and sometim€»s exhausting to the jiatient,
even where it is not accompanied by discharge of blood or pus.

CHAPTER II
MALFOBMATIOyS OF THE ANUS AND RECTUM

While the proportion of malformations of the anus and rectum in
the total number of children bom is very small, the actual number is
far from inconsiderable. ^loreau stated to the Paris Academy of ^ledi-
eine that he had observed during a practice of forty years in the Mater-
nity Hospital only four cases of imperforate anus. Couty, of Havre, in
an experience of 3,500 confinements saw 3 cases. Collins, in the Mater-
nity Hospital of Dublin, saw only 1 case in 1G,000 children, while Zohre,
of the Vienna Maternity Hospital, reported only "i im])erf orations in
50,000 children born in that institution. In the Paris Maternity Hospital
from 1871 to 1885 there were 5 cases of ano-rectal malformations in
20,G00 births, and in the Cochin lying-in hospital during the same period
there was only 1 case in 10,5753 births. These facts agree in the main
with the estimate of Starr, who stated that these malformations occurred
about once in 10,000 births.

Authors differ as to their relative frequency in the two sexes. Thus,
while Sedillot states that girls always furnish the greatest number of
ano-rectal anomalies. Curling found in 100 such cases 58 boys and 42
girls ; Bouisson in the same number of children found 53 girls and 47
bovs. In our own collection of 140 cases so far as the sex was known
there were 52 boys and 70 girls. If the cases of atresia ani vaginalis
are included, the preponderance will be in favor of the female sex, but
omitting these cases, there is no appreciable difference in the frequency
with which malfonnations occur in the two sexes. These statistics all
refer to gross malformations, and are not entirely accurate, inasmuch as
many of these abnormalities arc of a partial nature and present no phys-
ical symptoms calling attention to them in early life. As a consequence
the victims often go to old age without knowing that any deformity
exists.

The neglect of systematic examination of the rectum in new-born
children bv accoucheurs and midwives allows manv of these minor mal-
formations to go unobserved. Thus one sees quite frequently instances
of congenital stricture, valvular occlusion, and rectal malformations in

48 THE ANUS, RECTUM, AND PELVIC COLON

persons who liavi* reached the age of puberty, supposing they were ana-
tomically |)i»rfect. Morgagni records a case of this kind in which a
woman who lived to lx» one hundred years of age, was married, bore chil-
dren, and iK'rformed all the dutit^s of life without knowing she had any
malformation until siiortlv before her death.

The iin])(>rtanci» of such examination and the early recognition of
malformations can not Ik» ovcR^stimated, for it is only in the earliest
stages that we can hope to remedy the cases of complete occlusion, and
it is at this stage also that we may do most to prevent the minor malfor-
nuitions jiroving serious in later life.

Welch, of Haltimore, has shown that the meconium at the time of
birth and for some hours thereafter is a sterile fluid, but that after
the digestive proet^sses have taken ])lace in the intestinal canal it be-
comes infectious and is no longer free from danger to surgical wounds.
This fact would indicate the advantages of early opc^nition from an asep-
tic point of view, for it is the rule in such operations tiiat the meconium
escapes into the wound and thus exposes the latter to whatever infec-
tious germs it may contain. The large majority of deaths from oi)era-
tions of this kind are due to peritonitis or sepsis which follow the escape
of the intestinal contents into the peritoneal cavity or wound. The
earlier, then'fore, that nMiiedial measures are undertaken, the less dan-
ger will there be of septic infection.

In the section on embrvolo*rv it was shown that the rectum and
anus are developed from two entirely differtMit layers of the blasto-
derm, that the blood supply of these two organs come fn>m different
sourit's and return by ditfen^nt routes to the general circulation. Arrest
in the development of one, then*fori\ is not neivssarily assocMatiMl with
that in the other: in the majority of cases when^ then* is malformation
or di>phuvment of the rectum, the anus is oniinarily normal, and vice
r«'r.v'». On the other hand, malformation of either one of these organs is
very likely to W assiK-iatinl with malformation in other parts of the body
derived fn>m the same laver of the blast mlerm. Thus, children with mal-
fornuuions of the rectum are very likely to suffer with cleft i^late, nasal
and pharvniTral oli>truetii»ns, or other abnormalities of the alimentair
tract. Thit>e with malformations of the anus are likely to be associated
with Uial format ion- of the uro-genital organs, such as hypospadias, ex-
strophy of ih./ lijaddrr. atresia ani vaginalis, etc. : Other malformatioiK,
surh a- i:tf'«nrjities v.f the pelvis, al>M^ntv or twisiing of the coccyx, doee
appo>ir].»n -.f ihv- iiaVr i-^hii, and absence or im]vrfect f onnation of the
|H^rina iim, nmy }^ as*cK-iaT*-<l with malformations of the rednm and aiiua.
It is n^«i within thf- -<-"j».? **f thi- Kn^k. however, to consider mMMtroritieiy
so tht- T» \: -or:]] V- ivitriri-d to those malformations affiectii^ the lectoi
and an 13'^ on] v.

MALFORMATIONS OP THE ANUS AND RECTUM 49

The classical division of these malformations was first laid down
by Pappendorf in 1781, and has been closely followed by most writers
since his day. In this classification the rectum and anus are considered
as one and the same organ, and no distinction is made between malfor-
mations resulting from arrest of development in the parts originating in
the epiblast and those originating in the hypoblast and mesoblast. As
the writer has always observed this distinction, Pappendorf's division is
modified as follows :

Malformations of the Anus

a. Entire absence of the anus.

b. Abnormal narrowing of the anus.

c. Partial occlusion of the anus.

d. Absolute occlusion of the anus.

e. Anal opening at some abnormal point in the perineal, scrotal,
or sacral region.

Malformations of the Rectum

a. Rectum entirely absent.

b. Rectum arrested in its descent at a point more or less removed
from the anus, the anus being normal.

c. Rectum opening into some other viscus, with anus present in its
normal position or absent.

d. Rectum and anus normal, with the exception that the ureter,
bladder, vagina, urethra, or uterus opens into it.

With this division we are able to elearlv follow out the malforma-
tions duo to the arrest of development in the difTerent layers of the
blastoderm.

MALFORMATIONS OF THE ANUS

a. Entire Absence of the Anus.

Cases in which the anus is entirely absent are comparatively rare.

The nurse or medical attendant when examining the child for sex
will immediately recognize the entire absence of the anus, whereas if
it is only partially formed the deformity is generally overlooked. In
these cases there may be a depression in the skin at the point where the
anus should be, but sometimes there is a small corrugated button of
skin or protrusion at this point. At other times there is simply a slight
discoloration, with more or less rugae of the skin tissue centering around
the normal point. Again, the skin or central rhaphe of the perinaeum
may extend in an unbroken line from the scrotum to the coccyx (Fig. 35).
In such cases the rectum may reach down almost to the skin, it may open
into some other viscus, or it may be arrested in its descent at a greater or
4

be found
whereas in other c
ill which there is
the slightest Indica
of an anus the rec
will be found closi
the surface of the b
'rhiw fact is of ini)
liiiKf from a pract
|"iiril of view, show
tliiit the absence
vci-y slight devel
iiii'dt of the a
wnuld be no indical
fur doing an abdi
inal operation for
]K'rforation until
cnruful search throi
perinanim 1
been made.

Associated with t
form of malformat
we are likely to h;
other deformities
the external genital organs, such as atrophy of the vagina, hy
spadias, exstrophy of the bladder, and defonnities of the pelvis. 1
tuberi isehii are likely to bo unusually close together, and the pel
itself may be so narrow and generally smaller than normal tl
the deformities will be observable from a simple inspection of 1
parts. The genital organs also may be set farther back toward the c
eyx, and the space between the bladder and the sacrum may be so narr
that it would be almost impossible to insert the finger between the
These malformations it will be seen arise in tissues all having tb
origin, as the anus, in the epiblast, and may be independent of any i
formities or arrests of development in the tissues arising from the otl
layers of the blastoderm.

Diagnosis. — Where the, anus is absent there is no difficulty in reec
nizing the fact by sight. Where such observation is not made at the tii

MALFORMATIONS OP THE ANUS AND RECTUM 61

of birth it will soon be noticed that there is no passage of meconium or
fsecal matter; that the child is restless, and soon begins to strain; the
abdomen becomes tense and swollen, and after a few days the child ejects
its food, digested or undigested, according to the state of the stomach.
With the first appearance of such symptoms, ocular and digital examina-
tions are called for, and when these are made there is no difficulty to
diagnose the malformation. As this is one of the types of imperforate
anus, the consideration of treatment will be postponed until all have
been described.

b. Abnormal Narrowing of the Anus.

In these cases the anus is present, and may appear perfectly normal
to the superficial observer, but upon examination it will be shown that
it is unusually narrow at some portion. This narrowing may take place
at any point from the margin to its junction with the rectum, or it may
extend throughout the whole length of the anus. As the length of the
normal anus is from 1 to 2^ centimeters (| to 1 inch), the narrowing
which can be properly attributed to it will be limited to this extent.

The narrowing may be annular and very short, being formed by
bands or membranes extending from one side of the anus to the other,
or it may extend from the margin to the upper limits of the anus,
consisting in a general incapacity of the entire anal canal. This condi-
tion differs from the narrowing of later life produced by pathological
causes in that there is no hypertrophy of connective tissue, no cicatricial
tissue, and no hardening of the parts; the anus is soft and flexible, and
its walls continue so upward to the rectum. The conditions attributable
to inflammation may develop later on in life, owing to the passage of
fa»<al matter through this abnormally narrow channel, and the conse-
quent irritation therefrom, but in those cases which have been observed
at the time of birth there has not yet been reported any evidence of
pathological processes having taken place.

The question of the size of a normal anus at the time of birth is
rather difficult to decide; it depends upon the size of the child, but in
general one may say that the anal canal at birth ought to admit with com-
parative ease the little finger of a man's hand, or the index finger of a
woman's. If the sphincters are normally developed they will be found
to <rrasp the finger gently, and yet easily enough to admit its passage
well into the rectum; where there is abnormal narrowing this sphinc-
teric action is generally deficient, and one finds it difficult or impossible
to introduce the finger through the contracted canal. These cases are
the ones in which children are reported to have been constipated all their
lives, and who frequently develop strictures or fissures in early life.

Pailhes, in a thesis before the medical facultv of Paris, discusses this
subject at length from the point of view of congenital strictures. He

52 THE ANUS, RECTUM, AND PELVIC COLON

shows that many of these cases reach adult and even old age wit!
discovering the true nature of their condition, and yet their hist<
and lifelong experiences would go to prove that the narrowing had
isted at the time of birth. We must differ with Trelat, Eeynier,
Pailhes in calling this condition stricture at the time of birth, bee
that term designates a pathological narrowing of a canal which has 1
of normal proportions, and they all disclaim any such process ir
production. The pathological condition in these cases comes on s
birth through obstruction and consequent irritation from the faecal
sages. It is true when these cases are treated in adult and later
that the condition is then one of stricture with all its pathological
companiments, and may be classed (as Pailhes has done) under the h<
ing of congenital stricture, referring, of course, to its origin and
to its pathology; but the congenital feature consists in an abnorm
small anal canal incapable of being dilated by the faecal mass.

Diagnosis. — The diagnosis of this condition is not so easy as tha
total absence of the anus. There is generally more or less room for
passage of the meconium, and as gas escapes through very small j
sages, the child in early life is not much disturbed by its accumulati
As long as the faecal passages are semifluid, as they should be in inf
life, these abnormal narrowings of the anus will produce no subject
symptoms; but as soon as the faecal material begins to be solid, obstr
tion and irritation will take place, and the patient will have to str
and suffer pain whenever a movement of the bowels occurs. Such cl
dren soon learn to dread the hour for being sent to the commode, «
the result is a marked constipation with all its evil effects. The o
absolute diagnosis of these malformations is that made by the eye a
finger.

Serremone has called attention to congenital narrowing as a frequi
cause of fissures, both in children and in adults. When these fissu
are found in infancy, however, they must be clearly distinguished fr<
those due to the dry, brittle mucous membrane found in heredity
syphilis. Digital examination in these cases will elicit a narrowing
one point or throughout the entire length of the anus. When the canal
large enough to admit the tip of the finger, the extent of the malforn
tion and the density of the surrounding tissues can be easily told. Wh
it is too small for such examination, the uterine probe or some su
instrument can be passed through, and, being bent upon itself, o
may be able to determine the nature and extent of the narrowir
The older the patient is, the more dense and inelastic will be t
constrictures; and the more unyielding they are, the more distress w
thev occasion.

The child may pass through infancy and childhood with no oth

MALFORMATIONS OF THE ASUS AND RECTUM

Diptoma than thoi-e of eonatipatioD. This, however, may alternate
(rith a pseud o-diarrlioea — that is, the child may have impaction, and yet
t the same time suffer from the frequent passage of fluid fceces around
"the ffpcal mass. The author saw an interesting case of this kind some
years since in a boy four years of age, who was brought to the clinic on
accoant of the diarrhcpa. He was having twenty to thirty passages
daily, was emaciated, pale, and septic iu appearance, his abdomen was
greatly distended, and his physiognomy suggested tubercular enteritis.
Examination under chloroform revealed a narrow tubular anus not
large enough to admit the little finger, and incapable of being dilated
without tearing. It was therefore incised posteriorly. Within the fol-
lowing hour he passed more than sis pounds of hard, lumpy ficces. An
t^samination of the child's rectum at birth would have shown this de^
fonuity, and persistent dilatation at that time would have prevented
the sufTering and necessity of operation.

Those cases in which the narrowing is not observed until in adult
• can only be recognized as congenital from the subjective history.
uelsey (Diseases of the Rectum anil Anus, p. 74) has related a case in
hich the condition was discovered at tlie age of thirty-eight. Trelat
«■ one at fifty-two, and the author
s seen one at twenty-seven. None
t these patients had any idea they
fere malformed. In general terms
} may say an anus that will not
aiit a No. 5 Wale.* bougie in iu-
nts, or a No. t in adult;-, may be
Jled ahnontially narrow.

Partial Membranous Occlu-
sioQ of the Anns.

This variety of mall'ormatiou of
I anus is not rare. It cimsists
^ a partial occlusion at some level
[ the anal canal by a membrane
fold of tissue. If the fold is
tnated at the margin or outside
f the anal canal it is composed of

Sometimes it occurs in the an— sunuKANurB Oc.lvsi'js of thb

lape of a central rhaphe extend- asis,

e from the scrotum to the coccyx,
1 s small opening on one side or both, at the point where the anus
, be, thus allowing the passage of fluid fasces or meconium
ig. 36).
When the occlusion is higher up, the membrane is composed of muco-

THE AKUS, RECTUM, AND PELVIC COLON

cutam-ans tissue, and has a cresccntic or cinulnr shiipc with a bhibII
opening either in the middle or upon one side. These openings may be
of considerable nize. or barely larpe enough to admit a probe. The
smaller the opening, the more likely it is to produce eonstitutional and
subjective symptoms early in life. When the membrane is situated a»
high as Ij to 2 centimeters (| to \ of an inch) from the margin of the
anus, it will be duo probably to im|wrfeet absorption of the ano-reciai
membrane. Such cases, however, must be distinguished from those in
which there is an abnormal fold lower down. These cases have been
described as congenital strictures, but should be classified under the head
of congenital ma! format ions. As in the previous class, they have neither
the pathological nor |)hysiea] iharaeteristics of stricture. They are gen-
erally iilwervcd i-arlicr in life than the preceding class, and are much
more easily dealt with, in that they do not involve the deeper layers of
the anal wall. When attention bus k'cn i>ncc called to them the diag-
nosis is easy, because
all of the malformation
is within roach of the
linger or the probe. a»
well as within ocular
observati<m. They are
frequently seen in adult
life, and produce so
little disturbance that
they lire of no surgical
importance (Fig. 37).

<l. Complete Obitrac-
tion of the Anna b;
a Xembranona DU-
phra^.

The distinction be-
tween this and the last
variety of malformation

Fio. 37.— Partui, Memri«anoi> ", ii,i*i.>n or tiik .\sr!', of the anUS Ib simplv

ub«rvidiiifljuanibnj-.i«-,.y^i,r.of«e... ^^p ^f degree. The

fonuor represented a
partial occlusion not immediately dangerous to life, while this represents
a complete occlusion, which must be overcome in order that the child may
live. SticIi eases are extremely rare, and are among the easiest to rem-
edy. In those the anus is simply doscil by a thin membranous diaphragm
resembling very much the hymen, which is composed of fibrous or muco-
cutaneous tissue, very thin and flexible, that extends in crescentic layers
from one wall of the anus to the other. If the rectum is properly devel-

r""jrv/7^

Hf.

MALFORMATIONS OP THB ANUS AND RECTUM 55

oped in these cases one can easily see or feel the bulging of the meconium
against this thin diaphanous membrane.

It has been assumed that this form of malformation is simply an
arrest in the absorption of the membrane dividing the proctodaeum and
the enteron. Its location in some cases is too low down to justify any
such general conclusion. The measurement laid down by Trelat, and
again by Bodenhamer, gives the length of the anus as 1^ centimeter (f
of an inch) at the time of birth. Now, if this diaphragm were the
unabsorbed membrane between these two portions of the intestine, it
would be located at the level at which the partition is found. Writers
who have described these cases speak of them as being found at ^ a
centimeter, J of a centimeter, and at 1 centimeter from the anal margin.
The author has seen three such cases. In one the membrane was situ-
ated just i a centimeter {^ of an inch) from the margin of the anus;
in another it was situated a little less than 1 centimeter (g of an inch) ;
and in the third at ahnost exactlv 1 centimeter. Thev were all covered
below with a muco-cutaneous membrane. The membrane in one case was
so thin that it was punctured with the flat end of an ordinary probe,
and then diN'ulsed bv the fingers. Four vears afterward this child was
seen, and there was no evidence of the remains of the membrane, but the
sagittal line of the pecten was clearly marked and well above the point
at which the membrane was attached, judging by measurement. In the
other two cases later observations were not obtainable. One should not
infer from this that occlusions from arrest in absorption of the sieptum
between the proctodeum and enteron do not occur, for they do; but they
are not the onlv membranous occlusions of the anus. Later on we will
>ee that in some cases the anus is occluded by one and the rectum by
another separate and distinct membrane.

Diagnosis, — The diagnosis of these cases is based upon the ilbsence
of discharges of meconium, inability to introduce the finger into the
rectum, the obstruction being low down, and the thin fluctuating feel of
the occluding membrane.

e. Anal Opening at some Abnormal Point in the Perinaeum or Sacral
Begion.

This variety of malformation is described ordinarily as a malforma-
tion of the rectum itself, and in some instances it is such, for we have
cases in which the anus is more or less developed in its proper site, and
yet the rectum opens at some other point of the perineal or sacral region.
In the majority of cases, however, where the rectum opens at one of
these abnormal positions there is no other anus present, and a careful
examination of the abnormal opening will show that there is a more or
less developed sphincter around the aperture. Where such a sphincter
exists, it seems quite natural to call this opening the anus, especially

THE ANUS, RECTUM, AND PELVIC COLON

if we can show that the pavement epithelium which covers the skin
lines the lower portion of the intestinal canal extends for any dist
upward in the abnormal opening. Where this pavement epithel
ceases abruptly upon the edge, and is transformed into columnar
theliuni, without evidence of the gradual transition between the
Been in the normal anus and rectum, then we may properly classify t
under malformations of the rectum.

There is no fi.\ed position, nor even a general one in which i
openings may be found; in fact, sometimes there is more than one ori
The openings may be in the anterior or posterior part of the perint
d'i'^. 38), to one
ur the other of
siifrum, or outsidt
I ho gluteal fold.
(Ir.'.l, the rectum
ilir small intestine
Imiii known to o
..II ihe thigh, the
ilnriiun, and the shi
ili'i'. The anus is i
:illy developed in
rn>rnijd site in the
ter cases.

It is not inten
to classify under i
head those cases
which the rect
opens at such rem
points, or into ot
organs. We refer h
to those in which
anus opens at an
normal position in ■
perinasuni or sacral
gion. They have b»
described by some
fistulous openings, I
they have none of 1
pathological characteristics of fistula. There is no pus as«)ciated w
them, there is no cicatricial contraction at the time of birth, and thi
is every evidence that the folding in of the epiblast simply occurt
at an abnormal position.

Duignasis. — The diagnosis of such cases consists simply in seei

MALFORatATIONB OF THE ANUS AND BECTFM 57

I -them. It is important, however, to determine whether there ia sphinc-
'c txmtrol over the passages. If there is, interference will not be
justified; but if there is not, it should be undertaken as soon as the
I child's condition will admit of it with safutv.

MALFORMATIONS OF THE RECTUM

a. Entire Absence of the Bectum.
This variety of nialformntion is one
[nose without esploralory ineisinn. The
1 no wise indicates the probable abt-fini
i which the imperfo-
I TBle anus is well formed
rectum may be
e at hand, hanging'
josely in the pelvic
larity, atlachcd to
ne other jiortinn of
i abdominal wall, or
t may be entirely ab-
■ent (Fig. 39). In cases
I wliere there is no ex-
ternal evidence of an
anus or rectum, the
. latter may be closely
ttached to the perineal
No defects of
e conformation
; sufficient to pre<li-
e the entire absence
f the rectum, Boden-
and Verneuil
tarp suff^stod the use
[ the stethoscope ap-
to the perineal
n to determine
existence of gas
imperforate anus.
le information obtained from this ia so far from reliable that one
only call it a negative process. The absence of the rectum can
determined only by a search through both the perineal and abdom-
routes.
The entire absence of the large intestine forms one variety of mal-

THE ANUS. RECTPlf, AND PELVIC COIXtN

^ int

^ft eat

formation in the revised classification of Pappendorf and Bodenhamer.

In sucli rasts th<j small intestine opens at some abnormal position, a?,
for example, the shoulder, the
neck, the chest, the tefiophagas
tlie stomach, or, a£ in some in*
stiinces, through the umbilicus.
Siioh cases, however, are beyond
the domain of rectal surgery only
tn so far that if the child should
rciuii the age at which it would
bt'ar surgical interference well.
an artificial anus, either in the
|iorinii'iim or at some convenient
l"isiiinn of the abdominal wall,
injjrht bo made to take the place
"f iho-i.' abnormal openinps,

/'. The Rectum arrested in its
Descent more or less removed
from the Anus, the Anns being
Normal.

Ill this variety of nulfornu-
_ tion tlie t'uteron is either arrest-

FAiLEu i-i RKACH THi Anvt. ed in ilevelopuient and fails to

come in apposition with the proc-

todieum (Fig. 40), or it may pass downward in the wrong direction and

parallel with the cul-de-sac of the proctmlivuiu (Fig. 41). The distance

at which the rectum is arrested

above the anus is very variable.

Sometimes it is only a few lim-^

removed, while at others il i-

found entirely above the pilui

cavity. Again it may be a)'|Mi-

ently in apposition with the atiil

cul-de-sac, and yet, when the iiicin-

brane dividing the two is incised,

no meconium wilt appear. In

such cases there exist multiple

obstructions. Fried berg, quoted

by Ball, mentions a case of this

kind in n-hich the walls of the

intestine were found adhering to

each other in two places, and

Schenck records a similar case in

MALFORMATIONS OP THE ANUS AND RECTUM

tate
■Uot

■ which he states that the rectum «as divided at two levels by annular,
Ittm, membranous septa. Bodenhainer, Bushe, Curling, Molli^re, and
hUata^j all confirm these reports, and Vnillemier records a case in which
Itlie rectum was divided into four distinct compartments by three septa.
" ^casionally there will
found a distinct
[Abroua cord that ex-
tends from ihe closed
tl-df-sae of the anus to
undes«entii'd recium
iXFig. 42). AVhen the
^itrrtam descends paral-
lel with the anal ciit-dt-
aaf, and yet fails to
come in apposition with
it, the former generally
imes & position par-
lie I with the coccyx
«n>l sacrum, while the
latter passes upward
alongside of the pros-
^land or vapina.
these cases the peri-
leai earity may ex-
tend downward and
backward between the
two occludetl ends and
render it impossible to
pa«s from one to the
other without entering

this cavity. In the interesting case described by Amiissat (Troisi^me
m^moire, Paris, 1843J not only did the two nilK-iJe-sar fail to meet
one another, but the anal cul-de-sae opened into the vagina (Fig. 43),
while the rectal ail-dvsac ended a short distance from the skin just
anterior to the coccyx,

it has been claimed tlfat these multiple septa and the fibrous coid
leading from the anal cul-de-sac to the enteron are indicative of the
gut having been patulous in ftetal life and become occluded through
inflammatory or pathological processes. No better answer to this theory
can be given than that of Ball, who says:

"" rn*|uestionably this cord is very frequently present, but it by no
means follows that its presence presupposes a pen-ious intestine. On
the contrary", its presence can be shown with much greater probability

THB ANUS, HBCTDM, AND PELVIC OOLOS

to have developmental origin; the mesenteron which originates from
the hypoblast, as before mentioned, forms the upper portion of the rec-
tum, but from it the mucous membrane alone is developed, a layer of
mesoblast subsequently surrounding the tube to form the muscular and
other external portiona
of the intestinal wall;
L-onsequentlv, when the
development of the cul-
de-sac of mesenteron
becomes, from anj
cause, arrested, it doea
not follow that the
growth of Uie other
tunics originating from
the iiiewblast should
be arrested also; and
when there is no mu-
cous coat to be sur-
rounded, it can be read-
ily understood how this
portion of mesoblast
can form itself into the
rounded cord. Again,
we must remember how
exceedingly rare it is
for a mucous canal ta
be obliterated by in-
flammation, unless at-
tended with a very
considerable superficial
loss of substance. The
only instance that 1 know of in v»-hich a mucous canal is obliterated
during the process of development in the human subject is that of
the urachuB, but even in this case evidence of the mucous membrane,
and even small mucous cavities, are still found in the cord which
forms the remains of this fwtal structure. I have recently had
an opportimity of carefully examining a case of this kind from a
patient under Professor Bennett's care in Sir Patrick Dun's Hos-
pital, in which, after failure to meet the rectum by perineal incision,
a colotomy was performed, but the result was fatal. In this instance
there was a very firm und strong cord extending from the cul-de-sac to
the anal portion; a microscopical examination of this cord showed it to
be composed entirely of muscular and connective tissue, without a trace

MALFORMATIONS OF THE ANUS AND RECTUM 61

of mucous membrane. I was also able to determine another important
point in this case. If the anal depression is composed alone of procto-
da^um, it is obvious that, as it originates entirely from the epiblastic layer
of the embr}'0, it should have its surface covered with scaly and not
columnar epithelium. I consequently obtained a small piece from the
fundus of the anal depression, and made sections of it. There was not
a trace of glandular epithelium to be seen in it, so that, in this case at
any rate, the conclusion was unavoidable that the malformation was due
to the fact that the mesenteron did not descend low enough for the proc-
todsBum to meet it; and that, I believe, is the explanation of the major-
ity, if not all of these cases."

In addition to this it should be remarked that there is no other evi-
dence of previous inflammation in the intestinal canals of such children.

Diagnosis. — The diagnosis of these cases is not made frequently
until some days after birth. The normal appearance of the anus does
not suggest the necessity of digital examination, and it is not until sub-
jective symptoms, such as meteorism, nausea, and faecal vomiting, begin
that the real condition of affairs is recognized. The anal cul-de-sac
under such circumstances measures from 1 to 1^ centimeter (f to f of
an inch) in depth, and frequently less. The finger is arrested at once
upon attempts to introduce it into the rectum.

If the cnteron is close down to the cul-de-sac of the anus, with the
finger in the latter, when the child cries or its abdomen is pressed upon,
an impulse can be felt. If, however, it is at some considerable distance,
or if it descends alongside of the anal canal, such an impulse will be
aK^ent. It is impossible to tell accurately by any method the distance at
which the rectum will be found from the anal cuUde-sac, and the fact that
the peritoneal cavity may intervene between the two renders the introduc-
tion of trocars or aspirating needles for diagnosis very dangerous. The
only method to determine the distance is by actual dissection, and this
should be done immediately upon recognition of the condition of affairs.

c. Sectum opening into some Other Viscus, the Anus being Present
in its Normal Position, or Absent.

This variety is by far the most frequent of all malformations of the
rectum and anus. It comprises about 50 per cent of all the cases, and
the large majority of them are of the vulvo-vaginal type.

Leichtenstem (Ziemssen^s Encyclopaedia, vol. vii, p. 485) says that
in 375 cases of rectal malformation, 40 per cent were of this variety;
Bodenhamer says that 85 out of 287 cases belonged to this class. When
it is recalled how completely the anterior is shut off from the posterior
part of the perinaeum by the perineal fascia?, it is difficult to understand
how this malformation can occur so frequently in male subjects; on the
other hand, when the fact is recalled that the rectum and genito-urinary

62 THE ANUS, RECTUM, AND PELVIC COLON

apparatus are at first comprised in one general cloaca, the malfo
tion seems likely enough. The division of the parts not having
perfect, some small communication is left, and through this the s<
tions of the intestine escape, keep it patulous, and at the same
prevent that weight in the intestine itself which would naturally c
it to sink downward and come in contact with the ascending cul-di
of the proetodasum.

The various types of these malformations are designated aecor
to the organ with which the rectum communicates, aa follows :

Atresia ani \ei
lis: Where the rec
opens into the b
der.

Atresia ani i
thralis: Where the
tum opens into
urethra.

Atresia ani vagi
lis: Where the rect
opens into the vagii
' Atresia ani ut
na?: Where the rect
opens into the utei
Atresia Ani Vt
calis. — When the r
tum comq;iunicai
with the bladd
whether in the m
or female, it is usua
by a very narrow cai
lined throughout wi
mucous membra
(Fig. 44). In fema
this communicati
very rarely takes plai
In males, however,
is not so rare. T
opening is likely to be at the trigone or higher up in the fundi
Where the opening is down below between the orifices of the uretei
the communication is generally but an elongated, narrow canal, ru
ning diagonally or obliquely through the walls of the bladder, ai
furnishing only a very restricted outlet for the contents of the ei
teroE. Where the opening is in the fundus of the bladder it is usual

MALFORMATIONS OF THE ANUS AND RECTUM 63

wider, and there is an exit for the intestinal contents. There have
been no eases reported where these openings have involved the ureters
or their exits.

Diagnosis. — The diagnosis of these cases will vary in difficulty ac-
cording to the time when the child is seen. Usually it is simple enough ;
the absence of any passages from the anus will suggest an examination,
and imperforation will thus be determined.

The appearance of the dark greenish stain of meconium in the urine
is sufficientlv characteristic to indicate communication between the rec-
turn and urinarv tract. The amount of this matter seen in the urine will
indicate to a greater or less degree the size of the opening into the blad-
der. Sometimes the quantity is so small as to barely stain the urine,
and sometimes it is so abundant that the urine may appear to be pure
meconium. In the latter class of cases it will require close watching to
determine whether the opening is in the bladder itself or in the urethra.

Ball says, " The fact that the meconium is intimately mixed with
the urine, and it only appears during urination, would at once distin-
guish this variety from atresia ani urethralis." This is very logical and
clear if we could observe the child during the urinary passage, but, un-
fortunately, this act generally takes place during the absence of the
physician, while the child is asleep, or at such times as it is almost im-
yjossible to obsen'c it, and consequently we have to draw our conclusions
from the staining of the diapers and clothing. Constant oozing of me-
conium from the urethra would indicate that the opening was not in the
bladder, but it does not prove it. The rapidly fatal course of such cases
renders dihitory proceedings in the diagnosis of this condition very dan-
gerous. Unless the condition is rapidly relieved, and the contents of
the bowels are turned away from the bladder, cystitis will result, with
subsequent infection of the ureters and kidneys, and the child will die.
On the other hand, if the opening be small, as it usually is when the
lower portion of the bladder is invaded^ the child will likely succumb to
the obstruction of the intestine. The prognosis in such cases is uni-
formly bad. The operation necessarj' to alter the condition is of such
magnitude that most children are unable to stand the shock; on the
other hand, delay subjects the victims to the double risk of intestinal
obstruction and septic infection of the bladder and genito-urinary
organs.

Atresia Ani Urethralis. — In a certain number of cases the rectum
opens into the urethra (Fig. 45). This condition may occur in the male
or female, but it is much more frequent in the male. The opening may
oc-cur at any point along the whole tract of the urethra, but in the major-
ity of cases it occurs in the membranous portion. The communication
is generally by a long, narrow, tubelike channel, passing from the un-

THE ANUS, RBCTD5I, AND PELVIC COLON

descended recfuin down in front of the ]>eriDeal fascia, and opening
the posterior surface of the urethra. Tins condition is not so serio
the preceding. Eowan reports a ea.se in which the child defe
through the penis for two months without causing any signs of in

mation. Bodenh

cites a number of
in which the vii
have lived to tht
of twenty - one
thirty years res
ively, always de
ting through the
thra. The ope
may also occur at
prepuce or freaur
in the ease of C
(Fig. 46).

-_.. , , _- _ _,^ ^ diagnosis of this

§ :'/< fvt' 'lition is Bomei

M y ^ more simple than

K Y .^B i.if atresia ani ve

^L ^H lis. The mecon

^E "^B or f ipcal matter pa

^^L ^1 either constantly

^^L Hfl I at stated penods,

^^^p ^^ . mixed with urine,

^^K ^H independent of

^^P ^1 urinary act. The

testinal contents .
be found escai
from the meatus at any time, and no evidence of cystitis or neph:
seems to develop. If the communication between the rectum and
thra be very smatl, as it generally is, the patient may suffer from
struction and distention of the bowels and all the consequent com
cations; but if the opening be fairly large there may he no subjee
symptoms whatever and no indication for immediate action. Ur
such circuni stances it can be easily understood that the prognosis in s
cases is-much more favorable than in the preceding class. Moreo
the fact that the rectum is usually low down in the perinjeum in tl
cases makes the probable outcome of an operation to restore the anui
its normal position much more encouraging.

Atresia Ani Vaginalis. — This variety furnishes about 50 per cent

MALFORMATIONS OF THE ANUS AND RECTUM

all the cases of lualfornialiou of the recluiu. The frequency with which
it occurs will never be known, inasmuch as it produces so little sub-
jt'ctivc inconvenience that patients go through life, perform all Iheir du-
ties, marry, bear chil-
dren, conduct their
houaeliolds, and yet
do not know that any
deformity exists.

Buckmaster reports
a case of a woman
tliirtv-two years of age
whose rectum opened
into the vagina near
the vulva, and who
never knevr that she
was deformed until ex-
amination for a uter-
ine complaint revealed
the condition. The
author observed in the
Philadelphia Hospital
a prostitute whose rec-
tum oj)ened by a sort
of valvular orifice into
vagina, and who
lived to the age
twenty-eight years
lithout knowing she
in any way de-
nied (Fig. 47). The
nicatiou be-
fen ihe rectum and the vagina in this variety of malformations may
e located at any portion of the vaginal tract, from the posterior rul-
t down lo the verj- margin of the vulva. It may also he between
lie anus and vagina, thus involving practically neither organ.

The opening may he very small, but it is generally of sufficient pro-
rtions to allow the free and regular e8ea])e of meconium and also of
I matter, unless the latter becomes very hard. The opening may be
^the center of the lower end of tlie rectum, or upon the side, in which
e the organ usually ends in a large, dilated cul-de-sac. Sometimes the
^ning is by a somewhat elongated, tubular canal, and in these cases
t passage of fsKial matter will be obstructed as soon as the condition
jt the bowels becomes the least solid.

flft

TIIE ANDS, BECTCM, AND PELVIC COLON

Itiill rii"iTls a itifQ of A womnn, the mother of six childron, who had
this form of malformation all her life without the slightest inconve-
nience. Hu says: " The anus opened into the lower portion of the va-
gina, and was i-o far proviileJ with u s|)hincter that when the tip of the
finger was intiHxlucel
into the rectum it was
li^'htlygras|>od. There
was not the least in-
continence, and the
bowels acte«l regularly
t'veri' day." Ricord
and M(Kliin have re-
ported similar cases.
Buck master haa
i-ollecteil 27 eases of
this malformation, the
aj;es running all the
way from six months
to forty years. He
int'hules also in th».
collection Morgagni's'
case at one hondredj
years of age,

Caradec (Gazette
d*hdpitaiix, 18(i3) has
reported the case of
n woman, thirty-two
years of age, in whom
the anus and vagina
were normal, except
that from the margin
of the vulva, between the orifices, there was an opening, slightly oval
and large enough to admit two fingers, with its longest diameter an-
tero- posterior. This opening led into a cul-de-snc lined with mucoua
membrane, which at its entrance offered a certain resistance like that
of the sphincter. The anterior wall between it and the vagina waa
thicker above than below. The posterior wall, on the contrary, wa«
thicker below, and presented a fistulous opening large enough to admit,
the tip of the finger at about 5 centimeters {'i inches) above the anna.
The woman suffered no inconvenience until after marriage, when ftecal
matter began to pass by this median opening. Caradec termed this
malfonnation a second vagina, but it appears that it would have been
more appropriately tenned a second anus.

MALFORMATIONS OP THE ANUS AND RECTUM 67

In this variety of malformation the anus may be perfectly formed, or
it may be entirely absent. In some cases there is an opening into the
vagina as well as a perfectly formed connection between the anus and
rectum. In these cases the openings into the vagina may never be sus-
pected during virginity. I have heard of one case in which it was claimed
that the passage of faecal matter through the vagina was due to trauma-
tism during the sexual act. Closer examination proved that there was,
and had alwavs been, a sort of valvular communication between the
vagina and rectum, lined throughout by mucous membrane, and that
the passage of fjecal matter through the vagina had only been prevented
bv the existence of a close hvmen.

Out of 36 cases of malfonnations not included in the statistics so
far collected by others the author finds 18 cases of this variety. Tlie
openings into the vagina are usually large enough to admit of the pas-
sage of ordinarily formed fsecal masses, they cause little inconvenience
in early life especially, and happily do not demand any immediate opera-
tive interference. The child will grow and thrive, and if the opening is
not large enough to admit of the passage of fa'cal masses, it can be
dilattMl to a sufficient extent to serve all practical purposes, until the
child attains an age at which surgical operations can be safely per-
formed. The prognosis, therefore, in such cases is always good. There
is no excuse, however, for the malformation being overlooked, and the
child allowed to reach the age of puberty or even older years with such
a deformity. These cases emphasize the necessity of examining the
rectum at birth. They are practically harmless if recognized and treated
pn^perly, but if neglected, they may be discovered at a time when such
a deform it V would wreck the life of the woman.

Atresia Ani Uterince. — Communication between the uterus and rec-
tum is of the rarest occurrence. Only two cases of this condition have
lieen reported. The opening in one of these cases was in the posterior
lip of the cervix, in the other the site was not mentioned. Xo case has
been reported in which the intestine communicated with the fundus of
the uterus. The tracts of communication in the cases reported have
been small and contracted, only allowing a feeble escape of meconium
through the vaginal orifice. In each case the gut had been supposed
to open into the vagina, but upon dissecting the rectum away it was
found to enter the uterus itself. Such cases are too rare to merit any
lengthy discussion. They are simply instances of the freaks of nature
which are seen and exhibited as monstrosities in museums or patho-
logical laboratories.

(1. Where the Bectum and Anus are Normal, but have opening into
them Other Organs, such as the Ureters, Vagina, or Uterus.

Numerous oases of this form of malformation have been reported.

68 THE ANUS, RECTUM, AND PELVIC CX)LON

Bodenhamer has collected T cases in which the ureters opened into the
rectum at the ])eritoneal retlection, and 9 cases in which the vagina
terminated in the rectum. The author has seen 1 case in which the
vagina ojK'ned into the rectum at ahout 1 inch above the anal orifiw.
The uterus in this case opened l)etween two little i)illars or rudimentan*
vulva*. There was absolutely no vaginal formation upon the external
surface. The two little ])illars came together and formed a nuHiian
rhaphe which ran backward to the rectum. The uterus could lx» easily
felt through the o]>ening into the vagina from the rectum, and there was
no cul-dr-snc in the vagina Inflow this opening. The woman suffered no
inconvenience whatever from the malformation, and decline<l to have
anv operation done to remedv it. Most of thesje cases occur in females,
and the diagnosis is not made until jniberty. In the case which the
author saw, the malformaticm was discovered through ineffectual at-
tempts at sexual intercourse. When opportunity for examination is
afforded there is no ditliculty in diagnosing such malfomuitions.

Treatment. — While the method of operation in malformations of the
anus is of great moment, the time at which it should be done is of para-
mount importance. When there is complete atresia, what is to he ac-
complished must be done at once in order to afford the child any chances
of life. On the other hand, in those cases in which there is an exit for
the meconium and fluid faeces, a more conservative course may be
adopted until the child has grown to such an age that its strength will
admit of whatever surgical manipulation may be necessary. If the
exit for the nu^conium be very small, but within reach, it may be
gently dilated, even though it be in bad position, until the child's age
will justify radical surgical interference.

When we realize how much at times depends upon the life of a
single infant, how absolutely lives may depend upon the altering of
such a deformitv as this, and how dear the life of everv child is to its
mother, we can comprehend how necessary it is for every physician to
be prepared to act — act ])romptly and wisely in such an emergency.
The prime object in all oi)erations for malformations of the anus and
rectum is to give an exit to the intestinal contents. Such an exit
should be made convenient, permanent, and effective, if it can be done
without jeo])ar(lizing the chihrs life. We must therefore consider first
in what j)osition the outlet can be placed with the greatest safety to
the child. After this our efforts should be directed toward obtaining
all the functional activity of the normal organ; therefore, if possible,
the opening should be made at the proper time in the normal site and
as far as possible surrounded by the normal muscles and tissues.

Operations for imperforate anus are comparatively modern. The
Greeks and Komans seem to have looked upon this malfonnation as

MALFORMATIONS OP THE ANUS AND RECTUM 69

beyond the surgical art. The first instances given of an operation for
this condition is that of Egineta (Marius Durand, Gaz. des hopitaux,
Paris, December 1, 1894, p. 1301), who in the seventh century relieved
in imperforate anus by incising the saeptum. This method was the
:)ne generally adopted from that time on, the incision being dilated by
wax bougies or by the finger. It is remarkable that at tliis early period
the line of scientific surgical technique should have been so clearly
foretold. The description given by Durand does not indicate any blind
plunging with the knife, but a careful incision into a bulging sac. The
3perator knew and saw what he was incising, and this is the whole
secret of the modem operation.

Later on the use of the trocar as an instrument for searching after
the rectal pouch was introduced, and for a long time the method of
incision was little used. Children falling into the hands of general
practitioners were subjected to the trocar operation, and most of them
were left to die if this metliod failed. In 1834, Breschat reported he
had obtained twelve successful results by the method of perineal inci-
sion. This popularized the method in France. In 1787, Sir Benjamin
BeU, says Bodenhamer, advocated a dissection through the perina?um,
dilating the wound by the use of his finger, and searching for the rectal
ampulla in the hollow of the sacrum with the trocar, if it were not
found lower down. Shortly after this Dr. John Campbell, quoted also
by Bodenhamer, successfully performed this operation in Flemings-
burg, Ky. This was the first successful operation for imperforate
rectum in the United States. Hutchinson advocated dissection for
1| to 2 inches, and after this trusted to the trocar only. Dieffenbach
made a crucial incision in the perinjeum, excised the triangular flaps, car-
ried his dissection to the height of 1 inch, and then substituted the trocar
for the knife to penetrate upward and backward into the hollow of the
sacrum until the rectal pouch was tapped, when the path of the trocar
was dilated and the meconium allowed to escape. " If this procedure
faile<l, the cannula was allowed to remain in situ, and a piece of sponge
was forced through it and left to dilate the space beyond. If after this
dilatation the pouch could not be reached, colotomy was performed^'
(Matas, Surgical Treatment of Imperforate Anus, p. 7).

For a long time no attention whatever was paid to the preservation
of the anus, nor was any attempt made to do anything more than to
give the contents of the bowel a free outlet through the incisions made.
The question of retraction and closure of the incisions was first brought
up and discussed by Dionis (Bodenhamer) in 1740, and aftenvard by
Malvn in 1840, who both maintained that the retraction of the perineal
muscles would efficiently prevent the recontraction of the wound. This
assertion has not been confirmed by surgical experience.

70 THE ANUS, RBCTUM, AND PELVIC COLON

Rouz (Gaz. (les hopitaux, 1851, vol. vi, p. 434) first laid special
stress upon the importance of preserving the sphincter fibers while
dissecting the perina»um. He made a clean surgical dissection by the
use of the knife, preserving as far as possible whatever rudimentary
developments of the external sphincter existed in the perinaeum. He
still followed, however, the faulty technique of allowing the meco-
nium to escape through the open perineal wound regardless of its
depth, thus exposed the child to infection, and if the peritonaeum had
been opened, allowed the contents of the intestine to eztravasate into
this cavity.

In 1835, that great and original thinker, Amussat, published in
the Gazette de Paris an article entitled " The History of Operation
for Artificial Anus, Practised with Success by a Xew Procedure in a
Case of Congenital Absence of the Anus, with Some Reflections upon
the Oblitonition of the Rectum." From this operation and report
begins the scientific and radical treatment of malformations of the
anus and rectum. In this paper also was first thrown out the sugges-
tion that room for operative procedures about the rectum and pelvis
might be obtained by the removal of the coccyx, thus for the first time
pointing out the possibility of the sacral or Kraske operation and all
its modifications.

It seems tliat the French and Germans have utterly forgotten the
suggestion of Amussat in all their writings on, and developments of,
the sacral route. Verneuil, writing in 1873, stated that the possibility
and usefulness of resection of the coccvx had occurred to him as far

ft'

back as 1853, but lie had not put it into practise, owing to want of
op])()rtunity, until 1870. In this valuable ))aper, so often referred to,
we can recognize the suggestion of Amussat, who was, no doubt, original
in his work and thought, if not the pioneer in this line. The chief
feature, however, of Amussat's recommendation was not the removal
of the coccyx to gain space for operation; it was the fact that he dis-
sected the rectum loose and brought it down, suturing the mucous
membrane of the gut to the skin at the margin of the anus, if an anus
existed, or at the nearest point to the normal position of the latter
to which he could bring the undescended rectum. This furnished an
exit to the intestinal contents upon the outside, which was sealed off
from the wound by a close apposition of the parts. He advocated that
the rectum should be freely detached from all its surroundings so as
to bring it down to its normal position, if possible, without any ten-
sion; and that it should be drawn out of the wound and emptied of
it5 meconium before suturing. Ho advised the free and wide dissec-
tion of the periucTum, as well as the removal of the coccyx, if neces-
sary, to accomplish this. He also advised, where it was requisite, to

MALFORMATIONS OP THE ANUS AND RECTUM 71

open the peritonaeum, as this could be done with as little danger
through the pelvic route as through the abdominal. From his day to
the present time all methods of operation upon imperforate ani dnd mal-
formations of the rectum have been based upon these propositions of
Amussat, and barring the introduction of aseptic surgery, there has
been no radical improvement in the method which he proposed. It
is said by some authors that Amussat's proposition to remove the coccyx
was not to gain space, but in order to afford a position higher up and
nearer the undescended rectimi, to which the latter could be attached
in case of difficulty in bringing it down to the normal anus.

What he says is: " After having resected the coccyx, in order to gain
more room for reaching the rectum, the space thus left will afford a
convenient position to attach the latter in case it can not be brought
down to the normal position." To those interested in the development
of modem technique for operations upon malformations of the rectum
and anus, the reading of Goyraud's articles published in 1856 (Gaz.
med. de Paris, pp. 509, 524, 538, 601, and 639), and Matas's brochure,
1897, is suggested.

A discussion of treatment under the individual types of malforma-
tion has been avoided for the reason that such discussion would neces-
sitate nimierous repetitions with regard to technique. We shall there-
fore consider the treatment in general, and point out its application
to each particular form of malformation mentioned in the text. In the
first place, then, let us study those malformations of the anus and
rectum in which there is absolute occlusion. In such cases it is neces-
sary that immediate and radical operative interference should be under-
taken. The policy of waiting for a day or two to see if spontaneous
opening will not occur, or with the view of allowing the child to gain
strength, is most fallacious. Where there is no aperture at the time
of birth there is little or no probability that it will show itself after-
ward. The child at birth is quite as able to withstand surgical shock
as it is two or three days later after suffering from intestinal obstruc-
tion. Statistics of the operations performed within the first twenty-
four hours show a decided advantage over those done at later periods.
In general, we may say the earlier the operation in all cases of complete
, occlusion, the more favorable will be the prognosis. Every hour's
delay, therefore, is a waste of valuable time. The complete absence
of the anus is no indication whatever of the distance at which the
rectum will be found; indeed, its distance is generally in inverse pro-
portion to the development of the anus. Therefore, the amount of mal-
formation found in the anus, or its entire absence, will not indicate
in any manner the difficulty of the operation.

The prognosis in a case depends largely upon the facility with which

72 THE ANUS, RECTUM, AND PELVIC COLON

the rectum is found and brought into position, but this can not be
stated with any certainty except after operation. It is the duty of
the surgeon to explain clearly to the family that life is impossible
without such an operation, and that no ])ossible advantage can accrue
from delay. The operation itself should be undertaken with the great-
est aseptic precautions. No anaesthetic should be given to children of
this age. They bear pain well, and the danger of shock from this
is less than that of local or general anaesthesia.

Before beginning the incision, it is well to use every method at
our command to determine if possible the position of the rectum. The
skin at the normal position of the anus, or at some }>ortion of the
perina'um, may be of a greenish tinge, due to the transmission of the
green color of tlie c(mtaine(l meconium through the attenuated tissue.
There may he bulging at some point in the perina^um, indicating the
near approach of the rectum. With a hand upon the perina?um and
pressure on the abdomen, one may sometimes feel an impulse from
the rectal pouch when the child is caused to cry or strain; percussion,
w^hile the stothosco))e is apj)lied to the perinjeum, may also aid us to
determine the proximity and site of the rectum.

Other methods, such as introducing a sound into the vagina, the
bladder, or the urethra, have been advised; but the consensus of opinion,
among those who have seen the most of this sort of surgery, is that
they are without any material benefit. Finally, and that which has
been the most frequently used and a<l vised, the introduction of an
aspirating needle, or a trocar, into the j)erina»um, and backward into the
hollow of the sacrum, may be used to determine the position of the
rectum. So far as this operation is concerned, exploratory needles
are dangerous instruments. In their introduction through the per-
ina?imi into the rectal pouch, even if the latter can be found, one can
never be assured that they do not j)a8S through a diverticulmn of the
peritoneal cavity, and upon being withdrawn will allow the meconium
to escape into this cavity, exj)osing the child to all the dangers of
septic peritonitis. The aspirating needle is slightly less dangerous than
the trocar. A fine one may be introduced into a bulging point, or at
a place where impulse can be felt, and meconium withdrawn; then,
without withdrawing it, one may dissect down along its track and open^
the gut. Unfortunately, however, the tension in all these blind rectal
pouches is so great that even the sticking of a needle into them may
cause rupture and extravasation of meconium into the peritonseum or
track of the aspirating needle. Beyond these cases, in which the bulg-
ing or impulse are perceptible, no search with the trocar or aspirating
needle should ever be made; and, indeed, in these very cases, the adTan*
tages are altogether with the plan of careful, patient dissection*

MALFORMATIONS OP THE ANUS AND RECTUM 73

After liaving determined as far as possible the position of the rectal
pouch, the operation can be undertaken at once. In cases in which
there is no anus, one should endeavor to make one. A straight incision
should be made from the point at which the anterior margin of the
anus would naturally appear (Fig. 4), back through the skin and sub-
cutaneous tissues to the tip of the coccyx. If there be a rudimen-
tary anus the incision should begin at its posterior margin. Having
cut through the skin and subcutaneous tissue, we come down upon the
external sphincter muscle, or the fibrous band which takes its place
when absent. In the majority of cases in which the anus is altogether
absent, the sphincter is absent also. At any rate, whether fibrous or
muscular tissues exist at this point they should be divided by a blunt
periosteal elevator instead of by incision, and pulled gently apart. After
this the dissection can be carried upward as far as is necessary in search
for the undescended rectimi. This median incision should be invari-
able; whether the impulse from the rectum is felt to one side, anterior
or posterior to the anus, the incision and the division of the sphinc-
ter should always be the same. The dissection in searching for the
rectum should be carried upward and backward in the hollow of the
sacrum in order to avoid wounding the bladder or other pelvic organs.
When the rectum has been found, an effort should be made to loosen
the pouch from all its attachments, and bring it out through the open-
ing which has been made, with a view of preserving the functional
activity of the anus. This should be done, if possible, without open-
in*: the pouch. Sometimes, however, it will be found impossible to
bring it down into the wound until its distention has been reduced.
Just here we have the one useful indication for the trocar. When
the <rut has been freed from its attachments, and it is found insuifi-
ciently long to be brought down into the wound, the trocar may be
inserted and the meconium drawn off entirelv outside of the wound,
thus reducing the distention and lengthening the gut. After this it
will generally be found that the latter can be brought down into the
wound without difficulty. Sterilized gauze should be packed around
the trocar and well into the wound during this process, and the gut
held firmly by pressure forceps. It is a better plan, however, if the
gut can be brought outside of the wound, to do so, and having packed
the eclges of the wound with gauze, incise it as freely as necessary to
afford an exit for the contained meconium.

The suggestion of Matas that a running stream of saline or other
aseptic solution be carried over the parts during this process of empty-
ing the rectal pouch seems to be contrary' to the opinion of most
surgeons. It is better to use simple, dr}- sponges, thus keeping the
parts free from the discharge.

74 THE ANUS, RECTUM, AND PELVIC COLON

Having emptied the rectal pouch of its contents, the next
in the operation is to fix it in its normal site if possible. This is
by suturing the mucous membrane to the cut edges of the skin a
fiite of the normal anus. It is necessary to emphasize here thai
sutures are not placed in the peritoneal or muscular walls, but ir
mucous membrane of the gut. The intention is to seal off the per
wound from contact with the faecal discharges, to bring the inner !
of the gut upon the outer surface of the skin so that the alvine
charge will be carried entirely outside of the wound. If there be si
fluous mucous membrane, acting somewhat as a prolapse of the rec
it would be all the better, so far as this intent is concerned.

Vincent has advised that when the anus must be made at some o
than the normal position, it would be well to dissect two ellip
flaps of skin from either side of the wound and carry the mucous n
brane outward over the edges of the wound, uniting it to the ski
the points from which these flaps have been dissected, thus affon
a larger area of denuded tissue for the attachment of the gut, am
the same time carrying the discharge from the intestinal canal n
thoroughly away from the deeper section of the wound. This is a n
-excellent suggestion. When the gut has been brought down and se
in its normal position at the anus, the closing of the posterior \
of the perineal wound should be made with sutures passed deep eno
to take in the fibers of the external sphincter and hold them in posit
until reunited. Silkworm sutures or chromicized catgut are most su
ble for this jmrpose. With regard to the sutures to be used in fast
ing the gut to the margin of the skin, authorities differ; a good i
sterilized catgut is preferred: first, because it has less tendency to
through the tender membranes than does any other form of suture; s
ond, it does not have to be removed; and third, after it is introdui
it swells and stops up the holes through which it passes more or 1
-effectually imtil it has become practically absorbed. Silkworm gut 8
silver wire are stiff and too unpliable to bring the points into cl<
apposition.

The author prefers a broken, continuous suture. By this is mee
a continuous suture carried half-way around the rectum and tied, a
then a second one carried around the other half. The advantage
this suture is that it more completely seals off the wound from t
rectal discharges than do the interrupted sutures. Its being brok
in two places gives the anus more opportunity for dilating, and pi
vents the suture acting as a purse-string to contract the orifice. Whe
there is any difficulty or tension necessary to bring the gut down
the margin of the anus, this may be relieved by passing an anchori:
fiuture through the external wall of the gut or the mesorectum, if

MALFORMATIONS OP THE ANUS AND RECTUM 75

can be found, and out through the skin, tying it over a wad of gauze,
and thus taking the traction off the sutures in the mucous membrane.

The dressings should be of soft absorbent gauze moistened with
boric-acid solution, and held in place by a diaper. The abdomen
should be incased in a snug roller-bandage to avoid straining.

Cases in which iht Rectum is arrested High Up in the Pelvis, — The
incision and methods of suturing the gut, when found, are applicable
to all forms of imperforate anus. We come now to the study of those
forms in which the rectum is removed, or arrested, in its descent at
a greater or less distance from the cul-de-sac of the anus. In such
cases the anus may be absent, or it may be perfectly developed, ending
in a cul-de-sac about 1 to IJ centimeter (about ^ inch) in depth. The
method of dealing with this cul-de-sac will be described later, as we de-
sire at this time to devote out attention to the undescended rectum.

In order to thoroughly comprehend the difficulties of searching for
the rectal pouch, it is necessary to understand the space in which the
operation must be performed. This space is outlined by the tuber
ischii upon each side, the scrotum in front, and the coccyx behind.
The distance in infants between the tuber ischii is normally about 1^
to 2 centimeters (f to J of an inch), and does not differ materially
in the sexes. That from the scrotum to the coccyx averages from 4
to 4^ centimeters (1^ to IJ inch), and from the posterior commis-
sure of the vagina to the coccyx in girls about 3 to 4 centimeters
(^tV to 1^ inch). The distance from the anus, when developed, to
the tip of the coccyx would average about li centimeter (^ of an
inch). With these measurements in view, we can understand that the
operative field or space would be embraced in an elliptical figure
with a maximum length of 4 centimeters (1 ^ inch) and a maximum
breadth of 2 centimeters (} of an inch). The depth of the pelvis, or
rather the distance from the tip of the coccyx to the promontory of
the sacrum, is about 6 centimeters (2 -J inches). The distance from
the perina^um, at which the peritoneal cul-de-sac is found, varies con-
siderably, but it may be stated that in general this pouch in females
is about 2 centimeters (J of an inch), and in males it is 2J to 3 centi-
meters (1 inch to 1-j^ inch). It should be borne in mind that those
are normal measurements, and that in cases of malformation of the
anus and rectimi there is also likely to be some malformation of the
pelvic frame. This malformation generally takes the form of abnormal
contraction, and the space for operative procedure is thus reduced. It
is well to mention here also the fact, shown by Cripps, that where there
is malformation of the anus and rectum there is likelv to be some
abnormal distribution of the peritoneal cul-de-sac. This may pass
downward and backward almost to the skin near the tip of the coccyx.

THE ANIT9. RECTPM, AND PELVIC CX)LON

tlius scparalmg iho omU of Iho procludtL'iiiii and the (.'iiteron hv a true
peritoneal cavity (Fig. 48). Such an arrangement of the perilonxum
would render it impoasible to introduce an aspirating needle or trocar
from the anus into the rectum without passing directly through it, and
would ncces:-itate the tiihTieijiifUt infection of that cavity when the
instrument was with-
draw-n. As it 18 im-
possilile to predicate
6uch a condition or its
absence before opera-
tion, one shouhl abao-
lutely limit the use uf
the trocar to carrring
the fluid contents of
the rectum beyond and
outside of the wound,
lifter the organ haa
been found, and it is
impossible to bring it
outside of the wound
before emptying it. It
can bo readily seen
from the measure-
ments al>ove given
that f^pace for o|>era-
tivu manipulation is
very limited, and with
the bladder, uterus,
and other pelvic or-
gans in position, the
operator will have to
be very careful in
working in so small a
space lest he injure
them. The chief space of the pelvis thus left for operative manipula-
tion is in the hollow of the sacrum, and in order to reach this, one has
to dissect backward and upward around the point of the coccjtc, work-
ing largely by feeling and not by sight.

The methods which have been devised to increase this space have
been numerous and ingenious. The first was that of Amussat, which con-
sisted in removal of the coccyx. This operation, simple in itself and very
easy to perform in children, is objectionable because it takes away the
normal attachment of the anal and rectal muscles; it also removes the

MALFORMATIONS OP THE ANUS AND RECTUM 77

support to the lower end of the rectum, and thus invites prolapse and
posterior rectocele. Carrying this operation one step farther, we have
the various modifications of the Kraske or sacral operation. It is not
necessar}' to describe them here, further than to say that whatever
portion of the sacrum it is thought wise to remove can be done by a
strong pair of scissors without the use of a chisel or bone-cutting instru-
ment. The danger of injury to the nerves, shock, and tlie removal of
rectal supports and muscular attachments are tlie objectionable features.

If one could say positively when he begins that the rectum was high
up, and the space would have to be increased, there is no doubt but
that the Rydygier operation, described in the chapter on excision of
the rectum, would be a practical and safe procedure. Such a radical
o]K*ration, however, would not be justified unless we liad some absolute
assurance that the rectum was high up in the pelvis.

A more conservative plan is that of Vincent, who takes advantage
of the soft, cartilaginous condition of the bones at this period, and
splits the coccyx and the lower i)art of the sacrum tlirough their center
with a large pair of scissors; then the edges of the wound are re-
tracted and ample space for operative manipulation, and a good, free
view of the whole pelvic cavity are afforded. After the rectum has
been found and brought into its normal ])osition, deep sutures are
used to bring the bones and tissues togetlier, and thus the pelvic frame
is absolutely restored. This operation, as described by Matas, Vincent,
and others, has proved entirely succcvssful, and the ultimate results
have been most satisfactory'. Theoretically there is one objection to
it, and that is in cases in which the rectum can not be brought down
to its normal position, and must be attached to the upj)er end of the
wound, it will necessarily bring the gut out between two flaps of bone.
In such instances the bone flap or Kraske operation would be more
satisfactor}\ Xevertheless, in the Vincent operation there would be
little difficulty in peeling out the cartilaginous section of the sacrum
or coccyx so as to make the flap soft ui)on one side in such an emer-
gency, and the ultimate results would be the same as by the other meth-
ods. The space for operative manipulation having thus been materially
enlarged, the succeeding stei)s of the oi)erati()n will be in full view and
comparatively simple. Dissection should be carried ui)ward into the
hollow of the sacrum to the depth of 5 or G centimeters (2 or 2g inches).
At the same time careful palpation should be made witli the finger in
the wound to elicit, if possible, any imimlse from the child's crying
or from pressure upon the abdomen by an assistant. Where such
impulse is felt it arises from the rectal pouch or from some loop of
sigmoid, and dissection should be made in this direction. At this stage
of the openition it is best to introduce a sound into the bladder of

78 THE ANUS, RECTUM, AND PELVIC COLON

the male or the vagina of the female, in order to determine the ex
location of these organs, and thus avoid wounding them. The fibn
cord which sometimes leads from the imperforate anus up to the rec
pouch (Fig. 42), when found, should always be kept in view and f
lowed closely, as it is a certain guide to the rectal pouch. ^Vhe^e t.
cord does not exist we must depend upon careful dissection in on
to find the gut. When it is not found in the hollow of the sacn
after having dissected upward for the space of 5 or 6 centimeters
or 2J inches) from the margin of the anus, dissection in this line
no longer advisable; but the operator should carry his incision throUj
the soft cellular tissues forward and upward, entering the periton(
cavity at once, if the rectal pouch is not reached before doing so. T
dangers in this operation are not from opening the peritoneal cavil
but from allowing the intestinal contents to escape into it. The auth
would not advise opening the peritoneal cavity unnecessarily under ai
conditions, and much less so in a feeble child; but the old dread
invading this cavity has caused the waste of much valuable time, ai
has been the cause of death in manv cases. Therefore, when the rect
pouch has not been found, after a reasonable dissection in the hollo
of the sacrum, the immediate and free opening of the peritonaeum
advised. When this has been done the search for the rectal pouch
simple enough. If it is distended and tense, and in the pelvic cavil
at all, it will be easily felt. It may be attached to the promontory (
the sacrum off to one side of this bone, or it may be floating loog
in the peritoneal cavity. In the latter instance it is generally easil
brought down, and can be attached to some portion of the wound witl:
out much tension. When, however, it is attached to the promontor
of the sacrum, or to its side high up, the process of bringing it dow:
is much more difficult. The difficulty lies in the fact that the recta
pouch is covered over and bound down to the bone by a peritoneal foh
which entirely envelops the lower end, and is really the cause of it
non-descent.

The splitting of this peritoneal covering, and the enucleation of th<
rectal pouch so as to bring it down to the margin of the wound, hai
been attempted with some success. This, however, is a most difficuli
procedure, and the author questions ver}' much if it would not be wisei
to do an inguinal colotomy as soon as such a condition of affairs ij
found to exist, or, if possible, bring a loop of the sigmoid flexure down
and attach it to some point of the perineal wound. When the rectum
is found, the greatest care must be exercised to loosen its attachments
and drag it down so as not to rupture the inferior mesenteric artery,
and thus obliterate the blood supply to the parts. When it has been
brought down in the perineal wound at the normal position of the anus.

MALFORMATIONS OF THE ANUS AND RECTUM 79

or higher up, if necessary, the peritonaeum should be closed by gauze
packing before the gut is opened to allow the escape of the meconium.
If the development of the rectal pouch is so short that it can not be
brought outside of the peritoneal cavity, then this cavity should be
closed, the perineal woimd packed off, and inguinal colotomy done at
once. Sometimes, where the rectum can not be found by perineal inci-
sion and dissection, and inguinal colotomy has been done, it will
descend at a later period, and the operator will be able finally to
approximate the anus and rectum at their normal positions.

The fixation of the rectum in this form of malformation is prac-
tically the same as that in simple imperforate anus. The mucous mem-
brane should be sutured to the skin at the normal anus if possible, and
if not possible, it should be sutured at the lowest point of the perineal
wound to which it can be brought without too great tension.

An interesting case illustrative of the conditions just mentioned is
reported by Kronlein (Berlin, klin. Woch., 1879, p. 126). He opened
the peritoneal cavity after a dissection of 3 inches without finding the
rectal pouch. The finger end introduced in the cavity failed to find
the missing cul-de-sar, and he immediately attempted inguinal colotomy.
Here again he met with a difficulty in the close attachment of the colon
to the lumbar region, which absolutely prevented his bringing the colon
up into the abdominal wound. He was therefore compelled to bring
up and open the next and most distended loop of intestine. He does
not state whether this was the small intestine, sigmoid, or transverse
colon. Nevertheless the child recovered, and seven mcmtlis later,
" when the finger was introduced into the artificial anus," a resisting
body was felt in the pelvis, which he supposed to be the distended
rectum. The perineal incision was reopened, and he found that the
distended rectal pouch had since the operation descended low enough
into the pelvis to be brought down and sutured at the site of the normal
anus. This case is quoted in illustration, first, of the wisdom of early
incision into the peritoneal cavity; second, of the difficulty which may
arise in inguinal colotomy in children; third, as illustrative of the fact
that the rectal pouch may continue to grow and descend, and eventually
reach a position from which it may be attached to the normal anus
long after birth. In Kronlein^s case the inguinal anus closed in three
we(»ks after the rectal pouch was attached to the anus.

Treatment of the Anal Cnhde-sac. — We come now to consider the
management of those cases in which the anus is fully developed and
the rectum more or less removed or has descended alongside of the
anal ml-de-saCy as illustrated in Fig. 41.

In these cases the external sphincters are normal and the anal cul-
de-sac, for the space of 1 to 1^ centimeter (f to | of an inch), is per-

80 THE ANUS, RECTUM, AND PELVIC COLON

fcctly formed. Tlie treatment of this cuUde-sac and the question of
union between it and tlie rectum (wlien the latter has been found) has
created considerable discussion. The oj)eration of end-to-end union
between the two cuh-ih'Sac is a very difficult one to perform, and most
uncertain in its results. Recent surgical opinion and the results of
oj)erations upon this class of cases have convinced me that it is l)est
to dissect away the lining membrane of the anal cul'de-sac and bring
the rectal mucous membrane down to the margin of the skin thus
freshened and suture it there. The incision in such cases would depend
upon whether the rectal pouch can be made out without dissection or
not. In case this was ])ossible, the incision through the anus should
undoubtedly be made in the direction in wliich the rectal pouch is
felt; but if the ])osition of tlie rectal j)ouch can not be made out with-
out dissection, then it should be made from the posterior margin of the
anal nil'de-sac back to the coccyx, just as in the previous operations.

ilatas, in a case in which the rectal pouch descended in front of
the anal nil-cle-snr, sutured the end of the rectal pouch to the perineal
margin, left in sifii the anal nil-de-sac and incised the sa»ptum between
the two. He says: ** The objection to lateral ano-proctorrhaphy (as we
might distinguish the suture of the bowel to the rudimentary anus as
practised in my case) is, that it leaves a larger anal orifice than is
required, and that the interj)osition of new mucosa in the i>osterior
segment will act as a wedge and will interfere with the perfect grasp
of the sj)hincters." He therefore advises as a better procedure the
total excision of the anal nil-(h'sar, leaving the marginal anal mucosa
intact, and suturing to this the mucous membrane of the rectal pouch.
Aside from the diflicultv of end-to-end suture of the rectal and anal
pouches (the circumference of the rectal pouch being always much
greater than that of the anal) there will be imperfect coaptation and
danger of valvular stricture eventually succeeding.

Coloiomy in Cases of Imperforate Anus. — Thus far we have only
referred to the operation of colotomy as a last resort in cases where
the rectum could not be found, or where it was impossible, owing to
other complications, to establish the anus at its normal position. The
operation, however, merits a closer consideration. Some surgeons hold
that an inguinal anus should be made as a preliminary operation to
perineal search for the undescended rectum in all cases in which the
latter can not positively be felt through the anal cul'de'Sac or perina?um.
They hold that it is more certain and less fatal than proctoplasty, and
that it does not intei-fere with the ultimate establishment of the anus
at its ])ro])er site after the child has grown stronger. The arguments
in favor of such a procedure are not without weight. The rapidity with
which such an operation can be performed is urged in its favor, and

MALFORMATIONS OP THE ANUS AND RECTUM 81

can not be ignored. The fact that the sigmoid flexure is sometimes
difficult to find in children, or that it generally rests upon the right
side instead of the left in early infancy, does not militate against it.
To one familiar with these conditions it is not difficult, if the abdomen
is open, to sweep the finger clear across the pehis in these little ones
and find the loop of intestine in which it is desirable to make the arti-
ficial anus. Again, it is urged that in this operation an opportunity
will be afforded to search the sacral curvature and deeper pelvis, and
thus accurately determine the absence or presence and the location
of the undescended rectum. Moreover, it is claimed that the amount
of traumatism and mutilation of the tissues necessary to perineal search
for the rectal pouch will be greatly lessened by a preliminary colot-
omy, and that if, after the abdomen is opened, the operator discovers
the rectal pouch within easy reach of the j)erinjeum, the abdominal
woimd can be promptly closed and the perineal operation performed
with much greater certainty, and with smaller incisions than wliere
it is attempted ah initio. Furthermore, the advocates of preliminary
colotomy claim that after the artificial inguinal anus is establislied
and the patient has recovered from the same, it will be quite feasible
to pass a blunt probe or sound through the lower seguient of the gut
into the rectal cul-de-sac and thus determine the exact location of
this pouch. With the probe in this position one can dissect down
npon it with comparative ease and establish the anus in its normal
position at a time when the child is well able to withstand surgical
interference. These advantages are undeniable, and should be given
due consideration.

The arguments against such an operation have been based chiefly
upon the danger of invading the peritoneal cavity, and the high mor-
tality which has followed the operation. Since Lawson Tait has prac-
tically dissipated the fear of invading this cavity, and since it has been
sho>*'n that under proper aseptic precautions and with due celerity the
peritoneal cavity of a child can be opened almost as safely as in those
of greater years, this argument has lost much of its weight. Xo one
would controvert the proposition that if the faecal exit could be es-
tablished at the normal site without invading the peritoneal cavity,
or subjecting the child to too great and protracted surgical procedures,
such a method would be preferable to inguinal colotomy. But when
the child is extremely weak, when immediate relief is urgently de-
manded, and when the condition will not justify even the delay of a
prolonged search for the rectal pouch, inguinal colotomy undoubtedly
has its advantages.

Another argument against the performance of this operation in
children is based upon the thin and fragile texture of the intestine

82 THE ANUS, RECTUM. AND PELVIC COLON

during infancy. It has been held, and justly so, that its tissues will
not bear suturing well, that they are not strong enough to hold the
gut fimily in the abdominal wound, and therefore there is great danger
of their breaking loose and allowing the loop of the intestine to drop
back into the abdominal cavity after it has once been opened, thus
infecting the peritonanim and producing a fatal termination.

If it was necessary to depend upon sutures to hold the gut in posi-
tion, these facts would be sufficient to condemn the operation, except
as a dernier ressort. But tliis argument loses its force when we consider
the fact tliat the best operators no longer use sutures to support the
intestine in colotomy. Maydl and Reclus have established the fact that
few if any sutures are necessary in the j)erformance of this operation,
and tliat a glass rod passed through the mesentery from one side to the
other of the wound forms a safer, a more permanent, and better support
to the intestine than any number of stitches can possibly do. Hun-
dreds of operations done after this manner with perfect success have
confirmed their opinions that the dangers of infection, tearing loose,
and puncture from st it dies and stitch-hole abscesses have been entirely
obliterated by their method. Not (mly is this true, but the time of the
operation has been greatly shortened and the dangers of surgical shock
proportionately decreased. Thus, where circumstances seem to demand
it, an inguinal colotomy may be safely and quickly made in children
with imperforate ani, and by it valuable lives may be saved which would
almost certainly be lost if any other method were adopted. The ques-
tion of closure of the artificial inguinal anus will be discussed later on;
but it may be stated here that in children such apertures will generally
close spontaneously if a normal exit for the intestinal contents has been
well established.

The choice of operations, therefore, between the perineal dissection
in search of the rectal pouch and inguinal colotomy will depend first
upon the knowledge which we have of the proximity of this pouch and
the child's ability to withstand surgical operation. Where there is no
evidence that the rectal pouch can be easily reached, and where the
child is in an enfeebled condition, with distended abdomen, fa>cal vomit-
ing, and nausea in progress, one should not hesitate to choose the
abdominal route, perform an inguinal colotomy at once, and thus aflFord
an immediate exit to the intestinal contents, and an escape for the gases
which are causing the distention and the constitutional disturbances.

Proctoplasty Versus Colotomy, — The tenn proctoplasty has been
adopted by recent writers to describe the various perineal methods for
operations upon imperforate ani. There has been a long and animated
discussion concerning the comparative mortality from proctoplasty and
colotomy in these cases. Able and vigorous writers have been engaged

MALFORMATIONS OF THE ANUS AND RECTUM

upon either side. Recently the wage of battle seems to favor the
perineal method.

In the total number of operations done, there is no doubt that the
percentage of fatalities is less in proctoplasty than in colotomy. It
must not be forgotten, however, that a large number of the cases done
by the former method have been of the simplest type, and have required
operations of no magnitude. In many of these cases the rectal pouch
has been in apposition with, or very close to, the perinaeum, so that
it could be reached by a very shallow incision and without involving
any important organs. The list of these operations also includes many
cases of malformation, such as atresia ani vaginalis, which would not
have proved fatal had nothing been done for them. On the other
hand, the cases in which primary colotomy has been performed have
been those of the most desperate character, many of them having
already undergone prolonged perineal search previous to the colotomy
operation.

In studying the comparative figures, therefore, we must not attach
too great importance to the percentage column. In the old statistics
the operation of puncture by the trocar was always included, and a
very high mortality resulted. Thus, Anders gives for it 50 per cent,
Curling 76.4 per cent, and Cripps 82.3 per cent. This operation is
now practically abandoned, and need not be considered here.

The following brief table represents the comparative results of
colotomy and proctoplasty in the collections of cases by Anders, Curl-
ing, and Cripps:

Mortality from Different Operations for Imperforate Anus

Anders.

52.8 per ct.

Colotomy, primary..

Colotomy, secondary
— i. e., after proc-
toplasty had Deen
attempted

Proctoplasty

Proctoplasty, omit-
ting atresia anij
va^nalis 38.2 per ct.

Total cases ' 67

30.5 per ct.

Curling.

47.6 per ct.

39.3 per ct.

100

Cripps.

68.4 per ct.

32.7 per ct.

40.4 per ct.

Author.

43.7 per ct. (32 cases).

45.2 per ct. (42 cases).

39.3 per ct. (66 cases).
140

From the table one will see at a glance that the perineal method
is less fatal than colotomy. We must not forget, however, the varia-
tions in gravity between the class of cases in which the one and the
other operation is adopted.

In a study of the modem journal literature upon this subject, 140
case.s in which operations have been done for malformations of the
rectum have been collected. Of these, 66 cases were performed by the

84 THE ANUS, RECTUM, AND PELVIC COLON

perineal and sacral route with 26 deaths, a mortality of 39.3 per (
In 42 cases colotomy was done secondary to perineal and sacral op
tions with 19 deaths, a mortality of 45.2 per cent. Thirty-two priE
colotomies were done with 14 deaths, a mortality of 43.7 per cent,
introduction of these tables would consume too much space. But air
without exception primary colotomy was done in the most grave co
tions. This is emphasized by the fact that the mortality in immed
colotomies is very slightly less than in those which were done seconc
to extensive perineal operations. These facts are borne out by thos
Matas (Transactions of the American Surgical Association, 1897). '
high mortality given by Anders for colotomy in these cases is explai
by the fact that in 21 operations done, 12 of the patients had previoi
been subjected to prolonged perineal operations, and thus their condii
was not what it should have been in order to begin the colotomy. M<
over, the low mortality in his table for proctoplasty in general is made
from a number of exceedingly simple cases in which there were c
membranous divisions between the rectum and anus, and others of a
sia ani vaginalis. If these cases are left out of his tables the morta
from colotomies will be largely decreased, and that from proctoph
will be considerably increased. But, after all allowances are made, pi
toplasty, or the perineal operation, still has the advantage in a sma
mortality. Nevertheless, it is the condition of the child and the urge:
of the case, and not the statistical mortality which should determine ui
choose proctoplasty or colotomy in any individual instance. In
hausted children with t}Tnpanites and symptoms of intestinal sepsis,
most expeditious methods of relief are demanded, and, as Matas ^
says: " Under such adverse conditions it can not be denied that ingui
colotomy is the quickest and safest operation.^^

Treatment of Abnormal Narrowing of the Anus. — In cases of abn
mal narrowing of the anus no operative procedure is called for in 1
early period of life, provided a reasonable exit exists for the fluid C(
tents of the bowel. Gradual and gentle dilatation with bougies,
with an ordinary uterine dilator, will generally bring the parts up t(
comparatively normal size. This conservative method of treatment \^
afford the necessar}^ exit for faecal matter, and in this condition t
child may wait until it has developed sufficient strength to stand sur,
cal procedures. If the contraction should prove to be of a fibre
nature, which condition is exceedingly rare, posterior proctotomy, <
which is better still, the excision of the fibrous tube, bringing down
the mucous membrane and suturing it to the skin may be performed
a later date (Ijannelongue, Bull, et mem. soc. de chir. de Paris, 188
p. 200; Degouy's Theses, Lyons, 1894; Couty, Theses, Paris, 1889; ai
Vauclaire, M6d. infant, Paris, 1895, p. 86).

MALFORMATIONS OF THE ANUS AND RECTUM 85

Treatment of Partial Occlusions. — When the obstruction consists of
a fold or band of skin running from the scrotum or posterior commis-
sure of the vulva back to the coccyx, there is no advantage in delay
even though there be a moderate exit for the meconium. Such a band
can be snipped off at its ends with scissors and dissected away. The
anus should then be periodically dilated until it assumes its normal
shape and size. When, however, this partial occlusion occurs at a
liigher level, and the exit for the meconium is very limited, the ques-
tion as to management is somewhat more difficult.

Matas {op. cit.) states that simple incision of these crescentic
diaphragms has not been satisfactory. The procedure, he says, is fol-
lowed by recurring strictures and consequent obstruction to the fa?cal
passages. He therefore advises the total excision of the membranes
and suturing the edges of the wound together. Most authors, however,
do not appear to have seen any such results from simple incision in
these cases. In fact thev state that if such membranous obstructions
are thoroughly incised, they will atrophy and entirely disappear. The
author's experience has been limited to 4 cases of this kind, and he
has not been able to follow them to any late period of life; but two
of them he has seen at the ages of four and six years respectively,
and no such strictures had occurred. He is of the opinion that Matas's
views are largely theoretical upon this point, and that inasmuch as the
simple incision is almost entirely without danger and involves no shock
it ought to be employed in all these cases. If a stricture should occur,
it may be resected later on in life. The possibility of litTmorrhage in
incising these obstructions should alwavs be borne in mind. One case
has been reported in which the child died from this cause.

Treatment of Complete Occlusion hy a Membrane or Diaphragm. —
These cases are among the simplest as well as the rarest of rectal mal-
formations. Usually this membrane is so thin and diaphanous that
the color of the meconium is transmitted through it, the bulging of
the rectal pouch is easily felt when the child cries or when pressure
is made on the abdomen, and there is little doubt about the close prox-
imity of the pouch.

Sometimes these membranes are so thin and fragile that even
examination with the finger, especially if the nail be sharp, will rup-
ture them, and there will be a spurt of meconium from the anus. At
other times, however, the membranes are more dense and fibrous, and
while the impulse can be felt, ordinar}' pressure fails to rupture them.
The impression to the touch in such cases is vevy similar to that pro-
duce<l by the bag of waters in the early stages of labor. In such simple
cases a crucial incision through the membrane, carried from one side
to the other of the anus, will be all that is necessary. The little tri-

86 THE ANUS, RECTUM, AND PELVIC COLON

angular folds left by such incision atrophy and disappear^ and no
remains of them can be seen in after life.

Unfortunately, however, there is sometimes more than one such
membrane. When this is the case the fluid which escapes through the
first incision is only a thick serum or nmcus and not meconium. Great
care must be exercised in determining the nature of this fluid, else
in these cases the operation will lie of no avail. The finger should be
introduced well uj) into the rectal pouch after the incision is made,
the parts well dilated, and the operator should assure himself that no
secondary membrane exists at a higher level. Voillemier's case, in which
there were three sucli distinct membranes, forcibly illustrates the
necessity of such precaution. One point nmst be taken into considera-
tion in those cases, an<l that is that the impulse imparted to the finger
may bo due to fluid in the peritoneal cavity. Incisions through such
mombranos should bo made with the greatest aseptic precautions in
order to prevent any disastrous results following. When a second mem-
brane is found to exist, a tubular s])eculum should be inserted and the
parts carefully observed to see that the cavity from which the first
fluid escapes is lined with mucous membrane and is entirely shut off
from the peritoneal cavity. Through this sj)eculum, under aseptic pre-
cautions, a long as]>irating needle may be introduced through the second
membrane if fluctuation and impulse can be felt. If meconium is
drawn through this noodle, then, with the needle still in position, an
incision may be made through the second membrane and the wound
gently dilated.

At those higher levels wide crucial incisions are to be avoided, as
they may accidentally involve the ])oritoneal cavity. The making of an
exit sufficient for functional purposes is as much as can be safely under-
taken in such cases, and if, at a later period, the lateral folds thus left
produce any obstruction or inconvenience they may be excised by
scissors or Pennington clips.

Treaivient of Cases in trhirh the Reel urn opens at some Abnormal
Posifion on the Skin. — Interference in such cases is not generally
urgently demaudod, especially if the opening be in the perineal, sacral.
Niilvar, or abdominal regions. The exit is generally sufficient for
functional purposes during early life, and the time at which operative
interference is undertaken can be selected with reference to the con-
venience of the family and the condition of the child. Happily in
these cases there is no necessity for prolonged, blind dissection in search
of the missing gut.

The abnormal opening, if it be not too far removed from the natural
anus, should be dissected out, together with the rectal pouch, and
sutured to the skin at the site of the normal anus. Wliere the abnormal

MALFORMATIONS OP THE ANUS AND RECTUM 87

opening is too far removed from the perinspum to be brought down and
sutured in this position, the rectum should be searched for by perineal
dissection, and if found should be brought down and its mucous mem-
brane sutured to the skin at the site of the anus. The ftpcal current
will thus be turned in the natural direction. The abnormal openings
will gradually atrophy and close under such circumstances. If they
do not, however, at a second sitting they may be dissected out, invagi-
nated, and closed by Lembert sutures.

Where the abnormal opening is connected with the rectum by a
long fistulous tract, as in those cases where it opens at the prepuce,
the lower end of the scrotum, or in the glans penis, obstruction will
be likelv to occur. Such cases demand an earlv interference. The
obliteration of these long mucus-lined tracts, without a too elaborate
dissection, is a question of considerable diflliculty. The author's opinion
is, although he has had no experience in such cases, that the opening
into the rectal pouch at the normal site of the anus should be estab-
lished just as soon as the child's condition will permit. When this
has lK?en done, the tract leading to the abnormal oj)ening should be
cut across at a point close to its entrance into the rectal pouch, and a
ligature should be applied to the proximal end. This end should then
be invaginated into the rectum and retained there with Lembert sutures.
The cut end of the remaining portion of the tract should be closed in
the same manner and left to atrophy after it has been thoroughly
cleansed. It is a well-known fact that mucous tracts thus abandoned,
so far as functional activity is concerned, do atrophy and become noth-
ing more than fibrous cords which are not detrimental to the individual.

Where the abnormally placed anus is at some such remote position,
as on the abdomen, the chest, the shoulder, or in the neck, the ingenuity
of the operator will be put to the severest test to devise some means of
establishing a convenient outlet for the fjecal material. It is improba-
ble in such cases that the rectal pouch is or can be brought near to
the j)erina?um. If a loop of the sigmoid or colon can be brought down
and sutured at the anal site it will probably serve all necessary pur-
poses. Othem'ise an artificial anus should be made in the left inguinal
re«rion after the manner of Witzel or Bailev. Certainly no interfer-
ence beyond dilating the abnormal opening to facilitate the escape of
the intestinal contents should be undertaken in such a case until the
child has arrived at an age to justify a prolonged and difficult surgical
operation.

Treatment of Cases in which the Rectum opens into Some Other
Viscus. — This class of cases embraces about 40 per cent of all cases
of malformation of the rectum, and the large majority of them are
those in which the rectum opens at some point in the vagina or vulva.

88 THE ANUS, RECTUM, AND PELVIC COLON

The Rectum comnmnicafes with Bladder, — Where the rectum opens
into tlie bladder it is a question of immediate operation or death in a
sliort time from infection.

The size of the opening into tlie bladder has little to do «*ith the
prognosis. The freer the discharge of the intestinal contents into the
bladder the more rapid will be the progress of infection. The prog-
nosis in this condition is always unfavorable, and yet operation offers
the only liope of life.

All teachings with regard to such malformations are largely theo-
retical. Some few cases have been operated upon, but scarcely two by
the same method. ^lartin (Diet, des Scs. med., vol. xxiv, p. 127) sug-
gested as a means of relief in these cases that a perineal anus should
be established and the recto-vesical siv])tum incised down to the neck
of the bladiler, thus furnishing a free exit for the combined contents
of the two organs. This a])pears to be a very blind operation, and its
eventual benelit to the child would be of a most doubtful character.

From a rational point of view there are two methods of procedure
in such cases, both of which involve abdominal section. The author
believes such cases should be o])erated uj)on at the earliest possible
moment by a full, free incision into the abdominal cavity. After this
the condition of the ])arts and the location of the opening into the
bladder will determine the future steps of operation. Where t!ie com-
munication is high up and can be reached, it is perfectly feasible to
separate the two organs at the j)oint of communication, invaginate the
openings into each, and suture them, provided there is an external ori-
fice for the esca})e of the fa'cal matter from the rectum. If, however,
there is an imperforate anus this condition should be remedie<l first
by procto])lasty or colotomy.

Where tlie opening into the bladder is low down, in the neighbor-
hood of the trigone, and beyond the reach of the operator to suture
with any degree of certainty, it will be better to make a permanent
inguinal anus, and close up the lower end of the colon entirely. There
is little danger in such cases that the urine will escape upward into
the gut, and if the fiecal current is shut off from the bladder the distal
end of the divided intestine will atrophy, and eventually the communi-
cation will close.

The fact that this operation condemns the child to an artificial
anus all its life must be considered by the parents and surgeon. These
artificial ani are no longer the nightmare which they were in former
days. p]ven in adults they are so made at the present day as to possess
almost absolute control, and in a position in which they are compara-
tively convenient. Xow, when such an arrangement is made in infancy,
the child is taught from birth to utilize it, and it becomes just as con-

MALFORMATIONS OP THE ANUS AND RECTUM 89

venient as if it were in its normal position. Such an anus made in child-
hood develops eventually almost as perfect sphinctcric control as has
the normal anus. Certainly there is no question of choice between the
two procedures, if it is possible to cany out the first with any degree
of safety; but where the opening is so low down that one can not reach
and safely suture it, colotomy is the more conservative operation, and
offers a better prognosis.

The Rectum communicates with the Urethra, — In this type of cases the
dangers of infection are less than in the preceding variety, and while
the escape of meconium is limited the condition is generally not an
urgent one. The conditions for surgical interference are also much
more favorable, the bowel is always lower down and nearer the pelvic
floor, and tlie point at which the rectum opens into tlie urethra can
be made out by touch or by the use of a fine probe. When it is in the
membranous or bulbous portion it will be easy to dissect down upon
the rectal pouch, disconnect it from the urethra, and bring the fresh-
ened edges of the orifice by which it emptied into the urethra back
to the normal position of the anus after enlarging it to whatever extent
is neeessar}' to produce a good aperture. When the opening is near
the meatus the case should be treated as advised for preputial cases.

The time at which tliis operation should be done depends largely
upon the condition of the child. When tliere is a free escape of
meconium and no distention of the abdomen, tlie operation may be
deferred until the child's strength justifies surgical interference. If,
however, tlie escape of the meconium is obstructed, the abdomen
i^woUen, the child fretful and peevish, the oj)eration should be done
at once.

As to what becomes of the opening in the urethra after such an
ojK^ration as this, one has only to consult his experiences with perineal
section for strictures and fistula in adult life. If the urethra is split
and the redundant mucous membrane cut away, these fistulous tracts
close spontaneously and without difficulty. So also in the child. After
the rectum is detached from its connection with the urethra a simple
perineal fistula is left, which eventually heals of its own accord. The
prognosis in such cases is comparatively good.

The Rectum opens info the Vagina. — In these cases the opening may
occur at any point from the margin of the vulva up to the junction
of the vagina with the uterine cervix; it is generally free enough to
allow the passage of meconium, and even solid matter, without great
difficulty: it may be com})aratively large, and yet the discharge of
meconium be obstructed by an imperforate hymen. In such cases the
diagnosis is made from the bulging, greenish membranes between the
vulvae, and incision of the hymen should be the first step in treatment.

90 THE ANUS, RECTUM, AND PELVIC COLON

If the opening between the vagina and the rectum is not sufficic
free it should be dilated by bougies or a uterine dilator. Pui
interference should be governed by the condition of the child.

At what age should the operation for vaginal anus be un
taken? In the author's experience, children at the age of thre<
five years stand surgical operations very well. He has operated v
a large number of children at this age for various conditions of
rectum and anus, and has never yet seen one suffer particularly f
surgical shock or haemorrhage. From this and some experience a
the malformation under consideration, it would appear wise to se
this period of life for its correction. If, however, the condition is
covered in infancy, and the aperture is too small to admit of
functional activity of the intestine, one may be called upon to de<
whether it is not better to operate then than to dilate the opening
wait until later years. The author has no hesitancy in saying di
it and wait. In general the opening will be found sufficient for fu
tional purposes, and the time most suitable and convenient may
elected for operative interference. Many methods have been devi
for carrying out this procedure. One of the first operations consis
in making an incision through the perinaeum and anus up to the
normal opening in the vagina, thus giving an exit to the faecal mat
through the perinapum at the site of the normal anus. A tube or cann
is passed into the rectum and kept there until the anterior portion
the wound has healed. Such operations are far from successful. La
on the operation was modified by making this same incision, cutti
and dissecting the mucous membrane from around the margin of 1
abnormal opening, and suturing the anterior edges of the gut togetl
from this point down to the level of the perinseum; the mucous me;
brane of the gut was then sutured to the skin at the site of the norn
anus, and the perinaeum and vagina were closed by deep sutures as
the ordinary operations for complete rupture of the perinaeum. Su
operations were fairly successful, but it was a long time before t
patient obtained any sphincteric control over the movements of ti
bowel.

Another operation consisted in dissecting upward in the perinaeu
until the rectal pouch was found; the mucous membrane of this pou(
was then sutured to the skin at the margin of the anus, thus leavir
two exits to the rectum, one in the vagina and one in the anus. Tl
operators trusted that, owing to disuse, the opening in the vagir
would close spontaneously. Such hopes, however, were fallaciou
Later on they were led to attempt to close the abnormal openings l
cauterizing them, which procedure led to a number of successes, bi
was not altogether satisfactory. Especially was this operation unsu*

MALFORMATIONS OF THE ANUS AND RECTUM 91

cessful in cases in which the condition had been allowed to reach adult
life, owing to the fact that the sphincter muscles having never been
brought into action had atrophied and practically disappeared, conse-
quently the patients upon whom the operation was done suffered from
persistent incontinence of fa?cal matter. After this the problem of
correcting the malformation was practically solved by Eizzoli (Gross's
System of Surgery, vol. ii, p. 205, sixth edition), who says that inas-
much as these vaginal ani always possess a certain amount of voluntary
control there must exist around them a sphincter muscle, and that
the presen-ation of such an organism would be of the utmost impor-
tance to the child. His method of accomplishing this is as follows:
An incision is made from the posterior margin of the vagina backward
to the point at which the normal anus should end; the perineal tissues
are carefully dissected to reach the rectal pouch; this is then carefully
loosened from its attachment all around, and the vaginal anus is dis-
sected out intact, dragged down to the position of the normal anus,
and carefully transplanted there. The perineal tissues in front of the
gut are then brought together by buried catgut or deep silver sutures,
and the mucous membrane of the vagina is carefully sutured, thus restor-
ing completely the recto-vaginal sa}ptum, and closing all communication
between the two organs. By this procedure the natural opening in
the intestine is perfectly preserved with all its sphincteric power, and
the danger from non-union or retraction of the parts is practically
obliterated. It also has the great advantage of restoring the perimvum
and recto-vaginal sa^ptum, a matter of the utmost importance to the
woman. Another advantage in this operation is that it practically
obliterates any diverticulum in the rectum at the point of communica-
tion with the vagina, such as is ver}' likely to occur in operations by
other methods; and, again, it obviates the necessity of repeated opera-
tions such as were necessary in the cases of Aveling (Lancet, December
20, 1884), and Buckmaster (Trans. Amer. Gynaec. Ass'n, 1894, vol. xix,
p. 2T5). Cases sometimes occur in which this operation is not feasible,
owing to the fact that there are two or more openings into tlie vagina,
as has been reported by Ainsworth (Bodenhamer, op. cit., p. 227). In
such instances much ingenuity must be exercised in performing a plastic
operation which will cover the necessities of the ease. If two openings
are close together they may be converted into one by a simple incision,
the margins of which may be puckered with a purse-string suture and
attached by the mucous membrane to the margin of the skin at the
site of the normal anus. When, however, these openings are separated
by some considerable space, it would be better to dissect out the lower
opening, completely detach the rectum from all its attachments up to
the upper opening, and close this by inversion and the Lembert sutures.

92 THE ANUS, RECTUM, AND PELVIC COLON

The lower abnormal anus should then be transplanted to the posil
of the normal anus.

The Rectum communicates with the Uterus, — Such cases are practie
so rare that one can scarcely speak with any definiteness concern
their treatment. As stated before, the author knows of but one cj
and no operation was performed to remedy it. It seems, howe^
that the proper proceeding in such cases would be to establish an ai
at the normal site, if possible, and to follow this by laparotomy, divis
of the canal connecting the two organs, and inversion and suture
the apertures in each, after the same manner as has been advised
those cases in which the rectum communicates with the bladder,
however, the rectal cul-de-sac ends at its communication with the uter
the establishment of the anus at the normal position would be prac
cally impossible. The only recourse left to us under such circu
stances would be the establishment of an inguinal anus and the closi
of the lower end of the gut. If, however, upon opening the abdom
for this procedure the sigmoid flexure and rectal pouch are fou
sufficiently long to reach the perineal floor, one might dissect t
rectum from its attachment to the uterus, close the opening in th
organ, and finally bring the opening into the intestine dowTi and sutu
its mucous membrane to the skin at the site of the normal anus. Su'
a proceeding, however, has never been attempted, as far as can
learned, and the above remarks are simply suggestive.

The Bectum and Anus are Normal, hut have opening into them t
Ureters, the Uterus, or Vagina, — Some 20 cases of such malform
tions have been described by various authors. Bodenhamer has co
lected 7 in which the ureters terminated in the rectum, and 9 i
which the vagina or uterus ended in this organ. In those cases i
which the ureters terminated in the rectum the bladder was foun
absent, and the rectum performed all the functions of both organ
Any operation intended to remedy such a deformity would be irrationa
inasmuch as there would be no reservoir into which to transplant th
ureters. The dangers of infection traveling from the rectum up th
ureters and into the kidney will always exist; although Xature seem
able to protect herself in such cases, and persons with these abnormal]
ties have lived to a comparatively good age without suffering froii
such complications.

In those cases in which the uterus or vagina opens into the rectum
operative interference may be safely undertaken if a proper perioi
and state of the patient be selected. Unfortunately the victims of thi:
malformation rarely realize their condition, and cases have been knowi
to grow to womanhood, marry, and bear children successfully, evei
although afflicted with this deformity.

MALFORMATIONS OP THE ANUS AND RECTUM 93

Ball ssLYs: " It does not appear that there would be greater difficulty
in operating upon these cases than in those of a converse condition
already described, where the rectum opens into the vagina/^ This
might be so or not, from the fact that where the vagina or the uterus
opens into the rectum the communication is not by a small, narrow
opening, such as is the case in the inverse condition, but by a large
patulous communication which it would require an extensive operation
to close. Only one operation, so far as I am aware, has been under-
taken for this condition, and that was successful (Bodenhamer).

CHAPTER III
EXAMINATION AND DIAGNOSIS

The importance of local examinations in diseases of the anus an*
rectum can not be overestimated. Here more than in any other poi
tion of the body are the diseases liable to progress rapidly, and care
lessness and errors in diagnosis often allow the simplest affection t
assume great magnitude. In constitutional and self-limited disease
delay of a day or two in making the diagnosis seldom results in an]
injury to the patient; but in progressive diseases, such as those gener
ally found in the rectum, a delay of even a day may be followed by tin
most disastrous results, to say nothing of the discomfort and suffering
which the patient is unnecessarily forced to bear. The author has re-
ported elsewhere (Transactions Georgia State Medical Association, 1899]
a case of ordinary thrombotic haemorrhoids in which the family physiciaE
failed to recognize the condition. After two or three days the throm-
bus became infected, and an abscess developed which burst into the
rectum, thus constituting a blind internal fistula, necessitating an opera-
tion and more than two months of convalescence. In the abscess was
a broken-down clot, showing clearly that the trouble had originated in
a simple thrombotic hemorrhoid. Under proper diagnosis and man-
agement, this patient would have been cured in three or four days,
and he would have been spared not only the loss of much time and a
great deal of suffering, but also an actual danger to his life from sepsis.
In the large majority of rectal diseases an early diagnosis and proper
treatment will result in a rapid cure, and in malignant diseases of the
rectum it is only in the early stages that there is hope to eradicate
them. In such cases, therefore, positive and immediate diagnosis upon
the first appearance of the symptoms is of paramount importance.

The subjective symptoms in rectal diseases are always referable to
more than one pathological cause. They are of great value, but no
diagnosis should ever be made of any rectal condition until the patients
have been thoroughly examined, both by digital and instrumental meth-
ods. The embarrassment of the patient and the disagreeable task for
the doctor will never be an excuse for the omission of such examina-
94

EXAMINATION AND DIAGNOSIS 95

tions. Diagnosis of rectal diseases in their early stages is sometimes
ver^' difficult, inasmuch as the subjective symptoms are often referred
elsewhere. Such reflex symptoms should be known and appreciated by
everv' physician, and should emphasize the necessity of local examination.
The methods employed in the examination and diagnosis of rectal dis-
eases may be classified as historical, digital, and instrumental.

Historical Examination. — When the patient consults the doctor for
any form of disease, whether rectal or othenvise, a careful review of
his family and personal history is imperative. It is sometimes tedious
and monotonous to listen to a patient tell his own story in his own way,
and often much that is irrelevant is introduced; but after all it has its
advantages. It calms his nervous sensibilities and makes him feel at
home with the physician, to whom he is, perhaps, a stranger. There
is nothing so conducive to confidence in a patient as the impression
that his physician is patiently and thoroughly interested in his case.
Therefore, when such patients enter the consulting-room, a history of
their personal and family life should be patiently heard. Heredity may
or may not have any great influence in diseases of the rectum, but
many patients have a very positive impression that it does, and to these
the fact that the doctor is looking into it is very consoling. A man's
occupation, his environments and his habits may or may not have any-
thing to do with the symptoms from which he is suffering; but it is
very important in advising individuals as to regimen that one should
be sure they are not already following this very course, even to excess.
As an example of this, the author had a patient consult him some years
ago who was much displeased with a consultation which he had had
only a few hours previously. The cause of his discontent was that
the doctor had told him he needed more physical and outdoor exer-
cise. The young man was an athlete who had gone stale from over-
training, and was well aware of the fact that any increase of exercise
had persistently made him feel worse. A man's environments may not
have anything to do with his disease, and yet when one is unacquainted
with these, he may sometimes carelessly attribute symptoms to them
or give advice concerning them that make him appear ridiculous. A
calm hearing, therefore, of the patient's history will be advantageous
in more ways than one. After this has all been told, one may begin
a direct examination with regard to the symptoms which have been
detailed. The method of the physician's examination often impresses
a patient favorably or unfavorably, and has much to do with gaining
or losing his confidence. If our inquiries are at random and our ques-
tions are ambiguous, and if we omit to inquire into what the patient
considers his important symptoms, he is very likely to suppose that
we know little about them. Whereas, if our inquiries are concise, direct,

96 THE ANUS, RECTUM, AND PELVIC COLON

and to the point with regard to the symptoms of which he complains,
and if we by a knowknlge of reflex effects call his attention to spip-
toms which he has inadvertently observed, or which he has neglected
to observe, he will at once be convinced that the examiner knows what
he is talking about, and will submit with confidence to his directions.
In recording the history of a patient, his name, age, home address, voca-
tion, and domestic station should all be noted. His familv history should
be briefly but carefully j)ut down. His personal histor}' from infancv
ought to be incjuired into, and all the material facts with regard to early
habits and diseases should be elicited as far as possible. These early
habits and diseases often have a material bearing upon rectal diseases,
^lany patients are aware of the fact that they have been constipated from
infancv, and some will detail indistinct recollections of rectal diseases
in early life. The knowledge of these facts is of the utmost importance
to the examiner. After such general facts have been taken cognizance
of, the direct and local examination of the ])atient should be taken up.
The symptoms suggesting local examination of the rectum may be enu-
merated as follows:

First, indigestion, flatulence, loss of appetite, irregularity of the
bowels, or constipation.

Second, \-ague aching pains about the pelvis or sacral region and
shooting down the left leg.

Third, a sense of constriction or weight about the pelvis. This is
especially important in males.

Fourth, spasmodic or ])eriodical dysuria, without adequate cause, in
the geni to-urinary apparatus.

Fifth, a tendency to diarrluva, especially in the morning.

Sixth, the presence of mucus, pus, shreds, or blood in the fsecal
discharges.

Seventh, irregular menstruation or dysmenorrhoea in young women.

Eighth, restlessness at night, picking the nose, scratching of the
abdomen or anus, and vitiated appetite in young children.

All or most of these symptoms may arise from diseases of the rec-
tum, and at the same time mjinv of them mav be due to other affections.
The fact that they are very frequently due to rectal disorders renders
a local examination imj)erative. These facts should be known to the
family practitioner more thoroughly even than to the rectal specialist,
for he is the one first consulted in regard to these conditions, and it is
nearly always through his advice that the rectal surgeon is consulted. The
patient generally knows there is something wrong with his rectum when
he consults the specialist, and therefore these reflex symptoms are not
of so much importance in his examination as in that of the family
practitioner. The latter should be prepared to examine the rectum

EXAMINATION AND DIAGNOSIS 97

quite as well as the chest, and he should not hesitate to do so in any
CHiie presenting symptoms referable to it. When through delicacy and
bashfulness the patient refuses to allow such an examination, the physi-
cian j>hould equally as firmly refuse to prescribe for the symptoms.
After the general facts and liistory have been recorded, and their bear-
ings duly weighed, one should then inquire into the existing conditions,
as follows:

State of the Bowels, — One should examine as to the habitual state
of the bowels: whether it is normal, constipated, or diarrha^al. If the
patient is constipated, to what extent does this condition exist. Is
there a stool every day, or does it only occur when laxatives have been
taken? When the stool does occur, is the faecal material soft, con-
sistent, and of normal shape, or is it small, tape-like, or hard and in
little balls? It is important to know when the stool has been passed
whether it is of sufficient quantity and clean, or covered with mucus
and tin^red with blood. If the condition of the bowels is diarrhieal,
one should inquire whether the passages are watery or semifluid,
whether large quantities are j)assed and ])ainlessly, or whether the
passages are scanty, mucous, and attended with pain, tenesmus, and
subsequent exhaustion.

Pain. — If the patient gives a history of pain, one should inquire as
to the exact point at which it is felt; whether at the anus, within the
rectum, in the sacral region, about the pelvis, in the inguinal region,
or, as often happens, in the uterus, neck of the bladder, or urethra. It
is also imj)ortant to know whether it extends to other regions. Pain
shooting dc)wn the leg, for instance, has been described by Hilton as
constantly associated with rectal disease. The time at which the j)ain
occurs should also be inquired into; whether it is before or after stools,
and how long it lasts; whether it is persistent, occurs with every stool,
or (mly occasionally. Again, one ought to know the nature of this pain;
whether it is acute, cutting, burning, or of a dull aching character. All
of these symptoms are of material importance, for they point with more
or less accuracy to the proper diagnosis of the case.

Itching and Spasm of the Sphincter. — Patients, when asked about
pain in the rectum, often say they have no real pain, but rather dis-
comfort, uneasiness, and itching, or sometimes a spasm of the anus.
The time and circumstances of such symptoms should be carefully
noted.

Protrusitm. — The patient should be asked if he suffers from any
unusual protrusion about the anus; if so, we should inquire as to when
it occurs and how it is brought about; whether by straining or upon
slight exertion. One should also know whether it disappears spon-
taneously or if it is necessary to restore the parts to their normal posi-
7

98 THE ANUS, RECTUM, AND PELVIC COLON

tion; if so, is the restoration diflficiilt or easy. It is necessary also to
know whether such protrusions are liard or soft, smooth and regular,
or localized and nodular. One should furthennore inquire if the
patient can produce the protrusion at will, or whether it only appears
when he goes to stool. He should also know whether there is any pain
produceil by handling the protrusion. If it is present at the time of
examination, one should examine carefully the rug», whether they are
circular or run uj) and down, and he should also observe any abrasion,
ulceration, or other abnormalities upon the 4)arts.

Habits. — The habits and history of the patient should be most care-
fully inquired into. Is he accustomed to the use of enemas? Is he
in the habit of sitting Umf: at the shrine of Cloacus with his pipe and
pai)er as companions? Is there an unsatisfied feeling of something
more to come away when the bowels have moved? Is he the victim
of pedcTasty? Has he a history of venereal disease? Has he an heredi-
tary tendency to tuberculosis or to malignant growths?

All these points should be carefully noted, and by the time one
has obtained a satisfactory account of them, he will generally have
information such as will aid and direct him materially in the local
examination.

Preparation of the Patient for Examination, — In onler to make a
proper and careful examination of the rectum, all constricting clothing
should he removed or loosened: corsets, tight waistbands, or anything
which has a tendency to crowd the small intestines down into the
pelvis, or prevtmt their rising upward toward the diaphragm, should
be removed. '^^Die rectum should always be emj)ty in order to make
a final and satisfactory examination of this organ; but sometimes, where
an imperfect or unsatisfactory history of the habitual state of the
bowels has been obtained, it is better to examine the patient as to this
condition first, then move the bowels with an enema, and proceed with
the complete examination later on. The author has time and again
had j)atients come to him who had previously taken enemata, and yet
found their rectums full of hard, inspissated faecal material. Whether
this material had come down into the rectum after the movement of
the bowel, or whether the injection had failed to remove it, it was
impossible to say. As a rule, therefore, if it is practicable, the first
examination of a })atient's rectum should be made before an enema
is given. By such an examination, if pus, blood, nmcus, or inspissated
fa'cal material are present, they can be seen; whereas, if an injection
has been taken and the rectum thoroughly cleaned out before the
phvsician examines it, these substances mav be entirelv removed, and
the condition causing them may be overlooked. It requires a little
more time to make the double examination in this way, but in the

EXAMINATION AND DIAGNOSIS

author's experience it !ias been more satisfactory. If upon the pre-
I liiuinury esammatioQ the rectiuii is found full of fa.>cal matter, or sub-
I sLaneeH interfering with a thorough diagnosis, an enema should be
giTen anil the patient allowed to retire until these have been passed.
I M"here the physician's office is not so arranged that the toilet-room is
[ kdjoioing it, he should always have at hand a commode, bo that in
? of an emergency after giving the enema the patient may relieve
I liimsclf at once without the danger of an
I accident in passing from one room or floor
■ to another in onier to reach the toilet. The
I cut here given {Fig. 4!)) illustrates a very
I practical and efficient commode for the physi-
Ician's offiec. It is so arranged that there is
Iterj' litlle escape of fiecal mior from it, and
P'at the same time one would hardly suspect
' that it was anything but an ordinary stoot.
For the specialist's office certain double fau-
cets and stopcocks have been arranged Ijv
which a patient can be given an enema or
irrigated directly from the water-pipe. Such
an arrangement is described by Dr. Kelsey
f u follows:

It consists " of a glass jar holding one
allon, which stands upon a shelf 7 feet above
he floor, and is filled by a rubber tube con- nn-i, i. Wy.,

Krting with what is popularly known as a
nrbcns' faucet, by which either hot or cold water can be drawn from
e same tube at pleasure." The apparatus may also be used for irri-
ptiog the rwtuni. the temperature being regulated by a thermometer
I Ihc jar. and the flow may be kept up indefinitely.

This is an excellent arrangement, but the jar should not be set
lore than 3 feet above the level of the patient, for too-great force is
'tohjet^tionable for either irrigation or enemata. It is not indispensable,
however. The ordinary fountain syringe serves every purpose for giv-
ing rectal enemata. It can be sterilized, and the tips, at least, should be,
after each use of them. The question of what sort of a tip is best for
rviog a rectal enema will be often asked of a physician. A hard-rubber
d an olive-ehaped end, smooth, polished, and well lubricated, or a
■dium-sized soft-rubber catheter, are the only instruments with which
% patient ought ever to administer an enema to himself. WTien the pliy-
aician or a trained nurse is called upon to give the enema, the tip de-
Icribcd, or a small-sized Wales bougie, are the instruments of choice.
ordinary Davidson bulb syringe is preferable to the fountain syringe

100

THE ANUS. RECTUM, AND PELVIC COLON

when the injection is given through a long tube like the Wales bouj
inaarauch as the impulse lifts up the folds of mucous membrane fr
in front of the bougie and facilitates the passage of the instrument '
ward into the sigmoid flexure.

Immediately after the enema has passed, the patient sliould be 1
upon a lounge or table before any protrusions or prolapse, which n
have opcurretl during the action of the bowel, have di.sappeared. Soi
times it is well to feel or exiimine the parts before the patient lea

Fia. 50. — Lin Latibai. ob SiHs'a Posrcni.
The bed of the lounge being rubud bo as to fomi n table.

the commode, as motion, especially walking or climbing up on a tabl
may cause their retraction, and the opportunity of viewing them wi
be tliuB lost. In order to avoid this, it is well to instruct the patiei
before he retires to the toilet-room or seats himself upon the commod
tliat he shall not replace any prolapse, and shall simply use a litt
moist cotton or gauze in cleansing himself. One should always ha\
present in his office, if possible, a trained female nurse or an attendai
to wait upon ladies and prepare them for examination, to adjust tlie,
clothing, and assist in the administration of enemata. She shoul
not he present, however, during the questioning of the patient, as th
part of the examination should be confidential. While the autht
recognizes their usefulness and convenience, he holds that their pre;
ence as a protection to the doctor is an acknowledgment of woaknes

EXAMINATION AND DIAGNOSIS

101

minn his own jiart, and an insult to every lady who eufera his apart-
Dients.

Potilwn for Examiuatiim. — Tliere are four positions in which a
patient may be examined for diseases of the rectum, and each of them
has its special use. The first and most generally useful \a the jjeft
lati-rul, so-called Sims's position (Fig. 50). This is obtained by laying
the patient upon the left side, the chest upon the table, with the left
ann behind the back, the thighs well Hexed upon the body, and the
hips elevated upon a hard pillow. In the large majority of cases this
position is sufficient for all examinations, whether digital, ocular, by
specula, or through the sigraoidoseopo. In very stout people, however,
the rectum is so retracted and covered in by the large folds of the but-
tock that it is difiicuU to obtain a good view of the parts in this posi-
tion, and almost impossible to introduce an ordinary speculum with
salisfaction. In such eases other positions are found more satisfactory.

Sxaggeralfd IJlhotomtj Pusition (Fig. 51). — This position is ordinarily
the nuwt convenient for operations upon the rectum, and it also has

I Brid of usefulness in exaniinationa. The author has several times

tflemptcd to introduce the sigmoidoscope in the Sims's and also in

lie knee-ehi'si posture without avail, and has succeeded with com-

ive ease after having placed the patient in the lithotomy poai-

In stout patients this position affords an excellent view of

EXAMINATION AND DIAGNOSIS

103

, and in females it enables us at the same time to examine
p condition of the uterine organa and determine tiicir influence upon
; recta] symptoms. Every physician's office is furnished with sonic
iblc, chair, or device by which such a position can be easily obtained.
Thi Kner-fhest Posture (Figs. 52, 53).— This is obtained in several
Where the patient is strong and able to retain himself in posi-

ho, M.— pATIEJrf

1 for eome time, or where the examination is to be very brief, he
r be placed upon a table resting upon his knees, the shoulders or
; lying upon the same level as the knees, the body well flexed

104

TDE ANUS, RECTUM, AND PELVIC COLON

upon the thiglia. In this position the weifrlit of the abdominal
gang is taken entirely off the rectum, and tlie dilating effect of atr
pheric pressure can be easily obtained. It is almost inipoasible to ni
tain this posture under anieslhesia without a specially prepared
paratus for holding the patient, such as that employed by Dr. Ho«
Kelly (Fig. 54). Such an apparatus could, of course, be uwd with
an anffisthetie, but it would be very uncomfortable to the patient. Mi
over, this position, although a most useful one, is an exceedingly
barrassing one, especially to ladies: it is difficult to induce tiiem
:!-.-ume it in the I
I'l.ue, and vci-y d
.lilt for them to mi
lain it in the gecc
Miirtin, of Clevela
]\A& devised a com;
■.iili'd but exceedin
usuful chair (Fig.
Ijy which the pati
can be placed in t
poMition and held th
fur an indefinite per
without much diacc
fort or embarrassme

The Squaiiing
Stool Posluri. — T
position is not gen
ally given a« one
_ which to make exa

(■luirt, inations. The auth

Iiaa found it very ui
ful, however, in a number of conditions. A patient sometimes fin
it very difficult when lying upon the side, or when in the knee-eht
posture, to strain and bring into sight lu-otnisions or prolai>se8 whl
habitaaUy occur when at the stool; but when in this position he «
easily produce them. When a patient is in other positions, especial
the knee-chest posture, prolapse of the third degree is likely to reced
and the diagnosis may he impossible; whereas in the squatting postu
such a prolapse is easily brought down by the patient's straining,
that it impinges upon the end of the finger introduced into the ami
and the diagnosis is easily made. The position is also useful in ca»
of stricture and tumors of the rectum which are above the reach of tt
linger. When they are only removed a short distance above the reax
of the index finger, if the patient is placed in this position and eauai

EXAMINATION AND DIAGNOSIS

105

' to bear down, thoy may frequently be brought witliin reach, and thus
information may be elicited which could not be otherwise obtained
except by the adniinist ration of an an^ethetic.

Apparatus. — There is great difference of opinion among the medical

men and speeialists as to the advantages of lounges, chairs, or tables

for the examination of patients. Ordinarily a good gynaecological table

will serve every purpose. A lounge is generally too low for exaniina-

[ tione, but it is sometimes of the greatest convenience in the doctor's

[ office. Cliaira also have advantages, in that the patient is seated thereon

[ and by special mechanism placed in any position desired by the operator.

[ The author uses a lounge devised by the late Dr. Little (Fig. 5G). The

bi.'d or tht' lounge is 5 feet long and 'ih feet wide, and its nioelianicira
I is simple. When it is lifted up it fonns a tabic 3J feet high (Fig. 50),
I and is abundantly large for any operation or position which may be re-
[ quired in a physician's office.

Rccenfly, however, in order to obtain the advantages of the knee-
I ebeet posture, and to maintain it without inconvenience and exhaustion

io a patient, the ingenious chair of Martin has been used. This chair is
I a modification of the well-known Yale gynascologieal chair, which by
I a crank places the patient from a Sims's position into a perfect knee-
[ chest posture without his moving or being inconvenienced. A patient
\ is seat«d in the upright position, his right leg crossed over the left, and
[ the left arm rests upon the back of the chair. The pillow is held with
|th« right arm underneath the head, and the chair is thrown back-

lOG THE ANUS, RECTUM. AND PELVIC COLON

ward into a horizontal jmsition. Tlie retaining shoulder-strap is placed
over tlie right arm and attaelied to the snap which holds it. With the
lever in the right hand, the crank which controls the screw is then
rapidly revolved and the patient is turned slowly and gradually into
tlie posture indicated in the cut. The head of the i>atient rests upon
a device which is arranged so as to support it, and in this way every
advantage of the knee-chest posture is obtained. For specialists in
rectal diseases this chair is of great assistance, and for one who is in
the habit of using a diair for gynaecological and other work, the com-
bination in no wise detracts from its ordinary usages. Pennington, of
Chicago, has devised a table in which Martin's principle is carricnl out.
It is liglit an<i can be easily transported from place to place. All such
appliaiu-es are convenient and of assistance, but they are not absolutely
necessarv.

In all examinations of the rectum it is better to begin with the
Sims's ]M>siti(>n. It is the least embarrassing to the patient, and is gener-
ally the only one which will be necessary.

Ej'terunl Appro ran res. — Having placed the patient in position, a
careful observation of all external appearances should be made. The
shape of the anus should be noted; whether it is normal, protruding,
or retracted and funnel shaped, and whether the pigment about it is
normal, increased, or reduced. The epidermis should be examined
carefully for parasites and pediculi, and its condition noted; whether
it is normal, wliite and sodden, or red and excoriated; whether it
is moist or dry and brittle, smooth or nodular and swollen at points,
and whether there are any scars, ulcerations, or fistulous openings
about the anal orifice. Palpation of the parts is of importance, for by
this are elicited any tense or painful points that indicate abscesses or
peri-rectal inflammation and induration. By palpation it is possible
to follow up a fistulous tract through its indurated line, and thus to
make a diagnosis without the use of a probe, which is always painful
an<l often unsatisfactory. If there are any external growths, such as
condylomata, fibroids, ])olypi, or connective-tissue ha?morrhoids, these
should be carefully examined, and their condition, whether painful,
inflamed, constricted, or thrombotic, should be noted. Little thrombi
about the anus are very frequent, and sometimes cause a distress entirely
out of pro])ortion to their ap])earance. If there is a protrusion present,
one should carefully observe all its characteristics, especially the direc-
tion of the ruga\ and whether or not it is excoriated or ulcerated.
Epithelioma of the anus is often ap])arent u])on the external surfaces,
and where it is so one may clip off a small section for microscopic
examination without much pain to the patient by the application of
cocaine or orthoform. Assuming that no such external abnormalities

EXAMINATION AND DIAGNOSIS 107

exist, the examiner should proceed to look higher up. With the but-
tocks pulled well apart and the patient straining slightly, one can see
pretty well all of the anal canal. If there be a fissure or haemorrhoids
they can generally be brought into view by this means, and polypi low
clown may also be seen during this part of the examination. One should
be careful to note the condition of the rauco-cutaneous border of the
anus, for frequently the dragging of the buttocks apart stretches this
membrane, and if it is in an unhealthy condition such as the dry,
brittle state in which it is found in atrophic catarrh of the rectum and
in some forms of syphilis, it will crack in numerous little points, some-
times bleeding, but more often appearing like little button-holes — not
deep enough to cause actual pain, but sensitive to the touch and to
irritants. At this point one should observe the condition of the radiat-
ing folds of the anus. If one or more of them is inflamed or swollen,
it would indicate some ulceration or irritation in that area of the rectum
directly above it. If, however, they are all congested and hypertropliic,
some general inflammation or affection of the rectum will be indicated.
Valvular constriction of the anus may sometimes be determined by such
an ocular examination.

Digital Examination. — Having proceeded thus far, the physician
will have obtained whatever information is possible without digital or
ocular examination of the rectum itself. Here the educated finger
becomes our most important agent, at least so far as the first four
inches of the organ are concerned. This should ])e well lubricated
before any attempt to introduce it into the rectum. The author has
tried many substances as lubricants for instruments and the finger in
rectal diseases, and has finally settled upon vaseline as the most satis-
factory', except in cases where some stimulating or cauterizing substance
is to be applied. In such cases one should use some sort of lubricant
which can be washed off, and which will not interfere with the action
of the drug. Ordinary non-irritating or Castile soap is probably as
gcxxl as any other substance under such circumstances, but there are a
number of vegetable preparations upon the market which serve this pur-
])os(* wry well. Such lubricants should be kept in collapsable tubes.
The old pot of oil or jar of grease into which the finger and instruments
are dipj)ed day after day, infecting one patient from another, is a relic
of medical barbarism, and should be discarded from every physician's
oflice. The vaseline or lubricant in tubes can be sterilized, it is clean
and convenient, and the slight increase in expense is inconsiderable.

In introducing the finger into the rectum, one should remember
that the anus is closed by a very sensitive, irritable muscle, and that
any roughness or undue haste will cause spasm and increase the diffi-
culty and pain of an examination. It should be introduced slowly

108 THE ANUS. RECTUM, AND PELVIC COLON

and with a boring motion, first upward and foni-ard toward the vagina
or ])rostate until the internal sphincter muscle is passed, and then
backward into the ampulla of the rectum. A mistake in directing the
linger, or roughness in its use, will cause pain and spasm such as will
discourage the patient, and sometimes prevent a thorough examination.
As the linger is ])assed through the anus one should study the condi-
tion of the sphincter muscle. A twitching, tender, spasmodic sphincter
indicates some acute disease near the margin; a hard, firm, resisting
sphincter indicates a chronic condition which has caused hypertrophy
of the muscle; and a relaxed, flaccid, lifeless one leads us to suspect
some exhausting, malignant, or ctmstitutional disease. As the Unger
passes beyond the margin of the external sphincter it should be swept
around the anal canal to examine the crypts of Morgagni and the pil-
lars of (ilisson, to elicit, if possible, the existence of any ulceration or
other patliological condition. Hypertrophied j)apilla» may be diagnosed
by this procedure. It is just at this point, between the external and
internal sphincter, that the educated linger most often recognizes the
internal ojx'uing of a fistula, fluctuation of perirectal abscesses, and the
presence of small foreign bodies which have lodged in the crypts or
been caught in tlu' grasp of the nuiscles. The education of the finger
to recognize abnormalities in this jK)rti()n of the rectum is the first and
most important step in the (level()i)ment of a rectal specialist. Without
this tactile erudition one can never make a success in the treatment of
these diseases. There is no one thing that \\r[\\ give more satisfaction
in practise than the ability to diagnose the internal opening of a fistula
by touch. The comfort to the patient, the certainty of the operator
when he feels the oj)ening, and the great assistance it affords him in
operating upon tortuous fistulous tracts, render this accomplishment
of inestimable value to one who practises in this line. An uneven
spot, elevated or depressed, with an indurated base, and more sensitive
to touch than the rest of the circumference, reveals to the experienced
examiner more than any probe can tell, and he who has experienced it
a few times recognizes the ccmdition as unerringly as the skilful musi-
cian will a string out of tune.

After the examination of this portion of the organ, the finger should
be carried through the internal sphincter and swept gently around its
upper surface. The impression that internal haemorrhoids can be felt
in this way is a mistake. Unless there is true hj'pertrophy of the con-
nective tissue one can not feel them at all. He may, however, recognize
ulcerations whether simple, tubercular, or specific. As the finger is
swept around the rectum the levator ani muscle can be felt and its
condition determined. One can also determine whether the mucous
membrane is smooth and without the normal folds, thus indicating

EXAMINATION AND DIAGNOSIS 109

atony; or whether it is harsh and dry, thus indicating atrophy of its
glands and insufficient secretions. Foreign bodies lodged in the am-
pulla of the rectum often assume a position just above the internal
s]>hincter, and can be felt by the finger when they are in this posi-
tion. Polypi and other neoplasms, strictures, procidentia, and inflam-
matory conditions, may also be diagnosed by this means. A knowl-
e<lge of the sensation imparted to the finger by the various pathologi-
cal conditions is indispensable to the proper diagnosis of rectal dis-
eases. The soft, irregular edges of a tubercular or simple ulceration,
and the Iiard, indurated feel of the specific type, require experi-
ence to distinguish tliem. The smooth, soft, slimy feel of a polypoid
growtli is entirely different from tlie hard, nodular one of carcinoma.
The true fibrous and the soft inflammatory stricture give entirely differ-
ent sensiitions to the touch, but it requires education of this sense and
experience to distinguish them. The condition of the prostate and the
uterus and its appendages sliould also be carefully noted in digital
examination of the rectimi. Frequently we are able to feel the nodular
surface of an inflamed cervix pressing down upon and irritating this
organ. A prolapsed ovaiy or retroverted uterus, a flbroid or cystic
tumor, a ha^matoma, or even an extra-uterine pregnancy, may be made
out by digital examination of the rectum. Frequently symptoms re-
ferred to this organ are due to diseases elsewhere. A stone in the
bladder or urethral stricture mav cause rectal svmptoms only. The
specialist in rectal diseases must therefore practically be an accom-
plished g\naHologist and gen i to-urinary surgeon. He may not do the
o{>erative work of such, but so far as the diagnostic knowledge is con-
cerned he should possess it in both branches.

Wliile the finger is still in the rectum the coccyx should be grasped
between it and the thumb externally, and moved backward and forward
to determine whether there is any inflammatory or tender condition
about it. Hectoceles, both anterior and posterior, should be thoroughly
ex]>lored for foreign bodies or hardened fa?cal masses. As the finger is
withdrawn, if the patient is requested to bear down, internal haemor-
rhoids, if present, will frequently follow it out through the anus. If
there is blood, mucus, or pus in the rectum, it will also follow the finger
u po n wi t h d ra wal .

The odor is also important. That imparted by carcinoma in the
rectum, once smelled, can never be forgotten; that of ulceration, whether
simple, specific, or tubercular, is entirely different. There is a feculent,
sickening, dead smell to the discharge from a carcinoma which is pro-
duced bv no other disease.

Examination by the finger is practivially limited to the first 4
inches of the rectum. With the patient bearing down and the surgeon

110 THE ANUS, RECTUM, AND PELVIC COLON

pressing upward upon the perinaeum, the thumb being carried I
over the coccyx and the fingers over the perinaeum, or vice ve
another ^ inch can possibly be gained; but 4^ inches is the limil
digital touch. Where the disease is higher up some other met
must be adopted.

Introduction of the Hand into the Rectum — Manual Examinatioh
Extending the principle of tactile examination, Simon, of Heidelb<
demonstrated in 1872 the feasibility of introducing the whole hi
into the rectum for the purposes of examination. In order to acc(
plish this, the patient must be anaesthetized, and the hand should
thoroughly lubricated. The fingers are introduced into the anus <
after another, and the spliincter muscles gradually stretched until
palm and finally the whole hand is introduced. The dilatation m
be very slow and with a boring motion. After the hand passes throu
the grasp of the sphincter muscle it will slip into the widest porti
of the rectum, where the space is ample. This portion of the recti
is not covered by the peritonaeum, and there is little danger of inju
as it is very distensible. From this point upward, however, the g
grows narrower, and if Houston's valves are much developed, there w
be points at which there is a partial constriction. After the hand 1:
been carried from 4 to 5 inches upward general constriction will beg
to be felt, whether the gut is normal or diseased, and from here <
the greatest gentleness and care are necessary to avoid traumatism
the gut. In the first portion, above the great ampulla of the rectum, tl
peritonaeum covers the front surface of the gut, and as we ascend
passes more and more to the sides, until it finally entirely surroun<
the intestine on a level with the third piece of the sacrum. At th
point, where the rectum joins the sigmoid, one will always find a markc
contraction in the caliber of the gut; and the introduction of the har
through this is fraught with danger, unless the hand be very smal
Whatever examination can not be made by the introduction of t\v
fingers through this contracture had better be left undone until a
exploratory laparotomy shall clear up the question. The dangers c
the latter are less than the introduction of the whole hand throug
the recto-sigmoidal juncture. Simon states that with half of the han
passed through this contracture, the abdominal cavity may be exam
ined to the extent of several centimeters above the umbilicus; on
rarely has occasion to pass his hand higher up than this. Accordiuj
to Simon's directions, a hand measuring 25 centimeters (9 J inches) ii
circumference may be thus introduced without danger. The autho
believes, however, that a hand that requires a kid glove larger thai
No. 7 J should never be introduced into the rectum except in a lif
or death emergency. The danger of this procedure has been discusser

EXAMINATION AND DIAGNOSIS 111

by many writers. Four cases have been reported in which death fol-
lowed the operation. They are as follows: H. B. Sands (New York
Medical Record, June, 1874, p. 301) introduced a hand measuring 19
centimeters (7^ inches) in circumference 12 inches up into the gut
(the arm being too large to allow it to pass any farther), but dis-
covered nothing by this examination. One week later he made a sec-
ond examination, this time introducing his right hand 15 inches above
the anus. The circumference of this hand is not stated, but it was
presumably larger than his left. By this examination he diagnosed a
stricture of the ascending colon. He then did a right lumbar colot-
omy. The patient died from shock on the following day. In the speci-
men removed, the " caput coli '' showed separation of the tnusndar fibers
and rupture of the peritoneal coat at 8 inches above the anus. Some of
the longitudinal muscular fibers in the sigmoid were separated, but there
was no rupture through the gut wall. We call attention to the fact that
the peritoneal injury was not at the rectum but in the caput coli, and
the .separation of the muscular fibers was apparently as much at this
portion as in the rectum itself. P'urthermore, attention is invited to
the fact that it was impossible for the hand to have been introduced
up to the caput coli, and therefore these injuries must have been the
result of the operation for colotoniy and not of the examination.

Weir (Xew York Medical Journal of 18T5, p. 414) reported the
case of a woman, aged fifty, who complained of symptoms of obstruc-
tion, and upon whom manual examination was performed. He was
unable to make any diagnosis, although he succeeded in touching the
kidney with his hand. A lumbar colotomy was performed, and the
patient died the next day. The autopsy revealed no peritonitis, but
alK)ut two teaspoonfuls of free blood in the Douglas cul-de-sac. There
was a rent in the muscular and peritoneal coats of the bowel on its
anterior aspect, just where the peritona}um is reflected from the bladder
upon the rectum. The mucous membrane was not ruptured, and there
was no evidence of peritonitis. A close stricture of the transverse
colon was found with a large accumulation of faecal matter above it.
The patient rallied from the operation, it is said, and the cause of
death seemed very obscure. If it had been from rupture of the bowel
there would have been peritonitis and other symptoms associated there-
with. If from shock, it may as well be attributed to the operation of
colotomv as to the manual examination. The third case referred to
by Weir (Medical Record, 1875, p. 201) occurred in St. Luke's Hospital
under the care of Sabine. This patient died at the end of four days,
and the post-mortem examination showed a laceration of the mucous
coat of the rectum with ecchymosis, but no rupture of the gut. There
seems to have been no perforation in any of these cases. Dandridge

112 THE ANUS. RECTUM, AND PELVIC COLON

(Cincinnati Jjancet and Observer for 187G) reported the case of a man
with a psoas abscess, who was in the hospital with a condition of sup-
puration apparent, but no dia^iosis had been made. On ^larch 22d rhe
doctor explored the rectum with his hand, passing it through what
seeme<l to be a constriction of the bowel, as though it were bound down
by a fals(» membrane just above the rectum. Before reaching the prom-
ontory of the sacrum, a large swelling posterior to the rectum was ob-
served. The examiner j)roceede(l with due care, exploring the surfaces
of the vertebras the psoas muscle on both sides of the common iliac,
and upward to the bifurcation of the aorta. His associate. Dr. Connor,
then repeated the examination. The circumference of the hand is not
given in eitlier ca.s(». This man suffered from surgical shock and tem-
perature for three days, some evidences of peritonitis developed which
praelically subsided upon the third day, after which time the patient
developed pneumonia and diivl on tlie tenth day. The autopsy revealed
sei)tic j)neum()nia witli ])us in the ])leural cavities, and pleural adhesions
showing evidences of an old inllammation. There were flecks of recent
lymph throughout the peritoneal cavity binding the loops of intestines
tog<^ther. There was no fluid found in the abdominal cavity. The
mucous membrane of the intestine was normal. On the anterior surface
of th(» rectum there was a slit-like tear in the peritomeum about 5
inches from the anus. There was no sj)ecial evidence of inflammation
in its immediate vicinity. The nnicous membrane corresponding to
this ru])ture was normal. At the same level, on the lateral and pos-
terior asp(»ct. there were two abscesses in the wall of the bowel. Just
above the sj)hincter there was a tear through the mucous and muscular
coat, but there seemed to be no infection or inflammatory complication
from these. Psoas abscesses and necrosis of the lumbar vertebrae were
also found. Dandridge c<mcludes that the peritonitis was due to the
rupture of the peritonaeum 5 inches above the anus, and to the mucous
mend)rane torn through just above the sphincter; and yet he distinctly
says in his rej)ort that there was no evidence of acute in ff animation around
eitlier nne or the other of these points. It seems that with all the patho-
logical complications in this case, it is rather straining a point to at-
tribute the fatality to the manual examination of the rectum. Thus,
taking the four cases, one may say that while they show deaths fol-
lowing this procedure, only one of them (that of Sabine) seems to
be clearly due to it. These cases have been somewhat extensively
reviewed, because they are so often quoted to show the fatal results of
such examinations. They do not appear to be conclusive. At the same
time one should not underestimate the dangers of this method. In
malignant diseases, in ulcerations, and in cases in which atheroma of
the arterial system exists, it should not be undertaken. But in cases

EXAMINATION AND DUGNOSIS

113

of forcifrn bodies and of faecal impactioa in the sigmorli flexure, the
eoat^i of the bowel being otficrwise healthy, or for purposes of exploring
the i>flvie cavity, under the same conditions it may be sardv carried
out, |irovide<l the hand of the operator does not measure over 20 centi-
nielera (Ti inches) in circumference. The author has done it more
than a hundred times, and has not yet had any unfortunate results
further than a temporary incontinence of fieces, which lasted for about
ten days in one case and less in others. Wliile this method is useful
and still has its place in rectal surgery, it has been largely superseded
in the last fi-w years by the advances made in instrumental examina-
tions of tiio n-ftuiii.

Instrnmental Examination of the Return.— Light.~In all methods
of inslrumenLal examination of the rectum, the question of light is a
Tery important one. It can hardly be gainsaid that reflected daylight
i« generally the most
I Mtisfactory for rectal
pttami nation. When
1 not be ob-
tained, the electric
ight is the best siib-
titule. In large cities
towns lighted by
fleet rieity the street
nrreni can be used
■ this purpose. An
rtlinan- hand - lamp
■ritb a reflector around

I be used to throw the light directly into the rectum, or it may be
iflected from a head-mirror. The illustration {Fig. S7) shows an electric
1-light which is more satisfactory than any other, and which for gen-
ral illumination of the lower rectnm and operative work is all that can be
sire<l. For deep examinations it does not focus as perfectly as the re-
ed light, and is therefore not so good. In smaller places, where there
0 street current, or in the country, some form of storage or dry-cell
ittery will be found useful. Small electric batteries are in the market
ieh furnish a light of about G candle-power. They are easily portable,
nd some of them have ingenious attachments which make them very
leful in other instrumental examinations. A little care in the manage-
int of these batteries and renewing the cells occasionally is all that
I necessary to supply a most efficient and reliable light for the treat-
B^nt of rectal diseases. The same batteries are also usefl for illurai-
wting purposes in the pneumatic proctoscopes, which will be described
liter un. The complicated gaslight brackets and lamps with condensing

114 THE ANUS, RECTUM, AND PELVIC COLON

lenses are troublesome and no longer necessary since the electric li<
can be so easily obtained.

Attached to the Martin chair is an apparatus with many comj
cated screws and joints for directing the light into the rectum. 1
inventor uses it with great dexterity, but others have been unable
do so satisfactorily.

A very useful light for night and country practice is that kno'
as the acetylene bicycle-lamp. This bums for a long while after it 1
once been charged, and gives a very bright and concentrated \ig
which can be used either directly or by reflection. One of these lam
of small pattern is a very convenient adjunct to a general operating bj

Kelsey advises carrying in such a bag a quantity of magnesin
strips which, being burned, produce a very bright light for examir
tions at the patient's house. To one in the habit of using the pne
matic proctoscope, such aids will be unnecessary, inasmuch as he w
always carry along with him the little battery belonging to this instr
ment, and this will supply abundant light. One of the best of the
batteries is made by the American Endoscopic Company.

Specula. — Formerly, that portion of the intestine above 5 inch
was practically a terra incog^niia. Within the past few years, howeve
thanks to Howard Kelly, we have become as familiar with the appea
ance of the upper portions of the rectum as we are with that of tl
vagina or any other open cavity of the body.

The old-fashioned specula only gave us a partial view of the fir
4 or 5 inches. They served their purposes very well, and as instn
ments for treatment some of them are even now superior to mar
of the modem instruments, but their field is very limited. The intei

Fio. 68. — Kelbey'b Fio. 59. — Conical Bivalve

Rectal Speculum. Kectal Speculum.

of every speculum is to afford a good view of as much of the rectun
as possible. As will be seen at a glance, the instruments illustratec
(Figs. 58, 59, 60) afford only a partial view of the circumference oi
the intestine, and a very limited view of its length. The Sims's rectal
speculum (Fig. 61) would give a very fair view of the anus and rectum

EXAMINATION AND DIAGNOSIS

115

for 4 inches up, providod the patient hud fortitude enoiifjh to bear the
pain; but where there are hjpmorrhoidSj polypi, or tumors of tho rectum,
they prulapse into the fenestra of
the wire blades, and being caught
cause great pain upon withdrawal
of the instrument. I( should not

be need except under general anjesthesia. The Bflm^ objection may be

offered, only in a leas degree, to the Kelsey speculum.

The O'Neill s[>eeu-

I lorn (Fig. 62), which

mdertakee to combine

1 one the bivalve and

iDcetrated conical

VoIb, is sometimes

r«-»y useful instru-

lent.' The blades are

ftlikely, however, to

inch the folds of the

nucous membrane vr

a-iiiorrhuidul develup-

fmenU and cause cou-

siderahle pain. It only

gives an imperfect view

of about 4 inches of

the rectum.

The speculum illus-
Untcd in Fig. 63, devised by tho author, is a modification of the Brinck-
k erhoff speculum, with two fenestra. By a turn of one-quarter of a circle

116

THE ANUS, RECTUM, AND PELVIC COLON

it gives a view of the entire eireumference of the reetum; it is made
in two sizes, one 3 inehes and tlie other 6 inches long, thus practically
giving a view of about 5 inches of the rectum. Up to the time of Kelly's
paj)er in 18J)5, this was probably the most satisfactory speculum for
rectal examination, and it is still a verv useful instrument in the local
tn^atment of luemorrhoids, diseases of the crypts of Morgagni, internal
blind fistula, and ulcerations in the lower j)ortion of the organ.

A small laryngoscopic mirror may be used in connection with this
instrument in order to obtain a perfect view of the anterior and pos-
terior ruJs-de'sac of the rectum which dij) down behind and in front
of the internal sj)hincter. This mirror also serves to examine the
crypts ni Morgagni, and to determine any fistulous openings about the
lower j)orti(m of tlie rectum.

The ordinary Sims's vaginal s])eculum, such as is possessed by every
surgeon, has been variously modified by Van Buren, Kelsey, Ilelmuth,
and others (Fig. ()4). The modifications all consist in removing one
end of the speculum and adding a straight handle so
that the buttocks will not interfere with its introduc-
ti(m into the rectum. These are all useful instruments

and the rectal specialist should
possess them; but to the general
]>ractitioner they are not a neces-
sity, for he can get along very
well with the ordinarv Sims's
speculum. For use in connection
with this instrument one should
possess some sort of a rectal re-
tractor. I have found Pratt's
(Fig. 65) very satisfactory, al-
though the physician may easily
arrange one for himself out of
stiff copper wire, bending it to
suit his own convenience.

The self-retaining speculum
of Mathews (Fig. 6Cy) is a favorite
one with many operators, espe-
cially in the West; but it is open to the same objections that have
been mentioned in reference to the Sims's rectal speculum.

Formerly the Ferguson tubular vaginal speculum was used by the

introduction of a rectal bougie through it as an obturator, and thus

introduced into the rectum. It formed a very satisfactory instrument

for the examination of this organ so far as the instrument reached.

In 1863, Bodenhamer introduced to the profession a long steel tube

Fio. <\4. — Van Btren^s
Rectal Si-kcilim.

Fio. 65.— PBATrt
Kbctal Rbtractok.

EXAMINATION AND DIAGNOSIS

117

the Big-

arranged with a sort of a spiral conformation which made it flexible at

the endj and thus enabled him to pass it into the sigmoid flexure. He

'-Baid by this means and a tij-stem of mirrors he could observe tliu condi-

ItioD of the gut above

ihe recto-siginoidal

juncture, and also the

jniicous membrane of

flie rectum all the \ra.y

MS he withdrew it. The

instrument was never

generally adopted.

Andrews, of Chica-
go, later on devised
what is known as his
tubular speeula. one
being straight and the
other curved so as to
conform with the curv-
atures of the rectum.

He claimeil that with this instrument he was able to e
moid flexure, and to thoroughly observe all its eireumference by the
aid of a concave mirror which is introduced into the epecnluui after
the obturator is withdrawn.

Cook, of Indianapolis, also devised a tubular speculum similar to
Andrews's.

The advice in regard to their use by the inventors is to lay the
patient up<m the side, introduce the speculum, and examine the nuicoua
membrane of the intestine as it prolapses over the end of the instru-
tipon its withdrawal. The principle of atmospheric ballooning or
leuraatic distention is never hinted at in any of their writings, nor in
the books upon rectal diseases in which these tubes are describod
and recommended.

In 18!)5, Kelly, of Johns Hop-
kins Hospital, introduced to the
profession a set of rectal and sig-
moidal tubes of different calibers
and lengths, designed for examin-
ing the rectum and sigmoid flexure.
There were no curves to these in-
struments (Fig. 67). The inventor
showed, if not for the first time, at least more forcibly, that a straight
isstmrnent could be introduce<l through the anus into the sigmoid and
op to the descending colon. Not only was this principle illustrated.

118 THE ANUS, RECTUM, AND PELVIC COLON

but the application of tlu» ballooniiiir of the nH'tuiii hy atmo.spheric
piv'ssure was brought into [»roininenre as an adjunct in llie use of tubu-
bir spccuhi.

Marion Sims, in IS I.*). tU^nionstratcil to the worhl the advantages
of alniosj>heric pressure in ballooning the vagina. Van Biiren, in 18T0,
demonstrated to his class in l>ellevue Hospital tlic application of this
method to I lie rectum; at the same time he gave credit to Dr. Sims for
the discovery. Allinjrham advised the use of this method and devi:3ed
a tube U*r it: he also acconls to Dr. Sims the honor of priority. But
none of these authors had umlertaken the scope of examination which
K«'llv intrcxluced, nor luul any of them used in tliis wav the cvlindrical
tubes, ei tiler siiort or long. To Kelly, therefore, belongs not the inTen-
tiou id' a tuhe, still les> the discovery of tlu' inflating power of atmos-
pheric pressure, but simply their ju'actical and ingenious application
to rectal surgi'ry. lie populari/jMl the nu'thod, one may say, or at
least showed us its possibilities. His method is given in his own words:
*' Aunsthesia is unnece>sary in using most of the sj)ecula which are
of :i\\\M caliber, and nnue of the vari«uis manijmlations are fHiinful.
'^riie j>atient kneels on an ordinary table (a common kitchen table is
quite cnnvenieut) with the elbows >prea<l out at the sides so as to bring
the chest as close to the table as possible, while the thighs are perpen-
dicular to it, suj)porting the ])elvis as high as possible. The buttocks
are drawn apart, and the blunt end of the obturator is laid on the
anus, which is coati'd with vaseline. The direction of intnuluction
shouhl be at first downward aiul forward, and when the sphincter is
well ])ass«'d, up under the sacral |)romontory. The monu'nt the specu-
lum clenrs the sphincter an^a, and the obturator is withdrawn, the air
rushes in audiblv ami <listends the bowel. The bowel is ilhuninnted in
the following manntM*: a strong light — «lay light will answer, but an elec-
tric light is most convenient — is held close to the sacnim where a
lu'ad-mirror directs the ravs through the tube into the bowel." He
recommeii<ls as a practical set of these instruments (Fig. 68) sufficient
for all ordinary purposes, a short proctoscope 14 centimeters (oj inches)
long and '^'i millimeters (3 of an inch) in diameter; a long proctoscope
of 'in centimeters (^; inches). an<l a sigmoidoscoj)e of 35 centimeters
(1;{'J inches), all being (d* the same diameter.

For examining the extreme lower «»nil of the anus, a proctoscope of
o centimeters (*i inches) or less will be found convenient, and for
treatment and o])erations in the rectum, tubes of various diameters will
be needed. Long applicators or dressing-forceps, specially devised for
use through these tubes, are necessary to wipe away mucus and adherent
f;vcal masses which obstruct the view. A curette or scoop (Figs. (>l>, 70),
devised by Kelly, is very useful for removing fa?cal masses and curet-

120

THE ANUS, RECTUM, AND PELVIC COLON

tiii^ small ulcerattKl areas, as well as for obtaining: spoeimens of
neoplasms for microscopic examination. Along with this set of instru-
ments Kelly introduced a conical sphincter dilator (Fig. 71). It is a

Fn.. til*.— Kklly'h Kectal Curette.

useful instrument, although not a necessary' one. Kelly's description
of the use of the long sigmoidoscope is rather enthusiastic. He says:
" Upon introducing the sigmoidoscope, the longest speculum, the instru-
ment is continued

Yui. 7<».— Kelly'8 Kectal Scoop.

Fi«. 71. — Kelly's SpiiiXiTXR Dilatoi.

up into the dilated
sigmoid flexure in
the false pelvis by
turning the handle
to the right. At
some point in the })assiige the atmospheric distention ceases, and the
lumen of the bowel can then only he shown farther by cautiously push-
ing the end of the instrument on through the lax, collapsed folds.''

From this one would judge that there was little or no dilHculty
in passing from the rectum into the
sigmoid flexure, even with the obtura-
tor of the instrument withdrawn; but
such a statement is unintentionally
misleading.

Where the sphincter is relaxed,
the coccyx movable, and the angle of flexure between the sigmoid and
the rectum is not acute, the straight instrument may be introduced into
the sigmoid flexure with comparative ease; especially is this true in
women. But where the opposite conditions exist, where there is spasm
at the recto-sigmoidal juncture, or where the sigmoid is bound down
in the pelvis, this introduction is not only difficult, but extremely pain-
ful and dangerous as well. When the gut is well distended the instru-
ment niay be so directed as not to impinge upon the walls; but un-
fortunately this distention from ajmospheric pressure ceases ordinarily
in the flrst loop of the sigmoid, and from this point upward the edges
of the tube scrape against the walls of the gut and frequently wound
them.

Anjpsthesia is advised by some for making such examinations; the
author, however, is opposed to this, believing that the sensations of
the patient are the safest guide as to how much pressure shall be used

EXAMINATION AND DIAGNOSIS 121

in order to avoid injury to the parts. Moreover, there have been
noticed occasionally, after sigmoidoscopy under chloroform, a temporary
paralysis of peristaltic action and great difficulty in reestablishing the
regular faecal movements. The exact pathology of this condition can
not be stated, but it is one of those complications which may follow
the use of these instruments.

In order to overcome the difficulty of passing the straight instru-
ment around the promontory of the sacrum, the author devised a
mo<lifieation of the
Kellv tube, which
consists in the intro-
duction of a flexible
obturator bv which the
instrument is given a

M/T7- «.rt\ fio. 72. — ArTnoR'8 Modification of

ercier curveCtiif. <2). ^ , ^

^ ^ ' Kelly's Sigmoidoscope.

Bv this an inclined
plane comes in contact with the promontory of the sacrum, and one is
able to pass this point more easily and witli less pain tlian with the
straight instrument. The modification is only useful in the longer in-
struments necessary for examining the sigmoid.

Martin has devised a modification of the obturator in the Kelly
tubes, which consists in the introduction of certain grooves through
which ointments may be applied to the inside of the rectum. This
obturator is also perforated, so that one may inject air or fluids into
the bowel while the speculum is in position. Beach has also modi-
fied the instrument by carrying an electric light to its inner end
through a supplementary tube, a principle employed in the endoscope
and cystoscope. The successful use of all these instruments, however,
depends upon atmospheric dilatation of the rectum and sigmoid. The
patient nmst be placed in the uncomfortable knee-chest posture, and
even in this position cases will occasionally be seen in which the atmos-
pheric pressure will fail to balloon the parts. In the majority of
cases this ballooning ceases in the first loop of the sigmoid, and noth-
ing more can be seen above this area than that portion of the mucous
membrane which collapses over the open end of the instrument. The
author has found in a number of cases, in which there had been
chronic proctitis or attacks of pelvic cellulitis with adhesions of the
uterus and ovaries to the rectum, that the latter organ did not balloon,
and examination by these tubes was very unsatisfactory. Such diffi-
culties have led to the development of artificial means for distending
the rectum.

Pneumatic Proctoscopy, — In 1890, Dr. Franz Heuel, after having
experimented with his inflating endoscope, also made an attempt to

THE AND8, RECTUM, AND PELVIC COLON

introduce the principle into proctoscopy. This is referrwl lo in nr^Vt
to give credit to the man who tirat attempted practical pneuniaiic
proctoscopy, although thia instrument waa of little value-
In 1899, Pen-
a ^.1-1 ^^ 3 nington, of Chica-

^^1 ^ ■£ - — --^^i^^^ go, introduced sq

^IM ~ "^^ji*^^^^ instrument known

a:^ his pneumatic
proctoscope. This
apparatus consists in
a tube closed by an
accurately fitting
glass ca[i, so thai
tlie rectum can be
ilisteiiiieil by air
pumiK'd into it from
a Imnd-hulb. The
light is reflected
through the glass
into tlie rectum.
This method of illu-
mination, however,
is not satisfactory' on
account of refrac-
tion by the glaa
plate.

Working at the same time, and upon independent lines, Lawa, of
Philadelphia, devised an instrument similar in many respects to that
of Pennington, but
which is an improve-
ment in that the
illumination is se-
cured by an elec-
tric light carried
into the inside of
the tube by insu-
lated rods (Figs. 73,
74). By this means
the whole cavity is
well lighted. This
instrument was a
great improvement
on any hitherto de-

r ilitlurcDl Hlzet ; D, haa.
witli jtldiH wiudow; G, intlutliiK bulb; jf, butlar]'
; J, K, ukvtHo llglit and intulntiiie rods.

BXAMIKATION AND DIAGNOSIS

12;

vis(^!, but certain featurps in it detracted from its usefulness. The
Clip u-hicb closes the instrument is attached by a screw-thread which
■jimelimes binds, and thus necessitates uneonifortable manipulation of
the ioslrument in adjusting it; the electric light occupies a considerable
|>ortion of the caliber of the tube and thus obstructs the vision to
some extent. If there is much secretion or fipcal matter in the bowel,
this ie liable to flow down over the end of the light and obscure it,
thus requiring its removal and cleansing before the examination can
be continued; this is tedious and annoying, and often results in the
breaking of the lamp. These objections are not vital. They are over-
come by a mollification of the instruTuent devised for the author by the
Electro - Surgical In-

slrunieat Company, of ^^^l ^ thlim^^^

Rochester (Fig. 75). ^mml *-•

Aulhor'* Pnramalic
Pmrhncopf. — Th is i n-
strument is composed
of a large cylinder (F),
into one part of the cir-

umferenee of which is

itteii a small metallic

oh? d(«ed by a flint-

^nss bulb at its distal

nd. The electric lamp

G) is fitted upon a

»ng metallic stem, and

irried through the

nail cylinder to the

id of the instrument,

I U shown in the illus-

stion.
Tlie proctoscope is

itroduced through the

aus with the obturator

i) in position. As soon as the interna! sphincter is passed, this ob-

irator is withdrawn and the bayonet -fitting plug (B), which contains

ilher a plain glass window or a lens focused to the length of Ihe

Ktnunent to be used, is inserted in the proxinial end of the instrument.

"his plug is ground to fit air-tight, and thus closes the ioatrunient

erfectly. The plug being inserted in the tube, a very slight pressure

pon the hand-bulb will cause inflation of the rectal ampulla to such

D extent that the whole rectum can be observed and the instrument

tn be carried up to the promontorj' of the sacrum without coming in

Fill. 75.— TlTTLK'S PNEITMATII! PWUIT.IBCUFK.

A, obturator; B, plugwiUi gluu window dosing audof tabs;
C himdlo : £). lyirds roiiiKWIlng iiLilrumcnt itlth liatterr ;
E, iufluting DppiinilUB : F. ttialn tu1« ol [iroctflacopc.

124 THE ANUS, RECTUM, AND PELVIC COLON

contact with the rectal wall. Further dilatation will show the direction
of the canal leading into the sigmoid, and by a little care in manipulating
the instrument and keeping the gut well dilated in advance, it can be
carried up into this portion of the intestine without the least traumatism
of the parts. If any faecal material obscures the light by being massed
or smeared over the glass bulb the pllig can be removed, and a pledget
of cotton, introduced with a long dressing-forceps, will wipe this off so
that the plug can be reintroduced and the examination continued with
very slight delay or inconvenience.

The adjustable handle (C) fits on th^^m of the instrument and
thus converts it into a Kelly tube. This instrument is operated with

an ordinar\' drv bat-
tery of four cells. It
is better, however, to
have one with six
cells, as it will not
require being re-
t:. »., m , T o t:. ^ charged so fre-

F lo. 7b. — Tittle p Long Siomoidopcopie with Flexible Ob- ^

Tl'RATOR GIVING THE InhTRI'MENT THE MeROIER ClRVE. CJUCntly.

The tubes are
made of various lengtlis, from 4 to 14 inches. The very long ones
are supplied with the flexible obturator, which gives them the Mercier
curve (Fig. 7()), like that in the author's modification of the Kelly tubes.

For the beginner in the use of this instrument it is better to have
a plain glass window in the }>lug, for magnifying lenses are very likely
to mislead him with regard to the pathological conditions.

The 4-inch instrument enables one to examine the entire rectum,
but does not give any view of the sigmoid flexure. The 10-inch tube
is sufficient for any ordinary examination of the rectum and sigmoid,
but one should also have the 4-inch size for convenience. The very
long tubes are very rarely called for, but they are useful in large indi-
viduals with long sigmoids or loose mesocolons which may possibly allow
the instrument to enter into the descending colon.

With this instniment it is possible to see all of the sigmoid flexure,
and possibly even to enter the descending colon by very careful manipu-
lation. Ordinarily it does not require any anaesthesia. It can be used
in the prone or Sims's position, and the view which it gives is incom-
parably beyond that obtained by any other means.

In using it one must remember that the bright electric light
intensifies the coloring of the parts, and may lead to false conclusions.
Until one becomes familiar with the changes in appearance pi'oduced
by such a light, it is better to make separate examinations by reflected
daylight so as to avoid this.

EXAMINATION AND DIAGNOSIS 125

Usually it is perfectly feasible to pass these tubes into the sigmoid
flexure without introducing the obturator. The pneumatic pressure
produced by the hand-bulb straightens out this organ, causes it to rise
up above the pelvic brim, and thus facilitates the introduction of the
straight instrument, and at the same time allows one to see considerably
beyond the end of the latter.

It may be suggested that there is danger of rupturing a weakened
and inflamed intestine by such distention, but as a matter of fact it is
never so great as to produce any such effect. Whenever the pressure
assumes any force the air will escape through the sphincter or the plug
will slip out. In cases of relaxed sphincter it is necessary to apply a
collar of wet cotton or gauze around the tu])o, and press it firmly
against the anus in order to retain sufficient air to obtain ballooning
an<l thus permit the examination. One precaution should not be
omitted, and that is, when one has finished his examination with this
instrument he should remove the cap and allow the air to (»scape from
the sigmoid and rectum before he withdraws the tube.

Laws's instrument is supplied with a supplementary cap, through
which an applicator can be introduced and medicines a})plied to any
given j)oint. A curette for scraping ulcers or neoplasms may be used
through this aperture. The author has found it more satisfactory,
however, to locate the pathological condition which is to be treated
right over the end of the tube, remove the cap, and then treat it. In
this way there is more room for the use of instruments, and one can
withdraw and reintroduce them at pleasure.

When the examination is prolonged, condensation of moisture upon
the ^lass mav also obscure the view. To avoid this it is well to heat
the glass by dipping it in hot water before the cap is screwed on. The
examination of the rectum according to this method is practically pain-
less. The Sims's position is employed and is not uncomfortable, and
the results give the utmost satisfaction. These instruments serve all
the purposes of the Kelly tubes, and the general practitioner needs
only the one set.

Atmospheric pressure in examinations of the rectum has been made
use of by Carpenter, of Kentucky, in connection with a duckbill specu-
lum and a long rectal retractor; and by Martin, who describes a method
of distending the anus with the index fingers so that the air rushes in
and dilates the rectum, thus affording a good view of the parts. These
methods are ingenious, but they are not to be compared with those
described above.

The Limit of Ocular Examination. — The extent of the intestinal
canal which can be seen through the rectum has greatly increased by
these modern methods of examination. Reference has been made to

126 THE ANUS, RECTUM, AND PELVIC COLON

the possibiliiy of examining tlie descending colon. For a long time tlie
author was under the impression that lie had been able to do this, but
numerous experiments made u|K)n the cadaver convinced him that this
was practically impossible. Abbott, of Minnea{)olis (American Gjtmbc.
and Obstet. Jour., July, 1900, p. 20), has duplicated these experiments
and arrived at the same conclusions.

According to his measurements a straight tube passed farther than
12 inches would impinge against the liver or diaphragm. There is no
doubt that he is correct in the statement that a 12-inch, onlinan*
Kelly tube is as long an instrument as is ever necessary. With a pneu-
matic proctoscope of this length, however, one may examine the entire
sigmoid flexure, and very occasionally where the mesentery of the
descending colon is very long, may possibly see into this portion of the
intestine. In the large majority of instances, however, the field of
ocular examination is limited to the sigmoid flexure.

Prnhrs. — The ordinary little silver probe, 4 to 5 inches long and
rounded at both ends, is practically useless in examination of the
rectum. These instruments should be 8 or 10 inches long, and fur-
nished with a handle flattened and roughened on one side so that it
can be manipulated with ease, and the operator can always tell in which

Fio. 77. — AurnoR^s Silver Probk.

i^^Ql^^

direction the end is pointing (Fig. 77). They should be made of pure
silver in order that they may be bent in all directions throughout their
entire length without danger of breaking.

As an instrument to locate the internal openings of fistula? the
author has practically discarded the probe until the patient has been
anaesthetized, for one can do this quite as well by digital touch and
with much less pain. After the patient has been anaesthetized the
instrument is of great value in following the tortuous course of the
fistulous tracts as they pass through the cellular and muscular tissues
about the anus to reach the rectum. A very fine probe made of pure
silver is often useful in internal blind fistulae, and especially in de-
termining diseases of the crypts of Morgagni.

Rectal Scoops. — Another instrument which is of great use and should
be possessed by every operator upon rectal diseases is that known as

Fio. 78. — Tuttle's Kkctal Spoon.

the rectal scoop. That of Kelly is made of hard steel, is sharp, and
can not be bent. The smaller scoop (Fig. 78), made of soft copper,

EXAMINATION AND DIAGNOSIS 12T

is the one which the author most frequently uses to scrape off hard
faecal masses, cleanse the crypts of Morgagni, or curette ulcers.

Applicators and Dressing-forceps. — Applicators and dressing-forceps
are necessary instruments in rectal examinations. They should be long
enough to reach through the proctoscope and cleanse the field of ob-
servation. One should have a number of applicators so it will not be
necessary for him to stop and reapply the cotton as he proceeds in his
examination; they should not have roughened ends or screws. By a
little care and manual dexterity one can apply cotton on a perfectly
smooth wire so that it will not slip off, but can be removed without
difficultv.

These instruments should be of different lengths, as the very long
ones necessary for the sigmoidal tubes are not convenient to use in the

FlO. 70. — AUTHOR^S DbE88INO-KORCE1*8.

shorter instruments. Long, straight dressing-forceps (Fig. ?9), with
handles slightly bent downward so that the hand will not obscure the
view, is the most useful form.

In addition to this one should also have a pair of long alligator
forceps (Fig. 80) by which he can reach and seize small foreign bodies,
polypi, or villous growths for the purpose of removal or examination.
These forceps are
useful because thev
can be opened and
shut in a much
smaller s]>ace than t? on a v it

^ Fio. 80. — Alligator Forceps for Use

those in which the through PRocTuycoPE.

joint is in the mid-
dle of the shaft. Tenacula and fixation forceps are also necessary in the
examination of the rectum. The double-spring tenaculum of Burns,
to catch the rectum and draw it downward, might sometimes be very
useful. The advantages of such an instrument would principally be
to obtain specimens for microscopic examination. Sponge-holders are
practically superseded at the present day by the dressing-forceps or
applicators.

Blunt Hooks, — There are a number of varieties of these of different
shapes and sizes useful for the examination of the crypts, pockets,
valves, and internal blind fistulas of the rectum. By having these
instruments one is able to save considerable time and trouble in bend-
ing and twisting his probes to the proper shape; but their possession

128 THE ANUS, RECTUM, AND PELVIC COLON

is not a necessity, for a pure silver probe can be turned into a bl
hook of any angle in a moment's time.

Bougies and Sounds, — Before the days of tubular specula bou^
and sounds were made much use of to examine by the sense of to
those portions of the rectum above the reach of the finger. At pres
they are not so much used for this purpose, although some surge
still adhere to them as diagnostic means. They are of great use in
treatment of strictures, certain forms of prolapse, and catarrhal con
tions of the sigmoid flexure, but of comparatively little value in di
nosis. They are made of various forms, sizes, and materials. Tl
are conical, cylindrical, and fashioned after the urethral bougie d 6ai
In general it may be stated that hard, stiff rectal bougies are v<
dangerous instruments^ and should never be used above the lowei
inches, if indeed they have any place at all in rectal surgery. T
old English rectal bougie was made of web and shellaced, thus maki
a smooth surface, which by soaking in hot water became more or L
flexible. It was more useful than the hard-rubber bougies on tl
account, and until the introduction of the Wales instrument was t
one most generally used. These instruments were made conical a
cylindrical. At one time it was quite the fad in England for peop
suffering from constipation to go by certain offices on their way
business and have these instruments passed.

Other rectal sounds are made of metal and vertebrated so that th«
bend in all directions. The objections to such instruments are th
the joints become rusty, they lose their flexibility, and they are ve
liable to break off in the rectum.

In 1883 Dr. Wales introduced to the medical profession a mod
fied rectal bougie composed of soft rubber. He describes it as fo

Fio. 81. — Walks's Soft-Rubbkr Rectal Bouois.

lows: "A conduit runs through the center and terminates in th
point of the bougie for the purpose of commanding a stream c
water that might be required at any moment to facilitate the intrc
duction of the instruments. The points of the bougies are made ii
various shapes — spherical, conical, and olivary — with the view of meet
ing the necessities of special cases. The surface is perfectly polished
which, by reducing friction, increases the facility of introduction am
eliminates the unpleasant sensation of dragging caused by a rougl
instrument" (Medical Chronicle, Baltimore, 1883). Some of these in
struments are made with a sort of bell-shaped concavity with sharj
edges in the olivary tips. This is very objectionable, and in selecting

EXAMINATION AND DIAGNOSIS 129

a set it is advisable to avoid these. A conical is better, than an olivary
end (Fig. 81). These instruments are introduced by thoroughly lubri-
cating them, and passing them gently upward until an obstruction is met.

An ordinary Davidson bulb syringe is then attached to the instru-
ment, and a stream of water is carried through in order to push out
of the way any folds of mucous membrane or masses of fajcal matter
which may obstruct its passage. In this manner the rectum is dilated
by the fluid, and the bougie will pass imobstructed to the promontory
of the sacrum if there be no stricture to prevent it. At this point
some little pressure is necessary, and the stream of water should be
persistently carried through in order to pass this flexure. After the
instrument has once entered the sigmoid flexure the force of the stream
will lift the folds of mucous membrane from in front of it, and it will
pass without difficulty into the gut. If it is long enough and quite
flexible, it may be even passed into the descending colon. These are
by all means the most satisfactory rectal bougies, both for the general
practitioner and for the specialist. They are made in different sizes,
being numbered from 1 to 12. The smaller sizes are excellent instru-
ments to give high enemata or rectal lavage. Wales also introduced
with this bougie a thin rubber cap or sheath, which lie used as a dilator
for strictures after the instrument had passed tlirough the same. This
sheath was tied to the bougie, and air or water was pumped into it until
it dilated two or three sizes above that of the bougie, thus stretching
the stricture by a soft and elastic pressure. The ordinary Wales bougie
is about 12 inches long. This is not sufficient to reach and enter
the descending colon. The author is not aware that Wales ever recom-
mended their being made any longer; but Wyeth, of New York city,
has had made for him a set of these instruments 26 inches long, includ-
ing the sizes 6 to 10. These long instruments may be used with great
satisfaction in diseases of the sigmoid flexure and descending colon, and
are a most desirable addition to our armamentarium.

The rectal bougie a houle (Fig. 82) is a very useful instrument to
determine the length or extent of a stricture. After the latter has once
been established and the size of the opening in it has been determined.

Fio. 82. — RxcTAL Bougie a boulx.

these little acorn-shaped bougies may be passed through it, and upon
withdrawal, owing to their obtuse base, will catch and thus more or
less accurately show the height to which the contracture extends. They
are made of hard rubber or flexible wire, with different sized tips which
can be screwed on according to the case in which they are to be used.
9

130 THE ANUS, RECTUM, AND PELVIC COLON

The stem is very flexible and can be bent in any direction. Thev are
best used tlirough a cylindrical speculum. The latter is passed up to
tlie stricture, the bougie a boule is carried through it and then through
the stricture. By this means it is possible to see accurately the opening
into the stricture and avoid any undue manipulation and force in the
introduction of the bulbous bougie into it. Andrews, of Chicago, has
devised an instrument of this kind made upon an inflexible stem, and
bent so as to conform to what he considered the normal curve of the
rectum, but this fonn of instrument does not seem equal to the other.

Anaesthesia in Bectal Examinations. — Thus far we have only men-
tioned tlie subject of anivsthesia in examinations for rectal diseases in
a cursory manner. In many of the old books upon this subject it is
assumed or distinctly stated that any examination beyond that which
can be made with the finger requires general anaesthesia. Modem
methods have done away with this necessity. It is never required for
an examination of the rectum and anus except in hypenesthetic patients
with \Qry painful affections. Where these conditions exist the patient
should be ])repared to have whatever operation is necessary done at
the same time tliat tlie examination is made. The sensation of the
patient is a most important aid in the diagnosis of disease, and it should
always be utilized as far as possible in an examination.

The dangers of the use of long tubes under anaesthesia have been
mentioned, and also those of the introduction of the whole hand. The
same remarks ap}>ly to the use of bougies. While anaesthesia is helpful
to the surgeon, it is not always best for the patient. Happily it is
seldom demanded exce})t in operative procedures.

The author has been much disappointed in the use of cocaine for
examinations; it lias failed to prevent pain or proved so dangerous in
the rectum that he has almost discontinued its use for these purposes.
Applied to the skin or muco-cutaneous membrane, it is almost inert,
and when injected into the rectal cavity it is attended by very alanning
symptoms. The author has twice had patients near the point of death
from introducing less than 1 drachm of a 4-per-cent solution of cocaine
into the rectal cavity; and he has seen several cases in which after
cocaine had been used for the purpose of cauterizing ulcers and fistulae
the patient had gone into collapse, and had been resuscitated only
with great difficulty. On account of these experiences he never injects
the drug into the rectum.

When there is great tenderness small pledgets of cotton soaked in
solutions of cocaine or eucaine may be introduced through a cannula.
To these pledgets threads are attached so that they can be removed at
any moment, and thus the amount of the drug can be controlled. By
dragging down on the threads the drug can be held in exact apposition

EXAMINATION AND DIAGNOSIS 131

with the area it is desired to influence. Ethyl chloride and the other
local anaesthetics have proved useless so far as the rectum is concerned,
except as adjuvants to the introduction of hypodermic needles. It can
not be insisted upon too strongly, however, that the patient's sensations
during a first examination are important; nor can it be stated too posi-
tively that to a skilful practitioner anaesthesia, either local or general, is
seldom necessary in order to make a practical diagnosis of rectal
diseases.

In some cases local examination fails to determine the nature and
cause of rectal disease. The condition may be above the point of
examination, or the manifestations may be so obscure that it is impossi-
ble to determine their exact pathology. In neoplasms, one should
always remove a specimen for microscopic examination before finally
deciding upon their malignancy. In other obscure conditions, a careful
analysis of the discharges and of the faecal contents of the bowels is
necessarv.

•r

Examination of Faeces.* — Examination of the faeces is accomplished
bv four methods:

Macroscopical, Microscopical, Bacteriological, and Chemical.

Fa?ces are the materials discharged from the bowels, made up in
greater part of the remains of food after the process of digestion.
Associated with these remains are fluids secreted from the digestive
tract, desquamated epithelial cells, bacteria in large numbers, and occa-
sionally fortuitous substances, such as parasites and their ova, blood,
pus, gall-stones, etc.

In health from 140 to 200 grammes per day are discharged by an
adult. Though varjung within wide limits, they are usually of a light-
brown color. Certain foods and medicaments mav cause them to be-
come ver}' dark or even black, as after the ingestion of huckleberries
or iron. Again, when the flow of bile is impeded they may become
light yellow or gray. In certain forms of enteritis, as in t}'phoid or
cholera, they may become gray or green.

Commonly the evacuations take place once everj' twenty-four hours,
but it is not uncommon to find persons in perfect health whose evacua-
tions occur but once in forty-eight hours, and again others whose habit
it is to evacuate twice in twenty-four hours. In pathological states
these intervals may vary from ten to fourteen days or more on the
one extreme, to intervals of a few minutes on the other.

In a healthy individual the fcTces are of a pasty or dough-like con-
sistence, and are molded to the shape of the bowel, sometimes as long,
sausage-shaped segments or a series of boluses closely massed together.

♦ For this section the author is indebted to Dr. F. M. Jeffries, director of the
New York Polyclinic Laboratory.

132 THE ANUS, RECTUM, AND PELVIC COLON

Disturbances of digestion quickly alter this consistence from the
hard, dry masses of constipation and the dry, clay-like stools of liver
disturbances to the fluid and wateiy^ stools of a simple enteritis, or of
the graver disturbances, such as t}T)hoid or cholera.

In addition to the obser\'ation8 as to color and consistence manv
constituents may be obser\'ed macroscopically. Blood or pus in large
quantities may be recognized as such; seeds of fruits and vegetables
appear unchanged, and in the lientcric states all kinds of food ])ass
through wholly unaffected. The writer once had submitted to him for
examination a pint or more of bodies about the size of hickory nuts
which a patient was said to be passing regularly, and which proved on
examination to be halves of orange segments sans mastication, sans
digestion. The writer has also seen pills and even compressed tablets
appear unaffected in the dejecta.

Skins and seeds of fruits and vegetables, as of apples and toma-
toes, usually are readily recognizable, as also are shreils of vegetable
fibers.

Enteroliths, whicli are gall-stones, may sometimes be found, and are
of a considerable degree of importance as an aid to diagnosis. They
may readily be overlooked, as they are frequently soft and of a clay-like
consistence; but a clieinical and microscopical examination will de-
termine their character.

ilucus, whicli normally serves to coat the fa?ces when properly
formed, may sometimes become greatly increased and constitute a con-
spicuous part of the stools. In cases of mucous colitis the greater part
of each movement may be made up of mucus, and frequently it fairly
forms a mold of the intestine and is passed as long strands of a struc-
tureless, more or less tough, whitish mass. Osier reports an autopsy
where such a condition existed, and says that the intestine was lined
as with a membrane, and that upon its removal the mucosa appeared
to be uninjured.

In ulcerations of the intestine the stools may occasionally contain
fragments of intestinal mucosa.

From their characteristics the stools of various diseases have re-
ceived names suggested by their appearance, as, for example, pea soup
in typhoid, rice-water in cholera, and tarry in yellow fever.

The characteristic odor of normal fa?ces is due to the decomposi-
tion of the food residue and to the secretion of glands about the anus.
This odor varies in part according to the nature of the food ingested.
In some diseased conditions it becomes very pronounced and disagreea-
ble, and is largely due to micro-organisms. Pure cultures of some of
these micro-organisms impart an odor which is readily recognized as
contributing to the fa?cal odor.

EXAMINATION AND DIAGNOSIS

133

Parasites and parts of parasites^ many of which are recognizable
by the unaided eye, are common constituents of the dejecta. They
comprise a not inconsiderable group, and, according to the literature,
the list continues to grow.

It is not within the province of this article to describe the various
forms occurring in faeces, but they will simply be enumerated in the
order as classified by Von Jaksch:

1. Protozoa

r Platoda .

2. Vermes.

Ccstoda.

3. Inssects.

Rhizopodaj^onadines.

Sporozoa . Represented by coecidia.

fCereomonas intestinal is.
Megastoma entericum
Trichomonas mtestiualis.
Parama^eium coli.

'Taenia solium.
Taenia saginuta.
J Taenia nana.
Taenia diniinuta.
Ta?nia cueumerina.
' [Bothrioccphalus latus.

I ( Distoma hepaticuni.

Distoma lanceolatum.
Distoma Rathouisi.
Distoma sinense.
^Distoma felineum.
f Ascaris lumbrieoides.

r Ascaridae -j Ascaris mystax.

[ Oxyuris vermicularis.
StrongvlidaB Anchylostoma duodenale.

Trichoiraehellda, j ?j|Seiu"''"
[st'rSSyS}- AuguiUula iutctinalis.

Trematoda.

Annelida,

order
Xematoda

The microscopical characters of the faeces are easily determined.
In proceeding to examine under the microscope, the material is spread
out in a thin layer underneath a cover-glass and examined with low
powers as with | and ^ inch objectives. It may be necessary to dilute
them with water or a 3-per-cent salt solution before they are in a
condition for microscopical examination. The substances derived from
the food are first to be considered.

1. Vegetable cells unaltered or in various stages of disintegration —
isolated or grouped as developed, some containing chlorophyll but
most devoid of it.

2. Muscle fibers recognizable by their structure but appearing swol-
len and stained vellow.

3. Fat and oil globules.

4. Starch granules, hydrated and sometimes unhydrated. They may
be recognized by their blue color when treated with a weak iodo-potas-
sium-iodide solution.

5. Fibrous tissue of white fibrous and yellow elastic varieties.

134 THE ANCS. RECTUM, AND PELVIC COLON

6. Detritus. Granules large or small, grouped or isolated, pale or
dark in eolor.

7. Always associated with these are bacteria, which are abundant
and of numerous varieties, prominent among which are the Bacillus
coli commune and the Bacillus proteus \'ulgaris. None of the bacteria
normally found are of pathogenic character, although they may exhibit
pathogenicity at times.

8. Molds and yeast fungi are frequently associated with the bac-
terial flora.

In ])athological states the bacteria may increase to an enormous
amount and the fjvces may contain pathogenic bacteria, as the typhoid
bacillus in typhoid fever, the comma bacillus in Asiatic cholera. Tuber-
cle bacilli mav be found in cases of tubercular ulcerations.

The detection of the pathogenic bacteria is not a simple procedure,
and should be left to the bacteriologist.

9. From the intestinal tract itself epithelial cells are constantly
shed. They may appear normal or in all stages of disintegration, ac-
cording to the length of time they have constituted a part of the "stools.
They are, as a rule, stained yellow.

By far the most important microscopical elements of the faeces
are the animal parasites. Some of these are microscopical, and others
have ova which would escape detection without microscopical examina-
tion.

Amcebi coli, which belongs to the rhizopoda, is found in certain
dysenteric stools, and occurs usually in tropical or subtropical regions.
It can not be distinguished from the Proteus amoeba, so conunon in
the waters of all localities. It is merely a mass of protoplasm devoid
of a cell-membrane, possesses a nucleus and one or more vacuoles.
The j)rotoplasm is granular, and frequently contains cells and granules
of detritus which it has devoured. It exhil)it8 the same motility notice-
able in its prototype, the Proteus am(vl)a. It may be as small as a leu-
cocyte, or so large as nearly to fill a field of a ^inch objective. In eases
where its presence is suspected the stools should be examined perfectly
fresh and should be kept warm. In selecting material for such exam-
ination, gather up the particles of viscous or jelly-like material. Such
stools may bo kept on hand for future examinations if a little carbonate
of soda be added and they be kept at about the body temperature.

A variety of cr}-stals may occasionally be seen in the faeces.

Fatty acids are found in the form of minute, short, slightly curved^
colorless crystals. They are soluble in ether.

The fatty crystals have been found in abundance in alcoholic stools
and the stools of jaundice, especially in children. They are abundant
in the stools of infants during lactation.

EXAMINATION AND DIAGNOSIS 135

Fatty soaps^ which occur in long, colorless, needle-like crystals ar-
ranged in stellate groups, may be seen. They are not soluble in ether.

Hsematoidin crystals, usually somewhat atypical in structure, of a
light-brown color, resembling somewhat an irregular sheaf of wheat,
may be foimd free or enclosed in globular masses of a substance re-
sembling mucin. They have been observed in cases of chronic intes-
tinal catarrh, as the result of haemorrhage, and also in cases of nephritis.

Charcot-Leyden crystals are sometimes found in fti^ces as in anky-
lostomiasis. They are colorless and are octahedral in form, resembling
those in semen and the sputum of asthmatics. They have been found
in a variety of conditions, and by their almost constant appearance in
conjunction with the various entozoa, their presence may be considered
as pointing to an infection by some form of intestinal parasite.

Cholesterin is a normal constituent of the faeces, but its appearance
in crystalline form is unusual. It occurs in the form of irregular rhom-
bic plates which frequently appear in groups. Tliey are colorless, thin,
highly refractive, and are soluble in ether. When treated with dilute
sulphuric acid and tincture of iodine they give a characteristic reaction
of a violet color followed by blue, green, and red. No diagnostic im-
portance can be attributed to these crystals.

Phosphate of calcium in the stools appears either as wedge-shaped,
colorless bodies in groups, with converging apices, or yellowish, round,
dumb-bell or oval bodies, which are usually fissured. Their occurrence
is rare and of no clinical value.

Calcium oxalate crystals, in the pyramidal form common to urine
sediments, frequently appear in the fa?ces in health or disease. They
are in more abundance during a vegetable diet.

Triple phosphate crystals (ammonio-magnesium-phosphate) are com-
mon to fluid stools. They are usually in the form designated as the
coffin-lid, and are found only in alkaline stools. They are readily
soluble in acetic acid.

Sulphide-of -bismuth crystals are found in the stools after the admin-
istration of some form of bismuth. They resemble haemin crystals,
and are dark brown or black rhombic bodies.

Bacteriological Examination, — As previously stated, the bacteriologi-
cal examination belongs to the expert bacteriologist.

The organisms found even in healthy stools are numerous and
diversified, and in many of the inflanunatory conditions no new forms
have been discovered. In catarrhal and diarrhoeal stools the bacterio-
logical flora is extensive. It would appear that these conditions are
not attributable to any one organism or group of organisms. A germ
to be an etiological factor need not at autopsy be found to have invaded
the connective tissues; the bacteria may produce their effect solely

13^ THE AXTS, RECTTH, AXD PELVIC COLON

through their poisonous products. Among those mentioned as hayii
been etiological factors are streptococcus, staphylococcus. Bacillus pj
cvaneus. Bacillus lactis aerogenes. Bacillus coli conmiune, spirillum
Finkler and Prior.

Other bacteria are the typhoid bacillus in typhoid fever, the chole
bacillus in ^Vsiatic cholera, the diphtheria bacillus in diphtheritic e
teritis, the tetanus bacillus, the Bacillus aerogenes capsulatus, and tl
tuliercle bacillus. This last ororanism mav be discovered bv the follow
ing prfK-erlure:

If the strKils are fluid, smear them in a thin layer on glass slide
or if not fluid, they must be dissolved in water to a pasty consistent
and then smeared as described. A number of slides should thus 1
prepared, as the great dilution causes the bacilli if present to be wide
scattered. After allowing the smears to dry spontaneously in tl
atmosphere, they must be passed rather quickly three times through
Bunsfii or alcohol flame to " fix '* them. Then immerse them for ha
an hour in the following solution:

Z ieh UN e else n's Carbol-fuchsin

Saturated alcoholic solution of fuchsin 10 c. c;

Five-per-eent carbolic-acid water 90 c. c.

Remove from this solution, carefully wash in running water, an-
decolorize for about two minutes in a 5-per-cent solution of sulphuri
acid. Wash in water again and counterstain for three minutes witl
an alcoholic solution of methylene blue. Wash finally in water, dr
between folds of blotting-paper, and examine with a -j^y-inch oil immer
gion objective. If tubercle bacilli are present they will be contraste<
by their bright-red color, as all other bacilli present will have reacte<
to the blue dye. It must be borne in mind that they are never presen
in great numbers, and that before a negative decision can be determinec
the investigator must have patiently searched over several preparations

The chemical examination of the fapces is of little importance owinj
to the paucity of data that may be obtained thereby, or to the failun
of such data to be of any clinical value.

Mucin is a constant constituent of the stools. For its detectior
the stools are to be dissolved in water and an equal quantity of lime-
watcjr added. After the mixture has stood for several hours it is filtered,
and to the filtrate an excess of acetic acid is added. If mucin is present
a turbidity or cloudiness will appear.

Albumin in the stools may be detected by mixing them with water,
and after allowing the mixture to stand a short time it is filtered and
the filtrate rendered acid by the addition of a small quantity of acetic

EXAMINATION AND DIAGNOSIS 137

acid. This is then put in a test-tube and heated nearly to the boiling
point. If albumin is present a cloudiness will appear. It is recom-
mended that the test-tube be nearly filled and the upper portion only
be heated, so that the lower unheated strata may be used for comparison.

For the detection of peptone in the stools Von Jaksch recommends
the following procedure: The stools are rendered pasty by the addi-
tion of water, boiled and filtered while still hot. The filtrate is to be
treated with acetate of lead to precipitate its mucin; it is then filtered
again, and the filtrate, which should be not less than 500 cubic centi-
meters in volume, is acidulated with hydrochloric acid. To this add
phosphotungstic acid until a precipitate ceases to form. The fluid
is then immediately filtered. The precipitate is washed on the filter
with five parts of concentrated sulphuric acid in one hundred parts of
water until the fluid which passes through is colorless, to get rid of the
salts. The precipitate is then washed from the filter with as little
water as possible. Place in a watch-glass, add barium carbonate until
the mixture is alkaline, and then place on a water-bath at the boiling
point and heat for about fifteen minutes and apply the biuret test as
follows: Treat with caustic potash and add, drop by drop, a 10-per-
cent solution of sulphate of copper. Peptone is shown by the formation
of a color ranging from bluish-red to violet, and varying in intensity
according to the quantity present.

Urea is one of the normal constituents in the stools, and when it
is desired to ascertain the total quantity of nitrogenous substances
eliminated in questions of metabolism, it becomes necessary to estimate
the urea in the stools. The method of Von Jaksch is here recom-
mended. Before drying the stools treat them with dilute acid to pre-
vent the evaporation of ammonia. Dissolve the dried stools in three
or four times their volume of alcohol, allow this to stand twenty-four
hours and filter. The precipitate is washed on the filter repeatedly with
alcohol, the filtrates are mixed, and the alcohol distilled off. The resi-
due is treated with nitric acid, and the resulting crj'stalline pulp allowed
to stand for some hours, when the crystalline masses which have formed
are pressed between folds of blotting-paper, dissolved in water, and
treated with carbonate of baryta until carbonic acid ceases to form,
and then dried on a water-bath. The drv residue is then extracted
with boiling alcohol. On evaporation the urea remains in long, slender,
prismatic cr}'stals. The usual tests for urea may be applied to these
crystals.

Of the carbohydrates in the stools, starch and sugar are the two which
will be considered.

Starch, as already stated, may be recognized microscopically. To
test for either starch or sugar the faeces should be boiled with the water

138 THE ANUS, RECTUM, AND PELVIC COLON

and the concentrated filtrate tested. For starch use the iodo-potaa
iodide solution, when its presence will be manifested by a blue col
For sugar, use Fehling's or the phenyl-hydrazin test.

Various other substances which may be found normally or patl
logically in the fa?ces are hardly of sufficient importance to warn
mention in this work; and, besides, their detection and estimation :
quire skilled manipulation and elaborate laboratory facilities.

CHAPTER IV

CATARRHAL DISEASES OF THE RECTUM AND SIGMOID:

PROCTITIS AND SIGMOIDITIS

The structure of the mucous membrane and the functions of the
rectum and sigmoid render these organs peculiarly susceptible to catar-
rhal affections. Not only are they studded with myriads of Lieberkiihn
follicles, forming, as it were, little ciypts for the lodgment of infectious
materials, but it is at these points that the excrement itious matters of
the alimentary canal in their most concentrated form lodge for varying
periods before being passed out of the body.

The mucous membrane here absorbs from the fa?cal mass a large
proportion of its fluids, in which are many bacteria and infectious
germs. Here the faecal mass becomes hardened through this absorption
of its moisture, and by friction and pressure excoriates, sometimes actu-
ally wounds the mucous membrane, and thus produces lesions that
become infected and result in catarrhal proctitis.

The intimate connection and similarity of structure between the
mucous membrane of the rectum, sigmoid, and colon render it impossible
to discuss the disease in one part without taking into consideration the
others. Moreover, inasmuch as the chief sym})toms of catarrhal inflam-
mation of the sigmoid and colon are often referred to the rectum or
associated with some symptoms in this organ, it has become the province
of the rectal specialist to look into and treat these diseases whether
they are confined to the rectal ampulla or extend to the caput coli
itself. Since the invention of the modem instruments for examining
the sigmoid flexure, the direct observation and application of remedies
to these parts has simplified their treatment and in many respects
altered our views entirely with regard to their pathology. It is impossi-
ble in any case of catarrhal disease to draw a dividing line where the
condition begins and where it ends. In the majority of cases, instead
of the inflammation being confined to the rectum, it extends throughout
the sigmoid flexure and upward into the descending colon. There are
instances in which the disease is confined to the rectum; but it is very
rare that there is a catarrhal colitis or sigmoiditis in which the rectum

139

140 THE ANUS, RECTUM, AND PELVIC COLON

is not more or loss involved. In considering, therefore, the catarrhal
diseases of the rectum, one can not confine himself to this organ alone,
but must extend his obser\'ati()ns hi;Ljher up in the intestinal canal.

In the acute form of j)roctitis one may generally recognize a definite
period of beginning, and come to some conclusion with regard to its
origin; but the chronic fonns are so insidious in their approach and
so devoid of positive symptoms in their early stages that one can rare-
ly tell how long they have existed, their cause, or their probable dura-
tion.

Catarrhal inflammation of the lower end of the intestinal tract im

be divided into two broad classes. Simple and Specific.

Simple catarrhs consist in acute catarrhal inflammation, atrophic
catarrhal inflammation, hypertrophic catarrhal inflammation.

The specific forms are gonorrlueal catarrhal inflammation, diphthe-
ritic catarrhal inflammation, erysij)clatou8 catarrhal inflammation,
dysenteric catarrhal inflammation, syphilitic catarrhal inflammation.

SIMPLE CATARRHAL INFLAMMATION

Inflammations of the nmcous membrane which are not due to
any sjx'cific germ yet recognized are among the most frequent dis-
eases of the human race. Especially is this true in large cities, and in
those climates where the individuals are subject to frequent and excess-
ive changes in temperature, overheated houses, poor ventilation, in-
dulgence in stimulating and highly seasoned foods, and the lack of
physical outdoor exercise.

Prediitpositinn. — Individuals differ in their susceptibility to these
inflammatory processes. Some patients live for years in certain cli-
mates, resist the sudden changes and exposure that pertain to their
environments, indulge in almost all sorts of excesses with regtrd to
diet, and never suffer from any catarrhal disorders; while others develop
them on the slightest exposure or indiscretion. Sudden change of
temperature, alteration in diet, indulgence in some stimulating food or
drink, or even change of water, will be followed in these individuals
by catarrhal inflammation of the colon and the rectum. This pre-
disposition is undoubtedly hereditary, for it can be traced from genera-
tion to generation in families.

It is impossible to state at what ]>oint the disease most frequently
begins. It may develop at either end of the large intestine, and pro-
gress steadily toward the other as long as its treatment is neglected.
In adults the sym]>toms and history- of the case may give some indica-
tion of its origin, ])ut in children this is always too unreliable to justify
conclusions ui)on this point. AVe must therefore depend largely upon

FOLLICULAR PROCTITIS

INFUMMATOHV CONDITIONS
OF THE RECTUM AS SEEN THROUGH THE PROCTOSCOPE

CATARRHAL DISEASES OP THE RECTUM AND SIGMOID 141

I local examination. Happily we can examine a child's rectum just as
• well as an adult's, and whenever persistent constipation, diarrhoea, or
irregularity in the faecal movements of an infant are discovered, a
rectal examination should be made at once. Within the last year the
author has introduced the small proctoscope into the sigmoid flexures
of four children imder the age of two years (one being less than nine
months old) without the slightest difficulty. In three of them a marked
catarrhal inflammation of the lower end of the colon was found, which
yielded readily to local applications, and the patients were rapidly
cured. The influence of age, sex, and occupation vary in the different
types of the disease, as well as the symptoms, and therefore it is advisa-
r ble to discuss each variety separately.

^ Acute Catarrhal Proctitis. — Like catarrhal inflammation in other

J raucous tracts, this comes on suddenly, and may be frequently traced

to a clearly deflned exciting cause. It may be ushered in with a slight

I chill, aching pains over the body, especially in the sacrum and around

; the pelvis, and slight elevation of tempemture. Generally, however,

the patient does not observe these sjrmptoms, but describes the disease

as dating from the first sensations in the rectum.

Symptoms, — The earlier symptoms are fulness followed by a sense
of weight, lieat, and burning in the rectum. If the disease is high up
there will be more discomfort than real pain, but tenesmus, bearing
down, and desire to go to stool will be marked. Pains that radiate
to the back, legs, and pelvic organs, difficulty in and a frequent desire
to micturate, are noticed; the bodily temperature may be elevated, the
pulse quickened, the tongue furred or coated white, and there may
^^ headache or general malaise. The patient is always more comforta-
We lying down than in the erect posture.

Some describe a sensation as if a foreign body was in the rectum
causing the sphincters to contract, and when the bowels move, the
fecal matter, which is generally fluid, is ejected through the narrowed
^nfice in a small forcible stream.

If the disease be severe, leucorrhcea or cystitis may be produced in
^^nsequence of the intimate nervous, vascular and lymphatic connec-
tions; but where these occur, one should always suspect and positively
eliminate the gonorrhoeal element as an etiological factor before he
Concludes that he has to deal with a simple catarrhal proctitis. During
^he first twenty-four hours of acute catarrhal proctitis there will be dis-
charged from the rectum a thin, fluid faecal matter; later on this fluid
^ill be tinged with blood and contain mucus; if the inflammation per-
sists and is severe, ulceration will take place; indeed, the whole mucous
Membrane of the rectum may slough off and be discharged. After this
the discharges from the rectum will be muco-purulent or sanguino-puru-

142 THE ANUS, RECTUM, AND PELVIC COLON

lent, the fa?eal materials being mixed with blood and pus in large
quantities.

From the beginning the desire to go to stool is frequent and impert-
tive, and requires the i)atient to remain close to the commode. The
act does not relieve the desire, and the patient constantly strains to
rid himself of what seems to be a foreign body in the rectum, but
which is nothing more than the inflamed, swollen, and c&dematoiu
mucous membrane. The sensation is comparable to that of granuli-
tion of the conjunctiva, where there is constant desire on the part of
the patient to get rid of something in the eye. In children the mucous
membrane frequently prolapses, producing the condition described by
Euser as '* ectropion recti.''

The introduction of the finger or speculum is ver}' painful, and
may even require ana'sthesia. To the touch the parts feel dry, hot,
and swollen in the first stages; after secretion has begun they appear
moist and slimy, the walls of the rectum seem close together, and the
caliber diminished.

Through the speculum the membrane appears of a bright-red color
(Plate I, Fig. 2), dry, and (edematous in the beginning; later on the
color is darker and the surface covered with mucus; occasionallv this
assumes the appearance of a pseudo-membrane.

The inflammation in acute catarrhal proctitis is generally confined
to the mucous membrane and the subnmcosa. Rarely the deeper tis-
sues may be involved, and even the muscular wall itself may be per-
forated, resulting, as Kelsey has pointed out, in acute peritonitis and
death. Under ordinarv circumstances the inflammation subsides under
rest and proper treatment, the symptoms grow less marked, and the
patient recovers in a few days; at other times the disease passes into
the chronic form. When nothing more than the mucous membrane
is involved, this ends the acute phenomena: but when deep ulceration
occurs, perirectal abscess, fistula, or stricture may result.

Etiolofjij. — Pinworms, lumbricoids, impacted fa?ces, and foreign
bodies may all set up a catarrhal inflammation of the rectum. Im-
proper diet, such as sauces, highly seasoned foods, hot tamales, green
peppers, etc., are frecjuent causes of the acute variety. Chronic con-
stipation is not very frecjuently the cause of acute proctitis; this con-
dition is slow in development, and the mucous membrane becomes
accustomed to a condition which approaches by such gradual and insidi-
ous steps. Fermentation or putrefaction in the intestine, which some-
times follows a change of diet, water, and en\dronments, may induce a
sudden and acute catarrhal inflammation of the colon all along its
course. This occurs more frequently in summer and in hot climates
than under other conditions.

CATARRHAL DISEASES OF THE RECTUM AND SIGMOID 143

Infection is, however, the chief of causes. VThen the faecal mass
reaches the sigmoid flexure and rectum, the moisture is largely absorbed,
and the hard, insoluble substances are likely to stick out beyond it and
thus irritate or wound the mucous membrane. This renders the lower
portion of the bowel very liable to infection from the bacteria always
present.

Rheumatism and gout are closely related to catarrhal inflammation
of the intestines (Curling), but not as etiological factors. The same
conditions which cause them, viz., fermentation and putrefaction in
the intestinal canal, are frequently the cause of proctitis and colitis.

Prolapse and intussusception may be the cause of catarrhal inflam-
mation. This is brought about by the friction of the membrane upon
itself, the irritation from the passage of fa?cal masses through a nar-
rowed channel, and a circumscribed interference with the circulation
of the parts. In prolapse, where the gut protrudes and recedes from
time to time, it is irritated by this process and by rubbing against the
clothing; its circuLation is interfered with by contraction of the
sphincter, and it is desiccated by exposure to the atmosphere; as a
result catarrhal inflanmiation frequently occurs. Tumors of the rec-
tum, uterus, and ovaries, displacements of the uterus, stone in the
bladder, and whatever causes undue and unnatural pressure upon the
rectum, will cause a localized congestion at that point, and set up an
inflammation which may spread in all directions. It may also be caused
by inflammations of the uterus and its appendages, the prostate and
seminal vesicles.

Sitting upon cold stones or wet seats is very frequently the exciting
cause of acute catarrhal proctitis. Coachmen are said to be particularly
liable to the disease on this account. The author has seen a number of
cases in young people who, after exciting exercise, such as tennis, base-
ball, or cricket, have sat down upon the damp ground, thus causing a
sudden chill to the parts, which resulted in attacks of acute catarrh of
the rectum and sigmoid.

Acute congestion of the liver sometimes terminates in catarrhal
inflammation of the rectum, due to obstruction of the portal cir-
culation, and also to the irritating influences of excessive discharges
of bile which follow such attacks. Mild attacks of this disease mav
also be produced by the action of irritating cathartics, such as jalap,
aloes, gamboge, rhubarb, podophyllin, and senna.

Finally, attention must be directed to personal idios^-ncrasies with
regard to the development of this disease. In the author's experience
an acute catarrhal condition of the lower end of the intestinal tract
would be produced in one individual by a single cup of coffee; another
patient could never eat strawberries without having afterward an acute

144 THE ANUS. RECTUM, AND PELVIC COLON

rectal catarrh, almost dysenteric in its nature; another suffered from
this condition if he drank a single glass of ordinary apple cider. These
idiosyncrasies might be multiplied, but they are not pertinent to the
subject; each individual forms a problem in himself, and no generaliza-
tion can be drawn from them.

Treafment, — The treatment of this fonn of disease like all others
demands the removal of the cause if possible. When it is due to
irritating, infectious, or putrefying substances in the intestinal canal,
thev should be evacuated at once either bv saline cathartics or intestinal
lavage; if there be foreign bodies or impacted fjeces in the rectum, these
should be removed; but great care should be exercised in their removal
to avoid all traumatism and injury to the parts. The dilatation of the
s])liinoters gives great relief to the patient when the catarrhal inflam-
mation is low down about the margin of the anus.

Saline laxatives, such as sulphate of magnesia, sulphate of soda,
cream of tartar and sulphur; or some of the mineral waters, such as
Kubinat, Hunyadi Janos, or Apenta are exceedingly useful. One should
not hesitate in the use of these medicines to give a sufficient quantity
to i)roduce a thorough washing out oi the i)arts by the watery move-
ments which they ])roduce. Small doses do more hann than good, and
even in ]>atients who are very weak and debilitated no bad result fol-
lows full-sized doses of these remedies.

After the ])owels have been thoroughly cleaned out, antiphlogistic
remedies should be applied; irrigation with cold water is very grateful
to most ])ntients, to others ver}- hot water soothes the parts more
efTectually, and in a number of cases alternating currents of hot and
cold water may be used with very gratifying results. The hard-
rubber rectal irrigator (Fig. 83) of the author and a fountain syringe

will be found very satisfactory
for this purpose. It is made
in various sizes so that it can
be used with comparative com-
fort in cases with both con-
tracted and relaxed sphincters.
Fi(i. S3.— TuTTLE'8 Rectal Irkioator. It consists in a hard-rubber

cylinder, through the center of
which runs a small tube connecting with three openings in the distal
end. This tube carries the fluid into the rectxmi. The large cylinder has
numerous openings u])on the sides large enough to admit of the passage
of small faecal particles, and it is connected at the outer end with a dis-
charge pipe, to which is attached a rubber tube long enough to reach a
basin on the floor when the patient lies upon the bed. The instrument
can be taken apart and thoroughly sterilized. It is used with

CATARRHAL DISEASES OF THE RECTUM AND SIGMOID 145

the patient l3ring upon the side, and any quantity of fluid can be
thus i)assed through the rectum without wetting the bedclothes or
necessitating a movement of the bowels. When the hot and cold water
are alternated a Y-tube is used to connect the irrigator with two
syringes containing the water. By this means therapeutic agents may
be applied to the parts; solutions of carbolic acid .5 to 1 per cent, of
boric acid 5 per cent, of thymol 2 per cent, nitrate of silver 1 to 2,000,
of hydrastis 1 to 2 per cent, of the aqueous fluid extract of krameria 5
to 20 per cent. After the irrigation has been continued ten to fifteen
minutes, the fluid should all be drained out of the rectum through
the irrigator, and a suppository of opium and iodoform introduced.
The particular solution used for irrigation will depend upon the indica-
tions in each individual case. Krameria and nitrate of silver are the
most generally employed.

Sometimes the p^rts about the anus are so tender that the intro-
duction of the irrigator can not be borne. In such instances two small
rubber catheters can be used, one for the inflow and one for the exit
of the irrigating fluid. The use of enemata is not advised because
they only increase the tenesmus and the desire to go to stool. Some-
iinies after the irrigation, the introduction of a small amount of flax-
seed tea, about 1 ounce, with ^ to 1 grain of opium and 30 minims of
the aqueous fluid extract of krameria will prove very soothing to the
partes, and be effectual to quiet tenesmus, llegulated, unirritating diet
sliould be enjoined. Most writers insist upon the use of milk, but this
article is so prone to produce hard, tough scybala? which constipate the
individual and irritate the inflamed surfaces by their passage over them,
that thin gruels, beef, mutton, and chicken broths, or some of the pre-
pared foods, such as Mellen's, Carnrick's, or beef peptonoids, are to be
preferred.

After the acute inflammatory stage is passed, when suppuration and
ulceration occur, the irrigation with antiseptic solutions should be con-
tinued, and if the disease is low down, the rectum may be sprayed with
some astringent solution, such as nitrate of silver or protargol; powders,
such as bismuth, aristol, or antinosine, may be insufflated through a
tubular speculum directly upon the ulcer if it be isolated, or all over
the rectal wall if there is general ulceration, by placing the patient in
the knee-chest posture and obtaining atmospheric dilatation. Sulphate
of copper, and also sulpho-carbolate of zinc, in mild solutions, have
acted very well as sprays in this condition.

The bowels should be induced to move at regular intervals, and the
rectum should be irrigated after each movement. The patient should
be kept in bed until the pus and blood have entirely ceased to be dis-
charged. The dietary regimen, however, should be kept up for some little
10

140 THE ANUS, RECTUM. AND PELVIC COLON

time after the patient has ^ot up. If the disease is high up in the
sigmoid flexure or colon, lavage through the long rectal bougie should
be carried out with the j)atient in the knee-chest jMjsture, and large
quantities of the sohition should be introduced: as much as '<? gallons
of boric-acid solution or a 1-to- 10,000 bichloride of mercury- niav be thus
introduced. The solutions rapidly ccmie away, and there is no danger
from the amount of the drug which will be absorbed.

Medicines ])y the mouth are not generally effective. Antiferments,
such as beta-naphthol, salol, subnitrate of bisnmth, and creosote, may
sometimes be effectual in the prevention of further fermentation in
the intestinal canal. The enteric ])ills, composed of sulpho-carbolate
of zinc and covered with a coating which is not soluble in the acid secre-
tions of the stomach, are occasionallv effectual. These cases are more
benefited by the use of a pill that contains sulphate of copper 1 grain,
and extract of oj)ium :J grain than ])v any other drugs; these are given
every twi^ hours, and the result is sometimes magical in the relief ol' the
tenesmus and the tendencv to diarrhcea. (\istor-oil, as a laxative, has
not proved as effectual in producing a movement that is watery and
cleansing as have the saline preparations, and, moriH>ver, it leaves a tend-
ency to constipation in the patient which is not satisfactory; neverthe-
less, many authors prefer this to all other laxative medicines m such
conditions. In minute doses (5 minims), repeated every two hours, it is
sometimes very soothing to the bowel and checks the tendencv to diar-
rhcea. Fluid extract of hamamelis and liquor of bismuth, of each from
1 to 2 drachms, is spoken of very highly. To the out-of-town practi-
tioners, who have not large pharmacies to order from, the llaxsee<l tea,
witch-hazel, and astringent washes will generally prove quite satis-
factory.

CHRONIC PROCTITIS AND SIGMOIDITIS

There are two types of chronic catarrhal inflammation of the rec-
tum and sigmoid, the hifpertrophic and atrophic. The acute form may
merge into a chronic state, and when this takes place it generally de-
velops into what is known as hypertrophic catarrh.

Hypertrophic Catarrh. — This type is sometimes described as acute
and chronic, but practically it is always chronic. It has been confused
in some recent writings (Quenu, Ilamonic, and Keclus) with proliferat-
ing rectitis. which is a syphilitic inflammation. It is not confined to one
portion, but affects all of the large intestine, the sigmoid and rectum
as well.

Pathological Anatomy. — The mucous membrane and submueosa in
this condition are always thickened; the glandular elements of the

CATARRHAL DISEASES OF THE RECTUM AND SIGMOID 14"

Fio. &4.^IlTPEinitapiiio Catjuuuta

Speciuivti ahowing iucrciuie in dei'tlj
inleitiAulnr BUbsWni't.

nienihrane are markedly liypertrojihied; the Ijieberkulm folliclos ai-e
deepened, the intertubular substance is increaeed (Fig. 84), and there
is an increase in the number of goblet or mucus-producing cells.
The connective tissue of the eubraucosa is increased; here and there

|< elastic fibers are found in

IVit, but there is no evidence
cicatricial formation.

[Around the blood-vessels,

I' which are numerous, ami

B between them and the true

Biinucosa, is a mass of ein-

■ 1n-ronio tissuu of variable
f Ibickness. The blood-ves-
V0el walls appear normal or
Iflomcwhat thinned.

Bacterial culture from

■the scrapings of this con-

IditioB show only the spores

md bacteria ordinarily

■ found in the intestinal
Itracl. The miico-pua, col-

fctcd by scraping, showB under the microscope pus-cells, leucocytes,
land various bacteria, together with small masses of fiscal matter and
liuvligested particles of food.

Elitihiiy. — The cause of this condition may be intra- or txlrn-inte.n-

\nttl: it may follow acute colitis or proctitis, or it may develop from

B^c same causes which produce these conditions. It may also be pro-

Vduccd by conditions external to the intestine. Adhesive bands which

^constrict the colon or which rub against it during peristaltic action may

luse congestion, thus setting up a hyperemia and hyperplasia which

rentuate in iiypertrophic catarrh.

Abdominal tumors or displaced uteri that press upon the intestine
jay excite this condition; movable kidneys, especially those which
plide up and down with every respiration, and rub against the wall of
tbe ascending or descending colon, may induce, or certainly they may
H-p up, an inHammatory condition of the large intestine which ex-
tends to the rectum. Catarrhal appendicitis also has its influence in
>duciDg or protracting this disease. It has frequently been held that
H form of appendicitis is due to the catarrhal condition of the bowel,
I [imposition which it is impossible to prove or disprove. The fact re-
lains, however, that a patient with a catarrhal condition of the colon,
implicated by catarrhal appendicitis, will very often recover very
romptly if the appendix is removed. Pathology and bacteriology have

148 THE ANUS, RECTUM, AND PELVIC COLON

thrown no particular li'rht upon the etiology of this disease, and it i3
only from clinical observations that we can draw our conelugions. The
same irregularities in diet, habits, and exercise which produce acute ca-
tarrhal c()nditi<ms of the intestine will also produce this. The chief etio-
h)gical factor in this disease is said to be chronic c<mstipation.

Syntp((n/is. — In the early stages of this disciise the symptoms are
vague and indeiinite, unless it succeeds an acute catarrh, under which
circumstances there is simply an amelioration of the acute symptoms
and a gradual develoj)ment of the chronic condition. The disease is
not confined to the rectum; it usually alfei-ts the sigmoid flexure and
colon as W(»ll ; hence the symptoms may Ik^ referred to a wide area.
There are flatulence, tenesmus, loss of ai)petite, and general malaise: the
tongue is flabby and coated white: diarrlm^i sometimes alternates with
constipation; the stools are eith(»r soft, semifluid, and mixed with muco-
pus, or they may be hard and round like sheep-balls, and covered with
this muco-purulent secretion. As the dis(»ase progresses the constitn-
tional antl digestive symptoms Inn'ome more marked; i)eriodic tenes-
mus occurs, after which tln^re is a profuse passage of thick, glairy mucus
mixed with pus, and sometimes tinged with blood. The patient is nearly
always aware of the approach of such attacks, and is much exhausted
after the mucous passages. Then* is not much pain about the lower
end of the rectum, but rather a feeling of weight and discomfort.

The secretion from the mucous membrane is abundant, and some-
times it ooz(»s out through the sphincter, kee]>ing the anal tissues moist
and macerat(*d. Occasionally this produces an erythema or dermatitis
which mav Ik? mistaken for moist eczema. The discharge is sometimes
so profuse that a ])atient is compelled to wear a na])kin. The mdial folds
are hy])ertro])hied, and between them there frecjuently occur small fis-
sures, but as the sphincters are relaxed these are not very painful. Pru*
rifiis is one of the most freijuent symptoms, and sometimes the only one
which induces the pati(»nt to consult a physician. The disease occurs
most frequently in plethoric, fat, flabby individuals, but it is also seen
in thin, neurotic persons.

Around the anus one may frequently see hypertrophies of the papillae
develop into ty|>ical condylomata with dendritic formation. This condi-
tion extends well up into the anus, and l)ecomes less marked as the ano-
rectal line is approached. The hypertrophy, however, seems to begin
again in the mucous membrane, and extends indefinitely. To the digital
touch the mucous membrane presents a soft, doughy feeling with a some-
what closer approximation of the walls than is normal. Through the
speculum it appears cedematous, paler than usual, and covered with a thin
coat of whitish secretion (Plate T, Fig. 5). The swollen membrane bnlgep
out into the fenestra of the conical speculum, or falls down amd complete-

CATARRHAL DISEASES OF THE RECTUM AND SIGMOID 149

ly covers the end of the proctoscope. ^Vhen the muco-pus is wiped off,
the membrane presents through the magnifying glass a cauliflower-like
appearance, whitish and granular. It does not bleed easily, and the end
of a fine probe being pressed'down upon its surface, tlie tissues will meet
together above it. By scraping with a rectal scoop one may obtain a cer-
tain amount of muco-purulent fluid the composition of which has been
already mentioned. Haemorrhages are not characteristic of this dis-
ease, neither are haemorrhoids. The latter sometimes develop, but they
are of the connective tissue and not the haemorrhagic tyi)e ; the mucous
membrane covering them is thickened, but the autlior has never been
able to establish the transformation from cylindrical to stratified pave-
ment epithelium over the parts, as has been described by Hamonic and
Quenu.

There is often a sensation after stool of something more to come
away. This may result from a partial prolapse or from the retention of
a certain amount of mucus in a posterior or anterior rectocele. The in-
troduction of the finger into the rectum will sometimes result in the
passage of this accumulation, and the patient will be relieved. After the
passages of muco-purulent material there is often a burning, itching sen-
sation around the anus.

The papillae around the upper margin of the pecten are frequently
much hypertrophied, and the crypts of Morgagni are swollen and in-
flamed. Constipation becomes a most annoying feature in the later
stages ; the patient does not succeed in having a movement of the bow-
els without the greatest effort. Large doses of laxatives and recto-
eolonic flushing are necessary in order to provoke a movement. In
the meantime between the stools the patient suffers from an inclination
to defecate, which results, after more or less straining and tenesmus,
in the passage of a small quantity of mucus, sometimes tinged with
blood and pus. There are swelling of the abdomen, intestinal griping
pain, nausea, and vomiting. The patients gradually develop vague
nervous sjinptoms, become apprehensive and h}T)ocliondriacal, or they
may have grave mental symptoms.

Treatment. — The treatment of this form of catarrh is necessarily
prolonged and tedious. Where a tumor, floating kidney, displaced
uterus, or tenderness over the appendix exists, one should not commit
himself to a too favorable prognosis from local treatment, for it may be
necessary to operate for the complication before a cure can be obtained.

It may be asked why we do not operate immediately in such cases.
If it is an extremely chronic condition, and modern treatment has been
tried without effect, then it would be perfectly proper to do so. But
where the case is a snbacate one, where the condition has lasted only
two or three months, where no proper dietary regimen and local treat-

150 THE ANUS, RECTUM, AND PELVIC COLON

nient have been carried out, one can not pay that all the therapeutic
measures have been exhausted ; these should be tried before any serious
operation is undertaken, provided life and general health are not endan-
gered by such delay.

Assuming that the etiological factor is intra-intestinal, the first o\h
ject in the treatment should be to n'move it. Get rid of whatever irri-
tates the intestinal mucous membrane, whether it be hanlened faH?al
masses, fermenting intestinal products, cestodes, or whatever foreign
substance may be in the patient's bowels or rectum.

The best thing for such nidical cleaning out of the intestinal canal
is sulphate of magnesia 5 parts and bicarbonate of 8oda 1 part. A table-
8|)oonful of this mixture should be given before breakfast in the morning,
and repeated every two or thr(»e hours until a thorough watery evacua-
tion is obtained. After this the colon should ho flushed with 2 or 3
quarts of boric acid or normal s^iline solution. The patient's hips should
be elevated, or he should be phuH»d in the knee-chest posturt*, and a Wales
bougie, Ti inches in length and of small calilK»r, used for the purpose.
This fluid should lx» given at a tempt^rature of about 100°, and should
1)0 retained as hmg as possible in order to obtain the antiseptic influence
of the drug upon the folds and follicles of the nnicous membrane. After
thorough cleaning out of the intestine the j)atient should be put upon
a chieflv nitrogenous diet, (iluten bread or onlv the crust of stale bread
should be allowed. Meats, fowl, fish, and eggs are all admissible; but
in the veget^ible line only those forms should be used which are practi-
cally free from sugar and starchy elements. Of all articles of food, white
potatoes are the most injurious in catarrhal diseases of the intestine;
there is nothing which ferments more rapidly or furnishes a better
medium for the growth and incr(»ase of bacterial products than this vege-
table. Spinach, lettuce, (t^h'ry, and such vegetables are all advisable in
these cases. A little w(»ll-cooked rice may be allowed. String beans,
when fresh and grec^n, can also bi» given.

The eifect of coffee and tea is variable ; in some patients they have
no detrimental influence, while in others no improvement can be obtained
until these beverages have boon absolutely sto])ped.

The milk diet, suggested by many writers, has not proved itself bene-
ficial, because it forms hard, insoluble stools which irritate the mucous
membrane of the colon as they pass through, and if there be any inflam-
mation at the lower end of the n^ctum, it often results in fiecal impac-
tion there on account of the pain which the patient anticipates from the
stool.

Stimulating drinks and alcohol in all forms should be interdicted.
Hot water before each meal sometimes has a most excellent effect. Large
quantities should be advised in the beginning to flush out the stomach,

CATABBHAL DISAASBS OF THE BECTUM AND SIGMOID 151

intestines, and kidneys. Two or three glasses may be taken before each
meal ; a pinch of salt added sometimes makes it more palatable.

The bowels should be regulated by mild laxatives if necessary. Malt
and cascara, taken upon going to bed, is generally effective. Drugs that
are preventive of fermentation are beneficial. Great benefit will be ob-
tained from capsules or powders containing —

SaloK j rr ^.

Pancreatin, J * * & • - »

Boric acid gr. v.

To bo taken one hour after meals.

Beta-naphthol has occasionally seemed to act more satisfactorily than
the above combination. Very good results have followed the internal
administration of ichthyol, which is given in the form of enteric pills
containing 3 to 5 grains each. When there is a tendency to griping and
diarrhoea, as there occasionally is in this condition, small doses of castor-
oil, 5 to 10 drops taken in capsules every three or four hours, will quiet
this materia 11 v.

The local applications will depend very largely u])on the extent of
the disease. Where the sigmoidoscope reveals the fact that the inflam-
matory phenomena extend well up into the colon, local aj)plications
through the speculum will be practically of little benefit. Tn such con-
ditions it is well to place the patient in the knee-chest posture, and with
the long bougie, described above, introduce 1 to 3 quarts of a 2- to 10-per-
cont solution of aqueous fluid extract of krameria. Extract of hydrastis,
1 ounce to 2 quarts of hot water, a l-to-10,0()0 solution of bichloride of
nioreurv, or a l-to-5,000 solution of nitrate of silver may all be used in
the same manner. The krameria, however, havS given the best results,
and generally under its use the condition rapidly improves. This drug
as found ordinarily in the shops is absolutely useless. The preparation
which is recommended, according to a fonnula devised for the author
by Dr. ^liiller some ten years ago is prepared as follows:

Macerate one pound of bark of krameria in a long percolating tube for twenty-
four hours. After this a mixture of 20 per cent glycerin and 80 ])er cent water
is allowed to percolate through it. The percolate should be constantly stirred and
refiltrated through the bark the second time. The filtrate is then evaporated down
tci one pound, thus obtaining an aqueous fluid extract containing grain for grain
all the therapeutic properties of the bark. The preparation should be kept in a
dark place and not ex]K)sed to the air.

This can be mixed freely with water in any proportion, and throws
down no sediment ; it can be introduced into the tenderest rectum with-
out producing irritation ; it is an astringent, and apparently soothes pain

n-2

THE AKUS, RECTUM, ASD PELVIC COLON

and roducvs influiiuiiution. For irri}!atii)n it is used Jn strengths of from
2 to 30 per i-ent, and for local applications it may be used pure.

If there in any ulwratlon within view through the ?ignioidoscop«,
the parts uliHuld be !>ponged or sprayed with a 2-per-ccut solution of
nitrate of silver. Applications of iodine or antinosinc arc aliw u^ful
under these cinniiiistanw'S.

Injections of t-weet-oil and iodoform have not been satisfactory in
my hands in this form of calarrli, hut occasionally relief has been given
in the spasnuniic altack^i by high injections of 6 ounces of olive-oil, with
lialf un oiinei' of glycerin.

Hccenfly some ven- go()d results have been ubtiiineil from high injec-
tions of 1 or 'i per eiml ichlliyo] in olive- or eod-iivor oil. Four to 6
omiccs are injocteil omi' in two or three days.

Bitter tonics, coil-liver oil, hypoiiliospliites, lione marrow, and such
products as juotonuclein or organo serum should all be tried along with
the local tri-utTiieiit before resorting to surgical measures; but. on the
other liund. one sliould not wait on these too long.

Atrophic Catarrh. — This is the nuist freijucnt type of catarrhal in-
flaiumiitiou of the rectum, and it is always chronic. It is found fre-
quently in [ii-ople about the age of pulierly, and in constantly increasing
numlM'rs as they ]>rogress in years. The process may begin in early life;
it consists in a general iitrophy of the mucous membrane and its glanda-

lar elements throughout

the rectum and sigmoid
flexure. It is usually lim-
ited to these parts, and
rarely ascends as high as
the deiicending colon.

Paiholoijieal Aiialomg.
— One observes upon ex-
amining the mucous mem-
brane in these eases an
irregular, bosselated, or
granular appearance. The
surface is dry, rough, in-
elastic, and without any
salient vegetations. At-
tached to the surface here
and there are small inas.<=eB
of <lry fa'cal material, and occasionally little islands of necrotic epi-
thelium or pseudo-membrane (Plate I, Fig. 2).

Microscopic examination .'hows the epitbelium absent in manv places,
but always present in the deeper portions of the crypts of Lieberkiihn.

CATARRHAL DISEASES OF THE RECTUM AND SIGMOID 153

These follicles are generally atrophied, the intertubular tissue decreased
(Fig. 85), and their goblet-cells are few in number. The cylindrical
epithelium is said to assume the stratified pavement type in this dis-
ease (Quenu, Hamonic). This change does not extend more than 1
or 2 centimeters above the ano-rectal line; it is confined to the super-
ficial surface of the membrane^ and does not involve the tubules.

The connective tissue of the submucous coat is dense and slightly
thickened ; it does not contain embryonic tissue and elastic fibers, as in
the hypertrophic form. The solitary follicles are often enlarged and
distended. At points there are distinct granulations and ulcerations ac-
companied with hypenemia and multiplication of the blood-vessels, but
there is no alteration in the blood-vessel walls.

Etiology. — It has been suggested that this disease may be produced
by emanations from foul closets and improper detergent material. The
author at one time laid some stress upon these factors, but in recent
years he has seen such a large increase in this type of disease among
a class of people in whom such factors could not be frequent that they
are no longer considered seriously. The fact that this condition is so
frequently associated with obscure syphilitic disease, leads him to sus-
pect this in almost every case; whether it be acquired or hereditary,
vicious or innocent, it is a distinctly etiological factor in this type of
infiammation. In the majority of cases there is a history of chronic con-
stipation associated with the habitual use of laxative pills, purgatives,
and hepatic stinmlants, all of which contain some resinous cathartic and
irritant to the mucous membrane of the rectum. In most of them the
continuous use of condiments, and stimulants to the appetite and diges-
tion, late dinners and midnight suppers, associated with little outdoor
exercise and arduous social functions, contribute to the production of the
disease. Excessive school duties, close, unventilated study-rooms, and
improper or insufficient food, all have their influence. Many of those
who suffer from this condition in early life also suffer from a dry, catar-
rhal condition of the nasal mucous membrane, which seems to show that
the rectal condition is a part of a general constitutional tendency.

This type of catarrh may also result from the practice of sodomy, the
use of irritating enemata, and from foreign bodies in the rectum whether
introduced voluntarily or accumulated by passage through the intestinal
canal ; it also results by vascular or lymphatic extension from chronic
inflammation of the pelvic and genito-urinar>' organs. Very frequently
it is associated with old pelvic cellulitis and the adhesions that result
from this condition. Perirectal abscesses, fistulae, and haemorrhoids are
frequently associated with the disease, but their etiological influence is
verv doubtful.

Symptoms, — The patient will complain, as a rule, of long-continued

154 THE ANUS, RECTUM, AND PELVIC COLON

constipation. The stools are dry and hard, coated more or less with
mucus, and sometimes tinged with blood; there is often severe pain
after them, and this circumstance leads to the diagnosis of fissure in ano.
Heat and burning in the n^gion of the sacrum and in the rectum are fre-
quent symptoms; the sphincters are always more or less spasmodic. In-
troduction of the finger or of the speculum is often painful. Stretching
apart of the folds of the buttocks will produce cracks or minute fissures
in the muco-cutaneous tissue of the anus. These little fissures mav be
j)roduced by the passage of a hard fa^'al mass, and result in burning,
itching, and sometimes actual pain. They are very shallow; they occur
at any i)()int in the circumference regardless of the radial folds, and heal
rajMclIy, only to recur wh(»n the parts are stretched again.

Ihemorrhoids are a constant complication of this typi* of the disease.
Frc(|uently llicsi* are assumed to bt» the cause of the disease instead of
th(» result, and the patient is ojK'rated npon only to Ix? disappointed in
finding himsi'lf unimj)roved. To the eye the nmcous membrane is bright-
hmI and of a shiny appearance, with little masses of inspissated f»ced
adhering to it here and there (Plate I, Fig. 3). It does not protrude
itself into the fenestra, nor does it collapse over the end of the tubu-
lar speculum, as in the hy])ertrophic form. The surface is dry to the
touch, and adheres to the finger as the latter is pushed upward; there is
a general atony of the walls of the rectum in old cases; the rugae seem
almost obliterated, and the valves of Houston stand out more promi-
nent Iv than is usual. There is nearlv alwavs marked dilatation of the
rectal ampulla in th(»se cases. Often when the finger passes the internal
s])hinct(*r it glides into a widely distended cavity, the sides or top of
which it can scarcely touch. In this pouch faecal masses accumulate and
fretpiently lie from day to day until they become quite large, and some-
times result in fa'cal impaction.

riceration is more frecpient in this form of catarrhal disease than in
the hyiiertrophic. The mucous membrane of the entire rectum may be
erodi'd and more or less deeply ulcerated in spots (Plate I, Fig. 6). This
is due to the traumatism produced by the passage of dry, hard fjeces over
an imj)n)])erly lubricated nmcous membrane and subsequent infection.
The resting of these hard masses in one position may interfere with the
circulation and produce ulceration, (\mstipation, flatulence, and indi-
gestion are always a ])art of this affection; the complexion may be sallow,
and the skin harsh and dry; the tongue is frequently coated a dirty yel-
low, and there is a bad taste in the mouth on rising in the morning; the
a])])etite is frequently impaired, and the patient loses flesh; the stools are
always hard, lumpy, and coated slightly with mucus, blood, or pus. Pru-
ritus is often an annoying symptom, and interferes with the patient's
rest at night.

CATARRHAL DISEASES OF THE RECTUM AND SIGMOID 155

Treatment. — This form of inflammation, being limited largely to the
rectum and lower sigmoid, is plainly within view through the procto-
scope, and consequently is more susceptible to local treatment than the
other forms.

The whole field affected can be observed and treated from below, and,
as a matter of fact, no treatment from above is likely to prove efficacious
except in so far as it prevents irritating and infectious materials from
passing through the diseased area. Whatever will produce non-irritat-
ing, soft, and easy stools will conduce to the healing of these parts. It
will be unnecessary to continually flush the colon by drastic purges in
order to keep the parts clean. This may be accomplished by simple ene-
ma ta, or more completely by lavage of the sigmoid flexure and rectum
through the ordinary rectal irrigator, and by this means the constant
peristalsis and motion of the parts caused by cathartics will be avoided.

When there is reason to suspect the possibility of syphilitic infection,
it is well to administer specific remedies along with the local treatment
for this condition. As has been stated elsewhere, the use of mercury in-
ternally is inadvisable on account of the peristaltic action and diarrhoia
which it induces. It allows no rest to the parts. Inunctions, mercuric
baths, and the hypodermic administration of the drug are all superior
to its internal administration in cases of this kind. At the same time a
certain amount of iodides should be given if the patient's stomach does
not rebel against them.

If there is no specific element in the case, tonics, such as cod-liver
oil, hypophosphites, and some assimilable form of iron are always called
for. As a rule, however, iron is objectionable in that it tends to consti-
pation and the production of hard, irritating stools. Malt with various
tonic cimstitiients is an excellent remedv; combined with the fluid ex-
tract of cascara, and administered at bedtime, it gives a certain but easy
nu>vement of the bowels on the day following. This and cold water
enemata are the chief remedies for regulating the bowels in this condi-
tion; though occasionally recourse must be had to others, such as small
doses of calomel and soda, podophyllin, colocynth, and saline waters.
These latter, however, should not be repeated frequently.

The diet, while it should be as carefully governed in this condition
as in the hypertrophic catarrh, is not necessarily so limited. Starchy
products may bo taken in moderation, and also a few sweets. Potatoes,
however, for the reasons before indicated, are interdicted. Coffee and
tea are both injurious in these cases, and alcohol is to be avoided. Pure
food in generous quantities, fresh air, and outdoor exercise, especially
horseback riding, should all be encouraged.

Local Treatment. — For the local treatment a great many remedies
are recommended in the books upon rectal and general diseases, but argo-

156 THE ANUS, RECTUM, AND PELVIC COLON

nin, nitrate of silver, ichthyol, hydrastis, and oil with glycerin are those
that will be found most useful. These remedies should be applied after
the rectum has been thoroughly emptied either by a laxative or cold-water
enema; they may bt» introduced through the Wales bougie, and should
always be carried up into the sigmoid llexure as high as the disease ex-
tends. The stnMigths of the solutions are governed by the condition of
the gut. When then? is an extremely dry condition of the mucous mem-
brane, with tenacious nmcus and inspissated fascal masses adherent to it,
the parts should be wiped off with j)ledgets of cotton, and comparatively
strong stimulating ai)plications made. In such cases the cavity should
W swabbed out or sprayed with a 2- to o-jH^r-cent solution of nitrate of
silver. This treatment, however, if carried out in the sigmoid flexure,
])roduces considerable griping and i)ain : th(»n»fore, when the disease ex-
tends high up the use of argcmin in solutions of 5 to 10 |kt cent is to be
preferred. This drug is a])])lied as follows:

The patient is j)laced in the knee-chest posture, the pneumatic sig-
moidoscope is carried up well into the sigmoid flexure, the latter being
distended by pneumatic ])ressure; after this the eyepiece of the instru-
ment is removed, and ^ to 1 ounce of the solution is poured into the gut
through the tube: the eye])iece is then replaced, and the gut again dis-
tended as the tube is withdrawn, leaving the solution well up in the
sigmoid. As soon as llie s])eculum is removed, peristaltic action car-
ries the drug downward and a])plies it to all the jmrtions of the intestine
below.

Irrigation with hot water stimulates the circulation in these condi-
tions, and hastens the absorption of any inflammator}^ products which
may be present. It is useless, however, to inject a pint or quart of
hot water into the bowel for this ])urpose and allow it to be passed
out within a few moments. The irrigation should be carried out
by means of a rectal irrigator (Fig. 83), and should be kept up for
fifteen to twenty minutes at a time. The water should flow very
slowly, and the temperature should be gradually increased until it
reaches 115° F.

After the irrigation, the applications of argonin or nitrate of silver
will be more effectual, inasmuch as the mucus and pus will have been
washed away from the parts. This treatment should be carried out daily
at first, and afterward the periods may be lengthened gradually until
the applications are necessary (mly once a week. Sometimes where the
irrigation and stimulating applications set up irritation in the rectum
and sigmoid, it is well to inject into the sigmoid at bedtime 2 or 3
ounces of a 20-per-cent solution of the fluid extract of krameria. These
methods of treatment frequently keep the bowels regular without any
laxative medicines or cold-water enemata. If there is much itching and

CATARRHAL DISEASES OF THE RECTUM AND SIGMOID 157

burning, and if the skin cracks easily about the margin of the anus, appli-
cations of the following mixture will give great relief :

5 Acidi carbolici 3j;

Acidi salicylici 3ss.;

Glycerini 5j.

This should be painted over the anus at bedtime.

After this an ointment of 5 per cent ichthyol and 95 per cent lanolin
is applied. By treatment with the Wales bougie the sphincter is grad-
ually but gently dilated, the mucous membrane becomes softened under
the influence of the ichthyol and lanolin, the itching is relieved by the
carbolic compound, and the patient's symptoms rapidly improve. If
necessary, a cold-water enema is given every morning to move tlie bowels.
This may be continued indefinitely. It not only induces a proper move-
ment, but also reduces the congestion of hamiorrhoids. Occasionally
where the fissure-like cracks in the mucous membrane involve the ends of
the sensory nerve, stretching under nitrous-oxide gas or ethyl chloride
will be necessary. These cases, however, are exceedingly rare.

Nothing except soft cotton or moistened tissue paper should be used
for detergent purposes. In this condition washes and bathing are not
injurious at all, inasmuch as they keep the membrane softened and flex-
ible, and thus prevent to a certain extent the cracking. Sweet-oil and
iodoform have l>een used a number of times in this condition, but expe-
rience shows they are not equal to the remedies described, and are much
more expensive. When there are ulcerations upon the mucous membrane,
as in Plate I, Fig. 6, an insufflation of antinosine directly to the ulcer-
ated spot is of great benefit. The author has applied nitrate of silver
to these conditions, and has found that the healing has been slow and the
suppuration marked. Under the use of antinosine and iodine there is
no suppuration to speak of, and the healing is exceedingly rapid. In
cases in which there is a marked posterior rectocele care should be taken
to see that this pocket is well emptied, and that no small fa?cal balls or
foreign substances accumulate therein.

In very chronic cases much benefit will be derived from a nightly in-
jection of 3 ounces of olive-oil and ^ ounce of glycerin. Albolene with
1 per cent of carbolic acid or ^ per cent of menthol seems to have a sooth-
ing efTect in some cases. Occasionally when the haemorrhoids are marked
and so inflamed that local treatment of the parts is irritating and pain>
ful, it is necessary to operate upon these first and treat the catarrhal
condition aften^'ard.

With the patient under anaesthesia for the ha?morrhoidal operation
the author has sometimes touched the mucous membrane at spots all
around with the thermo-cautery, and has found that it had a remark-

158 THE ANUS, RECTUM, AND PELVIC COLON

ably good influence upon the condition. As a rule, however, it is beti
not to interfere with the Jiaemorrhoidal growths in this condition un
the catarrhal phenomena have been controlled, and in a large number
cases they will be found to have disappeared along with the catanrl
condition.

Fistulas and extensive ulcerations occur in connection with tl
disease, and should be treated by the methods laid down in the chaptf
upon these subjects. The treatment of the two conditions need not i
terfere with each other, except in those cases in which the fistula
dissected out and the parts sewed together. Here one must wait un
the parts have healed. Under other circumstances the treatment of t.
catarrhal condition may be continued immediately after operation, ai
thus considerable time will be saved.

SPECIFIC CATARRHAL INFLAMMATIONS

Of these we have mentioned in our classification four special vai
eties. The gonorrhceal and syphilitic types will be treated of in tl
chapter upon venereal diseases of the rectum and sigmoid.

Dysenteric Proctitis and Sigmoiditis. — It is not proposed here to g
into a scientific discussion of dysentery, but simply to review the sul
ject very briefly in its relation to the rectum and sigmoid flexure.

Dysentery has been assumed to be a constitutional disease. IjSlX
authorities, however, agree that the condition originates in a local infe<
tion, and the majority of them are of the opinion that the most frequen
site of this infection is in the sigmoid or rectum. The hepatic an
splenic flexures of the colon are also frequent sites. In sporadic dysen
tery the rectum and sigmoid are practically all that are affected. On th
other hand, in the endemic and epidemic forms, the whole length of th
colon, and even the small intestine may be involved. In every case, there
fore, the rectum and sigmoid sooner or later take a very prominent par
in this disease, and frequently are the only sites of inflammation. It I
on this account, and the fact that the disease often hangs on as a sort o
chronic diarrhcea, with ulcerative or inflammatory proctitis, that it is
thought wise to introduce the subject here.

Etiology. — Ileat, cold, excessive exercise, improper diet, bad water
faulty drainage, and all the circumstances and environments of arm)
life have been at one time or other designated as the causes of this dis-
ease. Bacteriological investigations, however, have changed all these
views, and we now look upon it as the result of a specific pathogenic
agent.

Flexner, in a careful study of this disease, concluded that the causa-
tive agent is the same in all the different types. He questions the influ-

CATARRHAL DISEASES OF THE RECTUM AND SIGMOID 159

enee of amiBba^ dysenteria? in the production of endemic or tropical dys-
entery, and says that the evidence upon which the belief in this is based
can not be regarded as convincing. He states that these organisms have
been proved to exist in other diseases, such as cholera, typhoid fever, pel-
la«rra, and simple colitis, that they are also found in the dejecta of healthy
individuals, and therefore their pathological influence in dysentery can
not be proved. That they may produce inflammation and even ulceration
when associated with bacteria he says has been proved, but authors diti'er
as to the power of the anueba? alone to induce intestinal lesions. Coun-
cilman and Lafleur consider it as the absolute cause of dysentery, while
Kartulis, Kruse, Paschal, Flexner, and Cruikshank all hold that it must
be associated with bacteria or other pathogenic organisms in order to
bring about the disease.

H. F. Harris, of Philadelphia, found it impossible to cultivate the
ama»ba» dysenteria?. He therefore attempted to cultivate all the iiecal
discharges from a dysenteric patient, and to doterininc if these mixed
cultures were capable of setting up the disease. In four pupj)ies these
experiments were absolutely without effect. As the amceba coli was the
imly organism in the fa*ces that was probably absent from the cultures,
he concludes that this is the pathogenic cause of the disease.

Marchoux (Comp. rend, de la Soc. de Biol., Xovember 11, 1899) ob-
servwl in Senegal 47 cases of ama^bic dysentery. He injected the fieces
into tiie recta of cats and produced the disease in them. The discharges
from these animals were introduced into others, and the disease was car-
ried through a series of 10 without any variation in the sympt(Mns. Oc-
casionally he found abscesses of the liver in the injected cats. Inasmuch
as the anuelxe were not isolated, the question still remains open
whether it alone was the cause of this particular type of dysentery, or
wlietlier it was associated with other bacteria, such as were necessarily
pres<*nt in the fa?cal injections used by Marchoux.

The conclusions reached by recent authorities studying this subject
in the Philippines, Japan, and West Indies are that there are three types
of dysenter}': First, a mild catarrhal form, which runs its course in a few
days, and is never fatal except in very feeble or wounded ])atients;
second, a dysentery due to a mixed type of bacillus, such as has been de-
scrilx^d by Flexner as the Bacillus dysenteria^ and, third, amcebic dysen-
tery* produced by amoebae that differ probably from that which is ordi-
narily found in the intestine. After reading over these reports as care-
fullv as possible, one is led to the conclusion that the first variety of
which the writers speak is nothing more than a simple catarrhal inflam-
mation, such as we have described in the first paragraph of this chap-
ter; and that the other two types are due to the amceba^ dysenteria^ to-
gether with the BaeiUus coli commune, and that the different grades or

160 THE ANUS, RECTUM, AND PELVIC COLON

variations of the disease arc simply modifications due to the amount of
the septic bacteria absorbed bv the individual.

The constitutional element of the disease is an infection. So long as
the mucous membrane is intact this infection does not take place, but
as soon as a lesion occurs, the organisms, being present, at once enter
and ])rodu(e it. Acute catarrhal inflammation or injun* to the mucous
membrane of the intestine may thercforc furnish an entrance for thesje
germs, and conscMjuently cause a specific dysentery. Articles of food that
increase fermentative or putrcf active action in the large intestine irri-
tate the nmcous membrane of that organ, and probably furnish suitable
menstrua for the development of these bacilli, which incrt»ase in such
numbers that thcMr toxicity immediately makes its impression upon the
individual. The irritation produced by these fermentations, by foreign
bodies, and by hard stools furnishes an open gate for the entrance of these
bacilli into the system. Without going into a wide discussion of the
influeiu-es of the different bacteria, it mav be said that all authors are
practically unanimous in the opinion that the disease is due to local
invasion or infection by some pathogenic agent; and that the original
infection, and, in the large majority of cases, the chief area affected,
is in the lower portion of the large intestine: in other wonls, the rectum
and sigmoid flexure. If this is so, the study and treatment of this dis-
ease should be through the rectum.

Pathol u(j II, — The aniceba^ enter the colon through the stomach and
small intestine, but they do not multiply in this portion of the aU-
mentary tract on account of the acid reaction of the contents; they re-
quire an alkaline medium in which to grow. As they descend through
the colcm the conditions become more and more favorable for their mul-
tiplication, and they invade its mucous membrane, so that it becomes
swollen, (XHlematous, and breaks down. Murray says that the bacillus
passes through the mucous membrane and invades the submucosa, caus-
ing necrosis there, and thus cuts off the blood supply of the mucous mem-
brane. The latter becomes gangrenous and is cast off, leaving an ulcer
sometimes deej) enough to ex])ose the muscular coat. He states that
"the amceba? may penetrate into the intermuscular saeptum and reach
the serous coat, where the same process goes on as in the submucosa, and
perforation nuiy follow.'' The destniction to the submucous layer may
be much greater than that of the mucosa, and the latter may be under-
mined to various extents bv tortuous sinuses which communicate with
one another.

According to this writer, the mucous membrane seems to suffer least,
and its lesions appear to be due to those in the submucosa. Other pyo-
genic organisms, such as streptococci and colon bacilli, are always present
to infect the ulcer, thus converting it into a suppurating one. The cases

CATARRHAL DISEASES OP THE RECTUM AND SIGMOID 161

wliich the author has seen have been of the chrome type, and therefore
he has not observed any of those rapidly progressive and grave eases
which are said to involve a large portion of the colon, and produce
gangrene and death in a short time. The ulcerations observed in the
rwtum and sigmoid have been very variable in shape and size. Most
frequently they appear like little troughs cut out of the mucous mem-
brane, apparently following the course of the blood-vessels or lymphat-
ics. At other times they coalesce, forming more or less extensive
nlcers. The mucous membrane is undermined, and the pui-ulent dis-
charge is out of all proportion to the apparent size of the ulceration.
This fact is in keeping with the reports of pathologists, that the de-
struction of the submucosa is much greater than that of the mucous
membrane itself.

Symptoms. — The symptoms of acute dysenteric proctitis are aching
in the pelvis and about the anus, burning and heat in the lower end of
the rectum, tenesmus, diarrhoea, and rapid exhaustion. The temperature
may Ije high or it may ])e only slightly above normal ; the pulse rate is
always increased; there may be tympanites and tenderness over the abdo-
men and symptoms of peritonitis; there is a frequent, painful diarrhoea,
the passages being accompanied by tormina, and followed by severe burn-
ing pain. The stools are first mixed, partly solid and partly fluid; they
then change to a waterj^ condition, and finally resolve themselves into
discharges of mucus, which is at first tinged with blood and afterward
mixed with pus. The frequency of these stools is almost unlimited.
Where the disease is of a simple type the symptoms pass away in a few
days, and the patients suffer no permanent ill effects. If the inflamma-
tion, however, is not checked in its early stages it goes on to sloughing
and ulceration. This ulceration is ordinarily confined to the mucous
membrane, and in the large majority of cases heals without leaving any
evidences behind. When, however, the inflammation goes farther, as in
the amoebic type, it may result in deep ulceration and be followed by
strictures. (See chapter on Stricture.)

The local appearances in the rectum and sigmoid are at first those
of acute catarrhal inflammation: redness, swelling, more or less protru-
sion or exstrophy of the mucous membrane around the margin of the
anus, spasm of the sphincter, swelling and oedema of the radial folds.
The mucous membrane itself appears at points abraded, and sometimes
patches of a sort of diphtheritic membrane may be upon it. Superficial
erosions or ulcerations occur later throughout the rectum and in the
sigmoid.

In the amoebic type the ulcerations assume a peculiar shape. They
appear like little grooves or channels cut out of the mucous membrane,
irith sharp, well-defined borders, resembling very much the longitudinal
11

162

THE ANUS, RECTUM, AND PELVIC COLON

section of a worm track through a piece of wood. These little ulcei
tions come together, cross each other at points, and sonietiraes form st
late ulcerations (Fig. 86). Occasionally the mucous membrane betwe
the tracts breaks down, and we have an irregular ulcerative area. T
w, trouf;!i-!ike ulceration, however, Is typical of thia disease. T
a\ithor first observed it
1893, in an officer in tl
United States Navy, se:
home from Japan with
history of having had t,
pho id-malaria followed I
chronic diarrhcea. Tl
supposition was that i
was suffering from
chronic typhoid ulee
Following this, anothi
case was observed in
sailor who gave the sait
history; and shortly aftei
ward, through the kinc
ness of Dr. Tilden Browi
of this city, a third ps
tient waa seen, all o
whom presented this typ
of ulceration and gave ■
history of attacks of ma
laria(?) followed by iliar
rhu'a. The author wa
under the impression a
that time that the condi
tion was a peculiar type of malarial ulceration of the rectum; withii
the past four years, however, he has come in contact with a numbei
of these patients who have returned from our new possessions, ii
whom the history lias been more clearly related as that of amcebii
dysentery, and more recently he has seen 3 cases which developed it
or near New York. The local symptoms in these cases were identical
with those before observed, so the earlier cases were probably amoabic
dysentery. A typical case of this type of rectal ulceration has been
demonstrated to the class at the Polyclinic, and while some of the
students were examining the ulcers through the proctoscope, others
were observing through the microscope the am«?bffi dysenterise, which
had been passed in a stool just before the patient was placed upoo
the table. The scraping of the ulcers themselves with a small reo-

(liniBbie drxenterlK were rrment in tliu rcrtuDi nt tbo
time IhiB drRvtag won niade. Trachitnonu intesli-
mUb were hIbo foULiJ in Oie bIooIb ut a luler jwriud.

CATARRHAL DISEASES OP THE RECTUM AND SIGMOID 163

ial spoon furnished further specimens of amoeba, together with some
streptococci and colon bacilli.

When the disease becomes chronic the frequency of the stools is very
variable; at times they are as numerous as 30 in twenty-four hours. Oc-
casionally the patient will have periods of relief in which there are only
two or three stools during the day, and then without any apparent cause
ihey will become frequent again and contain large quantities of pus,
mucus, and blood. In one patient there were remissions of one to three
months, during which time his bowels were comparatively comfortable,
the stools well formed and contained very little mucus. At the end of
this period all the old symptoms returned, and he began to lose flesh
rapidly and suffered from such exhaustion that his life was despaired of.
A?i a rule, however, the remissions only last for a week or two, and then
the symptoms recur. Sometimes the succeeding attacks grow less and
less virulent, and the patient seems to outgrow the disease ; at others, the
attacks grow worse and worse, and finally end in death from exhaustion
or from perforation and subsequent peritonitis.

Abscess of the liver is the most frequent complication reported by
those who have seen the largest number of these cases. The supposition
that am(ebic dvsenterv onlv occurs in tropical climates is not borne out
by the facts, for the author has seen 5 cases who had never been much
south of the thirty-fifth degree of latitude. Of course these are sporadic
eases, but they clearly show that the amoeba exists in temperate zones.

Attacks of so-called biliousness or hepatic congestion very frequently
occur in connection with the chronic type of this disease. Loss of flesh,
pallor, and progressive anaemia succeed one another.

Treatment. — Under the old methods of treatment with opium, ipe-
cac, and astringent substances the mortality in endemic and epidemic
dysentery ranged from 25 to 50 per cent. In the sporadic type the symp-
toms were less severe and the results less serious.

Many years ago Dr. Alfred Stille, of the University of Pennsylvania,
stated in a lecture that the etiological factor in the production of dysen-
tery was some form of colonic irritation. He did not presume to state
that it was due to a specific germ, but claimed that the rational treat-
ment of this disease consisted in flushing the colon by large doses of sul-
phate of magnesia and washing out the rectum by full enemata of flax-
seed tea or hot water. The exact statistics which he gave at that time
are not recalled, but the mortality in several epidemics in which this
method of treatment had been used was stated to have been very low.
Modem pathological investigators have proved the wisdom of this great
teacher's doctrines, that this disease is due to a local invasion and infec-
tion of the lower portion of the large intestine by toxic and septic germs
which rapidly multiply in the alkaline condition of the colon. The ra-

164 THE ANUS, RECTUM, AND PELVIC COLON

tional treatment, therefore, of this disease would consist in cleaning om
the intestinal canal and keeping it free from bacteria in order that the
media favorable to the deveU)pment of these pyogenic agents may be as
limited as possible.

W. J. Buchanan (British Meilical Journal, February 1, 1900) reports
the treatment of 555 consecutive cases of dvsenterv with 6 deaths, a
mortality of a little over 1 per ci'nt. His method consisted in the admin-
istration of sodium sulphate, 1 drachm four times a day.

C'ruikshank (Journal of the American Medical Association, Janu-
ary 5, 11)01, p. 54) expresses the opinion that the disease being a local
condition, due to local infection, the principle of treatment is to cleanse
the canal and kec]) it free from the infecting bacteria, and thus to pre-
vent further absorption. At the same time efforts should be made to
allay the local inflammation already present. He states that sulphate of
magnesia thoroughly fulfils all of these principles, and that it is as near
a specific in dysentery as quinine is in malaria. The author can confirm
personally that this remedy affords more relief to the suffering than any
other drug. As to its ultimate results, the statistics of Cruikshank. Mar-
choux, Stille, and others prove its efficacy. It is a mistake, however, to
suppose that one single dose of Epsom salts administered in the begin-
ning of an attack of dysenter}- is all that is necessary. The remedy
should be repeated every two hours until large watery movements have
been produced. If exhaustion follow these, stimulants in the shape of
cognac or blackberry brandy should be administered. The food should be
limited to sterilized milk and aninuil broths. After the bowels have been
thoroughly emptied by the use of the saline, the rectum and sigmoid
should be irrigated three or four times a day with normal saline solu-
tion, boric acid, or other mild antiseptic solutions, all of which should be
used c(^ld, as a low temperature kills the amoeba? dysenteria?. Not only
will this irrigation prove grateful to the patient and reduce the burning
and tenesmus, but it will also check the absorption of the toxic germ
and reduce whatever congestion and inflammation are already present.
If the patient is in a very low and exhausted condition, high enemas
of salt solution may be used at a temperature of 110° to 120°, and thus
obtain their stimulating and cleansing effects. The salts should be given
again on the following day, or as soon as the symptoms of tenesmus
and diarrhoea recur.

Some writers claim that enemata of weak solutions of quinine act as
specifics in ama»bic dysentery, but others who have tried them fail to con-
firm these statements.

Eldridge (Public Health Reports, Januarv" 5, 1900) has collected the
statistics of epidemics in Japan for twenty years. Out of 1,136,096
cases there were 275,308 deaths, a mortality of 24 per cent. He states

CATARRHAL DISEASES OF THE RECTUM AND SIGMOID 165

that the disease consists in an inflammation and ulceration in the colon
and rectum ; and that the bacillus found in these cases by Shiga resem-
ble very much that of typhoid fever. The results of his treatment by
the serum method reduced the mortality to 8 per cent. Other investi-
gators have experimented with similar methods, but as yet no system of
treatment has approached in efficacy that by the sulphate of magnesia
accompanied with rectal lavage.

In the chronic type there is a much more obstinate condition to deal
with; it practically resolves itself into chronic ulceration of the rectum,
sigmoid, and colon. Constant rest in bed is an essential element in the
treatment of this condition. The bowels must be kept as empty as pos-
sible, and at the same time rest from persistent peristalsis is desirable.
Irrigation, with mild antiseptic solutions, together with a bland^ unirri-
tating diet and antiferments by the mouth, are the principles upon which
the treatment is to be based. In the 8 cases of this type which the
author has treated the nitrogenous diet has been strictly enforced.
The patients have been kept absolutely upon peptonized milk, animal
broths, eggs, fish, and fowl, with the smallest quantity of toasted or
gluten bread. Beta-naphthol, salol, boric acid, ichthyol, and pancreatin
have been administered according to the apparent indications in the
case. The local treatment which has proved successful in all the cases,
save one, has been irrigation of the rectum or flushing of the sigmoid
and colon with saline solutions. After this has been passed, 4 to 6
ounces of the 10-per-cent solution of the fluid extract of krameria were
injected through a long Wales bougie; this procedure was repeated twice
daily at first. On every second or third day ^ an ounce of a 10-per-cent
solution of argonin was injected into the sigmoid. In 3 cases 2 per cent
ichthyol was substituted for the argonin. By this method the stools can
be greatly reduced in a few days; the discharge of mucus rapidly subsides,
and the blood and pus disappear altogether; the griping, tenesnnis, and
pain about the rectum are greatly reduced, and the patients soon recover.
In 1 case it was necessary to continue the treatment for fourteen weeks,
inasmuch as every time it was remitted the diarrho?al symptoms recurred.
As the ulcerative condition improves, the frequency of the treatment
may be reduced until it is applied only once in two or three days, and
finally is discontinued altogether. Nitrate of silver when applied to the
ulcers sometimes has good effects, but is less satisfactory than argonin.

Dr. Murrav states that after all these remedies have been tried faith-
fullv there still remains a certain number of cases in which local and
constitutional treatment fail. He ad\ises that if the patient is not re-
stored to health after four months of local treatment, the parts should
be put at rest by the formation of an artificial anus, preferably upon the
right side. This is in the line of the methods advocated by English sur-

166 THE ANUS, RECTUM, AND PELVIC COLON

geons in obstinate eases of membranous eolitis. After the artificial anus
has been made, the colon may be treated both from the rectum and from
the new oi)ening, and thus thoroughly irrigated, while at the same tim«
it is protected from the entrance of any fresh germs through the stom-
ach. The artificial anus, he states, should remain open for several
months, and not until the colon is proved to be free from ulceration and
amirbae by examination of the irrigations for several weeks, should any
attempt be made to close it. The author is thoroughly in accord with Dr.
Murray's views upon this subject ; as yet he has not seen a case which
would justify this operation, but under similar circumstances he would
certainly proceed as ^lurray did in one case: establish a right inguinal
anus and obtain absolute functional rest for the colon, together with an
opportunity for a more thorough local treatment.*

Diphtheritic Proctitis. — At various times, previous to the discovery of
the Klebs-LoelHer bacillus, writers upon intestinal and rectal diseases
have described certain conditions as diphtheritic infiammation of the
rectum and colon. Trousseau (Klein, Micro-organisms and Disease, p.
77, third edition, 188G) describes a case of diphtheria of the anus occur-
ring during the course of an ordinary- case of the disease in the larynx
and trachea.

The author is not aware of any initial case of diphtheria of the rec-
tum or anus, and if it should occur in connection with the disease in the
throat, he would only consider it diphtheritic upon the absolute demon-
stration of the specific bacillus in the membrane. During all such ex-
haustive diseases as sepsis, Bright's disease, diphtheria, tuberculosis, and
in the later stages of typhoid fever, pseudo-membranes occur in the rec-
tum and throughout the colon, composed of fibrin and albumin, resem-
bling the diphtheritic deposit. It is generally of a brownish-white color
due to the staining of the fa?cal masses, is closely adherent to the intes-
tinal wall, and is not associated with anv true catarrhal or inflammatory
condition of the intestine. This condition does not generally develop
until the patient is in extremis, and it is rarely recognized except post-
mortem.

Microscopic examination has failed to develop any specific germ or
bacteria. Careful search for the Klebs-Loeffler bacillus has always given
negative results. I^pon the whole, then, we must conclude that, so far as
medical literature and experience go, diphtheria of the rectum and anus
is as yet unproved.

♦ Gibson's method of irri^atinp tln^ colon through a small valvular openiog in
the caecum may prove very useful in these cases. See page 191.

CHAPTER V
CHRONIC COLITIS, MUCOUS COLITIS, MEMBRANOUS COLITIS

The rectal specialist is so often consulted with regard to chronic
diairhcea, constipation, and the passage of mucus and membrane, with
or without pus and blood from the rectum, that it is absolutely essential
he should know the conditions which cause these, and be able to manage
them. Formerly such conditions were considered constitutional affec-
tions and treated by the general practitioner. To-day they are consid-
ered by the best authorities as surgical, and referred to specialists in this
line. Some still maintain that they arc the result of general constitu-
tional affections, such as ansemia, chlorosis, or neuroses ; the latter is a
very popular view, and held by some of the best general practitioners.

Since writing upon this subject in 1888 the author has had the oppor-
tunity, through the courtesy of his professional friends, to examine and
treat a large number of these cases, after long periods of rest in bod
and treatment on the neurotic theory had proved unsuccessful, and
favorable results in these cases have followed management upon the basis
of a local inflammatory' disease.

Close investigation has led to the conclusion that the three types of
colitis mentioned at the head of this chapter, and described as separate
diseases in the works upon general medicine, are practically one and the
same, only in different stages of development. The pathological changes
are always the same, consisting in a hypertrophic catarrhal inflammation
of the colon.

Etiology, — The causes of this condition are the same as those of
hypertrophic proctitis, and have been enumerated in the preceding chap-
ter. The neurotic element has always appeared to be an effect rather
than a cause, although, no doubt, chronic catarrhal colitis may develop
in individuals who are alreadv afflicted with some nervous condition.
Under such circumstances it is a complication rather than a cause or a
result. If the disease was a neurosis, one would find it much more fre-
quently in insane institutions and hospitals for nervous diseases than
an\-where else. Thompson, in an interesting article (Xew York Medical
News, 1900, vol. vi, p. 849), takes this view with regard to the neurotic

167

168 THB ANUS, RECTUM, AND PELVIC COLON

element. In discussing a case he says: '* Although he began to develop
all the train of nervous symptoms above referred to, there can be no
doubt that none of them had any primary relationship to his trouble,
but were purely secondar}-. The beginning of the disease was clearly
duo to local irritation excited by local causes, acting first on the lower end
of the intestinal tract, and gradually extending upward." He holds
that the origin of the disease is in the lower end of the intestinal tract,
either the rectum or the sigmoid iiexure, and extends upward from that
point ; that the source of irritation is generally hardened faecal masses or
other foreign bodies that rest in the diverticuli of the intestine, and act as
irritants; and that the conditicm may be produced by horseback exercise
or bicycle riding. Irritation from the outside, such as pressure by uterine
or ovarian tumor**, mav also occasion the disease.

It is a well-known fact that hardened faecal masses and foreign bodies
may lie in the intestine for long periods of time and set up much irrita-
tion, and yet the patient may have liquid or semiliquid stools periodically
without moving them. There are certain other conditions, however, not
ment ion(»d in the books, which occasion colitis. They may be called reflei
rather than active causes; yet when they are removed, the symptoma
disappear and the ])ationts rapidly recover. Among these attention is
invited to three, which are verv' frequently associated with so-called
membranous and mucous colitis. The first of these is inflammatory
adhesion of the colon or sigmoid flexure to the pelvic organs or walls;
whether the inflammatory ])rocess which occasions the adhesion ex-
tends to the mucous nu»mbrane of the rectum, or whether the irritation
produced by its being held firm and immovable while the f»cal masses
j)abs over or rest upon it, is a question which is difficult to decide ; but, as
a matter of fact, after attacks of ])elvic or general peritonitis, the colon
or sigmoid llexure may become adherent to some other organ of the ab-
dominal cavitv, the adhesive bands interfere with, the functional motions
of the intestine, and result in a localized catarrhal inflammation at the
points opposite them. This may be due to the fact that the intestine,
being held immovable at this point, the peristaltic action of the parts
above produces a temporary intussusception through the fixed portion,
and thus bv friction and more or less obstruction the inflamed condition
is brought about. One of the chief seats for such adhesions is in the
neighborhood of the left ovary and in Douglas's cuUde-sac; another seat
is in the neighborhood of the gall-bladder, where the transverse colon
passes in close proximity to it, though this adhesion is more rare than
that in the pelvis.

These pelvic adhesions sometimes hold the sigmoid so firmly at-
tached in Douglas's cul'dc-sar, or behind the uterus, that it can not rise
up into the abdominal cavity when distended with gas and faecal mate-

CHBONIC COLTTIS, MUCOUS COLITIS, MEMBRANOUS COLITIS 169

rials. Constipation and fa?cal impaction are frequently the result of
this, and are very difficult to overcome. Through this process the faecal
masses are retained in the sigmoid unduly, catarrhal inflammation is
established, and even ulceration may result.

The second condition, which may be termed reflex in the production
of colitis, is subacute inflammation of the vermiform appendix. It has
been the author's experience to see a number of patients who had suf-
fered from digestive symptoms, constipation, mucous and membranous
colitis, with general debility and nervous exhaustion, in whom the colitis
c-ould be temporarily checked or benefited, and yet after brief periods of
time it would return. In 5 such cases the conditions were associated
with more or less tenderness over various portions of the abdomen. In
only two of them was it limited to the region of the vermiform appendix.

In one of these cases very recently operated upon the symptoms were
all in the pelvis, and shooting down the right leg. So much was this the
ea.se that the author was firmlv convinced that the condition was one of
pelvic adhesion that attached the sigmoid flexure either to the perito-
naeum of Douglas's cul-de-sac or to some of the uterine appendages.
This view was not shared by the gynaecologists who were called in consul-
tation, both of whom declared that the condition was a neurosis, and
that there was no local condition to justify an operation in the woman's
case. The fact, however, that these adhesions produced just such symp-
toms, and had been relieved by breaking up the adhesive bands and re-
storing the sigmoid flexure to its normal position, led, against the advice
of the consultants, to laparotomy for exploratory and remedial purposes.
It was a surprise when the hand was passed into the pelvis to find that
the ovarian adhesions were so slight that they could not possibly have
caused the woman's pains, and that they were not attached to the sig-
moid at all. On further investigation, however, it was found that the
vermiform appendix was hard, thickened, subacutely inflamed, and ad-
herent to the peritonaeum of Douglas's cul-de-sac; it passed directly
across the sigmoid flexure, and thus prevented the latter from rising
up into the abdominal cavity, as it should do normally. There was a
slight adhesion of the sigmoid to the anterior rectal wall, which was
easily broken up. The appendix was removed, the caecum restored to
its position on the right side, and the sigmoid flexure brought up above
the brim of the pelvis and sutured to the abdominal wall. Within a few
days after the operation the discharges of mucus decreased, the bowels
became regular, and the woman's pain absolutely disappeared.

In the other 4 cases the symptoms were just as marked, and finding
nothing in the rectum or sigmoid flexure to account for the irritation,
it was decided to perform exploratory laparotomy. The appendix was
found in a state of subacute catarrhal inflammation in 2; in 1 it con-

170 THE ANUS, RECTUM, AND PELVIC COLON

taiucd pus, and in the fourth the organ was 5 inches long and adherent
to the floor of Douglas's cul-de-sac. It was removed with the happy
result that the s}in])toms in all four cases disappeared with remarkable
promptness. The reflex influences, therefore, of subacute appendicitis
in the production of mucous and membranous colitis is well worthy of
further study.

In a recent acute case of catarrhal appendicitis, in which the appen-
dix became adherent to the posterior alnlominal wall right over the spinal
vertebra, symptoms of acute colitis and passages of mucus developed
within five days from the original attack, and receded just as promptly
upon the removal of the inflamed organ. Such cases will certainly have
their bearing in the search for a cause in any obscure case of mucous or
membranous colitis.

Another condition, suggested as a cause of colitis, is floating kidney.
How often this condition influences the inflammation of the colon, and
whether it has any initial exciting effect or not, is impossible to state.
The facts from personal experience are limited to a few cases, and to only
two operations for the relief of the same. In 4 cases of chronic mucou*
and membranous colitis the coexistence of movable kidney upon the right
side has been observed. As these kidnevs did not seem to be attached
to the intestine in any way, it at first seemed improbable that they could
act as exciting causes of the disease. Finding, however, cases in which
no other cause could be ascertained, in which the kidnev was more than
ordinarily mobile, and therefore demanded restoration and fixation on its
own account, it was decided to make the experiment and to observe its
influence upon the intestinal condition. At the time of the operation
the woman had Ijeen treatc^d for several weeks by local applications with
more or less unsatisfactory results with regard to the passages of mucus
and membrane with the stool. She was operated upon on October U,
1900, and after the incision was made and the kidney exposed, the fol-
lowing state of affairs was obsen'^ed : As the woman lay upon her side and
breathed deeply under the influence of ether anaesthesia, the kidney
moved at least 3 inches with every respiration ; upon inspiration it shot
downward with considerable force and slid along the posterior surface
of the colon for about 2 J inches, and on expiration it shot upward again,
thus repeating this frictional action upon the intestine. It seemed clear
that such traumatism would have an irritating effect upon the bowel; in
the kidney it undoubtedly ])roduced congestion, hypertrophy, and gen-
eral thickening, the organ being almost twice its normal size, and yet
without any evidence of interstitial or cortical disease. The capsule was
split, the body of the kidney sutured to the fascia of the muscles as well
as the two lips of the incision in the capsule, and the wound closed her-
metically. Not a single complication or bad symptom followed, and

CHBONIC COLITIS, MUCOUS COLITIS, MEMBRANOUS COLITIS 171

nrithin one week from the time of operation the mucous discharges abso-
lutely ceased, and there has not been a return of the same up to the
present date, although the patient still suffers pain in the region of the
kidney. A few local applications were made to the congested mucous
tnembrane in the rectum and the sigmoid afterwards, but had nothing
prhatever been done to the lining membrane of the intestine, it is be-
lieved that the colitis would have been cured by the removal of this con-
stant irritation. One other case of this kind has been seen since writing
the above, in which Dr. Wyeth, on the author's advice, anchored a float-
ing kidney and relieved the membranous colitis it caused.

Effort has been made to find some facts with regard to this feature
yf the disease, but literature seems to furnish nothing. This experience,
liowever, may lead in time to the relief of a certain class of cases which
have heretofore been signally intractable.

The occurrence of albuminuria and haematuria in connection with
colitis has been observed by many practitioners. Thompson refers these
conditions to the absorption of colon bacilli into the blood through the
abraded mucous membrane of the colon. May they not be due to the
inflanmiation produced in the kidney by its mobility?

In connection with these extra intestinal causes of colitis, attention
may be called to the subject of abdominal aneurisms. In 6 cases
obser\'e<l by the author and his associate. Dr. WoUbrock, intractable
mucous colitis has existed in connection with aneurisms of the aorta
upon the level of the transverse colon. All of these patients have suf-
fered from pain just above the umbilicus, constipation, flatulence, and
reflex digestive disturbances. The crises ordinarily preceding the pas-
sages of mucus were absent in a large measure, and the rectum and
sigmoid were less affected by h3rpertrophic catarrh than is usually the
case.

It seems that the undue pressure of the aneurism upon the transverse
colon and its interference with the solar plexus may possibly have some-
thing to do in the causation of colitis.

Pathology, — The fact that this is not a fatal disease accounts for the
paucity of knowledge with regard to its pathological anatomy. Most of
oar information has to be drawn from the examination of the so-called
membranes themselves, assisted occasionally by post-mortem examina-
tion of patients who have suffered from this condition, and yet died from
some other cause. As these other causes are generally exhaustive dis-
eases, such as nephritis, diabetes, pneumonia, and sepsis, it is difficult to
determine their exact influence upon the chronic condition of the intes-
tine, for it is well known that a certain kind of pseudo-membrane may
be developed in the colon during the course of any one of the.^e condi-
tions. The membranes discharged are generally flakes, tape-like or some-

172 THE ANUS, EBCTUM. AND PELVIC COLON

times tubular, that represent the caliber of the intet«tinal canal. Some-
times the tubes or tape-like masses are very extensive, measuring 2 or 3
feet ; generally, however, they are only a few inches long. They are com-
posed of a laminated albuminous material, structureless and devoid of
fiber, and enclose in their laminae small faecal masses, numerous bacteria,
epithelial cells that have undergone fatty degeneration, cr^'stals of cho-
lesterin and phosphates, a certain quantity of pus and leucocytes, and
sometimes the whole epithelial lining of the mucous follicles. These
shreds or tubes may be very thin or sometimes nearly J of an inch thick,
quite firm in parts, but shading off into a tenacious glairy mucus, which
clearly indicates their nature. They are, undoubtedly, formed first by the
secretion of this glairy mucus from the glands, which becomes coagulated
in layers, the foreign sub:?tances and excoriated epithelium being caught
in these laminje as they are successively formed. Under the microscope
these membranes appear stnictureless and transparent. *' The inner
surface of the membrane appears to be reticulated, and presents depres-
sions or perforations which correspond to the mouths of Lieberkiihn fol-
licles." Epithelial cells are occasionally grouped around these openings,
showing tliat the lining of the follicle has btvn cast off and become in-
corporated in the membrane. Sometimes these are larger than the nor-
mal follicles.

The muscular walls are generally thin and atrophied. The veins are
often dilated. At certain spots or areas there are congestions and ex-
coriations of the mucous membrane; the latter are bright-red in color
and present the ai)pearance of shallow ulceration. The glandular and
submucous layers of the intestine are hypertrophied, distended with
mucus, and the epithelial cells appear to be undergoing fatty degenera-
tion. There is no diminution in the caliber of the gut, but throughout
its extent there is an hypertrophy of the follicles and glandular layer.
The fact that the membrane is very rarely found post mortem shows that
it is not retained in the intestine for any length of time after its forma-
tion. When it has been found, it has been confined to a limited area, was
verv easilv detached, and ulceration has been verv rarelv seen In^neath it.
The question, however, wiiich is of great interest in regard to these condi-
tions is the fact that the passage of this mucus should be preceded always
with such severe tormina and griping pains and yet be unaccompanied, so
far as post-mortem examination shows, bv anv severe lesion in the wall
of the gut. There is no reason why a simple increase in the secretion of
mucus and the passage of an unirritating soft mass of membrane should
be preceded or accompanied with severe pain. These masses are no
larger, no firmer, no more adherent, and no more irritating than the
ordinary fa?cal mass. If it is true, as the pathologists tell us, that there
is no ulceration nor particularly active inflammation at the points upon

CHRONIC COLITIS, MUCOUS COLITIS, MEMBRANOUS COLITIS 173

which these membranes are formed, it seems impossible to account for
the pain through any inflammatory process. Thompson states that this
condition is probably due to some particular bacteria, which may cause
the pain. If such was the case, some form of bacterial organism would
have been found more or less constantly present in the discharges of
membrane and mucus which have been so carefully examined by patholo-
gists in the last few years. The only explanation of these pains that
seems practical lies in adhesions of temporary volvulus or intussusception.
The fact that the faecal passage sometimes precedes the passage of mucus
does not contraindicate these conditions; it only signifies that the peri-
staltic action of the gut below the intussuscepted portion carries whatever
faecal matter there is in that part of the bowel downward, and produces a
movement without giving relief. The irritation produced in the mucous
membrane by intussusception or volvulus may cause a hypenemia and
localized inflammation with increased secretion of mucus, which, being
retained, becomes thick, tenacious, and membranous. When the intus-
susception relaxes, or the volvulus imtwists, this mucus or membrane is
passed rapidly downward and out through the rectum. The patient gen-
erally attributes his relief to the passage of mucus, but it seems more
rational to ascribe the relief to the relaxation of spasm in the intestine
at the point of constriction.

The mucous membrane of the rectum and sigmoid flexure in colitis is
always congested, sometimes slightly ulcerated, thickened, and secretes
more or less mucus. The author had under his care a physician who had
suffered from this condition for a long period; the pseudo-membrane in
his case was seen frequently through the sigmoidoscope attached to the
mucous membrane of the sigmoid flexure, and was wiped off with pledgets
of cotton, a part of it being membranous and the rest gelatinous. There
was undoubtedly a prolapse or intussusception of this portion of the in-
testine into the upper rectum in his case, and when he suffered from
his acute attacks, if a long Wales bougie was passed sufficiently high and
water injected to distend the sigmoid, the tormina ceased, and his pains
were relieved; moreover, if these bougies were passed regularly, almost
regardless of what medication was thrown in, the attacks could be
almost entirelv averted. This case and several similar ones have led to
the conclusion that this intussusception is the principal cause of pain.

Symptoms. — The disease generally occurs between the ages of twenty
and fifty. Some cases have been observed under ten years of age, and
others in those over fifty, but these are exceptional. It occurs in thin,
anaemic, hypochondriacal individuals, as well as in the well-fed, rotund,
and plethoric. The symptoms are chronic intestinal indigestion with
flatulence, capricious appetite, and a tendency to melancholia or mental
depression.

174 THE ANUS, RECTUM, AND PBLVIC COLON

Constipation is the rule, the faecal mass often being in little, round,
hard balls, and coated with mucus; though this condition may alternate
with diarrluea. The diarrhoea is due to the irritation produced bv the
lodgment of small, hard masses in the saccules or diverticuli of the in-
testine. The fluid fa'ces j)roduced bv this cause or bv cathartics pass over
or around these masses and leave them in situ to continue the irritation.
The patients are generally sensitive to cold, attributing this condition to
imperfect circulation; the tongue is slightly furred with a whitish coat,
and the abdomen is generally more or less distended with gas. White
states that these j)atients sometimes have cystitis and pass mucus with
the urine. lie (juotes Da Costa as saying that they are frequently the
subjects of i)()ils.

The mental depression and intestinal symptoms, while more or less
present at all times, have periods of exacerbation in which there is abso-
lute lack of a})])etite, great distention with gas, griping abdominal pains,
and increased constipation. After hours or days of suffering in this man-
ner a mass of membrane or mucus is dischanred from the bowel and the
griping ceases, but the pain and soreness renuiin for several days. In
severe cases thes(» ])assages of mucus and membrane may continue daily
for a long time. Ordinarilv thev are not mixed with blood, but some-
times bright blood passes with the membrane. White reports a case in
which this condition continued for several weeks; the patient was so
weakened that he gradually sank and died. The author has seen 1 case
in which i a pint of this mucus was discharged every day for a like
period, but there was no blood; she had very little griping or pain ex-
cept at periods two or three days apart. In other cases in which the
discharge of mucus and membrane was verj^ limited, the pains and ex-
haustion have been very great. This exhaustion after the passage of the
mucus and membrane is one of the typical symptoms of the disease; the
patients are utterly collapsed, sometimes unable to sit up until hours
after the stool; they gradually lose strength and color, and become sal-
low and depressed, with forebodings and fears. Their natures are greatly
changed ; this is probably due to the fact that they suppose their ailment
to be of a much more serious nature than the physicians deem it to be.
Authors have laid stress upon the existence of urates and uric acid in the
urine as indicating a rheumatic or gouty origin of the disease; this is
believed to be erroneous.

There is no relationship between eating and the periods of pain and
griping; sometimes these occur just before taking food, sometimes im-
mediately afterward, and sometimes at remote j)eriods from it. Insom-
nia is quite frequent; whether it is due to the disease itself, to the pain, or
to the mental anxiety concerning it, is a question very difficult to answer.
A confused state of the intellect is not infrequently present and due prob-

CHRONIC COLITIS, MUCOUS COLITIS, MEMBRANOUS COLITIS 175

ably to auto-intoxication, anxiety, and brooding. The symptoms may re-
mit and the mucus cease to be discharged; then they recur with increased
virulence and continue for varying periods, to disappear and recur time
after time. Only those eases can be said to be positively cured which are
proved to have been due to some reflex or local cause which has been
absolutely removed; and even in cases where the appendix has been at
fault and has been removed, there have been occasional mild recurrences
of the disease. As is stated by Glasgow (Journal of the American Medi-
cal Association, 1901), it is essentially a chronic disease, very seldom
fatal, but of great annoyance to its victims.

Treatment. — From what has been stated in the preceding pages, one
can readily understand that there is a very great diversity of opinion with
rc»gard to the treatment of this condition. By those who hold that it is
simply a neurosis, nothing more is advised than general tonic and seda-
tive treatment directed to the nervous svstem or the mental condition.
Change of residence, travel, baths, amusements, nerve tonics, electricity,
etc., compose the lines of treatment which are laid down by those who
adhere to this patholog}'. To those who believe that it is simply a ques-
tion of chronic constipation, some method of emptying the bowel, and
keeping it so, associated with those means which go to restore the nerv-
ous and physical tone of the individual, are all that is necessary. The
length of time, however, required for the treatment of these conditions
by the means and methods of these two schools, and the numerous fail-
ures of such treatment to improve the condition even temporarily, speak
volumes against the correctness of any such theories. The etiology
which has been advanced in the preceding pages differs so materially
from these that it involves an entirelv different line of treatment. If this
condition is due to intussusception, adhesions, reflex influences, such as
appendicitis, floating kidney, enteroptosis, or malpositions of the repro-
ductive organs in women, the treatment consists in determining as far as
possible which one of these conditions is responsible, and remedying that
if feasible. Xearly all the authors who write upon this subject agree that
there is a congestion or catarrhal hyperaemia of the mucous membrane
associated with swelling of the glandular and submucous layer at the
points upon which these membranes or mucous shreds have been found.
Those who have examined the rectum and sigmoid have verified the au-
thor's observations of the fact that there alwavs exists a certain amount
of hypertrophy and hyperplasia in the mucous membrane of these or-
gans ; whether this condition is primary or secondary to the membranous
colitis it is ver}* difficult to say, though the latter view seems most tena-
ble, because the rectum and sigmoid may be restored frequently to their
normal condition by persistent and well-directed local treatment, and yet
the condition will recur, unless the colitis above has been cured at the

176 THE ANUS, RECTUM, AND PELVIC COLON

same time. Glasgow {loc. cit.) states that while a large number ot
these cases are due to api)endiceal inflammation^ they may be treated Inr
therapeutic measures and the colitis cured. He advises the use of iA-
thyol internally in 3- to 5-grain doses three times a day. The author hzi
used this remedy in connection with 3 of these eases for a period of
about one year previous to the publication of Glasgow's paper; the
drug is not a specific, but it is a useful adjuvant to other lines of
treatment. 8o far as the appendix is concerned, the radical removal
of this appendage whenever and wherever there is any evidence of in-
flammation or adhesion about it is advisable. Medical treatment is use-
ful for the time being, but its results are not permanent. A catarrhal
appendix with just a little bit of tenderness, no temperature, and slight
elevaticm of the pulse, is a dangerous api)endage. The part does not
drain well, is likely to become infected at any time, and keeps up reflexes
sometimes, such as membranous or mucous colitis and functional dis-
orders of the digestion, for years. Such appendices should be removed
at once, and in the majority of instances the melancholic, ansemic, and
dyspei)tie patients, who are supposed to be the victims of neurotic co-
litis, will immediately begin to improve.

The influence of floating kidney upon membranous colitis is a matter
upon which an exj)ression of very positive opinion is not at present ad-
visable. In a series of 12 cases published by Dr. Einhorn, in all of which
there were digestive troubles and membranous colitis, 8 of them suffered
also from floating kidney upon the right side. In the author's observa-
tions G cases of membranous colitis have been afflicted with very mobile
right kidneys. The amount of mobility in the kidney does not seem to
be in proportion to the irritation which it produces. Those kidneys
which float loosely around in the abdomen, sometimes descending almost
to the pelvis, seldom give their possessors very much annoyance ; whereas
the kidney which slides up and down between the posterior abdominal
wall and the ascending colon, moving some 3 or 4 inches downward with
every inspiration, and upward on expiration, have been the most annoy-
ing form of this condition, and it is the only form in which there was any
marked degree of membranous colitis.

It is not proposed to describe here the methods of removal of appen-
dices or of fixation of floating kidneys ; but it is suggested that when no
other cause for colitis can be determined, and when there is a positive
diagnosis of either one of these conditions, surgical intervention may,
and probably will, result in the relief of the intestinal symptoms. Opera-
tive measures should be preceded by appropriate therapeutic treatment,
but it is not believed that these remedies should be persevered in for in-
definite periods unless some improvement in the symptoms is observed.

The therapeutic measures advised are : First, the absolute cleansing

CHRONIC COLITIS, MUCOUS COLITIS, MEMBRANOUS COLITIS 177

out of the intestinal canal. The fact that saline laxatives produce large
and copious watery defecations does not by any means prove that the in-
testines have been thoroughly cleansed ; one may be more confident of a
proper cleansing of the intestinal canal when the patient has moderately
soft, smooth, well-formed faecal passages. Fluid movements easily pass
over hardened faecal balls retained in the diverticuli of the intestinal
wall, and these balls may be left there for weeks and months to act as
constant irritants, while the patients are daily having semifluid move-
ments from the use of saline laxatives. Wylic has suggested the use of
equal parts of glycerin and castor-oil as a laxative in these cases, giving
a tablespoonful of each three times a day, and continuing this for two
or three weeks; he says that so far from its producing diarrhoea, it only
keeps up a smooth, easy movement, sometimes semifluid, and is the most
successful means to remove the hardened faecal masses which accumulate
and lodge in the folds of the colon ; this combination has been used by
the author in varied proportions, but never so protractedly as Wylie rec-
ommends. The daily administration of a moderate dose of malt and
cascara acts practically in the same manner. This, with massage of the
colon and lavage through the long rectal tube, has succeeded generally
in the removal of all these accumulations. The use of a cannon-ball
weighing about 5 or 6 pounds, and covered with chamois skin, is very
advantageous for massage; this is used by the patient ever}' morning;
beginning at the ca?cum, it is rolled upward over the ascending colon,
across the transverse, and downward over the descending colon time after
time. It acts mechanically, and also by stimulating peristaltic action.

At night, before the patient retires, it is a good plan to inject through
the long bougie, or, if this is impossible, by slow instillation through a
fountain syringe, a mixture of cotton-seed or sweet-oil and glycerin into
the sigmoid flexure; the quantity of this to be used dei)ends upon the
ability of the patient to retain it ; some take only 4 or 5 ounces, while
others retain 1 to 2 pints. This should be administered in the knee-
chest posture, and injected ver}- slowly in order that it may find its way
as high as ])ossible. The patient should lie with his hips elevated and
his head low down for half an hour after the injection is given, and if
possible he should retain the mixture all night. In the morning his bow-
els should be moved by a cold-water enema, if necessary, and a regular
time should be established for this procedure. After this 1 pint of a 5-
to 10-per-cent solution of the aqueous fluid extract of krameria should
be injected through the long Wales bougie. Hydrastis and hamamelis
are also useful for this purpose, but not as good as the krameria.

The diet is of the utmost im.portance, and, contrary to the ordinary
practice in these cases, that reconmiended by Von Xoorden has been
found to act best. This consists of meats in abundance — beef, mutton,
12

178 THE ANUS, RECTUM, AND PELVIC COLON

fowl, fish, ogg^y and anything of the nitrogenous tj'pe are admissible: of
vegetables — the leguminous varieties, together with those of a fibrous ni-
ture, such as spinach, asparagus, celery, etc. — may be allowed. Starches,
swt^ets, coffee, tea, and alcohol should all be avoided. As to bread, either
Graham or whole wheat bread, as distinguished from those made from
finer flours, are the best to use. Corn-bread is much relished by these pa-
tients, and does not seem to have any ill effect when made without sugar.
All wheat broads should be used stale or toasted to avoid the fermentative
action of improperly cooked yeast. The condition of achylia reported
bv Dr. Einhorn has not lK»en met with, and it can onlv be said that when
there are evidences of stomachic indigestion, of whatever type it may be,
it should 1)0 attended to according to approved methods.

Therapeutic remedies seem to have little or no effect except to relieve
the symptoms temporarily; pancreatin, boric acid, ichthyol, and salol are
probably the most satisfactory drugs, and they are used when there are
flatulence and evidences of fermentation. Tonics are indicated in those
cases in which there are feeble circulation, anaemia, and general debility,
but iron is contraindicated on account of its constipating effects. Drugs
which stimulate the appetite and assist in assimilation seem to have a
good effect. PVeding with the proper character of food, however, is the
one essential indication. As Da Costa pointed out nearly thirty years
ago, the milk diet does more harm than good. Where there is marked
local inflammation in the rectum and sigmoid, with excoriation or ulcer-
ation, local treatment to these conditions should be carried out after the
methods described in the chapters on proctitis and ulceration of the rec-
tum.

Outdoor exercise and mental and physical occupation are essential to
the cure of these patients, especially those with marked depression and a
tendency toward melancholia. A change from a low, damp climate to
high, dry, mountainous areas is frequently of benefit. This, however,
is not essential, as the condition is a local one due to direct or reflex
irritation, and when these exciting causes have been removed the mucous
and membranous discharges will cease, the patient will begin to ingest
and assimilate proper quantities of food, and through this the anaemia
and general physical debility will be removed.

Secondary Membranous Colitis. — This term is given by Hale White
to those conditions in which a membranous deposit forms upon the walls
of the colon secondary to some other grave and constitutional disease.
There are rarely any symptoms of the condition during life beyond a cer-
tain amount of tenderness over the region of the colon and sigmoid.
There is scarcely, if ever, any discharge of mucus, and diarrhoea, if there
be any, is generally of the involuntary type. The disease is therefore
not a local condition, and as it presents few symptoms referable to the

CHRONIC COUTIS, MUCOUS COLITIS, MEMBRANOUS COUTIS 179

lower end of the intestinal tract, its full consideration here would be
out of place. Occasionally, however, in the course of such diseases rectal
symptoms develop; blood, pus, and mucus are discharged, and the rectal
specialist is called in to determine the nature of the condition. It seems
advisable, therefore, to refer briefly to the causes of this condition, and
those readers who are interested in the subject can follow it up in the
journal literature and in works upon general medicine.

First, these membranes may arise from traumatisms to the colon, or
from swallowing some corrosive substances, especially toxic doses of
mercury. The explanation of this, as given by Virchow (Berlin, klin-
ische Wochenschrift, 1887, No. 50) is, that the mercury is absorbed
through the stomach and small intestines and excreted into the colon,
thus forming an irritation or inflammation which results in the pro-
duction of the mucus or so-called membrane.

Second, this condition may be due to sepsis; patients with acute
septica?mia in which the whole constitution is involved in the toxic
process, with great debility, impaired circulation, and low vitality, are all
subject to this disease. The colonic symptoms occur late in the affection,
and the membranes formed are rarely, if ever, passed during life. White
cites a number of instances in which these membranes were found post
mortem; among them a case of gangrenous umbilical hernia; 1 of fatal
puerperal fever; 1 of septicaemia due to premature labor or abortion, in
which dark-green patches of membrane were located near the sigmoid
flexure; another of general sepsis with gangrene of the foot, in which
there were grayish leather}^ membranes formed in the rectum and sig-
moid flexure; another of sepsis and general cystitis, in which the mem-
brane began just within the anus and extended for 3 inches upward as a
grayish-brown coagulation with necrosis and submucous hjemorrhages
extending as high as the splenic flexure, and finally, one of acute suppu-
rative cellulitis of the neck with whitish patches in the ascending colon.

There is nearly always some involvement of the kidneys in these
conditions. Constipation is more frequent in these cases than diarrhoea.
If general peritonitis exists there will be tympanites, and sometimes ana-
sarca. The author has seen the condition once in a case of gangrene of
the leg followed by general septicaemia, three times in cases of em-
pyema with symptoms of general sepsis before death, and once in septic
peritonitis following operation in a case in which a large tubal abscess
broke into the peritonaeum.

Third, secondary membranous colitis may occur in cases of chronic
Bright's disease; both simple and ulcerative inflammation of the rectum
and sigmoid result from this disease. Wilks and Moxon state that they
observed the formation of a tough whitish membrane attached to the mu-
cous membrane of the colon in patients who died from this condition, but

180 THE ANUS, RECTUM, AND PELVIC COLON

they do not state whether there was any suppurative inflammation of the
kidnevs or not. Bristowe and Dehilield both state that these inflamma-
tions of the eoh)n may occur in the late stages of fatal pneumonia^
White has seen cases occur during the course of fatal diabetes, and Vyv-
Smvth has observ(»d it in a case of carcinonui not connected with the
intestine. The fact that the condition does not present symptoms during
life, that it is rarely observed except at autopsies, and that all the ca?«
in which it has ]KH.»n observed, except, iK»rhaps, in a few following mer-
curic j)oisoning, have jjroved fatal, renders a discussion of the treatment
impossible at the present time.

TJlcerative Colitis. — ritvratinn of the colon frequently occurs as a
result of Bright's disease, typhoid fever, tulx^rculosis, dysenter}'. and
malignant neoplasms. It is frequently found in the post-mortem room
afttT deatii from other causes in ])atients who present no ante-mortem
symptoms of the coniliticm, and whose intestinal functions, so far as their
history showed, appi'arcd to have Ix-en perfectly normal up to within a
short time before death. It is not proposed to discuss here the condition
that arises from these specific causes, but to study those cases of simple
ulcerative colitis with chronic diarrhiea and symptoms referable to the
rectum and lower end of the intestinal canal.

Ktiohtjii. — The cause of ulceration of the colon can not alway? be
told. In some cases there is a history of typhoid fever, dysentery*, or
chronic diarrhoea; sometimes it develops during the course of a mem-
branous colitis, at others the condition seems to originate suddenly and
without any ])remonitory symptoms. It is said to occur frequently in
the insane. Campbell (British Journal of Mental Sciences, 1808, p. 5?(i)
reported v'8 cases that occurred in the institutions for the insane with
which he was connected. Cowan, Ackland, and Targett claim that ulcer-
ation of the colon mav be due to the disease of the central nervous sv?-
tern, and White has rej)orted ^i cases that occurred in Guy's Hospital
which seem to corroborate this view.

Cowan calls attention to tlu' fn»(|U(»nt occurreniT of ulceration of the
rectum and colon in the insane*. Enrich (Lancet, May 18, 1895), while
admitting that this is the fact, states that the lowered vitality of luna-
tics renders them an easy prey to all sorts of diseases. He therefore
believes that these ulcerations are not <lue to trophic neuroses, as Ackland
and Targett claim, but to some other cause that operates upon these
weakened svstems.

Age seems to have some influence in producing it. In 28 cases re-
ported by White and Coleman, seventeen years was the youngest and
fifty-nine the eldest. In tlie autopsies at the Xew York city almshouse
ulcerations of the rectum and colon are among the most frequent patho-
logical changes. Many of these have been due to tuberculosis or to

CHBOXIC COUTIS, MUCOUS COLITIS, MEMBRANOUS COUTIS 181

atheromatous changes in the blood-vessels. The condition extended in
patches from the rectum to the cjecum.

Sex seems to have no predominating influence. In Wliite's cases
there were fifteen men and thirteen women.

Climate and occupation have not been shown to have any decisive
influence in the production of the disease; in mild climates it occurs
quite as often as in the warmer regions, and even in the very cold sec-
tions of Russia and the high mountainous regions of the United States
this condition seems to be quite as fre<|uent as in the other sections.
Laborers in lead works, and miners who have considerable to do with
quicksilver and mercuric preparations, seem to be affected with the dis-
ease somewhat more frequently than those engaged in other industries.
The question whether the absorption of the metals occasions this, or
whether the constipation produced by these occupations is the cause of
the ulceration, remains yet to be answered. The fact that the disease
oct-urs most frequently in ana?mic, broken-down individuals suffering
with some other form of disease, or having suffered from some exhaustive
condition, makes it likely that these ulcers are due to trophic or circula-
tory changes. On the other hand, they may be due to the invasion of
weakened tissues by the septic bacteria always present in the colon. As
a matter of fact, it is now generally believed that there are present in the
human sj'stem at all times the elements of sepsis and toxaemia, and that
it is simply a question of perpetual war between these elements and the
animal tissues. When the system is in a normal, strong, and healthy
condition it resists the invasion of these bacterial enemies. When it is
weakened by improper nourishment, overwork, anxiety, or disease, the
balance is thrown to the other side, and the invasion of septic bacteria
Wonies effective in the production of disease. Such may be the cause of
these ulc(?rations in the rectum and colon. The balance is thrown upon
the side of the bacteria.

There is often a history of some organic disease of the heart, liver,
kidneys, or spleen, but Hale White says in one-half of the cases the rest
of the organs are perfectly healthy. Rheumatism with its cardiac com-
plioations, gout with its thickened and calcareous joints, he])atitis with
abscess and biliary disturbances, and, most frequently of all, diabetes and
chronic Bright's disease, are associated with this form of colitis. Camp-
bell {loc.cU.) found chronic Bright's disease in 11 out of 28 cases of
ulcerative colitis, and 8 out of 18 cases of membranous colitis. Cowan
reports a similar state of affairs in the institutions over which he has con-
trol. The author has seen 2 cases of the disease in which there was
marked diabetes, and in 1 the glycosuria amounted to 6 per cent. Yet
the very large number of all these diseases that are not associated with
ticeis of the colon renders the condusion necessary that they are not

182 THE ANUS, RECTUM. AND PELVIC COLON

exciting but rather j)re(lisposin|[; causes to the condition. This is throw-
ing us back once more upon the theoretical conclusion that the disease is
due to the invasion of specific bacilli under the circumstances favorable
to their excessive development.

Pathology. — Much has been written and said about the pathology of
ulcerative colitis, and yel there seems to be very little hannony of opinion
with reirard to the same. The ulcers mav be found anvwhere from the
anal margin to the tip of the appendix, even this latter organ being some-
times involved. Their depth and extent are ver}' variable, at times
being tiie size of a split pea, at others being as large as a silver quarter,
and gradually sloj)ing down to the base; occasionally they involve the en-
tire circumference of the colon. The muscular wall of the gut usuaUy
forms the ))ase of the ulcer, but sometimes they are superficial and may
not extend to the submucims tissue; in other cases they penetrate the
muscular wall and even the peritonaeum, but usually this membrane is
healthv over the seats of the ulcers. The mucous membrane between the
ulcerated areas is dark, purplish, and congested.

The tendencv of ulcers is to extend circularlv around the intes-
tine. They may be so numerous, however, that only small patches of
mucous membrane remain, which patches White describes as having a
sort of polypoid api)earance, and even having been mistaken for poh'pi.
He reports a case in which there were over one hundred superficial ulcers;
the author has reeentlv seen a similar case in which there was scarcely a
square inch of mucous membrane between the anus and the caecum.
Omerod and Barlow reported cases in which there were numerous per-
forations at one time. Delafield stated that the follicles are infiltrated,
swollen, and break down, forming what he terms "productive ulcers,"
which from his descriptions closely tally with those referred to here.
The early ulcers seem to devt»lop either along the lines of the mesen-
tery or of the longitudinal folds. The epithelium of the Lieberkiihn fol-
licles is clouded and swollen ; there is an accumulation of small cells in
the submucous layer which is (edematous and thickened, and thus narrows
to a certain extent the caliber of the gut. The follicles may be the seat
of ulcers or they may be cut off flush with the ulcerated surface, leaving
a portion of them below this surface.

Syjtiptojns, — The disease may begin in a variety of ways. Delafield
states that in the large majority of instances it begins in the rectum and
travels upward. White says that it may begin at any point in the whole
course of the large intestine. In some cases there is a sudden onset of
sharp lancinating pains in the course of the colon attended with griping
and a tendency to frequent movements of the bowels. These pains last
for a short while, disappear, and the patient may feel nothing more of
the kind for several days or weeks, when they occur again. They last

CHRONIC COLITIS, MUCOUS COLITIS. MEMBRANOUS COLITIS 183

sometimes an hour or more, at others they continue for two or three
days. The stools do not at first contain any mucus, pus, or blood, but if
the pain is persistent, and the recurrence frequent, there will be evi-
dences of ulceration in the discharge of these substances. If the ulcer is
high up the blood and pus will be mixed with the stool, and the blood will
be dark and decomposed or clotted ; if it is in the lower part of the sig-
moid flexure or in the rectum, the blood will be fresh and will precede
the stool. The periodical occurrences are said by White to be typical
of the disease. The pain, which in the first attacks is not very severe, in-
creases with each recurrence. The amount of pain bears no relationship
to the amount of ulceration, nor is it influenced by the ingestion of food.
The cause of pain is probably not in the existence of an ulcer, but in the
irritation of the ulcer by the intestinal contents, which sets up irregular
peristaltic or spasmodic action of the bowel. The number of the stools
varies greatly : in one case there were 35 to 36 stools a day for one week
during the acute attack, in others the number reached any\i'here from 5 to
15 or 20 stools a day. The diarrhoea may alternate with short periods of
constipation. A distinction between the diarrhoea in these cases and that
in dysenteric and acute catarrhal inflammations of the rectum and colon
should be clearly understood. In the latter conditions there is a con-
stant tenesmus and desire to go to the water-closet, a feeling of incom-
pleteness in the defecatory act, a desire to remain straining upon the
seat. In this condition, however, the inclination is not continuous. It
is frequent and imperative at the time. The bowels having once moved,
there is complete relief for the time being. The patient does not suffer
in the interim, but after a while the imperative demand recurs, and must
be yielded to at once. The stools may be thin and watery, or they may be
semifluid. Sometimes hard faecal balls, as in mucous or membranous
colitis, occur, but this is not the rule. They are generally semifluid and
possess a foul, feculent odor, which is often very suggestive of malignant
disease. Mucus is not generally present, but, as said above, blood and
pus soon begin to appear in the stools. When the blood occurs as a clot,
it is sometimes smooth on one side and rough on the other, showing that
it has recently been detached from the floor of an ulcer (White). Along
with the blood and pus there may come shred-like masses of sloughing
material containing leucocytes, epithelial cells, and small adherent
masses of faecal matter.

Vomiting is said to be an early symptom in the disease, but in the
author^s experience it has only occurred in occasional and in very
severe attacks. When the nausea and vomiting are very severe blood
may be contained in the vomited material, but this is generally due
to the rupture of some small venule in the throat or esophagus, and
does not come from the ulcers of the intestine. The tongue is at first

184 THE ANUS, RECTUM, AND PELVIC COLON

coated with a white furry coat, but it soon becomes red upon the
edi^ros and more or loss brown in the middle, ven' much resembling
the tongue of typhoid fever. The patients suffer greatly from thirsL
Progressive ana»mia, loss of flesh and strength, and great depression in
spirits are the natural sequences of the disease. The temperature in
the disease is ven* irregular; in some cases it never goes above 100' F.
during the whole course of the malady, in other cases the temperature
has gone as high as 104.5° F., and may vary at times 4 degrees
between night and morning. It sometimes droj)s below normal, and
within a few hours is up again some 3 or 4 degrees. The condition
resembles very closely typhoid fever with ulceration of the bowel.

The course of the disease may be \qt\ short, patients having died
from it in three or four days. Such a result, however, is probably
due to perforation and subsequent peritonitis. Under other circum-
stances <leath from ulceration occurs after long periods of suppura-
tion and general sloughing of the mucous membrane of the intestine,
and it is then due to exhaustion or amylaceous degeneration of the
organs. White states that the prognosis is always grave, and that
he is exceed inglv doubtful in anv case that recovers whether after all
the diagnosis was correct. The course, he says, is fatal in about eight
weeks. Continuous high temperature, persistent pain, tympanites, and
very frequent stools associated with the loss of blood and increased
purulent discharge, are all unfavorahle symptoms.

Diaf/Nosis. — It is likely to be confounded with but three conditions,
viz.: dysentery, typhoid fever, and malignant disease of the large intes-
tine. Reference has been made to the distinction between dysentery
and ty})hoid fever and this disease. In malignant disease the onset \b
very much more gradual, the teni])erature is never high except in the
very last stages, the patient is not troubled with griping or diarrhoea,
but generally with constipation that requires cathartics to move the
bowels ; after th(» movement has once lx»en obtained, the patient seems
fairly comfortable for some time, later on the passing of mucus and
blood are indicative of malignant disease. One who is thoroughly
versed in the examination of malignant diseases of the intestine will
rarely be deceived hy anything else, for the peculiar feculent, path-
ognomonic odor from malignant ulcers is characteristic. In ulceration
of the colon there is rarely any discharge of glairy mucus, but the
sanious pus is very abundant.

Treatment, — So far as any local influence of medication goes, no
definite results seem to have been obtained in these cases by adminis-
tration through the mouth. The chief indication seems to be to find
out the cause of the debilitated condition of the system and treat that
as far as possible. The ulcerated colon and rectum themselves need

CHRONIC COLITIS, MUCOUS COLITIS, MEMBRANOUS COLITIS 185

local treatment together with a bland, nnirritating diet in order to
preTent further irritation and multiplication of the ulcers. Ordinary
irrigation of the rectum through the rectal irrigator is of no practical
benefit in these cases^ as the fluid does not reach high enough. The
use of long bougies, even of the soft-rubber type, is dangerous, because
the rectal wall at the ulcerated spots is liable to be so thin that even
the slightest distention or pressure may rupture it and set up a fatal
peritonitis.

The treatment that affords the most benefit is this: Place the pa-
tient in the semiknee-chest posture by elevating the hips upon two
or three pillows and letting the shoulders, chest, and knees rest upon
the surface of the bed; in this position introduce the rectal tip of an
ordinar}' fountain syringe into the rectum; elevate the fountain only
about 2 feet above the level of the patient, and then turn on the stream
and \et the fluid find its way into the colon. By requiring the patient
to remain in this position for ten or fifteen minutes, breathing gently
but deeply, the fluid will gradually pass into the intestinal canal so
slowly that there is no danger of distention and very little tendency
of the bowels to reject it. The fluid should be started at about 105"*
or 110*' F., as it will gradually cool off during the slow instillation.
By this means it is possible to reduce the frequency of the stools,
to check the discharge of blood, and together with proper regimen,
diet, and tonic medication, to restore the patients to health. The
fluid injected has been one of two remedies : either the aqueous
fluid extract of krameria, which seems to act better than anything
else so far as checking the diarrhoea and ha?morrhage is concerned, or
the fluid extract of hamamelis. The strength of these solutions de-
pends largely upon the condition of the patient and the sensitiveness
of the colon; in some cases the krameria may be used as strong as 20
per cent, in others it may be used in the strength of 5 per cent. Ham-
amelis is not used stronger than 10, and generally in from 1- to 3-
per-cent solutions. The amount of the latter used vanes from 1 to
6 pints, and the patient is required to retain it as long as possible.
When the hjemorrhages are frequent, in the commencement of the
treatment a combination of ergot, cinnamon, and hydrastis may be
used internally; gelatin has been recently advised for this pur})ose,
but the author has had no experience with it; by the combination
of these remedies with the irrigation mentioned above the haemor-
rhages may be checked very promptly in all the cases. The ulcera-
tion, however, is a more obstinate affair, and its cure depends not
only on keeping the intestine free from irritating substances and
washing out the septic germs, but also upon building up the patient's
general condition. Stimulation of the assimilative organs and the ad-

186 THE ANUS, RECTUM, AND PELVIC COLON

ministration of predigested and nourishing foods are of the utmost
importance. Bone marrow, haemaboloids, protonuclein, fresh beef
juice, pla^mon, and such remedies are used in small quantities and
frequently, together with a sufficient amount of rich Burgundy wine
as a stimulant to the heart and digestion. When these local and gen-
eral measures fail recourse may be had to functional rest of the parts
by making an artificial anus above the ulcerated portion. Thus far
the author lias not found one whose condition would admit of it who
would give his consent to having a right inguinal anus made. So long
as they are not desperately ill the patients cling to the belief in medi-
cation and local treatment without operation. White holds that
when the disease shows no inclination to heal bv local treatment, a
right-side inguinal colotomy is not only justifiable but imperative. He
recommends the injection of a 25-per-cent solution of perehloride of
iron as high u]) in the colon as possible, in order to control haemorrhage;
but the author has elsewhere expressed his objections to this remedy,
and need not repeat them here. Delafield, Da Costa, W. H. and W. K.
Thom})son all advise the use of castor-oil in small doses for the relief
of diarrhea. The author has tried it many times and finds its action
very uncertain : sometimes it seems almost a specific in the early stages
of the disease, while in others it seems absolutely useless, so that he
has come to doubt its efticacv in true cases of ulcerative colitis.

Follicular Colitis. — Scattered throughout the mucous membrane of
the rectum, sigmoid, and colon, there are a large number of solitary
follicles, upon the function of which physiologists fail to throw any
light. They are not glandular in their structure; they are neither
secretive nor absorptive. They are much more frequent in the colon
than in the sigmoid and rectum. Their seat is in the mucous mem-
brane proper, but their bases dip down into the submucous tissue.
During the course, or as a result of chronic catarrhal inflammations,
these follicles become inflamed, the pressure upon the membrane above
them results in a necrosis, and small, well-defined, circular ulcers
are left.

White states that this disease occurred about once in five hundred
post mortems made at Guy's Hospital, London. In a large number of
autopsies made at the Xew York C'ity Almshouse during the last sii
years only 3 cases of this condition have been observed. Notwithstand-
ing the fact that White says the condition is never diagnosed during
life, the writer has seen and recognized 5 cases of this kind in his
clinic and private practise. In 2 of these the disease was chiefly in the
sigmoid, in 2 it was just below the recto-sigmoidal juncture, and in 1
it was at the lower end of the rectum.

Etiology. — The cause of this condition is very imperfectly known.

CHRONIC COLITIS, MUCOUS COLITIS, MEMBRANOUS COLITIS 187

It occurs during the course of, or as the result of, other inflammatory
diseases. Holt reports having seen the condition 20 times in 70 fatal
cases of non-tubercular diarrhoea in infants; he states that it never
occurred in cases of less than one week's duration, and it was more
frequent in those that lasted longer than eight or ten weeks. In the
20 cases the ulcers were confined to the colon in 15, to the small
intestine in 2, and were found in both 3 times. Those which were
found in the small intestine were in the lower end of the ileum near
the caecum. Those in the colon were most frequent in the sigmoid
flexure, the lower portion of the descending colon, and the rectum.
In the cases reported by White all of them are said to have died from
some other disease, such as dysentery, cancer, membranous colitis, ty-
phoid fever, or tuberculosis. He calls attention to the fact that in the 5
cases which died from tuberculosis and in whicli he found follicular
ulceration of the colon, there was not a single instance of tubercular
ulceration of this organ.

In the cases observed at the almshouse 2 were in tubercular patients
and 1 in a case of chronic ulceration of the colon. In the tubercular
cases the autopsies confirmed the statement of White, and in the
other case the follicular ulcers were dotted here and there between
the larger ulcerations. In none of these cases were any tubercle bacilli
or giant cells found in the ulcers. In the author's clinical cases 2 gave
a history of having had " acute dysentery," which had resulted in a
chronic diarrhoea, with hard, lumpy stools occasionally; upon examina-
tion there were evidences of typical hypertrophic catarrh. In another
there was obstruction in the sigmoid and colon which, upon explora-
tory laparotomy, proved to be due to adhesive bands. These were
broken down, and under rest, proper diet, and sigmoidal irrigation the
condition disappeared. In the fifth case, in which the inflammation
was centered around the lower portion of the rectum, there was a
histor}' of chronic constipation, operations for ha?morrhoids, stretching
of the sphincter, and much instrumental interference with the organ.
All of these cases, therefore, were associated with or followed some
inflammatory process in the walls of the intestine. So far a case of
simple, uncomplicated, follicular inflammation of the colon or rectum
has not been met with.

Pathology, — The pathological changes in this form of inflammation
consist in a congestion of the mucous membrane around the follicles
with hyperplasia and an accumulation of small, round cells inside of
them (Fig. 87). As this increases the follicle becomes distended and ele-
vated above the level of the mucous membrane. Pressure from this dis-
tention and friction from the passage of the faecal mass over it cause
necrosis of the epithelial covering and rupture of the wall of the folli-

188

THE ANUS, RECTUM, AND PELVIC COLON

ck. This leaves an ulcer with sharply cut edges, slightly undermimMi
and with a flat base, never erater-like. The ulcers are not dt^t'p, ant
rarely coalesce, although the whole gut may be honeycombed witli then
(Fig. 88). They vary in size from a hemp-seed to a split pea-

White and Holt state that they show no tendency whatever to heal,
but in the fifth case, mentioned above^ and in which the affected
mucous membrane was removed, there were several cicatrices which
seemed to have originated in follicular ulcers that had healed. So far
no case of perforation of the gut from this condition has been recorded.

Gaylord and Aschoff (Pathological Histology, p. 168) have observed
a condition which they denominate "colitis n/slica"; it appears to be
very similar to follicular colitis. They state that in chronic inflamma-
tions of the colon the mucous membrane is studded with minute, clear
vesicles which are produced by dilatation of the gland lumina, the

CHRONIC COLITIS, MUCOUS COLITIS, MEMBRANOUS COLITIS 189

openings of which have become occluded. Chronic irritation of the
mucous membrane^ they claim^ causes agglutination of the mouths of
the glands, and the continued secretion of the glands thus closed re-
gults in small spherical cysts which project above the surface of the
gut. The clinical symptoms and macroscopical appearances described
by these authors coincide with those of follicular colitis. The patho-
logical changes, however, and the manner in which the cysts are formed
differ materially from those ordinarily described in this disease. It
remains to be determined, therefore, whether this is another disease or
a new pathology for the old one. The author recently removed a small
spherical mass from the rectum the histological examination of wliicli
seemed to point to the latter view.

Sifmptoms, — The symptoms in these cases are very similar to those
of chronic inflammation of the rectum and colon, and vary according
to the site of the affection. AVhere the disease is found in the sigmoid
flexure and colon the symptoms are those of chronic hypertrophic ca-
tarrh. When it occurs below the recto-sigmoidal juncture the patients
suffer chiefly from muco-purulent discharges, frequent desire to defecate
without any results, tenderness over the lower end of the spine, and
vague j)ains shooting down the legs.

In the case in which the disease was limited to the lower end of
the rectum the patient's symptoms were those of ulceration of the
rectum and anus. She had already had an operation for hjemorrhoids
four months previous to consultation for the new condition. The
wound from this operation had not healed, and there remained a
chronic ulceration in the anterior left quadrant of the rectum. The
patient had frequent painful movements composed of pus in abun-
dance, some mucus and blood. Every two or three days she passed
small balls of fapcal matter, which became coated with the contents of
the rectum through which they passed. The ulcer in this case prac-
tically obscured the sjTnptoms of follicular disease, and the diagnosis
was made solely upon ocular examination. The condition was so
marked that its benign nature was doubted; all the affected mucous
membrane was excised and submitted to the pathologist for examina-
tion.

Pathological Report by Dr. F. M. Jeffries :

'*The macroscopical ap])earaDce is as though the mucosa were thickly beset
^th miliary tubercles. Each nodule is round, projects slightly above the surface,
and is yellowish in color. So numerous are they that each appears to be in con-
tact with its neighbor. The submucosa and muscular coats ap])ear to be unaffected
and devoid of induration.

** Microscopically the mucosa is beset with solitary follicles or small masses of
lymphadenoid tissue that resemble in all respects, except numbers, the normal soli-
tary follicles.

190 THE ANUS, RECTUM, AND PELVIC COLON

*^ Between the follicles the crypts of Lieberktihn are normal, as are also tii
submucous and muscular coats.

*' At one point where tissue was selected for microscopical examination, gram
lation tissue was observed associated with the submucosa — probably the site of
previous operation."

All of these eases suffered from flatulence and digestive derange
ments; they found little relief from the use of laxatives and remedie
for indigestion. In one case the patient suffered with the most aggra
vated symptoms, such as alternating diarrhoea and constipation, di&
charges of pus with thin mucus, followed by extreme exhaustion anc
tenderness all over the abdomen. Upon laparotomy, adhesive bandi
were found which produced a constriction of the gut; these were
broken down and the bowel released. In the walls of the ileum and
throughout the colon there were myriads of little hard bodies about
the size of No. 2 shot, some of them as large as a small pea. The
intestine was not opened to determine the nature of these bodies, but
there is little doubt that they were inflamed solitary follicles. Ex-
amination of the three other cases through the sigmoidoscope showed
here and there little nodular swellings when the intestine was put
upon the stretch. The summits of these elevations were sometimes
abraded and bled upon touch (Plate I, Fig. 3). In the other cases
the elevations had disappeared and in their places there were small,
well-defined, shallow ulcers. The bases of these ulcers were smooth,
flat, and granulating. The mucus secreted was not so abundant as that
in hypertrophic catarrh nor so thick and tenacious as that in the
atrophic variety. At the same time this condition may be complicated
by either of these varieties of inflammation, and consequently one can
not place much dependence upon the character of the discharges.
When the disease is situated low down, one may feel with the finger
small nodular elevations giving the impression of miliary tuberculosis,
but this location of the disease is so rare that few physicians will ever
have the opportunity of feeling it. The diagnosis practically depends
upon the sigmoidoscope and ocular examination through it.

Treatment, — The treatment in this condition depends upon the
cause and the location of the ulcers. Where there are evidences of
intestinal obstruction, such as in the case related above, they should
be removed. Where there is a catarrhal condition of the rectum and
sigmoid, the treatment should be based upon the character of this
disease. If the ulcerations are in the sigmoid and rectum within view
through the sigmoidoscope, local applications of argonin, nitrate of
silver, or antinosine may be made.

While there is some tendency to diarrhoea and frequent movements
of the bowels, this can be controlled better by thoroughly flushing out

CHRONIC COLITIS, MUCOUS COLITIS, HEXBRANOUS COLITIS 191

the intestine bv a good dose of Epsom salts or castor-oil ereiy second
or third Diorning than by the use of opiates. The case in vhich the
di^ase was located at the lower end of the rectom appears to be unique.
The trentment adopted, viz., the excision of all the di.^ased mucous
membrane and suturing together the health; edges, proved perfectly
eatisfnctory for the time being, but the period that has elapsed since
the operation is too short to claim for it radical and permanent cure.

If the condition should be diagnosed as existing in the upper por-
tion of the sigmoid and colon, it should be treated as advised for
ulcerative colitis. In those cases in which this disorder is complicated
bv membranous colitis the treatment will be necessarily tt^llnu^ and
prolonged, and one may be finally compelled to make a right dlostomy
in order to afford the parts functional rest.

The disagreeable features of this method of treatment have been
largely overcome by Gibson's "valvular colostomy" (Medical Record,
1901, vol. i, p. 405; Boston 3fedical and Surgical Journal, vol. i, 1902),

Fin. fiB A.— First Tiib or Srmai n> VAL-rnjM CoLonnxT (Gibf>

which is applicable to all forms of chronic colitis, and is carried out as
follows: The cscum is exposed by an intermuscular incision an inch and
a half long parallel to and just above Poupart's ligament. An oi^pnin;:
is then made in the anterior longitudinal band of the gut sutf]''i<-ntly
large to admit a good-sized soft-rubber catheter. Two or thn-*- ti'.-r- of
sutures are then introduced in the serous surface of the gut ( Fi^'-. h'* .\
and 88 B), so as to infold the latter and form a sort of Urat or valv<;
protruding into the caliber of the intestine (Fig. 88 C ^. The end.- of the
last tier of sutnres are left long, and carried through the e<lge- of th*;
abdominal wound, thus closing the tatter, at the same time holding th<r
gut in apposition with the abdominal wall. The cathf:ter U l-fi in f'lr
ten dsjB or more, nntil the parts have healed. After this, it i-^ tiik'rn

192 THE ANUS. RECTUM, AND PELVIC COLON

out and reintroduced as often as is necessary for the purposes of irri-
gation. The slight fa?cal fistula is controlled by a small pad, and ilie
patient is not confined during the troatnient.

By this means the entire colon is irrigated from above downrud
vith medicated solutions, according to the judgment of the eurgeoo.

Fio. 8S B.— Laht Ti:

Bolton in his case used nitrate of silver 0.01 per cent, followed by a
saline solution 0.05 per cent.

The operation is practically without danger, and, while it does not
turn the fa'ciil current a^iide and pive functional rest to the colon, it
enables one to keep the latter fr^'c from irritating substances by frequent

Fio. >i,i C— LoxoiTttiiNAL Se.hun sjiowi^cg Bekilts or Infoldiho bv Gibson'

irrigation, and at the same time avoids the disagreeable features of an
artificial anus. The small fteeal fistula will close spontaneously after the
use of the catheter is discontinued, or if it does not, it is an casv matter
to dissect it out under cocaine ana'stliesia and close it by sutures.

CHAPTER VI
TUBERCULOSIS OF THE ANUS, RECTUM, AND PELVIC COLON

Tuberculosis is now recognized as the etiological factor in a number
of conditions about the anus and rectum, the pathology of which was
formerly unknown. The disease may develop primarily or secondarily
in the skin, mueo-cutaneous, mucous, and cellular tissues, and is always
due to the tubercle bacillus.

In the skin and mucous membrane it assumes some interesting types,
each of which was not long ago considered to have a special pathology,
but which are now known to be due to this specific microbe. In the
cellular tissues it develops abscesses and fistulas, and in the muscles fatty
or destructive changes, which permanently disable them. It is propa-
gated by direct invasion of the adjacent tissues or through the lym-
phatics. It advances in inverse proportion to the amount of fibrous
tissue in its path; a pure cicatrix forms a barrier through which it
can not pass. In the present chapter tulx?rcular lesions of the skin,
muco-cutaneous tissue, and mucous membrane will be considered, and
the study of the involvement of the cellular and muscular tissues will
be reserved for the chapters on Abscess and Fistula.

Owing to the different anatomical structures and varied relation
of the parts, tul)erculosis will be described as seen in the perianal re-
gion, the anal canal, the rectum, and the pelvic colon.

PERIANAL TUBERCULOSIS

In the skin about the anus, rich in hair follicles, sebaceous and
€udoriparous glands, foci of tubercle bacilli often lodge and develop
most destructive processes. They are divided into miliary, ulcerative,
lupoid, and papillar}' or verrucous tuberculosis.

Miliary Variety. — This type of the disease is very rare; it is seen
almost entirely in cases affected with tul)erculosis of other organs, and
is said bv Chiari to occur almost exclusivelv at the muco-cutaneous mar-
gins; the author has seen it well outside of this area in the perianal
£kin.

18 193

194 THB ANUS, RECTUM, AND PELVIC COLON

It develops as minute nodules or infiltrations which feel like small
shot or millet-seeds beneath the ei)idermis. They are always muhipie,
and grouped in crescent ic or circular shajw. They develop in the glands
of the skin, and gnulually grow larger until jiressure upon the over-
lying ej)itliclium causes necrosis, and it falls, leaving shallow, cup-shaped
ulcers with ragged, indurated borders. Small miliary nodules may be
seen covering the surfact* and edges of these ulcers. They discharge t
scant amount of sero-pus and do not bleed on touch. They are mure
painful than most tul)ercular jiroct^sses. As a rule, they remain station-
ary until the patient succumbs to the pulmonary affection, but they may
spread, coah'sce, and form extensive ulcers. Observations as to the
histology of the surrounding tissues have not been nmde, but numer-
ous tulM»r(lc bacilli were found in scrapings from the ulcers.

Trnilwrnf. — This local condition is so nire and of so little impor-
tance compared with the intestinal and pulmonary lesions which accom-
pany it that no one has formulated any treatment for it. The appli-
cation of the gal va no-cautery or X ray might destroy the bacilli and
cause healing, but the general constitutional condition is the chief factor
in the case, an<l all effort should be bent to remedv this.

Change of climate, creosote, cod-liver oil, hypoi)hosphites, forced
feeding, and all the hygienic measures adopted in general tuberculosis
should be em])loyed ; but after all, nothing that is known at present
can (»nabl(» one to give a favorable ])rognosis in such cases.

Ulcerative Variety. — All tulKTcular processes of the superficial tegu-
ments arrive sooner or later at an ulcerative stage. The characters of
these ulcers differ according to the tissues involved and the constitu-
tional condition of the patient.

Sim])l(» tubennilar ulcers of the anus begin in an obscure manner.
They may develop from contusions, wcmnds, and injuries, or they may
be i(li()])athic.

The patient generally has a history of tuberculosis e'ther hereditary
or acijuired, but there may ho no marked localization of the disease.
A small induration or nodule occurs in the superficial layers of the skin.
Traumatism, friction, or injury may cause a breaking down of the tis-
sue<, and ulceration results. This mav Ik* brought about bv an attack
of diarrlKca, a horseback or bicycle ride, or a throml)otic ha?morrhoid.
It may start in the anal canal or in the skin itself around the anus; it
may be confined to the latter tegument, or it may be limited to the
anal Ciuial.

As to the comparative frequency with which it attacks the two por-
tions of the anus, it is difficult to decide. In nearly all of those cases
which the author has observed, the ulceration has at one time or another
involved both the perianal tissues and the anal canal. Hartmann, in his

^Bob:

ERCITLOSIS OF THE ASUS, RECTUM, AND PELVIC COLON 195

ezh>u^i*« studies upon this subject, states that he has four times seen
ihese ulceratiuns atmo^t entirely surround the anus, destroying all the
cutaneous tissues with the exception of a smitll bridge of skin which
was left intAct without involring the anal canal. They may develop
singly and spread to both sides of the anus, or several ulcers may develop
at one time and coalesce to form one large, irregular ulcer (Fig. 89).
Thpy are irregularly round, the edges more or less ragged, and they tend
lo spread circularly an'l upward into the anal canal at the same time.

The borders are clear-
cut, undermined, with a
pale sloughing edge, which
fades off into a rose-col-
or»d border in the skin.
There is an induration or
hyi>t'rtropliy around the
margin; the base of the
ulcer is irregular, grayish
in color, and presents a
sort of elevation in the
center, with a depression
amund the edges beneath
the undermined skin
(Plate 11, Fig. 3).

The granulations are
pale, do not bleed easily.
»nd are of verj- unequal
iJzcs, Here and there
«callereil over the ulcers
are small yellowish pim-
ples or tubercles which
svem to be embedded in

tjie tissue. These may be picked out with a needle or a sharp spoonj
but they do not come away with gentle wiping or irrigation. When
they are picked out they will leave a sort of cavity, smooth and shining,
ami about the size of No. 8 bird-shot. Hartniann stated that the surface
of these ulcers was always soft and supple except in two cases. The
author has excised a number of them, and has yet to find one in which
there was not an induration beneath the area involved; he has found
in the scrapings tubercle bacilli, thus proving their nature; and be-
Deatfa the granulating tissues of the ulcers there was a smooth, glistening
tissae that showed a fibrous alteration of the teguments beneath, or,
intact, a real cicatricial development, in which no tubercle could be

IB tsct. a rea

196 THE ANUS, RECTUM. AND PELVIC COLON

Pain is not a marked symptom. Ordinarily the patient suffers ver
little even from faecal passages or the direct handling of the parts. 0(
casionally, however, when the ulceration invades the anal canal an
assumes the form of fissure, the pains become more severe at the tim
of defecation. As a rule, however, tubercular ulcerations of the ana
canal and its margin are both comparatively free from pain. Al
most without exception has this been the case in the large number o
tubercular ulcerations of the anus seen in consumptive patients in th
hospital on Blackwell's Island. In two cases in which the ulcers wer<
excised, previous to the operation and immediately thereafter the pa
tients suffered no pain whatever ; but when the wound had almost healed
and there remained only a small granulation at the margin of the anus
they began to complain of sphincteric spasm and pain following tin
faecal movements.

In another case, in which a tubercular ulceration was cauterized witl
the Paquelin cautery, there was no pain previous to it, nor after the
first cauterization ; but after the second, when the discharge had almost
ceased and the ulceration was apparently healing, the patient suffered
more or less acute pain after fgecal movements. At this time, examina-
tion of the slight discharge, and also the scrapings of the ulcers, failed
to demonstrate the presence of any tubercle bacilli. The tubercular
process was afterward reestablished in this wound, and it became again
painless to the touch. It is difficult to understand why these ulcerations
are not painful. There is the inflammatory element, the development of
fibrous tissue, the involvement of the sensitive nerve areas — in fact,
every element necessary to account for the production of pain, but no
satisfactory explanation of its absence has been offered.

The discharge from these ulcers is generally limited, of a thin puru-
lent character, and very rarely tinged with blood. Sometimes there
may be a mixed infection, and the quantity of the discharge is materially
increased.

When this type of ulcer extends into the anal canal it does not
usually assume the form of fissure, as do most other ulcers, but seems
to spread over the radial folds and dowTi into the sulci at the same
time. It is usually limited by the " white line " of Hilton, but may
extend upward to the border of the sphincter, and end in a clear-cut
margin, somewhat indurated, with a perfectly healthy mucous membrane
just above it.

The progress of tubercular ulceration around tlie anus is vari-
able. Sometimes it is very slow, while at others it is rapid and de-
structive in the highest degree. Contrary to the history of syphilitic
ulcers, there is no tendency to heal in one part while they progress in
another. A tubercular ulcer in the absence of treatment shows but one

TUBERCULOSIS OF THE ANUS, RECTUM, AND PELVIC COLON 197

tendency, and that is to progress in all directions; under general con-
stitutional and local treatment it may be healed, but if left alone its
onward march is stopped only by death; it is not, as a rule, fatal in
itself, but it remains as a disturbing element until the end comes
through development of other tubercular lesions or some form of in-
tercurrent disease; ordinarily it is acute pulmonary or genito-urinary
nberculosis.

ANAL TUBERCULOSIS

Tuberculosis may attack the anal canal either by extension from
;he perianal region or primarily. Indeed, it is often a question whether
;he disease originates in the perianal or intra-anal tissues. In the
inal canal the miliary or nodular type is rarely observed, but the ulcer-
itive form is very common. It assumes the shape of fissure simply
m account of the conformation of the parts, the overlying membranes
yeing corrugated or compressed into folds by the contraction of the
sphincter. It does not long remain confined to the sulci, but rapidly
extends toward the cutaneous margin and upward upon the radial folds,
iometimes crossing over from one sulcus to another, entirely destroying
the muco-cutaneous covering.

The ulcers may be single or multiple. In the latter case they soon
coalesce to form one ulcer which mav entirelv surround the canal. Thev
ire distinguished by their clear-cut though irregular borders, their
jrayish-yellow bases, with here and there round tubercles in the granu-
lar mass, and bv the little foci of disease that extend into the subcu-
taneous tissues like worm-holes in wood, and sometimes result in sub-
tegumentar}' fistulas (Plate II, Fig. 1).

The absence of pain in any marked degree is the most characteristic
feature of the intra-anal tubercular ulceration. All other forms mav,
under certain circumstances, produce acute, lasting pain, resembling
rue irritable ulcer, but with the tubercular ulceration this almost never
xjcurs. It is true that tuberculosis may be ingrafted upon an irritable
ilcer, and we mav have the two conditions combined in the same
mus, but under such circumstances one will have the history of lively
)ains and spasm of the sphincter having existed for a period entirely

00 long for the tubercular ulceration to have remained so limited in
extent. Had the lesion been tubercular at the beginning there would
lave been greater destruction of tissue than is seen in such mixed cases.
Chancres, mucous patches, and rodent ulcers of the anus are all much
nore painful than the tubercular variety. The explanation of this fact
nay lie in the relaxation of the muscles, or it may be due to the fact
hat lx?neath and around the tubercular ulceration there is alwavs formed

1 connective-tissue envelope or wall which is not thick, but which pro-

198 TUE ANUS, RECTUM, AND PELVIC COLON

tec'ts the deeper tissues from infection bv the pathogenic process and
thus avoids the involvement of the sensitive nerve roots in a proc«»of
perineuritis associate<l with muscular ctmtraction. Involvenient of the
luntrs and other or^rans is much more frequent in tuberculosis of tlw
anal canal than in that of the perianal re^rion. The higher the inYolT^
ment of the intestinal canal^ the greater is the probability of general
tuberculosis.

Patholotjical Anatomy. — The pathological examination of these
ulcers shows always upon the cutaneous border degeneration of the
corneous layer of the epithelium. There is hypertroj)hy of the papillirr
layer and great infiltration of the chorion, which dijw well down into the
deej)er layers of the derma. The granular stratum is depressed by the
inlla minatory processes. The Malpighian bodies are sometimes hyper-
tr()]»hied or swollen, sometimes absent. The blood-vessels present evi-
dences of tuberculosis in the thicktMied and fibrous condition of their
walls. The ])apilla\ hyjUTtrophied an<l infiltrated, compose the fleshy
granulations, and by their conglomeration pn)duce the caseous follicle?.
Tlu»se fleshy granulations apiu'ar rough and elevated in spots, but do
not have deep sulci dipjjing down lM»tween them, as in condylomata. A*
Ilartmann savs: "In these masses there exists a numlx»r of caseou:^
tracts which start out, in general, perpendicularly to the surface of the
ulct'ration. Th(»se tracts, which oj)en probably by small mouths upon
th(» surface, are lined with epithelial c(*lls, and rt»sult from the fusion
of a large number of tulxTculous follicles, as is pnn'cd by a certain num-
ber of isolated follicles." My examinations have not demonstrated theM
facts, hut wc must acci»pt the reports of such careful work as has been
done hy the authors (jUot«Ml (Chir. d. rect., vol. i, p. 124).

The most important elenu^nt in these pathoh)gical examinations.
however, is the cicatricial or fibrous layer which develops in the deepest
tissues down below these tracts and outside of the area in which the
tubercles are found. This material not only involves the smooth and
striated muscular libers, but also the blood-vessels and the nen'es; the
latter are iuiluded in sbenths of embryonic cells and a sclerotic tissue
siinihir to tiiat developed in the muscle. In this portion of the ulcera-
tion we have to deal with a purely intlammatory process w'.ich forms a
sort of wall around the tuluTcular focus, thus obstnicting the invasion
of the surrounding healthv tissues bv the tulnTcle bacilli.

The rationale of this is shown in the fact that where a cicatrix e.\i«ts,
till* disease does not progress bi»yond it. Cicatricial tissue is an absolute
barrier f o the extension of tubercular processes. A tulnTCular ulcer may
involve the whole circumference of ibe anus and never dip deeper down
than the derma. iM-cause this wall of connective tissue is formed at its
base. Quenu relates a case in which the ulceration develojXMl near the

a. LUPOID ULCER

a. SUPERFICIAL TUBERCULAR ULCERATIONJ

ANAL TUBERCULOSIS

TUBERCULOSIS OP THE ANUS, RECTUM, AND PELVIC COLON 199

site of an old fistulous tract, and states as a very interesting experi-
ence that the ulceration never crossed or broke down the cicatrix left by
the old operation. His experience is by no means unique. It is easily
explained by the facts that cicatricial tissue is almost devoid of blood-
vessels, and is absolutely free from lymphatics, and the progress of the
tubercle is always along one of these lines. This is the most important
discovery with regard to tubercular ulcers in recent years, second only
to that of the bacillus, and it forms the basis of all local treatment.

Fatty degeneration of these ulcers is a very rare occurrence. In-
volvement of the lymphatic glands occurs, if at all, early in the process.
Pulmonary or genito-urinary tuberculosis may develop from the disease
in the anus, but usually they precede the latter.

Treatment. — In the large majority of cases the local lesion is a
minor consideration compared to the probable constitutional involve-
ment. The healing of the sore depends upon the power of resistance
in the tissues, and the better the physical condition of the patient the
greater will be this power. All treatment, therefore, which depresses the
vital forces, which decreases the tone of the tissues in general, or which
interferes with the free and full oxidation of the blood will be detri-
mental in the management of these cases. Thus, extensive operations
which confine the patient to bed or even to the house are unadvisable.
Prolonged local treatment, which requires the patient to remain in
large centers of population, or to be confined in hospital wards, is not
likely to prove successful. Change of climate, outdoor exercise, forced
feeding with fats and hydrocarbons, together with massage and oil in-
unctions, will do more for these conditions than local treatment or sur-
gical of>erations ; at the same time the latter need not be neglected.

The parts should be kept clean by bathing with peroxide of hydro-
gen, solutions of bichloride of mercury, or other antiseptics. If the
ulceration is extensive, a gauze dressing moistened with one of these
solutions should l)e kept applied. Painting the ulcer with a solution of
methylene blue, 10 grains to the ounce, seems to have a good effect, and
can be carried out by the patient himself. As a rule, powders seem to
make these ulcers worse, but recently some very good results have fol-
lowed the application of orthoform. In one case a large tulx»rcular
ulcer, involving almost the entire anus and dipping well into tlie
ischio-rectal fossa and the perineal triangles, has almost completely
healed under the combined use of this drug and the met hy lone-blue
applications. The same ulcer grew steadily worse during treatment by
the actual cautery and many other methods ordinarily advised.

Kecently the Roentgen rays have been recommended for these cases,
but nothing definite is known as to the results of this treatm(?nt. The
occasional application of the actual cautery, together with the local

200 THE ANUS, RECTUM, AND PELVIC COLON

and hygienic measures indicated above, appt»ar to be the most rehable
methods. The cases treated by orthoform and methylene blue, up to
the pn^sent writing, are too few to justify one in recommending the
method unreservedly; it appears, however, to be worthy of further trial.

Lupoid Ulceration of the Anus. — For a hmg time it was believed that
lupus was a specific variety of ulcer. Kecent studies in patholog}', how-
ever, have shown it to lx» onlv one of the manv manifestations of tuber-
culosis. It is of a particularly aggravated form, slow in its march, yet
fearfullv destructive of tissues.

Under the title Estliioniene and Lupus Exedens this condition has
been described with great detail by R. W. Taylor (New York Medi-
cal Journal, Januarv 4, 18JM)). His conclusions at that time were that
the condition is a sy])hilitic manifestation. This view, however, has
been abandoned, and we now come to recognize in lupus only another
form of tuberculosis. Those who formerlv held that the condition was
syphilitic advance the theory that the peculiar course of the ulceration
was due to inoculation of tubercular or scrofulous individuals with
syphilis. Were the ulceration of a syphilitic nature, as has been held
by these writers, constitutional treatment would have modified its course,
checked its advances, and prevented its recurrence, but such is not the
case. Upon these ulcerations syphilitic medication has no effect what-
ever.

The condition is characterized by progressive ulcerative destruction.
Ordinarily it b(»gins at the muco-cutaneous margin either of the anus or
the vulva. The outline of the ulcer is irregular, clear-cut, and indurated.
One sees at tiiues a slight tendency to cicatrize at certain points, but
after a short time these cicatrizations break down, reulcerate, and spread
farther in the tissues. Taylor does not state what was the final result
in the cases which he saw, but of the 5 cases reported by Allingham,
3 certainly, and probably 5, finally succumbed to tuberculosis. Be-
neath the ulcers there is always the develojmient of fibrous infiltra-
tion identical with that which we have described beneath the sim-
ple tubercular ulceration, and through which the destruction of tissue
does not break until very late in the disease. Upon this point Kelsey
says, in recounting an interesting case upon w^hich he operated and
tried to remove the ulcerated conditicm by scraping and cauteriza-
tion: " I was surprised to find it impossible to reach healthy tissue below
the ulcer without removal of an immense mass of inflammatory thick-
ening. There seemed to be no healthy connective tissue near the sores,
but sim])ly a brawnv, honeycombed condition, resembling, after scraping,
a mass of hard cheese, with a network of connective-tissue fibers nin-
ning through it.''

The spaces between these fibers were undoubtedly due to fatty de-

TUBERCULOSIS OF THE ANUS, RECTUM, AND PELVIC COLON 201

generation of the muscular fibers and tubercular invasion of the lym-
phatics and cellular tissue. In this same case specific treatment was
carried to its full extent, but without effect, and the patient finally died
from exhaustion. The extent to which this form of ulceration may
proceed is exemplified in the following case reported by Angus Mc-
Donald (Edinburgh Medical Journal, 1884, p. 910):

Quoting Duncan's description of the case, he says :

" * A case to which I was called some years ago is, so far as I know,
so unprecedented in the amount of destruction as to be worth describ-
ing. I only saw it once in consultation. The disease was at one time
regarded as cancerous. The patient, aged about forty, had had the
disease for at least five vears, and she lived manv years after mv visit.
While the disease was already extensive she bore a child. On the hips,
just l)eyond the ischial tuberosities, were long scars, thin and bluish, of
healed ulcers. The entire ano-perineal region was gone, there being
a hollow space as big as a fcetal head. The urethra was entire, as well
as the mucous membrane between it and the cervix uteri, which was
healthy. Except the anterior portion of the vagina, no trace of it, or of
the anus or rectum, was discoverable; behind the cervix uteri the bowel
oi)ened by a tight aperture, just sutiicient to admit a finger; when the
fa?ces were hard she could keep herself clean, but only then. Although
the extent of ulceration was severe the patient was attending to her
household duties.' To this graphic descri})tion of the case I can fully
subscribe, with this addition, that latterly the ulceration went still
higher up into the pelvis, leaving the bowel hanging loose for some
distance from the upper level of ulceration, giving it the appearance of
the torn sleeve of a coat. This patient lived two and a half years
after the time referred to by Dr. Duncan, and died of exhaustion and
diarrhiea, Notwithstanding this shocking amount and prolonged con-
tinuance of ulcerative action, there was no involvement of inguinal
or other glands.''

Allingham, Ball, and others have seen cases similar to this, but less
extensive. Bender (Vierteljahr. f. Derm. u. Syph., Wien, 1888, p. 891)
describes one in which a large portion of the rectum was involved. Ordi-
narily, however, the ulceration is limited to the cutaneous and muco-
cutaneous tissues.

Generally the ulcer begins in one or more little circular or semi-
circular infiltrations in the skin or muco-cutaneous tissue about the
anus. These break down, ulcerate, and, spreading at their borders,
the little foci coalesce and form larger ulcers. The edges are sharp-
cut and not so much undermined as in simple tubercular ulcerations.
In one respect it seems to differ entirely from these, in that it *
tendency to heal temporarily and produce cicatrization in cert

202 TUE ANUS, RECTUM, AND PELVIC COLON

but this only lasts for brief periods, when it breaks down again, and the
destruction of tissue advances beyond the original limitations. Some-
times the ulcerations may take on a serpiginous form, advancing in
two or more narrow tracts. After a time the intervening tissue be-
tween these tracts gradually breaks down, and the whole area becomes
a part of the original ulceration. The edges of these ulcers are never
thickened or indurated to any great extent. The granulations are
genenilly pale, although occasionally they may be bright red and ex-
uberant. Bender describes them as a reddish-brown, and sometimes of
an efflorescent type. The base of the ulcer itself is soft, but the under-
lying inflammatory deposit gives to it a stiff, inelastic feel upon firm
pressure.

The pathological examinations of these cases made by Besnier and
Schuchardt place the tuberculous nature of the ulcers beyond doubt.

In one case seen in the city almshouse, a man, aged seventy-four,
had sutTered from ulceration about his rectum for a number of vears.
It never gave him any particular pain, and only required the wearing
of a cloth to protect his clothing. When seen by the writer it had be-
come somewhat diHicuIt to move his bowels or to walk. Examination
showed a vast ulcerated area involving the entire circumference of the
anus, and extending as high up as the upjK?r border of the external
sphincter. The skin for 2 inches around the entire anus was destroyed,
and the ulceration dipped down into the cellular tissues posteriorly and
at the sides of the rectum to a depth of i an inch or more. The mar-
gins of the ulceration were not indurated but slightly undermined.
There were at points in its circumference evidences of attempts at
cicatrization, but there was no contraction or apparent diminution in
the size of the ulcers from these efforts at healing. The granulations
were not exuberant or efiloroscent at any point, but were more of a
grayish-brown, proud-flesh nature. Beneath these granulations there
was a hard resisting base which extended outside the margin of the
ulceration and upward until it joined the wall of the gut. At the upper
margin of the ulceration the mucous membrane of the rectum, clear-cut,
infiltrated, and somewhat elevated, seemed absolutely to limit the in-
vasion of the disease, and was perfectly healthy at a distance of one or
two lines above.

The patient had pulmonary tuberculosis at the time, and was taken
from the hospital shortly afterward to a home in the country, where,
it was since learned, he died from the disease.

The area of ulceration from side to side measured 5^ inches, from
before backward 2J inches, and the de])th from the margin of the anus
upward behind the rectum was about ^ an inch.

There appears to be quite a difference of opinion between Ailing-

TUBERCULOSIS OP THE ANUS, RECTUM, AND PELVIC COLON 203

ham and other observers concerning the clinical appearance of lupoid
ulceration, its location, and the nature of its invasion. The former holds
that it occurs in the rectum, and its tendency is to attack the mucous
membrane rather than the skin; that it does not invade the neighbor-
ing tissues by infiltration or through the lymphatics, forms no sec-
ondary deposits, produces no hardness, and does not affect the follicles.
He states that the diagnosis can be positively made on sight.

Others (Ball, Cripps, Kelsey, Gant, Taylor, and Qu6nu) state that
it is generally found in connection with the disease in the female geni-
tals, and is largely confined to the skin and muco-cutaneous membrane ;
that there is induration about the base and edges; that microscopic
examination establishing the presence of tubercle bacilli or giant cells
is necessary to distinguish it from epithelioma and syphilitic ulceration,
and that it does extend along the lymphatics.

All agree that it is essentially a destructive lesion and of a tubercular
nature, with clean-cut, irregular, rarely symmetrical edges that may or
may not be undermined.

The writer has observed two cases almost from their incipiency.
Both were in males, and began in the skin at the anal margin. One
developed around the cicatrix of an old fistula, as in the cases of Schuch-
ardt and Besnier, and the other in a skin-tab just below a fissure.
Both started as little nodules or indurated masses in the skin. These
seemed to have no relation to the hair follicles, but in one case appeared
like obstructed sebaceous glands. The nodules in each case broke down,
discharged a sort of cheesy pus, and left round, clear-cut ulcers. These
soon coalesced and formed one large ulcer, which slowly but steadily
extended around the anus and into the anal canal. In one case the
process involved the mucous membrane to the height of ^ an inch, in
the other it stopped abruptly at the ano-rectal line. In the fistula case
the cicatrix seemed to limit its extent in one directicm, so that only
half of the circumference of the anus was involved. In the other the
disease spread all round the aperture (Plate II, Fig. 2). In both cases
there soon developed a fibrous or cicatricial deposit beneath the ulcera-
tion, which extended almost to the healthv skin outside of it. This
mass was penetrated here and there by small, soft spots due to fatty
degeneration of the muscular fibers.

The ulcerations were irregular in shape, with well-defined, indu-
rated borders slightly undermined. The bases were brownish-gray, de-
pressed, and covered with scant, purulent secretion. There was prac-
tically no pain in either case.

Histological examination of the scrapings showed tuberd*^ ^ """'
present in both cases. The extension seemed uniform and
lines of any vessels or lymphatics. Time and again in b

204 TUB ANUS, RECTUM, AND PELVIC COLON

parts appeared to be healing and tlien broke down again, leanng the
ukrer deeper and more extensive than before. In neither case were
bright-red or elllorescent granulations, as described b}' Bender, seen
except in very small spots. The ulcers did not bleed easily on touch.

Treatment, — The usual treatment of this condition consists in the
application of chemical or actual cauterization. Nitric acid, chloride of
zinc, acid nitrate of mercury, etc., have been advised, as have also the
Pacjuelin and galvano-cautery. Where there is pain this will be some-
what relieved for a time by such applications, but the benefit is only
temporary. According to Piffard, the application of strong solutions
of ])eroxide of hydrogen used every few days seems to be more effectual
in the (h^struciion of the tubercle bacilli and the development of healthy
granulations than any of the other chemical agents. It may be well
in the beginning of the treatment to cauterize the parts thoroughly
bv the Pa(|iU'lin cauterv, but one must alwavs remember that the con-
stituti(mal conditicm of the patient suffering from this fonn of disease
is not such as to justify any great shock or destruction of tissue, and
that th(» lack of vitality in the parts may cause such a burn to result
in extensive slough, and thus do more harm than good. WTiile actual
cauterization is sui)erior to chemical, or excision, or curetting in these
C(mditions, the author can not hut sound a note of warning in view of
the experience which he saw some three years ago in the New York
workhouse.

A young man having an extensive lupoid ulceration about the mar-
gin of the anus, which the attending surgeon looked upon as chancroidal,
was etherized and the ulceration excised, the base being thoroughly
burned with a l*aquelin cautery. The patient suffered extremely from
shock. There was great sloughing of the tissues, so much indeed that
the whole external sphincter and lower inch of the rectum for one-half
of its circumference were destroyed. The patient suffered from incon-
tinence, and within a few weeks developed acute tuberculosis, from
which he died in about five months. The examination of the specimen
showed ty])ical characteristics of tubercular ulceration. Conservatism,
therefore, is of the greatest importance in the treatment of these ulcers.

Methylene blue, 2 per cent in water, has held the disease in check
better than nnv other remedy in my hands, but nothing has cured it.
Electrolysis and the X ray have been recommended, and recent reports
seem to confirm its usefulness; tuberculin has been tried, but in. vain.

Curettage, followed by the actual cautery, together with general con-
stitutional treatment l)y tonics, cod-liver oil, creosote, and forced feed-
ing, appears to give the most unifonn results.

Verrucous Ulcerations of the Anus. — A very rare variety of ulcera-
tion of the anus has been described under the above name. The fiist

TUBERCULOSIS OP THE ANUS, RECTUM, AND PELVIC COLON 205

Mscs reported were by Toupet and Boutier (Congres pour T^tude de la
kuberculose, 1893, p. 509) in 1893, At the same congress M. Hart-
Eoann reported two cases of this condition (ibid., p. 59). It reseni-
l>les epitheliomatous or papillomatous ulcerations of the margin of the
mus. Judging from the descriptions given by these authors, it would
ippear to be of the nature of tuberculosis varicosis acutis or luj)us
papillaris varicosis, as described in the works upon dermatology. In a
»se communicated by M. Duplaix the appearances of the ulcers are
iescribed as follows:

" Scattered around the anus in places there are small vegetations
slightly jutting out above the healthy skin which surrounds them. In
places the skin, slightly ulcerated, shows small columns separated one
from another, agglomerated and adherent at their bases, but free at
their other end. There is a mixture of small mammillations and of the
villous points. The lesion extends into the anal canal and prolongs
itself 4 or 5 centimeters into the rectum, where one with the finger is
able to feel numerous anfractuosities sej)arated by the healthy mucous
membrane. The whole rests upon an indurated base, and gives an
abundant purulent secretion, sometimes mixed with a little blood."
(Quenu and Hartmann, p. 105.) Hartmann states that in one case
which he observed, the ulceration was in the neighborhood of a cold ab-
scess of the margin of the anus, and had the appearance of a papilloma.
The chief characteristic of these ulcers is their papillary or manimillated
appearance. They may be confined to the cutaneous tissue, or th(\v
may penetrate the anal canal and rectum, as in the cases of Hartmann
and Duplaix. The villous formation sometimes becomes crusted over,
thus forming a dry scab, which in a short time comes away, leaving a
raw, papillomatous surface, the papillte being separated by small bloody
fissures. The base of the ulcer is indurated, but this induration does not
extend into the surrounding tissues. The lymphatic glands are enlarged.

The tubercular nature of the ulcers has been verified bv inoculation

of rabbits and histological examination. In all the cases in which seg-
ments of the ulceration were examined, there were found in the super-
ficial part of the skin and in the papillary prolongations of the chorion
tracts of embrj'onic cells containing giant-cells and tubercle bacilli. In
one case Hartmann found veritable tuberculous follicles with the three
tj-pical zones composed of giant, epithelioid, and embryonic cells. In
one case there was a fistulous tract which extended 6 centimeters under-
neath the skin and mucous membrane.

The patients did not complain of much pain except in two in-
stances. In cases in which the ulceration invaded the rectum there was
a diarrhoea accompanied by slight pain at the time of defecation. In
one instance there was faecal incontinence. The ulceration appears in-

206 THE ANUS, RECTUM, AND PELVIC COLON

sidiously; the patient notices only a slight roughness at first, then a
swelling and tenderness of the parts, and finally a discharge of either
pus or blood. In all the cases so far rei>orted there have been evidenws
of pulmonary tuberculosis.

Treatment. — The nature of the ulceration being undoubtedly tuber-
culous, the treatment should l)e based uj)on the same principles as those
laid dowTi for the treatment of simple tuberculous ulceration of the
anus and rectum.

TUBERCULOSIS OF THE RECTUM AND SIGMOID

Primary tuberculosis of the lower portion of the intestinal tract
is exceedingly rare. There are a few instances in which the disease
has been found in tlie recta of children, but in adults it is almost un-
known. As secondary to the disease in other organs, however, it is
comparatively frcijuent.

An exjunination of 75 cases of tul)erculosis in all stages at the Alms-
house Hosi)ital showed ulceration of the rectum and sigmoid in 22—
i. e., 21). 3 per cent. This large percentage is due to the fact that many
of the cases were selected for examinati<m on account of having had
some intestinal disturbances. The statistics of Louis, Lehbert an4
Bayle, Willigk and Kisenhart state that lesi<ms of the intestine occurred
in 4J) to 80 per cent of their tubercular patients. The ileum and ca?cum
an* the most frequent sites owing to tlu» preponderance of solitary folli-
cles at these points. Fcnwick in 500 autopsies found tubercular ulcera-
tion of the rectum and sigmoid in 14.1 per cent and 13.5 per cent
respectively. No case is n^ported, however, in which these were pres-
ent without involvement of the lungs and other organs. We have seen
two instances which aj)pearfd to be primary tuberculosis of the rec-
tum. They were both small, round, or elliptical ulcers with ragged,
undermined edges, gray, conical bases, and not indurated. A few tu-
bercle bacilli were found in the scrapings, but no giant-cells. In one
case the })atient subsetiuently develoj)ed pulmonary tuberculosis, the
other apparently recovered. It is possible, of course, that the bacilli
may have come down through the intestinal canal, lodged in the ulcer,
and may not have been its cause. The facts and symptoms, however, do
not warrant anv such conclusion.

Infection of the intestinal walls occurs through the invasion of the
lymphoid or solitary follicles by tubercle bacilli. These may enter the
canal through the ingesticm of food, and there is no reason why they
may not pass down and infect the sigmoid and rectum. Abrasion or
injury is not necessary for the invasion by the bacillus, but no doubt
contributes to it.

TDBEBCUliOSlS OP THE ANUS, RECTUM, AND PELVIC COLON 207

SecoBdarj' tuberculosis of the rectum occasionally occurs as miliary
leposits beneath the mucous membrane, and frequently as ulcerations.
iThe milian' type is generally secondary to tuberculosis of the genito-
Ivrinary organs, espe-
Bdally of the prostate.
3 two of the cases ob-
I «ervetl, the condition
developed after the re-
moval of prostates
which were proved be-
yond all doubt to be
tuberculous, and in all
cases there were symp-
toms indicating tuber-

1 . * .1 -.1 nUr Vfl'. — 1 I'DKKi'l'LAK UL<:EKATI'pn INF THE tlECTI'M WITH

culosis of the gemt&t SiHuioiis Fietila

tract. It is always, so

far as our experience shows, located in the anterior rectal wall. It
consists in little miliary deposits which feel like btrd-shot beneath the
mucous membrane. These may remain stationary for a long time, or
they may break down and form small cu]i-like ulcers. The latter some-
times coalesce and form larger ulcerations, or they may burrow and
connect witli each other underneath the mucous membrane, thus forra-

; small submucous fistulas (Fig. i)0).
In one case it was possible to scrape out one of these little miliary
It was a round, cheesy mass, quite firm ; and under the
nicroscope it showed numerous round cells undergoing cheesy degcnera-
I, with here and there a tubercle bacillus. No giant-cells were found
I this specimen, but their absence is not unusual in such tubercles.
The little ulcer from which this tubercle was removed healed perfectly
after cauterization with carbolic acid. This condition has not been
seen by the writer above the
rectum, and it is not reported
in any of the statistics to
which reference has been made.
Tubercular ulceration of the
rectum and pelvic colon sec-
ondary to tuberculosis of the
respiratory organs is not un-
common. It is rare to find it
. in these portions without its involving the ileum, Cfccura, and other por-
s of the colon, but in 2 cases in which the patients died from pul-
bonary hiemorrhage the ulcerations did not extend above the sigmoid.
Histological examinations show that the disease begins in the soli-

o. 91— Triksvimb Sim'^x i.f Ti

t^lCU or Till BlCTUU, SIIIIWINO
CxtmS AHD L'NDEIUItStll ElWKB.

SOS

THE ANUS, RECTUM, AND PELVIC COLON

tarj follicles. The lining cells of these increase, their nuclei multiply^
giant-cells are developed, the whole undergoes a caseous degeneration,
the overlying epithelium becomes necrosed, and an ulcer is formed. A
transverse section of one oJ
those ulcers (Fig. 91) shows a
central elevation, which grad-
ually declines to the periphery
beneath the mucous membrane,
thus causing an underniininf
of the latter. In the elevated
portion of the base small yel-
low tubercles may sometimes
be seen with a low-power mag-
nify ing-glaas, or even with the
eye.

The ulcers are originally
round or elliptical in shape,
but they spread by degenera-
tion of the borders, or coalesce
with one another until they
form large, irregular patchea.
(Figs. 92, 93). The ulcers fol-.
low chiefly the course of the
blood-vessels ; hence, in the ;
lower portion of the rectum,
they spread in all directions, in ■
the upper portion horizontally,
and in the sigmoid their ten- '
dcncy is to encircle the canal<
(Fig. 94). In this and in the ,
colon, where the ulceration has'
extended arouml the gut and
thus followed the blood-vessela ■
and lymphatics to their end,
the process may he arrested,
the parts cicatrize, and a true
_ stricture be formed. This '

Siouoiu pathology may be criticized,

but the section of a stricture
having tubercular characteristics under the microscope, and with tuber-
cular ulcers above and below it, is presented in Fig. 95. I
Beneath nil tubercular ulcers there is a deposit of fibrous material, i
whether they occur in the intestinal canal or outside of it, which has |;

Tl'BERCULOSIS OF THE AKUS. RECTUM, AXD PELVIC COLON 209

Q described as an effort on the part of Nature

the bacilli (Fig. yti). She builds, as it wore, j

Ition, and so long as it remains intact the dis-

will be limited to that spot. Green and

iKartin have called attention to this, eaying it

lexplains why perforations 80 seldom take place

a tahercular ulceration of the intestinal tract,

Si/mptnvis. — The s^-niptoms of tuberculosis

of the roctum and pelvic colon will depend

uiKin the site and extent of the disease. Where

It is localized they will be those of chronic

■nflanimation of'the organs — viz., pain in the

back, diarrhcca, or frequent desire to defecate

without relief, discharges of pus, blood, and

mucus, and disturbances of digestion.

The discharges are never so abundant as

in syphilitic ulceration, but the odor is more

gangrc-nous- The blood is never abundant;

^«onieliuies it is fresh, and at others tar-like,

idicating that it has been retained for a

tile, and ordinarily it is mixed with the

to defend tissues against
1 wall around t!ie infec-

Asliby savs that fatal haemorrhages may

■or from these ulcers, but the statement is

t eorniboraled by other observers.

There is no acute pain at the site of the

kenition, and only very rarely is there any

iening of the caliber of the gut to cause

ftruetiun to the fa'cal passages in the rec-

, but this may occur in the sigmoid.

To the finger the ulcers give the impres-

iOD of a soft, granulating mass on a firm base,

surrounded by irregular, slightly thick-

i edges. Through the speculum they ap-

■ as irregular ulcerations with slightly

levated, gray, sloping bases, surrounded by

Ightlv thickened and undermined edges

:■ 97)-

In the last stages of general tuberculosis,
re the whole intestinal tract from the
im down is involved, the patient will suffer
I tenesmue, diarrha?a, tympanites, diges-

i; disturbances, and great emaciation. The

^'T^- {

FlO. P5. — TtrBBttClTLAK StWO.

210

THE ANUS, RECTUM, AND PELVIC COLON

frequency of the stools is diBtressing, and the discharges of pus ind
black, tar-like blood are more abundant.

Examination with the finger in such cases does not reveal much, it
the whole rectum is bathed in a slimy muco-pus wLitL obscures evm-

FtO. Wi;.— PlInTllWirB'HlKAPH IT TvBBBfll-AB TtCirt OF TMl KxOTVM.

thing. After the secretion is wiped away, one may see through tl»
speculum large areas denuded of mucous membrane with little islets of
healthy tissue here and there. At other times there appear linear ulcer-
ations branching like the limbs of a tree from a central point, and
forming little ulcerated crevices, apparently following the lines of tbt
arterial supply. The mucous membrane between these tracts is swoHeB^
red, and undermined. It soon breaks down, and the whole is converted
into one large ulcer, such as has just been described. This extreme e
dilion iatfniy seen in late stages when dissolution is imminent.

Diai/nosis. — Diagnosis of initial tuberculosis of tht^, rectum ie TOT
difficult. The nature of the ulcer, as described above, its tendeiii^
to follow the course of the lymphatics and blood-vessels, the dead, gr>f>
tsh elevated base and undermined edges, are all indicative of the n
of the ilisease. The discovery of tulwrcle bacilli in the dischargee o
scrapinp from the ulcer would, a
course, settle its pathologj* to a cep-
tain degree, but one must always
bear in mind that tubercle bacilli
may be passed through the intes-
tinal tract, and that they might be
founf.1 in the pus of an ulcer, whicli'
ulcer itself was not tubercular. .
more positive and certain diagnos
could be determined by excising the*
Fp". v;.-TiMEii.'(HR Lr.rii. WITH sviii jj^gg ^q^ examining this for giant*'
Edo™'^^" "^ '^^^'^ """^ tubercle bacilli. The cul-

ture test is our final resort, but thi»
is generally impractical. The clinical features of the case, however, a
fairly reliable. In those cases associated with general or putmonsiT^
tuberculosis the histori- of the case, the general physiognomy of the pft-
tientj the character of the ulcers running parallel with the blood a

^ k

TUBERCULOSIS OP THE ANUS, RBCTUM, AND PELVIC COLON 211

lymphatic supply of the rectum, the great loss of fat, and the sunken-in
condition of the anal margin, together with the appearances of tubercle
bacilli in the discharges from the rectum, will serve to confirm a diag-
nosis wliich is always inferred when symptoms of diarrhoea, indigestion,
and intestinal disturbances occur in the tuberculous.

Treatment. — The treatment of tuberculosis of the rectum and pelvic
colon is not encouraging. In a few localized conditions in the rectum
the ulcers may be scraped out, cauterized, and healed under the best
hygienic conditions, but these cases are ver}- rare. In the large majority
general tuberculosis of the respiratory or genito-urinary system will have
been established before any notice is taken of the intestinal complication.
All that can be done in such cases is to keep the parts clean by colon
flusliing with antiseptic solutions, and protect thiMn fn.m irritation as
far as possible by a bland but nourishing diet.

The hygienic and therapeutic measures suggested in the section on
anal tuberculosis are applicable here, but the j)rognosis is not so favor-
able. It is simply a question of general tuberculosis, the cure for which
has not vet been found.

Hyperplastic Tuberculosis. — Under this title, suggested by Coguet
(These, Paris, 1894), has been described a peculiar condition of tuber-
cular infiltration of the intestinal walls. It occurred most frequently
in the ileo-ca»cal region, but was found in other portions of the large
intestine, particularly the rectum. Delbet and Mouchot (Archiv. gen. de
med., 1893, pp. 513, 668) referred to it under the title of rectitis hyper-
troi)hique, proliferante et stenosante. It is characterized by extensive
formation of fibrous and tuberculous granulation tissue in the wall of
the gut. It induces a sort of fibrous hyperplasia instead of caseation
and necrosis. In the large intestine it resembles scirrhous cancer very
much, and even Billroth once removed a section of the gut affected by
this disease imder the impression that it was carcinoma (Wien. med.
Presse, 1891, p. 193).

Ijartigau (The Journal of Experimental Medicine, vol. vi, p. 41) says:
" For years hyperplastic tuberculosis of the rectum has been confused
with syphilis of this viscus." The pathological nature of this condition
in the rectum was first pointed out by Sourdille (Archiv. gen. de med.,
1895, vol. i, pp. 531 and 697; vol. ii, p. 44).

The walls of the rectum are greatly thickened, stiff, and indurated.
Thev form a cvlindrical tube which does not collapse a^ does the normal
rectum. The mucous membrane is frequently ulcerated, but not always
so. The chief seat of infiltration by round cells and fibrous tissue, in
which tubercle bacilli are abundant, is in the submucosa and circular mus-
cular layers. Scattered over the mucous membrane an* papillomatous
outgrowths continuous with the submucosa. The solitary follicles are

212 THE ANUS, RECTUM, AND PELVIC COLON

swollen and inflamtnl. Outside of the muscular layer of the gut is i
fibrous layer in which the blood-vessels present evidences of peri-end-
arteritis and endarteritis. The serous coat mav Ix* thickened or not:
in some cases it is markedly so (Hartmann and Pelliet). The whiJe
presents a combination of tuberculous and simjde inflammatory lo?ioL\
Ijjirtigau claims that it is a purely local, if not primary, tubercul«
as the lungs and other organs are rarely involved.

The diagnosis of this condition is exceedingly dillicult. Its treat-
ment is said to be ])urcly surgical. The writer, however, exceedingly
doubts the j)n)])riety of operative interference in such a chronic, slowly
progressive, tubercular condition. In the writer's opinion, local inter-
ference in such cases, just as in chronic tubercular fistula, would likely
excite a new activity in the disease and do more harm than good. In
all probal)ility constitutional treatment, fresh air, and good foo<l, to-
gether with such local treatuient as is indicated for the ])reveution of
secondary infection in the ulcers, would give better results.

CHAPTER VII
VEyEREAL DISEASES OF THE ANUS AND RECTUM

Vexereal diseases of the anus and rectum are comparatively rare
in the United States. The enlarged foreign population has increased
the practis^e of sodomy and pederasty, and every now and then one
mec»ts a case of primary venereal disease in these organs. The chief
varieties are gonorrhoea, chancroids, herpes, and syphilis.

Gonorrli(Bal Proctitis. — This disease is not so rare at present as in
the days of Bumstead, Van Buren, and Otis, who stated that they had
never met with a case. Its symptoms are so nearly like tliose of simple
acute catarrhal proctitis that until the discovery of the specific germ
by Xeisser one could not positively say whether a given inflammation
was of a simple or specific nature, and its existence was therefore a
disputeil point for many years. In 1874 Bonniere made some interest-
ing experiments with regard to the susceptibility of the mucous mem-
branes of the body to gonorrhoeal virus; in a patient with gonorrhceal
()[)hthalmia and urethritis the pus from the infected regions was
>nu'ared upon the mucous membrane of the nose and anus. The nose
showed no symptoms of the disease, but on the second day evidence
of infection was seen about the anus, and upon the fifth day purulent
gonorrhceal discharge from this part was noticed. He then injected
the pus into the rectum through a hollow tube, but with negative
H'sults. From the repetition of these experiments he concluded that
all the mucous membranes covered with pavement epithelium or sup-
plied with papilla? and a superficial subepithelial network of lymphatic
vesscds are susceptible to the gonorrhceal virus ; while those covered with
cylindrical epithelium and having a superficial subepithelial network
of veins are refractory.

Tyjucal blennorrhagia of the anus is not an uncommon affection,
esjX'cially in women, and it needs no argument or prolonged historical
account to prove its existence. In the rectum the disease is compara-
tively rare, at least it is rarely diagnosed. Goslin, Billroth, Rollet,
AUingham, Winslow, Bernard, and Tardieu, have all reported cases
of the disease, but these writers based their opinions upon subjective

213

214 THE ANUS, RECTUM. AND PELVIC COLON

and circumstantial evidence, the specific germ not having been discov-
ered at the time of their obsen-ations. Xeisser himself has observed
2 cases of rectal gonorrha»a in which the microscope showed gonococd
lx»vond the question of a doubt. Bumm (|Uotes a case obsen*ed br
Wolff with a distinct history of the practise of sodomy in which the
discharge contained numerous well-defined gonococci.

Matterstock reported a case from the practice of Frisch in great de-
tail; he not (mly examineil the discharge during life, but also sections
of the mucous membrane taken post mortem. The patient was a giri
seventeen years of age, a sodomist by practice, who suffered from pain
and burning in tlie rectum which was unbearable at defecation. These
8ym])toms came on about fifteen days after her last coitus per rectum.
The anus was funnel-shaped, reddened, and showed some loss of epithe-
lium. There was a ])erianal eczema, and the pus oozed out between the
swollen radial folds. This j)us contained numerous gonococci, some
free and others enclosed in the pus-eells. There were both cylindrical
and squamous epithelial cells floating about in the pus, and now and
then a pus-cell ap])eared which was literally stuffed full of gonococci
80 as to give the nucleus a crescentic shape.

The woman also had a discharge from the genitals, in which i
similar exhibition of gonococci was found. Through the speculum the
mucous membrane of the rectum appeared swollen, bright-red, and
bathed in pus. At a distance of about 4 centimeters (If inches) from
the anal margin there was a shallow erosion or ulceration of the mucous
membrane. This patient died from pulmonar}' disease before the gon-
orrh(i»al alFection was cured, notwithstanding the treatment had been
kept up for about six months. The nnicous membrane of the rectum
was excised j)()st mortem and the histological examination showed t
partial disapi)earance of the Lieberkiihn follicles, together with exfolia-
tion of cylindrical ej)ithelium : there was a typical proliferation of cells
and c(mnective-t issue infiltration of the borders of the ulcers and con-
siderable infiltration of the muscular walls of the rectum bv roimd cells
containing single nuclei. In the poh-nucleated round cells were
abundant goncMocci, which were also free in the superficial layers of
the mucosa. *' Their presence was limited to the parts covered with
cylindrical e])ithelium, while the infiltration of the round cells d^
scended to the margin of the (external sphincter" (Annales do dermat.,
Paris, 181)2. p. 3:30). These facts are practically confirmed by Hart-
mann and Quenu, who state that the limitation of the gonococci to
the superficial layers of the mucous membrane is accompianied by dif-
fuse inflammatory infiltration of the deeper tissues where the coed
are absent.

In 1892 the author reported (Jour. Cutan. Venereal Diseases) 3 ctsfli

VENEREAL DISEASES OP THE ANUS AND RECTUM 215

of gonococci of the rectum, in which the discharges, taken from 2J
inches above the anal margin, showed free gonococci, and pus and
epithelial cells crowded full of them. Since that time 3 other cases
have been observed, in 2 of which there was also blennorrhagia of the
anus at the same time. In these 6 cases in which the rectum has been
affected, the condition has not been as obstinate as that reported by Mat-
terstock, although the pathological examinations have exhibited prac-
tically the same changes. It is a question whether his case did not
have tuberculosis of the rectum complicating the gonorrhoea. As a
matter of fact urethral gonorrhoea is always very slow in healing in
tubercular patients, and the same may be the case in that of the
rectum. While, therefore, one may say that the rectal mucous mem-
brane is less susceptible to the gonorrhoeal poison than is that of the
urethra and anus, nevertheless it may be attacked. Especially is this
the case when there is constipation or any other cause which produces
slight traumatisms of the mucous membrane during the presence of the
gonococci in the rectum.

Etiology, — The cause of this disease is undoubtedly the direct
inoculation of the mucous membrane of the rectum or anus by the
gonorrhoeal virus. This occurs through extension of the disease from
the vulva to the anus and rectum, through careless handling of other
parts affected with the disease, and conse(iueut conveyance of specific
germs to the rectum, or by unnatural coitus, the active party being
affected with the disease. It has been claimed that it mav occur
through metastasis, but such an origin is unlikely.

Rollet (Diet, encyc. des sciences med.) has reported a case in which
infection occurred in a patient who suffered from an urethral discharge
and introduced his finger into the rectum in order to produce a move-
ment of the bowels. The finger was evidently infected with the dis-
charge and thus inoculated the mucous membrane of the rectum. In
Matterstock's case, and in 3 of the author's, the condition was brought
about by the practise of unnatural vice, and this is perhaps the most
frequent source in men. In women, however, gonorrhoea of the anus
is usually due to secondar}' inoculation from vaginal discharge^.

Symptoms. — The symptoms of the disea^^e are sensations of uneasi-
ness, itching, and heat about the anus, which may occur at any time
from twenty-four hours to five days after exposure. These rapidly
grow more distinct, the heat changes into a burning, the itching into
pain, defecation becomes onerous, and the patient suffers constantly
from dull, heavy aching in the sacral region. From the fifth to the
seventh day the patient will probably have constitutional distui-bances,
the pulse and temperature becoming elevated. There is frequent desire
to go to stool, followed by the passage of mucus and pus, and when

216 THE ANUS, RECTUM. AND PELVIC COLON

the fiveal passages occur thev are tingc»d with blood and accom-
panied by great pain. The discharge is at first thin and milky-white,
but hiter greenish or brownish-yellow and very abundant in quantity.
The appearance of the anus and rectum will depend upon the habits
of the ])atient and the parts involved. If he be a sodomist the anus
will appear infundibuliform, the sphincters will be relaxed, and there
will lx» a pouting or exstroi)hy of bright-rtnl (inlematous muc-ous mem-
brane about the orifice; the muco-cutaneous folds will be bathed in pus,
excoriated or ulcerated, and fissures formed. Ha^norrlioids are not
generally developed by this infiammatory i)rocess, and will not be pres-
ent unless thev existed before the infection.

Wlien the disease involves the rectum the mucous membrane be-
comes bright red, swollen, tense, and painful. It bleeds upon touch,
is batlied in a profuse secretion of nmco-pus which dribbles from the
anus, this orifice In'ing inij>erfectly closed on account of the swollen
folds. As tlie disease j>rogresses ])atches of excoriation or ulceration
occur. This ulceration is superficial, the edges are never undermined,
and the base is granulating.

C'tmdyloniata, fissure, and submucous fistula may complicate the
condition. The disease in the anus is self-limitetl, and if proper atten-
tion to hygiene and cleanliness is observed the patients will rapidly
recover in the majority of cases. Probably a very small proportion of
tliese cases are ever seen by physicians: the invalids being ashamed of
their practices, suffer from their ailments and treat themselves rather
than be exposed and degraded by the examinations and admissions
which medical treatment would entail. If the disease extends above
the internal spliincter it may persist for long periods and become
chronic. While no case of stricture from this cause has been reported,
it is not imreasonable to suj)jM)se that the same inflammator}" deiHwit
and cicatricial contraction which follows this disease in the urethra
may also be developed in the walls of the rectum.

f)in(jno.sis. — The diagnosis depends largely upon the presence of
grmococci in the discharges. The profuse and purulent nature of the
latter, the extreme irritati(m, and tlie coexistence of gonorrhoeal in-
flannnation in other organs, are all indicative of the nature of the
disease. '^I'he final test, however, is the finding of Neisser's coccus.
The si)cciniens for examination must be collected in a most careful
manner in order to eliminate any possibility that the pus comes from
the genital organs; the anus is wiped off as gently and thoroughly aft
possible witli absorl)ent cotton, then washed with an antiseptic solution
of boric acid or bichloride of mercury, and then a speculum, such as
the Kelly anoscope or the authors conical instrument, is introduced
with the patient lying upon the left side or in the knee-chest posture*

VENEREAL DISEASES OP THE ANUS AND RECTUM 217

The specimen should be taken with a platinum- wire loop from the wall
of the rectum and not from the discharge which flows down into the
speculum, lest by any chance some of the secretion from the anus should
have been carried upward on the end of the instrument. Several speci-
mens should be examined to corroborate one another. The methods
of staining and the typical appearance of these ^onococci are well
described in books upon bacteriology and genito-urinary diseases, and
need not be detailed here. Blake and Shuldham tell us that "when
gonorrhoea has reached the chronic stage we may fail to find the dip-
lococci or true gonococci, but encounter instead pseudo-gonococci,
staphylococci, streptococci, or tubercle bacilli." Therefore the nega-
tive diagnosis should not depend alone upon not finding these bacilli.
The history- of the case, the appearance of the anus, the relaxed
sphincters, the excessive discharge, the extreme pain on defecation, and
the fissures between the anal folds should all be considered in coming
to a final conclusion.

Prognosis. — The prognosis in these eases is favorable when the indi-
viduals are otherwise healthy. If, however, there be a tubercular di-
athesis or constitutional syphilis, manifestations of these diseases are
likely to develop during an attack of rectal gonorrhcea, either of which
renders the prognosis very serious and the course of the disease exceed-
ingly protracted. This was the condition in the case reported by Mat-
terstock, in which the disease lasted for over six months, showing little
tendency to heal. The patient died at the end of this period from
general tuberculosis. Why it should be so it is difficult to answer,
but the fact remains that acute inflammations of the rectum^ from
whatever cause, are very liable to become chronic and intractable, even
incurable, in cases affected with pulmonaiy tuberculosis. Therefore in
cases with such diatheses our prognosis should be very guarded.

Treatment . — In anal gonorrhoea the parts should be kept clean by
frequent sponging with antiseptic solutions, such as bichloride of mer-
curv, Thiersch's solution, or solutions of creolin. Nitrate of silver in
mild percentages, argonin, protargol, and permanganate of potash rap-
idly destroy the gonococci, and are therefore very useful; when the
disease has progressed to excoriation, or when ulceration has occurred,
these local applications should be repeated two or three times a day,
and the parts should be protected from rubbing against each other by
small pledgets of gauze or cotton soaked in antiseptics. As bOon as
the gonococci disappear from the discharges, it is well after cleansing
the parts thoroughly to apply some inert powder, such as stearate of
zinc, oxide of zinc and calomel, subiodide of bismuth or aristol, insuf-
flating it well between the mucous folds frequently enough to keep tlie
parts dr}'. If there are condylomata they may be clipped off, or better.

218 THE ANUS, RECTUM, AND PELVIC COLON

still cauterized with nionochloracetic acid, and kept dry with the powder
as before.

Wliere the ulceration is deep or sluggish, cauterization with nitrate
of silver should be used.

The bowels should lx» kept open, but it is not well to induce fre-
quent diarrha^al ])assages because they irritate even more than a solid,
well-formed movement. If there be concomitant disease of the genitil
organs, the vagina should be tami)oned n»gularly in order to avoid the
dribbling down of the fresh discharges from these organs upon the anal
surfaces. Ordinarily there will be no necessity to dilate the sphincter
in such cases, and yet there may arise emergencies from pain and spasm
of this muscle which would necessitate this procedure, which should
be jM'rformed only as a last resort, as it would likely deepen the fissure-
like ulcerations, increase the inflammation, and probably result in the
infect icm of the rectum, whereas the disease was originally limited to
the anus. When the disease has involved the rectum, active and ener-
getic measures are requisite; irrigation with boric acid or very mild
fiolulions of bichloride of mercury (1 to 10,000), or permanganate of
potash (1 to 4,000) should be made two or three times a day. It is
scarcelv necessary to remark here that rectal enemata do not answer
the purposes of irrigation in these cases. Permanganate of potash of
a strength sulticient to be bactericidal is very irritating to the intestinal
canal if left tliere for any time, and brings on intense and painful
griping. Therefore it is im])ortant that a proper rectal irrigator should
be used, such as that illustrated in Fig. 83; or if the anus be too tender
for the introduction of instruments like this, two soft-rubber catheters
should be introduced and the irrigation carried on by using one of
these as an inflow and the other as an exit for the solution.

If there is much spasm of the sphincter and pain from defecation,
dilatation of the muscles should be carried out under anaesthesia. In
sucli conditions this o])eraiion may be resorted to earlier than in the
cases in which the anus only is affected, as there will be no longer any
fear of infecting tiie rectum, and the operation will furnish proper
drainage and relief for the accumulated discharges.

Jullien advises the use of tannic acid as an application to the anus,
but it is too irritating and not as satisfactory' as the powders mentioned
above. The application of pure ichthyol to the fissures will hasten the
healing. If a submucous fistula should occur, it must be laid open
at once and treated as an ulcer so that it can not act as a hiding-place
for the gonococci from which they may break forth and reinfect
the parts.

The irrigations should not be discontinued until eight or ten days
after the discharge has entirely ceased, for the gonococci are liable to

VENEREAL DISEASES OF THE ANUS AND RECTUM 219

be concealed in the follicles and the discharge may be lighted up again
several days after it has once ceased.

Rest in bed is essential to successful treatment, especially when the
rectum is involved; but this, like every other rule, must have a certain
amount of elasticity. Cases inclined to ansemia, debility, and tubercu-
losis do not stand confinement in bed very well, and it is wise to alter-
nate it with periods of mild exercise in fresh country air. Bitter tonics,
cod-liver oil, predigested foods, and occasionally a little wine will be
found of advantage in bringing up the strength of these patients, and
sometimes accomplish a cure, whereas the simple local treatment has
resulted in failure.

Chancroid of the Anns. — This is a not infrequent disease about the
anus, and in this position the characteristics vary, as may be accounted
for by the anatomical relations of the parts, their functional activity,
and the hygienic care which is devoted to tliem by the lower classes, in
which the affection is generally found.

In the United States it is comparatively rare, but in Europe and
the Eastern continent it is not at all infrequent; nearly all of those
observed in the author^s clinic have been negroes or emigrants from
southern Europe. Fournier states that he found tlie disease in 1 in
445 men and in 1 in 9 women suffering from venereal diseases. Period!
found 2 out of 83 cases of venereal disease, both in women. Sturgis
found 8 in the same number of cases, all in wome^;i. Jul lien is said to
have found 14 cases of this condition in a total of 42 chancroidal ulcers
(Quenu and Hartmann, Chir. d. rectum, vol. i, p. 404). Sick, in his re-
view of venereal diseases in the Hamburg General Hospital from 1880 to
1890, found only 1 case of chancroid in the anus in 9,884 men, whereas in
11,826 women and infants he found 224 affected with it. From these fig-
ures one can readilv observe that while in men chancroid of the anus is a
very rare affection, it is by no means uncommon in women. This fre-
quency in the female sex results from the close proximity of the anus
to the genital organs and the facility with which discharges from the
vagina may trickle down upon the anal region. It is due occasionally
to contact with the male organ during the act of coition, and also
to the comparatively greater frequency of the practise of sodomy than
of pederasty. In the majority of cases chancroids of the anus are
secondarv to chancroids elsewhere, and therefore mav be said to be
due to auto-inoculation. They are usually limited to the perianal
region and the anal canal, and rarely extend above the muco-cutaneous
bonier unless they assume the phagedenic type, when they may involve
the rectal mucous membrane and result in great destruction of tissue,
even of the muscular wall of the gut.

Etiology, — There are two theories in regard to the origin of chan-

220 THE ANUS, RECTUM, AND PELVIC COLON

croids, in both of which it is assumed that the disease is the result of
the local action of micro-organisms. The later schools have generally
accepted the theory that a chancroid is nothing more than an ulcera-
tion due to the inoculation of abraded surfaces by pyogenic microbes.
They account for the special characteristics of the ulceration by re-
ferring them to the anatomical and physiological characters of the parts
in which they occur; they hold that inoculation in this region with
pus from other suppurating conditions, such as pustules, carbuncles,
or furuncles, will produce characteristic chancroids, and finally, that
thes(» sores occur in pe()j)le who, owing to their bad hygienic habits,
are susceptible to infection by micro-organisms. On the other hand,
good authorities claim that the chancroid is due to inoculation with a
specific virus; they chiim to have found certain bacteria always asso-
ciated with the ])yogenic micro-organism in chancroidal lesions whidi
are capable in pure cultures of reproducing the ulcers even when the
inoculations are practised under asei)tic precautions. In support ol
these theories thev hold that a chancroid alwavs results from contact
with the discharge from a chancroid, and does not result from inocolir
tion by discharges from other sources; that the chancroid always rona
a typical course in a given location; that auto-inoculation can be sae-
cessfully repeated almost indefinitely, and tliat the inoculated ulceiiy
after two or three general i(ms, cease to contain pyogenic microbes.

Ducrey, Welander, and Krefting " describe as the specific micro-
organism of chancroid a short, thick bacillus with rounded ends much
like a dumb-bell, about ^ a micromillimeter in length. The micro-
organism is found in the j)rotoplasm and between the cells, often in
chains and groups " (White and ^lartin. Venereal Diseases, p. 274).
Thev describe the characteristics of this ulceration, and state further
that in no instance was auto-inoculation successful from a chancroid
in which this bacillus was not present. Many other observers have
failed to confirm these observations, and inasmuch as proof afforded
by the inoculation of pure culture is still wanting, one must conclude
that the presence of a s]>ecific virus is suh judice,

Prrianal Chancroids. — Chancroids occurring in the cutaneous tis-
sue around the anus upon the perineal and coccygeal regions possess
the characteristics of erosions more than ulcerations. Thev are shallow,
do not discharge a great amount of pus, and show little tendency to
spread. So frequently are they associated with the condition else-
where tliat one writer has termed them " satellites of other chan-
croids." They are more often multiple than single, as many as fifteen
being seen in one case (Fig. 98). Some doubt the chancroidal nature
of such ulcers and claim that they are only intlammatory phenomena,
but the facts remain that they are secondary to chancroids elsewhere;

VENEBEAL DISEASES OF TUE ANL'S AND RECTUM

221

' they are auto-inocukble: they are associated witli hyperli-opliy and sup-
puration of the lymphatk'S, and do not tend to burrow unduroeath the
skin. These characteristics seem to distinguish them from general
ulcerative conditions.

Anal Chancroids. — The sulci between the radiating folds of the
anus form a most excellent lodging-place for chancroidal germs, and
owing to the frequent breaks in the mucous membi-ane at these points
inoculation occurs with the greatest facility. Here the chancroids
appear as grayish-yellow fissures between the fnld^;. wnd might be over-
looked in the beginning escept for the pain ivli:. '■ ''i. ■ ■■!...!.iie. They

Flo. BS.— MULTIPLE PlKIiSiL C

may be distinguished from simple fissures by the existence of chan-
croids elsen'here in the body; by their color, which is leas bright and
red; by the secretion of pus, which is much more abundant; by their
being maltiple. and fimillv by the fact that they are anto-inoculable.
So far as the pain is concerned there is no difference between these
and the true irritable ulcer of Allingham. As a rule they involve
cutaneous and subcutaneous tissues freely, but seem to be arrested
it the level of tile mucous membrane. They may extend through one
of the sulci between the radial folds until they reach the upper end
of the anal canal. Here and below the folds lliey spread circularly
(Wund the anus and thus take on a sort of hoiir-glnss shape. In this

k^'

222 THE ANUS, RECTUM, AND PELVIC COLON

position extreme chronicity is their chief characteristic. They advance
slowly and heal equally so. The chancroid in one sulcus infects an-
other and another until the whole anal circumference may be involved.
The base is ^ray and slugj^ish, the secreti(m is free, sometimes fetid and
tinged with blood, and occasionally little fistulas pass through the folds
from one sulcus to another. Molliere has stated that if the case be com-
plicated with haMuorrhoids the virulence may die out, leaving simple
varicose ulcei's which are not auto-inoculable (Maladies du rectum,
p. ()TJ)).

p]xtreme i)ain following defecation brings on constipation in these
cases just as it does in siini)le fissure. The patients in consequence
suffer all the symptoms of irregular fa?cal movements, loss of sleep,
and reflex digestive derangements.

T rent m cut. — There is little tendency toward spontaneous healing,
and frecjuently it is im])ossible to bring this about without forcible
divulsion of the sphincter.

It should always be remembered lx»fore having recourse to the
knife or forcible stretcliing of the sphincters, that these practices open
up the lymphatic channels for the absorption of pus and may result,
as in the case of Kieord and Foumier, in septica}mia, phagedsena, and
death. One should therefore be slow in recommending such a radical
measure. The excessive pain and the entreaties of the patient for
relief, incline <me to operate at once; but in one case in which the
sphincter was divulsed, the ragged edges of the hypertrophied radiating
folds cut off and a dirty, irregular, ulcerating mass surrounding the
anus cleaned, the i)ain was relieved for twenty-four hours, then re-
turned in all its severity and was followed in a few days by perianal
abscess and a suppurating inguinal bubo. Either of these conditions
might have occurred without the operation, but they were not present
before or at the time of tlie operation, and it is possible that the pro-
cedure was the cause of them.

Conservative treatment therefore ought always to be practised, and
practised i)atiently before undertaking any operation. The bowels
sliould be ko])t o])en by mild laxatives, not by cathartics, and the parts
cleansed by frequent bathing with antise])tic solutions and the applica-
tion of soft, soothing dressings. The following treatment advised by
the author in Morrow's Svstem of (rcnito-Urinan^ Diseases has proved
satisfactorv in most of his cases:

The parts after being thoroughly washed and cleansed are touched
with a solution that contains equal parts of carbolic acid and tincture
of iodine. This is followed by washing with lime-water or blackwash
and applying a powder of calomel and oxide of zinc. If the ulcer ex-
tends within the anus it may be necessary to introduce a speculum in

VENEREAL DISEASES OP THE ANUS AND RECTUM 223

order to treat the parts thoroughly. One should do this even if the
pain is severe enough to necessitate the administration of nitrous oxide
or ethyl chloride for every treatment. Methylene blue, 10 grains in
each fluid ounce, is an excellent application in these cases, especially
where there is a tendency to chronicity or phageda?na.

The insufflation of orthoform upon these ulcers will in many in-
stances relieve the acute pain produced by dressing them; it is not
uniform in its action, however, for in some cases it has not given the
slightest relief. Iodoform is said to possess a specific action upon chan-
croidal ulcers; in hospital practice one may use it freely, but its disa-
greeable odor has ostracized it so far as private patients are concerned.
Aristol, antinosin, and resinol may all be used in place of the above
powder, as may the mixture of oxide of zinc and calomel, which is
simpler and much less expensive.

Chancroidal Tnceration of the Eectnm. — Some few cases have been
described in which the chancroidal ulceration lias extended from the
anus into the rectum, but these can not be considered true rectal chan-
croids. A chancroid of the rectum itself must originate in that organ
and is usually due to sodomy.

Chancroidal ulcers occurring around the margin of the anus do not
pass easily beyond this region, from the fact that the sphincter con-
stantly closes this aperture and acts as a barrier to advancing germs.
The fgecal movements also sweep out before them the germs that may
have nearly gained access to the rectal cavity. Those chancroids of
the rectum which have been reported have generally been associated
with others about the anus and upon the buttocks, and it is much more
logical to attribute the latter ulcers to infection from within the rectum
than lire versa.

That chancroids may extend from the anus into the rectum must
be admitted. All who have had much experience in rectal and venereal
diseases have seen such cases. The fact that the invalids affected do
not even give up their vicious practices while the sore exists renders
it possible that the virus may be carried upward into the rectum, and
the ulcers are thus the result of auto-inoculation. On the other hand,
a certain variety of chancroid known as phagedenic has a persistent
tendency to progress in one or more directions, and if the sphincter
muscle is relaxed, as it frequently is in this class of patients, there
will be no obstructive barrier against the progress of the disease into
the rectum. Mason, Van Buren, and others have reported such cases as
this, and claim that they have seen strictures of the rectum caused
by them.

Symptoms. — The symptoms of chancroids of the rectum are in the
main those of ulceration, viz.: diarrhoea, tenesmus, and a profuse dis-

224: TUB ANUS, RECTUM, AND PELVIC COLON

charge of pus, sometimes tinged with blood. There may or may not
l)e pain. The patient is generally unwilling to confess that he has any
knowledge of the cause of his disease.

The ulcers are irregular in shai)e, grayish in color, and shallow
with ragged borders and pale, feeble granulations. They may be sta-
tionary or have a tendency to rapidly extend. Occasionally they involve
the deeper tissues of the gut, invade the submucous and muscular
coats, and may even destroy the sphincter itself. Under such circum-
stances they are termed j)hage(lenic. When a tendency to spread exists
the j)us burrows underneath the mucous membrane, and submucous
or subniuscular fistuhe may develop.

Treatment. — The maniigement of chancroids within the rectum '^
practically the same as that of acute ulceratiim of this organ. The
patient should bo confined to bed. The bowels should be kept regular
but not (liarrlKcal, and the r(H-tum should be irrigated with antiseptic
solutions, such as boric acid, thymol, bichloride of mercury, carlM)lic
acid, etc., two or three times a day. If the ulcer appears slug^rislu
slightly stimulating applications will sometimes be useful. If it has
a tendency to ])rogress rai>idly, the application of jmre nitric aciil or
the actual cautery to its edges will sometimes check this. Iodoform
su])positories are very useful in these conditions; though pure carlmlic
acid ai)]>lied once in throe or four days, and the daily insuillation of
the zinc and calonu^l powder ui)on the ulcer produces excellent results.
Pure ichthvol acts w(»ll in lissures when they exist. A bland, unstim-
ulating diet should be enforced, and morphine should be administered
if nec^ossary to relieve the ]>ain and control too frequent stools.

Phagedenic Chancroid. — Any chancroid may assume a phagedenic
condition, which may be either acute or chronic. This change in the
nature of the ulcers is due to constitutional conditions. Didav and
Doyon (Therapeuticpie dos malad. voner. et des malad. cutan., 1876, p.
181) have ])roved this fact by experiments with inoculation. They
have shown that if a healthy j)erson is inoculated from a phagedenic
chancroid he doyolo])s only a simple, soft sore; and on the other hand,
if a ])erson who suffers from a ])hagedenic chancroid be inoculated from
a simple chancroid, the point of inoculation will at once take on the
phagedenic symptoms. In the acute form the j)hagcdenic chancroid
resendjl(»s an intense cellulitis at first. The deep tissues become in-
volved as well as the superficial, the parts are swollen, cedematous, and
painful, the temperature is elevated, the ])ulse rapid and feeble, and
the tongue dry and ])asty. Oroat dostniction of tissue results, large
suppurating cavities form, and the overlying teguments slough away.
The lymphatics in the vicinity soon become involved and suppurate.
Eollet states that the pus from these buboes is not auto-inoculabley

VENEREAL DISEASES OF THE ANUS AND RECTUM 225

but this statement has not been corroborated. One can not say that
these general symptoms are in any way peculiar to chancroids. They
are comparable to pyaemia and due to the absorption of pyogenic bac-
teria, which are always present in chancroidal ulcers.

Metastatic abscesses may form in any portion of the body, and unless
the disease is rapidly checked it is likely to prove fatal. Wh2re the
patient recovers, it is generally through a prolonged convalescence with
resulting large cicatrices in the region of the sloughs.

In the chronic form of phagedenic chancroid the onset is very
insidious; the ulcer first shows a sluggishness in the production of
healthy granulations, especially at one or the other of its borders. At
the anus it has a tendency to extend from without into the rectum.
While it is cicatrizing at one area it advances at the other. There are
no marked constitutional symptoms, and the ulcer is less painful than
acute ulcerations about the anus usually are. The lymphatic engorge-
ment is less marked than in the other varieties of chancroids, and
suppuration of the glands is unusual. The ulcer tends to spread super-
fieiallv and often involves onlv the mucous and submucous tissues. Oc-
casionally, however, it may involve the deeper tissues, and cause inflam-
mation and cellular infiltration of the muscles that surround the anus
and rectum. It is only in these rare instances in which the ulceration in-
volves the muscular walls that chancroids can be said to produce a stric-
ture of the rectum. Dupres (Archiv. J. de mcd., 18(58, p. 257) first de-
scril)ed this condition of phagedenic chancroid as an etiological factor
in the production of stricture of the rectum; Mapon (Amer. J. of Med.
Sc*., 1873, p. 22) wrote in confirmation of his theory; Van Buren (Dis-
eases of the Rectum, 1881, p. 237) stated that he had seen a chancroid
of the anus become phagedenic, extend into the rectum, and at a later
period had verified the existence of a stricture due to its cicatrization;
Bridge (Archiv de Dermat., 1876, p. 122) recorded the case of a stric-
ture of the rectum due to chancroidal ulcers in which it was necessary to
perform a lumbar colotomy in order to relieve the intestinal obstruction.

The weight of evidence seems to support the view that stricture of
the rectum may be produced by phagedenic chancroids. The author
has seen three cases of chancroids of the anus which had left contrac-
tion of that orifice, but the strictures never ascended higher than the
internal sphincter, and could not therefore properly be called stric-
tures of the rectum. On the other hand all of these cases were treated
by cauterization, either by chemical agents or the actual cautery, and
the question therefore remains in doubt whether the stricture was pro-
duced by the cauterization or by the chancroid itself.

Treatment. — In the acute variety the patient's general condition is of
paramount importance. Abscesses should be evacuated as soon as possi-
15

226 THE ANUS, RECTUM, AND PELVIC COLON

ble; the operator should be very careful not to make too wide incifiionf
lest he open up healthy tissues for infection with the vims; yet neverthe-
less the inflamed cellular tissue should be freely incised. After the ab-
scesses have been opened the parts should be frequently irrigated with
antiseptic solutions, and in the meantime hot poultices should be applied
in order to increase the circulation and limit the sloughing as much
as possible. The temperature should be controlled either by coW
sponging, or, if necessjiry, by the use of some of the modem antipyretics.
These latter should be used with the greatest caution, as they are all
depressing, and the chief diificulty in these conditions is to maintain
the patient's strength until the pya»mic processes can be controlled.
Tincture of the chloride of iron should be frequently administered,
and bichloride of mercury in small doses will generally have a very
good effect. Quinine seems to act well in some cases, while in others
it excites the patient too much to be of benefit.

Assuming the condition to be one of sepsis due to the absorption
of pyog(»nic bacteria, and not to any specific chancroidal virus, one
should apply the principles of antiseptic surgery and even resort, if
necessary, to intravenous saline infusions or the injection of antistrep-
tococcus serum.

In the chronic form there appears to be a local condition of lowered
vitality in the parts. The fact that the ulcer heals upon one border
while it advances upon the other shows that the tissues of the latter
have less power of resistance than those of the former. Where a well-
developed, healthy granulation is once established, the progress of the
disease in that direction is checked. Sometimes mild astringent or
cauterizing agents suffice to produce this granulation and thus check
the advances. Kitrate of silver may be tried at first, and following this
one may have recourse to nitric or chromic acid, caustic potash or acid
nitrate of mercury, or finally to the Paquelin or galvano-cauter}' itself.

The modem improvement of the galvano-cautery enables us to apply
it now at every point in the circumference of the rectum, and if thor-
oughly done it will generally check the disease. This application, how-
ever, is not without its dangers, as a patient has died from shock within
a few hours after the application of the Paquelin cautery to a phage-
denic chancroid. One should therefore prepare his patient for such
an ordeal by rest in bed, general constitutional and nerve tonics, and
by strong stimulation.

After the cauterization the parts should be dressed with a 5- to 10-
per-cent solution of picric acid, which relieves the pain of bums.

Maclaren (Edinburgh Clin, and Path. J., 183, p. 697) has recorded
the case of a woman with a " pellagrous, phagedenic chancroidal ulcer **
which, notwithstanding cauterization and treatment by all recognized

VENEREAL DISEASES OP THE ANUS AND RECTUM 227

methods, continued for eight years without material improvement. It
was noticed in this case that the contact of the menstrual discharges
with the parts that had healed immediately caused them to break down
again. He therefore scraped off the granulations, dissected out the
inflamed tissues beneath, and brought the parts as near together as
possible by button sutures. After this the vagina was tamponed and
kept so until some time after her recovery, particularly at the menstrual
periods. Other operators have not been so successful in their efforts
to check phagedena by excision. The experience of most has been
that the fresh edges of the wound rapidly assumed the old phagedenic
condition, and the area of the ulcer is only increased. On the whole
one must largely depend upon constitutional treatment, good hygiene,
and occasionally the application of the actual cautery for the cure of
this condition.

Complications. — Chancroids of the anus and rectum may be com-
plicated by the coexistence of true Hunterian chancre in the same lesion ;
but mixed sores present no characteristic features at first beyond those
of typical chancroids, which proceed in their regular course for some
days or weeks, when the bases become indurated and the cicatrizing
edges undergo cellular infiltration. At the Siime time the ulcer will
secrete more pus than a true chancre and is auto-inoculable.

The appearance of secondary syphilis is the pathognomonic evidence
of the combined nature of the sore.

Chancroids may exist in connection with secondary syphilis.
Syphilitic ulcerations and even broken-down mucous patches may re-
semble chancroidal ulcers in a marked degree, and as these ulcerations
always contain pyogenic germs, auto-inoculation may produce a pus-
tule and yet not be convincing evidence of their chancroidal nature.
On the other hand, if one assimies in these cases that the disease is
chancroidal, he may overlook the syphilitic nature of the ulcers. Anti-
syphilitic treatment should never be resorted to until secondary lesions
appear to clear up this confusion.

The occurrence of fistula, fissures, and stricture as complications
of chancroidal ulcers have been mentioned. There is one form of
fistula, however, which deserves especial mention. In chronic chan-
croids without any marked phagedenic tendency about the anus there
occasionally occur small subtegumentary fistula? that extend upward
underneath the radial folds or columns of Morgagni; they may pene-
trate the mucous membrane above, but they are generally of the incom-
plete variety. When the chancroid assumes the fissure-like type these
little fistulas are very likely to be overlooked unless the parts are care-
fully examined with a very fine probe. When they are not recognized
and treated the discharge from them keeps up the ulceration below in

228 THE ANUS, RECTUM, AND PELVIC COLON

spite of all the treatment which one can apply. These little tracti
should be laid open freely and cauterized either with pure carbolic
acid or with the galvano-cautery. The reflex complications which occur
in chancroids of the anus and rectum are not peculiar to this particulir
form of ulceration; thev occur in all the inflammatory involvements of
these orprans and include dysuria, frequent and painful urination, irrego-
larities of the menstrual functions, and sometimes in pregnant women
who have no symptoms of syphilis, abortion.

SYPHILIS

This protean disease manifests itself in primary, secondan*.
tertiar}' lesions in the skin about the anus, in the anal canal,
within the rectum. It is seen at all ages and in ever}' class of society.
It may be inherited from either j)arent, or the child may be infected
with it during birth througli tlie presence of the disease in the mothert
genitals. It is acquired through natural and unnatural vice, througli
accidental or innocent contact with diseased persons, or indirectly
through the use of toilet articles which have bt^en used by syphilitics.

Chancre. — The initial lesion of syphilis is always a chancre. It
occurs in the anus somewhat more frequently than was formerly ad-
mitted. Pean and Malassez, combining the reports of Bassereau, Four-
nier, (Here, Martin, and Carrier, present (Etude clinique sur les ulcera-
tions annales, Paris, 1871, p. 88) the following statistics: In 1,237 extra-
genital chancres of all regions in men, they found 7 chancres of the
anus, in 175 in women there were 14 chancres of the anus. From
these figures it would appear that the infection occurs at the anus in
1 out of 177 cases in men and in 1 out of 13 cases in women. Sick
(Jahrbiicher der Ilamburgischen Staats-Krankenanstalten, 1890, t. 2,
Leipsic, 1 892, p. 453), in summing up the venereal diseases occurring in
the general hospital of Hamburg, 1880 to 1890, found in 9,884 maleB
affected with venereal diseases 1,010 mucous patches, 1 true chancre,
and 1 chancroid of the anus; in 11,826 females and infants affected
with the same diseases there were 986 mucous patches, 9 true
chancres, and 224 chancroids of the anus, 404 anal fissures, 3 perineo-
anal chancres, 1 anal gumma, 2 rectal gummas, and 10 strictures of the
rectum.

Salsotto, quoted by Qucnu and Hartmann, found in 201 extrageni-
tal chancres only 2 of the anus. Jullien (Traite pratique des maladies
vencriennes, Paris, 1879, p. 583) found 11 chancres of the anus in
2,171 cases of extragenital chancres in men and 39 in 473 cases in
women, making a proportion of about 1 in 119 in men and 1 in 12 in
women. Quenu and Hartmann, gathering statistics from the services

VENEREAL DISEASES OF THE ANTS AND RECTUM 229

of Professor Foumier, of Paris, and published at different times by Nivet
(These de Paris, 1886-1887, No, 205), Morel-Lavalles (Annales de der-
inat. et de syphilog., 1888, p. 375), Veslin (Annales de dermat. et de
syphilog., 1890, p. 317), and Feulard (Annales de dermat. et de syphilog.,
1890, p. 320, and 1892, p. 805), determine that in 778 extragenital
chancres there occurred 52 chancres of the anus, of which 26 were in
males, 25 in females, and 1 in an infant. Foumier's latest statistics
(Les Chancres extra-genitaux, 1897, p. 485) give in a total of 10,000
chancres, 52 of the anus and rectum, 37 being in men and 15 in women.
The proportion in the two sexes is 1 in 192 cases in men and 1 in 25
cases in women. Duhring, of Constantinople (Gaz. de medic, de Paris,
892, p. 381), states that out of 42 extragenital chancres 31 were found
about the anus or within the rectum ; what is still more remarkable is
the fact that 26 out of the 31 were in children, and of the 5 in adults
4 were in males and 1 in a woman. The disparity between these
figures and those of Sick seems to indicate how much more frequent
is the practise of unnatural vice in the French capital than in its
German neighbor. The statistics of Duhring from the Turkish capital
are too horrible for belief. Pospellow (Archiv f. Dermat. u. Syph.,
1889, Xos. 1 and 2) and Neumann (Wiener medic. Wochenschr., 1890,
No. 4) found in 282 cases of extragenital chancre 8 chancres of the
anus, all of which were in women. In over 3,000 cases of rectal dis-
eases treated at the Polyclinic Hospital there were only 3 cases of true
chancre of the anus, 2 of these being in boys and the other in a woman.
These facts show that except in those countries where the practise of
unnatural vice is frequent the disease is very rare and largely confined
to the female sex. This is also in keeping with the anatomical facts,
as referred to in the earlier portions of this chapter. In men the
occurrence of the disease in these locations is almost positive evidence
of the practise of sodomy, but in women the possibility of the infection
of these parts through their contact with the male organ or through
the discharges from the vagina render them much more liable to anal
chancres. All statistics, however, upon this subject must be taken
rum grano salis, especially in men. The shame of such practices as
cause this local inoculation in males deters them from consulting the
doctor, and as the symptoms are not unbearable, probably a large pro-
portion of them are never seen. Possibly many cases of secondary
syphilis, in which the patient denies any knowledge whatever of the
original source or site of the infection, may have originated in true
chancres of the anus or rectum.

The initial lesion may occur in the skin surrounding the anus,
between the radial folds, in the anal canal, or in the rectum itself.
Those below the ano-rectal line are termed anal, and those within the

230 THE ANUS, RECTUM, AND PELVIC COLON

sphineteric contraction above tliis line are termed rectal ehancred. The
contagion, as admitted by most obsen'ers, is carried in the blood and
in the secretions from a chancre or from secondary lesions; the normal
secretions, such as saliva, sweat, milk, and semen, are said not to conTej
the disease unless mixed with discharges from some inflammatory lesion.
Whatever the source of the contagion, the primary infection is always
a true, hard chancre at the seat of inoculation. The infection may
occur through immediate contact, and generally does so occur, but it
may also be brought about by mediate contagion, such as the use of
towels, sponges, cloths, syringes, etc., which have been previously usei
by patients affected with the disease.

The author siiw a case of hard chancre of the anus in a private
patient some years ago, in whom the disease was caused by the use
of a syringe for taking a rectal enema, the instrument having been used
by a brother who was suffering from constitutional syphilis. While
such instruments may be used with impunity so long as there is no
lesion in the skin or mucous membrane, the moment they come in
conflict with a tissure-like crack, an abraded hemorrhoid, or a small
erosion of the skin, infection is very likely to occur.

Anal Chancres. — The most common seats of these chancres about
the anus are in the skin just outside of the radial folds and in the sold
between these folds. A sufficient number of observations of this char-
acter has not been made to justify any generalization with regard to
the comparative frequency in location. Of three cases of chancre of
the anus one occurred in the skin just below the radial folds and the
other two between them. Those which develop upon the skin around
the anus do not differ materially from the cutaneous chancres on other
portions of the body. They are generally superficial and circular in
the first stages, resembling abrasions; their bases are indurated, the
e<l;j:es red but not infiltrated, and the center dark, grayish, and some-
times fissured. After they have existed for a week or ten days the
edges become infiltrated and the whole mass hard, indurated, and re-
sisting. The sores are said to be painless, but there is always more
or less discomfort produced by them whether upon the skin or muco-
cutaneous border.

When they occur between the radial folds or at the anal margin they
usually assume the shape of fissures. The distinction between them and
true fissure in ano is said by Ball, Quenu and Hartmann, AUingham
and Kelsey, to be easily made, owing to the absence of pain in the parts.
Two patients affected with chancre between the radial folds suffered
just as acutely after movement of the bowels as they would have done
from any other fissures of the same extent and location. The only
difference between these ulcers and true fissure was that they were

YENEBEAL DISEASES OF THE ANUS AND RECTUM 231

indurated and healed rapidly without even stretching the sphincter;
whereas the majority of true fissures have no such tendency. In the
first stages of chancre occurring in this location it will be very difficult
to decide between these two conditions^ as the induration is not well
marked until ten days or two weeks after the development of the initial
lesion. The bases, it is true, are hard and infiltrated at an earlier period,
but as it is difficult to grasp these between the finger they give the
impression of cicatricial thickening rather than cellular infiltration. In
one chancre between the folds the base was at first a brownish-gray; this,
however, soon disappeared and left a bright-red, granulating surface
which bled easily upon stretching the buttocks apart. In both these
cases the chancre healed in about four weeks, and in four cases that were
observed the constitutional symptoms of sjrphilis developed within the
first eight weeks.

Where the chancre occurs a little higher up, or intra-anal, Hart-
mann states that the patient complains of a sense of uneasiness and
discomfort, never of an acute pain. In the cases that occur upon the
akin and between the radial folds one may see the lesions by gently
separating the buttocks; in the intra-anal form it is necessary to pull
the edges of the anus forcibly apart and sometimes even to use a
speculum in order to observe them. Here the chancre assumes the
circular or round form at first, at least it appears so when the parts are
stretched open. The edges are slightly elevated, the base is smooth
and indurated, although this latter condition, it is said, is difficult
to make out. The mucous membrane just above the edges of the ulcer
appears to be perfectly healthy. The edges of the ulcer are rose-colored,
and the idcer itself secretes a very scanty muco-purulent discharge,
sometimes slightly tinged with blood. If the discharge is abundant it
is evidence of a mixed or complicated sore.

Chancre may develop upon a prolapsing or hypertrophied external
hjpmorrhoid (JuUien). In such cases the development is most charac-
teristic and the induration very great. Where the chancre involves
the muco-cutaneous border there may develop ijitense induration of
the cutaneous tissues below, even almost cartilaginous in its nature
(Xeumann, Annales de dermat., Paris, 1893, p. 1326).

Mixed Sores. — Chancre may be complicated with chancroid, thus
causing a mixed sore, as has been described in a preceding section.

Auto-inoculation is never a safe diagnostic guide in this region be-
cause of the possible presence of pyogenic germs in the ulcer which might
make it successful even in cases of true chancre. Simple hard chancres
may be so irritated and infected by the passage over them of faecal
matter that they assume a phagedenic tjrpe resembling chancroidal pha-
gedsena. Thus one must admit a phagedenic condition as complicating

232 THE ANUS, RECTUM, AND PELVIC COLON

true chancre, such as is described by Medina (Thtee, Paris, ISDl-'S^,
No. 288), and Quenu and Hartniann (loc. cit.y vol. i, p. 79).

Course of the Disease. — The experience of Fournier, Carrier, and
others, who state that the course of these local sores is a ven- slow one,
has not been confirmed ; for those which the author has seen have healed
comparatively promptly. They say that the parts may be inflamed,
assume a dark vencms color, sometimes resembling intertrigo, the radial
folds may become engorged, and in tlie midst of these diffuse lesions
the chancre itself may be passed unobserved. Such a diffused conges-
tion of the parts must be very rare, and would indicate to the writer a
mixed infection.

Sometimes the folds bordering upon the ulcer become hypertrophied
and develop into muco-cutaneous tabs. French authors speak of these
as condvlomata. On this side of the Atlantic the term is not used with
this significance; here it means vegetating excrescences upon the skin
or mucous membrane which have a warty or papillomatous character.
These develop about the anus in the course of syphilis, but they are
among the secondary manifestations of the disease, and not connected
with the initial lesion. The rapidity with which the chains of inguinal
glands u})on both sides of the body l)ecome successively enlarged is one
of the most reliable diagnostic symptoms of chancre of the anus. The
development of secondary symptoms, however, is the only absolute proof
with the initial lesion.

The rapidity with which the chains of inguinal glands upon both
sides of the body become successively enlarged is one of the most
reliable diagnostic symptoms of chancre of the anus. The develop-
ment of secondary symptoms, however, is the only absolute proof that
any given sore is syphilitic. Chancre w^th minor degrees of hyper-
trophy of the inguinal glands may be the beginning and end of syphilis,
or a patient may have a true chancre without any secondary develop-
ment, and years later be affected with a true outbreak of tertiary syphi-
lis; these courses indicate that the systemic resistance at the time was
sufficient to overcome the virus of disease^ but the seeds of constitu-
tional infection remain latent, and at some period of depressed vitality
overcome this resistance and develop with great intensity. At other
times the secondary development may be so mild that it does not make
any iin])ression on the patient, and passes away only to reappear years
afterward in the shape of severe tertiary lesions. These facts empha-
size the necessity of the most careful observation for considerable peri-
ods of time after a suspected sore, and also to guard the reader against
a too favorable prognosis in any such case.

Chancre of the Bectum. — Chancre of the rectum proper is one of
the rarest of diseases. ^Vfartineau (Lec^ons sur les deformations vulvaire

VENEREAL DISEASES OP THE ANUS AND RECTUM 233

et anale, 1886, pp. 152, 174, 176) has reported three eases, 1 entirely
above the internal sphincter, 1 on its level, and 1 between the two
Bphineters. Foamier himself says that he has seen 4 cases, but of these
the diagnosis was absolutely certain in but 1 (Les Chancres extra-geni-
taux, Paris, 1897, p. 486). MoUi^re {loc cit., p. 636) only credits one
of these, that of Fournier. Ohmann-Dumesnil (St. Louis Medical and
Surgical Journal, 1900, p. 294) has reported two chancres, one on the
verge of the rectum and the other 3 inches above the anus, both in
women. Trelat and Vidal de Cassis also claim to have seen cases.
Hartley (Journal of Cutaneous and Genito-Urinary Diseases, 1891, p.
218) has reported a most carefully observed and indubitable case as
follows:

J. McG., thirty-two, male, U. S., organist, was admitted to the Roosevelt
Hospital, September 20, 1890.

Family History. — No tubercular, renal, or cardiac ailments. No rheumatic
history.

Personal History, — No tubercular, renal, or cardiac disease. Denies all pre-
vious venereal diseases. Had dysentery some years ago.

Present Cortdition. — About three weeks ago the patient noticed severe pain at
defecation, and a small lump just within the anus; pain now continuous; tenes-
mus after each passage ; blood has been present at stool at times. He has suffered
from constipation for a long time.

An ulcer is found just 1 inch from the anal margin. It is about the size of
a quarter of a dollar. The base is indurated and the ulceration is very 8ui)erficial.
Sacral glands felt enlarged. There is no evidence of any other lesion.

Operation, — September 20th. Usual antisepsis. Bichloride and boric-acid
irrigation of the rectum ; sphincter dilated. Bivalve speculum used. The ulcer
is seen just 1 inch within the rectum ; it is superficially eroded with a distinct
but not cartilaginous base.

Excision of Ulcer. — Cauterization with Paquelin cautery. Iodoform powder.
Suppository of opium, gr. ij ; opium pill, gr. j, t. L d. Patient ordered to wartls
and to be watched for any evidences of syphilis. September 25th : movement of
bowels; daily irrigation. September 30th : ulcers healing rapidly. October 1st:
roseola over the surface of the chest and abdomen. October 5th : discharged from
the hospital improved. October 20th : patient applied to-day for treatment in the
out-patients' department, stating that his medicine had been used up and that he
desired more. Patient presents a papular syphilide involving the face, forearm,
trunk, and portions of the extremities. The ulcer of the rectum is healed.
Patient is put upon antisyphilitic treatment.

A careful inquiry as to the mode of infection was instituted. Patient for the
first time during his treatment here admits that three weeks before admission to
the hospital, while in Baltimore, he was the victim of another man.

After this confession the patient was lost to view.

The painlessness of the lesion described by some authors is not
borne out by the cases of Fournier and Hartley, both of w}ios(» patients
complained of severe pain, the sensation of a lump or foreign body

234 THE ANUS, RECTUM, AND PELVIC COLON

within the anus, tenesmus after eaeh stool, and the occasional passage
of blood with the faxres. The existenct* of chancre within the rectum is
very positive evidence of sodomy, although it is possible for the infec-
tion to occur, as in the case of anal chancre, through the use of an
infected syringe-tip.

Symptoms. — The symptoms of chancre in this location, as drawn
from a few exjwriences, are more or less acute pain at the time of or
following defecation; a discharge of muco-purulent or purulent secre-
tion, with or without the presence of blood. Examination gives to the
finger a sensation of an ulcer slightly depressed in the center, with
clear-cut borders and an indurated base. These ulcerations are venr
superficial. The sacral glands may be enlarged if the sore has existed
for any length of time. One would not expect to find the inguinal
glands enlarged at so early a jx»riod as in chancre of the anus, owing to
the fact that the lymphatics above the sphincter ascend by a different
route from those below.

The histology of chancre of the rectum does not differ from that
of the sore found elsewhere except in the tissues involved.

Treatment of Initial Lesion. — The treatment of chancres of the anus
and rectum is practically the same as that for the lesion elsewhere,
with the exception that in these locations it is much more difficult to
keep the parts clean, and it is more usual to have the sore complicated
by septic conditions. Great care, therefore, is necessary to avoid these
complications. When the chancre is outside of the anus frequent wash-
ings with antiseptic solutions should always be practised. After the
parts have Ix^en thoroughly cleansed and wiped dry, one should apply
some of the powders mentioned in the treatment of chancroid. The
mixture of equal parts of oxide of zinc and calomel is excellent, because
it is devoid of any disagreeable odor, it is inexpensive, and seems quite
as effective as any other powder. There might be an objection to the
use of calomel under such circumstances because of the possibility of its
being absorbc^d, and thus masking the constitutional syphilis or delay-
ing its appearance. When ulcerative lesions are sluggish and inclined
to suppurate, antinosin or tincture of iodine stimulate them to granu-
lation, and apparently hasten the healing.

After the powders have been applied, the folds of the buttocks and
the radiating folds of the anus should be carefully separated by small
pledgets of gauze or absorbent cotton to prevent the friction or abra-
sion occasioned by clothing or by their rubbing together.

When the chancre is well within the anus or inside of the rectum,
it will be necessary to introduce a speculum in order to cleanse the part
thoroughly and apply any medication. Tender such circumstances the
fenestrated conical speculum is by all means the best, as it can be intro-

VENEREAL DISEASES OP THE ANUS AND RECTUM 235

duced with comparatively little pain, and the remedial measures applied.
Suppositories containing such drugs as iodoform, aristol, and noso-
phene will be advantageous if the ulcer is well within the rectum, but
useless if it is in the anal canal. The bowels should be kept open, but
not by drastic cathartics, which bring on diarrhoea and irritation of the
rectum; one smooth, gentle movement daily is the most satisfactory,
and this can be obtained by a morning enema. If the ulcer is in the
rectum, it may be necessary to use opium to prevent too frequent
stools. Irrigation of the rectum by boric acid or mild bichloride solu-
tions should be used after each stool. In Hartley's case the ulcer was
excised and the base cauterized with the actual cautery, and yet secondary
symptoms promptly appeared. This method of treatment has not met
with the general approval of the profession, and experience witii it has
not been such as to encourage its adoption in the treatment of anal or
rectal chancres. If kept clean and dry, and the patient remains (juiet for
two or three weeks, these lesions will generally heal and leave nothing
more than an indurated spot, which gradually disappears, so that its
site is unrecognizable.

Secondary Manifestations. — Secondary syphilis manifests itself in
this region in a variety of ways. Around the anus one may observe the
same lesions which occur upon the skin elsewhere in the body. They
are modified to a certain extent, however, by the close approximation
of the parts and their habitually moist condition. Thus, the macular,
scaly, moist papular and tubercular syphilides in this region are very
liable to be transformed into mucous patches or ulcerative conditions.
These two types are therefore most frequently seen.

Mucous Patches, — Next to the mouth and throat the anus is the
most frequent seat of mucous patches. In women they occur at some
time in a large percentage of cases of constitutional syphilis. They fre-
quently begin in the vulva and spread to the anus, but it is not at all
rare to see the first patch develop in the latter situation.

The course of their development is as follows : There is first an
erythema between the folds of the buttock. This may occur even before
the initial lesion heals; when the latter is located in this region it may
imperceptibly change into the mucous patch, thus occasioning a sort of
transformation in situ. In point of time the patch corresponds to the
macular eruption upon the skin. It appears at first as a dull red zone,
wiiich gradually fades into the surrounding skin. There is a sort of
cedema below the epidermis which elevates the epitheliim above the
derma. This oedema is not sufficient to produce a vesicle or bulla, but
the epidermis becomes macerated and falls, or is rubbed off by the
friction of the parts, leaving a superficial erosion. At this period the
condition may be mistaken for an acute eczema. There is little itching.

236 THE ANUS, RECTUM, AND PELVIC COLON

however, the discharge is scant and thin, and there is no cracking of
the tissues, as occurs in that disease. Soon afterward there forms u[»on
the surface a grayish-white fK»llicle or membrane somewhat elevated
above the level of the skin. The cutaneous tissue l)eneath this is infil-
trated and hypcrtrophied in the suiK»rficial layers. These changes con-
stitute the mucous patches. They may be single or aggregate, and
involve the entire circumference of the anus. Generallv thev are dirfk-
shaped, and situated upon the two folds of the buttock, which lie in am-
tact with one another. In the second stage the patch appears as a sim-
ple, elevated, pearly spot situated upon a supple base of ver}' slightly
indurated skin, and is termed the " plaque porcelainique.'' As the con-
dition develo})s, the patches become more elevated, but are pressed
flat by the buttocks, and secrete a thin, ftvtid fluid which keeps the
parts moist and irritated. In this stage, on account of their flat sur-
face and broad bases, they are terrae<l " condylomata lata '' (Plate Y, Fig.
1). The papilbr over which these patches are situated, through cellular
infiltration and irritation by these secretions, soon begin to hy])ertrophy;
the branches shoot u])ward, the vessels nmltiply and dilate, the summit
of the growth increases in weight, while the base remains the same,
and there is developed a cauliflower growth distinguished as vegetating
mucous patches or venereal warts. This condition, while due originally
to specific disease, is no longer a purely syphilitic affection; but, on
the contrary, a papillomatous growth, which does not yield in the least
to internal antisy})hilitic medication. The fact that the secretion from
these growths is auto-inoculable would seem to prove their non-syphi-
litic nature. Within the rectum mucous patches are said to be very rare,
but the author believes they are more frequent than is supposed. Baren-
sprung (Charit^-Annal., 1885, Bd. vi, p. 57) long ago observed them
during the eruptive stage of syphilis, and Muron (Gazette med., 1873,
p. 8) suggested that stricture might result from their ulceration.
Molliere reported a case in which the patch was 5 centimetres above the
anus. The colored drawing (Plate III, Fig. 1) shows a pear-shaped
mucous patch on the middle Houston's fold, which was demonstrated
at the clinic in May, 1900. They give rise to no marked symptoms, and
are therefore probably overlooked.

E. Tiling, of Innsbruck, examined 1 10 cases (45 men and 65 women)
in the eniptive stage of sy])hilis with reference to secondary mani-
festations of the disease within the rectum. He foimd plaques or papules
in 1(> cases. They were located generally on the posterior wall, but
sometimes on the sides^ and in 3 cases involved the entire circum-
ference. The plaques were frequently ulcerated, but in only 3 was
there pain in defecation or loss of blood. In 1 case, in which the
plaque was situated very high, the jxatient suffered from tenesmus (E.

VENEREAL DISEASES OF THE ANUS AND RECTUM 237

Lang, Pathologie und Therapie der Sjrphilis, vol. i, p. 325). This expe-
rience emphasizes the importance of early rectal examinations in con-
stitutional syphilis, and proves that specific ulcerations often occur here
unobserved early in the disease. These ulcerations may excite inflam-
maton' processes which result in stricture later on. Such strictures,
although originating in sjrphilitic ulceration, may be purely fibrous and
possess no specific pathological characteristics, such as gmnmata and
endarteritis.

Small Red Pajmles. — Along with, or sometimes before the appear-
ance of the mucous patches, there may occur small red papules around
the anus or between the radial folds. They rapidly break down and
leave small ulcers, which assume the shape of fissures when they occur
in the latter position. These fissure-like ulcers may also occur inde-
pendently of the papules. They are said to be painless, but one has
to see onlv a few such cases to have his mind disabused of anv such
misconception. They are distinguished from the ordinary fissure by
being multiple, of a grayish color, with raised edges, slightly indurated
base, and by the existence of other manifestations of syphilis in the
individual. In one case a small red papule was seen 1 inch above the
sphincter.

Secondary Ulcerative Lesions, — Between the secondary and ter-
tiary ulcerations of the anus it is difficult to draw the line. Lesions
ordinarily considered to be secondary may come on years after the in-
fection. The author has reported elsewhere a typical mucous patch
appearing in a patient nearly four years after the initial lesion, and as
ulcerative syphilides are later manifestations than mucous patches, it is
reasonable to suppose that they may occur at even more remote periods.

Where the disease runs successively through the primary, secondary,
and tertiar}' stages it fades so imperceptibly from one into the other
that it is impossible to state when one begins and the other ends. As
a rule, secondary ulcerations are characterized by their early development,
shallowness, small destruction of tissues, and healing without leaving
cicatrices. They may, however, vary in these respects, sometimes being
ver}' destructive, when occurring in the early history of the disease, and
at other times they may occur in superficial form long after the initial
lesion and secondary cutaneous manifestations nave passed away. Thus
it seems that the character of the ulcer is of much more importance
to determine the stage to which it belongs than the period of time at
which it appears, and ulcerations having secondary characteristics, as
just described, may occur within the first few weeks after the primary
lesion, or even years afterward, and clinically and histologically they
are identical in both periods. They are secondary ulcerations at what-
ever period of the disease they occur.

238 THE ANUS, RECTUM, AND PELVIC COLON

The method of their development is various. Tamowsky says:
" Where a constitutional syphilis exists, but without any positive evi-
dence of the disease, an abrasion or local inflammation may take on
the characteristics of syphilitic ulceration, and healing, leave a char-
acteristic syphilitic cicatrix, smooth, white, depressed, and pigmented at
its borders.'' But this type of ulceration ordinarily occurs in the ter-
tiary stage.

Mucous patches through infection or the virulence of the disease
may break down and leave ragged ulcers about the anus, such as the
French call " rhagades.'' Papular, macular, and pustular syphilides,
occurring about the anus, rapidly become ulcers. They may also
begin as local inflammatory effusions or cellular infiltrations. As
these increase the circulation of the parts becomes choked, the tis-
sues break down, and there results an irregular ulcer, gangrenous
or bright-red in color, with elevated edges, sometimes bleeding easily
upon touch, and comparatively painless. The ulcers are frequently mul-
tiple, the intervening integument being perfectly healthy; when they
occur between the radial folds, they assume the elongated appearance
of fissures, the folds themselves become hypertrophied, have a gray,
sodden appearance, and all the parts are bathed in a thin, purulent secre-
tion; in these sites the ulcers are not painless — in fact, without other
evidence of syphilis, one could scarcely distinguish them from simple
fissures.

Sometimes the anal ulcers extend upward and involve the mucouB
membrane, but ordinarily they heal or remain stationary and are
chronic.

In the Rectum. — Above the ano-rectal line one rarely observes any
secondary syphilitic manifestations other than the ulcerative. These
lesions may be either single or multiple; they probably begin in an
abrasion, then follows cellular infiltration, necrosis of the tissues and
the formation of small crater-like ulcers with clear-cut indurated borders;
they rarely extend in the early stages deeper than the submucous tissue.

Unfortunately they present few symptoms at this time, and are there-
fore not recognized until they have reached the chronic stage, when they
are characterized by their extensive area and great destruction of tis-
sue. The entire thickness of the wall of the gut may be destroyed and
the sacrum left bare. If situated upon the anterior wall of the rectum
they may even perforate the peritonaeum (Molli^re, op, cit., p. 645).

The tendency of all syphilitic ulcers is to extend in the line of the
blood-vessels and lymphatics. Thus about the anus they progress cir-
cularly and forward toward the groins, while in the rectum they travel
upward. In the latter position, however, owing to their multiplicity, they
sometimes coalesce and entirely surround the organ. In ulcers about

VENKREAL DISEASES OF THE ANUS AND RECTUM 239

the anus, the lymphatics of the inguinal region are the first affected,
while in ulcers of the rectum those in the hollow of the sacrum become
enlarged. The enlargement of these latter glands must not be mis-
taken for gummata. If the ulceration becomes chronic and develops ter-
tiary characteristics, as it progresses upward in the rectum, it often heals
at the lower margin, leaving a bluish- white cicatrix. The walls of the
rectum beneath the ulcers feel leathery and parchment-like. The dis-
charge is greenish-yellow, purulent, tinged with blood, and very abun-
dant. Mucus is ordinarily absent from the stools. The odor is foetid
and disgusting, but distinctly different from that which characterizes
the discharges from carcinoma.

The patient suffers from tenesmus, a feeling of weight and pain
about the sacrum, and frequent stools. He may rest fairly well at night,
but upon rising in the morning he will immediately pass a large quan-
tity of this sanious pus from the rectum. Later in the day he may have
a natural movement, but at various times throughout the twenty-four
hours he will be called to the closet, only to repeat his early morning ex-
perience of passing greater or less quantities of this greenish-yellow
secretion.

When the condition has existed for some time the sphincters become
relaxed, the radial folds hypertrophy, and the fluid may dribble out
through the anus, keeping the parts moist and irritated. From this
irritation there may develop extensive ulcers about the anus. Whon
they heal they sometimes leave a ragged condition of the anal folds
resembling a cock's comb, but not so red. This condition has been con-
sidered by some as pathognomonic evidence of syphilis. Thus Sir James
Paget says : " I will not venture to assert that these cutaneous growths
are never found except in syphilitic disease of the rectum, but they are
verv common in association with it, and so rare without it that I have
not seen a case in which they existed either alone or with any other
disease than syphilis." While agreeing in the main with what this
eminent surgeon has said, the author still believes that this condition
may develop from other inflammatory conditions than the syphilitic.

The development of rectal ulceration in the early stages of syphilis
is evidenced by the following brief histories :

J., thirty-two, admitted to the Workhouse Hospital, August 25, 1897.
Family history dear. Had been quite well all her life, but given to dissipation.
Examination showed clearly a copper-colored, macular eruption over all the body
and upon the face. She admitted having had a vulvar chancre during the last
week in June. This lasted about four weeks, and healed without any treatment,
except keeping it clean.

Diagnosis. — Secondary syphilis. Treatment, protoiodide of mercury.

September 5th. — Patient complained of aching in her back, diarrhoea, and pains
•hooting down her legs. Examination showed the anus perfectly healthy, even

240 THE ANUS, RECTUM, AND PELVIC COLON

as high up as could be seen by forcibly separating the radial folds. Upon intnK
ducing the finger into the rectum a shallow, ulcerated spot with an indurated hue
a1>out the size of a 25-cent piece was felt. The edges were not particalaiij
elevated, and the mucous membrane around the ulcer appeared to be healthj.
Through the speculum the ulcer appeared grayish-white with a crater-like base and
irregular, clear-cut edges. It involved the right posterior quadrant of the rectil
wall. It was superficial, bled easily, and secreted a greenish-yellow pus in abun-
dance. The eruption was still present upon the patient's body. The sacral glindi
were enlarged, as were also the epitrochlear and post-cervical. The inguinal
glands were not unusually engorged. The ulceration had occurred within tn
weeks of the initial lesion.

Tlie following history of another case seen in March, 1900, in the
same institution, showed that the rectal ulceration coexisted with a
characteristic secondary eru})tion, alopecia and mucous patches in the
throat :

Lizzie , aged twenty- four, a public prostitute. Family history indefinite,

habits vile. Suys she never had any venereal disease until six weeks previoa^
when she had a ** breaking out on her privates."

She entered the hospital February 28th, complaining of great pain with loos of
blood at each defecation, and thought she was suffering from piles. At the stioe
time the body was covered with papular syphilides, the hair came out easily, and
there were two mucous patches in her throat. Local examination showed tbe
nidial folds of the anus hypertrophied, and between them there were granulating
fissures which bled easily upon touch, or when the parts were forcibly aepanted.
There were no mucous patches around the anus, but upon introducing the finger
into the rectum there was found an ulcer extending upward for about 2 inchei^
almost entirely surrounding the rectum, and connected below with the fiasorei
between the folds. At the u[){>er end the ulcer terminated abruptly in healtby
mucous membrane. Tlie base was hard and leathery, the edges elevated and
indurated. It was shallow, and bled easily upon touch.

In this case, as near as can l>e estimated, the rectal ulcer occurped
within eight weeks of the initial lesion. The third case was one seen
in private practice. It was in a young man in whom the initial lesion
occurred on the lip. The induration from this lesion had not disap-
peared at the time of the examination, although the sore had healed.

He had at the time of examination a faint copper-colored eruption upon hk
body. He complained of heaviness and aching about the anus, pain before a
movement of the bowels, and a discharge of pus from the rectum, especially upon
rising in the morning. The anus was healthy with the exception of hypertrophy
in two of the radial folds. There were no fissures and no inflammatory process
apparent upon the outside. The examination of the rectum showed at the height
of H inches a distinct ulceration with clear-cut borders, giving to the finger Ifaat
leathery, parchment-like feeling so characteristic of syphilitic lesions. The spec-
ulum confirmed the impression given to the finger. There appeared at first a
profuse, yellowish-green purulent secretion ; when this was wiped away an ellip-
tical ulcer was seen about 2 centimeters long and 1 wide. It was nodular and

VENEREAL DISEASES OF THE ANUS AND RECTUM 241

slightly depressed, the edges indurated, but not much elevated, and the rectal
wall beneath it seemed to have lost its suppleness.

He stated that the sore on his lip first appeared eleven weeks before consult-
ing me.

In this case the ulceration occurred within twelve weeks after the initial lesion.

Numerous cases could be cited in which the ulcerations have oc-
curred within two, three, or four months after inoculation, but these
appear to be sufficient to establish the fact that they do occur in tlie
early secondary stages of syphilis. The first two cases left the institution
much improved but not well, and it is impossible to say what was the
final result in them. In the last case the patient was observed for over
two years, and there was never the slightest evidence of any stricture of
fche rectum, showing that, if these ulcers are treated in their early
stages, this disastrous complication may be avoided.

The fact that one can not obtain the history of initial lesions, pre-
vious secondary symptoms, or present manifestations of the specific dis-
ease, ought not to deter him from making a diagnosis in cases of char-
acteristic syphilitic ulceration of the rectum, such as the following :

Mrs. S. came to the Polyclinic Hospital, October 15, 1895, sufferiDg from a
profuse rectal discharge which she said had existed for two months. There was
nothing in her appearance to suggest syphilis. Her husband had died from tuber-
culosis one year previous. She denied ever having suffered from any skin erup-
tion or any local ulceration. Her skin was clear, and there was no marked engorge-
ment of the lymphatic glands. The anus was normal with the exception of hyper-
trophied radial folds. There were no ulcers between these folds. The sphincter
was relaxed so that purulent discharges from the rectuhi constantly oozed out,
necessitating the wearing of a napkin. Examination of the rectum showed exten-
aive destruction of mucous membrane of this organ as high as 4 inches above
the anal margin, and surrounding the entire gut. The walls were stiff, inelastic,
and nodular, and bled easily upon touch. The rectal ampulla was constantly
ballooned, but there was no contraction of the caliber of tlie gut at this time.
Around the lower margins of the ulceration there were distinct evidences of the
healing processes in the existence of bluish-white, depressed cicatrices.

The discharge was a yellowish-green pus tinged with blood, and very abun-
dant. At first tuberculosis was suspected in this patient, but careful examination,
day after day, failed to show any tubercle bacilli. Finally, after three months,
the patient consented to take ether, and a small section of the ulcerated mucous
membrane was removed for examination.

Histological report by William Yissman, ^f. D.:

" This specimen shows the epithelium of the mucous membrane entirely de-
stroyed. The LieberkQhn follicles are largely obliterated, there being a few small
depressions, which appear like the lower end of such follicles lined with columnar
epithelium. There is an intense cellular infiltration of the submucous tis.mies
dipping dowu into the muscular layers, and presenting the appearance of new-
formed fibrous cells.

242 THE ANUS, RECTUM, AND PELVIC COLON

** The blood-vessels show distinct endarteritis. Embryonic cells are distrib-
uted along the whole course of these vessels, and at no place are there any giant-
cells or tubercle bacilli, nor are there any accumulations of epithelium whick
would indicate carcinoma. On the whole, one would describe this condition m
productive inflammation with fibrous and cellular infiltration. This is a conditidi
frequently found in chronic syphilitic inflammations.'^

Aiitisyphilitic treatment was begun at once, but too late, for the
patient shortly afterward developed a papillo-squamous eniptioB all
over her body, on the palms of her hands, and on the soles of her ft»et;
engorgement of the etTvieal glands was not found in his patient
Either the woman concealed the true history of her case, or it consisted
in a latent form of syphilitic infection, which first exhibited itself ii
the rectal ulceration, and afterward in the cutaneous eruption. Not-
withstanding the most vigorous antisyphilitic treatment, the use of ln«l
remedies and constant dilatation, it was not possible to prevent contrac-
ture in her rectum ; and to-dav, after seven years, she still has some
ulceration, and finds it necessary to pass the rectal sound twice a week in
order to keep the passage open.

The author luul under his charge in the Polyclinic Hospital in 1901
a case with exactly similar conditions in the rectum. Her uleeratiou
develo])ed about nine months after the initial lesion, and have now con-
tinued for two years. When the ulceration has reached the destructive
stage general and local treatment may finally heal the ulcers, but they
can not prevent the formation of stricture. The prognosis is therefore
always grave.

TreaUnent. — The treatment of these secondary types of syphilitic
inflanmiation of the rectum consists in the administration of merenij
and keeping the parts clean, thus avoiding as far as possible any sec-
ondary infection by streptococcus or other pyogenic bacteria. Like
many of the cutaneous lesions of syphilis, the secondary manifestatiom
of sypliilis in the rectum will sometimes disappear without constitu-
tional treatment under proper antiseptic care of the parts, but medica-
tion should not be neglected. A large number of destructive ulcera-
tions and incurable strictures of the rectum, called syphilitic, are not
due so much to the syphilitic virus as to the septic infections occurring
through the lesions; because of this more stress is laid upon the local
treatment of these conditicms than upon the constitutional. This sec-
ondary infection explains also the statement so often made by syphilog-
raphers and proctologists that mercury and iodide of potash have little
or no effect upon syphilitic ulcerations of the rectum.

A mixed condition, specific and septic, must be dealt with, and there-
fore treatment should be directed in two lines. Complete drainage, even
if the sphincter muscles must be dilated or incised, is requisite to heal

VBNEREAL DISEASES OP THE ANUS AND RECTUM 243

these ulcers, and frequent washings and dressings are important in order
that the parts may be kept free from septic bacteria. To accomplish
this the patient should be confined to bed, if possible in a sanitarium or
hospital, where these directions can be systematically carried out.

After the ulcers have been thoroughly washed and freed from the
secretions, they should be dusted over with some dr}'ing antiseptic
powder, as antinosin, iodoform, aristol, calomel, or boric acid. When
calomel is used, it is well to wash the parts off with lime-water after-
irard, as it will remove the particles more effectually than any other
fluid, and is at the same time a good antiseptic. Stimulation of the
ilcerations by the use of nitrate of silver, sulphate of copper, or other
igents may sometimes be necessary. The tubular speculum and the
mee-chest posture enable one to insufflate powders upon all parts of the
•ectum or to spray them with various medications. The bowels should
)e regulated to move once a day if possible ; the administration of a cer-
ain amount of opium to control the tendency to diarrhoea is often
idvisable.

The constitutional treatment in these conditions is similar to that
>f secondary syphilis in any other portion of tlie body. It consists in
he administration of mercur}^ in as large doses as the patient will bear.
'n rectal syphilis the drug should be given by inunctions, baths, or
lypodermically, as the internal administration is likely to aggravate the
endency to diarrhoea, and should therefore be avoided. Iodide of pot-
ish in this stage of the disease is advised by most syphilographers, though
ts efficacy is questionable. Mercury is probably the only drug which
las any direct effect upon the specific virus ; the iodide acts by hasten-
ng the absorption of the inflammatory deposits, but probably does not
iffect the virus itself. Inasmuch, therefore, as these patients usually
nffer from digestive disturbances, it is best to refrain from using this
>r any other medication by the stomach, except such as are directed
oward the improvement of functional action in the digestive organs.

Tertiary Lesions. — The chief characteristics of tertiary lesions in the
•ectum are as follows:

a. They develop in no regular order with relation to the initial
esion; they may come on immediately after the secondary eruption, or
nonths, even years later ; indeed, they may never come at all.

According to the statistics given by Morrow {op. cit., vol. ii, p. 139),
hey only occur in about 10 per cent of the cases of constitutional
yphilis. Of this number, about 25 per cent occur in the skin and the rest
n the nen'es, bones, and special organs of the body.

h. Another characteristic is that they are likely to be recurrent.
rhey pass away or are dissipated by the action of medicines, and at long
leriods thereafter reappear again.

244 THE ANUS, RBCTUBi, AND PELVIC COLON

c. They arc localized, involve the deeper tissues, are destractive, and
leave cicatrices on healing.

d. They do not yield readily to mercury,
c. They are only mildly contagious, and are nearly always auto-in-

oculable, showing that the ulcers are mixed infections.

The chief types of these affections are gummata, destructive ulcera-
tion, ano-rectal sy})hiIoma, and proliferating proctitis.

Gummata. — Gummata may occur in any portion of the body in
which there is connective tissue. At the anus they are exceedingly rare,
while in the rectum they are somewhat more frequent, thus revcKing
the order of primary and secondary lesions. Fournier states that he hi*
never observed a gumma of the anus except in an extension of gumiM-
tous ulcerations occurring in the neighborhood, and in cases of ano-rectil
syphiloma. Molliere (p. ()41) descrilK?s a gumma occurring primarily at
the anus. Verneuil (Gazette des hopitaux, 1888, p. 202) has reported a
most interesting case of this kind in which the gumma appeared as an
induration at the margin of the anus, about the size of a small orange,
and extending across the ischio-rectal fossa; it was smooth, elastic, and
painless to the touch, and, bt»lieving that the tumor contained pus, be
incised it with a bistoury, but obtained nothing beyond a discharge of
blood. Some days afterward suppuration took place, and a fistula re-
sulted, for which an operation was done. The ulceration and indura-
tion having jK»rsisted, he placed the patient upon antisyphilitic treat-
ment, and obtained a complete cure after a limited time. This case
is in line with several that the author has seen, and reported under
the head of fistuhp, inasmuch as he had not seen them in the gumma-
tous stage. There were induration and ulceration of the wounds with-
out any tendency toward healing until antispecific treatment was begun,
after which it progressed promptly enough. A number of times nodu-
lar deposits beneath the radial folds of the anus have been seen in
cases of tertiary ulceration of the rectum, which may have been gum-
mata, inasmuch as they disappeared under the influence of local treat-
ment to the ulcers and constitutional treatment for the disease: ther
were not recognized as such, however, and seemed to be simply inflam-
matory deposits. Taylor (Journal of Cutaneous and Geni to-Urinary
Diseases, ISSf), p. 220) records a case in which the gumma was situated
in the recto-genital sa?ptum.

Gummata within the rectum have been reported by Bumst^ad and
Taylor (AVnereal Diseases, p. 607), Ball (op. cit., 225), Zappula (Archi?
f. Derniat. und Syphilog., Prague, 1871, p. fi2), Poelchen (Archiv fiir
Path, und Physiolog., Berlin, 1892, ]). 27), and Keuster {ibid., p. 275).
In one case, from which the drawing was made (Fig. 99), the patient had
suffered from syphilis five years previously. She had been treated at the

VENEREAL DISEASES OP THE ANUS AND KECTUM

345

' time. anJ liad noticed no manifeetationB during the three years preceding
the time of examination. Slie complained of pain at defecation, bearing
iiiwa, and the feeling as if some foreign hody was in the rectum. Ex-
amination showed a dry, brittle condition of the anal mucous membrane,
with some hemorrhoids, and a smooth, globular swelling about 1 inch
above the margin of the anus, freely movable both upon the muscular

and mucous wails of the gut. An operation was performed to overcome
the Qasures, the haemorrhoids were removed, and the little nodular swell-
iog was dissected oat.

The pathologist's report described the growth as typical gummatous

niuteriat, with granulation tissue in all stages of development. The

patient was at once put upon antisyphilitic treatment, and the operative

wounds all healed without any complication.

Jl In the case of Zappula there were found in the lower portion of the

^^^ctum some globular, smooth, elastic masses; at a distance of about 4

HEentimeters (]| inch) above the anus there was a similar mass about

^ihe size of a small hazelnut, and painless to the touch; there was no

ukeration and no cachexia. The diagnosis was properly made, and the

tumors disappeared under the administration of iodide of potash. He

ates that symptoms of absolute obstrucfion occurred in this patient.

246 THE ANUS, RECTUM, AND PELVIC COLON

but it is difficult to understand how a tumor of this size in the rectum
could possibly occasion it ; evidently there must have been other and
larger gumniata above, or the symptoms were due to some other cau>e.
Molliere reported a case, somewhat similar to this, in which the gummi
was of a much larger size. When occurring in the rectum these tumois
appear as round, elastic, and painless deposits in the submucous tissuiij
and in their early stages are not attached to either the mtu:ous or muscu-
lar wall of the gut. Later on they may involve both. They are gen-
erally localiz(»d, may be single or multiple, and of any size from a hemp-
seed to a small orange (Poelchen's Path., p. 51).

There is no marked inflammatory zone about them, and they are not
accompanied with any contractile fibrous bands in their early stages, al-
though there may be a slight deposit of fibrous tissue in the neighbour-
hood of the growth. They do not suppurate, but undergo a sort of fatty
degeneration according to Molliere, and thus break down. The facts that
they do not produce abscesses, are not painful, and do not occur in
chains distinguish them from engorged lymphatics. WTien they break
down infection takes place, causing inflammation and an increase ia
the inflammatory deposit. The condition thus resolves itself into an
ulcer, which, healing, leaves a contracting cicatrix that may cause
stricture of the rectum. Temporary stricture of slight degree may
result from gummatous infiltration and fibrous deposit around it, but
these strictures do not become permanent unless there is some destruc-
tion of tissue by necrotic or ulcerative processes. All the reported cases
in which gum mat a of the rectum have been recognized and treated
without the occurrence of ulceration, have recovered without leaving
strictures. Thus one may refer to the cases of Zappula, Taylor, Four-
nier and Gant, in which all the syphilitic manifestations disappeared
under general treatment and left no contracture.

When gummata disintegrate, the destruction of tissue may be ex-
tensive, sometimes even perforating the wall of the gut; if this occurs
upon the anterior wall in females, it may result in recto-vaginal fistula.

Taylor states that involvement of the rectum may be secondary to
an " indurated cedema " following infiltration and ulceration of the
vulva or anus earlv or late in the disease ; that ulceration from such
conditions resembles the chancroidal, and that it has a tendency to the
production of rings of connective tissue about the rectum. He says that
these rings are not gummatous in their nature, and the induration and
swelling occasioned by them should not be mistaken for this form of the
disease. In other words, they are simple inflammatory products and not
syphilitic. The importance of this statement will be appreciated when
we come to the study of stricture of the rectum, and learn that many
strictures in syphilitics are not syphilitic.

VENERBAL DISEASES OF THE ANUS AND RECTUM 247

Tertiary Ulcerations, — One of the most frequent manifestations of
tertiary syphilis is a dry, brittle condition of the muco-cutaneous tissue
about the anus resembhng that seen in atrophic catarrh. Forcible sepa-
ration of the buttocks or stretching of the anal canal in these cases will
produce little buttonhole-like slits in the membrane, which bleed and itch,
but do not cause actual pain. The passage of a hard stool or the intro-
duction of a bougie will cause these rents. They are sometimes points
of infection, and ulcerations result which combine both specific and
septic characteristics. The process extends upward between the radial
folds, and may involve the mucous membrane of the rectum to an in-
definite height; the ulcers may become phagedenic and result in great
destruction of tissue, as in the case of Lane (Lancet, London, 1891,
vol. i, p. 486), where almost the entire perinaeum, together with the
anal and vaginal orifices, were destroyed, notwithstanding antisyphi-
litic medication.

Tertiary ulcerations also result from traumatism, disintegrating
gummata, and from necrosis of tissue due to occlusion of the arterial
supply by endarteritis.

The anus and rectum are subject to frequent traumatisms from
hard stools, foreign bodies, etc.; in women they are often injured dur-
ing coitus, pregnancy, and childbirth; all such injuries may take on
a specific nature in syphilitics. That they do not yield to mercury and
iodides is due to their constant irritation and infection by the fa?cal
passages. Such ulcers lose their specific characteristics under specific
treatment, and histological examination then reveals only a chronic
inflammatory condition; those due to gummata and endarteritis usu-
ally maintain their specific characteristics until they are healed, because
the process is more deeply seated and requires a longer time for eradi-
cation.

Tertiary ulcers occur most frequently just within the rectum ; they
are deeper than the secondary ulcers, are crater-shaped, have yellow
indurated bases, sharply defined borders, and are rarely ever under-
mined. Surrounding and beneath them the rectal wall is thickened,
stiff, and inelastic, which condition, when it involves any considerable
portion of the circumference, sooner or later results in stricture.

Infection is an important element in their tardy healing, and may
have much to do with the fibrous deposit that causes the contracture.
This, together with systemic conditions, such as diabetes, Bright's dis-
ease, and tuberculosis, is accountable for those widely destructive phage-
denic conditions, many of which have been collected an" reported by
Hahn (Arch. f. klin. Chir., Berlin, 1883, p. 395). In one case, seen
some years since, the entire anus and sphincters were destroyed, the
membranous urethra was left bare, and the mucous membrane of the

248 THE ANUS, RECTUM, AND PELVIC COLON

rectum entirely obliterated to the height of over 6 inches. Xotviih-
standing there was a distinct history of syphilis in this ease, micro-
scopic examination of the si>ecimen removed showed only chronic inflam-
mation, with here and there slight endarteritis. These ulcers not
infrequently perforate the rectal wall and result in fistulas of various
types, which do not differ from simple fistulas except in tardiness of
healing.

The suppuration in extensive ulcerations of this type is sometimes
enormous, llahn has reported a case in which it amounted to a liter
j)er day, and recently in the Polyclinic Hospital a case was treated in
which it was almost as much. The odor is not characteristic as in
cancer.

Ano-recfaJ Syphiloma of Fournxer, — Foumier (Lesions tertiaires
de Tanus ct rectum, Paris, 1875) describes under the above heading a
specific fibrous inriltrati(m of the rectal walls: They are thickened, mam-
millated, and rigid in feeling, without any ulceration. He states that
it is essentially a hyper])lastic proctitis tending to sclerotic change, as is
seen in the kidneys, liver, and other organs in late syphilis. It begins
in the submucous tissue, and, according to him, when ulceration oceuK
it is the result of the j)rocess and not a part of it. He says (France
medical, October 31, 1874) that "the essential redoubtable phenomena
upon which depends all the evolution of this pathological process is a
tendency to contract. This contracture is, by virtue of its fibrous tissues,
comjmrable in this to inodular tissue, that it retracts without cessation
upon itst'lf.'' Foumier states that the disease is always due to acquired
syphilis, but Ball mentions a case in a boy ten years of age suffering
from congenital syphilis. Van Harlingen (International Encyclopaedia
of Surgery, vol. ii, p. 519) claims that the disease rarely extends beyond
2J inches from the anus. This limitation, however, is not corroborated
by other observers. Maclaren (Edinburgh Clin, and Path. Jour., 1883-
^84, p. 875) considers this a form of infiltrating gumma. His micro-
scopic reports, however, disprove this, for he says: " The tumors were
composed of dense, fibrous tissue sparingly supplied with blood-vessels/*
a condition not seen in gummata.

The majority of syphilographers have adopted the theory of Four-
nier, and the weight of authority is therefore in its favor. They state
that in the early stages it produces no symptoms such as pain, discom-
fort, or obstruction to the movement of the bowels : that the onlv method
of diagnosing such conditions would be by early digital examination^
which would show a thickened, infiltrated, inelastic condition of the
rectal wall containing more or less nodular masses extending for sev-
eral inches upward from the anus: that this condition proceeds until
constipation from gradual contraction of the rectum results, and the

VENEREAL DISEASES OF THE ANUS AND RECTUM 249

mucous membrane breaks down, owing to friction, abrasion, infection, or
some interference with its circulation. According to this theory the
stricture occurs firsts and the ulcerations which follow it are produced
by other causes than the actual specific disease. There is no authenti-
cated report of the careful observation of such a course of events in a
single instance, and it appears to the author, therefore, as purely the-
oretical.

The experiences and opinions of others upon this condition of the
rectum, so ably described and defended by Fournier, are given here,
though in many years' experience in rectal examinations the author has
never observed a single typical case of this ano-rectal syphiloma, lie
has observed a number of cases in which the patient had suffered from
syphilitic proctitis and ulceration in the secondary stages of the disease,
which ulcerations had healed, the patients had thought themselves cured,
and discontinued treatment, but after\i'ard found that the disease had
returned in the form of fibrous infiltration and stricture of tlie rectum.
In everv one of them there were characteristic bluish-white cicatrices,
and the patients gave a history of having suffered from irritation of the
rectum and a discharge of mucus or pus at some previous time. The
condition which Fournier described exists, but it is associated with a
history or evidence of a previous rectal ulceration. Fournier alone
positively and unequivocally claims to have observed this condition
from the beginning, and even his reports do not eliminate the possi-
bility of previous ulceration. Quenu and Hartmann, in their excellent
work, cite only one example of this condition, and this they say was
preceded by syphilitic ulceration of both the rectum and anus (o/y. cii.y
vol. i, p. 92). It seems, therefore, that the condition originates in
specific ulceration, which becomes infected, and thus sets up a proctitis
with fibrous infiltration. In proof of this we may cite the fact that
mercury and iodides have no effect upon it, as they would do if the
infiltrate were syphilitic in its nature.

Proliferaiing Proctitis, — Under the title Rectitis Proliferante Syphi-
litique, Paul Hamonic (Annal. med. chir. trans., France et etrang.,
1886, vol. ii, p. 3) has described a condition which he considers a pecul-
iar .«yphilide. The disease consists in a growth characterized by fragile
villous prolongations, of feeble resistance, from the mucous membrane
of the rectum. In the cases cited the tumors filled up the rectum,
and yet, according to Hamonic, they did not tend to form a stric-
ture. Kelsey (op,cit., p. 335) has detailed a case, which may be of
this same character, under the title of syphilitic ulceration of tlie rec-
tum. The author has also reported a case of this nature, but in which
true obstruction of the rectum took place. Here there was a specific
fibrous stricture underlying the hypertrophic granulations or villous

250 THE ANUS, RBCTUM, AND PELVIC CX)LiON

condition. Such a state of affairs may be brought about by irritating
(liscliarges from specific or non-specific ulcerations.

In the autlior^s case the history of long-standing ulceration was clear.
The condition entirely disappeared under antiseptic and antisyphilitic
treatment after colostomy, but left only a narrow fibrous canal where
the rectum had been.

The pathological examination of all these ulcerated types of syphilis
of the rectum shows a consistent sequence of events; first, the dest^l^
tion of the cylindrical epithelium of the mucous membrane, which maj
afterward be rephiced by a corneous or pavement epithelium covering
a cicatrix (Hartmann); second, a cellular infiltration by embryonic ele-
ments sometimes containing yellowish nodules of a gummatous t3rpe,
almost surrounded by a fibrous or sclerotic zone. In the early stages
the blood-vessels are multiplied and dilated ; in the later stages they are
decreased, contracted, and always present evidences of endarteritis. It
is simply a question of the age of the process, whether the cells are
young and feeble or whether they are old and surrounded by strong |
zones of sclerotic tissue, as to whether it can be resolved or not.

Syphilitic Stricture of the Rectum, — Enough has been said above to
indicate my belief that unadulterated syphilitic strictures of the rectmn
are very rare. There is not an authentic case on record in which care-
ful, systematic examinations throughout the early stages of the disease
have failed to show ulceration of the rectum at some time previous to
the stricture. Any solution of continuity in the mucous membrane of
the rectum forms an open doon^'ay for septic infection and consequent
inflammation.

While we know that a large number of strictures of this organ occur
in people in whom there is a more or less distinct history of constitu-
tional syphilis, yet we must bear in mind the fact that because a patient
once had syphilis will not account for all his pathological accidents in
after life. He may have a stricture of the urethra, the rectum, or cesoph-
agus, that is not syphilitic in its nature, and upon which antis^^philitic
medication will not have the least effect. Those who claim that this
condition is due to a primary infiltration of the rectal walls by syphi-
litic material fail to fortify their opinions by a record of careful pre-
liminary examinations. Have they ever examined the rectum of one
of these cases throughout the course of his disease a month or a year
before they found the stricture? All admit the process of stricture
formation by ulceration, but try to explain away the complicating effects
of infection by abstruse theories of syphilitic cellular infiltration of the
rectal wall.

The first stage of these strictures consists in an ulceration, trau-
matic or otherwise, of the nmcous membrane. This is followed by the

VENEREAL DISEASES OF THE ANUS AND RECTUM 251

deposit of a soft embr^'onic tissue in the submucous wall of the gut,
together with infection by colon bacilli or other germs. This inj&ltra-
tion and infection penetrate downward into the muscular wall. The
mucous membrane may reform over this area, producing a soft cicatrix,
over which the epithelium, changed to a stratified type, is established,
and presents a bluish-white appearance. This cellular infiltration having
once penetrated the muscular wall of the gut, finds a channel of least
resistance between the circular fibers, and thus gradually infiltrates the
whole circumference. The profound infiltration has a much greater
tendency to surround the gut than has the superficial, because in the
superficial and submucous layers it follows the course of the blood-ves-
sels. Thus we sometimes find a limited ulceration upon the wall of the
intestine with an extensive, deep infiltration almost surrounding the
gut. In the early stages of this infiltration these tissues are soft and
dilatable. They also yield comparatively good results to the adminis-
tration of antisyphilitic medication and dilatation, but if organization
of fibrous tissue has taken place, if the muscular fibres have become
atrophied or transformed into fibrous tissue, medication and dilata-
tion are no longer permanently effectual. One may give mercury
and iodide and stretch the parts to the highest limit, but they will
recontract.

The comparison made by Monot between rectal stricture or ano-
rectal syphiloma and syphilitic testicle is not at all logical, because wo
have to deal in one case with a true glandular organ, and in the other
with a muscular and mucous membrane. Injury to the mucous mem-
brane, infection, ulceration, and inflammatory deposit are the steps in
the production of ever}' stricture, and in the syphilitic this inflammation
takes on the character of the constitutional disease — viz., gummatous
deposits and endarteritis.

For the pathology and further consideration of syphilitic stricture
the reader is referred to the chapter on Strictures of the Rectum.

Treatment. — The treatment of tertiary syphilis of the anus and
rectum differs from that of the disease elsewhere in the body only in
the management of the local conditions. It consists in the adminis-
tration of the iodides in as full doses as the patient can bear, inunc-
tions or hypodermic injections of mercury, and the topical treatment
of local conditions. As many of these patients suffer from digestive dis-
turbances, it is frequently found that the iodide of potash aggravates
these conditions; it should be administered in milk, the essence of pep-
sin, or the elixir of lactopeptine. Giving it in moderate doses and fre-
quently will often accomplish better results than a few large doses given
in water, and at the same time the patient is being nourished ; when
milk is not acceptable to the individual, the iodide can be dissolved in

252 THE ANUS, RECTUM. AND PELVIC COLON

it and then converted into whev bv the addition of a little rennet. The
fluid portion of this whey contains practically all of the iodide, and is
generally well borne by the stomach. The iodide of potash niay be
alteniated with the iodides of sodium, lithium, and strontium; the
amount which may be administered in a day is very variable: some pa-
tients stand exceedingly large doses, while others can take only moder-
ate quantities; in general, one is able to obtain as good results from
(50 to 100 grains of the drug j)er day as from the enormous doses recom-
mended in certain sj)ecial works.

As to the mercuric inunctions, the methods of carn*ing this out
are descrilx'd in all books upon thera])eutics and geni to-urinary diseii«L
Very good results may be obtained by enclosing 3 or 4 drachms of mCT"
curie oint!n(»nt in a llannel amulet, which is fastened around the pi-
tientV neck by a band, thus allowing it to hang about the middle of his
chest or between his shouhhT-blades ; this is much more deanlv thantho
ordinary inunctions, and seems to accomplish as good results. For
hyjxxlermic administraticm bichloride of mercury has proved most sati^-
factory, but siil icy late of mercury seems to be very effectual.

The local treatment of the different manifestations is practically
the same as that descrilx»d for s(»condary syphilis. Rest in bed, functional
rest to the parts by the ])roper regulation of the bowels, antiseptic irri-
gations or washings, and occasionally stimulation by mild cauterizing
agents in the sluggish, ulcerative conditions, are the general lines upon
w^hich this sho\ild be conducted. When there is extensive ulceration
and ])rofusc jnirulent discharge from the rectum, drainage of the parts
sho\ild Ik* established by dilatation of the sphincters, and if necessary
the introduction of two small drainage-tubes in order to prevent the
accumulation of these septic discharges in the ampulla. With the two
tubes in place one may irrigate the parts frequently without disturbing
the patient very much. Solutions of benzo-naphthol, boric acid, /3-naph-
thol, bichloride of mercurv, and chloride or bicarbonate of sodium are
all useful for this purpose.

The dilatation of the sphincter should be gently and carefully made
so as to produce as little traumatism as possible. The swollen hyper^
trophied folds around the margin of the anus should ordinarily be left
alone, as they will largely disa])pear after the inflammatory process has
subsided. Condylomata developing around the anus may be treated by
cutting them off w^th scissors, cauterizing them with the actual cauteij,
or, better still, by the application of monochloracetic acid, followed by
some drying powd(»r, such as has been mentioned before. Aft«r the
ulcerations have begun to heal, the rectal dilator or a largo-sized bougie
should be used every two or three days to prevent contraction.

In those severe types in which the mucous membrane of the rectum

VENEREAL DISEASES OF THE ANUS AND RECTUM 253

is practically destroyed, the utmost patience and perseverance will have
to he exercised by both doctor and patient ; months and years of treat-
ment are necessary to heal such conditions.

There is no doubt that healing may be hastened by absolute rest
tb-ough the production of an artificial anus, a proceeding that may be
justif ed in these cases, although very few patients will submit to it. It
has been carried out by Hartmann, Hahn, and several other surgeons,
and the author has treated three cases in this manner, all of which
healed finally but not rapidly. In two of them there was permanent
stricture left, which rendered it inadvisable to close the artificial anus;
in the other the ulceration healed in about three months, and the
colostomy was repaired shortly thereafter; but the rectum never as-
sumed its normal, smooth, elastic condition. In one of the first two
cases an artificial anus had been made and closed by another surgeon
previous to my seeing her, and the ulceration and stricture of the rec-
tus had recurred after the closure ; so it was best to make a permanent
artificial anus after Bailey's method in her case. Such experiences lead
^^ the conclusion that, while these ulcerations heal more rapidly by
^^ing the parts absolute functional rest, at the same time one should
"^ Very guarded in prognosis, for healing even under these circumstances
^^ slowr, and the condition is likely to recur after the normal channel is
^established.

The treatment of stricture will be considered in the chapter upon
that subject, and the methods of making artificial ani can be found in
the chapter on Colotomy.

Hereditary or Congenital Syphilis of the Anus and Rectum. — Lesions
of the anus are among the earliest manifestations of hereditary syphilis.
They may occur at any time after birth up to several years of age,
but the most frequent period at which they are observed is during the
first three months. In the large number of hereditary syphilitics which
pass through the eleemosynary institutions these manifestations about
the anus are unrecognized, or considered simple irritative lesions due to
lack of cleanliness and proper diapers. It is not until the later mani-
festations of hereditary syphilis appear that a true diagnosis is made
in the majority of cases. However, there are instances in which late
seeondar\' cutaneous and osseous lesions have occurred in infants in
whom earlv examination had failed to disclose anv rectal or anal affec-
tions. On the other hand, over 50 per cent of the children bom from
syphilitic parents have manifested the disease within the first six months
through lesions about the anus. Besides those cases in which the parents
were known to be syphilitic, the author observed in his clinic for diseases
of children at the Northern Dispensary of Xew York, a number of cases
of hereditary anal syphilis in infants whose mothers were free from any

254 THE ANUS, RECTUM, AND PELVIC COLON

external manifestations of, and denied having suffered from, the dis-
ease; this would indicate, of course, infection from the father.

The disease first appears in children as a sort of erythema or derma-
titis around the anal region, which may occur within the first few davg
of life, or it may be delayed for several months. Elsewhere a ease was
reported in which the author obsened this erythema at the age of
three days (Morrow's System of Genito-rrinar}' and Cutaneous Dis-
eases, vol. ii, p. 436); since that time he has seen a child apparently
born with it, as the condition was pn^sent twenty-four hours after birth.
The parents of this child were both syphilitics.

The erythema is often accompanied by a fragile condition of the
mucous membrane and shallow fissures between the folds of the anus.
If these fissures are not ])resent, they may be produced by the forcible
separation of the buttocks. The conditicm is very easily confounded
with that irritated condition called chafing, which is produced by contact
with the urine and fiecal materials ; the brittle condition of the mncoug
membrane, however, and the numerous small fissures between the radial
folds will serve to distinguish these two conditions.

In the early stages the skin is slightly pigmented, red, or copper-
colored in a zone extending about 1 or 2 centimeters around the anus;
but after a few days the skin becomes somewhat thickened and elevated,
and thin, sero-purulent discharges are set up, which soon assume a
foetid odor. The little dry fissures do not extend beyond the margin
of the s])hincter in this early stage, but if the condition is not treated
they may penetrate the anal canal itself, become infected, and develop
into progressive ulceration of the anus and rectum. This ulceration
mav occur within the first three or four months of life. Little fissures
may be complicated by hypertrophy of the radial folds. When they
have existed for a considerabh* period without treatment they take on
the characteristics of true fissure — i. e., they cause pain, burning, and
constipation due to fear of going to stool on account of suffering. A
marked instance of this was recently observed at the clinic.

A child fifteen months old s\iiTered from constipation and*little in-
flamed tabs about the margin of the anus. It had typical pigmentation
and induration of the tissues about the orifice. The mucous membrane
cracked easily at various points upon forcible separation of the but-
tocks, the inguinal lymphatics were enlarged, and in the posterior wall
of the rectum, about 3 inches above the anus, there was a smooth, round,
elastic deposit, over which the mucous membrane moved easily, and
which itself could be moved upon the muscular wall. There were no
other enlargements above or below it, which w^ould have been the case
in all probability if this was a lymphatic engorgement. It is needless
to say that this growth was a true gumma. There was a distinct painful

VENBREAL DISEASES OP THE ANUS AND RECTUM 255

fissure and sentinel pile, which the illustration shows (Plate III, Fig. 3).
If the diagnosis of these erythematous irritations about the anus be
in doubt, and if the history of the case does not justify one to assume
syphilis to be the etiological factor in their production, he may wait
for the development of other S3rmptoms to corroborate his opinion.
Ordinarily these symptoms are not slow to appear. The lack of normal
development in the patient, the appearances of the squamous lesions
upon the soles of the feet and in the palms of the hands, the dry, rigid
condition of the flexures of the joints, Hutchinson's teeth, and fre-
quently the development of other cutaneous manifestations, will lead
to a positive diagnosis. It is a question, however, whether in such
cases one had better not adopt the principle of Wood, and, admitting
that there is a possibility of hereditary syphilis in every child, treat
it upon that principle, and give the innocent babe the benefit of a
doubt. Delay is sometimes disastrous; whereas in most of the causes
in which the condition is recognized immediately after birth, and
treated actively, the disease can be mastered, and a comparatively
healthy child developed. From the first to the fourth year late mani-
festations of syphilis develop in hereditary cases. The little patient
described above suffered (so his mother said) with redness and chafing
about the anus since he was bom, though there had never been any
other skin lesions, and the child seemed to be fairly nourished. He had
typical Hutchinson teeth and general glandular enlargements. Aside
from this and the anal manifestations, there was no other evidence of
syphilis. The mother stated that the father had suffered from breaking
out on the body and sore throat at various times.

In 1893 a child two years of age, who had suffered from shortly after
birth with inflammation about the rectimi, was brought to the clinic.
This cliild not only had induration, thickening, and pigmentation about
the anus, but also ulcerative lesions about the folds of the nates. There
was an inelastic, leathery condition of the rectal wall, and three well-
marked gummata in the organ. There were also crescentic patches of
papular syphilides at several points upon the body. The father denied
venereal taint, but at the very time had a tertiary eruption upon his
body, and was suffering from a small syphilitic ulcer in the rectum,
which he supposed was an inflamed hgemorrhoid. I have followed these
cases up to within the past year. The father is apparently perfectly
well. The child has grown to be a healthy maiden ; the induration and
thickening of the rectum have entirely disappeared, and one could not
recognize the fact of her ever having had the disease.

Ball (op. dt.j p. 184) reports a case in a child ten years of age in
which there appeared to be the condition known as ano-rectal syphiloma.
In the chapter on Congenital Malformations reference was made to

256 THE ANUS, RECTUM, AND PELVIC COLON

syphilis as an etiological factor in the production of congenital stric-
tures of the anus. Bodenhamer (op. cit., p. 63) looks upon this as an
established fact.

Notwithstanding the majority of manifestations of syphilis in chil-
dren are hereditary, one ought always to bear in mind the possi-
bility of its being acquired. Quenu and Hartmann give an interest-
ing case of this kind, in which a child of two years of age passed
through a typical sequence of early and late secondary syphilis, fol-
lowed by well-developed tertiary symptoms. The father of this child
is said to have contracted syphilis after the child's birth, the mother
was free from the disease, and therefore by inference the authors con-
cluded that it was a case of acquired primar}' syphilis, and not hereditary
disease. Bearing upon this same subject, we also refer once more to
the remarkable statistics of Duhring, of Constantinople, who states that
out of 31 chancres of the anus and rectum, 26 were in children, all of
which must have been acquired and not hereditary. Whether these in-
fections were due to accidents or unnatural vice the author fails to
state.

Syphilitic ulcerations of the anus and rectum in children do not
usually involve any extensive area, nor are they accompanied with any
great destruction of tissue; the process seems to limit itself to the
cutaneous, mucous, and the immediate underlying tissues.

Treatment. — The constitutional treatment of hereditar}' syphilitic
manifestations about the anus differs in no wise from that of hereditary
syphilis in other portions of the body.

Mercuric inunctions either through the stomach bandage, by rubbing,
or through the wearing of the amulet-like bag containing mercuric oint-
ment, arc all good, and should be persisted in for long periods. Iodide of
potassium or other salts in small doses, together with tonics, especially
hypophosphites and cod-liver oil, should also be used.

As to the local conditions themselves, applications such as have
been mentioned for the treatment of these conditions in adults, only in
milder proportions, should be adopted. Equal parts of glycerin and
cod-liver oil have been found to be an excellent remedy in these chil-
dren, in that it is not only ii nourishment and a tonic, but it also keeps
the fapcal movements soft and regular.

Prognosis. — The prognosis in these cases is variable. Just in pro-
portion to the early recognition and radical treatment adopted will it
be good or bad. The majority of cases, if seen and treated during the
first two or three months, will escape all later manifestations of the
disease. In some children, however, the general vitality is so feeble,
even at the time of birth, that no troatnient, specific, tonic, or other-
wise, succeeds in establishing good health. Especially is this the case

VENEREAL DISEASES OF THE ANUS AND RECTUM 257

in foundling asylums and eleemosynary institutions, where the lack of
pnjiHjr food and general hygienic surroundings make the conditions un-
favorable.

In the better walks of life, where every need can be met, and every
luxury afforded, these children generally escai)e the manifestations of
the disease, owing largely to the fact that the intelligence and general
knowledge of their parents upon these subjects lead them to an early
recognition of their responsibilities in the case, and the admission of the
facts, so that no time is lost.

In the lower walks of life ignorance, carelessness, and lack of clean-
liness all contribute to negligence and late recognition of the child's
condition ; hence the prognosis in this class is unfavorable.

CII.VPTER VIII

NON-SPECIFIC ULCERATIONS

The term non-specific is employed here simply to distinguish the
various types of ulceration from the venereal and tubercular varieties.
Many of them may be due to just as specific bacilli, but so far these
have not been isolated and specialized. The general plan already out-
lined will be followed, and the subject will be divided into:

Ulcerations of the Perianal Region.

Ulcerations of the Anal Canal.

Ulcerations of the Rectum and Sigmoid.

ULCERATIONS OF THE PERIANAL REGION

Ulcerations at the margin of the anus and of the cutaneous tissue
surrounding it are not limited to any age, sex, or environment; they
are more frequently found in those in the lower walks of life where
attention to hygiene and cleanliness is not much observed. They are
due to traumatisms followed by infection, irritating discharges from
the anal and rectal canals, gonorrhoea, chancroid, chancre, syphilis,
herpes, ringworm, tuberculosis, and carcinoma.

Traumatic Ulceration. — Traumatic ulcerations of the perianal region
differ from cutaneous ulcerations elsewhere in the body only insomuch
as they are influenced by the anatomical relations of the parts. While
the skin upon the buttocks is tough and thick and the epithelium
homy and dr}% that aro\md the margin of the anus becomes thinner
and thinner as it approaches the muco-cutaneous surface. In it are
embedded sebaceous and hair follicles, together with many sudoriferous
glands and an increase of pigment. In the mouths of these little folli-
cles and glands the bacteria and bacilli which normally inhabit the
intestinal canal, and are conscHiuently brushed over this area by the
fjecal passages, find a habitat and are always present. Any traumatism
or abrasion of the parts therefore becomes easily infected and an ulcera-
tion results, the progress and extent of which will depend upon the care
given to the lesion, the vital resistance, and general constitutional con-
258

NON-SPBCIFIC ULCERATIONS 259

dition of the invalid. When extreme cleanliness is observed, antisep-
tics are used, and the parts are protected from constant friction, they
generally heal kindly in individuals otherwise healthy; under other
conditions the infection becomes progressive and they may extend
over large areas.

WTien the ulcer originates in a superficial lesion and affects the
surface of the skin only, it will ordinarily limit itself to these tissues;
but those due to furuncles or perianal abscesses may extend to in-
definite depths.

Simple ulcerations are due to infection by various pyogenic germs,
including staphylococcus, pyogenes albus or colon bacillus. Tliey may
be single or multiple. Their shape is very irregular; the edges are
red, but not much inflamed, and gradually slope down to the base,
which is crater-shaped, highly granular, sometimes furrowed, and
bathed in a purulent discharge.

There are no constitutional symptoms, and the lymphatics are
rarely involved. Wiping or cleansing the parts causes a bloody oozing.
The act of defecation may be somewhat uncomfortable, but does not
occasion acute pain; sometimes a slight bleeding follows it owing to
the abrasion of the surface, but there is never anything like a ha3mor-
rhage. Pruritus is often a very annoying symptom.

Little abscesses may develop in the deeper layers of the skin owing
to infection of the sebaceous or hair follicles, but they rarely pene-
trate the subcutaneous cellular tissue.

Treatmetit. — The treatment of such ulcerations consists in the pro-
tection of the parts from friction and keeping them surgically clean.

In the first stage the patient should be kept ver\' quiet and the
parts washed frequently with permanganate of potash or peroxide of
hvdroiren, followed bv a l-to-2,000 solution of bichloride of mercury.
A pledget of gauze soaked with the latter solution should be placed
between the folds of the buttocks to prevent their rubbing against
each other and thus developing other ulcers. When the pruritus is
marked, a solution of methylene blue may be painted over the parts
once in twenty-four hours.

After the purulent discharge has been checked, applications of
some drying powder, such as bismuth, st carat e of zinc, or nosopliene
may be employed. A mixture of equal parts of starch and boric acid
is a ver}' good and inexpensive application. Where the ulcer is slug-
gish and disinclined to heal, an occasional touching of the parts with
tincture of iodine or nitrate of silver will hasten the process.

Regularity in the fa?cal movements and attention to the general
constitutional condition, giving tonics, if necessary, and regulating the
diet by wholesome, non-irritating foods, will generally be sullicient in

260 TUE ANUS, RECTUM, AND PELVIC COLON

these cases; but one should always bear in mind the possibility of
seoondarv infection of tlie ulcer bv tubercle bacilli.

Herpetic Dlceration of the Anns — Herpes. — Herpes is not fn^
quently spoken of as an affection of the n^ctuni and anus. This i<
surprising considering the number of cases which have been leponed.
Engle-Reimers (Jahrbiicher der Ilamhurg. Staats-Krankenanstalten,
vol. ii, p. 98, 1890) has reported *^5 cases of herpes ani that occurred
in 1,872 women aiTected with venereal disease.

Syphilographers in general acknowledge its frequent appearance
about the margin of the anus. While it is not generally understood
that it has any etiological connection with syphilis or other venereal
affect icms, it occurs fretpiently upcm the genital organs and seems to
have some contagious element. It occurs at the margin of the anus
close to the muco-cutaneous border, but involves the skin just as it
does at the margin of the lips. It may follow malarial fever, acute
attacks of indigestion, or occur during the course of pregnancy.

Pathohijii, — The pathology of this disease is not clearly understood.
It occurs as an idiopathic affectitm, and is also associated with many
diverse condititms. It mav be due to a neurosis, to loc^al irritation,
or to a s])ecial parasite, as has been claimed by St. Clair S^nnmere
(Brit. Med. J., December 19, 1891). It is also claimed that it is due
to rheumatism or gouty diatheses. Imt this seems very h}'pothetical.

Sifwpinms. — Herpes occurs as single or grouped vesicles over which
the epidermis is elevated, and in which is an accumulation of clear
or milky-white serum. These develop after a slight itching or burning
sensation in the ]>arts. They sometimes coalesce, forming one large
bleb, around which tiiere nuiv be considerable cedema of the tissues.

Owing to the cimtact of the ])arts these blebs soon rupture and
leave raw surfaces. They do not bleed, and at first discharge only a
serum which forms a sort of yellow crust over them. This soon drops,
however, leaving an open door for infection by the germs which are
always present in the sTvin about the anus or in the fax'al passages;
thus an ulceration develops. In such cases the herpetic natun* disappears
and we have to deal with a simple ulcer. At this period it is very diffi-
cult to distinguish the tlisease from chancroid or even true chancre, espe-
cially if the ])arts have been irritated by cauterants or acrid discharges
from the vagina. It may generally be distinguished by the period of
incubation, slight amount of induration, lack of destnictive tendency,
and absence of glandular involvement.

Treatment. — When seen in its first stages treatment is always rapidly
effectual. The bleb should be o])ened and its thin covering excised,
the parts should be washed with an antiseptic solution, and after this
a soothing drying powder should be applied. Either aristol or noso-

NON-SPECIFIC ULCEEATIONS 261

phene act extremely well in herpetic sores because they absorb moisture
and form a sort of protecting shield over the parts.

The prevention of relapses is of paramount importance in these
eases. The vesicles are liable to return on the slightest provocation.
The parts should therefore be kept scrupulously clean and protected
from friction by pledgets of gauze. They should be bathed in as-
tringent solutions, such as alum, tannic acid, and sulphate of zinc, to
toughen the epidermis. Quinine, strychnine, and arsenic should also
be administered for their effect upon malarial and nerve complaints.

Eczema of the Anns. — Eczema is not an infrequent alTcction of the
anus. Ordinarily it appears under the erythematous form and is ac-
companied by superficial fissures radiating from the center, which some-
times extend into the anal canal. It is verv often associated with the
same type on tlie scrotum and elsewhere in the body.

In its clironic form there is a certain amount of infiltration of the
perianal tissues. The skin is dry, brittle, and easily cracked by any
stretching.

The term moist eczema is no longer recognized by dermatologists,
but there sometimes occurs an alteration in the ervthematous form

around the rectum which justifies this nomenclature.

Vesicles containing serum, such as are described under the title of
Eczema Vesiculosum, have not been observed, but around the margin
of the anus and between the folds of the buttock there occurs a moist,
red condition of the skin following the original erythema and charac-
terized by burning, itching, and a watery discharge. 'I'his exudation
possesses that gluey character which stiffens fabrics and gives them a
slightly yellowish tinge when it comes in contact with them. It is
not associated with any formation of crusts, probably on account of the
close apposition of the parts, which prevents rapid evaporation. On
the buttocks and in the perineal and coccygeal sulci this moist, exuding
condition gradually fades off into the erythematous form upon the
scrotum and skin.

For the etiology of this disease the reader must consult the works on
dermatology.

Treatment. — Attention to hygienic conditions, regulation of the
bowels, diet^ir}' control, and the internal administration of such medi-
cines as will overcome those diathetic conditions characterized by de-
ficient oxidation and imperfect functional action of the organs in con-
sequence, will all be necessaiy for the successful treatment of this
condition. In the first place the uricai'mic state, if present, sliould be
attacked bv the administration of alkaline diuretics, the flusliing out
of the kidneys with large quantities of water, and sometimes one will
find piperazine a prompt and effectual remedy. Arsenic, sulphur, and

262 THE ANUS, RECTUM. AND PELVIC COLON

small (loses of iodide of jmtasli have been highly recommended. Pif-
fard speaks in glowing terms of viola tricolor in this condition, and
states that it has a decided action iip<m the kidnevs, to which is proba-
bly due its influence upon the disease. He advises its use in snuill
doses in acute cases, and in large ones in chronic conditions, varying
in amount from one drop to a teasjwonful acx-ording to the age of the
patient and the chronicity of the disease.

As to the local treatment, it would require a volume to even mention
the many combinations and preparations suggested for the treatment
of eczema ani. All irritating substances should be avoided. Hot water
applied persistently is one of the best ways of relieving the congestion,
itching, and irritation of the parts, and to this one may add a small
quantity of bicarbonate of soda. Some authors stnmgly disapprove of
washing the parts. Frequent scrubbing and friction of the diseased
area is objectionable, but the apj)lication of hot water does not necessi-
tate any such friction; it is simply daubed on with a soft wad of gauze
or a clean sj)()nge and held to the parts until it begins to cool off, when
it should be reapplied as hot as the patient can bear it.

If there is nmch sero-purulent discharge, the application of peroxide
of hydrogen in the strength of 10- to 2r)-volume solutions will some-
times rapidly control this and also relieve the pain and itching. ITie
old-fashioned blackwash is very effectual in the relief of these symp-
toms. Unguent um zinci oxidi, unguentum diachylon, hydrargj'ri am-
moniati, unguentum picis liquidi, or lanolin in which is incorporated
a small ])ercentage of bismuth, salicylic acid, resorcin, or carbolic acid,
may be applied. The strength and selection of these different oint-
ments will de])end upon the individual cases. Some are found in which
all washes and oily ointments are absolutely irritating, and it is there-
fore necessary to limit ourselves to some form of medicateil powder.
Lycopodium or the ordinary talcum toilet-powders, the subnitrate of
bismuth, and sometimes dennatol act with good effect upon the irritated
conditions of (»czema. All of these should be preceded by careful
bathing with antiseptic solutions and gently drying the parts with soft
absorbent gauze before the powders are applied. Stearate of zinc com-
bined with a small })eroentage of salol or aristol is very soothing to
the j)atient and ])roductive of healing.

Where the eczema is of the dr}' variety, with thickening and infiltra-
tion of the skin, deep fissures and puckering of the mucous membrane
about the margin of the anus, a more active treatment may be necessary.
Scarification with a cold or hot knife are inadvisable because infection
and deep ulcers are likely to ensue. The fissures should be touched
with strong solutions of peroxide of hydrogen or with the actual cau-
tery, and graphite ointment should then be applied. Ichthyol, 5 to 20

NON-SPECIFIC ULCERATIONS 263

per cent, is an excellent remedy in these cases. After thickening and
infiltration have disappeared, the use of hot water, ointments, and
washes as advised above may be begun.

Bodent Dlcen. — Under the above title Allingham originally described
a number of ulcers of destructive type occurring around the margin of
the anus. Among these he included a number which were of a distinctly
tuberculous nature. In the last edition of his work he divides these
eases into two classes, the lupoid and the rodent ulcers. In the first
class he describes those with typical tubercular manifestations, and in
which tubercle bacilli can be demonstrated. He still insists, however,
upon the occurrence about the margin of the anus of certain character-
istic ulcers, which are neither tubercular nor malignant. He states
that they occur in otherwise healthy individuals ; that the edges of the
ulcers, although hard and well defined, arc less elevated, and the bases
more indurated; that they are superficial in the beginning, but have a
greater tendency to extend into the deeper tissue ; that the surfaces are
more red and dry, and that the discharge is much less than in lupoid
ulcers. How they originate, whether in traumatism, moles, warts, or
cellular infiltration, he does not state. The description given resembles
very closely the typical Jacob's ulcer or lupus exedeus of dermatologists.
This type of ulceration does not attack the mucous or nmoo-cutaneous
borders. They are ordinarily described as attacking the skin about the
face, where they attain considerable size, and extend down to the bones
themselves. Dennis states that they begin as a hyperplasia of tlie epi-
thelium belonging to the sudoriparous and sebaceous glands or the hair
follicles ; that the pressure of this hyperplasia causes atrophy of the rete
Malpighii, but not degeneration; that the ulcers differ from epithelioma
in that the lymphatic nodes are less liable to become infected, there is
none of that typical ingrowing of the surface epithelium, and the cells
are smaller and the nuclei spindle-shaped.

Fordvce states that the infiltration at the base of these ulcers is
always less than in true epithelioma, and tlie distinguishing feature be-
tween the two is the disproportion that exists between the ulceration an<l
the new growth.

The disease alwavs occurs late in life. It has no connection with
pulmonary tuberculosis or any other constitutional disease. Its course
is very slow, the pain is limited, and the lymphatics are seldom involved.
The discharges are scant, thin, and sanious. The ulcer itself is harder
than the lupoid, but there does not exist below it that marked
<]evelopment of fibroid or cicatricial tissue which characterizes the
latter type.

Histological examination shows aggregations of epithelial cells ar-
ranged symmetrically throughout the structure. The capillary blood-

264 TUB ANUS, RECTUM, AND PELVIC COLON

vessels are largely increased, but there is no marked ehangc in their
walls. Tubercle bacilli and giant-eel Is are absent.

From these fads one is led to the conclusion that this type of ulcer-
ation is nothing more or less than a mild form of epithelioma modified
by senile processes.

Diagnosis. — It is almost impossible to distinguish these nicer? in
their early stages from the simple tubercular or lupoid tyjK^s. The char-
acteristics above descrilx^d are not well enough marked. They so closely
resemble the other varieties that one would not be justified to reach a
positive conclusion until a microscopic examination had been made, and
it had demonstrated the absence of tulxTcle bacilli and giant-cells with
their three inflammatory zones.

Treatment. — As the rodent ulcer is a type of epithelial growth, its
treatment should be carried out ujxm this basis. The radical excision
of the tumor will aj){)eal to every surgeon; however, experience with
excision of e])itheliomas at the anal margin has not l)een as satisfactory
as could be wished, l)ecause tiuTe seems to be a great tendency to recur-
rence. The author has seen but one removed from this site that did
not return within two years; one that involved the margin of the anus
and about 1 inch of the muc(ms membrane was removed in 1894, and
the patient remains well up to the present time, but four others re-
moved since that time have recurred. Radical cure is more likely to be
obtained by caustic potash or arsenical paste, used according to the
methods of Hobinson, who has IxH'n so successful in the treatment of
these conditions upon the face. There is no reason why these pastes
should not be applied to the margin of the anus as well as to the cheeks,
li])s, and facial regions. In one case in which this treatment was ap-
pli(»d the results were very satisfactory. T^)cal and internal medication
have little or no effect u])on the disease, but of late some excellent re-
sults have been obtained by the use of the Roentgen rays in this type of
ulcers.

ULCERATIONS OF THE ANAL CANAL

The ulcerations previously mentioned involve the cutaneous tissues
and are outside of the influence of sphincteric contraction.

The etiological factors in the present type are practically the same as
of those in the perianal region. Chancres, chancroids, secondary and
tertiary syphilis, tuberculosis, epithelioma, traumatisms, and infections
may all produce ulceration of this tract. It may occur through exten-
sion from the p(»rianal region and from the rectal cavity itself, or it may
originate in the anal canal. Where it extends from the perianal region
into the anal canal the diagnosis may be made from the nature of the
external ulcer, the depth and extent being determined by digital and

NON-SPEaFIC ULCERATIONS 2G5

r examination. Where they originate in the rectum it is much more
lit, as the nature of the ulcer below may be entirely different from
Krhich causes it. Carcinoma and stricture of the rectum are often
ated with simple ulcer of the anus.

ost ulcers of the anal canal assume the form of fissures at first,
resent the same symptoms — viz., pain at or following stool, spasm
sphincter, bleeding, and suppuration. The typical painful ulcer of
lal canal is a fissure, called also irritable or intolerable ulcer, which
€ discussed in a separate chapter. It is not sufficient that a pa-
complains of pain, sphincteric spasm, and occasional bleeding to
a diagnosis of fissure in ano. The nature of the ulcer is of the
it importance in the diagnosis and treatment. Tuberculous, epi-
matous, and venereal ulcerations between the radial folds of the
may all produce these symptoms, but treating them as such would
isastrously. Traumatic ulcers that follow operations or injuries
assume the shape of fissure, but without the characteristic pain
pasm of the sphincter one would not characterize them as such.
are simple, non-irritable, or tolerable ulcers. In many of these
the sphincter will have been dilated during the operations which
ced them, and yet there will remain fissure-like ulcers, which are
to heal, although painless and without any hypertrophy or spasm
J muscle. This condition is due to repeated infection by the fajcal
^es. In distinction from true fissure none of these ulcers ordinarily
singly, but often two, three, or four of the sulci between the radial
are affected at the same time. Moreover, they generally extend
or less into the mucous membrane of the rectum and outward upon
ataneous tissue. The bases are not indurated, and there is an
lant purulent discharge, sometimes tinged with blood, which is
le case in fissure.

nother fact of importance is that in simple, venereal, and tubercu-
cers of the anal canal the lesion is quite as frequently upon the
as at either commissure of the rectum, whereas in true fissure
ritable ulcer the lesion in 85 per cent of the cases is situated
diately at or just to one side or the other of the posterior i

in line. I * '

le symptoms and diagnosis of the specific forms of ulcer will be j.r|j

1 in the preceding chapters. |'

mple Dicers of the Anal Canal. — As just stated, these are usually
o extension from other parts or to traumatism with infection,
may affect the sulci alone, or they may involve all the circum-
?e of the anus. Such ulcers not infrequently follow operations for i n;

rrhoids, es|)ecially by the Whitehead method, for resection of the
end of the rectum, for prolapse, and for rectocele. They do not

. I

■1 I

• I

^66 THE ANUS, RECTUM, AND PELVIC COLON

ordinarily burrow deeply, but in healing, especially if their course is pro-
tracted, they are very likelv to leave fibrous strictures.

The sijmptoms are tenderness and pain at stool or on sitting down,
a constant discharge of pus, and gradually increasing difficulty in move-
ment of the l)owels. Diarrhoea or frequent desire to defecate, without
satisfactory results, and aching pain in the back and testicles, are often
present. Dysuria is frequently an annoying symptom.

Treatment. — Such ulcers are often verv difficult to heal even when
the sphincter has been cut or stretched. The protection of the parts
against constant reinfection is not easy. An oily dressing containing
ichthyol usually accomplishes this as well as any other, but sometimes an
application of nitrate of silver, after thorough cleansing with hydrogen
peroxide, will form an albuminoid coating, which acts quite well. Moist
absorbent dressings act better in these cases than drying powders.

liest in bed is almost a j)rerequisite for cure, and if the hips can
be kept a little higher than the chest it will be all the better. Occa-
sionally, however, when the ulceration surrounds the anal canal no local
treatment seems effectual, notwithstanding all such causes as syphilis,
tuberculosis, and epithelioma are absent. In such cases one may suc-
ceed by dissecting out the entire ulcer and suturing the edges of the
wound together.

ULCERATIONS OF THE RECTUM AND SIGMOID

The rectum is very frecpiently the seat of various types of ulcera-
tion, any of which may extend into the sigmoid. Traumatic lesions,
and consequently infected ulcers, are much less frequent in the latter.
This is explained by the fact that the parts are in relation with soft,
elastic tissues, they are movable, and the course of the blood-vessels is
circular. Thus a hard faecal mass does not bruise the pelvic colon, as it
would the rectum; in straining, the force is not exerted against an
immovable and resistant wall, as in the rectum, and finally the sliding
of the faK*al mass over the surface, the erect posture, and abdominal
pressure do not obstnict the circulation and cause congestion, as they
do in that part of the gut where the vessels run up and down. Aside
from the traumatic, pressure, and syphilitic types, however, ulcerations
are quite as frequent in the sigmoid as in the rectum. The two parts
are so inseparable, and the pathology and symptomatology so similar,
that it is best to study them together, always bearing in mind, however,
the differences in relationship and anatomical construction.

From a pathological point of view, and for convenience of descrip*
tion, they may be divided into simple, specific, and systemic ulcera-
tions. The term specific is still used here in the broad sense in which

NON-SPECIFIC ULCERATIONS 267

it was employed at the beginning of this chapter. Tlie simple ulcera-
tions are those due to traumatism or any other cause followed by infec-
tion from the bacteria present in the intestinal canal. They are —

1. Traumatic.

2. Catarrhal.

3. Varicose.

4. Ilaemorrhoidal.

5. Follicular.
G. Strictural.

The specific ulcers are those due to infection by bacilli not nor-
mally' present in the human system. They are —

1. Tubercular.

2. Venereal.

3. Dysenteric.

4. Diphtheritic.

5. Carcinomatous (?)

The systemic types are those due, or at least secondary, to grave
constitutional or organic diseases. They are —

1. Xephritic.

2. Diabetic.

3. Trophic.

4. Hepatic.

5. Marasmic.

Some of these divisions overlap one another in a measure, as both
pathological conditions may be present in the same individual and
operative at the same time in the production of ulceration. In such
cases there may be two distinct ulcers present in the same rectum, or
we may have tbe two types combined there, forming a sort of mixed
ulcer. Thus there may be simple ulceration of the mucous membrane
along with carcinomatous involvement of the rectum at a higher point.
Catarrhal, hemorrhoidal, and specific ulcerations may be all present at
the same time in one individual. A sim])le traumatic ulcer may become
infected by tuberculosis or syphilis, and thus its nature will be entirely
changed from what it was when first observed. It will be im])ossible
to repeat these complications under every type of ulceration, but the
reader should constantly bear them in mind, and in clinical work apply
the diagnostic tests in every case.

The specific ulcerations having already been described, the simple
and systemic tyipes will be considered.

Etiology. — Certain predisposing causes and symptoms are common
to many if not all types of ulceration in the rectum and sigmoid. They
may therefore be enumerated here once for all, and referred to under
the special varieties in order to avoid repetition.

268 THE ANUS, RECTUM, AND PELVIC COLON

Predisposing Causes. — Age: Eectal ulcerations are rare in very
young children, but in old people those types due to pressure, varicose
veins, and trophic changes are quite frequent. The condition, however,
is much more frequently seen in middle life. This may be due in part
to the preponderance in numbers at this age over the very old, but it is
also influenced by the more constant straining at exercise or labor, ex-
posure to accidents or injuries, and the frequency of surgical opera-
tions. In women the menstrual and child-bearing periods also pre-
dispose to it.

Sex: Women are more subject to ulceration of the rectum on ac-
count of the greater frequency of constipation, pressure on the organ
by misplaced or gravid uteri, tumors, badly fitting pessaries, and in-
juries duriug childbirth; also from the exposure of the organ to the
acrid and irritating discharges from the vagina. The influence of these
conditions, together with the various inflammations of the reproductive
organs and pelvic cellulitis in the production of rectal and sigmoidal
disease, is not sufficiently appreciated. Many cases of pelvic disease
in women fail to obtain relief after operations and treatment simply
because the intestinal conditions which they produce have not been
treated at the same time.

The interdependence of these two classes of diseases requires a tech-
nical knowledge of both in order to treat either one successfully.

Occupation : Occupation has some influence in the production of
the disease, in that those individuals who are standing upon their feet
most of the time, whose duties require them to lift heavy weights and
strain, and who are preoccupied sufficiently to interfere with regular
attention to the functional action of their bowels, are liable to suffer
from constipation, congestion, and other conditions, such as bring about
ulcers of the rectum and sigmoid. Painters, workers in lead and phos-
phorus, tailors, seamstresses, artists, etc., are all frequent subjects of
ulceration of the rectum.

Physiological Functions. — The functions and position of these part«
are most important predisposing causes. Forming, as they do, the final
portion of the intestinal tract and serving as storehouses for the harsh
and indigestible refuse, they are subject to continued pressure by the
mass, and to abrasions and wounds from the foreign bodies which it may
contain. Whenever the accumulation of faeces remains for any pro-
tracted period in the rectum or sigmoid it becomes very hard, and by its
constant pressure and to-and-fro movements, caused by peristalsis and
respiration, it is likely to produce congestion, abrasion, or even actual
wounds of the mucous membrane.

Bacteria : The fact that there are always present in the intestinal
canal, especially at the lower end, numerous bacteria and bacilli, predis-

NON-SPECIFIC ULCERATIONS 269

poses these organs to ulceration by the facility with which any injury
of the parts may become infected.

Bacillus coli commune, staphylococcus, and tubercle bacillus are
more or less constantly found here, and no amount of attention can
keep the parts free from exposure to infection by them. In other cases
peculiar bacteria are found. X. Solojew (Centralbl. fiir Bakteriologie,
Parasitenkunde und Infektionskrankheiten, 1901, I. Abthoilung, vol.
xxix, pp. 821-830) has reported a fatal ease of ulceration of the colon
and rectum due to the balantidium coli. The ulcers were extensive and
involved the entire mucosa, dipping into the muscular coat. While
various micro-organisms were found upon the surface, only this peculiar
parasite penetrated the deeper parts of the ulcers. He therefore con-
siders it the etiological factor.

The author has recently seen a case of chronic diarrha^a with ulcera-
tion of the rectum and sigmoid in which amoeba? dysenteria^ were found
at first, and later on numerous trichomonas intestinalis. Thayer (The
Journal of Experimental Medicine, vol. vi, p. 75) mentions this same fact.
He also calls attention to the presence of strongyloides intestinalis in the
colon in certain cases of chronic diarrhcca with intestinal ulceration.
The etiological influence of these parasites in the production of ulcera-
tion has not yet been determined, but the large variety of such agents
found in the alimentary tract makes the wonder grow that we do not
more frequently observe infection and ulcerations there.

Anatomical Causes. — The distribution of the superior liaMnorrhoidal
veins, the fact that they possess no valves, and that the collateral circu-
lation below is so feeble, predisposes the rectum to constant congestion
and ulceration. Especially is this true in consequence of the blood pres-
sun' upon these parts produced by the erect posture.

Pathological Predisposing Cannes. — Aside from the specific diseases,
such as tuberculosis, syphilis, dysentery, etc., certain other constitutional
anil organic diseases predispose to this condition. In general, one may
sav whatever enfeebles the circulation and reduces the cardiac force, so
that it does not move the blood rapidly through the ])ortal circulation,
will predispose to congestion and ulceration of the rectum. Valvular
disease of the right side of the heart, hepatic disorders, and atheroma of
the arteries all contribute to this disease.

As to the special diseases there seems to be some lack of harmony
among writers as to whether they simply predispose or actually occasion
the condition. It is a question whether Bright's disease has any pecul-
iar influence in producing ulcers of the rectum through the accuniulation
in the system of poisonous detritus which should be eliminated by the
kidneys; or whether, as Da Costa has brought out, in the later stages
of this disease the secretor}* organs of the body, especially the liver, the

270 THE ANUS, RECTUM, AND PELVIC COLON

pancreas, the spleen, and the heart as well, all take on more or less
of the sclerotic involvement of the kidney, and thus become a part and
parcel of the disease, the rectal ulcers being secondary to the involve-
ment of these organs, and not due to the chronic inflammation of the
kidneys alone. Of course in those cases which always occur in the late
stages of Blight's disease there is feeble cardiac action, general vascular
dilatation, and decreased blood pressure. In fact, all the tissues of the
body are in a degenerated or enfeebled condition, and predisposed to
suffer more than usual from slight traumatisms, as well as being easy
victims to infection by septic bacteria. At the same time, as we shall see
later on, the type of ulceration seen in these cases is entirely different
from any other rectal ulceration, thus lending color to the view that it is
due to Bright's disease itself.

The ulcers of the rectum that are caused by diabetes are similar in
their nature to gangrene of other portions of the body as produced by
this disease. It is simply a gangrenous or necrotic condition of the
mucous membrane that results from traumatisms or thrombotic obstruc-
tions in the venules, and may occur in acute as well as chronic cases of
this disease. The author has seen one case in a woman whose diabetes
lasted only a short time, and yet during that period the most extensive
ulcerations of the rectum and sigmoid occurred. There was nothing left
of the mucous membrane of these two organs beyond little islands or
patches about the size of a silver quarter, as high up as the longest
sigmoidoscope would reach. The fact that the ulceration extended after
the glycosuria had disappeared is in keeping with other reports of ulcer-
ation of the skin and gangrene of the extremities that occurred after
the glycosuria had disappeared.

Profound anaemia is a predisposing cause of ulcers of the rectum, as it
is of ulcers everywhere else. These patients are generally the subjects of
obstinate constipation, the stools are hard, and traumatism from this
source frequently affords an open gate to the bacterial infection which
results in the ulcerative process. Neuroses and mental diseases have
been frequently spoken of as predisposing causes to ulcers of the rectum
and colon. In the chapter upon mucous and ulcerative colitis attention
has been called to the fact that these diseases are very frequently met
with in institutions for the nervous and the insane. Some authors have
taken the view that it is the result of trophic changes, while others be-
lieve that they are due to specific, and even to contagious bacilli (Cowan).
On the other hand, lack of attention to the calls of nature, want of
exercise, and altered nervous conditions, such as reduce peristalsis and
vascular tension, all tend to produce conditions which predispose to
ulceration of the rectum and sigmoid. Four eases of ulceration of the
rectum and one of the sigmoid have been observed in cases of non-syphi-

NON-SPECIFIC ULCERATIONS 271

itic, multiple spinal sclerosis; in one case even an artificial anus failed
0 heal the ulcer. It appears, therefore, that these neuroses may be
ven more than predisposing causes in some cases.

Exciting Causes. — Traumatism or injury is the exciting cause of
be large majority of non-specific ulcerations of the rectum. These may
e due to surgical operations, rough introduction of syringe tips, the
mproper use of bougies, the application of cauterizing agents, the injec-
ion of corrosive substances in the treatment of haemorrhoids, the pas-
age of hard faecal masses, the introduction into the anus or passage
hrough the bowel of foreign bodies, and the rupture of haemorrhoidal
eins.

Next to surgical procedures the passage of foreign bodies, such as
ones, pins, fruit seeds, gall-stones, etc., is the most frequent source of
Icerations. The sharp points of these little bodies project out beyond
he faecal mass and scratch the mucous membrane, thus causing small
rounds, which soon become infected and cause ulcerations.

Pressure: Prolonged pressure from impacted faeces, from arrest of
he foetal head, and from too large pessaries, may interfere with the
ireulation, cause sloughing of the mucous membrane, and thus produce
Iceration of the rectum.

Crj'pts: The lodgment of foreign bodies or small masses of hard
aeces in the crypts of Morgagni may sometimes cause ulcerations which
xtend upward and involve the rectum.

Drugs : Finally, the toxic action of certain drugs or chemicals, such
s mercur}% capsicum, mustard, phosphorus, ergot, and carbonate of
mmonia, have been known to cause ulceration of the rectum and pelvic
olon.

General Symptoms, — The symptoms of ulceration of the rectum are
ery similar in many respects for all varieties. The size of the ulcer
s a rule bears no relationship to the amount of disturbance it produces.
Ixtensive ulceration well above the internal sphincter may cause very
light and indefinite symptoms, whereas a ver^^ small ulcer situated
^w down may occasion great pain, muscular spasm, nervous irritability,
nd reflex disturbances in nearly all the organs of the body.

Diarrha?a is one of the early symptoms of this disease. It some-
imes comes on with an acute attack of griping and pain in the course
f the colon. Such cases are due to colitis, and are described in the
hapter upon that subject. Frequently, however, it occurs as a gradu-
Jly increasing frequency of faecal movements. At first these will
•e comparatively normal and of sufficient amount. They will grow
mailer as the desire becomes more frequent, and instead of passing
aecal material the patient will have frequent calls to the stool, at which
lothing more than a small quantity of mucus will be discharged.

272 THE ANUS, RKCTUM, AND PELVIC COLON

Sometimes this mucus is tinged with blood, at others there may be
considerable quantities of pure blood poured out along with pus. Oc-
casionally the patient will pass quantities of material resembling boiled
sago. Later on these discharges change to a dark and grumous mateml
due to decomposed blood mixed with mucus, fa?ces, and pus. The
character of the discharge dilfers considerably in the various types of
ulcerations, as will be described under their appropriate headings.

Morning Diarrhwa. — One peculiar characteristic of the diarrhoea in
ulceration of the rectum is that it is generally quiescent at night,
whereas in the daytime the patient suffers from frequent calls to stooL
lie may have eight to ten or more passages during the day, and yet
go to bt»d and sleep all night without any disturbance. Upon rising
in the morning, however, he will be called upon at once to relieve
the bowels.

Delafield (Medical Record, 1895, vol. i, p. 577) states that this morn-
ing (liarrhiva is a constitutional or neurotic condition not due to local
intlanimation or disease, and descril)es five varieties, according to the
severity of the symptt)ms, but leaves one to infer that there is no I
organic disease of the intestinal tract to account for them.

With such an opinicm ever}- close obser\'er in rectal diseases will
take most jmsitive issue. True morning diarriuva, such as he has d^
scribed in his last fcmr divisions, is pathognomonic evidence of local
inflammation, stricture, ulceration, or neoplasm of the rectum, sigmoid,
or colon. There is no condition that more positively demands an
early and thorough examination of the rectum and sigmoid flexure
than this tendency to go to stool immediately upon rising in the morn-
ing, especially if that morning stool consists in mucus or purulent dis-
charges. There are persons who have a normal call to defecate as
soon as they ris(», or shortly al'ter rising, in the morning; the passages
are normal and there is no continuous call throughout the day in such
cases. But these are an entirelv different class from those described
by the author mentioned and which are discussed here. The morning
diarrhoea, which consists in the passage of mucus or pus, is due in
almost every instance to ulcerative disease of the rectum or sigmoid.

Pain. — This is a ver}- unreliable and indefinite symptom in ulcera-
tion of the rectum. Certain individuals suffer greatly from it, while
others have no pain at all. If the ulceration is high up in the rec-
tum a sense of weight and aching in the sacral region is the chief
discomfort of which most patients complain. If it is situated lower
down within the grasp of the sphincter, and involves the muco-cutane-
ous area where the sensitive nerve-onds center, pain of a sharp, lancinat-
ing, or burning character will be the chief symptom.

The amount of pain varies considerably with the character of the

NON-SPECIFIC ULCERATIONS 273

k tilceration. Tubercular ulcers axe almost entirely free from it. Sjrphi-
• litic ulcers vary considerably in this regard; sometimes they are very
s sensitive, at others the patient is almost absolutely without any pain,
:-i but this depends upon the location. As a rule ulceration of the rectum
>= V proper is not an acutely painful affection.

7* Incontinence. — Relaxation of the sphincter is not an infrequent

^? symptom of ulceration of the rectum. Sometimes patients almost en-
tirely lose control over their fsecal passages owing to this condition. It
does not occur, however, except where the disease has existed for a
long time or has been brought about either by serious constitutional
<lisease8 or vicious practices.

The symptoms elicited by sight and touch vary with each particular
class of ulcers. These variations when within reach can be apj)reciated
I by the educated touch, but the various instrumental aids for ocular
examination of the rectum enable us at the present day to distinguish
between the different ulcers much more clearly than before. Through
f the pneumatic proctoscope one can clearly see and diagnose ulcera-
tions in the upper portions of the rectum and in the sigmoid; the
character of the ulcers can be determined and the amount of contrac-
tion in the caliber of the gut can be accurately measured without any
danger of perforation. The appearance of special ulcerations will be
<Iescribed under their proper headings.

SPECIAL ULCERATIONS

Traumatic Dlceration of the Eectum. — This form, termed also
simple ulceration of the rectum, always originates in some injury to
the parts. The ulcerative condition is due to infection of the raw
surfaces by the bacteria always present in the rectum. This distin-
guishes them from those ulcerations which are due to specific bacilli,
such as tuberculosis, typhoid fever, dysentery, etc.

Ulcerations following surgical operations, when in patients other-
wise healthy, tend toward spontaneous healing, but they may some-
times be protracted on account of the irritation caused by the passage
of hard fapcal masses and the impossibility to keep them clean.

The lower the seat of an ulceration in the rectum, provided the
sphincter is kept relaxed, the more rapidly will it heal, because the
fa?cal materials do not rest so persistently upon the parts and cleanli-
ness is rendered more possible. Thus in open operations for haemor-
rhoids or fistulas the tendency is always for the lower portion of the
wound to cicatrize before the upper portion. Another thing which
must always be taken into consideration with regard to these traumatic
ulcers is the trophic condition of the parts. Whenever an ulceration
18

274 TUB ANUS, RECTUM, AND PELVIC COLON

in the rectum shows a tendency to chronieity it is evidence that the
resisting? power of the tissues is not sufficient to overcame the constant
infection from the intestinal contents. The circulation is either im-
perfect, the nerve supply is impaired, or the general reparatory pro-
cesses are below par. Constitutional treatment, therefore, becomes t
necessary fcatuR* in the management of these cases.

Chararterisiirs. — The appearance of sucli ulcers is largely the coni?e-
quence of the injur}' or wound in which they originate. If these invoke
only the mucous membrane the ulcers will be superficial and assume
the form of the original lesion. If, however, the operation or injury
involves the deej)er tissues of the gut wall they will then assume the
penetrating form, and, if not properly treated, may burrow into the
perirectal tissues and form an abscess or fistula. When upon the an-
terior Mall of the gut they niay even perforate the {>eritouseum or
the vagina.

The edges of the ulcers are generally smooth, sloping, and non-
indurated. The basics are comj)osed of simple granulations, neither
nodular nor ])n)liferating, bathed in a thick, milky-white secretion con-
taining j)us-cells, streptococci, colon bacilli, and the other bacteria
usually present in the rectum.

When the ulceration extends low down in the rectum, involving
the anal canal, it may assume the form of a fissure in ano. However,
ulcerations resulting from surgical operations very rarely present the
symptoms of this condition owing to the fact that the sphincter is gen-
erally well stretched as a ])reliminary step.

Sjftnpfoins. — The symptoms of traumatic ulcers are praetit*ally de-
scribed in the foregoing paragraph on general symptoms. They pos-
sess no i)eculiarities beyond that of chronieity, and frequently this
tendency is only comparative. Ulcerations following operations for
haMiiorrlioids should not be ex])ected to heal under three to four weeks,
and they may require five or six, while those produced by operations
for fistula and stricture sometimes require three to six months in which
to heal. The constitutional ccmdition of the patient has much to do
with this. The fact that an oi)eration or an accidental wound of the
rectum or anus is slow in healing shcmld not lead one to conclude that
it is tubercular, syphilitic, or malignant without much stronger evi-
dence. Assuming the erect posture too soon, too little and improper
attenticm to dressings and cleanliness, anaemia, poor circulation, and
feeble reparative powers may all bring about tardiness of healing in a
perfectly healthy wound.

Trcatmeni. — The treatment of this type of ulcers consists in perfect
drainage, ase])tic cleanliness, regulation of the bowels, and rest in the
recumbent posture. If the sphincter is not relaxed it should be dilated.

NON-SPECIFIC ULCERATIONS 275

The parts should be irrigated with antiseptic solutions two or three
times a day, and applications of astringent solutions, such as nitrate of
silver, iehthyol, or Peruvian balsam should be made.

Powders, such as liave been mentioned under specific ulcerations, will
be useful after the discharge is practically controlled. Iodoform is
one of the best in this condition.

Catarrhal Ulceration. — In the chapter upon catarrhal diseases of the
rectum it was stated that ulceration may result from any one of the
three varieties — the acute, hypertrophic, or atrophic catarrh.

The ulcerations that result from acute catarrhal inflammation of
the intestine are due to excessive inflammatory processes, followed by
necrosis of the mucous membrane and consequent sloughing. This
ulceration is a superficial condition, and is generally quite exten-
sive, involving more or less of the entire lining membrane of the
rectum. The symptoms are those of an acute inflaniinatory disease, fol-
lowed by a frequent desire to defecate and the passage of blood jnid pus.
The mucous membrane around tlie margin of the anus is generally
inflamed, and o?dematous, if it is not also involved in the ulcer-
ative process. The patient suffers from acute pains upon defecation,
aching and discomfort in the Siicral region, and always has more or
less temperature at different times of the day, especially in the
evening.

Ulcerations from the hypertrophic form of catarrh are very rare.
They are more likely to assume the follicular type and be localized in
the solitary follicles or lymphoid glands. They do not ])roduce any
marked suhjective symptoms, they rarely bleed, and discharge a thin
sero-purulent material which is not feculent but ({uite irritating to the
muco-cutaneous membrane.

The ulceration caused by atrophic catarrh is generally more of an
erosion than an ulceration. It consists in a localized breaking down
of the mucous membrane. The edges are not elevated or swoll(»n, hut
gradually <lecline to a shallow crater-like base. They bleed easily upon
touch, though not excessively. Tlu\v discharge a thick tenacious niueo-
pus which can be seen adhering to the spots when examination is made
by the speculum (Plate I, Fig. 6). This muco-pus often ccmtains small
bits of inspissateil fa»cal matter which gives the discharge a dark-brown-
ish color at times. Owing to the scarcity of the discharge diarrluea is
not a frequent symptom in this form of ulceration.

The minute description and treatment of these varieties of ulcera-
tions has been given in the chapter upon catarrhal diseases and need
not Ik* n?peated here.

Varicose Ulceration. — Under the above term many writers have con-
fused two separate and distinct varieties of ulceration, liokitansky

276 THE ANUS, RECTUM, AND PELVIC COLON

(Manual of Path. Anat., vol. ii, p. 107) described under the name of
" hipinorrlioidal ulcers " a condition which (libbs, Kelsey, Curling, and
others have called varicose ulcers of the rectum. It is necessan* for the
proper understanding of this subject to clearly distinguish between an
ulceration due to a varicose condition of the rectal mucous membruie
and those due to injury, strangulation, or sloughing of ha?morrhoidil
tumors. An ulcerated ha^morrhoid or an ulcer that occurs in a well-
developed lupniorrhoid is an entirely dilFerent condition from those
chronic, intractable ulcers which occur in general varicosity of the rectal
mucous membrane.

The lamented (lihbs, whose tragic death was the first fatality in our
late war with Spain, has clearly drawn this distinction (New York Med-
ical Journal, 1H\)'2, vol. ii, p. 9;^). Ball describes the same condition,
but unfortunately adopts the nomenclature of Kokitansky, who firet
likened it to chnmic varicose ulcers of the leg. The conditions are
almost identical, but if one examines these ulci»rs in the rectum he will
find no hyperphisia or fibrous thickening beneath them, such as is seen
in varicose ulcers of tlie leg. Thcv show no tendencv to cic*atrize. as do
the latter ty])e, and bleed much more easily, owing to the thin vascular
walls of this area.

Again, the so-called varicose ulc(»rs of the leg are associated in the
majority of cases with chronic 8y])hilis; those in the rectum are not.
Their chronicity is undoubtedly due to varicosities of the sujK»rior
ha»morrhoidal veins. The original exciting cause, however, is unques-
tionably some wound or injur}' to the nmcous membrane, or rupture
of one of the varicose veins. Infection takes place after this and causes
the ulceration. Whate\*er tends to ])roduce varicosity of the rectal veins
is a j)redisposing cause to the condition.

(Vij)ps {op rif., p. '^0(>), Quenu and Hartmann (op, cit., p. 413) state
that these ulcers are peculiar to old age. In the series of cases described
by Gibbs there was a number under the age of twenty years, and the
majority of them occurred in ])eople between twenty and fifty years of
age. The author has seen this character of ulceration in a patient as
young as seventeen years, and in the large number of old people in the
New York Almsliouse he has only seen three of these ulcerations in
patients above the age of sixty, whereas in his clinical and hospital
services he has seen a large number that occurred in patients between
thirty and fifty years of age.

Mode of life, environment, and nutrition seem to have very little
influence in its production. Heavy eaters and drinkers who t^ke little
exercise and are inclined to constipation are predisposed to this type
of ulceration, but it also occurs in abstemious, active, and anaemic indi-
viduals. The etiological factors in one type of cases are congestion of

NON-SPECIFIC ULCEBATIONS 277

the liver and constipation; and in the other feeble cardiac action and
weak relaxed blood-vessel walls.

Symptoms, — The ulcers usually occur well above the muco-cutaneous
border. As a rule, they produce very few symptoms besides the frequent
desire to defecate. This inclination is always more marked in the day-
time, the patient often passing the whole night without being disturbed.
There is always an inclination to go to stool immediately upon rising in
the morning, which generally results in the passage of small quanti-
ties of mucus and pus, with or without blood. Occasionally tliese pa-
tients suffer from quite severe haemorrhages. One or two cases have
been reported in which death was caused by this accident, but ordinarily
bleeding is not a marked characteristic.

Pain, other than a dull aching in the back, sometimes shooting
down the leg or around the pelvis, is generally absent, as might be
expected from the location of the ulcer above the muco-cutaneous bor-
der. Occasionally when they invade the muco-cutaneous tissue at the
margin of the anus the patient suffers from more or less acute pain.
In this condition spasm of the sphincter will also complicate the
ulceration.

The appearance of the ulcers upon ocular examination is tluit of a
sharply defined, irregular depression in the mucous membrane of the
rectum. The edges are slightly elevated, and tlie bases covered with a
yellowish pus, beneath which there are bright-red granuhitions. The
veins of the rectum surrounding the ulcerated portion, and, in general,
all over the rectum, are varicose, and when the patient strains they be-
come largely dilated. The patient may or may not have well-developed
ha^morrhoidal tumors. When such is the case the ulceration occurs at
the side of or between two such masses. Ordinarily these ulcerations are
supc*rficial, but, as Gibbs states, they sometimes eventuate in great de-
struction of tissue, even perforation of the bowel.

One striking characteristic is their extreme chronicity, with little
or no tendency to extend either in area or depth ; one case was seen in
which the condition existed for five or six years, the ulcer remaining
about the size of a twenty-five-cent piece, and with absolutely no con-
traction of the caliber of the gut.

Tenesmus and griping are ordinarily absent.

The condition of the bowels will dt^pend u])on other circumstances;
when they are soft and semifluid, bleeding and pain will be generally
absent; when they are hard, lumpy, and irregular, a small amount of
blood will appear with and after the stools, and a dull aching pain may
follow and last for an hour or two.

Digital examination reveals nothing more than a lesion of the mu-
cous membrane, with slightly elevated edges, and a soft elastic base.

278 THE ANUS, RECTUM, AND PELVIC COLON

There is little if any hyperplasia or thickening of the intestinal walls
about or beneath these ulcers.

Treatment, — The treatment of varicose ulcers of the rectum u
very tedious and frequently unsatisfactory. It is very difficult to get
patients to apprt^ciate the importance of a condition which gives them
so little real pain or inconvenience. At the same time it is almost im-
possible to heal these conditions without absolute rest in bed. They
insist upon sitting up, if they yield at all to the advice of confinement
They want to l)e propped up in bed, clothe themselves, and lounge about
the room in chairs or upon sofas, or even want to attend to business a
few hours each day. In chronic cases, with general varicosity of the
rectum, such lax regimen will rarely succeed. The patient should be
confined absolutely in a reclining posture. He may lie upon his side,
his back, or his stomach if he wishes, but his head should be on a level
with or as little elevated above his hips as possible. The modem treat-
ment of varicose ulcers of the leg by the elevation of the limb has proved
beyond a doubt the lx»nefit of removing the pressure of the blood column
in these conditions. So also in the rectum, in which this column is even
more unsupported than in the leg, there being no valves in the veins, it
is necessary to relieve the parts of that mechanical element of conges-
tion in order to bring about the healthy circulation and consequent res-
toration of tissue which has l)een destroved. If this were conscientiousiT
enforced, it is believcnl that the majority of cases of simple and varicose
ulceration would hoal of their own accord. Nevertheless something may
be done toward hastening such a cure.

The diet should be regulated so as to contain as little refuse material
as possible. An absolute milk diet is not best for these patients, as it
produces a hard, leathery stool, which, when passed through the rectum,
tears and irritates the already inflamed surfaces. An albuminoid diet
associated with a reasonable amount of fresh garden vegetables is more
acceptable as well as more effectual. A certain amount of milk may be
allowed with this diet, as it is nourishing and produces no bad effects
in combination with the other food. Alcohol, and if possible tea and
coffee, should be avoided, also all such condiments as mustard, pepper,
and the various sauces.

The bowels should be kept regular but not loose. After the bowels
have moved, and at least twice a day, the rectum should be irrigated
with a cleansing solution, either of bichloride of mercurj' (1 to 10,000),
boric acid, or Thiersch's solution, the ordinary rectal irrigator being
used for this purpose. By this means no accumulation of fluid will be
left in the rectum to irritate the parts and cause a tendency to defecate.

As local applications to these ulcerations a variety of substances are
useful. Most authors advise nitrate of silver in mild solutions. Occa-

NON-SPECIFIC ULCERATIONS 279

sionally, where the ulcer is sluggish and the base is sloughing, the appli-
cation of this agent may be of benefit. My own experience, however,
has been that tincture of iodine or a 10-per-cent solution of argonin
acts better. The insufflation of a powder of iodoform, aristol, or, better
still, antinosin upon these ulcerations seems to hasten their healing,
and also gives the patient the impression that something is actually
being done to heal the parts while he is resting in bed. This should be
done once or twice daily through a fenestrated or duck-bill speculum.
If the pain is severe a suppository of iodoform, opium, and belladonna
may be introduced two or three times a day to relieve the same. As to
giving any definite quantities of these drugs, it is impossible to judge
what will relieve one patient by any experience with another. Some
are very susceptible to opium, others to belladonna, and still others
to iodoform, and the proportion must be varied in each individual
case.

Injections of starch-water or of flaxseed tea containing small quan-
tities of the tincture of opium, or ointments containing small quanti-
ties of cocaine, may be of benefit, especially if the ulcers are so low down
in the rectum as to involve the sensory nerves. In the majority of cases,
however, the symptoms will not indicate the use of analgesics. Four to
ten weeks or more may be consumed in healing.

Drugs, such as hypophosphites, cod-liver oil, protonucloin, and
sometimes some assimilable form of iron, should be used in cases asso-
ciated with anaemia and general debility. Where signs of improvement
do not manifest themselves very soon, it is wise to eliminate all possibil-
ity of syphilis by beginning mercuric inunctions.

Massage is useful in all patients confined to bed, and makes up in
a measure for the lack of exercise. Forced feeding, such as is employed
in neurasthenia, should be avoided in these cases. The danger is in
overeating and congestion of the portal circulation. Sufticient whole-
some food should be allowed, but the digestive organs should not be
overtaxed. Water may be allowed in abundance, especially if taken hot,
and when there is any urica?mic tendency, citrate of lithia may be added
to it.

Hemorrhoidal Ulcers. — In distinction to the above varietv there is
the lesion caused by sloughing and ulceration of a well-defined ha?inor-
rhoidal mass. This may be due to thrombosis followed bv necrosis, trau-
matism from the passage of hard fa?cal masses or foreign bodies, strangu-
lation, or too rough handling of the tumor in efforts to reduce it. It
may also be produced by the application of ice in order to relieve con-
gestion, and by the action of corrosive substances applied to the surface
or injected into the body of the ha^morrhoid for the purpose of cur-
ing it.

280 THE ANUS, RECTUM, AND PELVIC COLON

Such ulcerations are entirely distinct from the varicoee ulceratioBS
which have just been described. They are associated with a localized
inflammatory condition; the hsemorrhoidal tumor itself is swollen and
hard; the ulceration usually consists in a fissure-like crack or split
through its center, or in a protruding stump from which the haemorriioid
has sloughed away. Where it is due to thrombosis, traumatism, or cor-
rosive injections, it generally assumes the fissure-like appearance in the
body of the tumor. Where it is due to necrosis following strangulation,
the application of ice, or cauterization, the summit of the tumor will
slough off and leave an ulcerating, teat-like stump. These ulcers do not
possess the extreme chronicity of the varicose variety — in fact, they haw
a tendency to heal spontaneously.

Sym/ftoms. — The symptoms of this variety of ulceration are: Firgt,i
hist or}' of the existence of ha^norrhoids either internal or external, and
of prolapse, strangulation, efforts at reduction, the application of ice or
cauterizing agents for the restoration or removal of the tumors. After
these conditions a fulness, throbbing, and aching of the parts will
have been experienced by the patient. Sometimes he will have suf-
fered from a chill and elevation of temperature. These symptoms will
have been suddenly relieved by the discharge of pus or blood. Then
follows an inclination to frequent movements of the bowels, which are
generally ineffectual, and associated with considerable pain. The
discharge is scanty and composed of pus and blood. Serious hsemor-
rhages sometimes occur; there is always more or less spasm of the
sphincter, and the pain is more marked than in the varicose variety.
Where the ha'morrhoid is only partly destroyed it may prolapse, and
being gras])ed by the sphincter, cause acute suffering.

Morning diarrha^a may or may not be present, but the patient is
frequently awakened at night by the spasmodic contraction of the
sphincter and the desire to defecate. If the haemorrhoid is of the ex-
ternal or mixed varietv the involvement of the muco-cutaneous border
may take place, and when such is the case the symptoms of fissure de-
velop.

Treatment. — The treatment of this form is entirely different from
that of varicose ulceration. It is absolutely and unequivocally surgi-
cal. The patient should be etherized, the sphincter thoroughly dilated,
and the ulcerated hjemorrhoidal mass taken away either by crushing,
the clamp and cautery, or by ligation.

The clamp-and-cautery operation by its stimulating effect and bac-
tericidal action seems to be as near a specific as one can desire. Where
the ulcerated ha^morrhoid is cleft in two by a deep furrow, each lateral
prominence should be clamped separately and the ulcerating sulcus be-
tween them cauterized with a narrow-pointed Paquelin blade, but if

NON-SPECIFIC ULCERATIONS

; furrow does not dip down deep, the whole mass may be included in
p and removed.

Tile after-treatment of such eases is identical with that for ordi-
ir ha>morrhoidal operations, with this exception: that more prolonged
1 bed. antiseptic washes, and restricted diet will be necessary to
-nin perfect results.
Folllciilar Uloeration of the Rectum. — -Follicular ulceration may oc-
r a( any portion of the large intestine. Its most frequent site is in
descending colon, sigmoid, and rectum. It has its origin in the
'' Accumulation of small round cells in solitary follicles. This acoumuk-
lion causes a swelling of the follicle followed by pressure on the epi-
thelial covering, which finally gives way. The follicle disintegrates, and
an ulcer results having sharply cut edges, slightly undermined, and vary-
ing in depth (Plate I, Fig. 5). They vary in size from that of a small
bird-shot to a small hazelnut. They may be single or multiple, the
whole mucous mem-

brane being studded
with them; they are
more frequent above
the recto-sigmoidal
jnnoture than below
it; they do not often
coalesce, but occasion-
ally the mucous mem-
brane twtween two may
break down, and thus
form an irregular ulcer.

HHiite states that all the patients in whom this has been found post
mortem have died from other causes, such as dysentery, typhoid fever,
tuberculosis, cancer, or membranous colitis. He states further that the
disease occurs about once in 500 post-morten examinations at Uuy's
Hospital, and yet with this important percentage he says that it is never
diagnosed during life. This latter opinion is not in accordance with
that of other observers. The author has certainly seen the condition
in the rectum and sigmoid flexure of living subjects a number of times.
In the majority of cases catarrhal disease precedes its development. That
Foration may occur from this form of ulceration is exemplified in Fig.
[00, illustrating the cavity of such an ulcer filled with fa-ces. It will be
■n that only the peritonfcum itself separates it from the abdominal
cavity. In this case numerous follicular ulcerations of the sigmoid had
involved and almost perforated the intestinal wall. Healing occurs slow-
ly, but is not accompanied by the development of any marked cicatricial
deposit. Ball (he. cit., p. ll!l) states that this condition may result

■gerf'

■|oo,

^necn

282 THE ANUS, RECTUM, AND PELVIC COLON

in stenosis of the bowel, but the \iTiter has never seen a ease of this
kind.

Symptoms. — The symptoms of this form of ulceration are very
meager. In the rectum itself the patient experiences no pain and no
uneasiness. There is some indication of intestinal indigestion associ-
ated with more or less griping and tenesmus, but without any real diar-
rhoea.

The action of the bowels may be perfectly normal so far as
the constituency of the mass is concerned, but the patient will com-
plain of more or less acute griping pains throughout the day and
night.

Bamburger has described little masses of inspissated mucus, looking
something like frogs' spawn or boiled sago, as having been discharged
from the bowels of patients suffering with this condition. The little
masses are said to be more or less of the nature of follicles, but Vir-
chow has shown them to be particles of undigested starch, and there-
fore it is doubtful if they have any real relationship to follicular ulcer-
ation. In the early stages, before ulceration takes place, one may occa-
sionally feel little millet-seed-like formations beneath the mucous mem-
brane, or elevations upon its surface, but it requires a delicate touch to
do this. Examination with the speculum, which is the only positive
means of diagnosis, shows in this stage very slight elevations, over which
the membrane appears smooth and shining.

The causes of this variety of ulceration are practically unknown, but
insomuch as it always occurs in connection with some other inflammatory
affection of the rectum, it seems rational to regard it as an infection of
the follicles by the discharge from these diseases.

Treatment, — The treatment consists in attacking the causative dis-
ease and applying local remedies to the ulcers so far as they can be
reached. In the case illustrated the patient was suffering from atrophic
catarrh of the rectum and sigmoid. The treatment consisted in that
detailed in the chapter upon this disease, and the four or five ulcers
which could be reached were treated by wiping them out with small
pledgets of cotton and insufflating antinosin upon the ulcerated spots.
The patient recovered in about six weeks, and has not been troubled
with the condition since.

Strictural Ulceration.— Cripps (loc. cit., p. 204) describes in detail
a condition of ulceration which he states is due to retained discharges
from a rectal stricture. He says : " It appears as if the superficial part
of the mucous membrane is onlv ulcerated, the submucous tissue still
forming a distinct membrane over the muscular coat, so that the bowel,
instead of possessing a soft, velvety linini!:, moving freely on the sub-
jacent muscular fibers, has a surface which, though smooth, gives a

NON-SPECIFIC ULCERATIONS 283

harsh creaky sensation to the finger, and is intimately blended with
the muscular coat. This extensive superficial ulceration may gradually
spread beyond the rectum to the colon. At a post-mortem examination
the ulceration is found to end very abruptly. So sharp is the line of
demarcation between the ulceration and the normal membrane that it
looks as if cut with a knife.'' The cases of this variety of ulcer have all
been afflicted with cicatricial stricture of the rectum.

The author has seen a number of such cases with superficial ulcera-
tion of the mucous membrane above the site of the stricture, but he is
not convinced of the pathology which Cripps indicates — viz., that the
destruction of the mucous membrane results from contact with purulent
secretion. Necrosis of epithelium or ulceration must exist before puru-
lent secretion is established. It appears more rational, therefore, to
attribute these ulcers to the irritation, traumatism, and infection pro-
duced by forcing the faecal mass through the narrowed channel or their
retention above the stricture.

Strictures of the rectum are ven* liable to be associated with consti-
tutional conditions, such as tuberculosis, syphilis, carcinoma, or exhaust-
ing di.sease, which conditions also produce inflammation and ulceration
of the mucous membrane of the rectum and sigmoid. Moreover, where
the patient is debilitated from improper feeding, irregular movements
of the bowels, and reflex disturbances of the digestion, the mucous
membrane of the intestine is very likelv to take on a feeble circulation
associated with a cellular deposit in its glandular organs, which accu-
mulates until by its pressure it causes a necrosis and subsequent ul-
ceration of the tissues. The fact that in the case which Dr. Cripps
quotes the stricture was cut and the obstruction and retention of the
discharge relieved, and yet the ulceration progressed until it involved
the whole of the bowel up to the splenic f.exure, proves that there was
some other etiological factor to account for it.

Symptoms. — The symptoms of ulceration such as this are practically
those of stricture. There is a frequent desire to defecate, and yet ina-
bility to accomplish the same; only when the bowels are fluid can the
patient succc^ed in having a satisfactory faecal movement. When this
has been accomplished, his desire to defecate is usually relieved for
twelve to fourteen hours, after which the inclination recurs and fre-
quent small passages of pus or mucus and blood take place.

Diarrhopa alternating with constipation, inability to pass well-
formed fa?ces, t\Tnpanites, and the accumulation of fa»cal materials in
the intestinal canal are all s^nnptoms of this variety of ulceration, as
they are of stricture of the rectum. The discharge of pus and blood
shows the presence of ulceration. The pathology and treatment of these
ulcers will be found in the chapter on Stricture.

282 THE ANUS, RECTUM, AND PELVIC COLON

in stenosis of the bowel, but the writer has never seen a case of this
kind.

Symptoms. — The symptoms of this form of ulceration are Teiy
meager. In the rectum itself the patient experiences no pain and no
uneasiness. There is some indication of intestinal indigestion associ-
ated with more or less griping and tenesmus, but without any real diar-
rhoea.

The action of the bowels may be perfectly normal so far as
the constituency of the mass is concerned, but the patient will com-
plain of more or less acute griping pains throughout the day and
night.

Bamburger has described little masses of inspissated mucus, looking
something like frogs' spawn or boiled sago, as having been discharged
from the bowels of patients suffering with this condition. The Uttle
masses are said to be more or less of the nature of follicles, but Vir-
chow has shown them to be particles of undigested starch, and there-
fore it is doubtful if they have any real relationship to follicular ulcer-
ation. In the early stages, before ulceration takes place, one may occa-
sionally feel little millet-seed-like formations beneath the mucous mem-
brane, or elevations upon its surface, but it requires a delicate touch to
do this. Examination with the speculum, which is the only positive
means of diagnosis, shows in this stage very slight elevations, over which
the membrane appears smooth and shining.

The causes of this variety of ulceration are practically unknown, but
insomuch as it always occurs in connection with some other inflammatoTy
affection of the rectum, it seems rational to regard it as an infection of
the follicles by the discharge from these diseases.

Treatment. — The treatment consists in attacking the causative dis-
ease and applying local remedies to the ulcers so far as they can be
reached. In the case illustrated the patient was suffering from atrophic
catarrh of the rectum and sigmoid. The treatment consisted in that
detailed in the chapter upon this disease, and the four or five ulcers
which could be reached were treated by wiping them out with small
pledgets of cotton and insufflating antinosin upon the ulcerated spots.
The patient recovered in about six weeks, and has not been troubled
with the condition since.

Strictural Ulceration. — Cripps {loc. cit., p. 204) describes in detail
a condition of ulceration which he states is due to retained discharges
from a rectal stricture. He says: " It appears as if the superficial part
of the mucous membrane is only ulcerated, the submucous tissue still
forming a distinct membrane over the muscular coat, so that the bowel,
instead of possessing a soft, velvety lining, moving freely on the sub-
jacent muscular fibers, has a surface which, though smooth, gives a

NON-SPECIFIC ULCERATIONS 283

harsh creaky sensation to the finger, and is intimately blended with
the muscular coat. This extensive superficial ulceration may gradually
spread beyond the rectum to the colon. At a post-mortem examination
the ulceration is found to end very abruptly. So sharp is the line of
demarcation between the ulceration and the normal membrane that it
looks as if cut with a knife." The cases of this variety of ulcer have all
been afflicted with cicatricial stricture of the rectum.

Strictures of the rectum are ven' liable to be associated with consti-
tutional conditions, such as tuberculosis, syphilis, carcinoma, or exhaust-
ing disease, which conditions also produce inflammation and ulceration
of the mucous membrane of the rectum and sigmoid. Moreover, where
the patient is debilitated from improper feeding, irregular movements
of the bowels, and reflex disturbances of the digestion, the mucous
membrane of the intestine is very likely to take on a feeble circulation
associated with a cellular deposit in its glandular organs, which accu-
nmlates until by its pressure it causes a necrosis and subsequent ul-
ceration of the tissues. The fact that in the case which Dr. (Vipps
quotes the stricture was cut and the obstruction and retention of the
discharge relieved, and yet the ulceration progressed until it involved
the whole of the bowel up to the splenic f.exure, proves that there was
some other etiological factor to account for it.

Symptoms, — The symptoms of ulceration such as this are practically
those of stricture. There is a frequent desire to defecate, and yet ina-
bility to accomplish the same; only when the bowels are fluid can the
patient succeed in having a satisfactory fjecal movement. When this
has been accomplished, his desire to defecate is usually relieved for
twelve to fourteen hours, after which the inclination recurs and fre-
quent small passages of pus or mucus and blood take place.

Diarrhoea alternating with constipation, inability to pass well-
formed fa»ces, tympanites, and the accumulation of fa?cal materials in
the intestinal canal are all symptoms of this variety of ulceration, as
they are of stricture of the rectum. The discharge of pus and blood
shows the presence of ulceration. The pathology and treatment of these
ulcers will be found in the chapter on Stricture.

286 THE ANUS. RECTUM, AND PELVIC COLON

tendency to i)erforation of the gut or any thickening or induration of
its walls. The condition seems to be due to amyloid or laidaceous de-
generation of the mucous membrane and its glandular organs.

Symptoms. — Aside from the general constitutional and local mani-
festations of the nephritic condition, such as oedema, anasarca, enfee-
bled heart action, debility, and reduced urinary secretions, symptoms of
indigestion, a tendency to diarrha»a, and great flatulency mark this com-
plictition of Bright's disease. The patient suffers little if any pain in
the rectum, but after a period of com])arative constipation, he gradually
begins to notice a looseness of the bowels, with excessive fluid discharges.
At first these discharges are watery, but later they become milky white
and purulent, and contain many shreds of degenerated or sloughing
tissue.

Examination of the rectum shows the whole organ to be denuded of
its lining membrane. The sloughing or ulceration is not in patches, but
appears us a general disintegration of the mucous membrane. While
there are no marked hiemorrhages, the granulations bleed easily though
not excessively upon touch. The griping and tenesmus are not marked,
but the patient soon lt)ses sphincteric control. The fluid passages run
away from him involuntarily, and his c(mdition is pitiable indeed. Hap-
pily this is one of the latest stages of the kidney affection, and is in-
dicative of an earlv termination. In one case which the author saw
some years ago, the patient had no idea that she was suffering from
anything more than anjvmia when she consulted him for an uncon-
trollable desire to defecate; she was having at the time some six or seven
stools a day, which did not annov her so much as the fact that when the
desire occurred it was impossible to control the same or to wait a
mom(»nt. Examination of the urine showed a large percentage of albu-
min with abundant granular and epithelial casts. The mucous mem-
brane was denuded over the first four or five inches of the rectum, and
the discharges from the intestine consisted of thin fjecal material and
large ([uantities of pus. Occasionally a little blood was mixed with these
discharges, although this was not frequently the case. No local or con-
stitutional treatment availed to control the symptoms, and the patient
died, at the end of four weeks, from unemic poisoning.

Treatment. — The treatment of this condition is hopeless, but some-
thing can be done to relieve the siilTering. The rectum and sigmoid
should be washed out with saline or boric-acid solution twice dailv, and
after this has come away, 2 to 4 ounces of 25- to 50-per-cent solution
of aqueous fluid extract of krameria should be introduced into the sig-
moid. A few minims of deodorized tincture of opium may be added to
quiet peristalsis and control the diarrha}a. The diet should be bland
and concentrated, such as milk and meat extracts. Occasional saline

NON-SPEaPIC ULCBRATIONS 287

purges to relieve the kidneys of too much work will do no harm, but,
as a rule, it is better to do this by keeping the skin active. Medication
should be directed to the kidney condition. Tannic acid, tannigen, and
such remedies should be avoided, but small doses of sulphate of copper
or nitrate of silver are admissible, and sometimes they control the diar-
rhoea remarkably well.

Diabetic TTlceration. — During the course of diabetic glycosuria con-
stipation often comes on in consequence of the atonic state of the bow-
els, deficient exercise, and the withdrawal of carbohydrate foods. Oc-
casionally, after this condition has existed for some time, flatulence will
be markedly developed, and sometimes excessive peristalsis and the tor-
mina ventosa of Kussmaul are easily aroused; with these conditions
there appears a serous diarrhoea associated with a discharge of pus
and blood, no satisfactory explanation of wliich has yet been given.
Clinicians are all aware of the tendency in diabetics to ulceration and
gangrene of the lower extremities and of the skin, especially whore
any pressure is exercised upon the parts. Frerichs, Ferraro, Kleen, and
others have reported ulceration of the intestinal canal in patients who
died from this disease. No one, however, has established any etiological
relation l)etween the two conditions.

It occurred to the author some years ago that pressure from the
hardened faecal masses during the constipated period of the disease
might also cause ulceration in the rectum and sigmoid. The examina-
tion of three cases which developed diarrhoea during the course of dia-
betic glycosuria has enabled him to verify this theory. In one the
ulceration was limited to the rectal ampulla, and extended over a space
about the size of a silver half-dollar; it was isolated and involved the
mucous and submucous tissue; the edges were dry, and the base feebly
granulating. In the other two cases the ulcerations were numerous
and extensive throughout the rectum and sigmoid flexure. Strange to
say, just about the time that these occurred, or shortly thereafter, the
excretion of sugar almost entirely ceased. In one of these cases the
ulcerations healed, but the diabetes recurred, and she succumbed later
to this disease with recurrence of the rectal comi)lication. In the other
two cases the diabetes has not recurred, and the patients have recov-
ered from the ulcerative condition and remain apparently well. In all
three cases there was a history of marked constipation preceding the
diarrhcea.

In the two cases with extensive ulcerations the stools varied from
eight to twelve a day. They were composed of quantities of pus tinged
with blood, and did not possess any particularly feculent odor. Once or
twice during the day they would pass more or less hard, lumpy, fajcal
material. In one the muco-cutaneous margin was involved, occasioning

288 THE ANUS, RECTUM, AND PELVIC COLON

so much pain that it was necessary to dilate the sphincter in order to
give the patient any rest. This patient also suffered from bed:?ores,
owing to lying in the recumbent posture.

Large doses of codeine used to control the glycosuria seemed to have
no effect upon the diarrhoea. Frequent irrigation, however, with a 20-
per-cent solution of aqueous fluid extract of krameria, together with
ichthyol internally, succeeded in controlling the condition, and restored
the patient to health after about twelve weeks' treatment. There is no
distinct literature upon this subject, nor is it possible to base any very
positive conclusions upon these limited observations, but the condition
is noted here as it has been observed, and a wider experience, it is hoped,
will determine its true patholog}'.

Hepatic Ulceration. — riet»ration of the rectum not infrequently oc-
curs in cases of clironic cirrhosis of the liver. There is no specific infln-
<?nce in tlie hepatic disease to produce this result. The obstruction to
the portal circulation causes congestion and dilatation in the supe-
rior ha^morrhoidal veins, and frequent haMuorrhages from these re-
sult. The infection of the rupture in the vein causes the ulceration.
These generally assume the form of ulcerated haemorrhoids. They
occur upon the summit of the ha?morrhoidal mass, and not between
them.

Treatment. — The treatment of this condition consists principally
in attacking the disease of the liver. One may be tempted to operate
upon the ha»morrhoidal condition, and thus remove the ulceration and
check the ha^uorrhages. This, however, is not ordinarily a wise pro-
cedure. As stated in the chapter upon Haemorrhoids, the checking of
these periodic losses of blood is likely to be followed by acute anasarca
and rapid aggravation of the hepatic disease.

Tlie bowels should be kept freely open and the rectum irrigated
daily with antiseptic solutions. If there is a tendency for the luemor-
rhoids to become strangulated by spasm of the sphincter, this muscle
may be stretched. Beyond this, operative interference is likely to do
more harm than good.

Trophic Ulceration. — Tn the chapter upon Colitis we have already
called attention to the trophic ulcerations of the large intestine, and
have referred to them as occurring also in the rectum and sigmoid flex-
ure. Ackland and Targett both claimed that ulceration of the large
intestine mav be due to diseases of the central nervous svstem, and
report cases which seem to confirm their opinion. White has reported
two cases occurring in Guy's Hospital which seem to corroborate this
view.

Cowan and Eurich state that the general lowered vitality of the
insane renders them an easy prey to all sorts of disease, and that the

NON-SPECIFIC ULCERATIONS 289

case? of ulceration of the rectum and colon in this class of patients
is more likely due to some other cause, such as traumatism and infec-
tion, than to trophic neuroses.

I'laTations of the rectum occurring in spinal disease and neuras-
thenia have been referred to, but there is no reason to suppose that they
did not result from the usual causes. On the whole, while there are some
evidences in favor of this type of ulceration, there are no characteristic
symptoms or positive proofs that it actually exists.

It mav \ye worth while to mention in this connection two cases of
iilo(»nition of the rectum and sigmoid following injuries to the spinal
cord, with paraplegia and temporary loss of sphinctoric control. In
both of these cases the paralytic symptoms disapj)oared, but there was
a marked decrease in sensibility about the anus. In one there were
numerous ulcerative patches throughout the rectum and in the lower
portion of the sigmoid flexure. There was no tuberculosis or syphilis
in either case to account for the condition. Without being able to dis-
cover any other cause, it is thought possible that these might be cases
of trophic ulceration due to injury of the cord.

Harasmic ineeration. — Some years ago it was the privilege of the
author to make autopsies on a number of children who iiad died from
the c(»ndition known as marasmus. The ages extended from two
months to three and a half vears. A number of these cases turned
out to be tuberculous, the mesenteric glands being enlarged and con-
taining tubercle bacilli. In others there were gummatous develop-
ments in different portions of the body which indicated syphilitic dis-
ease. In 5 cases, however, there was no evidence of either of these
specific affections. The children seemed to waste away and die simply
from malassimilation and exhaustion.

An examination of the intestines in these cases showed in 3 of
them extensive ulceration of the rectum, sigmoid, and colon. In one
case the ulcers extended well into the ileum. The condition resembled
verA' nmch that seen in the late stages of Bright's disease. There were
left here and there patches of mucous membrane, but these were always
covered with a sort of flaky deposit resembling very much the beginning
of diphtheritic membranes. Microscopic examination, however, failed
to reveal any specific bacilli in them. The walls of the gut were not
infiltrated or thickened, and there was no ap])roach to perforation in
any of the cases. Two of these cases were being treated for summer
diarrlura at the time of their death. The stools, however, dilfered
from the ordinary flocculent, green ones of this disease, in that they
contained considerable quantities of pus tinged with blood and very
little mucus. The explanation of this latter fact lies in the destruction
of the epithelial layer of the mucous membrane and the consequent
19

290 THE ANUS, RECTUM, AND PELVIC COLON

absence of goblet-eel Is. In all of the eases there was a histon* of
gradual wasting disease before the diarrhoea began.

Tlie stools at first had contained considerable mucus with blood.
but they had gradually become thinner, containing more pus than
mucus, until in the later stages they were almost entirely composed
of pus and undigested milk. The condition is undoubtedly the* result
of impaired circulation, probably accompanied by thromboses of the
intestinal veins.

The symptoms are those of a gradually increasing diarrhoea occur-
ring in marasmic children. There is little pain or griping, and the
stools gradually change from the green, mucous type to pus, serum,
and undigested food.

It is impossible to lay down any definite lines of treatment, as
every method failed in the cases seen. Reasoning from the condition
observed, however, one would suppose that some relief might be ob-
tained by Hushing the colon freely with saline solutions. This would
have to be <l(me with the child in the knee-chest posture and through a
long rectal tube, inasmuch as the sphincters are always so relaxed that
the fluid would flow out immediately if injected into the rectal ampulla.
The general treatment of the constitutional condition will, however, do
more for the patient than any local apj)lications. For this, liowever,
the reader must be referred to works upon diseases of children.

CHAPTER IX
FISSUBE IX ANO^IRRITABLE ULCER— INTOLERABLE ULCER

The terms which head this chapter have been used by various
writers to describe a type of anal ulcer chanicterized by acute pain
during or after stool. Gosselin first distinguished between the acutely
sensitive lesions at this point and those which were less so, calling
them tolerant and intolerant ulcers. Allingham designates the sensi-
tive type as " irritable ulcer." MoUiere suggested the better terms
tolerable and intolerable, holding properly that all ulcerations of this
n^gion occasioned some pain. The word fissure signifies a crack or
elongated break in the tissues. Tt may occur anywhere in the body,
but in common parlance it is applied generally to the lesion in the
anus. It is an ulcer, but distinct from those destructive and extensive
types which have been described in the previous chapters. Technically
it is limited to the sulci between the radial folds; it spreads up and
down but not circularly, does not involve the tegument covering the
folds and columns of Morgagni, and is painful at or after stool or upon
the escape of gases from the anus.

It occurs in all ages and conditions of life, but is more frequent
in the young than in the very old. In infants the disease is very likely
to Ix' the result of hereditary syphilis, but this is not necessarily the
case. It is chiefly found in adult life and in women, especially during
the child-bearing period.

Sex does not seem to influence it materially. Allingham says it
is more frequent in women, and Goodsall, working in the same hospital,
finds it oftener in men; in 329 cases of fissure he found it 190 times
in mm and 139 in women. In 324 cases collected by the author from
different sources it occurred 176 times in women and 148 times in men.

It may be single or multiple, but the typical painful fissure is
nearly always single. The multiple variety is rare except in atrophic
catarrh, gonorrhoea, and syphilis. In these conditions multiple fissure-
like ulcerations are comparatively frequent. Goodsall found in 221 cases
that fissures were single in 208; there were 2 fissures in 12 cases, and 3
in onlv 1.

291

292

THE ANUS, RECTUM, AND PELVIC COLON

tShapr, of Ulcers. — Much iinportuncu lina been attaclied by writers
upon this subject to the shape of the lesions. Most authors attempt
to confine the term to those linear or elliptical ulcers which are con-
fined to the groove Ijc-
tween two anal foUla
(Fig. 101). Recently,
however, no particular
importance is attached
to the shape. It may
be linear, pear-shaped,
elliptical, or rounJ.
Quenii and Hart maun
in an ehiborate study
of a number of cases
have come to the con-
clusion that this fis-
sure-like or elongated
shape is only apparent,
and that where it is
dissected out and laid
flat upon a block the
ulcer assumes a circu-
lar or elliptical form-
It is the site between
the radial or mucoua
folds, within the grasp
of the sphincter, which
gives it the elongated
shape and characterizes
it. In its other fea-
tures it does not differ from any simple ulcer; the edges are generally
inflamed and slightly elevated, but not indurated; they may be ragged
(Fig. 102) and appear slightly undermined, but the latter feature disap-
pears when the ulcer is stretched open. Tlio base is either a bright-red
granulating surface which bleeds easily upon touch, or it may be com-
posed of grayish, fleshy granulations covered by a thick pus or pseudo-
membrane. The elevated edges are folded or tucked in by the con-
traction of the sphincter, so that they rest upon the base of the ulcer,
thus irritating it and preventing heating as well as causing pain.

At the lower end of the fissure there is frequently a hypertrophy
of the skin or rauco-cutaneous tissue which resembles an external pile,
and has been called by Brodie the sentinel pile {Fig, 103). This may
be divided into two e;ir-Hke flajis by the Assure; it is always painful

PIHSURE IN ANO 293

■ the touch, and when dragged iipou it hrings on cliaractGristic

Location. — The site of Ihe lissiivc in ano is variable and may oocur
at any point from the cutaneous margin to the upper limits of tlie
culumnt; of Morgagni; the majority begin juet above the ano-rectal
line aniT extend downward. It may also occupy any point in tho anal
circumference. In men they are most frequently seen at or near the
posterior conmiissure, and rarely upon the sides or anteriorly. In
women they are comparatively often seen at the anterior commissure.

»Iii 132 cases in men recorded by Goodsall, the iissiiro was found at the
interior commissure but once, and in 8!) women it was found there
a times. The significance of these locations will be appreciated when
Ibe etiology and symptomatology of the disease are studied.

Elioltigi/.—lf all ulcers of the anal canal are considered to be fissures
ii will be necessary to invoke as etiological factors catarrhal diseases,
gDDorrha^a. chancroid, syphilis, tuberculosis, etc. The tj^pical anal fis-
s an ulceration entirely distinct from these types, not in its shape,
Br all of them may a^ume the elliptical or irregular shape; not in its
epth, for this is variable in all varieties: hut in its etiology, its symp-
nnatology, and profp-ess. Prom day to day, if one carefully obsei'ves a
Imple traumatic fis-
tre of the anus, he
Wy see signs of cica-
rization at its mar-
io which comes and
Uts for sliort periods,
oly lo break down
Igain. Sometimes
wen the ulcer nil!
HBttl completely and
amain so for a short
leriiid, breaking down
gain under the intlu-
Bee of hard fa-cal
assages and strain-
bg at stool. Surgi-

■1 operations may result in fissure-like ulcerations, but e
nal in the majority of cases without leaving a typical cicatrix.

Fissures may originate in any wound, excoriation, eruption, or
Bflammation around the anus. Anything which weakens the tissues
Dtd renders them liable to abrasion will act as a predisposing cause.
[be exciting cause, however, is nearly always the passage of hard fiecal
Basses with or without foreign bodies in them. The fact that women

V lhes(

294

THE ANUa RECTUM. AND PELVIC COLON

arc more frequently coustijmteil than men will account for the appar-
ently greater proportion of fissures in this sex. Injury to the mucous
membrane by syringe-tips, straining, or a severe sneezo or cough, may
rupture the delicate mucous membrane of the anus and cause fissure.

Alliugham alutea ilmt gelatinous and fibrous poh-jii are not at all un-
common causes of fissure: "The polj^pus is usually situated at the '
up[>er or internal end of the fissure, but it may be on the opposite '
side of the rectum. " Whatever causes narrowing of the anal canal, i
such as congenital malformation, hypertrophy and contracture of the
sphincter or levator ani nmscle, and stricture, may result in fissure. '
The condition may also. result from parturition, the passage of Ihe
child's head through the va^na so distending the rectum as to tear '
the mucous membrane. It is also said to result from malpositions of
the uteruSj sucli us anteversion and retroversion.

The fact that a large majority of patients suffering from fissure are '
also iifflicted with a greater or less degree of hsemorrhoidal disease
would indicate that there was some etiological relation behreen the '
two. The etatonient of (Juenu and Hartmann (op.cii., 431) that "0
to 80 per cent of fissures are due to htemorrhoids does not seem rensuna-
hle; it is more likely that the irritation produced by the fissure results

FISSURE IN ANO

295

in a hj-perwinift and congestion about the margin of the anus, and is
ilius the cause rather than the result of lia'morrhoids. The author
has seen a number of cases of Rsaiire in which tlie hffiinorrhoidal symp-
toms— protrusion, bleeding, and backache — all came on after the original
symptoms of fissure. The costiveness whicli causes the Assure will
also account for the hemorrhoids, so the relation therefore appears co-
incident rather than etiological. Boyer's tlieorj- that the fissure is due
lo spasmodic contraction of the sphincter puts the cart before the
horse and is no longer considered seriously.

Ball has advanced the idea that tj-pical Ussures are due to tearing
of the crypts of Slorgagni. lie says that they are brought about by
the lodgment of small fa-cal masses in these little pockets, which being
pressed upon by hard stools cause the edges of the valves to tear; this
rent is gradually extended by every subsequent passage until the whole
depth of the crypt is torn through and the muco-cutaneous tissue of the
anus !£ thus involved (Fig. 104). This theory is very plausible, and the
frequency with which fissures occur at the anterior and posterior com-
missure is entirely in keeping with the anatomical fact that the crypts
are more highly developed in these areas than in any otlicr poi'lion
of the rectum. A series of cxaruinatious instituted after tlie publica-
tion of Ball's article
(Brit. Med. Jour., 18SI1
-vol, ii. p. 583) have
shown that upon each
side of the postn i >
commissure there i-
■nost always a will :
Teloped valve of M :
gsgni aud one din >
le middle lirn .1
anterior conirni-
in women; ami j
;ly of all the cas
fissure obsened
has shown that the ma-
jority occiir at these two imintp^. Moreover, a careful examination of
i will frequently show two little papilla* or teats, which would
idicate the tearing through of a fold of the muco-cutaneous tissue;
metimes this fold is not entirely torn through, and the fissure presents
ilight pocket underneath the lower border accompanied with hyper-
r of the skin externally. This hypertrophy represents the well-
3 sentinel pile of Brodie which has been described. From all these
lets it seems rea.'ionable to conclude that while fissures may occur at

^hore

ptud:

296 THE ANUS, RECTUM, AND PELVIC COLON

any portion of the circumference of the rectum through a solution of
continuity in the covering membrane from any cause, it is likely that
many cases are due to the tearing of these little crypts as claimed by
Ball. There remain, however, a large number which occur in the verr
middle of the posterior commissure, above which point there is no crj-pt;
these are explained by the direction of the canal above the commissure,
which is backward, and consequently the mass exerts its greatest pres-
sure there.

Pathology, — The pathological changes in fissure vary from the
slightest abrasion to deep uleenition and destruction of tissue. In some
only the most supei-ficial layer of the muco-cutaneous tissue is involved,
while in others even the muscular fibers themselves are either laid bare
or become involved in an inflammatory process accompanied by fibrous
deposits and alterations in the vascular and nerve supply. In the
superficial variety, those which may be called acute, there is no indura-
tion of the l)ase, no thickening of the edges, and no great hypertrophy
of the sphincter muscle. In the chronic state, however, the edges of
the ulcers are elevated, irregular, and thickened, the base is hard and
inelastic, and the s])hincter muscle is hypertrophied and very resisting.
In this state it might be very dilficult to distinguish the simple fissure
from a true Ilunterian cliancre. Tlie time which it has existed and the
absence of other specific manifestations during that period should
decide this question. The elongated ulcer occurring between the radial
folds low down occasions a higher degree of sphincteric spasm and
hypertrophy than does the small round ulcer which occui-s above the
ano-rectal line. There is also more induration and inflammaton' in-
volvement of the neighboring tissue in the linear than in the round
ulcer.

Microscopic examination of excised fissures has been made by M.
Hartmann {op. cit., p. 422); upon the surface of the ulceration there
was a granular layer of round cells of unequal thickness lacking in
places; below this was a fibrous layer in which were scattered numbers
of round cells and fusiform granules crossed by bosselated blood-vessels
running parallel to the surface; still lower was a layer of smooth mus-
cular fibers more or less separated from one another by fibrous tissue,
and below this a cellular adipose layer in which ramified the blood-
vessels with their tunics and primitive nerve-roots. In the adipose
region the nerves and the vessels appeared normal, but in the deep
muscular layer the nerve-trunks were surrounded by fibrous material
(Fig. 105). They were altered and granular, and distinguished by their
lamellar sheath, and showed interstitial and intrafascicular neuritis
(Fig. 106). The mucous and muco-cutaneous border of the ulceration
presented a cavernous transformation, the epithelium assumed a strati-

(Qu^nn and llutmiuui)

FISSURE IN ANO 29"

fied, translucent appearance, the prulongations of the epidermis were
destroyed, and there was an infiltration with pranular cells accompanied
by venous thromboses and small intercellular hajmorihagcs.

There was no evidence in any of the sections of exposed nerve-ends.
The hisloiy of the cases from which tliese sections were taken is not
^ven in Hartmann's report. It is well known clinically that the pain
in fiBeures varies according to their duration; at first it is burning, cut-
ting, and lasts only a short time; but after they become chronic, it ia
a dull, throbbing ache which radiates to the back and down the legs.
In the first a sensitive nerve-end may be found exposed, whereaa in the
necond this sensitive nerve-end
may h«»c been destroyed by
the ulcerative process, and llif
peri- and interstitial neuiiti-
may hav« taken place in ilu
nerve deeper down. It wouM
liave proved more intere^im
and instructnt if Hartmiiin
had taken a series of cast in
their initial stages as mil a')
the«e apparently chronic lasts
from which he inado the nil
croseopic examinations \t the
same time thee* studies are of
ihe preattfit importance and
enable u to (.xplam in a intas
ure the old aching throbbint.
dull pain which follows defeta
lion in chronic fissure even
after they have healed bj cita
trization On the other hand
its pathology will not explain
thcacule burning ttaringpain

which octiir m the earh stages of acute fissure because m thm lases
there IS no induration no hypertrophj of the sphiniter and no possi-
bility of the neuritis as abo\e described Here it ii Bimplv a question
of u raw surface exposed to the irritating action of the fa>eal passages,
which surface differs in no wise from that at any other portion of the
body, save that the tissues are somewhat more highly endowed with
M-nsitivc nerve-ends. It is impossible, therefore, to conceive of a lesion
in these tissues without an exposure of some of those numerous nerve
filament*" which supply the anal canal, and this exposure accounts for
Mhe characteristic pain in the early stages.

298 THE ANUS, RECTUM, AND PELVIC COLON

Symptoms. — As a rule, patients can not say when the first symptoms
of fissure begin. Occasionally one will recognize a time when during
a difficult fa>cal passage there was a sensation of something giving way,
after which there occurred a slight discharge of blood and recurrent
pain at each stool. Such a history, however, is rare. Ordinarily he
will state that for some time he has noticed either itching or burning
after stool, accompanied with blood or mucus, and that he has a small
pile which is either always swollen or which swells after defecation.
The bleeding is generally confined to one or two drops, or simply a
staining of the detergent material. The discharge of pus may not be
sufficient even to soil the linen. Constipation will be complained of,
but if one sifts the facts, it will be seen that this has been brought on
more by the fear of pain following fa}cal movements than by any inac-
tivity of the bowels; it is an acquired habit rather than a functional
disease. In the beginning the patient could and would have had regu-
lar movements of the bowels had it not been for this fear of pain;
there is in most cases absolutely no obstruction to the fjecal passages,
and in the early stages no lack of moisture and lubrication in the
intestinal canal; it is simply a matter of voluntary control. The result
of this is that the fa»cal passages become more and more dry the
longer they are retained. They are thus made harder and more
irritating, and finally when a movement does take place, the irrita-
tion is much more severe than it would have been had regular move-
ments occurred, and the injury to the fissure or ulcerated membrane
is greater.

Pain. — The pain associated with fissure is very variable in time, na-
ture, and duration. It may come on at stool, immediately thereafter,
or half an hour to an hour later. It may be acute, cutting, tearing, as
if a wound were being pulled asunder, or it may be a burning, hot, irri-
tating feeling accompanied with spasm and bearing-down sensations.
Finallv, it niav have none of these characteristics, but assume a dull,
heavy ache, with throbbing and distress similar to an aching tooth.
The time which the pain lasts is also as variable as its nature. Some-
times it lasts for only a few minutes, and the patient is then able to
go about his business without any further disturbance until the next
stool. At other times the pain and smarting are so severe that he is
unable to move from his position at the toilet, or must seek his bed, and
lie there from half to three-quarters of an hour until the acute agony
has passed away. After this he is comparatively comfortable for the
rest of the day. In others still the pain does not come on for some little
time after the faecal movement, when it begins to smart and bum, this
sensation gradually changing into an aching, throbbing distress about
the anus and sacrum, which condition may last for several hours, or

FISSURE IN ANO 299

even in some cases all day long. Certain patients are never free from
discomfort.

There is a pretty clear relationship between these pains and the
character of the fissure. Those acute pains lasting for only a few mo-
ments are ordinarily due to superficial fissures which involve the up])er-
most layers of the muco-cutaneous tissues, heal partially or entirely
from day to day, and recur with each hard stool. They can Ik» pro-
duced by forcibly stretching the anal folds apart. Such fissures are fre-
quently associated with atrophic catarrh and late syphilis. The pains
which come on just after stool, and last for half an hour or more, are
ordinarily due to an ulceration between the radial folds of the rectum,
especially in the posterior commissure; there is a slight, red, granu-
lated base, thickening of the edges, and a sentinel pile, or two little
teats at its lower end. The dull, aching, throbbing pain which comes
on some time after stool is generally due to a fissure or ulceration situ-
ated in the upper portion of the anus, and involves the internal and the
upper fibers of the external sphincter. It is ordinarily of long standing,
deeper and more indurated than the previous vari(»ty, but its edges are
not so elevated and thickened, and it does not involve the skin at all,
and can only be seen by the use of a speculum or forcibly stretching the
anus apart. These late pains, occurring some time after a fanal move-
ment, indicate that the ulceration is high up, while those occurring im-
mediately thereafter would indicate a lower situation. In general, how-
ever, it may be said that the acuteness and severity of the pain is in direct
proportion to the nearness of the ulcer to the anal margin. The more
of the muco-cutaneous tissue involved the greater will be the pain. The
application of this is clearly brought out in the chapter upon Anatomy,
where it is sho>*Ti that the sensitive nerve-fibers approach the anus
from below, and are distributed in a gradually decreasing ratio as
we asct*nd into the anal canal, disappearing almost entirely after the
mucous membrane, has been reached.

Reflex Symptoms, — With the local symptoms of fissure a variety of
reflex phenomena occurs, sometimes even more annoying than the fissure
itself. Dysuria and painful urination are among the most frequent
complications. The first case of fissure that the author treated was a
man who complained of symptoms of urethral stricture, and who had
been treated for the same for a long time without any material benefit.
He was an orderly at the Blockley Hospital in Philadelphia, and close
questioning revealed the fact that his urethral symptoms were always
more marked at the time of and just after his ffccal passages, and that
at periods the farthest removed from the stool he was comparatively free
from his urethral symptoms. Examination of the man's rectum demon-
strated the existence of a small indurated fissure at the anterior com-

300 THE ANUS, RECTUM, AND PELVIC COLON

iiiissure of tht* anus, liuision of this soon resulted in its cure, and for
two years thereafter the patient was absolutely free from any urethnl
or urinary symptoms.

It is not nec»essarv, however, that the fissure should be in the ante-
rior commissure to produce these reflex urinan' disturbances, as prox-
imity is not the cause. The origin of the ner\*e supply to both set?? of
organs 1km ug practically the same in the spinal cord, irritation of the
nerve-ends in one is likelv to be reflected in the other.

Uterine and hearing-down pains often occur as a result of fissure in
ano. Backache and neuralgia shooting down the leg, indeed all over
the body, nuiy be the result of one of these nagging, irritaVde ulcrrs of
the anus. These widesj)read and vague disturbances arc, of c«>urse, due
in a measure to the nervous exhaustion and strain produced by long-
continued sutfering and irregular action of the bowels. Facial and occip-
ital neuralgia, sj)inal irritation, and temporary stnibismus have been
known to disappear almost immediately after operations for fissure; it
is not asserted that the latter was the cause, but it certainly seemed to be.

Diagnosis. — The diagnosis of fissure is considered very simple. It
is ofttm made simply from the descrij)tion of pains after stool, but pa-
tients have these from many causes; foreign bodies, stricture, chan-
croids, gonorrhoea, syphilis, and eczema all produce them. While these
symptoms are of the utmost importance, one should not make a final
diagnosis without a careful local examination. This should be insisted
upon in every case in whiih there are symptoms of rectal disease, and in
none is it more important than in this condition; first, because mistakes
in rectal diseases are likely to prove rapidly disastrous; and, second,
because in this particular disease local treatment or o]x»ration is the
only reliable means of cure, and therefore nothing can possibly be gained
bv delav.

To examine a })atient for fissure, the semiprone position is the most
convenient. The patient should be laid upon his left side, the hips
elevated u])()n ])illows, the thighs flexed ui)on the abdomen, and the left
arm thrown backward, so that the trunk rests practically upon the
breast. The buttocks should at first be j)ulled gently apart and the ex-
ternal surface of the anus examined. If there be a sentinel pile it can
be easily recognized, or if the ulceration involve the perianal tissue it
will also be clearlv seen.

Palpation around the anus will not only reveal the hypertrophied
and hardened condition of the sphincter muscle, but it will usually en-
able one to determine the probable point at which one may exi)ect to
find the cause of the pain. Pressure upon the margin of the anus alway*
gives pain just below the site of an ulceration, even though the ulcer
itself is not pressed upon. With the patient's assistance, pulling upward

FISSURE IN ANO

301

^n the right bullock, while the surgeon pulls downward upon the left,
anuy iiinj" generally be everted sufiieiently to see any typical fissure
ii-annl ulceration. In wouion this may W facilitated by the iu-
ion of the fingers into the vagina, and pressing backward and
downward, so as to evert the rectuni (Fig. 107). Theso maneuvers always
occasion more or less pain in true fissure. Sometimes it will be so great
that the patient can hardly stand an examination nf this kind. The
introduction of a amall quantity of cocaine upon a pledget of cotton
will o<?eflsii>nally relieve this imin, and enable one to examine the fissure
without great disturbance. As a rule, however, cocainu is very poorly ab-
sorbed [iy granu-
latitig surfaces,
and is often dis-
appointing in
these examina-
tions. If the pa-
tient can be in-
ducted tu sli-ain,
fissures between
the radial folds
can ffcnerally be
brought into
comparatively
good view. Fre-
quently, how-
ever, this effort
brings on the
typical pain of
fissure, and he
will be unable

to continue it. Under such circumstances, if one keeps at hand an
insufflating apparatus containing finely powdered orthoform, and will
Wow on the fissured surface a small quantity of this drug, he will
be able after a few moments to examine the parts in an almost
painless manner. Occasionally this drug fails, but in many instances
it affords great relief in the examination of ulcerating conditions of
the anus.

Having thus seen what is possible upon the outside and lower por-
tion of the anal canal, digital euamination should be made to deter-
mine not only the existence of a fissure but, if possible, its cause. The
elevated and thickened edges, the indurated base, or the smooth, soft,
circular ulcer just above the margin of the external sphincter, are easily
rwognized by the educated touch. AUingham states that at the upper

302 THE ANUS, RECTUM, AND PELVIC COLON

end of an anal fissure one often finds elavate papillae or small polypoid
growths which fall into the cleft, and thus prevent healing. He ?tat«
that these growths are not the cause of fissure as a rule, but that thej
a»rtainly keep the wound oi>en and prevent its healing. His further
statement, however, that when such growths are found it is not nece*-
sary to examine the rectum any further invites criticism. Assuming
that he is right in his statement that these little neoplasms are not the
cause of fissure, their discovery, therefore, will not have solved the
etiological })r()blem. One should not stop at this point, but earn' his
examination farther, and determine if possible whether theri' Ix* any
pathological or anatomical condition above this which will account for
the ulc(»rati()n.

In the introduction of the finger for the examination of fissure, it
should always l)e })ressed to tlie opposite segment of the anus from that
at which one supposed the lesion to exist. Thus if the patient coni-
j)lains of pain in the posterior segment, the finger should be carefully
pn\^sed forward and introduced to its full length. The rectum should
then be examined for any abnormalities, and the anus can be searched
for ulceration as the finger is withdrawn. With the use of orthofonn
and these precautions very little pain is occasioned by such examinations.
The ulcerations are largely within view by the separation of the radial
folds, and, moreover, they can be so clearly and distinctly felt that their
diagnosis is always certain. The snuiU round ulcer of the anus is not
so easily made out, and the speculum is of advantage to diagnose this
condition.

* The i)est instrument for the examination of these ulcers is the con-
ical fen(\st rated speculum (Fig. 03). The segment of the anus in which
the ulceration exists having been located by digital examination, the
speculum should be introduced with one of the slides opposite this area.
Where the sphincter is tense and hard, the snuiller sized speculum should
be used. After the instrument has been introduced to its full extent
the slide should be withdrawn and the ulceration can then be clearlv

•

seen. The Sims's vaginal sj)eculum is also ver}' useful in these cases.
The tubular specula and the anosco})e are not useful in the examination
of these conditions, inasmuch as they are very likely to i^lip out and
give the patient a great deal of pain just as the ulcers come into view.
Moreover, the conical sj)eculum enables us to treat these ulcerations
locally through the fenestra, the rest of the circumference of the anus
being thoroughly protected from any applications which one may make.
Treatment. — The treatment of anal fissure is ordinarily described

as ]jalliative and curative. There is no ])lace in rectal surger}' for the
palliative treatment of fissure. Opiates and sedatives which relieve the
pain always increase the constipation and make the faecal passages not

FISSU&E IN ANO 303

only more painful but more injurious to the diseased condition. The
treatment therefore resolves itself into the non-operative and oj)oraiive
methods. The first step consists in removing the cause if possible. For
those cases due to constitutional syphilis, the line of treatment is laid
down in the chapter upon Venereal Diseases.

In those cases in which a polypus or papilloma complicates the
fissure it is useless to attempt local treatment without the removal of
these neoplasms. Where it is due to constipation and atrophic catarrh,
these should be treated along with the fissure, as the latter is sure to
recur if these conditions persist.

The regulation of the bowels is of the utmost importance in chil-
dren as well as in adults. When the movements are regular, l)ut the
Faecal mass is hard and lumpy, an injection of a small quantity of sweet-
3il and glycerin during the morning hours will generally afTord great
relief. This may be injected through a small syringe at a time sonie-
jrhat previous to the usual period of defecation. One smooth, regular
passage a day is better than an occasional purging. AUingham reconi-
mends for this purpose the use of figs soaked in sweet-oil, or onions and
milk at bedtime. The use of figs as a laxative in rectal diseases is
objectionable from the fact that the small seeds are not digested in the
intestinal canal, and are likely to lodge in the ulcerated areas and cause
irritation, l^hosphate of soda given in the morning is sometimes effec-
tual in the production of such faecal passages. Saline laxatives, sulphate
of magnesia, sulphate of soda, etc., and the cathartic waters, such as
Ilunyadi, Friedrichshall, Apenta, and Rubinat, are more likely to pro-
luce frtMjuent thin, liquid passages, which are irritating. (Siscara with
malt is quite satisfactory, but one must ex})eriment with every patient
to determine the amount necessarv. The resinous cathartics, such as
gamb<»ge, })odophyllin, aloes, etc., are all irritating to a fissured anus.
Cripps thinks highly of a confection of black j)epper and senna in equal
parts, and recommends two large teaspoonfuls of this for an adult ui)on
rising in the morning.

The diet should be carefully controlled, and if possible the bowels
should Ik? regulated by this means rather tlian by medicine. Tf there
are haMuorrhoids, a cold enema in the morning will relieve the conges-
tion in these, and ordinarily produce a satisfactory movement of tln^
bowels.

yon-operative Treatment. — WTiere the fissure is acute and there is no
marked induration of its base, it may be cured without any operative
interference. The patient's constitutional condition should be built up,
and as much rest in the recumbent posture as possible should be en-
joined. Experience teaches that lying down immediately after fjccal
movements prevents in a large measure the pains of fissure. If there-

304 THE ANUS. RECTUM, AND PELVIC COLON

fore a patient's occupation })revent8 him from obtaining such rest during
the morning hours, it is wise for him to regulate his bowels to move
at an evening hour, so that he can go to bed and remain quiet afterward.

The injection of solutions such as starch-water and opium, iodoform
and (»il, and lead-water and laudanum after fsBcal passages appears im-
tional and })roductive of no good; the only possible relief which they
can atford to the fissure is through absoq)tion, and their effect u])onthe
nervous svstein ; thev do not come in contact with the ulcer, and add
more irritation through the introduction of the syringe-tip necessary
for their administration. If such remedies are necessarv it would be
better to administer the opiate hypodermically or by the mouth.

C'rip])s recommends an ointment composed of ferri subsulphate, 10
grains, and unguentum petrolii, 1 ounce. In some patients this ointment
gives pain, in others he says it is very beneficial. He also recommends
the aj)plicati(m <»f a small amount of the following ointment to the
fissured spot a few moments before the faK:'al movement, and again
after it has passed :

Vf, Ext. conii oi j :

Olei ricini oiij ;

I'ng. hinolinii .^ij.

Allingham states that there is nothing better as a local application
than the following ointment :

\\ llyd. subchlor gr. iv ;

Pulv. ()j)ii gr. i j ;

Ext. belladonna' gr. i j ;

Tng. sambuci 3j.

Ointments containing cocaine, bismuth, iodoform, aristol, resinol,
etc., and sometimes a certain amount of morphine, have been highly
recommended by various authorities. As a rule, however, thev are not
of much Ix'uefit, save the ointment of conium, recommended by Cripps.
Recentlv, however, the author's treatment of fissure in ano has entirelv
chan<rcd so far as local a])plications are concerned. It is no longer a
question as to the length of time a fissure has existed, whether it i8
curable by local treatni(»nt or not : the condition of the sphincter and
the amount of induration, together with the depth to which the idcert-
tion has extended, are the im]>ortant factors. If the sphincter is hvpe^
tro])hied, hard, and spasmodically contracted, if the ulcer is deep and
indurated at its base, with its edges thickened and the sentinel pile well
developed, one can not generally succeed in curing the condition without
some operative interference. Especially is this true if the muscular

FISSURE IN ANO 305

fibers are exposed and can be clearly seen by the use of a magnifying
glass. Where, however, these conditions do not exist one may confi-
dently predict a cure without any operation. The treatment consists in
the application, first, of small quantities of orthoform insufflated on the
surface of the ulcer; after a few minutes a pledget of cotton soaked in
pure ichthyol is applied ; these applications are made through the coni-
cal speculum, as was described above. The treatment is carried out every
other day, together with the regulation of the bowels. The introduc-
tion of the speculum serves to gradually dilate the sphincter and takes
the place of bougies. It is now some five years since this treatment was
commenced, and during that time not more than* 10 cases of uncompli-
cated fissure have been seen, which could not be cured without operative
interference. In the beginning of this method of treatment orthoform
▼as not known, and solutions of cocaine were used to relieve the pain.
Sometimes this was efficient and sometimes not. In those cases in
which the cocaine was ineffectual the patient suffered considerable pain
after the first two or three treatments, but it gradually grew less and
less at each succeeding one until the ulcer entirely healed. In the mean-
time, however, the faecal passages always became less painful after the
first application, and the patients have always l)een willing to bear the
pain of the application rather than to submit to the knife. When there
has been much spasm of the sphincter the parts may be smeared with
an ointment composed of —

IJ Ung. stramonii, ^

Ung. belladonme, V ^^ »^iv.

Ung. hyoscyami, J
M.

This always seemed to relieve the spasm and control in a large meas-
ure the pain that resulted from the application of the ichthyol. After
th- use of orthoform, this ointment is rarely necessary. Whenever
a hypertrophy of the sentinel pile exists or there are little teats they
should be cocainized and snipped oif with scissors.

The average length of time consumed in the treatment of fissures
by this method has been something less than four weeks, but in the
majority of acute cases relief is obtained in ten days to a fortnight. In
a large number of cases three or four applications of the ichthyol have
resulted in a complete cure. Where the treatment is not successful
within four weeks it is advisable that the patients submit to operative
interference. At the same time where the condition is complicated by
haemorrhoids or neoplasms of the rectum, such as polypi, adenomata, or
papillomata, local treatment will be of little avail, and the method will
be brought into disrepute by its application in such cases. Operative
20

806 THB ANUS, RECTUM, AND PELVIC COLON

treatment should therefore be resorted to at once under these con£>
tions.

The author 8 experience entirely agrees with the statement of Ailing-
ham, that lateral and anterior fissures can always be healed without
operative interference ; but that fissure, with induration and hypertrophj
of the sphincter, is always sure to recur when healed in this manner.

Nitrate of silver in solutions of from 2 to 50 per cent, and some-
times in the solid stick, is a useful remedy. It stimulates sluggisk
ulcers, destroys exuberant granulations, and forms a coating of albo-
minoid of silver over the lesion, which protects it from irritation by the
fa?ces. Occasionally it relieves the pain after one or two applicationa,
and accomplishes rapid healing. This, however, only occurs in shallow,
uncomplicated fissures. The other chemical cauterants are not so goiA
Painting the ulcer over with iodoform, 10 per cent, and flexible eollodion,
90 per cent, will sometimes give great relief. The parts should alwan
be held apart until the ether in the collodion thoroughly evaporates,
otherwise it will give great pain and blister the surrounding parts. Noso-
phene, dusted freely on the ulcer, will also form a protective coating
and is quite useful in kee])ing the parts dry. The treatment by ichthyol,
however, is the most Siitisf actor}-.

Operative Treatment, — The operative methods for the treatment of
fissure comprise dilatation, incision, and excision. Incision and excision
are probably both older methods than dilatation, and yet perhaps at the
present day the large majority of fissures are treated by forcible dila-
tation. This method is usually credited to Recamier, but upon investiga-
tion it was found that his method was not that of forcible dilatation at
all, but rather, as he calls it, a " massage cadence.'" It consisted in
introducing the fingers into the anus and grasping the sphincter muscle
with the thuml) outside, and in this manner carrying on a massage all
around the sphincter until, as he claims, it became softened and less
spasmodic. The results of this method are not clearly laid down in
literature, but shortly thereafter Maisonneuve (Clinical Chirg., t. ii,
18()4) advised and practised forcible dilatation. His method consisted
in introducing one finger after another into the anus until the whole
palm of the hand passed through the sphincters, then doubling the fin-
gers up lie further distended the parts with his fist until complete re-
laxation of the sphincter was obtained. At the time of Maisonneuve*s
operation anaesthesia was little known, and such a method was not likely
to become popular on account of the extreme pain it produced compared
with the simple operation of incision which Boyer had introduced many
years before.

The other method of dilating the sphincter, as has been described in
the chapter on ILTmorrhoids, consisted in introducing the thumb of each

FISSURE IN ANO 307

Itand through the aims, and with the fingers upon the tuberosities of the
ischii, dilating the sphincter thoroughly from side to side, and then with
the fingers upon the pubis and coccyx gently stretching it antero-
posteriorly. This procedure should be done slowly and gradually for
four or five minutes, stretching the parts in all directions until
the muscle l)ecomes so flaccid and loose that there is little tendency to
recontract.

There have been a good many theories advanced with regard to the
process by which dilatation relieves the pain of a fissure. Some hold
that it is entirely due to overcoming the spasm of the sphincter, arguing
that the suffering which patients endure is caused not by the ulcer itself
but by the muscular contractions which squeeze and irritate the exposed
nerves. Others hold that the relief is occasioned by the stretching of
the nerves, and is comparable to that which is seen to follow stretching
the nerve in cases of sciatica. Still others hold that the relief is occa-
sioned by the subcutaneous and superficial ha?morrhage in such cases
acting as a depleting, antiphlogistic agent to the local congestion. Re-
cent experimental studies in this lino seem to indicate that it may pos-
sibly be due to the reflex effect upon the spinal center due to temporary
traumatism of the nerve-ends. What is exactly accomplished by
stretching is not clearly understood. Experiments recorded by AUing-
ham, and repeated upon dogs by Hartmann, demonstrate that by stretch-
ing, the muscular fibers are not broken nor are their fibrous attachments
anteriorly or posteriorly severed. There are no haemorrhages in the
muscular tissue itself, and there appear to be no alterations in the ner\'e-
ends. The base of the ulcer is deepened, but it is impossible to sup-
pose that by this means alone a healthy ulcer can be established; if, in
short, the ulceration is due to infection of a traumatic lesion, this infec-
tion will still be operative after, as it was before the stretching. The
operation can not change the nature of the ulcer. Hartmann's conclu-
sions are that the relief obtained by forcible dilatation is due to the
production of " a reflex atony of the sphincters." Th^ fact that the
muscles soon regain their tonicity is opposed to this view. It appears
more probable that the relief is due to the fact that by the forcible
stretching, the nerves which are caught and held by inflammatory
processes are torn loose from these attachments, released from their
embrace, and also from the squeezing consequent upon sphincteric
contraction. This, like all the other theories, is purely hypothetical.
The fact that incision relieves the pain quite as promptly would indicate
that the effect was due to disabling the sphincter temporarily.

Some surgeons dilate the sphincter with divulsors, such as those of
Sims, Thebaud, and Worbe — that of Mathews is one of the best. In
cases in which there is a very strong sphincter a Van Buren or Sims's

308 THE ANUS. RECTUM. AND PELVIC COLON

vaginal speculum will be found to be helpful, but instruments are rarely
necessary in this operation.

In the face of the preponderance of testimony as to the curative
effect of forcible dilatation in fissure, the author is compelled to state
that his ex})erienee does not corroborate the opinions of the majohtj
of writers upon this subject; he has not only had it fail in his owi
operations, but he has seen a large number in whom the operatioo
had been practised by other surgeons without success ; at least the fissure
returned within a short time afterward. It is needless to say that in
those cases where there is a polypus at the upper angle of the fissure,
stretching alone will not cure the condition. It is necessary to remoTe
the complicating tumor. Sometimes it is overlooked, and this explains
the failure. The same may also be said of sentinel piles at the lower
angle of the wound. But laying these cases aside in which the opera-
tion may be said to have been incompletely done, there are still others,
esjxjcially at the posterior commissure, in which stretching does not
result in a cure. Where there is considerable induration and h}'per-
trophy of the edges of the ulcer, stretching, while it relieves the pain
for the time being, will not result in a permanent cure, owing to two
facts : P'irst, these hypertrophied edges fold inward and interfere with
healing: second, the fissure is practically seated upon fibrous tissue at
the juncture of the muscular fibers as they come together to form a
sort of tendon behind the anus, and these fibers are simply separated
by the stretching and not torn or paralyzed. The result is that the
infolding edges prevent rapid healing, and the muscles, speedily regain-
ing their power, reproduce all the old symptoms.

In such conditions the edges should be trimmed off and the musde
incised, as will be described presently. There is a difference among
writers with regard to the class of cases in which dilatation should be
practised. Allingham states that it is the safest method in old people,
and in tuberculous and vitiated constitutions. Mathews, on the other
hand, states that the operation should be avoided in such cases. To
one who has had very much experience in operations upon old people two
facts are prominent: the first is, that these individuals do not recover
nmscular tonicity with any degree of certainty; the other is that they
all bear suppurative diseases very poorly, whereas in aseptic conditions
their tissues unite in a most satisfactory manner (Tattle, Operations on
the Aged, Journal of the American Medical Association, vol. i, 1901).
With these facts in view one can realize that the operation of divulsion
may easily result in incontinence in these individuals. On the other
hand, incision may cause suppuration and death from exhaustion. It
will be better in such cases to adopt a method by which both of these
dangers can generally be avoided — i. e., excision with immediate suture.

FISSURE IN ANO 309

In cases of phthisis the fissure is very likely to be tubercular in its
nature, and incision and stretching are both undesirable. If the lesion
can be thoroughly excised, and the edges sewed together, it is perfectly
proper to do so. If not, these wounds had better be treated by the actual
cautery or by local applications. Where the fissures are multiple, forci-
ble dilatation is always advisable ; and in children who do not bear local
treatment patiently, this method is exceedingly successful, except in
those due to syphilitic disease.

Restdts of Dilatation, — At the time of dilatation there is always some
haemorrhage, but it is never alarming. If carefully and slowly done
there will be very little tearing or traumatism of the parts ; there is
always an extravasation of blood into the cellular tissue around the anus
and a consequent discoloration and congestion for a few days following.
Experiments have shown that there is no extravasation of blood in the
muscle, no rupture of its fibers, and no laceration of the fibrous rhaphe
(Qu^nu and Hartraann, p. 444). The length of time during which the
paralysis of the muscles lasts is variable. If one will examine the
anus of a healthy adult patient after it has been divulsed, he will find
that within an hour following the operation there is no longer any gap-
ing, and stimulation to the muscle will produce a certain amount of
contraction. This contraction continues to increa '^ until within
twenty-four to forty-eight hours the patient will have regained con-
siderable sphincteric control, and at the end of seventy-two hours ordi-
narily, complete sphincteric action will have returned. Even within a
few hours spasmodic twitching is resumed in most eases. The idea that
the sphincter remains paralyzed for a sufficient time for the ulcer to
heal is not borne out by facts.

If the healing of the fissure depends upon the maintenance for a
certain length of time of the paralysis of the sphincteric contractions,
the question arises whether it is not wise to introduce into the rectum
either a firm plug or bougie, and maintain it there for a few days, so
that by long-continued stretching this paralysis will remain more per-
manent. This method is employed by many surgeons after operations on
haemorrhoids, and the author has used it with good effect in fissure. The
Pennington tubes serve excellently for this purpose ; by wrapping with
gauze the plug can be made any size, and the rubber covering prevents
the granulations becoming caught in the meshes, and thus torn when
it is taken away. The tube is best introduced through a bivalve specu-
lum, and held in position by a safety-pin attached to a T-bamlage. By
this means the dilatation of the sphincters is maintained, and, strange
to say, after forty-eight hours the patient feels more comfortable with
the plug in place than he does with it out.

Unquestionably this prolonged dilatation hastens recovery and makes

310 THE ANUS, RBCTUBi, AND PELVIC COLON

the fa>eal passages at first much easier. It is advisable in any case of
severe fissure operated upon by the method of dilatation. Pennanent
incontinence has been seen to follow divulsion of the anus, and a loa
of sensation that indicates the approach of faecal or gaseous passages ii
not at all infrequent. The author has had two patients in whom this
operation has been followed by unconscious stools at night, requiiiog
them always to wear a napkin.

Method of Iricisioti. — The second method of operating in anal fiddure
consists in an incision through the base of the ulcer. This method
was first advocated by Boyer in 1788, and since that time has been
described under his name. Boyer, holding that the fissure was due
to spasm of the sphincter, advised complete section of that muscle in
order to absolutely control this spasmodic contraction. So far as can
be learned, he did not advocate cutting through the base of the uker
at all, but even sometimes made a section of the muscle upon either
side of the rectum, thus completely paralyzing it. The fact that these
operations, which did not affect the ulcer per se, resulted in immediate
relief of the painful symptoms, and a cure of the fissure lends color
to his theory. Pie also introduced a hard bougie surrounded with
chaq)ie, and thus kept up continuous dilatation. Following him, othen
thought that it was not necessary to incise so deeply, holding that it
was only the superficial fibers that kept up motion in the ulcerated
surface and thus prevented healing.

Mathews, even as late as 1895, advocated scarifying the fissure with
the edge of a knife instead of cutting the muscular fibers, and claimed
that he obtained just as good results. Among those who believed in
the superficial incision may be mentioned the celebrated Dupuytren,
Curling, and Copeland. The latter even held that an incision into
the mucous membrane alone was sufficient to cure a fissure. But un-
fortunately the majority of these ulcers has already passed beyond the
depth of the mucous membrane and invaded the submucous tissae,
sometimes even the muscular fibers, and therefore this operation will
not suffice.

The depth of the incision and the point at which it should be made
are of the utmost importance. It should be deep enough to put the
muscle thoroughly at rest. It should also be made through the ulcer,
for otherwise it would produce a site for infection and possibly a second
fissure. This applies to ulcers which are not directly in the anterior
or posterior commissure. In these cases it is only necessary to refer
for a moment to the anatomy of the region to see that an incision
directly in the posterior commissure would not sever the muscle. The
fibers of the external sphincter unite in a sort of tendinous prolonga-
tion at the posterior commissure. They do not decussate to any marked

FISSURE IN ANO

311

t proceed parallel with each other back to their insertion in
the coccyx. An incision therefore directly back to the tip of the
coccyx will result in the separatioa of most of thesi' fibers and the
cutting of very few. This will not put at rest the imiscular contrac-
ti"n, and therefore it will fail in fissure
directly in the posterior commissure.
Moreover, those fibers which are severed
liy the incieion will be cut at an oblique
angle, which is always slow to heal and
forms an irregular cicatrix which is not
t-onducive to the best functional action.'
of the muscle. Thus it will be seen why
in these cases operations by dii-ulsion
and incision have both faileil. In the
one the muscular fibers are disabled for
a short time and separated by the force
of stretching, in the other the fibers are
simply separated by the edge of a sharp *■'"■ los.— v-buai-kh Ihciskik yoaFi*-
knife, which may cut a few, but by no ', ^^^ ji^^^^ '"
means enough to paralyze the action of

the mucicle. The experiments of Quenu and the other Pitrisian surgeon,
whom AUinghain quotes but does not give his name, are very important
with regard to the observations upon this point. They say that there is
no rupture of the muscular fibers nor of the tendinous fibers. There-
fore tlieir contractility returns very soon.

All this digression derives its importance from the fact that it ex-
plains the failure of the commonly accepted methods in the treatment
of a great many cases of fissure. Those at the commissures should be
treated by incision, and this should be made on one side or the other
in order to sever the rauncles and ]tut them at rest. The V-shaped
iacLsion (Fig. 108) aer\'es excellently in these cases, because it puts at
rest the fibers of both sides over which the ulcer is situated. It also
cuts them squarely across, thus conducing to a email cicatrix. By
tifais incision many cases can be promptly cured which are rebellious
t the ordinary cuts and to divulfion. It succeeded in one case in
iiich these methods had been tried five times and failed.

Lfngth and Dtjilk of Jncifioii. — The length of the incision should
! a little greater than the ulceration, starting above it and ending
iightly below it. The depth of the incision should extend about a
larler of an inch deeper than the deepest portion of the ulcer. These
i the only .lafe guides.

As Allingham points out, there is much more danger of failing to

e a fissure by loo superficial incision than there is of incontinence

312 THE ANUS, RBCTUM, AND PELVIC COLON

from a single deep incision at right angles through the sphincter mui-
cles. He says that if the incision is made squarely across the mui-
cular libers the ulceration will heal before these reunite, and when the
union has been completed there will be a thin square cicatrix whid
will not interfere with the functional action of the muscle. If the
incision be made at an angle the fibers will not entirely separate, they
will unite too soon, and there will be a long, irregular cicatrix and
permanent lengthening and loss of }K)wer in the muscle.

It is therefore better to carry the incision a little too deep than to
take any chances of failure to cure the patient by too great a con-
servatism. A slight superficial cut will relieve the pain temporaiihr,
but it does not paralyze the sphincter for a sufficient time for it to
result in the healing of the ulcer and a cure of the fissure. If, hot-
ever, the incision is deep enough to thoroughly divide the musculir
fibers, they will retract and the ulcer will have abundant opportimitj
to heal before a sufficiently firm cicatrix has formed to enable the
muscle to act.

The theory upon which this practice rests in cases of great hypw-
trophy of the sphincter muscle is that this section and retraction of
the muscular fibers })ut them absolutely at rest until the cicatridd
union between their ends gives them an attachment through whid
they can exercise their powers. At the same time this cicatricial int€^
position lengthens their attachment and thus decreases their contractile
power. Tims a temporarily complete rest and the elongation of the
fibers through this interposition of the cicatrix brings about a partiil
atrophy of the muscle, restoring it, comparatively speaking, to ib
original state.

One great advantage of operation by the knife at the present d^
consists in the fact that general anaesthesia is unnecessary. In divuUon
it is almost a necessity, but by the hypodermic injection of cocaine or
eucaine it is possible to incise any case of fissure absolutely without
pain beyond the slight prick of the needle for the introduction of the
drug.

The strength of the cocaine solution to be used may be from 1 to
4 per cent. The infiltration method of Schleich is not only painful
but uncertain, especially where there is any amount of inflanunatioB
and infiltration of the parts. A 2-per-cent solution of cocaine or t
4-per-cent solution of eucaine is upon the whole the most satisfk-
tory. Five or 10 minims of the cocaine solution, if slowly and care-
fully introduced, will an«Tsthetize almost any anal fissure and enable m
to incise the muscle and scrape out the fissure without any pain. B
is necessary in these cases to use the finest hypodermic needle. IW>
in order that the minimum amount of pain may be occasioned by iti

FISSURE IN ANO 313

introduction; and second, in order that the amount of the fluid used
may be so slowly injected that it will disseminate itself over a large
area. Eecent experiments with medullary anaesthesia show what a
powerful influence minute quantities of a weak solution have when
applied directly to the nerve-centers or to the nerve-tissues themselves;
so that in these operations it is only necessary to bring the smallest
quantity of the solution into contact with the nerve-ends or the nerve-
trunks in order to completely ana}8thetize the parts. The best prac-
tice is to introduce the needle through the healthy skin just below the
fissure, and by this one puncture to carry the cocaine beneath and
upon each side of it in order to bring the drug in contact with the nerve-
trunks and nerve-ends supplying the diseased area. After the cocaine
has been injected for two or three minutes, a Sims or Van Buren specu-
lum can be introduced and the exact location and the extent of the
ulcer seen. A competent rectal surgeon ought to be able to tell this
by digital touch; but the addition of the sense of sight and the accuracy
with which work can be done which is clearly in view, compared with
that done only by touch, can not possibly be of any disadvantage to the
most expert surgeon, and it is an absolute necessity to those who only
operate semioccasionally.

If there be any proud flesh or exuberant granulations in the ulcer
they should be scraped out with a sharp curette or a Volkmann spoon.
After this the incision should be packed thoroughly with a small strip
of iodoform or sterilized gauze and the patient kept in bed for forty-
eight hours. This injunction with regard to keeping the patient in
bed makes the author liable to the charge of inconsistency between
practice and teaching in the eyes of many of his old students, for they
well know that more frequently than otherwise he operates upon these
cases of fissure in his clinic, allows them to get up and walk home an
hour or so afterward, and to resume their work upon the following
day. Many of the students have seen case after case return at the
next lecture absolutely free from pain and grateful for the relief
afforded them. Nevertheless, in private practice, it is not wise to take
the chances which one takes in clinical work. Many of these patients
in the clinic depend upon their daily labor for food and support for
their wives and children, and it is of the utmost importance that they
keep about in order to retain their positions. As a consequence the
majority of them would refuse to have anything whatever done which
entailed the necessity of their laying up from work. Thus while the
operation upon walking cases is not a method of choice, it is justified
by the necessities of the case. The results of this practice are sufficient
answers to the claims of French surgeons that the method of divulsion
requires less bodily confinement than that of incision. The effect of

314 THE ANUS, RECTUM, AND PELVIC COLON

general anaesthesia itself detains a laboring man from his work longer
than a whole operation by incision. Moreover, the latter causes no
traumatism, contusion, or extravasation of blood into the cellular tis-
sues, as does forcible dilatation.

The dangers of haemorrhage into the cellular tissues following forci-
ble dilatation are not to be ignored, as will be seen from the cases
described in another portion of this work (see chapter on Haemorrhoids).
It is needless to say that in the operation by incision all sentinel piles,
polypi, papillae, or hypertrophied edges of the mucous membrane
which fall down into the fissured tract or ulcer should be removed
at the same time that the muscle is cut. Unless these precautions
are taken no operation, whether by incision or dilatation, will prove
successful.

Other methods of incision have been advised. Hilton advised pass-
ing a sharp-pointed bistoury beneath the external sphincter muscle and
cutting upward through the ulceration. Demarquay (Archiv. g6n. de
m6d., 1846, p. 377) advocated the submucous incision of the muscle. By
this method a bistoury is passed from the margin of the anus upward be-
neath the mucous membrane and ulceration as far as the ulcer extends,
and the sphincter is then cut outward until relaxation is produced, as
is done in the subcutaneous operations for contracted tendons. As
Ball states, however, this operation and that of Copeland could only be
applied to those cases in which the ulceration was very slight or in
which there was no ulceration at all, but simply a congestion, in which
case no operation is necessary.

Allingham calls attention to the necessity of restoring any mal-
formations of the uterus before attempting operative procedure for
fissure in women. He also lays great stress upon the necessity of keep-
ing them in bed after whatever procedure is adopted whenever there
is any uterine or vesical disease. This advice is certainly wise, and
needs only to be mentioned to be appreciated.

Excision of Fissure. — In our discussion of the pathology and eti-
ology of fissure, attention has been called to a class of cases in which
there is marked induration and cicatricial formation at the base. It
has been stated that in a certain number, although the ulcer was com-
pletely healed, the patient still suffered from pains of a dull, aching,
neuralgic character about the rectum. These facts were explained by
the histological studies of Hartmann, which demonstrated that these
patients not only suffered from an ulceration of the anus but also
from a perineuritis in the deoper tissues below the ulcer, and that
neither stretching nor incision was al)solutely sure to relieve this con-
dition. Having seen a number of such cases upon which divulsion and
incision had proved failures, the author concluded some three years ago

FISSUBE IN AKO 315

that it would be wise in such cases to dissect out the indurated mass at
the same time that he either stretched or incised the sphincter. Up
to the present time he has operated on 7 patients. In 4 the fissure
was imcomplicated^ and after dissecting out the indurated mass and
incising the sphincter, the freshened edges of the mucous membrane
stnd skin were sutured over the site of the ulcer. In 3 of the 4 cases
primary union took place and the patient was absolutely well at the
end of one week. In the fourth case infection took place and the
stitches had to be removed upon the third day. The healing was some-
what protracted, but the pains were entirely relieved, and the patient
made a good recovery at the end of about five weeks. In the other
2 cases in which the dissection was done the fissure was complicated
with ha?morrhoidal disease. In one of these the modified Whitehead
operation was performed after dissecting out the cicatricial tissues about
the fissure and incising the sphincter muscle upon each side as illus-
trated (Fig. 108). In this case the result was ideal, both in regard
to the haemorrhoids and the fissure. Primary union took place all
around the anus, and at the end of ten days the patient left the hos-
pital perfectly well.

In the sixth case, in which the excision of the fissure was made,
the clamp-and-cautery method was used for the removal of the haemor-
rhoids and left the fissure wound open to heal by granulation. The
patient suffered considerable pain following the operation, lasting for
about five days. He was a hyperaesthetic individual incapable of suffer-
ing patiently, and was in the habit of taking opiates for relief. In
his case, therefore, it was necessarj' to administer numerous hypo-
dermics of morphine; but after five weeks the parts were healed, and
he has never had any return of his old pains, has entirely discontin-
ued his use of drugs, and he is now attending to his practice, which he
had practically given up on account of his fissure. Such a limited num-
ber of cases is too few from which to draw any broad conclusions. The
results, however, would seem to justify a wider application of the prin-
ciple in all cases in which the dull, aching pain following fjpcal move-
ments indicates the involvement of the deeper nerve-trunks in a process
of perineural inflammation. The possibility of specific taint, even in
the most innocent, has led in all cases in which a fissure has existed
for many months to giving the patient moderate doses of mercury and
iodide of potash, even though no other manifestations of the disease
were present. In 2 cases in which the fissure had already been incised
by other operators and had not healed, the ulcer was cured by local
applications together ^nth the administration of this mixed treatment.
Whether it affected an obscure, constituticmal sypliilis, or acted hy its
tonic and alterative effect, it is impossible to say. The necessity of

816 THB ANUS, RECTUM, AND PELVIC COLON

constitutional treatment in eases with tubercular and ansBmic tendencies
should not be overlooked.

One other feature which has afforded considerable satisfaction in
some of these cases has been the recognition of rheumatic or gouty
symptoms elsewhere in the body; these influences may also assume con-
siderable importance in the neuralgic and aching pains of fissure.
Wherever this constitutional tendency exists it is well to put the
patient upon nitrogenous diet and administer some anti-rheumatics,
such as salicylates combined with alkalies; Turkish baths at regular
intervals will also be useful in order to keep the skin and kidneys
active.

In conclusion, it may be said that while divulsion will be suc-
cessful in the majority of cases in which the fissure is laterally located,
and in which there is no considerable induration and neuritis, it is
by no means an absolutelv sure method for the treatment of fissure.
Sim})le incision is more certain, and will result in a cure in the
large majority of cases. It has the advantage that it does not re-
quire general anaesthesia, being done under the influence of cocaine,
and it maintains the relaxation of the sphincter muscle for a much
longer period than is accomplished by the method of dilatation.
Moreover, where the ulcer is situated above the external sphincter it
furnishes complete drainage and avoids the accumulation of pus and
fa»cal matter in the depression caused by the ulcer. This method is
not always successful in cases with marked induration; in those the
method of excision is the safest and surest so far as rapid and com-
plete cure is concerned; and this also may be done under cocaine.

Many of these cases are complicated with haemorrhoidal disease, and
the operation upon the fissure will be determined by the method
selected for the operation upon the haemorrhoids. If an open opera-
tion, such as ligature, crushing, or the clamp and cautery is chosen
for the haemorrhoids, it will be useless to attempt to suture up the
wound made by excision; but if the Wliitehead operation is adopted for
the hiemorrhoids, then the edges of the fissure wound should be closed
at the same time.

Submucous Fissure. — There is said to be a number of cases in
which the symptoms of fissure are associated with no local lesions that
can be made out by either digital or ocular examination. A case of
this type has been described elsewhere in the chapter on fistula. It is
not a true fissure, but a small submucous fistula due to ulceration and
burrowing downward from one of the crypts of Morgagni. There is
very little pus, apparently no induration, and yet the patient suffers
at and after every stool just as in cases of acute, uncomplicated fissure
in ano. It can be diagnosed by the introduction of a bent probe into

FISSURE IN ANO 317

one after another of the crypts; when the diseased crypt is reached a
very acute pain will be excited. An incision of the mucous membrane
overlying this little fistulous tract is not sufficient to relieve the condi-
tion; after laying open the fistula the sphincter muscle should be
incised throughout the extent of the tract and to the depth of about
a quarter of an inch below its surface. This will relieve the fissure-
like pain and in a short time radically cure the trouble. This condi-
tion is rare, but it is very distressing to the patient and puzzling to
the surgeon.

The Complications of Fissure. — Fissure is subject to the same com-
plications as all other ulcers around the margin of the anus and within
the anal canal. Acute inflammatory processes may set up from infec-
tion of the ulcer due to its being torn open afresh by hard faecal pas-
sages, and there may be a cellulitis, a phlegmonous abscess, or a fistula
as the result. Such an accident may also follow operations by incision
or divulsion. It is necessary, therefore, to call attention once more to
the necessity of antiseptic precautions in all operations upon the rec-
tum. Admitting that it is impossible to produce absolute asepsis here,
it is all the more imperative that it should be attained as nearly as
possible. If the rectum is thoroughly cleansed at the time of an opera-
tion, and the wound is packed with sterilized gauze, this will generally
protect the freshly cut surfaces in a filter-like way until healthy granu-
lation has been established. TNTiere there is already sepsis present in
the parts, it may be advisable to use a Paquelin cauter}' in the cutting,
in order that the lymphatics and blood-vessels will be sealed at the
moment and thus prevent infection by whatever germs may be present
in the wound or in the intestinal canal. This, however, is rarely if
over necessary in the treatment of simple fissure; and as it is likely, if
used in severing the sphincter, to cause greater contraction of that
muscle after healing, it should be employed with the greatest caution.
Haemorrhage has been said to result from fissure in ano. Undoubtedly
such might possibly occur, as has been reported in the preceding pages,
but as a rule the bleeding is only of a trifling nature, consisting in
two or three drops of blood after fjecal movements.

Incontinence is said to have resulted from incision of the sphincter
muscle for the cure of fissure; when this occurs it is due to the oblique
incision of the muscular fibers. There are mentioned above 2 cases
of incontinence following stretching of the sphincter muscle in elderly
people. The author is of the opinion that as many cases of inconti-
nence result from too rapid and too great divulsion of the sphincter
as occur from single incisions.

Strictures of the anus and rectum have been said to result from
the irritations of fissure. Prolonged and spasmodic contraction of the

318 THE ANUS, RECTUM, AND PELVIC COLON

muscle is said by Cripps to cause abnormal shortening and fibrous
degeneration of the muscle, and to result in true stricture upon the
level of the external sphincter, or more particularly in that portion
of the rectum and anus surrounded by the levator ani. The facts
which he states are plausible, and we must admit the possibility of
such a result. But this admission only emphasizes the necessity of
early and radical treatment of all ulcerations and fissures about the
anus.

CHAPTER X
PERIANAL AND PERIRECTAL ABSCESSES

The tissues surrounding the anus and rectum are subject to fre-
quent inflammations on account of the vast amount of cellular sub-
stance, the profuse blood supply, and the numerous lymphatics of this
region. This may be brought about by extension from rectal and anal
inflammations, by obstruction to the circulation, by the inoculation
of septic materials through some of the glandular tracts, or by the
deposit of these agents from the blood or lymphatic circulations.

Through variations of pressure due to the presence or absence of
faecal masses in the rectal ampulla and to changes of posture, the cir-
culation of the parts is at times greatly impeded, and at others abso-
lutely free. The influence of these variations in the production of
inflammatory processes about the rectum was referred to by Esmarch
many years ago. The constant presence of infectious bacteria in the
rectum and the functional action of the organ absorbing fluids from
the faeces render it always possible for these agents to be taken up by
the lymphatics and small blood-vessels and lodged in the perirectal
tissues. That which interests us, therefore, from a pathological point
of view is first, the character of the pyogenic bacteria, and secondly,
the nature of their invasion.

Recent bacteriological studies have thrown considerable light upon
the infectious agents in suppurating processes. We have learned to
distinguish by microscopic examination between the various kinds of
pus discharged from abscess cavities, and to base our prognoses largely
upon the known phenomena of these different pyogenic agents. Among
the bacterial contents of perirectal abscesses the tubercle bacillus is
frequently present. Koch has stated that tubercle bacilli are never
found in the rectum unless there exists a tubercular ulceration of the
intestines. Sormanani, after a prolonged examination and study of
the subject, attempts to explain the absence of tubercle bacilli in the
faecal discharges upon the grounds that these bacilli are destroyed by
the action of the gastric juice and therefore disappear in their passage
through the stomach. His examinations, however, simply showed the

319

320 THB ANUS, RECTUM, AND PELVIC COLON

general absence of tubercle bacilli in the faecal discharges, and his
explanation of this absence was purely theoretical. On the other hand,
von Jaksch and others have succeeded in finding the tubercle baciUi in
the stools of patients not affected with intestinal ulceration; and Car-
riere (Coiiipt. rendus soc. bioL, 101, p. 1098) has shown by elaborate
and patient experiments that exposure of tubercle bacilli to both natural
and artificial gastric juice for twelve hours or more has no effect upon
their virulence. Simmons (Miinchener med. Woch., 1900, p. 317) has
demonstrated that while the gastric juice prevents the multiplication
of tubercle bacilli, it in no wise destroys them, and after this secretion is
neutralized by the alkaline fluids of the intestine, the bacilli may go on
and develop just as if they had never been exposed to the gastric fluids.
From those experiments there is no longer any doubt but that the bacilli
reach the sigmoid and rectum through the digestive tract independent
of ulcerations higher up in the intestine.

It is no unusual experience to find a tubercular abscess at the
margin of the anus or in the perirectal cellular tissues, as the first
manifestation of tuberculosis, and it is unreasonable to suppose that
the bacillus enters through the respiratory apparatus and passes throng
the lungs into the circulation, and then lodges in this particular spot
when it is possible to take a shorter and more direct route through
the intestinal canal. How it enters the canal in cases with tuberculosis
of the nares, throat, and lungs, is very easily explained by the fact that
these patients often swallow the discharges and sputa. The bacilli may
be carried to the parts by ])atients handling handkerchiefs or objects
which have been used by the tuberculous, and thus cause local infection;
it is also possible that the use of syringe-tips, bougies, and other rectal
instruments which have l)een used upon tuberculous patients, may
carry the germs and deposit them upon non-tubercular patients.
Whether it is possible for these germs to be carried by detergent sub-
stances, clothing, etc., or wafted through the air, is a question for
bacteriologists to decide. The fact, however, remains that we do have
tubercular abscesses and ulcerations around the anus, and sometimes
in the rectum in cases in which there are no other tubercular foci. It
is impossible to come to any other conclusion than that these are local
infections, and that the bacilli reach the parts through the digestive
tract.

The next most frequent infectious agent found in abscesses and
inflammations about the rectum is the Bacterium coli. The fact that
this bacillus is so often found in perirectal abscesses is not conclusive
evidence as to its etiological influence. Pathologists tell us it is the
cause of suppuration, that it passes out between the tissues in the
same manner that the white blood-corpuscles and amoebae pass from

PERIANAL AND PERIRECTAL ABSCESSES 321

the blood-vessels and invades areas at a distance from the intestinal
tract. It is always present in the large intestine, and needs only the
slightest injury of the epithelial surface to afford it an entrance into
the tissues. Such lesions are frequent enough, and inasmuch as the
bacillus is always present, the question arises why it sometimes forms
abscesses and sometimes does not. Recent studies by Vaughan seem to
point to a probable explanation of these facts. He stated that the
toxic principle of the bacillus is enclosed in a capsule, and that it does
not produce inflammation or toxic symptoms until this capsule is broken
or dissolved. Ordinary alkalines have no effect upon this capsule. Nor-
mal gastric secretions will dissolve it and set the toxic principle free;
and furthermore, he considers it possible that the blood serum may
also have this effect. Therefore, when the bacillus enters into a tissue
largely supplied with capillary circulation, its capsule may be dissolved,
thus setting the toxic principle free and establishing inflammatory pro-
cesses which eventuate in suppuration. Thus the fact that normal
Bacterium coli is found in the discharge from an abscess does not prove
that this is the cause of the abscess. If its capsule is intact it is proba-
bly innocuous. It is rarely found alone, but almost always associated
with other pyogenic bacteria, such as the staphylococcus, streptococcus,
and tubercle bacillus. Hartniann and Lieffring in a study (Bull, de la
soe. d'anat. de Paris, 1883, pp. GJ), 161, 517) on the character of bacilli
found in perirectal abscesses, state that in 7 out of 10 cases they estab-
lished the existence of tubercle bacilli. In 4 of these cases this bacillus
was associated with the Bacterium coli. In only 2 cases out of the
18 studied were they able to find the Bacterium coli alone. Twice they
found the Staphylococcus aureus in a pure state. In 1 case the microbe
of tetanus was found, and in another staphylococci associated with
Bacterium coli and saprophytes. In numerous examinations which have
been made for the author of pus taken from abscesses around the anus
and rectum, no case has been seen in which the Bacterium coli was not
associated with either tubercle bacilli, streptococci, or staphylococci.
Aehard and Lannelongue (Bull, med., 1893, p. 73) have confirmed the
observations of Hartmann and Lieffring by the report of a case of
abscess of the margin of the anus, in the pus from which only the
colon bacterium was found. Muscatello (La reforme med., 1891, p. 145)
has also reported a similar case. In all cases, however, infectious germs
of some kind have been found. We mav therefore assume that the
septic origin of perirectal abscesses is thoroughly established, and that
the old theories of idiopathic, gangrenous cellulitis, and suppuration
are no longer tenable.

Course of Infection. — ^The methods by which such infection gains
an entrance to the tissues must therefore be studied in order to account
21

322 THE ANUS, RECTUM, AND PELVIC COLON

for the variations in character and course of these different tj-pes of
intluniniation. The lirst and most easily undei-stood method is through
some lesion of the mucous membrane or of the skin in these regions.
Wounds or injuries to the parts from whatever cause may afford en-
trance to the infectious agents into the perianal or perirectal cellular
tissues, '^rhe nature and dej)th of the wound sometimes govern the
extent of the infection, but the character of the germ and the activity
of the lymphatic and general circulation have nmch more to do with it.
Thesi' lesions, while thev account for the entrance of bacilli, do n«t
furnish us anv information as to the rout<? that thev travel in their
invasion of tlie d life rent perirectal tissues. There is a certain num-
ber of al)sci'sses whicli involve onlv the skin or mucoils membrane.
In these cases the entrance of tlie bacillus is probably through some
of the glandular organs of these teguments, such as tlie hair follicles,
the sebaceous glands, and the solitary or Lieberkiihn follicles.

These abscesses are nothing more than exaggerated furuncles, some-
times limited even to an aeneous nature. The lymphatics of the skin
mav become involved in these cases, and throus^h them an infection,
which originally only involved a small glandular crypt, will invade a
larger area. Such abscesses remain in this sui)erficial lymphatic system
and do not involve the deeper tissues of the ischio-rectal fossa or the
superior pelvic spaces.

p]czema, her])es, abrasions from the clothing, and irritation dae
to improptT detergent substances, may furnish an entrance to the infec-
tious agents which are swe])t over the part during defecation. The
course, however, is the same as that just described.

Other marginal abscesses occur as the result of thrombi or throm-
botic li;eniorrlw>ids. The question has been asked how infection enters
through a thrombotic haMUorrhoid. If these little thrombi, due to the
ru])ture of small veins around the margin of the anus, are examined,,
it will be seen that thev are very close to the surface of the skin or the
muco-cutaneous tissue. The tension j)roduced by the extravasation of
blood in the cellular tissue is quite considerable, and it is altogether
possible that this tc^nsion may result in rupture of fome of tlie s^
baceous or hair follicles in the deeper areas of the skin, thus affording
whatever bacilli exist in these follicles or upon the siLrface of the skin
an entrance into the subcutaneous tissue. On the other hand, pyogenic
agents which circulate in the blood with impunity, when poured into a
stagnant area may find a congenial menstruum in which to multiply,
and thus produce infection. Xecroses from pressure or rupture of the
cutaneous or mucous glands are probably the routes of infection in
most cases.

Desprey formerly accounted for marginal absgess upon the theory

PERIANAL AND PERIRECTAL ABSCESSES 323

of suppurating phlebitis, but that disease is always accompanied by
serious constitutional symptoms, and in these cases such are absent as
a rule. As to the entrance of bacilli into the deeper perirectal tissues,
certain cases may be explained by the i)erf oration of the rectal wall
either by foreign bodies, such as pins, fish-ljones, syringe-tips, or occa-
sionally by ulcerative processes in the mucous membrane. It is hardly
reasonable to suppose that infections originating in this way could pro-
duce abscesses not connected with the rectum, and vet it is undoubt-
edly a fact that a large number of these perirectal abscesses have no
connection with the rectum in the beginning. That ihev eventuate in
fistula is due in most cases to delay in operative treatment or to improp-
erly conceived surgical procedures. It is believed that perforating in-
juries of the rectum and anal wall will account for only a very few peri-
rectal abscesses.

The reader who has closelv studied the arrangement of the Ivm-
phatics, as described in the chapter upon the anatomy of the rectum,
will remember that the superficial vessels of this system which sur-
round the anus pass forward through the ]>eriiueum to join the inguinal
chain of glands, or backward to that behind the sacrum: the de<»per ones
pass through the ischio-rectal spaces to the hypogastric chain, and those
around the rectum pass upward to join the siu-ral and vertebral ganglia.
It has been proved beyond the shadow of a doubt that infection travels
along the lymphatic tracts. It is not the veins or the arteries in which
s<'ptic genns are found in angeioleucitis, but the lymphatic vessels.
Septic infections of the extremities travel rapidly to the axilla and
groin along the lymphatic channels. In the same manner infe<tiouji
bacteria enter the perirectal tissues. It is ni)t necessary that there
should be a puncture or deep wound for this to occur. The lyinphaties
in the skin and perianal tissues travel in a >ujK*rficial plane. Thus,
infections which enter these, spread either toward the scrotum and
groin or backward toward the sacrum. The lymphaties which originate
in the submucous area and in the columns of Morgagiii pass upward
and outward through the muscular fibers of the reetal wall and into
the cellular tissue which fills up the ischio-rectal and the retro-recial
spaces. These hTuphatic networks anasti)ii!ose with on«* i.iiotlH-r,
although the currents flow in opposite directions. Th*.* liiuit- of the
extension of sepsis is explained by the formation of thrombosi- or in-
flammatory obstructions in these channels, thus d«-nion*tratin;r one of
the conservative processes of nature. When the infection i- eherk'd
in this manner in one direction it may How ba/kward an'l i»ro;rr< ■**
in another. Thus an infection originatin;r in the auperfieial ti--iii-
may be checked in its progress, and through tli" ana-tonio-i- niay in-
vade the deeper tissues and so produce a combinarion of the hii]><rfl'ial

324 THE ANUS, RECTUM. AND PELVIC COLON

and profound infection. These facts with regard to the thromboses of
lymphatic trunks have been established i>y the bacteriological studies of
MetchnikofF aAd by the clinical obsen-^ations of Chassaignac.

The fact that abscesses occasionally develop at a considerable
distanc(» from the anus, following minor operations for ha»raoiThoi«ls
or fissure, can only be explained through this method of invasion. The
lympliatic system which connects with those subtegumentary areas of
the buttocks is that described as the middle luemorrhoidal lymphatic
system. The superior h5em()rrlioi<lal lymphatic system connects with
the gluteal tissues through the ischiatic notch and the obturator fora-
men; thus injuries in the anal canal are likely to be followe<l by
abscesses either in the ischio-rectal fossji or in the cutaneous tissues
of the buttocks, while those that occur in the rectum proper are venr
likely to be associated with abscesses of the retro-rectal space and of
the deeper submuscular tissue of the thigh.

The etiological factors therefore in perirectal and perianal intlam-
mations or abscesses are the various infectious germs which are found
in the rectum and the lymphatic system which furnishes these germs
a means of emigration into the surrounding tissues. " The richness of
the subsphincterian lymphatic network, the bunches of lymphatic
trunks ctmt^iined in the columns of Morgagni, the frequency with which
these lym])hatics are exposed to openings by slight abrasions and be-
come immediately contaminate^!, ex])lain for us the frequency of ab-
scesses of the anus *' (Quenu and ITartmann, vol. i, p. 131).

A recent and scientific classification of perirectal inflammations by
Quenu and Hartmann is so elaborate as to be confusing to the gen-
eral student, however satisfactory it may appear to the specialist. They
mav be broadlv classified as Circumscribed and Diffuse Inflammations:
and under these the s])ecial forms may be arranged. A sort of tabular
statement of this division is as follows:

Circuins('ril)od inflammutioiis or al>-
SC'OSSCS

f Topumentary.
Superficial -j Subtogiiinentjiry.

( Ischio-rectal.

I Rolro-rectal.
Profound - Superior pel vi -rectal.

/ Interstitial.

Diffuse inflammations 3 l>iff^is*^ iK*rireet«l cellulitia.

( Ganj^rencms perirectal cellulitis.

The order of sequence ordinarily adopted by writers u{)on this
subject is violated in this classification because the circumscribed
inflammations are very much more fr(»quent in occurrence and less
serious in their nature: moreover, the diffuse variety may restdt from
them.

Of the circumscribed inflammations, those which are below the

PERIANAL AND PERIRECTAL ABSCESSES 325

levator ani muscle are called superficial, and those above it profound.
Of each type there are three varieties, according to the tissues or areas
involved.

Superficial Absoeases. — The circumscribed superiicial inilammations
are te^umentur}', subtegumentary, and ischio-rectal.

Tegumentary Abscess. — This is the sijiiplest form of circumscribed
[lerianal inflammation. They are due to infection of the follicuhir or
ghuidular jwrtions of the skin, and muco-cutaiieous membran<' about
the margin of the anus. Tliey may Ije very proj)erly termed follicular
abscesses. The term " tubereux," used by the French, descriptive of
this form of inflammation, is very misleading, in that it is often as-
sumed to ascribe a tuberculous etiology to the conditicm. The inflam-
mati<m may be due to any one of the septic or infectious germs. It is a
direct infection and not due to any lymphatic projiagation. It may be
brought about by irritation of tlie glands from chafing, horseback-riding,
impro}>er detergent substances, rough clothing, and scratching of the
parts. 8t(mt, well-fed, inactive individuals, not overly attentive to the
hygiene of the parts, are very liable to this affection.

They develop as little furuncles or aeneous pimples about the mar-
gin of the anus, varying in size from that of a bird-shot to a good-sized
hazelnut. Their symptoms are identical with those of follicular in-
flammation of the skin elsewhere, beginning in a congestion followed
by swelling of the follicle, which eventually opens spontaneously and
discharges its contents either as a thin purulent fluid or as a necrotic
mass called a '' core." Occasionally these abscesses assume a graver type
H'sembling a carbuncle. The inflammation or infection extends from
one follicle to another until a large area of skin is involved which may
open at several distinct places close to the mouths of the separate folli-
cles involved. The flnal discharge, however, of a central necrotic mass
shows distinctly the nature of the disease, notwithstanding the fact
that it sometimes pei-forates the derma and invades the subcutaneous
or submuscular tissues. This latter condition is a complication and
not a part of the real tegumentary abscess. Patients generally de-
scribe these abscesses as boils. They may be single or multiple, and
sometimes one sucxH?eds the other until the patient's life is made miser-
able by their continued presence around the margin of the anus. As a
rule thev do not involve the anal canal itself, but are limited to the
cutaneous tissue about the margin. They do not therefore interfere
seriouslv with defecation, and are not the cause of anv functional de-
rangements of the intestinal canal. They interfere with sitting or walk-
ing, and may necessitate confinement to bed for greater or less periods
of time simply on account of the discomfort produced. There are
usually no constitutional symptoms such as chill, fever, and loss of

326 THE ANUS, RECTUM, AND PELVIC COLON

appetito, although the toinporature may be elevated a degree or more.
It is a localized disease.

In a neighborhood so richly endowed with lymphatics both of the
deep and superficial channels there is always a possibility of septic germ?
being taken up from any focus and carrie<l to other regions and infect-
ing them. These little abscesses are fairly well protecteil from such
dangers by the walls of the follicles, which are more resisting than the
overlying (epithelium, and hence opening and drainage generally occuis
in the latter direct i(m before the cellular tissue is involved.

Ttrutment. — The management of these cases is rather therapeutic
than surgical. Dilfuse intlammations and perirectal abscesses have fol-
lowed the reckless opening of superficial abscesses about the margin of
the anus or upon the buttocks. A good plan in these cases is to make
a very small opening and then apply j)ure ichthyol or carbolic acid
upon a fine applicator to the interior. The free application of pure
ichthyol will frequently dissipate these little inflammations or hasten
their resolution if simply paintc<l over the surface two or three times
a day without any iiuisiim being made, lleitzman advised the applica-
tion of an ointment of 10 per cent salicylic acid and 90 per cent of
glycerin ointment, (»s])e(inlly in those cases in which these little ab-
scesses had a tenth'ncy to recur; the ointment was given to the patient,
and he was instructed to aj)ply it the moment he had any pain at a
given spot, and in this way su])])uration has In^en prevented in a
number of cases, but it is not uniformly successful in this respect. Dr.
Swinburne stated thai he had been successful in aborting suppuration
in many of these cases by the injection of a strong solution of salcylic
acid into the inllamed follich*.

Attention to cleanliness is of the utmost importance, and bathing
of the ]);u"ts, especially after defecaticm, with antiseptic solutions, should
be advised.

Excision of these small isolated inflammatory foci has been tried
a number of tinu's. In the author's hands it has not proved successful
in the neighborhood of the rectum, owing to the fact that it is almost
im])ossil)le to sterilize the cutaneous tissues of this region.. Moreover,
as stated before, these abscesses are confined to the derma, and com-
plete excision would only necessitate the invasion of the subcutaneous
tissues and thus expose ])arts to infc^ction which are ordinarily exempt.
Jt is better, on the whole, to depend U])()n the applications of ichthyol
or salicylic acid where tlu'se small abscesses open spontaneously; if they
do not so open, puncture the a])ex with a small bistoury, and after
emptying the cavity fill it with pure ichthyol. The patient should be
ke])t in a recumbent posture until the acute inflammatory s^nnptoms
have disappeared.

PERIANAL AND PERIRECTAL ABSCESSES 327

Snbtegninentary Absoesset. — Circumscribed inflammations of the
subcutaneous and submucous tissues are among the commonest results
of anal and rectal lesions, and are rarely if ever idiopathic. They are
caused by infection of the lymphatics. Although they can not always
be traced to any definite solution of continuity in the skin or mucous
membrane, it is probable that in the large majority of cases they
originate in some such lesion. The infection is carried thence by the
lymphatics into the cellular tissues until it is arrested either in the
glandular apparatus or by thrombus of the lymphatic trunks, thus
limiting it to a focus in which it proceeds to multiply and destroy the
tissues, causing a circumscribed infiammation and abscess. Cliassaig-
nac, Kelsey, Hartmann, and others claim that these abscesses may
develo]) in isolated external or internal haemorrhoids due to a phlebitis
of the ha*morrhoidal vessels. They do not account for the phlebitis
in anv wav, nor do thev state whether the abscess causes thromboses
of the veins jr whether the thromboses precede the abscess. Fre-
quently such abscesses follow what are termed thrombotic Invmorrhoids,
but thev alwavs succeed the formation of a clot, and do not occur until
several davs later. It is difficult to conceive of such a circumscribed
phlebitis as would cause clotting of the blood and abscess in one little
hemorrhoid without any inflammation of the other venous trunks with
which it is connected, or any constitutional symptoms such as are found
in the ordinary phlebitic process. It seems justifiable therefore, in the
light of modem pathological investigation, to assert that subcutaneous
perirecinJ and perianal inflammations are ahraj/s due t(f infection of
immcdinte or remote injuries to the skin or mucous memhrane, and that
the propagation of this infection is aloufj the tracts of the himphatic
apparatus. The sources of such injuries have already been mentioned
and need not be repeated here. These abscesses may be subcutaneous,
submucous, or submuco-cutaneous. They are more frequent in middle
age, rarely occurring in the very old or very young, with the exception
of one variety, the tuberculous, which does occur very frequently in
children from two to six years of age.

Synijttoms. — The symptoms of this variety of abscess are variable.
Sometimes they develop obscurely without chill or fever, with very
slight if any pain, opening spontaneously and discharging small quanti-
ties of white, thin pus. Such a course is generally indicative of a
tubercular process. Ordinarily the physician is only consulted in these
cases after rupture and discharge of pus. He then finds a soft, boggy
mass with a small ulcerative opening either through the skin or muco-
cutaneous tissue, from which there oozes a thin, water}' pus upon ])res-
sure. There is very little evidence of inflammatory reaction such as
induration, redness, and pain about the parts. The skin or muco-

328 THE ANUS. RECTUM, AND PELVIC COLON

cutaneous tissue is undermined in all directions around the opening,
and if not properly taken care of this burrowing or undermiuing i&
likely to j)roceed to an indefinite extent. Sometimes it burrows up-
ward l)eneath the muco-cutaneous tissues and forms a fistulous tniet
between the coats of the rectum. This burrowing may take place before
the abscess opens. The opening then may occur in the rectal cavity,
thus forming a blind internal fistula.

At other times these abscesses are ushered in bv marked constitu-
tionai symptoms. The patient is attacked with a distinct chill, the
pulse is accelerate<l, the temperature elevated, and there is a fettling
of general malaise. Locally there is at first a feeling of discomfort
which gradually increa.^es to actual i)ain. l^)cal examination discloses
a hard, swollen area at some portion of the anal circumference, hot,
re<l, or violaceoUvS painful to the touch, and throbbing constantly;
cases with such acute constitutional se]>tic sym])toms, in which there
was a l)acteriological examination of the contents of abscesses, have
usually shown the presence of streptococci and colon bacteria. Thew
acute inflammatory symj)toms have never been met with in cases of
pure tubercular abscesses. The severity of the pain seems to be
proportionate to the height of the abscess. This can be understood
for two reasons: the fartluT we ai^cend into the anal canal the more
closely are tlie skin and nuico-cutaneous tissues attached to the mu?-
cular and fibrous aponeuroses; there is less cellular tissue in which
the abscess can distend, and the spasm of the sphincter i)roiluced
by the inflammatory processes also contributes to increase the j^in.
Sometimes the* abscesses develop entirely within the anal canal, in
which case one sees no outward manifestation of the same until the
buttocks are forcibly distended or the fingt»r is introduced into the
anus, when a j)rotnuling, globular mass, either indurated or fluctuating,
painful to the touch and obstructing the anal canal, will be found.
If left alone they open s])ontaneously either through the skin or the
nmco-cutaneous tissues; they rarely open into the rectum proper; they
may open near the u])per limits of the anal canal and thus form what
is termed an internal, blind muco-cutaneous fistula, or they may open
upon the skin to form an external blind fistula. The moment they
open, at whatever height or in whatever manner, they constitute what
is commonly called a fistula of one variety or another, and what is still
more typical they do not drain and heal as simple abscesses elsewhere,
but remain fistulous unless laid open throughout their whole extent.
No explanation of this fact has b(»en given, but every clinical obsen'er
is so familiar with it that he never hesitates in these subtegumentary
abscesses of the anal canal to carry his incision to the full height of
the cavity when he opens them, in order to avoid secondary operations.

I'EEIANAL AND PERIRECTAL ABSCESSES

329

When these ahscessee open witliin the anus and upon the skin at
■ time, as they sonietiniea ilo, they form eoinplete suhtegu-
l^ntAiy fistula?. In a very small number of caj^cs the infection may be
■ tireumacribed in the Bubmuwus tii^sue of the intentinal wall and thus

form an intramural abscess

uf the rectum (Fig. lOy).
These eases will be aeeoiii-
panled with mild constitu-
tional symptoms, such as
y headache, a slight eleva-
3 of tem|)erature, heavi-
s and aching in the pel-
is, pain on defecation, and
melimes dysuria. The
mptoms re.semble those
inilaniod, internal
Kniorrhoid, and unle,-.-

ime is educated in digital :

lination he may mis- , . - - . ■.

* one condition for the '~'~^ ~ j

In these cases the I

toger will discover a glob- | j

doughy, or elastic *'"'• "i:i.-i^T"A«VBiL rm Si-Bm-noca Ab*i-eiw -t

i in the rectum, some-

s fluctuating, sometimes bard, generally in one or other of the ante-

ior quadrants. The mucous membrane may or may not move over the

rfaee of the mass. By pressure downward with the finger of one hand

*above the mass, and that of the other upon the external margin of the

anus, the swelling may be outlined and grasped, but it docs not extend

near the cutaneous tissues. Its superficial location in these eases can be

well determined by the experienced surgeon. It is a matter of the great-

t importance that this should be done, for the opening of these intra-

mral abscesses by deep incision through the skin and perineal tissues Is

ely to result in diffuse, infiammatory periproctitis, and is almost cer-

mlt in fistula. While these subtegumentary abscesses are gener-

f circumscribed and of small extent, they may also assume a phleg-

is typK. extend over large areas, and invade the deeper tissues.

e author has seen one case that originated in this variety of

9 in which the whole skin of the perina-um was undermined from

B scrotum to the coccyx, and from one tuberosity to the other. The

K88 or burrowing eventually extended upward and forward into the

I region, resulting in suppuration of the glands of these parts.

itient retinered after prolonged constitutional treatment and

830 THE ANUS, RECTUM. AND PELVIC COLON

numerous surgical operations. Bacteriological examination of the dis-
charges were carefully made, but at no time was the pathologist aWe
to demonstrate the pR^sence of any other tyj)es than those of Staphy-
lococcus albus and colon bacteria. Those cases which progress to the
involvement of the deeper areas may be pro{)erly considered under the
subject of ischio-rectal and profound abscesses.

Treatment, — The treatment of subtegumentary abscesses is purely
a surgical one. Ice poultices and antiphlogistic remedies have no place
in the treatment of this ccmdition. WHienever a subtegumentary indun-
tion or swelling has been determined, unless complicated with syphilitic
or malignant diseavse, immediate and free incision should be made
whether pus has already formed or not. If the swelling be due to a
subtegumentaiT luemorrliage, the extra vasated blood ought to be lib-
erated at tlie earliest possible moment. If it be due to an infection,
thorough drainage and antiseptic irrigation will limit its progress. If
pus has already formed, the j)rompt evacuation of this material is the
only safeguard against extension of the abscess cavity.

In all these suj)erfieial abscesses the operation can be performed
under hypodermic injections of cocaine or eucaine. One accustomed
to the use of tliis drug can o])erate uj)on the most sensitive patient in
such cimditions as this without any more pain than the prick of a
fine needle. Cocainization having been established, the incision should
be made in the line of the radial folds. These abscesses are generally
monolocular and circumscribed, and require no curetting or breaking
down of necrotic tissues in their midst. Simple incision and drainage,
acconij)anii'(l with antise])tic washings, will effect a rapid and satisfactory
cure in the large majority of cases. The incision, however, must extend
from the highest to the lowest point of the abscess; diverticuli in acute
abscesses will generally heal without lateral incisions. The cavity
should be washed out twice a day with an antiseptic solution, and a
small gauze drain should be loosely ])assed into the woimd. Stretching
of the spliincter is necessary in those cases in which the incision must
he carried through the anal canal and in the intramural variety. The
latter are almost the only abscesses which one is justified in opening
by incision inside of the rectum. They are purely submucous, do not
involve the nniscular wall of the rectum, and if thoroughly opened and
treated by drainage and irrigation they will heal without the formation
of fistula or other complication. The important point is to leave no
pocket at the lower end of the cavity. This is likely to occur when
they open spontaneously. Under such circumstances one will find some
pus present in the rectum; he will still be able to discover the soft,
compressed swelling, and through a speculum can see the discharge
exude from the opening when he presses uj)on the mass. It is needless

PERIANAL AND PERIRECTAL ABSCESSES

331

to say that in audi couditions the cavity should be laid open to ita
lowfst cxtenL

Quiet and rest in bed are essential to the moat sittisfucliiiy reaultB
in the treatment of these eaews.

Isohio-rectal Ab»ceMes.— Tliese form a tj-pical variety of wliat is
known iis jMerirectal abstesaes. It is gonerally supfwaed that they com-
ptwe the large majority of periaoal und j)erirectal abecesaos; but, as
has been shown by Etchepare (Des abces ischio-rectaux, Th. de Paris,
1894, Xo. 35S), these fosstc are thu seat of abscessi^s in less tlian 18 per
cent of the total number of cases occurring in hospital practice; and,
furtbennore, as the large majority of superficial perianal abscesses are
treated by the family physician and arc never seen in the hospitals, it
K reasonable to conclude that the percentage of these abscesses is even
lower than Etchepare claimed.

They are generally situated araund the rectum itself and not at the
margin nf the anus. They are outside of the muscular ami niioneiirotic

layers of the rectum

and oonl canal and
l»eneath the skin niirl
superficial fat-i i
(Fig. nOl. They 11.
be limitt^ to 'li
side of the rectum,
may ocfur upon Im.i
sides simultaneuusiy.
becoming connected
posteriorly through
the little space be-
tween the aponeu-
roses of the levator
ani and tlie external
sphincter muscles.
When they occur
upon one side of the
rectum and open

epootsne«>usly or are incised after they have existed several days, they
ry likely to develop upon the opposite side within a period

four or five days. When opened they do not exhibit a single
cavity, but numerous foci containing pus. and may be described

multilocular abscesses. This honeycomb-like condition of the abscess

itv is due to the connective-tissue network which divides (he cellu-

mass into spaces, and in operating, unless great care Is exercised
open all of these, the pus contained in them will burrow or infect other

332

THE ASUS, HKCTl'M. AND PELVIC COLOX

regions, and there eecins to be no limit to their extent. When iioth
Kpat-es arc involved and connect with each other posteriorlv, thev f"nii
a »ort <>t dunih-hell or liorscshoc-shapcd cavit}'. Thia coinniuni(«-
tiun id not unifoniily jiretjent. 'Die infeetioD originatini: in sa
iiijiirj' of the anu^ or
lower portion of tlie n-c-
tuni, throu;;li which ihe
lymphatics of the iM,li Li-
rectal fo!«a bccoino in-
volveti, may travel upon
one side more rapidly ihan
it docs upon the other, and
an abscess thus develops
upon this side some dan
previously to ita develop-
ment npon the other. The
author has opened an i»-
chio-rectal abscess in hit
office on one day, and
with careful examination failed to find any Implication or even
lemlerness upon 1hc opimsite side, and yet within forty-eight hours
he has iM'in i-.illed to open a siiniliir abscess at this point, and doing
so imiler jienei-al iui;i'silu'sia has .■iearehcil carefully but in vain for
any connuunication betwi-en the two. As a rule, however, where
these ahKces.<i(i deviloii upon both sides they communicate with each
other pdslei'iorly ilirou};h the fonimen already mentioned, and ordi-
narily in such cases iin openinj; will be found in the poRterior commis-
sure of (he iinus. thus eonslitutinfr n true horseshoe fistula (Kig. 111).
This little pi'rf[irati(m of the mucous membrane at this point indicates
that the orijrin of the uliscess and llslula has probiihly been a fissure at
this seat, tliroufrh whiih the lymphatics of the ischio-rectal fossa havt
Ih'Couu' infected, Ahscifses that i)rifiiniite in the ischio-rectal fossa may
eoinmnnicate with the rctro-reclal space or Her rema by perforation of
the levator ani. ami thus there may be two main abscess cavities i-on-
nectinj; by a small ajRituii: (Fig. 112). Abscesses of the pelvi-reclal
sjiaces sometimes a]i])ri)ai-!i Ihe surface and open into the ischio-nvtal
fossil', hut wliclher thusc of the isc'hio- rectal fossie ever extend up-
wanl along the si.le ,>( the n^dum sufficiently high to involve the
superior pelvi-reclal spaces and infect the organs with which they
are in reliitiouship, is ilifilcult to say. All the cases in which abscesses
involved both sjiaces have given histories which led to the belief that
the abscess was originally in the sujierior space and had involvini the
ischio-rectal fi>ssa by exlimsion downwanl through the fibers of the

PERIANAL AND PERIRECTAL ABSCESSES

333

Vvalor ani muscle, either separatmg or rupturing them. Tliese ab-
scesses may also fonnect with submucous abBCosses by tracts passing
between the sphincter muscles (Fig. 113) or directly through them
»<Rg- 114).

^b The importance of all this lies in the fact that if tliese Buperficiul
^Bl»ce£ees may involve the superior spaces it lends a gravity which is
^bot nnlinarily nttachei] to them.

^B Etiology. — The cause of these abscesses is always direct or indirect

Hmfectinn. Puncture wounds and injuries from sharp bodies within

or outside of the ri>cluin may carry septic genus directly into the

cellular tissue and thus produce abscesses. Ulceration of the crypts of

|[orgagni or of the rectum proper may result in ischio-rectal abscesses
mgh direct extension of the ulcerative process or by infection
-ough the lymphatics. The frequent cause, however, of ischio-rectal
s is infection through some lesion of the anal canal. Small
nires or wounds in this region are very liable to become infected, and
le infection is likely to affect the middle lymphatics, these will in-
B the ischio-rectal fossie. These abscesses frequently follow opera-
! for fistula, stricture, and hieniorrhoida. In these cases it is sup-

334

THE ANUS, RECTUM, AND PELVIC COLON

posed that tlicy are motastatic. The author, however, has observeil, in
two eases in which ischio- rectal abscesses followed operations for hwinor-
rhoids, that upon opening the abacesa eavity there escaped a eoniiidera-
ble amount of decom-
posed or clotte*.! blood
along with thin sero-
pus; either the sup|ni-
rativc process caused
rupture of the small
vessel ig and ]ia.nnof-
rhage into the fossa,
or the vessels were
ruptured by the trau-
ma I is in necessan- to
dilate the sphinciers,
and infection occurrtd
later. The latter view
seems more rational.
It is very possible that
one o£ the lower

mo. 1L3,— laOIIO-HE.TAT. AKIl firElH-CI] t B ADBPKESE8 CnM- , 1-11 . -

liLsi.ATiBij bipmorrhoidal arlenea

which ramify in this
space may be torn by this stretching process, and it may go on bleuillng
until a distinct hiematoma is formed in the cellular tissue, and this may
become infected through the lymphatics leading from the operative field.
In the cases observed the symptoms of abscess appeared forty-eight and
sixty honrs after the operation.

Dilatation of the sphincter in small superficial abscesses at the anal
margin may residt in ischio-rectal abscesses by squeezing the pyogenii!
germs out into the perirectal tissues. Contusions and prolonge<] pres-
sure, such as are caused by long horseback or bicycle rides, may cause
these aliscosses either by obstruction of the circulation or by proilucing
small anal lesions which become infected.

Symptoms. — .\s a rule ischio-rectal abscesses develop as an acute
inflammatory process; the patient suffers either from a distircl rigor
or a feeling of chilliness creeping up and down the back and in the legs;
these are followed by fever, accelenitod pulse-rate, headache, and nt
first a discomfort about the rectum. This discomfort changes to a dull
aching, which gradually grows into an acute throbbing pain. In the
initial stage there will be no swelling apparent to the eye, but indura-
tion may be felt around the margin of the nnus upon one side or the
other. Redness and discoloration may or uiuy not be present, accord- ■
ing to the depth of the infection. In the very deep cases, in 'order to

PERIANAL AND PEKIBBCTAL ABSCESSES

335

■into t
kxtrei

feel the indurutiou it will bo neecseary to introduce the finger well
iiiio the ret'tum and press downward and outward while deep palpation
is made with the other hand upon the external surface. One will gener-
ally be able to make out in sucli eases a distinct circum^rlbed mass,
globalar and more or less fluctuating. When the inflammation haa
existed for some days, swelling, tension, and redness of the cutaneous
tissues about the margin of the anus will appear. Defecation is ex-
tremely painful : the [mtient suffers from difticnlty in urination, or may
he unable to urinate at all. The constitutional disturbances may be-
come very grave and approach a type of true septicaemia. Sometimes
the perianal area assumes an erysipelatous blush, and only a micro-
seopic examination of the blood and discharges can distinguish between
these acute, aggravated cases of perirectal cellulitis with circumscribed
abscesses and true erysipelas. The inflammatory processes may sur-
lund llie entire rectum and anus and extend through the pei-ina;um
the scrotum or inguinal regions. Thpse phenomena only octiir in
mely septic cases or those in which the treatment has been
lected. If opened early the discharge from these abscesses, which
are then small, is of a
creamy-white or dark-
hriiwniBh color. Where
the abscess has been
ihie to an extravasaliou
of blood, the clot may
^vbe discharged as a
^hole, or it may appear
I disorganized flocculi
|tixe<i with pus and

Sonu'tinies the pus

thin and ichorous

lad contains necrotic

loreds or fibrous tissue,

idicating the phleg-

: nature of the

Bcees. Such cases are

[ely to be followed by

meral septiciemia. It possesses a fietid, gangrenous, disgusting odor;
t has been frequently said to indicate connection with the rectum,
it is not the fact. Many abscesses possess this peculiar, fsecal odor
Isd have no connection whatever with the rectum.

The escape of gases from these abseesw^s when opened has also been
Ihought to prove theii- connection with the rectum. This is also an

"''^^^HS^H

^^^^^^^inBiT^

'I^^^^S^I

^^^^^^^HF -A S

IVfl

S^^^^P^ , M S

^■ifil

^■Buv/

^Vi

^MUi

;4' '

li^BTs-

^ip

Fm. 114.— Iwnio-i

336 THE ANUS, RECTUM, AND PELVIC COLON

error. In fact those abscesses which have a connection with the rectum
do not contain pent-up gas. When, therefore, an ischio-rectal abscess
is o])ened and gas escapes, it is quite a reliable sign that it has no con-
nection witli the gut itself. These gases are due to bacterial decomposi-
tion which takes place in the cavity. When an abscess has developed
upon one side and opens spontaneously, or has been incised, the tempera-
ture will rapidly subside and all the constitutional symptoms, together
with the pain, may disappear within twenty-four hours. The pain*,
however, may recur upon the same side or upon the opposite side, the
temperature and constitutional symptoms all reappear, and the patient
suffer quite as much as in the first attack. These symptoms are due
to the development of anotluT abscess in one of the small compartments
of the cellular tissue which was not broken down in the first operation,
or to infection upon the opposite side. The appearance, symptoms,
and (lia^mosis of this condition are, of course, more or less identical with
those of the first abscess.

All the physical and local symptoms of ischio-rectal abscess may
occur from haMiiorrhage into the spaces which never become infected.
The author has opened what appeared to be a small, deep-seated swelling
of this kind and turned out several hard clots with some blood serum,
but not a drop of pus. The tension and pain disappeared at ouce and
the parts healed without any suppuration whatever. When such svmp-
toms occur without the premonitory' constitutional phenomena, one may
anticipate finding this condition or a tubercular process.

Treatment. — All surgeons agree that free incision at the ver}' first
moment that induration can be made out is the onlv treatment which
is justifiable in these cases. Cold applications, leeches, hot poultices,
etc., have long since been found to be useless in causing resolution.
Thev mnv delav the fornuition of the abscess and destruction of
tissue for a period and give partial relief to the sufferer, but they
never abort the sup])urative process. When, therefore, a swelling or
circumscribed induration can be made out about the margin of the
anus in non-syphilitic cases, the parts should be cocainized and the
induration incised whatever its depth. Punctiu*ing with aspirating
needles to determine the presence of pus is not advised. It is not an
important question whether pus is already present or not; the object
to be attained is to furnish a free outlet through the shortest and most
harmless channel to the inflammatory products of the affected area.
If this contains only a clot or the products of non-suppurative inflam-
mation, a clean cut made with antiseptic precautions will do no harm.
Puncturing with a needle can result in nothing more than to distribute
the septic products through its track, and furnish no drainage unless
subsequent incision is made. The same objection holds good to punc-

PERIANAL AND PERIRECTAL ABSCESSES 337

ture with small tenotomes. Careful dissection should he made down
upon the indurated mass or abscess cavity by means of an incision wide
enough to give the operator a full view of what he is doing, and furnish
free subsequent drainage to the discharge. The external incision
should be wider than the widest portion of the abscess, if possible, other-
wise there will be pockets and diverticuli into which the pus will
burrow. The incision should be made parallel to but well outside of the
fibers of the external sphincter muscle.

After the abscess is opened the finger should be introduced into
the cavity and all the little honeycomb-like fossa^ of the cellular tissues
should be thoroughly broken down in every direction. Experience
teaches one the difference between the feeling of necrotic, suppurating
tissue and healthy cellular divisions; it is these necrotic and suppurating
fossje which should be broken down, and this can only be surely done
with the finger itself, because curetting with sharp steel spoons is very
likely to go beyond the diseased tissues and furnishes no indication of
the condition of the parts. These processes ought to be carried on
under constant irrigation with a l-to-2,000 bichloride solution. Should
there be considerable oozing or haemorrhage after the cavity has been
emptieil thoroughly, it should be tightly packed with gauze for the first
twenty-four hours; this packing, however, should be removed at the end
of this time and only a light gauze or rubber drain introduced there-
after, because it is of the utmost importance that the walls of the
abscess cavity should be allowed to approach each other as nearly as
possible in order that rapid union may take place.

Where the abscess involves both iscliio-rectal fossae simultaneously
or successively, the question of how to operate may puzzle the inex-
perienced. Simple incision will empty the abscess unquestionably, but
it does not provide for the communicating tract between the two ab-
scesses posteriorly, when such exists. Hartmann states that under such
circumstances he does not open the abscesses themselves, but opens
the tissues posteriorly between the coccyx and the anus, introducing
drains into the abscesses upon each side. The abscess may be opened
by moderate incision upon one side and by free incision, extending to
the posterior commissure of the anus, upon the other side, thus thor-
oughly draining this posterior fistulous tract in both directions, and
effect good results. In 2 cases in which there was a fistulous communi-
cation with the anus associated with bilateral ischio- rectal abscess, com-
paratively small openings were made in the anterior horns of the ab-
scess and small wicks of silk thread were passed from these openings
backward into the wound made at the posterior commissure of the
rectum, laying open the fistulous tract from the skin into the anus
and enlarging the communication between the two lateral abscesses.
22

338 THE ANUS. BBCTUBi, AND PELVIC COLON

In both of these eases the cures were remarkably rapid and exceed-
ingly satisfactory, being unaccompanied by any of the retraction and
infundibular shape of the anus which results when the cavities on
both sides and posterior to the anus are laid open.

The author has never seen fa?cal incontinence ensue from laying
open the abscess cavities freely, even though they entirely surrounded
the rectum. The objection to this operation is that it results in re-
traction of the anus, and leaves a deep depression between the fold*
of the buttocks below the spliincter muscle in which fa?cal material is
liable to be caught, and makes it very difficult to keep thoroughly
clean.

When tl^ese abscesses open spontaneously into the rectum or anus,
as they may do, they constitute internal blind fistula, and should be
treated as such. The question, however, arises as to the probabihty
of these abscesses resulting in fistula after they are opened externally.
Some writers have held that this is so likely in cases where the ab-
scess approaches very closely the rectal wall it is advisable in all suck
to convert them into fistulas at once, and operate by incision of the
rectal wall to the height of the deepest portion of the abscess. Such
practice can not be condemned too forcibly, ^^^lile a certain num-
ber of abscesses will result in perforation of the rectal wall subse-
quent to their incision, such consequences b}^ no means justify the
practice of subjecting a patient to the dangers of incontinence and pro-
longed cicatrization which necessarily follow the conversion of ischio-
rectal abscesses into true fistulous tracts. WTiere no pathological open-
ing into the rectum or anus exists, it is unjustifiable to make such an
opening surgically for the treatment of perirectal abscesses. There is
reason to believe that the large majority of perforations into the rectum
after the opening of ischio-rectal abscesses are due to imperfect tech-
nique in operation. The thorough but gentle dilatation of the sphinc-
ter muscles in every case of perirectal abscess is an important feature
of the operation; it gives the patient relief from whatever muscular
spasm may be occasioned by the perirectal operation and inflammatory
process; it removes obstruction to the passages of gas and fsecal matter
so that no undue pressure may be placed upon the thin rectal wall,
wliich has lost more or less of its external support in the evacuation
of the abscess; it prevents a spasmodic contraction of the rectal wall
and allows it to more closely approach the external walls of the abscess,
thus facilitating rapid granulation and the closing of this cavity. This
dilatation should always be made after the abscess has been evacuated:
attempts at dilatation before the abscess is opened are very liable to
result in rupture of the rectal wall, because this is always more fragile
than the overlying skin, ^loreover, the pressure and traumatism neces-

PERIANAL AND PBBIR£CTAL ABSCESSES 339

sary in such dilatation are likely to squeeze the pus contained in the
abscess into the lymphatics, dislodge the thrombi in these vessels, and
cause the septic process to extend into other and more remote areas.
Therefore, let the abscess be opened freely, its partitions be broken down
and washed out with antiseptic solutions, and after this let the sphincter
muscle be thoroughly dilated before the wound is dressed. With a
drainage-tube in the wound temporarily and a Pennington tube or
rectal plug in the rectum in order to facilitate the escape of gas as
well as to hold the rectal wall in close apposition with that of the
abscess, a fistula may be avoided and a rapid healing be obtained in
such cases.

PROFOUND ABSCESS

In the review of the anatomy of these parts attention was called
to the retro-rectal and superior pelvi-rectal spaces. Clinically these
spaces have been considered as one, and they are called the superior
perirectal spaces. Recent anatomical studies have demonstrated the
fact that they are divided into three — two antero-lateral and one pos-
terior. The two lateral ones have been denominated bv Richet the
" superior pelvi-rectal spaces "; the posterior is the " retro-rectal space,"
which occupies all the region between the rectum and the anterior
surfaces of the sacrum and coccyx. The blood-vessels ramifying in the
retro-rectal spaces come from the middle and lateral sacral arteries
with a few branches from the inferior mesenteric. Those in the
superior pelvi-rectal spaces come from the h3rpogastric artery and are
connected with the general circulation. The lymphatics of the two
spaces are also comparatively distinct; those in the retro-rectal space
develop about the lower posterior portions of the rectum and coccyx;
while those in the anterior spaces originate in the anterior wall around
the prostate, the neck of the bladder, the uterine organs, and connect
with the iliac plexus and the lateral trunks of the lymphatic system.
With such distinct anatomical divisions, vascular supply, and lymphatic
distribution, one can clearly understand why a distinction is made
between the circumscribed inflammations in these two areas and call
them retrth-rectal and superior pelvi-rectal abscesses.

The interstitial abscess represents a class occurring at more or
less remote points from the rectum itself in the muscular or cellular
tissues of the buttocks and due to infection carried from the perirectal
tissues along the course of the lymphatics through the obturator fora-
men or the ischiatic notch.

Eetro-rectal Abscess. — This variety develops in the cellular space
between the rectum and sacrum above the attachments of the leva-
tor ani (Fig. 115). It may be due to necrosis of the bones of the

TBE ANUS, RECTUM. AND PELVIC COLON

pelvis, the sacrum, coccyx, ileum, or bodies of the vertebra; il imt
result from perforation of the rectal wall by sharp foreign bodies in
the intestinal canal or by instruments, sucli as bougies or syrin^ ,
tips. One of the most frequent causes is the operation of posterior
proctotomy or incision of strictures unaccompanied by thorough drain-
age. Fistulous tracts outside of fibrous strictures of the rectum nar
also occasion it. flummata. the caseation and breaking down of tubtr-
(■ulous lymphoid nodules, and infection by propagation along the Im-
phatic channels tmm
nlceration of the m-
timi above the ei-
ternal sphincter mat
all cause them.

Quenu and Hirt-
mann state that ■!•-
eoesses of the appwi-
dix may extend into
thiif space and thu
open into the rechuu.
The appendix beinf
within the peritonwil
cavity and often ei-
tcnding down intoih*
pelvis, it appears tliit
such abscesses ut
much more likely to
invade the snpcrior
pelvi-recial than tht
rctro-reetal spaces.
The author has seen
one, and had commu-
nicated to him thr«
instances in which
such abscesses han
opened into the rec-
tum cither spontaneously or by rupture during an examination of thin
organ. The cases were all in women; they simulated tnie pelvic abscess,
and the perforation was always in the anterior wall of the rectum. The
appendicular origin was proved by subsequent operation. While, there-
fore, it is possible that such abacesses may penetrate the retro-rectal
apace, from these facts and the anatomical relations this course would
appear very unlikely. It is not unusual for retro-rectal to follow ischio-
rectal abscesses or varicose ulceration; they are not at all uncommon

PERIANAL AND PERIRECTAL ABSCESSES 341

after resections of the rectum, and they may also result from gunshot
wounds of the pelvis.

Symptoms. — The development of such abscesses is always obscure.
They are not usually ushered in by distinct rigors and constitutional
manifestations. A dull aching in the sacrum, with pelvic weight and
sciatic pains associated with slight elevation of temperature, general
malaise, constipation, with or without pain at the time of defecation,
and a gradually increasing sallowness of the skin such as accompanies
chronic suppuration elsewhere in the body, are the general symptoms.

Palpation around the margin of the anus and in the perinaeum
does not, as a rule, elicit any pain or induration. Examination of the
rectum with the finger may sometimes demonstrate the presence of
nodules more or less circumscribed and inflamed, or a diffuse, boggy mass
in the hollow of the sacrum. In the beginning this mass will not be
fluctuating, tense, or painful, but as the suppuration increases the ten-
sion of the parts becomes more marked, and partial obstruction of the
rectal canal with dysuria may develop. Eventually the abscess may
burst spontaneously into the rectal cavity, or it may perforate the
levator ani, infect the ischio-rectal fossa?, and finally open on the skin.

^\Tiere the retro-rectal abscess has existed for some time, it may
burrow between the fibers of the levator ani muscle and develop in the
wall of the rectum itself a submucous abscess such as has been found
in a case reported by M. Qu^nu (Quenu and Hartmann, p. 146). When
these abscesses secondarily invade the lower areas around the anus,
constitutional symptoms, associated with pain and great depression,
always ensue.

An interesting case of this kind occurred in the Polyclinic Hospital
in 1898.

Abstract of history:

J. P., aged fifty-two, janitor, had suffered for several weeks with a dull,
aching pain in his back, difficulty in movement of his bowels, and gradually
increasing weakness. Only a few days previously, however, he had his first
distinct rigor. This was followed by a high fever and acute pains in the buttocks
and around the margin of the anus.

When first seen the whole perianal region was distended, tense, hard, fluctu-
ating, and of a dark violaceous color that indicated the rapid approach of gan-
grene of the parts. Apparently it was a case of diffuse, septic periproctitis.
Incision, however, into the ischio-rectal fossa gave issue to an immense quantity of
most foetid pus. So sickening was the odor from this discharge that several of the
students were nauseated and compelled to leave the room. After evacuation of the
ischio-rectal cavity it was found that pressure through the rectum toward the hol-
low of the sacrum occasioned a continuous flow of pus from the wound. Searcli-
ing the cavity with the finger, a small opening was found between the ischio-rectal
fossa and the retro-rectal space. This opening was enlarged, and a long uterine
probe was introduced to its full length upward over the promontory of the sacrum

342 THE ANUS, RECTUM, AND PELVIC COLON

without reaching the upper limits of the abscess cavity. At the time, the author
was convinced that this abscess was due to a necrosis of one of the bodies of the
spinal vertebree, and gave an unfavorable prognosis with r^ard to the patienti
recovery. The only symptoms contraindicating such a prognosis were the acute
septic phenomena which had occurred in the later stages of the disease. Such
symptoms rarely accompany tubercular abscesses and those due to necroeis of bone.
This patient made an uneventful recovery after about ten weeks' reaidence ia
the hospital. The time between the first chill and the date of operation wis
entirely too brief for such extensive burrowing upward to have taken place, sad
therefore it was undoubtedly a case of retro-rectal abscess which had bunt through
into the ischio-rectal fossa and caused an acute suppurative process there.

Such abscesses may also burrow outward through the ischiatic notch,
forming divert iculi or pockets in the tissues of the buttocks. This
course, however, is verj' rare. Those occurring in this region are usually
metastatic or interstitial abscesses due to propagation by the lymphatics,
as stated above.

Treatment. — The treatment consists in thorough drainage. A semi-
circular incision between tlie anus and coccyx is the best in these cases.
After thorough evacuation, the cavity should be washed out with
peroxide of hydrogen followed by l-to-2,000 bichloride solutions. Gentle
curetting of its walls may be advisable sometimes, but one should be
careful in doing this laterally and anteriorly that he does not penetrate
the superior pelvi-rectal spaces or the rectal cavity itself. Unless one
is experienced in these operations he had better desist from such a pro-
cedure and allow nature to take care of the sloughing tissues.

After washing out the cavity one should introduce two long rubber
drainage-tubes and maintain them in position by suturing them to the
edges of the skin or pinning them there with a safety-pin. Through
one of these tubes an irrigating fluid may be carried in while it is dis-
charged from the other, and thus the abscess cavity may be kept entirely
clean. The sphincter should always be stretched after the abscess is
evacuated, and the stools kept regular but not loose. No packing
further than that necessary to check the first oozing of blood should
be used in those cases. It prevents drainage and delays healing. Tonics,
good, nourishing diet, and such specific medication as seems indicated
should be employed. It is also a good plan to keep these patients on
their feet most of the day, as this facilitates the drainage both through
gravitation and through pressure upon the parts by the pelvic and
abdominal contents. Sitting should not be allowed until the abscess
has practically healed, as tliis posture interferes with the circulation
and drainage of the parts.

Superior Pelvi-rectal Abscess. — These are not, as a rule, developed
from rectal inflammations, but generally arise from affections of the
bladder, urethra, prostate, uterus, or broad ligament. In women they

PERIANAL AND PEBIBECTAL ABSCESSES 343

are ordinarily termed pelvic abscesses^ and arise from infectious diseases
of the generative organs. In men they often occur as the result of
posterior urethritis or inflammation of the prostate^ and simulate ab-
scess of this organ.

Psoas abscesses, necrosis of the bones of the pelvis, suppuration of
the broad ligament, perinephritis, vesiculitis, and appendicitis may all
cause a collection of pus in the superior pclvi-rectal spaces. Abscesses
may also occur here as the result of inflammations or injuries in the
anterior rectal wall, the infection being carried by the middle lymphatics
and arrested here owing to the sudden bend of the vessels in the lower
part of these spaces. Traumatism from childbirth or instrumentation
of the uterus or prostatic urethra, operations for stone, prostatectomy,
and uterine tumors have all been known to produce these abscesses,
but the chief caiises are inflammations of the prostate, seminal vesicles,
uterus, and broad ligaments.

Symptoms. — The premonitory s}Tnptoms of such abscesses are those
of prostatitis, vesiculitis, and posterior urethritis in men, and the
inflammatory phenomena of pelvic or uterine disease in women. They
are often mistaken for ovarian and tubal abscesses or tumors of the
broad ligament.

They are usually ushered in by chill, fever, accelerated pulse-rate,
deep, aching pain, and interference with the urinary functions. Occa-
sionally they develop in a slow, insidious manner without chill and with
ver}' slight fever. Dysuria, haemorrhage from the bladder, and even
complete obstruction of the urine due to pressure upon the ureters has
been known to take place. (Edema of the scrotum and vulva with pains
in the perimeum and testicles are also sometimes present. Difficulty
and pain in defecation are not marked symptoms in the early stages.

Where the inflammation is of a tubercular type all of these symp-
toms will be less marked and more slowly progressive. Where it is
due to gonorrhoea, as it often is in both sexes, the temperature may
rise very high and the constitutional symptoms become alarming. The
abscesses have a tendency to burrow upward into the iliac fossa and
outward toward the abdominal wall rather than downward toward the
perinaeum (Fig. 110, B), owing to the greater resistance in this latter
direction. They may perforate the peritoneal cavity, causing acute
septic peritonitis and death within a short time. Inflammation may
also spread to this membrane without perforation, and develop either
a localized or general peritonitis. Perforation of other organs, such
as the bladder and rectum, may result at any time during their course.
The discharge of large quantities of pus from the rectum or through
the urethra accompanied by more or less relief from the feeling of
tension, weight, and pain within the pelvis, would indicate this.

344 THE ANUS, RECTUM, AND PELVIC COLON

Perforation through the vagina in women is rare, but may occur. The
diagnosis of superior pelvi-rectal abscess rests largely upon a histoiy
of diseases and symptoms connected with the genito-urinary and
reproductive apparatus; the patient rarely gives any account of previ-
ous rectal disease; perianal and i>erineal palpation only elicits a deep
tenderness but no swelling or induration. Digital examination of the
rectum will generally elicit a tenderness above the prostate in male
patients and to one side of the central line. In females the abscess ig
usually high u]), and requires a long reach of the finger in order to
determine its existence. Pain upon pressure, induration, and thicken-
ing of the rectal wall may be felt, together with a circumscribeil swell-
ing, which in thin people may be outlined by the finger in the rectum
and palpation of the abdomen from above. When the abscess has
existed for some time and become quite tense, it may extend down-
ward between the rectum and the prostate, enter into the ischio-rectal
fossa? by perforating the levator ani muscle, or even penetrate the
retro-rectal space.

The diagnosis is not difficult in these late stages; it is only in the
early periods of inflammation that one finds it hard to determine the
exact nature of the condition. It is useless to insist upon the impor-
tance of this being made early in view of the grave complications which
may result from delay. The fact that the patient has only slight eleva-
tion of temperature or a comparatively slow pulse-rate does not contra-
indicate the presence of deep pelvic abscess. Sometimes they develop
a low grade of fever with typlioid symptoms, diarrhoea, and mental
depression. These cases have been mistaken for typhoid fever more
than once. The urinary symptoms often mask the rectal symptoms in
men, and patients go from one hospital to another, having sounds
passed, the urine dra^n, and the bladder washed out for acute cystitis
and enlarged prostate, whereas the condition is due to pelvic abscess,
which is not diagnosed, if indeed a rectal examination is made at all.
In women these symptoms, instead of being referred to the urinary
apparatus, are generally taken to indicate an inflammatory condition
of the uterine organs, and vaginal examination is soon made. Gjmaecolo-
gists are in the habit of making rectal examinations in order to cor-
roborate tlie information obtained per vaginam, and the result is that
such abscesses rarely escape notice in this sex. In men they are situ-
ated, as a rule, anterior to and at one side of the rectum ; thev mav be
upon a level with or just above the prostate. In women they are liable
to be more upon one side than anteriorly, because the pelvi-rectal
spaces are practically separated in front by the close union between
the rectum and vaginal wall below, and because the lymphatics which
carry the infection run along the borders of the broad ligament and

PERIANAL AND PERIRECTAL ABSCESSES 345

are therefore distributed upon the sides more than anteriorly. The
general course which such abscesses pursue and the extent to which
they burrow have been already mentioned. They sometimes entirely
surround the rectum and destroy all the cellular tissues between the
levator ani and the peritonaeum. They may break a way through the
levator ani muscle, enter the ischio-rectal and retro-rectal spaces, and
finally make for themselves outlets at some portion of the circumfer-
ence of the anus. Wlien, however, one comes to open such n cavity
or to examine the discharges he will find it almost impossible to de-
termine the origin and pathological cause, owing to the fact tliat the
abscess has remained chronic for so long that the production of phago-
cytes and their destruction of the pathological bacilli often render
microscopic examination and cultures negative. In such cases, where
great destruction of tissue has taken place around the rectum, the
probability of absolute restoration of the functional action to the parts
is somewhat remote. Fibrous and cicatricial deposit are likely to result
in stiffness and contraction of the gut wall, which it is very difficult
to overcome.

In the early development of these abscesses it may be almost impos-
sible to diagnose them, although the general symptoms indicate pus
formation. Where the surgeon is unable to make out the collection
by combined digital touch and abdominal palpation, an examination of
the blood may show a marked increase of white blood-corpuscles, and
may give a fairly positive indication of the condition with which he has
to deal. Examination of the rectum by long rectal tubes, and even soft-
rubber bougies, is contraindicated in cases in which pelvic abscesses are
suspected on account of the danger of rupturing the wall of the rectum
and thus opening the abscess into it.

Treatment, — The treatment of this condition consists in evacuating
the pus at the earliest possible moment and affording the cavity a free
drainage.

The methods of evacuating these abscesses are not so easily de-
scrilxxl. Ziegler and many of the earlier surgeons advocated opening
them through the rectal wall. Wliere no pathological opening in the
rectum exists, it is rarely justifiable for a surgeon to make one. A
deep dissection through the perina»um to find and evacuate the abscess
cavity is the proper course. The rectum may be dissected away from
its attachments to the prostate and bladder for a distance of 2 J inches
in order to reach an abscess in the superior pelvi-rectal space and give
free drainage. If possible the surface wound should always be equal
to the widest portion of the abscess cavity. It is only by making such
incisions that diverticuli or pockets can be avoided. Deep punctures
with small, sharp bistouries are likely to wound blood-vessels which

346 THE ANUS, RECTUM. AND PELVIC COLON

can not be seen, they may penetrate the peritonaeum, they leave long,
narrow tracts in which the discharged pus causes infection and sec-
ondary abscesses, and drainage is never satisfactory through then.
Wide, free, open dissection to whatever depth the abscess may be, is
therefore the rule in this class of cases. Where the abscess is well
defined upon one side, the incision may be made upon that side in &
line parallel to the fibers of the external sphincter, but well removed
from tlie anus. Wliere it aj)parently surrounds the anterior rectum,
the incision should be carried upward in the recto-urethral plane, being
careful not to wound the urethra or to invade the peritoneal cul-d^m.
If the incision should extend as high as 2\ to 3 inches, the surgeon
should carry it upward by dull dissection and make effort* to push the
peritontvuin above by the finger rather than by the use of a knife.

When the abscess has been reached and the pus begins to be dis-
charged, a long tube should be introduced into the cavity and thorough
irrigation with peroxide of liydrogen, bichloride, or carbolic-acid solu-
tions should be carried on until it is thoroughly evacuated. After this
the finger should be introduced into the cavity, and as far as possible
the extent and direction should be examined. Tearing or stretching
of the opening into the cavity is not advisable, because the tissues are
tender and one never knows in what direction they will give way; it
may be into the peritoneal cavity, it may be into the bladder, or it
may be into the rectum. Therefore we should incise the wall in the
direction of greatest safety, guiding the knife or scissors with the
finger, and thus widen the opening into the abscess cavity without
danger of invading the other pelvic organs. After the abscess has thus
been evacuated and free drainage furnished, the sphincter muscle
should always be thoroughly stretched, in order to avoid any obstruc-
tion to the pasvsage of gas and fa?cal matters which might add an
additional strain to the weakened sgeptum, between the rectum and the
abscess cavity.

The curetting of such abscess cavities is rarely, if ever, advisable.
The author^s experience does not agree with that of Dr. Kelsey, who
says in his latest work, " Tliat to reach pus by a perineal incision would
seldom be practicable in these cases.^' Any perirectal abscess which can
be felt by the finger in the rectum can be reached by perineal dissection,
and should be so reached and opened. If by any possibility the urethra
or bladder has been opened by the ulcerative process, the conversion
of the abscess into a perineal urinary fistula will be by all means the
safest and surest road to cure.

In males there is only one other procedure, and that is the opening
of the abscess through the rectum, which is not only unsatisfactory
from the point of view of drainage, but it is liable to leave pockets

PERIANAL AND PERIRECTAL ABSCESSES 347

and burrowing diverticuli, and if there is perforation of the urinary
organs, will result in recto-vesical or recto-urethral fistula. Aside from
this, it only opens a new channel for infection of the walls of the abscess
by the bacteria of the intestinal canal. It need not therefore be further
considered.

The practice of introducing long aspirating needles through the
perineum or through the rectum into swellings or tumors between the
rectum and the bladder or prostate is objectionable for the reasons
that, introduced through the rectum, the pus is sure to follow the needle
outward, thus necessitating an opening into that cavity; if the tumor
proves to be a neoplasm, the needle carried through the mucous mem-
brane is very liable to infect the same and produce an abscess
or septic condition. If introduced through the perinaeum the dangers
of wounding the peritoneal pouch, and the fact that pus will surely
follow outward in the track of the needle if an abscess is present, and
infect a tract which it may be impossible to absolutely follow in dissect-
ing down upon the abscess, thus leaving a new line of infection which
is not properly drained, are sufficient to condemn it. Experience and
judgment in the examination of these cases should render the operator
certain enough of his diagnosis as to a collection of fluid in any case
in which he can reach the swelling with his finger, and whether that
collection be a cyst, an extravasation of urine or blood, or a collection
of pus, perineal incision and drainage should be made without the
blind test of aspiration.

As to drainage in these cases, a rubber tube is preferable to gauze.
In many instances gauze wicks have been introduced into the abdomen
after operations for appendicitis, and into abscess cavities about the
rectum and in other portions of the body for drainage, and yet when
those wicks have been drawn out there have been accumulations of
greater or less quantities of pus at the bottom of the cavities, which
the gauze wieka seemed to obstruct rather than to drain. The gauze
drain is not satisfactory where there is a thick, tenacious pus. Packing
of the abscess cavity is always imadvisable. The walls should be allowed
to come as closely in contact as possible. Therefore small drainage-
tubes just sufficient to keep the cavities free from collections of pus
are best. Frequent irrigation with antiseptic solutions is also impor-
tant. Sometimes a strong solution of bichloride of mercury (1 to 500)
is run into the cavity, and this is washed out with a milder solution
(1 to 5,000) immediately thereafter. If the wound exhibits a sluggish
tendency and the abscess does not heal as rapidly as the general condi-
tion would indicate, it will sometimes be advantageous to inject the
cavity or swab it out with 95-per-cent carbolic acid or pure ichthyol. In
order to apply the latter the drainage-tubes may be taken out, and a

848 THE ANUS, RECTUM, AND PELVIC COLON

narrow strip of gauze saturated with the drug introduced into the cayity
and left for two or three hours. It should then be removed and the
drainage-tubes reintroduced.

In such operations the sphincter muscles are to be avoided, but
incision of the levator ani is not only unavoidable but desirable. A
simple separation of the fibers may evacuate the pus which is situated
just above them, but as soon as the distention produced by the abscea
has disappeared these fibers will come together again, and thus the
abscess cavity will be very imperfectly drained. The muscle fibere,
therefore, should be cut at right angles in order to prevent this re-
contraction and interference with the drainage.

In women these conditions are likely to be very chronic and to
have existed for long periods of time before being opened. The chronic
pelvic cellulitis spoken of by different writers is often associated ^ith
collections of pus which neither increase nor decrease to any great
extent, but which remain in statu quo for month after month, the con-
nective-tissue deposit thickening and increasing about it all the while.
It is through this process that stricture of the rectum, even to the
extent of absolute obstruction, may be produced.

Constipation is always an unfavorable symptom in these cases, and
the longer the abscess exists the more marked will it appear. When
pus forms, whether in the tube or in the broad ligament, especially if
the superior pelvi-rectal spaces are involved, it should be evacuated
through the vagina, if possible, at the earliest possible moment under
the strictest antiseptic precautions, and free drainage be obtained.

Where the abscess points upward above the pubis or in the iliac
fossa, openings may be made in these regions and drainage secured. At
the same time healing will be facilitated if the abscess is given a de-
pendent drainage by dissections upward through the perinaeum or vagina^
into its lowest prolongation. This prolongation can be determined by
the use of a full-sized probe introduced through the abdominal opening
and felt with the finger of the other hand introduced into the rectum
or vagina.

Diffuse Septic Periproctitis. — Before the days of antiseptic surgery^
surgeons were accustomed to meet a diffuse form of inflammation
involving all the perirectal tissues. The condition generally followed
an injury to, or an operation upon, the rectal wall. It has been de-
scribed under the titles of perirectal cellulitis, septic periproctitis, and
by BouUy (Archiv. gen. de med., Paris, 1879, pp. 35, 162) as diffuse
pelvic cellulitis. The condition is characterized by an acute inflam-
mation of the perirectal tissues, especially those of the retro-rectal
and iscliio-rectal spaces. It is essentially a septic process of very
virulent nature. It comes on at any time from a few hours to three

PERIANAL AND PERIBECTAL ABSCESSES 349

days after an injury to, or operation upon, the rectum. Strangely
enough a case of this disease rarely occurs unless perforation of the
rectal wall itself has preceded it, and yet in its destructive processes
the walls of the rectum and anus are rarely involved. The inflamma-
tion is generally confined to the perirectal tissues. The infiltration
assumes at first a sort of semisolid condition, changing later to a sero-
purulent discharge when the tissues are laid open. The inflammatory
process may extend upward and forward, involve all the pelvi-rectal
spaces, and may invade the peritonaeum through extension, osmosis of the
septic agents, or by absolute perforation. In the first instance the
peritonitis will be of an intense septic type, or ultraseptic as described
by Quenu, unaccompanied by any great adhesions between the ab-
dominal organs.

Symptoms. — The patient does not usually suffer from a distinct
rigor, but at a period somewhere between a few hours and three days
after the operation upon or injury to the rectum, a creeping chilliness
comes on succeeded by accelerated pulse, high temperature, headache,
brown-furred tongue, and sometimes severe vomiting. The pain in
the wound increases greatly, with a sense of fulness and weight in the
sacral region; the discharges change to a grayish, bloody, foetid char-
acter, and the perirectal tissues assume a bright-red, tense, and shining
appearance. The mucous membrane of the rectum and anus remains
unchanged or becomes oedematous and swollen. Great weakness and
depression follow rapidly upon this condition, and the patient is some-
times seized with an exhausting, liquid diarrhoea. The constitutional
symptoms are those of general sepsis, very closely resembling that type
known as puerperal fever. All the perineal and inguino-crural tissues
may be involved in the process. Difficulty of urination, even suppres-
sion of the urine, may complicate affairs. Complete loss of appetite
and inability to retain food are ordinarily present. During the course
of the disease septic endocarditis or pericarditis may develop, thus
hastening the end. Unless checked by treatment the disease i-uns its
course and ends in death from the second to the tenth day.

Treatment. — The treatment is one of prevention rather than cure.
It is a disease which should not occur at the present day. Of course
there may be cases in which accidental injuries, such as puncturing
wounds, may invade the perirectal tissues and thus give access to the
virus, but such cases are so rare that one need hardly consider them.
The whole secret of prevention lies in antiseptic precautions and free,
wide drainage in all operations about the rectum. The operations
which are more likely than any other to be followed by such a complica-
tion are those of proctotomy for stricture or resection of the rectum
for tumors. If, however, the disease should occur notwithstanding

850 THE ANUS, RECTUM, AND PELVIC COLON

proper surgical precautions, the treatment consists in bold incisions into
all the swollen and inflamed tissues, followed by frequent antiseptic
irrigation with the application of heat in the interim in order to pro-
mote the circulation and prevent the occurrence of gangrene in the
parts. Where the symptoms of general sepsis are very marked, tk
injection of antistreptococcus serum may be of advantage.

It has been suggested also in such cases that saline infusions into
the veins will result in the destruction of the bacilli in the blood and
in sustaining the strength of the patient until the septic depression
has passed away. In instances in which this has been done in very
late stages, death followed in due time; experience, therefore, does
not justify the statement that this procedure will be of any practical
benefit. No drugs have any particular effect upon these septic condi-
tions. In the light of modem therapeutic researches, administering
carbolic acid in large doses might possibly be of some benefit. It his
been demonstrated that this drug can be administered in doses of from
3 minims in children to 12 minims in adults, every three hours, with-
out the production of toxic symptoms except in cases with personal
idiosyncrasies. It does seem to have some bactericidal influence in
such microbic diseases as whooping-cough, pneumonia, and typhoid
fever. It might therefore be advisable to administer it in septic peri-
proctitis. Salol accompanied with strychnine or quinine will be of use
to control the bodily temperature, while it is at the same time an
intestinal antiseptic. The main reliance, however, will be upon the
frequent antiseptic irrigations and repeated early incisions into all the
tissues involved.

Idiopathic Gangrenous Periproctitis. — Under the title of idiopathic
gangrenous cellulitis, Furneaux Jordan (Brit. Med. J., Jan. 18, 1879,
p. 73) has described an unusual type of perirectal inflammation. It
consists in a slowly extending cellulitis unattended by much swelling
and pain. It develops usually without any previous injury, but may
follow surgical operations about the rectum. In its general aspect it
resembles very much the condition seen in urinary infiltration of the
perina?um. It occurs, as a rule, in large, stout, well-preserved individuals
and in active and excitable men given to heavy eating and drinking:
as Jordan says: " In men sufficiently well-to-do to indulge at will, and
who firmly believe that excessive work needs excess of victuals and liquor;
in men who are indifferent to weather and have been notably exposed
to cold and wet.^^

The disease begins on the level of the anus, or sometimes in the
deeper tissues. It progresses very rapidly, and there seems to be no
limit to its extent. Gibbon (London Lancet, 1890, vol. i, p. 747) de-
scribed a case in which the process extended to the scrotum and entirely

PERIANAL AND PERIRECTAL ABSCESSES 351

destroyed it. Wyman (American Lancet, Detroit, March, 1892, p. 244)
has reported a case in which the whole perinaeum and skin over the but-
tocks were rapidly destroyed by the gangrenous process. Cases have also
been reported by Gerster and Kelsey in this country, but the most exten-
sive and remarkable one is that related by Quenu and Hartmann {op, cit.,
137). This was the case of a large, strong man, a heavy eater and
drinker, who was seized with pains about the region of the anus with-
out any known cause ; a rigid tumefaction and redness of the area about
the anus and perinseum followed, extending between the scrotum and
the thigh upward into the iliac region over the abdominal surface, even
to the axillary region. Great phlegmonous infiltration with blisters,
gangrenous plaques, and the development of gas in the two ischio-rectal
fossae existed. Posteriorly the infiltration passed across the sacrun.
The urinary apparatus in this case remained normal. The tongue was
red and dry, and the temperature reached 40° C. After about three
months' treatment, with frequent incisions and drainage of the involved
areas, this patient recovered.

Etiology. — Thus far no satisfactory etiology has been suggested for
this disease. In Gerster's case there existed a diabetic glycosuria, and
he suggested the possibility that it caused the condition. In the
other cases reported no such complication has been observed. Dun-
glison, adopting the term of Fuchs, described it under the title of
proctocace. According to Fuchs it is a common condition in Peru
(Quito and Lima), in Brazil, and on the Honduras and Mosquito coasts.
It is called by the Portuguese ^* bicho '' and " bicho di culo.'* In
Quito it is termed " mal del valle '* on account of its prevalence in
the valleys. It is also known in Africa, where it is called " bitios de
kis.'' ft'om its frequency in these regions one would judge that climate,
soil, and modes of life had something to do with its production. It
has been attributed to the use of decomposed foods and excessive
indulgence in condiments and spices. On the contrary, all the cases
seen by Jordan occurred in cold weather and in the high table-land
of mid-England, and no case has been reported in the female sex. It
seems, therefore, that climate can not account for it.

Symptoms. — The disease comes on with a chill followed by high fever
and great mental and constitutional depression. There is some pain
in the neighborhood of the anus; the skin is red and brawny, the epi-
thelium elevated and covered with small phlycta^na?, which soon break
down and leave black gangrenous masses which discharge an ichorous
fluid instead of pus. The chief characteristics of the disease are its
rapid extension and its tendency to light up again and invade other
tissues after it has once been apparently checked. Invasion of the
ischio-rectal and superior pelvi-rectal spaces and thus upward into the

352 THE ANUS, RBCTCM, AND PELVIC COLON

peritona?iim is its common course. It may enter the retro-rectal space,
passing out through the obturator foramen and invade the subtegu-
mentary tissues, as in one case described by Jordan. Wherever the
peritonaeum becomes involved death rapidly ensues. The temperature
runs ver}' high, the tongue is dry and red, and the whole condition is
characterized by great adynamia. Even after free incisions have been
made in the inflammatory mass the discharge does not assume the
nature of pus, but rather a sanious ichor of a most putrid nature. The
gangrenous process is self-limited. If the patient does not succumb
to sepsis and exhaustion during the early periods of the disease, it will
require the utmost skill and perseverance to maintain his strength
through the chronic process of getting rid of the large necrotic masses
which may be accompanied with frequent haemorrhages, any one of
which may bring on the end.

Treat me fit. — The treatment of this condition consists in earlv and
repeated incisions through all the gangrenous tissues in whatever neigh-
borhood they may be, followed by antiseptic irrigation and hot anti-
septic poultices. While these incisions do not give vent to any cir-
cumscribed collections of pus or ichor, they open the cellular channels
for the oozing out of the a^dematous collection in the necrotic masses,
and thus relieve the tension and prevent to a certain degree the absorp-
tion of the products of decay.

Owing to the fact that the blood-vessels themselves frequently re-
main intact, such incisions may be accompanied with dangerous haemor-
rhages. Jordan mentions an instance of this kind in which the ingenuity
of the attending physician was greatly exercised in order to control the
bleeding. He finally succeeded in doing so by the introduction of a
Barnes's dilator into the rectum, and distending this organ so as to
produce sufhcient pressure upon the parts to control the hapmorrhage.

Ligatures are not likely to prove successful, as the blood-vessels are
80 brittle and altered that they would likely cut through. Firm pres-
sure is the most reliable means of controlling the flow.

General stimulation together with hypodermoclysis is necessary, and
all those therapeutic and dietary resources for the maintenance of
strength in adynamic diseases should be taken advantage of. In the large
majority of instances the disease results fatally sooner or later from
8eptica?mia or general exhaustion.

CHAPTER xr

FISTULA

The Latin word fistula siynifiea a pipe or reed, and has been applied

a this disease on account of the occaeiunal reed-liko shape of tiie tracts

d the passage of air through them. It is a. mienomer, however, aa the

i^e majority of fistulas are tortuous, very irregular in 9ha|>e, and gasea

t pass through them.

Defliiltioii. — Ano-rectal fistula may be defined as any unitatitral

lenneJ eriendiiiij from the skin or muco-cutaneous tegument abmil Ike anus,

E*r frtmi the mucous membrane of the redum into or through the surround-

int/ I issues.

The essential characteristic of the disease is chronieity. A freshly
opened abscess, either external or internal to the rectum, forms a sinus,
but one which may heal
completely in a short time;
. unless it has both an ex-
■nal and internal open-
j; it would not be tcrmi.il
i fistula until it had shown
1 tendency to heal for a
isiderable period. 1 1
confusion if
Jke term were confined to
lat type ordinarily knowni
the complete variely.
jETndcr the accepted im-
mclature. however, every
Tronic abscess cavity i^
I fistula. Accordingly, tlicy
mplete.

Clun&eiition.~I iicom I'lete Fitttula. — Tliia variety embraces all those
s which o]ien on one surface only. When the opening is outside of
e ano-rectal line it is called blind external fistula (Fig. 116), and when
rithin the rectum, blind internal fistula (Fig. 117).

broadly classified as inrcmpletr and

354 THE ANUS, RECTUM, ANU PELVIC COLON

Complete Fistula. — This type includes all tlmse cases in whieli there
is both an external and iiitfrnal opening, and a ]»ervious tract from tlie
surface outside of the anus
into the cavity of the anus
..]■ rectum (Fig. 118).

Fistulas are also claasi-
lii.d according to the tis-
t -iii's involved. Those
uliit-h simply pass under-
jifath the skin, muco-cnts-
neoug or mucous tissuee.
are termed svhlfijvmtn-

LSI tnrij, snbmuco-cvtnneous, or
'^1 submucous (Figs. 117, A,
V ii!l). Those which pass
til.. 117— liLiM. i\iti.>»i. Fi^riLA... outside of the muscular

A. ,ui.taB>u,K.„uiry ; B, »ubaiK.u>..amUc. apparatus of the rectum or

anuB are called siibmuacular or sjibaponeurnttc (Figs. 116, 118).

In addition to these divisions there are also simple, aimpUj, and
compHcaled fistiilas. The simple fistula consists in a sinus tract lead-
ing from the akin or mucous membrajic into the perirectal tissue, or
a complete tract leading directly from an opening in the skin to one
in the mucous membrane.
of these conditions, such
as wide burrowing and
great tortuosity of the
tract, the existence of two
or more openings on the
skin with one in the rec-
tum, or two or more in the
rectum with one upon the
skin. By the term compli-
cated fistula is meant those
cases which are compli-
cated by necrosis of the
bones, or by connections
with other organs, such as
the bladder, urethra, va-
gina, and uterus. The lat-
ter require special consideration and peculiar treatment. It is there-
fore considered wise to study them apart from the ordinaiy ano-rectal

The complex variety consists in variations

Finally, fistulas may be classified according to their pathological

FISTULA

355

causes into specific and noti-specific types. The speeiiic types tire those
due to tuberculosis, c;aroinoma, and syphilis; the non-speeifie are those
<iuo to simple iaflainniatory processes or injuries. Ou account of the
tuberculous variety, this clasaifieation is of grout importance.

Krkquexcy of Fistula. — The frequeney with which fistula occurs
in comparison with other rcetal diseases inay be gathered from the statis-
tics of special hospital services. In St. Mark's Hospital, London, as
quoted by AUinghari, out of 4,000 rectal cases, 1,1)57 persons suffered
from fistula and 19« from abscesses, of which 151 subsequontly became
fistulas. One may therefore practically state that 1,208 out of 4,000
cases, or nearly one-third of all rectal diseases, were fistulas. These
statistics are taken from the walking cases, whereas the records of the
hospital show that two-thirds of those operated upon in this .Mecca fur
these sufferers were cases
of this diseasi".

In examining the re-
ports o_f the general hos-
pitals in this city it is
found that over one-lmlf
of the cases operated u[>on
for rectal diseases in five
I years were fistulas. In the
ID t dor's service at the
■olyclinic Hospital the
(erci-ntage is not so high;
d)is may be attributed to
ibe fact, however, that all
the inflanuiiatory and ca-
tarrhal conditions of the lower intestine are treated in this clinic, where-
at* a number of fistulas fall into the hands of general surgeons, and
■Cherofore the proportion is reduced. Even under these circumstances

a condition comprises one-fifth of all rectal diseases.

With regard to the proportionate frequency of the different varie-

t it may be said that complete fistula comprises about 70 per cent,
ind external fistula about 30 per cent, and blind internal about 10 per
int of the ciisea recorded.

.\fl to the frequency of simple and complex fistulas the experience
t surgeons differs greatly- If we consider <mly those cases complex
^hich have more than one opening either externally or internally, then
Sie complex variety will only comprise about 5 per cent of the cases
On the other hand, if we consider those cases complex which
Bonsist in tortuous tracts burrowing in different directions, or partially

-ounding the anus, the proportion between the two will be materi-

356 THE ANUS, RECTUM, AND PELVIC COLON

ally altered; in fact, the inajorit}' of chronic fistulas are complicated by
some such diverticuli or burrowing tracts. It would complicate matters
to consider all such cases complex; therefore it is better to confine the
term to those cases which have multiple openings upon one surface or
the other.

Etiohf/y, — With few exceptions all fistulas originate in abscesses.
They may occasionally be produced by penetrating wounds which ex-
tend from the external surface into the rectal cavitv. Two cases of this
kind liave come to the notice of the writer: in one the patient was
thrown from a wagcm and fell upon the metallic stem of an umbrelli.
which punctured the skin about 1 inch from the anus, and passed through
into the rectum 1.] inch ai)()ve the anal margin; in the other the condi-
tion was caused by squatting down upon the sharp stump of a weed.
This case has been referred to in the chapter on accidents imd injuries.
In each case complete fistula resulted.

Gunsliot and bayonet wounds may produce them (Med. and Surg.
History of the War of the Rebellion). Ordinarily intermediary abscesses
occur in such cases, but always there is infection which gives to the
wound the chnmic characteristics which constitute fistula. In general
one may say that abscess or destructive ulceration always precedes
fistula. Whatever produces these conditions may also cause it. Wounds,
injuries, tuberculosis, syphilis, stricture, etc., are therefore etiological
factors. Ulceration and burrowing from the base of mucous diverticuli
in the rectum and pelvic colon are said by Cruveilhier (Anat. path, gene-
rale, Paris, 1849, t. i, p. 5i)4) and Frant^ou (Th., Lyon, 1883-'84, No. 199)
to be the point of de])arture for internal blind fistulas. Perforating
tubercular ulcers of the rectum hav(> long been considered the originat-
ing cause of the disease*. Pathological researches, however, fail to con-
firm this view, which has been particularly elaborated by Koenig (lichr-
buch speciellen (Uiirurg., Berlin, 1809, vol. ii, p. 539). If this were
the case, there would be usually other ulcers around the internal opening
of the fistula, as tubercular ulcers of the rectum are rarely single. As a
matter of fact, in the large majority of fistulas, ulcers of the rectum are
not present except at the fistulous opening. Thus, in 41 cases of tuber-
cular fistula examined by M. Hartmann (R6^'ue de chirur., 1894) there
were only 2 cases in which there existed ulcerations of the rectum sepa-
rate from the internal opening of the fistula. Moreover, if the fistula
originated in a j)erforating ulcer of the rectum it would always assume
the type of a blind internal fistula at first, and present the symptoms
of such, but this is not the rule either in the simple or tubercular types.
The discharge from tlie rectum does not often occur until after the
symptoms of abscess have existed for some days — in short, the ulcer
develops after the abscess.

FISTULA 357

The question now arises, If they all originate in abscesses, why do
not these heal, and why the ehronicity which constitutes fistula? Many
theories and conditions have been evoked in the explanation of this fact.
It is easy to understand why a complete fistula does not close on account
of the constant passage of fsecal matters and gases through its tract, thus
preventing by mechanical action the agglutination of its walls. More-
over, the constant reinfection of the surfaces by such passages prevents
healthy granulation and healing. In internal blind fistula one can also
explain why healing does not take place on account of the imperfect
drainage and the constant escape of fjccal material into it.

These theories, however, do not apply to blind external fistula, in
which there is no passage of fjecal material or gases into the cavity, and
hence no constant irritation or apparent recurrent infection of the walls.
The cause has been ascribed to the mobility of the rectal wall which
forms a portion of the fistulous tract; the constant motion of a part will
prevent its union with another, and there is constant motion of the
rectal wall due to respiratory and involuntary peristaltic action. The
irregularity of the abscess cavity, the existence of necrotic tissues in
different portions of the tract — when the opening is not sufficiently large
for thorough drainage, and when these tissues have not been removed by
curettage or dissection — may prevent the closure of a blind external fis-
tula. These, however, do not explain those cases in which wide incision,
thorough drainage, and the removal of sloughing tissue have been prac-
tised, and yet they do not heal, notwithstanding the fact that the most
careful and persistent search has failed to reveal any opening into the
rectal or anal canals. In such cases Hartmann has suggested the osmotic
passage of gases and infecting agents from the rectum through the thin
rectal walls into the abscess cavity as a cause of persistent infection
and consequent delay in healing. While such a theory is ingenious and
possible, it is utterly without proof.

The whole secret of ehronicity in blind external fistula lies in two
facts: first, in imperfect drainage; second, in persistent reinfection, which
may come through an opening into the rectum which has not been found,
or through the original tract of infection, the lymphatic channels. Ke-
ferring to the chapter upon ischio-rectal and perirectal abscesses, it will
be remembered that the large majority of these was ascribed to infection
from some small lesion in the rectal or anal canals, the se[)tic material
being taken up by the lymphatics and carried into the surrounding tis-
sues. The abscess becomes circumscribed owing to a thrombosis of the
lymphatic trunks. This thrombosis stops for the time the current of
septic material from the original source, but as soon as the abscess opens
or is incised, the thrombosis in the lymphatic trunks no longer obstructs
the circulation in the distal tracts. Therefore these little lymphatic

358 THE ANUS, RECTUM, AND PELVIC COLON

vessels, still in connection with the rectal surface, continue their infec-
tion of the abscess cavity.

Suppuration extending from the abscess or from the rectal wound
may eventually follow along these tracts and enlarge them suflficiently
for the admission of a probe, whereas in the original condition they are
too small for tlie passage of either the pus or the probe; and therefore
whilo there actuallv existed a communication, it was too small for di?-
covcrv by the ordinary means of research. According to this view the
etiological factor in the conversion of an abscess into a fistula is its per-
sistent connection with the rectum or anal canal either through the
lyni|)hatic tracts or through a distinct opening.

The repair of abscess cavities de])ends upon the proportionate pro-
duct i(m of round cells and their destruction by microbic agent* (Quenu).
If the production exceeds the destruction, repair will proceed, and riVe
versa. If, therefore, a wound be properly cleansed of infectious material
and constantly kept clean, it ought in a general way to heal in due time.
Of course one must take into consideration the constitutional condition,
the rest and personal attention which a patient can give to his treat-
ment; but, assuming that these are satisfactory, the healing or chro-
nicity of such abscess cavities will depend upon the extent to which they
are protected from constant reinfection. The fact that quite a number
of perirectal abscesses and subsequent fistulas originate in injuries and
idcerations of the crypts of Morgagni, from which lymphatic absorption
and infection take ])lace, explains why the rectum is so often searched in
vain for their cause.

These ulcerations may continue after the opening and drainage of
the abscess, and unless a systematic examination of all these pockets
is made and the ulceration cured, suppuration may persist on account of
the fact that the cavity receives through its lymphatic connection with
the crypts a supply of pyogenic germs the destnictive power of which
overbalances the j)roduction of round cells, and thus prevents healing.
These facts emphasize the importance of searching for the original
source of infection, and for any minute communicjition with the rectal
cavitv.

Sex. — Ano-rectal fistula is undoubtedly more frequent in males than
in females (Bryant, Guy's IIosp. Rept., London, 1861, vol. viii, p. 87;
OrefTrath, Deutsch Zeitsch. f. C'hir., vol. xxxi, p. 18; Quenu and Hart-
mann, op, ri/., p. 180). In 425 cases collected from different sources
there were 332 males, 89 females, and 4 children in whom the sex was
not mentioned.

The explanation of these facts lies in the greater exposure of men
to those accidents which cause perirectal abscesses, in the fact that
they are less careful in their personal cleanliness, and in the habitual

FISTULA 359

overeating and drinking in the male sex — habits which predispose io
perirectal inflammations and abscess.

Age. — Fistula may occur at any period from birth to very old age,
but it is essentially a disease of middle life. Quenu and Greffrath state
that in 147 cases only 4 occurred under the age of eleven years. These
figures sliould not be taken as conclusive as regards the disease in chil-
dren. The institutions from which these authors obtained their statis-
tics are not hospitals for children; in fact, children compose a very small
proportion of the patients in either institution, and therefore the facts
do not properly represent the proportion of fistulas in infants. Deran-
Borda (These de Paris, 1882, Xo. 233) and E. Vigne (These de Paris,
1882, Xo. 187) have gone into this subject somewhat thoroughly, and
show that their occurrence in children is considerably more frequent
than is ordinarily admitted by surgeons to general hospitals. At the
Polyclinic Hospital 6 cases of fistula were treated in children under five
years of age during the past five years. The earliest age at which it
hjis been seen was one and a half years.

As to its occurrence in old people, it is still more difllcult to obtain
statistics. In the Almshouse Hospital of Xew York there has been a
large number of old people affected with fistulas, most of whom had
suffered from the condition for many years; one man, aged eighty-one,
said that he had had a fistula for over forty years, and suffered no more
from it at the time of examination than he had for thirty years past.
The majority of fistulas in old people will be found to have originated
in middle life.

Constitutional Conditions, — Some fistulas are said to arise from con-
stitutional diseases and specific inoculations; thus there are those which
follow attacks of typhoid fever, variola, measles, dysentery, and scarlet
fever; also those which arise during the course of Bright's disease, cir-
rliosis of the liver, diabetes, and rheumatism. If dysentery and typhoid
fever are excluded it is a question if any of these diseases have any
causative influence in the production of the malady. Ulceration of the
rectum may occur during the course of any exhausting disease, but it
is nearly always superficial, and the fistulas that result from it are
almost invariably submucous tracts running from one ulceration to
another. Typical fistula in ano rarely if ever results from such con-
ditions. In typhoid fever and dysentery one may occasionally find a
true perirectal abscess due to the infection of the parts b}- the specific
bacilli of typhoid or dysentery through the lymphatic channels, or by
the escape of these bacilli into the tissues through ulcerative perfora-
tions of the rectal wall; but even this type of fistula is exceedingly rare.

Tuberculosis. — The influence of tuberculosis in the production of
fistula is a subject which has been discussed so widely that one scarcely

360 THE ANUS, RECTUM, AND PELVIC COLON

dares to venture upon it without devoting an amount of time and space
altogether out of proj)ortion to a book of this character.

The etiological influence of tuberculosis in the production of fistuk
is by no means a settled question. Every surgeon admits that a certain
number are tuberculous, but whether it is an initial inoculation with
tubercle bacilli or is secondary to a focus elsewhere in the body is still
a mooted quest i(m. Some hold that there is no such condition as pri-
mary tuberculosis of the rectum, it being impossible, according to Koch,
for tubercle bacilli to reach the rectum through the intestinal canaL
On the other hand many competent observers believe that fistula is fre-
quently the primary manifestation of tuberculosis, and that when the
disease limits itself to this area it may remain localized for long periods
of time. In order to come to some conclusion in regard to the relation-
ship between tuberculosis and fistula it is necessar}- to look at the sub-
ject from two points of view: first, tuberculosis in the fisiulouSy and, sec-
ond, fistula in the tuberculous. Some elaborate statistics have been
comj)iled to determine this relationship, and yet none are particularly
satisfactory. AUingham states that 14 per cent of all fistulous cases
seen by him were tuberculous. Ilartmann, in a study of over GOO cases
of fistula, states that 30 })er cent were tuberculous; GreflTrath, 16 per
cent; and Meyer in a private conmumication states that in Mt. Sinai
Hospit^il of New York, 1) jV per cent of all the cases of fistula were tuber-
culous. In the author's experience nearly 50 per cent of the fistulas
that have come under his observation in the Polyclinic, Almshouse,
and Workhouse Hospitals have either suffered from tuberculosis at the
time or afterward.

There is a much closer agreement among observers as to the percent-
age of fistulas in the tuberculous, as the following table exhibits:

Taylor (London Lancet, 1890) 1 }>er cent.

Ilartmann {op. ctt., p. 4) 4.01

Brompton Hospital Reports 4

Douglas Powell (Quonu and Ilartmann, p. ISl) 5

St. Joseph's Home, Caldwell (3,000 cases) 0.9

Mt. Sinai Hospital (3,749 cases), Meyer 1.8

Almshouse Hospital, Xew York, tuberculous wards. 2.1

I C
««
<(
((

In these statistics one observes two classes: institutions in wliieh
there are surgical wards, and others in which there are none. It is
very clear in the case of the Mt. Sinai Hospital that all the fistulous cases
were sent to the surgical side and never reached the medical side,
whereas all the cases of general tuberculosis were sent to the medical
wards; therefore, the proportion among the tuberculous is verj- small.
On the other hand Ilartmann, Powell, and the Brompton Hospital re-
ports deal with a general hospital clientele. Such institutions take in

FISTULA 361

very few pulmonary consumptives, whereas they admit all cases of
fistula whether they are tuberculous or not; therefore their percentages
are unusually high compared to those of St. Joseph's Home, ^kleyer's
general statistics, and those of the Almshouse tuberculous wards. On
the whole the true percentage is probably somewhere between the 5
per cent of Powell and the -j^ of 1 per cent in St. Joseph's Home.
With such facts in view the influence of tuberculosis in the produc-
tion of fistula is undeniable. The fact that fistula in the tuberculous
is so much less frequent proportionately than tubercle in the fistulous,
renders it almost impossible to doubt the occurrence of j)rimary tuber-
culosis in these parts. Modern observers have come to hold to the view
that abscesses, ulceration, and fistula of the rectum may be caused
by direct inoculation of injuries and abrasions by the tubercle bacilli
ingested with the food and carried through the intestinal tract, not-
withstanding the observations of Koch. If such facts can be estab-
lished, if it is positively known that the anal manifestation is the only
focus of tuberculosis in the system, and if, as will be shown farther on,
this focus is absolutely walled off from any connection with the general
system, it will have a bearing of the greatest importance upon the man-
agement of such cases.

Syphilis. — Of the influence of syphilis in the production of fistula
little positive information is obtainable. Nearly all the eases of fistula
attributed to syphilis have been those secondary to stricture of the rec-
tum. In such the fistula is usually a complicated or complex one due
to perforation of the rectal wall by ulcerative processes, and the infec-
tion of the perirectal tissues subsequent to this. The fistula therefore
becomes one of simple infection, and not of a specific nature itself. This
might be said more positively if we knew the specific organism of
syphilis and could eliminate it by microscopic or culture examinations,
but unfortunately there are no means at present by which the presence
of such a germ can be proved or disproved.

A number of such fistulas entirely heal, whereas the stricture and
specific disease continue. This fact would indicate that the fistula
was a complication and not a part of the disease. On the other hand
there are fistulas supposed to be simple, inflammatory conditions, which
absolutely refuse to heal until the patients are put upon antisyphilitic
medication, when they at once assume a healthy granulation, and heal
promptly and thoroughly. It is therefore an unsettled question as to
how much influence syphilis has in the production of fistula; but with
regard to its delaying healing after operations for fistula, there is no
room for doubt.

Symptoms. — It may be assumed that the symptoms of abscess have
preceded those of fistula at some time more or less remote; that the

362 THE ANUS, RECTUM, AND PELVIC COLON

abseest* lias opened either internally, externally, or in both directions;
that the acute phenomena have disappeared, and that the condition his
xissumed a chronic state. From this time the symptoms may be said to
belong to fistula, and they will be reviewed as seen in the various types
■of the disease.

Blind External Fistula. — In this form of fistula, after the inflam-
niatorv symptoms have subsided, the abscess instead of healing assumes
an inoffensive, painless condition. The discharge decreases and be-
comes more serous; the tissues become somewhat thickened and brawny
about the aperture; there is some itching or irritation, sometimes a
slight dragging of the [)arts upon certain motions, and discomfort from
sitting in certain j)ositions; there is rarely, if ever, any absolute pain;
the diseluirge may recpiire the wearing of a napkin or some small dress-
ing, or it nijiv be; so limited that it scared v stains the linen; it mar

* • ft ' •

cease for certain periods owing to tire temporary' closure of the open-
ing; while this continues there will be a feeling of fulness and discom-
fort in the parts, but these rapidly disappear upon the reopening of the
aj)erture. l^his oj)ening and closing may go on for indefinite periods,
and sometimes the closure may be so firm that the abscess will burrow
and open at another j)ortion of the surface, this opening being followed
by the same n^lief as in the first case.

The symptoms during the period of closure are not those of an
acute abscess accomj)anied with chill, fever, and great distress, but they
resemble those of the cold abscess. During one of these closures the
secondary ()j)ening may take place within the rectum and thus form
what would a])pear as a blind internal fistula; but this condition lasts
only a short time, as the original opening or another upon the surface
is sure to give vent to the collected pus, thus producing a complete
fistula.

Palpation will reveal a thick and brawny condition of the skin over
the fistuhms tract, and generally an induration of greater or less ex-
tent beneath it. Deep pressure around the opening will give some pain,
and usually results in forcing a drop of sero-pus from the aperture.

There is ordinarily no pain on defecation, and no spasm of the
sphincters. In simple fistulas, and even in many cases of the localized
tubercular type, the patients remain in the best of health and fre-
quently increase in weight. The rectum presents no abnormalities to
the touch or sight except that one can sometimes feel the induration
of the fistulous tract through its walls.

Blind Internal Fistula. — The syinptoms of this variety are much
more obscure. The patient will give the history of rectal ulceration or
of having had chilliness and temperature with pain and fulness in the
rectum, followed by a discharge of blood or pus which gave partial

FISTULA . 363

xelief. The discharge, however, continues, and pain on defecation is
present with more or less tenesmus or spasm of the sphincter. If tlie
condition has existed for any length of time, hypertrophy of this muscle
may be present. All of these symptoms subside and recur from time
to time. The subsidence is associated with an increase of the discharge,
and the recurrence with a decrease. Owing to the fact tliat these fistulas
are usually submucous or subnmco-cutaneous, palpation around the
anus does not ordinarily give to the examiner a sense of tension, swell-
ing, or induration; nor does it produce that acute pain which follows
in abscess or blind external fistula.

With the finger in the rectum one may feel sometimes a small indu-
rated tract running upward from the base of the iistula to the opening
in the rectum, or if the cavity be only partially emptied of its con-
tentf!, a boggy, compressible mass may bo observed. Ordinarily the
opening can be felt and located. Where this can not be done, the use
of instruments will be necessary for the diagnosis. For this pur])ose
the conical, fenestrated speculum is by all means the most satisfactory.
By it one can bring the aperture into view, and while he presses with
his finger upon the lower part of the tract he will be able to see a drop
of pus exude from the opening. Having determined such an opening,
one can introduce a bent probe into it through the s[)ecuhmi, and by the
introduction of one probe after the other, each being bent a little more
upon itself, he can determine absolutely the depth and direction of the
tract.

Sometimes the small lar}'ngeal mirror may be useful to determine
the (»pening, especially in those cases in which it is situated in the
jwsterior rectal cuUde-sac, or when it leads downward from a valve-like
opening either in the rectal wall or in one of the crypts of Morgagni.

The introduction of the. probe in these cases usually cfiut^es an acute
pain when it approaches the anal region, and it may be followed by a
drop of blood.

Citmplete Fistula. — Complete fistula is generally more easily diag-
nosed than either of the other varieties. Aside from the historv of
abscess there is more irritation, greater spasm of the sphincter, more
or less pain on defecation, involuntary escape of gas and fjeces, difliculty
in maintaining cleanliness, and a constant disagreeable odor to the
parts, all of which have a depressing influence uj)()n a sensitive indi-
vidual, leading sometimes to attacks of hypochondria and even melan-
cholia.

The discharge is greater than in blind external fistula, owing to
the fact that the infection is more continuously renewed.

Pain is not a prominent symptom, but it is always present to some
extent. The external opening is often tender to the touch; it may be

364 THE ANUS, RECTUM, AND PELVIC COLON

elevated like a nipple or depressed by cicatricial conlraction. The in-
flaniiuatory symptoms of abscess may sometimes recur owing to tlie
obstruction in the fistulous tract by necrotic tissues or the escape of
fa'cal substances from the rectum. The fistula may also be kept tender
by the passage of irritating diarrhoeal stools which cause further infc^
tion, and may bring about the formation of other abscesses which open
into the first tract, or at other points upon the skin, thus producing
complex fistula.

The sphincrters in this type of fistula are nearly always spasmodic
and hy})ertrophied. An examination by palpation around the rectum
will nearly always elicit an indurated tract leading upward and toward
the anus. With the index finger of one hand in the rectum and that
of the other outside, one may generally trace this indurated tract to
the internal opening in the rectum. This oi>ening can almost always
be felt and absolutely determined by touch.

Di(i(jnosis. — Ordinarily when the patient presents himself for the
treatment of fistula, the diagnosis has been already made by himself or
his friends. To laymen every opening ab(mt the anus which discharges
pus is a fistula, whether it be acute or chronic. The surgeon, however,
must be more explicit; he should not only determine the existence of
a fistula, but its character, it^ origin and its pathological nature. In
all cases of fistula the history of injury, discomfort, pain, and fulness
about the rectum, with or without constitutional symptoms, can be
elicited by careful interrogation. The length of time existing between
such symj)tonis and the examination will detennine in a certain number
of cases whether the sinus shall be termed an abscess or a fistula. All
blind fistulas are practically chrcmic abscesses; when they have existed
for several weeks after having been opened and drained, and show no
tendency toward healing, they may be termed fistulas, but the fact that
an abscess has existed for weeks with insufficient drainage does not
justify the assumption that the condition is one of fistula, ^fany such
will heal at oncte upon proper drainage and treatment being estab-
lished. C'hronicity, therefore, under favorable circumstances for heal-
ing, is the ])athognomonic symptom of fistula.

To examine for fistula the patient should be laid upon his left side
witli the hips elevated, in the exaggerated Sims's posture, and close
attention should be paid to each opening and the intervening tract.

The External Opening, — (Careful observation should be made of all
the external parts. The external opening will appear as an ulceration, a
pouting tubercle (Fig. 120), or a small cicatricial depression near to or re-
mote from the anus; sometimes in submucous fistula it appears as a fissure
between the radial folds of the anus, and can only be seen by separating
the buttocks forcibly; occasionally it will be found closed at the time

FIHTUr.A

litis

of ilie examination, but ulien such ie the ca^e a small rose-colored or
whitish spot coverec] with a thin cicatrix or luucoua-Hke tissue will dis-
close its site. This tissue is very fragile, and can be broken by stretch-
ing the edges apart, or punctured with the end of a probe. After punc-
ture a small drop of pus will generally exude. In tuberculous subteg-
umentari- fistulas the opening may be at the margin or in the midst
of an extensive, ragged ulceration (Fig. 89).

Thf Tract. — Around the margin of the external aperture, if grasped
between two fingers, there will be felt a dense fibrous deposit. By care-
ful palpation one may follow this induration throughout its extent. If

FlQ. laO. — EXTISKAL OpFSTIKO (11

t goes deep into the perirectal tissues the finger introduced into the
ictum will trace it inward and around the anus until its internal o|)en-
^ is reached; sometimes it is necessary to use the fingers of both hands,
B being placed in the recttmi and pressing downward, the other pal-
lating the tissues around the anus. By this means the indurated tract
its direction can generally be clearly determined, and wherever
re ie an internal opening this induration will always lead directly
r by some circuitous niute to it. The tract is not always tubular and
, for large cavities may interrupt its course, and it may be very tor-
tons, almost surrounding the anus, but the expert finger can almost
ways detect the entrance into the rectum.

Tlit Internal Opening. — This opening may be wide and gaping, due
> ulcerative destruction; it may assume the form of a small papilla,
r it may be in the shape of a depressed cicatricial opening just large

366 THE ANUS, RECTUM, AND PELVIC COLON

onough to admit the end of a tine probe. It may also occupy the hist
of one of the crypts. It ought always to be located by digital toucL
When it has once been felt in connection with an external opening
there is no longer any question as to the existence of complete fistuk
To the educated finger irregularities in the mucous membrane, such as
ulceration, elevated papilla^ or depressed cicatricial openings, are easy
of recognition. When this touch is combined with the existence of t
fibrous mass leading from the external opening to the point at which the
internal irregiilarity is felt, the diagnosis is confirmed beyond a doubt.

The probe, therefore, is not necessary in the diagnosis of blind ex-
ternal or complete fistulas. Its use consists in determining the depth
and direction of the pockets and sinuses. In certain cases (Fig. 118) it
would be imj)ossible to introduce the probe into the internal from the
external opening on account of the tortuosity of the tracts; it is only
by incising them step by step that one is able to make the probe enter
the internal aj)erture at all. If one depended upon this instrument for
diagnosis of complete fistula he would frequently determine them to be
of the blind external variety, and openition on this basis would most
surely fail. The probe is very useful, however, in the examination of
fistulas with oj)enings remote from the anal circumference. In these
cases the tract is sometimes so deep and covered by such dense tissues
that it is impossible to make out its course by palpation, and while one
may siitisfy himself by digital examination of the existence of an in-
ternal opening, the direction and extent can only be determined by
the use of this instrument. It is also necessary in those cases in which
the oj)ening is through one of the crypts, for here the valve covers it
up and interferes with the touch. The surgeon should therefore have a
variety of these, some very fine, others of medium size, and still others
large and long; they should all be supplied with flat handles so that one
can always tell in what direction the point is extending when it is
introduced bent upon itself.

Another method of diagnosis of complete fistulas is that of injecting
colored liquids through the (external opening. A syringe tilled with
methylene blue, milk, or some other colored fluid is introduced into
the external opening, and the liquid is forcibly injected into the tract.
If an internal opening exists it is supposed that the fluid will come out
through the rectum. Such will be the case provided the internal oi)en-
ing is not valve-like, in which case the flap may be pressed up against
the side of the rectal wall, thus completely closing it, and only a false
inference can be drawn from the procedure. If too much force be used
the fluid may break through into the cellular tissues around the rectum
and thus do harm. The use of the conical speculum to determine the
internal opening has been already described.

FISTULA 367

We have laid great stress upon finding the internal opening, because
we believe that it is the most important step in the treatment of fistula. It
is the gateway for constant reinfection, and unless it is obliterated we can
not expect the parts to heal, however wide or deep our incisions may be.

The diagnosis of blind internal fistula will depend largely upon the
symptoms present in the case. These have been detailed above, but
it may be worth while to reiterate one particular feature, the remission
and recurrence of the discomfort and discharge which are always asso-
ciated with this type. With the conical speculum one is usually able
to see the opening, or at least determine the site from which the pus
discharges when pressure is made around the anus. Occasionally, how-
ever, there are symptoms of blind internal fistula where the opening
can not be determined. In such cases there may exist what is termed
a complete intrarectal fistula, which consists in two mucous openings
connected by a fistulous tract completely within the anus or rectum;
such a condition is rarely seen in the rectum itself except in cases of
multiple, tubercular ulceration, where two ulcers are connected by a sub-
mucous tract. Within the anus, however, it is not such a rare condition,
and has been termed " binmcous anal fistula "; the term complete intra-
anal fistula would more accurately describe it.

Complex Fistulas. — In complex fistula, while it may be ver}' easy to
find the internal opening, it is not always such a simple proposition to
determine which one of the numerous external openings is most directly
connected with it. All of them are connected with one general abscess
cavity by more or less tortuous tracts, and this in turn is connected with
the internal opening by another narrow channel. It is very easy to in-
troduce a probe into this cavity from either the rectal or cutaneous
aperture, but sometimes impossible to pass it from one opening to the
other. The chief thing to be learned is the course of the tract that
leads from the rectum into the abscess cavity; if this is obliterated and
the constant reinfection through it stopped, the other tracts can be
easily managed. The simplest way to determine this is to open the
cavity freely so that the finger can be introduced, and then pass a
probe from the rectal opening dowTi upon it. All this should be done
at the time of operation, as it requires general anaesthesia. With several
external openings in sight and the internal one located by touch, the
diagnosis of complex fistula is complete. Flexible bougies, the injec-
tion of colored fluids, and various probes are unnecessary to diagnose
this condition. The finger does it all.

Anatomical Character, — The surgeon should always determine the
anatomical character of a fistula before operating or giving an opinion.
The prognosis is very different in the subtegumentary and subaponeu-
rotic types. The distinction, however, is quite simple.

368 THE ANUS, BECTDM. AND PELVIC COUfS 1

In the subtcgHmentary variety there is usually a history of tcij
eligbt conatitiitioQal ilitfturbances, perhaps a thrombotie hemorrhoid or
a furuncle; the tract is generally straight, although they sometimes mo
circularly around the anus (Fig- 131); the induration Is not marked; tiie
external opening is patulous and rarely more than J to 1 inch from th*
anus, the internal is rarely above Hilton's line; the overlying tissues ut
healthy and the diseharj<:e is usually very scanty. The induration of lii*
tract or a probe passed through it can easily be felt by the finger tlirou^-
out its course.

In the submuBcular or subaponeurotic variety there is uanallj i
liiMory of injury or abscess with constitutional diwhirbanees; the tractt
__^_^^_^^_^^_^^^^,,^-^^^^ ■""" i" *" direction^
At< ^mSPEPV^PHVIB^V^ and may extend entire-

ly around the recttun;
the external opening
is a cicatricial depres-
sion or pouting tuber-
cle, generally moTft
than an inch fronv the
imus, and bears no coih
stant relationship to
the internal: the Utter
is usually between the
two sphincters, but
may be much highei^
the induration of the
tract and infiltration of
the .surrounding tisaaaa
ari' vcrj' marked; it is
ollcn difticuU to pass a
piobe from one open-
ing to the other; the
muscular or aponeu-
rotic fibi'rs may be felt between an instrument introduced into the listulg
and the finger in the rectum; the discharge is often profuse, and may be
accompanied by gas and fsecal material. Occasionally these fistulas pafli
directly through the muscles (Fig. 122): in such cases there is grat
hypertrophy of the sphincter and marked constipation.

Origiit. — It is a matter of importance for the surgeon to determine
not only the existence of u fistula and its anatomical character, but also
if possible its origin. Many fistulas originate in other organs than the
rectum.

A case reported by the writer (N. Y. Med. J., .luly 1, 1893) showed

tiie fallacy of concluding that a fistulous tract ia connpctfd with the
I rectuin simply because it closely approaches this orj^n. In this in-
l stance (Fig. 133) the (is-

tnia almost entirely sur-

IV /

rounded the roctuiii, and

o[>ened externally U|K)n

V /

the right side at a distance

of about -i inches from the

anus. After laying it open

ff .j^^

and following it first

\^0^^F

around the right side to

jpIP^

the anterior conunissurc.

and then around the po.i-

terior commissure and on

the left side forward in

the perinffiiim to the junc-

ture of the scrotum, it wns

diswnered that what was
apparently an ano-reelal

.,^

was really a urethral fis-

"^122

tula which had no connec-

'-'" " '■"

E^TIMSM >,■hr^. r Mr

tion whatever with the

I>rniMi Iron

I'""''""'""'" ■''-■'■""""■

rectum. An ano-rcctal fistula

the

ract of wl

ieh is very similar to this

is illustrated in Fig. 124.

Fistulas luny nisi, ori^^inaii

ill a

suppurating ovary or broad ligamenl

and open very close to

the margin of the

anus. These have no

connection with the

intestinal canal.

Necrnaia of the

f^-

bones of the pelvis,
psoas abscess, and tu-
bercular disiiascs ol

'J t

the vertebrip may all
result in fistulous

. ' L^

uponings around the
blind extermil fistula.

Fio. 1a3.-T»AL-T or Uai)(*HY Fiwi-

A ..<

'X »iuu..^Tri

In one interesting

Till AN<.-aK<-T*L VilK

try.

case which the writer

I flaw some years ago. a fistulous tract ran up posterior to the rectum,
«nd the probe impinged upon the mucous membrane at a height of

THE ANUS, RECTUM, AND PBLVIC COLdlT

about 2^ inches; on n^itk-ning the tract, however, it was found Uut
the condition was due to a deniioid cyst whicli had ruptured in the Uro-
rectal space, causing an ahscess in this location. Tlie remains of the
cyst were removed, and what had been supposed to be a chronic fistuli
rapidly healed.

Where the fistula originates in perforation or stricture of the rectum,
one should be able to determine these facts by digital and instrumenlil
eiCiLiuination. When it is due to infection through the lymphatic chan-
nels, the abrasion or ulceration through which the infection first i)c-
curred may heal and leave bo slight an evidence of its existence that it
will be impossible to determine the origin. The patient's previouB his-
tory as to diseases of the urethra, bladder, or generative organs should
bo investigated. Wherever a urethral stricture has existed, a deep
urethritis, or evidence
of pelvic ioflammation
in women, one niaj
suspect the origin of t
fistulous tract to be
other than intrarectal.
In a case uf peri-
ri'ctal abscess due lo
perforation of the
deep urethra with
snuiU filiform bougit
there was never any
urinary extravasation,
and yet within a fe»
hours after the intro-
duction of Ihc instrument a chill and fever followed, and a large absccM
developed, the symptoms being chiefly referred to the rectum. A deep
perineal incision was made, and a quantity of pus let out from an absccK
which seemed ready to burst into the rectum. The fistula that resnlled
from this abscess continued for some time, but was finally cured by
drainage and thorough dilatation of the strictured urethra.

Fistulas which result from carcinoma tind syphilitic stricture of the
rectum usually occur in such late stages of the disease that they are a
matter of small im[>ortance compared with the original disease. If the
diagnosis of cancer has not been made and proper treatment insti-
tuted before the occurrence of the fistula, one may practically say
that it is useless at this time to attempt any radical ioterferencp-
The origin of the fistula, therefore, will always have an important
bearing upon its treatment, and search for the same should never Itfi
neglected.

FISTULA 371

Pathological Nature of Fistula. — Having determined the pres-
ence, anatomical character, and origin of a fistula, its pathological nature
should be learned, as it is impossible to decide upon the treatment or
give a correct prognosis until this has been done. In those cases due
to carcinoma or fibrous stricture, only radical operations can promise
any penuancnt relief. On the other hand, those due to simple infection
and inflammatory processes may all be cured by minor procedures. The
rectum should be thoroughly searched for evidences of malignant or
specific disease; and the history should be investigated with regard to
typhoid fever, dysentery, and pneumonia, as abscess and fistula may fol-
low all of these conditions. The important pathological factors, how-
ever, are tuberculosis, syphilis, and cancer.

Tubercular Fistula, — To distinguish tubercular from non-tubercular
flstulas is said to be very easy, but it requires exact and scientific ex-
amination. While there are certain general characteristics of tubercular
flstula, one may be easily misled, when it is the primary manifestation
of tuberculosis, by the absence of constitutional and general symptoms.

The external opening in this variety may be large or small. Where
it originates in a perianal tubercular ulcer, it will appear as an irregular,
wide aperture with red undermined edges, and a base of pale, proliferat-
ing granulations. Where it originates in infection carried along the
lymphatic channels that results in an abscess which opens upon the
skin, the external aperture may be surmounted by a small, elevated, nip-
ple-like tubercle with an opening in its center. Always in such cases,
however, the skin about the tubercle will be undermined.

Some stress has been laid upon the long silky condition of the hair
around the anus, the club-shaped finger-nails, and the general physiog-
nomy of the patient, his voice, complexion, etc. All these symptoms
belong to constitutional tuberculosis, but they do not prove the fact
that the fistula itself is tubercular. One may occasionally see a simple
fistula in a tuberculous individual. Loss of flesh may be produced by
any irritating disease of the rectum, whether it is fistula, ulceration, or
fissure; all catarrhal diseases of the rectum and sigmoid and all in-
flammatory conditions of the lower end of the intestinal canal interfere
with the digestion, appetite, and reparative processes, and may result
in loss of flesh, so it is not a conclusive symptom of the tubercular nature
of a fistula.

The discharge from a tuberculous fistula is generally small in quan-
tity, thin, and milky white; it is rarely a thick, creamy pus. The indu-
ration about the tract of tuberculous fistula is greater, as a rule, than
that about the simple varieties.

Pain and sensitiveness to touch are markedly absent in tubercular
fistula, but this is not invariably so. Night-sweats, interrupted sleep,

372 THE ANUS, RECTUM, AND PELVIC COLON

and evening elevation of temperature may be seen in these cases; but
when they are present, genito-urinary or pulmonary tuberculosis is gen-
erally found to exist. While all these symptoms may lend probability
to the tubercular nature of a fistula, there is but one absolutely certain
method to diagnose it, and that is by microscopic examination and
culture tests. Examination of the discharges for the bacilli is often
misleading; very frequently one fails to find them in the pus, whereas
they may be abundant in scrapings of the granular tissue from the
fistulous tract, or in the perifistulous tissue after it has been dissected
out. Heredity and personal histor}', the general phenomena and local
appearance of a fistulous opening, will frequently enable one to predicate
the existence of tuberculosis, but the fistula itself can not positively be
called tubercular without the corroborative evidence furnished by these
means. It is important, therefore, that one living at a distance from lalx)-
ratories should prepare himself to make such examinations, and be able
to decide with a certain degree of promptness the pathological nature of
any fistula with which he has to deal. One should not presume upon a
negative result in physical examination as proving the non-tubercular
nature of fistula, nor should he conclude that it is tubercular because
there is a hereditary taint. The fistula should be judged from its
owTi tissues. Probabilities should not be relied on where knowledge is
obtainable. In tuberculosis and carcinoma this can be done, and no
fistula should be treated without it. In syphilitic fistula the histological
examinations are not so certain, though they may confirm the clinical
evidences.

The diagnosis of urinary fistula may be made from the history of the
case, the character of the discharge, the preponderance of urethral symp-
toms, the induration in front of the transversus perinei muscles, and may
be corroborated by the administration of a capsule of methylene blue by
the mouth, as after urination the fistulous tract will be stained blue.

Prognosis. — The probable outcome of any given fistula will depend
upon three conditions: first, the pathological nature of the fistula; sec-
ond, the constitutional condition of the patient; third, the amount of
tissue involved.

It is customary in books upon rectal diseases and general surgery
to describe fistula as a condition most amenable to treatment. As a
matter of fact, however, a very large percentage, if not a majority of
the cases of fistula operated upon in hospitals and treated by general
surgeons, are failures so far as cure is concerned. A search of the hos-
pital records reveals the fact that while nearly all the cases of fistula
treated are said to be imjn-oved, less than 45 per cent out of 2,196 cases
collected are even claimed to have been cured. These statistics do not
distinguish between the different varieties anatomically or pathologic-

FISTULA 37a

ally, and therefore no positive conclusions can be drawn from them.
It is reasonable to suppose, however, that those of the simple subtegu-
mentary type were all cured. Assuming this to be true, the percentage of
failures in the other classes will be largely increased. If these patients
had been cured there is no doubt that they would have been entered so
upon the hospital records, and therefore it is concluded that the treat-
ment of this condition in general hospitals is far from satisfactory.

There is no more difficult or disappointing condition to treat, and
in giving a prognosis one must always bear in mind the three conditions
mentioned above. Why fistulas fail to heal has been already discussed.

Cases of spontaneous cure have been reported by Bennett, Ailing-
ham, Bodenhamer, Eklwards, Ribes, Velpeau, and others. Bodenhamer
(Med. Record, N. Y., 1891, vol. i, p. 254) has related a case in which
he examined the patient and determined the existence of a complete
ano-rectal fistula but instituted no medical or surgical treatment. The
patient died from pneumonia about one year after this examination, and
the autopsy showed a simple cicatricial cord throughout the old tract
measuring about 3^ inches. It had thus been obliterated without any
treatment whatever.

The writer has seen 2 cases of complete subtegumentary fistula heal
within a short period after examination with a probe. In these cases
the tract had existed in one case three weeks, and in the other about
two months. The introduction of the probe seemed to start up a healthy
granulation, and thus induced healing. A number of cases of tliis kind
has been reported.

While such facts are interesting, it would be trifling with a patient's
confidence to hold out any hope of such a result except in the rarest
instances. The length of time required to cure a fistula is very variable.
When it can be dissected out and the wound sutured, if primary union
takes place the condition will be cured in about two weeks; but when
it is treated by the open method, tlie time varies from two weeks to
several months; three to six months is no unusual time for the healing
of extensive fistulas, even where the operation has been perfectly ])er-
formed. While the length of treatment necessary can not be predicted
in any given case, eventual cure can be confidently promised in uncom-
plicated, benign, and non-tubercular fistulas. So far as life is con-
cerned, if we except the malignant type, the prognosis is always good,
even in the tubercular variety, if unwise interference is avoided. This
brings up the subject of the advisability of operating in such cases.

Operations in Tnbercnlar Fistula. — Here again the distinction is
made between a tubercular fistula and a fistula in the tuberculous. It
seems unnecessary to discuss the question of radical operation for fistula
in well-established cases of pulmonary tuberculosis. Where it is of the

374 TUE ANUS, RECTUM, AND PELVIC COLON

complex variety and associated with much pain and great discharge, thug
occasioning exhaustion and excessive wear upon the nervous system, a
certain amount of inten-ention (just suihcient to relieve these symptoms)
may he justifit^d, hut it should not be undertaken with the hope of curing
the fistula. The majority of j^atients in this condition will succumb to
the j)ulinonarv disease before healing of the local lesion can be obtained
It may be set down, therefore, as an axiom that fistulas in well-developtJ
cases of j)ulmonary tuberculosis should be interfere<l with as little as is
compatible with local comfort. They usually cause verj- little disturb-
ance if j)roperly drained, and the shock consequent upon operations, the
loss of blood however slight, the influence of general amesthesia however
skilfully administered, add nothing to the strength of the patient. His
well-being in this disease depends altogether upon his power of resist-
ance to the invasion of the bacilli. Whatever weakens this power of
resistance decreases his hold upon life, and should be avoided as far as
possible. ()p(»rati(>ns u})on this class of castas have brought the ojK^rative
treatment of fistula into disrepute, and one should therefore, as a rule,
abstain from thcMu in cases of established jnilmonary, genito-urinary. or
intestinal tuberculosis.

In the matter of tubercular fistulas, however, the subject is a|>-
proachecl from another point. Here there is a localized tuberculosis,
and it is a (piestion as to whether these foci of disease can be eradicated
or not. If the radical removal of the infected focus is feasible, no sur-
geon would hesitate for a moment to say that it should be done as quickly
as possible, |)rovided that the patient is othenvise healthy. Fonnerly,
operations u|)on fistula were opposed by many surgeons on the ground
that they were salutary in that the discharge carried off the infectious
germs: that the bacilli circulating in the blood ftmnd at this point a
convenient exit from the body, and that the closure of this would onlv
dam them up in the system and thus cause infection elsewhere. With
the modern views of pathology such a doctrine is no longer tenable.
There is no reason to sup|)ose that a purulent discharge from a fistula
in an(» is more sahitary tlian one from tubercular glands or bones, and
vet every surgeon tonlav advocates the removal of these. Radical re-
moval, however, and not ])artial, is what is done in these cases. For
some years the author lias o|)])os(m1 the open operation for tubercular
fistulas u])on the ground that an incision into the perifistulous tissues
only opens the channels of absor])tion to infection by the tubercle bacilli
l)resent in th(» tract: and if a tubercular fistula must be operatetl u}>on
by the simj)le method of incision it had far better be left to its own
course.

If one will refer to tlie section upon the pathology of tuberculosis he
will observe that around these fistulous canals, outside of the lining

3T5

layer of ^ranuiatioD, tliore iii a gradually increasing fibrous or cicatricial
wall throughout their exient (Fig. 125). It will be observed also that the
further one passes from the canal outward into this cicatrieial tissue, the
fewer are the tubercle bacilli and giant-cells, and they disappear alto-
gether in the densest portion; this condition exhibits an effort upon the
part of Xature to protect herself against the invasion of the patliological
germs by a well-defined, limiting wall, which, if the fistula be properly
drained, will limit the disease in the large majority of instances, at
least for long periods. Break down that wall by incision or deep curet-
ting, and the lymphatic
^circulation is opened

for the admission of *>

this ^Hrulent bacillus.
Tliese facts can not be

-disputed, but many *

competent surgeons
and writers still advo-
cate this method of op-
eration because a large • .^ -^
number of supposed tu- f ' ^
liercular fistulas have i

been cured by it with- 1

out the development of
generalized tuberculo-
sis. In the large ma- \-
jririty of ihese eases the *>■-
tubercular nature of
the fistula has not been ■^— ^'

demonstrated. But, ad- ""■ '*'■ '"* ,i.„„T„a„ mumi

nitting that all the

cases reported were tuberculous, they do not disprove the possibility of
generalization taking place, and the relief obtained has not justified the
risk. Hartmann's 19fi cases do not prove anything contrary to this
theory, for he either dissected out the entire tuberculous focus and
united the healthy tissues by sutures, or he opened the fistulous tract
with a Paquelin cautery, thus sealing up the lymphatics and destroying
the tubercle bacilli by cauterization with a platinum knife heated to
» white heat. According to his own statements the cicatricial wall was
never broken down, nor were the healthy pcriftstulous tissues opened
even by the heated knife. Those are very different procedures from
laying the parts open and incising the fibrous wall in all directions with
i'knife: they attempt to remove or destroy the pathological element en-
tirely, and this is in keeping with our proposition.

370 THE ANUS, RECTUM, AND PELVIC COLON

On the other hand, there are a certain number of positive facts which
show the danger of laying o[)en these tubercular listulas by the knife
and curetting their cicatricial walls, as is advised in the operation of
Salmon. The writer himself has seen five cases in which tuberculosis
either of the lungs or of the ])eritona}um rapidly followed operations for
tubercular fistulas. In one case an Italian boy, who had suffered from
a fistula for over two years, was brought to the Polyclinic Hospital
November 10, 1897, and was examined by Dr. Page, one of the mo&t
expert diagnosticians of this city. No evidence whatever of pulmoDanr
tuberculosis could be detected. He had no kidney, liver, or bladder
symptoms which would indicate involvement of these organs. The fis-
tula was a typical tubercular one in its appearance, and consisted of &
straight, narrow canal leading from a point about 1 inch from the nuirgin
of the anus, upward and inward through the external sphincter and the
mucous nuunbrane into the rectum about ^ an inch above the ano-recUl
line. Tubercle bacilli were found in granulations scraped out of the
tract. The fistula was laid open, curetted, and cauterized with (^alvert's
carbolic acid. The* cicatricial tissue surrounding the tract was then
incised in several directions in order to hasten its absorption and to
establish healthy granulation. The wound granulated and proceeded
to heal as promptly as in ordinary fistulas. At the end of six weeks,
however, the })atient developed acute pulmonary tuberculosis and died
a little over four months after the oj)eration. In the meantime the
fistula had pcM-fectly healed.

Another instance was in a patient referred to the WTiter by Dr.
Sherwcll, of Brooklyn. lie had suffered from irritation of his rectum
for s(»veral months; there was always a certain amount of discharge, but
never any external opening which could be discovered; the condition
gave him no pain except after fa'cal passages, which brought on symp-
toms of fissure in ano. An examination of the lungs, kidneys, bladder,
prostate, and the other organs failed to reveal any evidence of constitu-
tional diseas(\ The rectum and sigmoid showed nothing pathological
save a small ulcer in the j)osterior commisvsurc about } of an inch from
the cutaneous margin. From this ulcer there extended downward and
outward a fistulous tract to the (^xtent of about ^ an inch. The ulcer
was crenated and irregular in shape, the edges undermined, and dis-
charged a scant sero-])urulent fluid in which no tubercle bacilli could
be found. The fistulous tract and the base of the ulcer were indurated
but not nodular.

He was admitted to the Polyclinic Hospital on October 5, 1900. On
October Gth an opiTation was performed by first incising and then dis-
secting out the ulcer and fibrous tissue. As the inflammator}' process
did not appear tubercular, and was very shallow, it was concluded that

FISTULA 377

the patient would suffer less from spasm of the sphincters if the wound
were left open to heal by granulation. He never had an unfavorable
symptom while in the hospital, and on October 13th the wound looked
so healthy and the patient felt so comfortable that he was allowed to go
home, with instructions to present himself for observation occasionally.
On October 16th he felt a sensation of chilliness and malaise, and later
he was seized with a distinct rigor. From this time on he was never
without some temperature; he mpidly failed in strength, and finally
died from tubercular peritonitis on January 5th. The patient, according
to his doctor and family, had never had a symptom of peritoneal trouble
before tliis operation. Microscopic examination of the specimen re-
moved revealed no tubercle bacilli, but there were some giant-cells sur-
rounded by euibryonic tissue which the author believes proved the
tubercular nature of the ulcer.

A third case, W. D., aged twenty-seven, presented liimself at the
clinic on January 2, 1901, with the history of having suffered from a
perirectal abscess some two months previously. This had failed to heal,
and caused him considerable annoyance. Examination showed the exist-
ence of a horseshoe fistula opening externally upon one side and enter-
ing the rectum at the posterior commissure about J an inch above the
margin of the anus. The fistulous tract upon the opposite side was
not open externally but discharged through the rectal opening. A
careful examination was made of the patient's lungs, throat, kidneys,
bladder, and prostate with negative results; he had no temperature, no
cough, and no symptom of pulmonary disease at the time he was ad-
mitted to the hospital. The discharge from the abscess was examined
by the microscope and no tubercle bacilli were found; the culture
test was not made. An effort to reduce the discharges by irrigation was
unsuccessful, and therefore it was advised that the tract be opened. This
was done February 1, 1901, under the strictest antiseptic precautions.
The parts were dressed with ichthyol and glycerin after having been
washed out thoroughly with bichloride solution. Bacilli were found in
a section of tissue removed at the time of operation.

Xo unusual symptom followed save a slight elevation of temperature
during the first twenty-four hours. After this the patient felt i)erfectly
well and began to improve in his looks, appetite, and general condition.
In four weeks the wound granulated and was filling up, but the patient
began to lose his appetite and feel exhausted, especially in the morning.
On February 10th he had a marked hapmoptysis which nearly cost him his
life, and from that time forward he rapidly developed tuberculosis of
the right apex with all the concomitant symptoms. At the sniiio time
under antiseptic dressings and treatment the fistulous wound on one side
practically healed, but on the other, after healing, it broke down and

378 THE ANUS, RECTUM, AND PELVIC COLON

had the typical appearance of a tubercular ulcer. He was taken from
the hospital and it was reported later tliat he died within six months.

It may be said tliat these cases are accidental, and that the constitu-
tional symptoms would have manifested themselves had no operation
been done, but there is no ])r()of of this. In the first case the patient
had carried his listula for two years without any pulmonary implication,
and yet developed it within a short time after operation by the open
method. In the second cjise the patient had suffered from his rectal
ulceration or fistula for over six months without any constitutional impli-
cation, and yet he developed tubercular peritonitis within two weeks
from the time of the open operation. In the third case the period dur-
ing which the patient had suiTered from fistula was no doubt brief, but
at the same time it was considerably longer than that between the opera-
tion and the development of the pulmonary symptoms.

Quite a number of patients suffering from pulmonary tuberculosis
have b(^en seen who are very positive that they never had any cough or
pulmcmary alfeetion until after operative interference with their fistulas,
and it is well known that the above cases can be supported by many oth-
ers Reported in medical literature. The results, therefore, do not justify
tlie risks of oj)en ineisiim.

Wliere the tubercular fistula can be entirelv removed, and the wound
close<l by innnediate suture, the probabilities of complete cure are very
encouraging; but when the fistulous tract is so deep and tortuous, or so
great in extent that innnediate closure is impossible, operation by the
heated knife is to be preferred. In the majority of instances the patient
will be more benefited by providing necessary drainage and cauterizing
the lining membrane of the fistulous tract than by laying it entirely
open; but even with the cautery the surrounding cicatricial wall sliould
not be broken down unless complete excision and immediate suture can
be j)ractised.

Trratfnrnt. — The treatment of fistula consists in the obliteration of
the chronic, suj)j)urating tracts, either by the process of granulation or
by excision with immediate suture. The first method is that which is
generally em])loyed. The means of inducing this granulation may be
described as the conservative and radical.

Cnnservaiive or Xon-openifive Methods. — By these terms we do not
mean a method without any incision; every fistula is practically a chronic
abscess, and it is hopeless to attempt to cure them without establishing
C()m])lete drainage; an incision to accomplish this is therefore always
necessarv.

In simple, blind external fistulas, complete drainage with curettage
or cauterization of the tract and dilatation of the sphincter will alv'ays
result in a cure without further operative interference. Where it does

FISTULA 379

not, one may very reasonably conclude that there is some connection
with the rectum through which reinfection is taking place, or a patho-
logical condition of the fistula itself, which destroys healthy granulation.
In a number of blind external fistulas cure may be effected by distending
the cavity with a saturated solution of nitrate of silver (9G0 grains per
fluid ounce), and after this has remained for two or three minutes the
parts are cocainized, the opening is enlarged so as to give perfect drain-
age to the cavity, and the sphincter is stretched gently either witli the
fingers or with the rectal dilator.* Thorough dilatation of this inuscle
is better, but it can not ordinarily be accomplished without general
anaesthesia. Hy the use of nitrous-oxide gas or ethyl chloride it is
possible to perform this operation in the clinic upon walking cases, but
in private practice one would scarcely dare giv(» even these gen(M'al
ana'sthetics and allow the patients to go home imniediatoly afterward.

Bennt'tt states that he has cured a large number of eomj)lete fistulas
by the injection of concentrated solutions of nitrate of silver into them,
and (ioodsall and Miles advocate this nu^thod of treatment in all eases
in which the inner opening is above the internal sphincter. The dis-
tention of the cavity by the solution of silver should always be followed
by the enlargement of the external opening in order that the necrosed
tissue and increasing discharge due to that cauterant may have a free out-
let. Formerly it was a practice to inject these tracts with erpial ])arts of
iodine and carbolic acid, which gave some very satisfactory results. Pure
tincture of iodine and tincture of rhatany, soluticms of copj)er sulphate,
the solid stick of nitrate of silver, and many other cauterizing agents
have bi*en employed from time immemorial in this method of treat nu*nt.
On the whole, however, the saturated solution of nitrate of silver is the
most satisfactorv. It is better than the solid stick, because it reaches all
the diverticuli and tortuous tracts, whereas the stick only apj)lies itself
to the accessible portions of the abscess cavity, and it is very likely to
break off when it is introduced into a deej) tract. In narrow, suV)tegu-
mentary fistulas, both of the com])lete and blind external variety, cm res
may be efri*cted by the introduction of a probe upon which nitrate* of
silver has been fused. The discharge and irritation are increased for a
few days following this treatment, after which healthy granulation
springs up and the tract becomes obliterated. After the injection or
application of the nitrate of silver, the slough which it produces will
all come away in about ten days, and ordinarily a healthy grjinuhition
will be established. If this is not the case, the application sliouhl be
repeated. AMiere the granulation is established, Iiowi'ver, the jii)i)lie;i-

* Powell advocates the use of pure earbolic acid instead of nitrat*- of >ilvjT. iirMl
claims to have obtained excellent results from it (Amur. Siir^. and (iyutvon].. April.
1902).

380 THE ANUS, RECTUM, AND PELVIC COLON

tion sliould not be repeated for two or three weeks. It niay be necessaiy
to inject tlie solution three or four times at such intervals before a cure
is acconi pi Lulled.

When the fistula is of the complete variety, it is well to inject a little
sweet-oil into the rectum before the nitrate of silver is introduced into
the fistulous cavity, in order to prevent the drug from irritating the
mucous membnine if it should pass through into the intestine. Goud-
sall and Miles, whose large experience gives weight to their opinion.

Flu. 126.— Allinuham's Lioatukk-carbikr.

in speaking of this method of treatment for fistulas opening into the
rectum above the internal sphincter, siiy: " Wlien after repeats applica-
tions the sinus still remains imhealed, it is better to leave it alone than
to incur the risk of probable incontinence by the division of the internal
sphincter for the cure of the fistula. In fact the patient should be
urged to tolerate the persistency of his fistula rather than take the risk
of loss of the power of control over the contents of the rectum.'' This
is undoubtedlv a too conservative view; in cases in which radical excision
with inmiediate suture is possible, there is no reason why the internal
sphincter sliould not be just as successfully sutured as the external.
The advisability of testing the methods of local treatment before resort-
ing to an operation which involves the cutting of the sphinctere can not
be contested; tliey not only succeed in many cases, but they possess the
advantage of finally decreasing the amount of discharge and reducing
the size of the fistulous tract to such an extent that, if they fail to cure,
the parts are in a nmch better condition afterwanl for radical operation.
In the treatment of complete fistulas by this method, it is important
that the stools be kept well formed, because if thin and water}' they will
escape through the internal opening and prevent healing.

It is the practice of certiiin itinerant specialists to wash out the
abscess cavity with ])eroxi(le of hydrogen until the effervescence caused
by it has ceased. After this they irrigate the fistulous cavity with a
solution of bichloride of mercury, carbolic acid, or nitrate of silver, and
repeat this treatment every second or third day. When the discharge
has been largelv controlled, thev dilate the mouth of the fistula with
forceps or lay it open under the anjcsthetic action of cocaine, and thus
obtain free drainage. The method is rational, and there is no doubt
that tliey succeed in curing a great many cases by this method.

Where these conservative methods fail to effect a cure after six or
eight weeks' trial one should then attempt radical operation. Before

FISTULA

381

wiofr lliia, howpTer, in fact before attempting any treatment wlintover,
one should satisfy himself absolutely with regard to the patholugical
natun- of the fistula, and if tuberculosis, eyphilig, or malignant disease
exists, he fihould be guided by the principles laid down in the preceding
section iif this ehapter.

The Lii/alure. — Tile Ireatment of fistulas by the use of the ligature
is ctaseeil by many among the cdnservative or non-operative methods.
The only ground for this is in the fact that the cutting is done without
a knife and there is no ha-morrbage. It accomplishes exactly Ihe same
ilivision of tissues as is done by incision, only in a much slower and
more painful manner. It has been employed since the time of Hip-
pocrates. Silk, linen, and elastic threads have all hevn used, but at
present only the nibber ligature is employed; this was liret utilized
for this purpose by Ijcc and Ilolthousfc; Dittel, of Vienna, afterward
employed it, and Allingliara and Bodenhamer adopted the niethiHl
after him.

The principle upon wliich the method rests consists in the cut-
ting through of the overlying tissues by the continuous contraction
of the elastic thread. It
was at one time supposed
thai healthy granulation
was established in the fis-
tulous tract and followtid
the ligature out as it cut
its way through by slow
attrition, thus obliterating
the tract at the same time.
This claim has been aban-
doned, however, and all
who employ this method
now use the small, round,
solid-nibbcr ligature. Il is
psssdl through the listu-
lons tract either with for-
ceps or by a specially de-
TiBcd inetmment (Fig. 12fi)
known as the ligature-car-
rier. Where the fistulous

traet passes beneath the skin an incision should be made through this
tissue, for where this is not done the pain is almost unbearable-
Having passed the ligature through the fistula, a small metal shield
or perforated shot is passed over the two ends and fastened by pressure
with a strong forceps while the rubber is fully extended (Fig. 137). The

382 THE ANUS, RECTUM, AND PELVIC COLON

advantages claiiiuMl for tliis mothod are that it occasions little pain,
does not confine tlie patient, is free from the dangers of hemorrhage,
and a certain number will submit to it who absolutely refuse to ht?e
any cutting operation done. Allingham says: " Those who find any
difficulty in getting the ligature to cut quickly and painlessly are
ignorant of the proper method of applying it "; but unfortunately he
does not give any description of this proper method. In the author's
experience it has proved successful in curing the few cases in which it
has been apj)lie(l; but, so far as the patient's going about with it or suf-
fering no j)ain is concerned, the claims of its advocates can not be sub-
stantiated. The experience of every j)atient that has been treated by
this method is that they have sulfered greatly and often been confined
to their beds while the ligature was cutting through; in two cases it has
been necessary to remove it on account of the pain. The only real
advantage which the nietliod s(»ems to possess over that of incision con-
sists in the absence of hiemorrhage. With the numerous instruments
at one's command by which bleeding can be controlled, this recom-
mendation carries little weight except in cases where the internal oj)en-
ing is very high in the rectum. One never sees at the present day
uncontrollable liaMuorrhage in operations for this condition; but. for
the sake of argument, admitting that the ligature does obviate this
possible danger, this advantage is more than counterbalanced by the
objections to it.

In its employment no antiseptic precautions are taken, and there
is no guard against infection of the freshly cut tissues from the bacteria
always present; it is followed by a dense, hard cicatrix; it only accom-
plishes after days what can be done with a knife or thermo-cautery in
a few moments: and finally, after the fistulous tract has been cut through
by this method, it will often be necessary to lay open and enlarge lateral
tracts with the knife or scissors. On the whole, therefore, if the tissues
intervening between the rectum and the fistulous tract are to be cut
through at all, it seems preferable that it should be done as rap-
idly as possible under antiseptic precautions and circumstances which
will allow the whole sup])urative tract to be laid open and treated
at one time without having the operation divided into two or three
sittings.

Tf the application is technically carried out and the ligature alwajfS
passed through the internal ]>athological opening, there is no doubt that
it will result in a cure in the large majority of cases. The finding and
laying open of the paiholof/icol irad leading into the rectum is the secret of
success in the treatment of fistula, whether it is done hy the ligature, hnifiy
ecraseur, or cautery. It is difficult, sometimes impossible, to trace long,
tortuous tracts with the ligature carrier, and puncturing the rectal wall

FISTULA 383

at the highest point of the cavity ho as to make a way for the tliread is
Kure to result in failure here, just as it does in op«ration by incision,
because a part of the fistula is left untouched ( Fig. 138).

It has been claimed that ffpcal incontinence is much loss likely to

^ occur from this method thau from operation by incision. Incontinence
lepends upon the amount of muscular tissue cut and the imperfect s

ijuare-

position of the fibers
ly across by a sharp
knife it will be k>ss
likely to occur than if
it is done by the crush-
ing process of a liga-
ture, for the widtb of
the cicatrix will be
less. There is neither
fact nor reasoniihlc
theory to Pubstanrlim-
this claim for the li;.'a-

■^re.

^H The writer is well

Bnrare of the fact that
A Duml)er of fistultm
have been cured by
the ligature which had
been unsuccessfully
operated upon by iu-
cision. The explana-
tion of these eases lies simply in the fact that the operators found the
[Mithological opening and cut it through with the ligature. Had the
original operators found this orifice and cut it through with the knife,
the operations would have been equally successful. It is simply a ques-
tion here to find and remove the source of infection by laying open and
draining the entire pathological tract.

In those cases where the internal opening is 3 to 4 inches above the
sphincter muscle, the elastic ligature is a safe and reliahle method of
laying open the tract. The advisability of opening such a tract at all,
however, is by no means settled. As quoted above, Goodstdl and Milea
absolutely oppose such an operation; Qn^nu and Hartmann believe that
incision is a dangerous procedure under such circumstances; they hold
I tbat complete excision with immediate suture is preferable, and the
Kasthor agrees with them.

FiKlvhilomtf. — One other conservative method of treating fistulas
Aould be mentioned. It consists practically in scarifying or incising

t Thact

384 THE ANUS, RECTUM, AND PELVIC COLON

the walls of the fistulous tract. It may be done with a blunt-poiDted
tenotome or the fistulotome of Mathews (Fig. 129). Fistulotomy is ap-
plicable only to comparatively straight and narrow fistulas. It is based
on tlie siime principle as internal urethrotomy, i. e., an instrument carry-
ing a concealed knife is introduced to the deepest portion: the knife is
then thrust out and with a quick motion it is withdrawn, thereby incising

Fui. 12t». — MaTIIKWh's FliHTLOTDME.

the walls of the fistuhi. This being done frequently scarifies the tract
in all its circuiuforcnee. The operation may have to be repeated several
times before a cure is obtained.

The claims made for this procedure, that it dissipates fear, avoids
ha'inorrhage, does not involve the sphincter, and requires no detention
from business, are chimerical and likely to mislead the inexperienced.
Blind incision inlo vascular areas can not possibly be free from the
danger of haemorrhage, and being made through infected tissues it is
also likely to induce sepsis. No adequate drainage is established by it,
and it may be foUowed by burrowing or collateral abscesses. Its field
is very limited, it requires a special instnmient, and, finally, its n^ult*
are not comparable to treatment by nitrate of silver, because it does not
improve the condition of the parts for radical operation if this should
become necessarv.

ft'

Operative Treatment of Fistula. — Of the operative methods, the three
which deserve consideration are inrisinriy excisiotiy and excision mth im-
medinle auiure.

Each of these should be undertaken with the most perfect surgical
technique. The patient should be as carefully prepared and the rules of
aT}tisepsis as perfectly followed as in any major operation. Antiseptic
methods are em])loyed here because the field is already infected and
ase])sis is impossible.

The Prpjmrniion of ihe rafient, — The best results-will be obtained in
those eases in which the iistula has b(»en treated by peroxide of hydrogen
and nitrate of silver until the ])urulent discharge has practically ceased
and the cavity contracted as much as possible. When the time and cir-
cumstances of the patient permit, this should always be carried out
The actual preparation of the patient for operation is practically the
same in all the different methods. The bowels should be thoroughly
cleaned out and the patient j)ut on a limited nitrogenous diet thirty-six
hours before the operation. Purgation should have ceased entirely be-
fore the operation is undertaken.

FISTULA 385

Along with the preparatory treatment one may institute an attempt
at intestinal antisepsis by the administration of beta-naphthol, salol,
boric acid, or sulpho-carbolate of zinc. While it is impossible to obtain
absolute asepsis of the intestinal tract, there is no doubt that cases
treated by this preliminary preparation have less intestinal disturbance
and sepsis than those operated upon without it. On the evening before
operating a large soapsuds enema shoidd be administered, and when this
has been ])assed the j)erianal region should be carefully shaved, scrubbed
with green soap, and dressed with absorbent gauze moistened in a solu-
tion of bichloride of mercury (1 to 2,000). This dressing should be kept
moist and retained in situ until the operation begins. Two hours before
tlie operation itself an enema of about 1 pint of borie-aeid solution
shouM be given.

The aniesthetic employed will depend upon the condition of the
patient and the extent of the fistula. Where it is proposed simply to
incise it, the parts may be amrsthetized by the hyj)oderniic injection of
cocaine; in the majority of subtegumentary fistulas this is all tliat
will be necessarv. In cases where there are extc^usive fistulas that
require large dissection and dilatation of the sj)hineters, general anaes-
thesia is much more satLsfactorv. Where it is not contraindieated
by cardiac conditions, chlorofonu is preferable to ether in operations
upon the rectum on account of the slight amount of nausea and retch-
ing which follow it. Ethyl chloride or kelene is an excellent anaes-
thetic for short operations, and as an adjuvant to the administration
of ether it is very useful, but it is not satisfactory in extensive opera-
tions on account of the fact that it does not rehix the muscles suffi-
cient 1 v.

A very satisfactory method is s])inal cocainization, because there is
less oozing from the vessels, and after the first few minutes wlien nauscii
exists the patient is more quiet, the sphincter muscles more relaxed, and
there is absolutely no pain; furthermore, in this method of anaesthesia
the rectum sometimes becomes insensitive before the feet and legs. Xo
vomiting or straining to dislodge the dressing follows it, and the anal-
gesic effect continues for several hours afterward, thus contributing to
the comfort of the patient. Tliere is generally some lieadache on the
following day, but this is not very severe. The remote effects of this
method have not yet been determined, and consequently it is not recom-
mended unconditionally.

After the patient has been anaesthetized the sphincters should be
thoroughly stretched. By this means whatever fluid or faecal material is
retained in the rectum can be removed and tlie organ cleansed. At the
same time any ulceration or internal fistulous opening can be seen,
and the operation will thus be simplified. It is important that the
25

386 THE ANUS, RECTUM, AND PELVIC COLON

stretching should be done before scrubbing the outside tissues, because
if the latter is done first, when the rectum is stretched open the rectal
contents will immediately flow out over the external parts which have
been scrubb(»d, and the cleansing will have been in vain. After
the sphincters have been dilated, the rectum irrigated with a 1-to-
2,000 bichloride solution, and scrubbed with cotton swabs, a good-
sized sponge, threaded on a strong silk ligature, should be introduce<l
to prevent the escape of any intestinal contents over the operative
field.

Having thus protected the lower portion of the rectum, the external
surface, the buttocks, the ])erina'um, and the scrotum should all be
thoroughly scrubbed with soap, bichloride of mercury, and alcohol.
The fistulous tract itself should be injected with peroxide of hydro-
gen or a solution of l-to-nOO bichloride of mercury, and thorough-
ly washed out in order to free it as far as possible from the pyogenic
germs.

Position, — The position of the patient for operations on fistulas de-
pends largely upon the habit of the operator. Some prefer the lateral

j)rone position, others the lithoto-
my position, and still others prefer
to have the patient laid upon his
chest and propped up in the knee-
chest posture. Practice should
vary according to the location of
the fistula; if there is an internal
opening in the anterior quadrant
of the rectum, it is best to have
the patient in the extreme prone
position with the thighs drawn well
up to the abdomen; if it is upon the side or posterior quadrant
the lithotomy position is preferable. The legs will be held in posi-
tion by two assistants, or better still by the Clover crutch (Fig. 130),
or Kelly^s straps. The upright posts upon the ordinary gynsecological
table serve fairly well, but they do not allow of as much separation of
the thighs as the apparatus mentioned, and the patient is likely to slip
back from the edge of the table when these are used. In the majority
of instances one may say that tlie lithotomy position is the more satis-
factory.

Instruments. — The instruments necessary for an operation upon fis-
tula are the following:

Probes, — These should be of various sizes, flexible, from 4 to 8 inches
in length, and have flat handles in order to determine the direction of
the points when bent.

Fig. 130. — Clover's I'rhtch.

FISTULA

387

■I

Fig. 131. — Brodif/s rm>BK-P(>iNTEi) Grooved

DlRE<T<>R.

Grooved Directors. — There have been a number of special directors
devised for operations upon fistulas. Some are made with probe points^
as that of Brodie (Fig. 131). Some are made of stiff steely and others
of flexible material.

Allingham has devised one, into the groove of which a sort of button
attached to the lower blade of a pair of strong scissoi^s fits, and thus
guides it as the tissues are cut through. These instruments are in-
genious, but an ordinary steel
or German silver grooved di-
rector serves every purpose.

Knives, — The operator
should be provided with two
c-ur\'e<l bistouries, one sharp and the other blunt-pointed, a good scalpel,
preferably of small size, and one with a long, narrow blade.

Scissors. — These should be straight, angular, and curved on the flat.
The Emmet cervical scissors is sometimes very useful, but not indis-
pensable.

Artery Forceps. — These should have very wide jaws and small points
(Fig. 132) in order that the ligatures will slip over them easily, as it is
frequently difficult to tie vessels in the rectal cavity over narrow-nosed
forceps. T-shaped haemostatic forceps (Fig. 133) are also very useful.
One should also have two or more long-blade pressure forceps in case
it is necessary to grasp
the lips of the wound
en masse.

Tissue Forceps. —
These should be of sev-
eral varieties. Plain
dissecting, mouse-
tooth, and tissue for-
ceps with wide bite are
all necessary at times.
Some of these should
be furnished with a
fixation clamp in or-
<ler that the operator
may loosen his grip at
times.

Needles. — These should be round, without cutting edges, and of vari-
ous curves and sizes. Those describing a semicircle (Fig. 134) are
almost indispensable in suturing deep fistulas.

The Needle-holder. — Without assuming to make comparisons, in a
general way the Wyeth needle-holder (Fig. 135) is by all means the most

Fio. 132. — Artery F<>RCEPt«

FlO. 133. — T-eiIAP£D IliBMOSTATlC FoRCEPt>.

388

THE ANUS. RECTUM, AND PELVIC COLON

Fig. 134. — Nkki>lk« fok Rectal

Sl'ROEUY (At'TlAL SlZK».

satisfactorv in rectal work. It inav be used with all kinds of needles,
and has one great advantage, that however small or fine the needle
grasped may be it is not broken.

Sittitre and Liijaiure Material. — Catgut, both plain and ehromicized,
silkworm gut, silk thread, kangaroo tendon, and silver wire are all used

at times for fistula, and should alwavs be
I J in one's operating bag.

^^.^j/ y Specula and Retractors. — The Van

Buren or Sims's duckbill specula are the
only ones which are of any particular use
in operations for fistula. Kectal relraeiors
are also quite useful in connection with
these instruments.

Sharp retractors are of great assistance
to hold the tissues apart when one attempts
to dissect out the fistula or to remove the cicatricial tissues at its base.
Tenarula. — One should always have two uterine tenacula in oper-
ating for fistula, as they are frequently of great assistance in accu-
rately approximating the edges of the wound when immediate suture
is attemj)ted.

Cautery. — One should never attempt any operation on the rectum
without a Paquelin or electro-cautery at hand. The fonner is much
more stitisfactory, and they are now made so conij)act that they occupy
little space in the operating-bag.

After all these preparations the surgeon may proceed with the actual
operation, choosing that method which is best adapted to the indi-
vidual case.

1n(Msi()\. — The operation of incision for ano-rectal fistula, while the
simj)lest is by no means the oldest of the procedures in this disease.
Excision, crushing, and the ligature were used many centuries before
Pott first advised this
simple method. It is
based upon the one idea
of overcoming sj)asm of
the sphincter, which by
keeping up a persistent motion in the parts, acting as a stricture of the
rectum, obstructing the free discharge of gas and fa?cal matters through
the anus, and thus forcing them out through the fistula, was supposed
to prevent its healing.

The oj)eration in complete fistula consists in the thorough division
of the sa^ptum between the rectum and the fistulous tract. This division
may be carried out by the knife, scissors, thermo-cautery, or the ecraseur.
Tn the incomplete type it consists in laying open the fistulons tracts

Fio. 185.— Wyetii'!* Nkkdle-holdxr.

through the skin or mucous iiietnbrane in order to obtain complete
draioiige and afford opportunity for the proper cleansing and dressing
of the parts. Salmon added to this incisions into the perifiatulous,
fibrous tissue, holding that they hasten the development of healthy
granulation. Pott in his original brochure upon this subject advo-
cated the turning of incomplete fistula into the complete variety in
order to overcome the mobility occasioned by the spasm of the muscle.
The sajut' advantages in blind external fistula may be obtained by
stretching the sphinc-
ter without the expii-
sure of the fistulous
tract to the infectious
bacteria io the intes-
tine, and with little
danger of chronic ul-
ceration of the rec-
tum and iucuntinenee
of fa^es. Wherever a
fistulous tract of this
type fails to heal after
this treatment, one may
|«et it down as a fact
the patient is
either syphilitic, tui>er-
nlous, or, what is very
piuch more likely to
i the case, there is a
Communication be-
iween it and the rec-

1 which the operator has failed to discover. It may he said that it
I never necessary to make a surgical opening in llic rectum for the

e of a fistula where no pathological opening exists.

The stops in the operation are as follows:

Blind external fistula should be laid open by a circular incision
rough the skin parallel with but outside or inside of the external
phincter; this incision should be wide enough to drain the cavity per-
fectly and leave no pockets. In the complete type the tract should be
opened little by little outside of the sphincter until a point immedi-
ately below the internal opening is reached; then with a grooved director
pB.'ised through this and out of the anus, the overlying tissues should be
cut in a perpendicular direction, thus severing the fibers of the sphincter
equarely across (Figs. 13G, 1.1~). If there are any connective-tissue bands
(^Tilling the cavity into compartments, these should be broken down or

390 TnK ANUS. RECTUM. AND PELVIC COLON

ncised, and the granulating tissue throughout the tistula should be
scraped away »-ith a curette or Volkmann's spoon.

Any arteries which are cut should be ligated, and the woiuid packed
firmly enough to control the oozing for the first twenty-four hours.
After this the dressing should he juat sufficient to hold the lips of the
wound apart and secure drainage. The firm packing of these wounds is
the source of great delay in their healing. The parts should be irrigated
with antiseptic solutions twice a day, and the gauze used for dressing
soaked in a 10-per-ecnt

te^r-

nii.xture of ichtliyoi
and glycerin or 5-per-
cent balsam of Peni
in eastor-oil.

The patient should
remain in bed for the
first week; after this
time he may begin to
go about, but should
not be allowed to as-
sume the sitting pos-
ture, inasTnuch as pres-
sure upon the parts
produces congestion
and delays union. In
nearly all the works

m ^

Tfto. m.-T,wr,ruK LAT,. o^KN O.T«,.« or 8pm»«T«« «, "Pon e«^e'"'l' surgery

the grooved director
hrough the tract into the rectum, if possible, and if not, to puncture
he rectal wall with it at the highest point of the fistulous cavity,
(ringing its end out through the anus, and then to introduce a curved
lirtoury along the groove and cut the tissues from within outward.
This blind, unscientific procedure may result in a cure where the
lirector passes through the pathological internal opening in the com-
ilete variety; when it does not pass through this opening and the
n-alt is punctured, it is almost sure to result in failure, because a part
)f the fistulous tract remains untouched (Fig. 128). The rest of the
fvound may be perfectly drained, but this little tract continues to in-
ect it, and will eventually prevent complete healing. By the tech-
aique described above one knows exactly what he is cutting; the
rectum is laid open only from the internal aperture outward, and
he muscles are cut at the angle most favorable for the restoration of
unction.

FISTULA 391

If the internal opening is above both sphincters, it is better to excise
as much of the upper portion of the tract as possible and suture it
together with the internal sphincter than to attempt the operation by
open incision. Even if the complete fistula can not be dissected out
and sutured, this upper portion will ver}' likely unite if the drainage
below is perfect, and thus the function of the muscle will be retained.
If there are large, hard masses of cicatricial tissue surrounding the
fistula, they should be dissected away as eompletely as possible, provided
one has thoroughly eliminated tuberculosis from the case. If, however,
the fistula is of tubercular nature, and it is deemed wise to operate
by the open method, the Paquelin cautery should be em{)l()yed instead
of the knife for all incisions, and the entire tract be burned instead of
curetted. The so-called Salmon back-cut into the cicatricial tissue is
not to be compared for a moment with actually dissect in^jc out the cica-
tricial tissue.

Excision of Fistula. — The treatment of fistula by excision is very
old. Ijong before the publication of Pott's classical paper in 1779, phy-
sicians had practised cutting out the fistulous tract, and with more or
less success. Owing to the fact that so nuich tissue was removed and
no regard paid to the preservation of the sphincter muscle, the results
were often disastrous so far as continence was concerned, and profuse
hapmorrhages frequently occurred through the imperfect nu»thods of
ha»mostasis at that period. Clieselden's method of introducing^: a poly-
pus forceps into the fistulous tract and cutting out all the tissue em-
braced b}' the blades was barbarous, and need not be (UscusschI at the
present time. The operation of excision has its merits in that it aims
at the absolute eradication of all diseased tissue, and where the dissec-
tion is so carefully conducted as to avoid too great (l(»st ruction of the
sphincter it will produce excellent results. In old cases with large
cicatricial deposits it is advisable, even if the resulting wound can not
be accurately brought together by sutures. The writer has succeeded
in curing by this method a number of such cases in which simple in-
cision liad utterly failed.

Excisiox WITH Immediate SuTrRE. — This ()j)eration, originally con-
templated for the treatment of small direct fistulas, is being more and
more applied to those of larger dimensions. It was originally introduced
by Chassaignac, who records a case in which he applied it in 1S5G (Traitt*
de Pecrasement lineaire, 1856, p. 168). He does not state how many
times he attempted the operation, but it failed owing to infection and
suppuration of the wound. No further attempts were made in this
direction imtil 1879, when Stephen Smith, of Bellevue Hospital, follow-
ing the imperfect antiseptic technique of that day, un<lertook the treat-
ment of a number of fistulas by radical excision and immediate suture.

392 THE ANUS, RECTUM, AND PELVIC COLON

While Smith's nietliod of I'xcisioii and introduction of sutures is prac-
tically the saine as that laid down by Chassalgnac, it is entirely due to
him that impetus has been given to the present method of operation,
and the recognized technique of its performance has been prescribed.

The preparation of the patient by purges, enemas, shaving, etc., must
be carefully carried out. It is important also tiiat the fistulous tract

should be treated with peroxide of hydrogen and antiseptic solutions (or
several days before the contemplated operation. After the patient ia '
aOEBsthetized he should be placed in whatever position affords the opera-
tor the easiest access to the parts.

The sphincters should be stretched and the parts cleaned according
to the directions already given. The succeeding steps of the operation
will depend upon whether the fistulous tract is a simple, straight oanal
or a tortuouB, irriguhii, abscess cavity.

In the hr-st milance the probe or grooved director should be intro-
duced through the fistulous ti'act; preferably a pure silver probe long
enough to be bent and held as a sort of traction loop (Fig. 138). Tiie
skm and nmcous membrane covering the fistulous tract should then be ,
inciaetl in a straight Ime from the external to the internal opening and
dissected batk a little to each side; the deeper tissue should then be

FISTULA

393

^m inuii

incised nntil one comes upon the cicatricial or indurated wall of the
fistulous tract; if this tract passes outside of the externa! aphiucter or
through its fibers, it wilt be perfectly feasible to cut these fibers trans-
Tersely and draw them to one side so that none of their suhstance will
be removed.

Having thus cut down upon the fistulous tract, but not into it, the
incision is carried around the external opening, and the entire indurated
lass dissected iipwani and inward until it is completely removed by a
liar inetsion around the internal opening (Fig. 13!)). In this man-
ner the fistula is excised i« iolo, and remauia threaded upon the probe.
On« must be familiar with the appearance of the diseased tissues in
such eases, and be verj- careful to go entirely outside of them in the
dissection. When during sucli an operatiun the dit^eased tissue is hi-

l Tsded by the scissors or knife, the instrument should be changed for
l«nother lest by any possibility the healthy tissues should be infected.
Having removed the tract, the application of the sutures is the next
Considerable ingenuity will need to be exercised in every case
Wio bring the parts accurately together. The first step consists in intro-

3»4

THE ANUS, RECTrjI, AND PELVIC COLON

iliictiig two or three silkworm-giit sutures from one side of the wound
to the oiIkt and oiitirt'ly below it; tliose are intended to prevent traction
on the di-epcr sutures, and tlieir ends are left loose until the latter are
all in place. After this tlie deeper portions of the wound are brought
together l»y !i continuous isiiture of niediiini-sized catgut. Plain steril-
ized gut is bettor for this purpose tlian the chromicized. As the tissues
through which these sutures ])ass are frequently of a fragile, cellular
nature, tlie niattrcss-stitch will bo found most satisfactory (Fig. 140).
Ijiiyer by layer the paits are brought t'igether until the wound is closed
to the level of the skin or nuicons ineiubnine. The divided ends of the
spiiinitcr are brought together by interrupted sutures. The deep suture
is not used to bring the skin and mucous membrane togetlier. Tlie
reason for this is that it is almost im|)ossiblc to sterilize the skin, and
hencG if the same suture wliick is used in the dee[>er tissues be passed
through it, infection is liable to follow its tract downward into the

dei'per portions of the wound. Subcutaneous suturing of the eiiges of
the wiuind has resullwl unsnlisFai'Iorily. The very slightest puncture
which will hold ihe edges iu apposition should he made in order that
the needle and llm-ail may not penetrate into the cellular tissues and
thus possibly infeet tlietii. My these means tiie entire tract is accurately

FISTULA 395

brought together and ologpd (Fig. 111). After this has been awimi-
pli^hod, the ileep anchoring or jeenforcing sutuifs first iiitroducwl are
tied together, thus supporiing the deeper ones and bringing Ihe [Ktrta
into elriTifr apposition. All bleeding nnd oozing should he tliorouglily
cheeked before the suturing begiiix. After the wiiiind has been aceu-

rately eluded, it shoidd be 8eaU-d vtilh ioilofontiizi-il tnUoilion anil
be pi-oteeted from the fa'eal disc-liiirgc' wliicli iriiiy esi-iijii! afi^'i
openii ion.

Another nietliod is to siiliirc tlu- e<!ges of the skin wound u|i t-
niart^in of the anns; tbo slit in ilie uim-ous lui-Nibrjiiu' i> iIu'm i-nu
otT, and that above its iipjHT angle is lun-meil up Iroin tin- li,-^lll-.
ft» in the Whitehetul operation for liji'iuorrhoi'l-, :iud is ih^n dm
ih)wn and sutured to tin; sinrnco skin a >li;rht ili-iaiice bwnml
margin uf the anus. The idea of this eonsi~ts in pnnhiiiu^r an :
Intely impervious layer covering thiit imrliiiii uf tln' wuuinl in>i'li
anus or rectum, so tliat there will be no po-siliility ul' ij'Ciil |i.ti'o1.
into the wound. Whatever diseliargis liii iir will pa-- "Vf-r iliis v
like flap of mucous nicndmine in which iIicit i-; no sol in ion ijl'iniiiiii
and will thus be discharged ontsidc witlioiil cuniin;.' into (-oiitji't
the edges of the wound. The external skin f;urfin.'i.' bein;; tli^n |irot(

thus

the

Site TIIK ASUS, KKC'TUM, AND PELVIf C-OLON

bv coHotliim and iiidjut dri'ssing vvrll run lUtle risk of becoming in-
fuclcl (Fig. H-i).

AhiT tlio (>|HTatioii lian bci-n thus i:oiii]tU'te(l, antiseptic gauze i* laid
over the woimd and liel<l in (losition with a flat retractor, m thai it
will be Ji[i)>osHibK> for the Kjionge in the rectum, wliich i:lioiilil be with-
drawn, to e<iitie in eoiituct with tlie edges of the wound during with-
drawal. After tills, with tin- retractor held in position and ii Siiiu's
vagiruti speculum iipim the opposite side of the rectum, a nie<liuni-siz^
dniintige-lube, wTaji|»'d with a small cjiiantity of gauze ami covered
with rubber pi-oteetive, is introduced about 3 inches into the rectum

Kr<i. Ha. — liKi'T.iL rciimcis •■r Kiwri..i ru'tr.ii hv i'nv nr Mrmi-ii Mevdr^te.

ami ailiiwcd tn remain for scvitjiI days in lU'der to facilitate the escape
of gas and iinv lluid Heees which may come down from the intestine
above.

The afler-lreatmeut cimsists in confining the patient absolutely to
bed, controlling the bowels by a certain i|iiantily of opiates for six or
scrcn days, and limiting him to lii[iiid nlbumcnoid diet. A milk diet
is not siitisfaetory in such cases owing to the hard, caseom, insoluble
stools prodiiceil by it. At llie end «( six or seven days the patient's
bowels are movei] by the injection of ■"> ounces of warm water and 1
ounce of glycerin, in which is dissolved 2 ounces of inspissateil ox-gall-

FISTULA 397

This proceeding may have to be repeated several times before an efficient
evacuation is obtained, but it is not advisable to attempt the use of
any laxative or purgative until the lower bowels have been relieved of
any accumulation of hardened faecal masses such as are likely to follow
the administration of opium and prolonged constipation. After these
masses have been dissolved by the ox-gall and glycerin, one may then
administer some mild laxative, and induce regular daily movements.

Rest in bed is incumbent upon these patients for at least two weeks
in order to secure firm and perfect healing of the parts, at wliich time,
if primary union shall have taken place, the fistula will be cured. The
little mucous flap does not unite to the skin surface to wliich it is sewed,
but does unite to the raw surface down to the margin of the skin. After
the stitches are removed that portion of it wliich extends beyond the
margin of the skin will retract and entirely disappear.

In complicated cases, in which the fistula consists in a tortuows,
irregular tract of greater or less dimensions in the ischio-re(*tal fossa,
the operation is not so simple. Here it is almost iinj)08sible to excise
the fistula in the manner described above, and consequently the tech-
nique diiTere somewhat. After incision the spliinirter nmscles and the
skin are dra^Ti aside, and then the fistula is dissected out from the
internal to the external opening. In the beginning it is well to flood
the tract with pure carbolic acid, allowing the same to remain for two
or three minutes, and then swab out the parts with 95 per cent alcohol.
Every pocket or diverticulum should be carefully opened and dissected
out in this manner. Having accomplislied this, if possil)le the deep
sutures should be introduced as described before. It may sometimes
be advisiible to pass one of these sutures around the wound in a horizontal
direction after the manner of a purse-string. The deeper parts of the
wound are then brought together layer by layer with continuous or
interrupted sutures, according to which produces the most accurate
apposition. As Smith states, there is scarcely any fistula which can
not be completely and thoroughly closed by this method of suturing.
The superficial layers, the ends of the sphincter muscle, and tlie skin
are brought together in the manner already described. As yet the
author has not had the opportunity to use the mucous flap in any exten-
sive operation for excision and suture of ano-rectal fistula, but tliere is
no reason why it should not be applicable to all types, and a means of
great protection against infection by discharges from the intestinal
canal.

After the closure of the wound, the deep purse-string or reeu forcing
suture should be tied as previously described, the sponge withdrawn,
and the parts dressed in the same manner as in the simple variety.

It is wise in cases of large dissection and suture to strap tlie folds

398 THE ANUS, RECTUM, AND PELVIC COLON

of the buttocks together with wide adhesive straps, and to bind the
knees together with a bandage or towel in order that the movements
of the patient in bed may not cause traction upon the wound and thus
break loose the sutures.

By this inetliod the absohite removal of the diseased tissues is accom-
plished, the accurate apposition of the parts insures better functional
results, and finally a great deal of time and exhaustion, which neces-
sarily follows the long processes of healing by granulation and suppura-
tion, arc saved.

The argument used against it is that primary union may fail, and
does fail in a number of cases. This is not a valid objection, for the
simple reason that where the union does fail, absolutely nothing is lost;
one has accomplished everything that is intended by tlie open opera-
tion, and the patient proceeds to recovery by the same process of
granulation which would have been necessary if no suturing had been
done. If the operator is careful in his after attention there is abso-
lutely no danger of fresh abscess and burrowing taking place. The
symptoms of such conditions are j)erfectly clear, and if one should form
it can be opened externally and drained, and the parts still lieiil in less
time than thev would bv the method of incision.

This UK^thod is inapplicable to those cases in which the fistula is com-
plicated by long, tortuous tracts that extend up into the superior pelvi-
rectal or retro-rectal spaces, but in any case in which the depth of the
fistula does not exceed 2 J inches excision and suturing may be accurately
carried out by a skilful operator.

In the application of these principles to the difTerent varieties of
fistula, the chief difficulty is to distinguish between the anatomical and
pathological types of the disease. Wliere the diagnosis is accurate, one
can not make any mistake in the selection of the method to be em-
ployed. T"li(» large majority of failures which follow operations for
fistula are due to one of two facts: either a specific fistula is mistaken
for a simple one, or the pathological opening into the rectum is not
found, and thus a f)art of the tract remains. If these errors are avoided,
every operation for non-specific; fistula ought to prove successful.

In blind internal fistula the technique varies slightly.

In simple subtegunientary cases in which the opening can be found
and a probe bent uprm itself introduced into it, a small counter puncture
may be made upon the lower end of the probe and the intervening tis-
sues can then be incised by scissors or the cautery, or it can be excised
and sutured. If the fistula has burrowed outside of the muscles into
the ischio-rectal fossa and beneath the skin, incision through this tegu-
ment will convert it into the comj)lete variety, and it should then he
treated as such. Where such a conversion can be made without the use

FISTULA

3f)!>

fof general anipsthesia it is always well to do this, and try draiuage and
stimulating applications for a week or two before resorting to i-adical
operation. This conservatism is especially important where the open-

^iIlg is above the internal sphincter and its tract passes outside of this
muscle.
Sometimes the fistulous tract does not run downward, but runs up-
ward undernealh the mucous niembratie of the rectum. In such casea
the upper portion of the tract may extend beyond the reach of the finger,
and the incision nuy possl-
I>ly be followed by seven'
haemorrhage. In sueb cases
one blade of a long, nai-
row pressure forceps may
e introduced into the tract
hile the otlier passes into
be cavity of the rectum;
bey are closed and al-
JDved to remain until the
are cut through.
■ the entire tract is imt
■id open at tlie first at-
upt, the forceps may bv
Btroduced a little higher
t a second sitting.

Where the tract leads
lovnward in a tortuous
lirection, and the probe
be passed from
within, it is sometimes pos-
sible by bimanual {iiilftation

I to discover the mduration
^ ^ ... , Fin. Ua.-V-liHAl'KIl BlIKO ImIMKSAL FlBTL'LA.

ta the perineal regmn, and
Id cut down upon it from the outside and thus convert it into a com-
Hi^te fistulu.
[ Sometimes these fistulas bifurcate and form Y-shaped tracts (Fig.
143)- When this is the case, laying open one of the branches will not
be followed by healing, but suppuration will continue. In operating
one should be very careful to search each side of the wound for any
snch diverging tracts, and if found lay them open at once.

The methods of treating these blind internal fistulas by injections

[ stimulating fluids without laying them open are utterly unreliable.

Ihe cavities are constantly reinfected by the intestinal contents, and

Jiout complete drainage and antiseptic treatment one can not expect

400

THE ANUS, RECTUM, AND PBLVIC COLON

them to heal. After the tracts have been laid open the sphincte:
should be thoroughly dilated and the treatment for simple rectal ulcei-
In these cases i-eat in bed is imperative, the diet shou

be carefully regulated, arm^
I lie stools kept regular arm^
st'iniaolid.

No force should ever l>6
used in the introduction
of a probe or grooved di-
rector into a fistulous tract.
The cellular tissues about
tlic parts are so soft that
llicy may be easily pcnp-
tmliid, and one may even
incise both the external
;iud internal openinfis and
yet leave a part of the fis-
tidu intact (Fig. 144).

After the fifltulous tract
has been laid open, it often
happens that the burrow-
ing around the rectum ex-
tends considerably above
the level of the internal
()pening. Many operators
claim that it is wise to incise the rectal wall up to the highest point
of such cavities. This, however, is rarely necessary. If the parts are
thoroughly drained and tiie sphinetors put at rest by stretching and
incision, these cavities will rapidly fill up by healthy granulation, and
the cutting of the internal sphincter will be avoided. If, however, there
should be a burrowing tract involving only the mucous membrane of
the rectum, it is safer to lay this open. In order to avoid hemorrhage,
the heated knife should be used for this purpose. All burrowing tracts
and diverticuli should be freely laid open into the main wound. Where
the fistula is connected by burrowing tracts with the retro-rectal or
petvi-rectal spaces, those cavities should be opened into the general
wound and drained by the introduction of rubber tubea.

Tlie dressing of the wounds after all these operations for lislula is
the same as that already described; they sJiould never be packed tightly,
inasmuch as this holds the tissues apart and results in delayed union
with extensive cicatrices.

Complex Fishila. — Quite a large percentage of fistulas are of the
complex variety. Any perirectal abscess or fistula, if improperly drained.

Fio. IM.

OF TmcT Dutououei

FISTULA

401

may resolve itself into this variety through burrowing and destruction
of tissue.

They are described as fistulas tvith lateral bvrrowiiig tracts, watering-
pot fistulas, and horstshoe fistulas.

Finttila u-ith Lateral Burrowing Tracts. — Any simple fistula resulting
iroiu an abscess left to open spontaneously, or occurring in individuals
with vitiated constitutional conditions, is likely to become complex
by burrowing tracts leading off from the abscess cavity. tJoodsall
pointctl out many years ago the rules of extension of fistulona tracts.
Those in the anterior quadrant proceed directly into the anus or rectum,
the aperture being found almost perpendicularly above the external
opening. Those in the posterior quadrants extend circularly around the
anus, and generally open at some point near the posterior commissure.

Subtegumentary fistulas at any point on the anal circumference may
burrow subcntaneously in all directions, because there are no connec-
tive-tJKiue walls to obstruct them. Those pituated anteriorly are likely
to extend forward into the pcriuieum and scrotum or upward into the
cruro-scrotal fold. Those
situated posteriorly bur-
row outward into the but-
tocks, or upward behind
the coccyx and sacrum be-
neath the skin. The ex-
tent to which these sub-
<?utaneou3 burrowings may
"take place is very remark-
able. In one case a small
ainlerior fistula burrowed
forward through the peri-
aa-iun and crural folds and
Tipward into the iliac rc-
f^ion. opening upon the
ekin at a point near the
anterior superior spine of
the ilinm. In another case ^^^ us — Kistit ors Tract pabbibo THuoroii Eitib-
(Fig. 147) a superficial fi.s- nal Sphisiteh.

tula burrowed upward out-
side of the sacrum and coccyx, turned anteriorly above the leve! of
the fourth sacral vertebra, passed underneath the gluteal muscles, and
opened at a point just below the greater trochanter.

An apparently simple, direct, subtegumentarj- fistula may have a
tract burrowing upward into the iscbio-rectal fossa {Fig. 145) or even
entering the superior pelvi-rectal space. iSubrauscular fistulas passing

402

THB ANUS, RECTUM, AND PELVIC COLON

through the ischio-rectal foesa are very liable to have burrowing sinases
leading off from them into the fossa of the opposite side, or into the
retro-rectal space (Fig. 14C). Where they extend around the anterior
or posterior commissure of the anus they are called horseshoe fistulas.
It has frequently happened that small subcutaneous fistulas, after
having been laid open, continue to suppurate for long periods, and upon
close examioation in these cases it has been discovered that small sub-
mucous tracts were burrowing upward beyond the internal opening of
the fistula.

The treatment of these varieties of complex fistula has been prac-
tically described under those of general operations. It consists in
the incision and thorough drainage of everj' burrowing tract, whether
it be superficial or deep. In the superficial variety excision and imme-
diate suture may be applied. Where simple incision is employed the
cutting should always be
made beyond the limit of
the burrowing of the tract
for the reason that the
edges of the skin rapidly
retract and may very eaaily
form a pocket before heal-
ing from the bottom has
taken place. It is neces-
sary to say something upon
the treatment of fistulas
opening at remote dia-
tances from the anus. In
certain of these cases the
large amount of tissue in-
volved and the extent of
the wound necessary to lay
open the entire tract cre-
ates a condition entirely
out of proportion to the
gravity of the disease. In
the case opening near the
trochanter (Fig. 147) the
laying open of the fistulous
tract would have involved the cutting of the gluteus maximus and
mediup, the gluteal artery and lesser sciatic nerve, together with a wound
of no less than 18 inches in length. In such cases it is advisable to
follow the fistulous tract from the external opening ss far as possible
with a long probe, and at that place make a counter opening large enough

admit a drainage-tube into it. From this incision the probe can
len be introduced still farther and a second counter opening made

I before, and so on until

a 19 made at a site about
r 2 inches from the anal
in. From this point
e internal opening <if
stuia all the overlying
mes may be cut through,
the condition treated
; of complete fistula
tending from the last
' counter-opL-ning. The fis-
tuloiiB tract Iwyond this
last coimter-opening is
treated by curetting, stimu-
lating applications, and
drainage. As a rule they
irill close rapidly and com-
pletely. Of course if there
should be lateral burrow-
injr tracts from this main fistulous canal, it would be necessary to lay
these open and drain as has been previously described.

Figtula vilh more Ihatt One External Openinii : Walering-ptd Fistula. —
"WTien a fistula has existed for an indefinite length of time and the drain-
age has been iasulfieientj numerous burrowing tracts may form and
each open externally upon the skin. In this manner there will be estab-
^ttsbed what haii been described as watering-pot (i^^tula. The number of
^MKh external openings is unlimited. Goodsall and Miles have described
^E case in which there wei-e forty-three separate and distinct external
^Bpertures. This by no means implies a multiplicity of internal openings,
^Kt in the majority of these cases there is only one.
^P The number of external openings, however, does bear some relation
to the size of the internal opening, to the constitutional eoudition of the
patient, and the duration of the fistula (fioodsall and Miles, p. 117).
(Ordinarily in cases with numerous external openings one will find a
large internal opening, generally between the two sphincters, and into
which the ends of one or two fingers can be introduced. Sometimes a
soft, flexible probe introduced through this internal ojiening will pass
directly out through the primary external opening, and where there is
any doubt in the mind of the patient as to which of these occurred first,
this may prove a practical solution of the problem.
^l The treatment of this condition will depend largely upon the consti-

404 THE ANUS, RECTUM, AND PELVIC COLON

tutional condition of the patient. As a rule it would be well to lay open
all the fistulous tracts into one large cavity, preserving as far as possible
the islets and tongues of skin in order to facilitate the cicatrization and
healing of the parts; but such patients are apt to be much debilitated
and weakened by the excessive discharges, and extensive operations are
therefore unadvisable. If it is possible to follow the tract from the
internal to the primitive external opening, it is better to lay this open,
curette and cauterize the same, and trust to the drainage thus obtained
to heal the other openings and the sinuses leading to them. In case that
does not succeed, the patient's condition will in the meantime be im-
proved by constitutional treatment and the checking of septic absorp-
tion, and he will be in a better condition to tolerate incision of all the
collateral tracts.

Excision and suture are impracticable in cases of this kind. Many
of those which the author has seen have been associated with constitu-
tional syphilis, and, while not being complicated by any sjrphilitic
stricture of the rectum, they have proved obstinate to treatment
until the effects of mercury and iodide of potash have been well
established.

Fistula with more than One Internal Opening, — This variety is much
more rare than the preceding. There may exist two internal openings
connected with two distinct fistulas, or there may be two or more con-
nected with only one external opening. It may be caused through punc-
ture of the rectal walls by a sharp bone, needle, or other foreign body
caught crosswise in the rectum and setting up two distinct abscesses and
fistulous tracts upon opposite sides. These abscesses may burrow, coa-
lesce outside of the rectum, and open by one common external aperture.
It sometimes happens also that in a horseshoe fistula or double abscess
of the ischio-rectal fossae, an opening may occur within the rectum on
each side, whereas only one exists externally.

The treatment of this variety depends entirely upon the anatomical
character of the fistulas; if they are subtegumentary they should be laid
freely open or dissected out and the wound sutured; if, however, the
tract is subnmscular it would be unwise to attempt an operation by incis-
ing both tracts at the same time. It is better to lay open one tract
thoroughly through the sphincter muscle, extend the incision laterally
so as to establish complete drainage, and at the same time cauterize the
other openings and tracts with a saturated solution of nitrate of silver.
If necessary secondary operations may be performed after the first has
healed, and ordinarily the remaining fistula will be so reduced that ex-
cision with immediate suture can then be performed with safety.

Horseshoe Fistula. — This consists in a fistulous tract surrounding the
posterior or anterior commissure of the rectum. Occasionally one finds

405

mplete

both conditions in the same patient, the fistula thus forming a c
circuit of the rectum (Fig, 148).

The typical horseshoe fistula consists in a tract that runs from one

ischio-rectal fossa above the aponeurosis of tlie external sphincter and

, around the posterior commissure of the rectum into the fossa of the

1 opposite side. It may liave one or two external openings; it niav have

one. two, or no int

lal openings; as .1 i-

there is one exti'i-

opening upon on.' ^■

or the other of t

anus, and one intern

Usually at the pusiir

coimnissure of llur n

tiim just abovi' t

inargin of the exteri

sphincter.

It is said by <
l>etent operators tli
tliis type of fisiuhi
X^arely tubercular, iii
my experience cm
chides with this npiin<
The posterior v;ii:i

is generally submuscu- ''" "~- - f"*"^ or iiukseshoe ii.-,., :.n

-« - i,!. 1 -1 ■ 1 September, imi.

l&r, in that it is above

the level of the external sphincter and passes above its aponeurosis.
The anterior variety is generally subtegumentary, owing to the fact
that there is no deep cellular tract between the perineal body and
the anus. The fistulous tract may therefore be of considerable depth
; each side of the perineal body, but is supei-ficial as it crosses the
interior commissure.

Treatment. — The anterior variety may be dealt with either by the
I method or by excision with immediate suture. When there has
lot been much burrowing and there are no tracts leading into the
■otuni and crural folds, they may be dissected out and the wounds
tiosed. This is generally an easy operation owing to the fact that
ulas in the anterior quadrants of the rectum usually open into the
Wtum quite low down, and ordinarily have no deep, burrowing tracts
■at extend up along the rectal wall. The tract generally consists in a
twell -developed, more or less globular cavity on each side of the perineal
nnected by a narrow, superficial tract that runs underneath
Ehe skin from one cavity to the other, and resembles a curved dumb-

406

THE ANUS, RECTUM, AND PELVIC COLON

Fio. 14'.K — Dumb-bell Fihtila.

bell more than a horseshoe (Figs. 149, 150). The lateral cavities are
not very deep, being ordinarily limited by the triangular ligament.

Excision and sutui-e
are therefore practica-
ble, but it require
skill and a complete
knowledge of the anat-
omy of the parts to
avoid the blood-vessels
and nerves which trav-
erse this area. Where
the condition does not
warrant an attempt at
this method of treat-
ment, the fistula
should be laid open by
careful dissection, the ends of the sphincter muscle being cut squarely
across and pulled to one side while the cicatricial tissue is removed.
It is not safe to use the cautery freely in this area as the slougliing
which follows it may implicate the urinary organs, but gentle curetting
and tlie application of carbolic acid to the tract may be safely used.
After this the ])arts should be packed lightly with absorbent gau7.e
soaked in oil and balsam, or in glycerin and ichthyol. In women great
judgment nuist be <»xercised in this class of cases not to destroy too
mucli of the perineal body; excision and immediate suture should al-
ways be j)erformed if
possible.

In the posterior
horseshoe fistula the
internal opening is
usually situated near
the posterior commis-
sure and between the
two s])hineters. It is
generally of considera-
l)lc size, and can be
made out distinctly

by digital touch. The
lateral burrow ings
may be superficial, Init
generally thev extend

*^ ft ft

deeply into the ischio-rectal fossa upon each side. The external
opening may be u])on eith(^r side, or there may be openings on both

Fio. 150. — Rkhi'lts of Opkration in preceoino Case.

Till" lit til' nits on either side reprc'soiit rotracttKl ondii of truiiA-

vcrsUK iHirinei AIkts.

FISTULA 407

sides. The cavities in such fistulas are generally so irregular that ex-
cision with immediate suture is not very practicable. In most of these
^cases the entire fistulous tract around the posterior commissure of the
anus is laid open from one side of the rectum to the other, always carry-
ing the incision in the skin a little beyond the extremity of the burrow-
ing. After this has been done and the parts have been thoroughly
scraped out, a grooved director is passed from the incision posteriorly
through the fistulous opening into the rectum, and the intervening tis-
sues are cut through. Frequently a considerable amount of dense,
nodular, cicatricial tissue is found at this point. When such is the
<*ase it should be dissected out. (loodsall advises allowing the fistulous
tract between the posterior wound and the rectum to remain untouched,
»nd states that this method has three advantages, viz.: tliat haemorrhage
<?an be more readily controlled by plugging the wound; that when the
l>owels move the wound will not be soiled by the escape of faeces or
Hat us; that should the fistula be closed without the division of the ex-
ternal sphincter there can be no loss of power even in that muscle.
Neither htvmorrhage nor division of the sphincter at this point are ever
serious, and soiling by faecal material is not so inimical to healing as
<*onstant reinfection from a fistulous tract. This is the siime old storv
which has been so often told in the treatment of fistula — an attempt to
cure the condition by leaving the pathological cause untouched. If it
were necessary to choose between leaving this portion or the lateral
tracts unopened, by all means select the latter, as complete healing
would be much more likely to take place.

Quenu and Ilartmann advise laying open the fistulous tract leading
from the rectum to the transverse canal by an incision going well back
toward the coccyx, then introducing drainage-tubes into the lateral tracts
and keeping them washed out with antiseptic solutions. They claim
to have obtained excellent results by this method. The objection to
laying open all the lateral tracts at the same time that the fistula is
opened lies in the fact that sometimes the whole anus will be almost
surrcmnded by the incision, thus dissecting it loose from its lateral and
posterior attachments, so that retraction and deformity will follow.
While this deformity does not result in incontinence, it produces a sort
of funnel-shaped approach to the anus which it is very difficult to keep
clean. Besides this, the large cicatrices are occasionally tender and
painful.

Another method consists in cutting through the fistulf)us tract into
the posterior channel connecting the lateral cavities; a probe is then
introduced into each of these and carried circularly forward until the
end rests beneath the skin at its anterior limits; counter-openings are
made at these points and two or three strands of large-sized silk drawn

ji^^sum^ i^?!»uUiar.A{t ril u-^^txn nut ^ju^, ^jmamat wH jf*9L -vioul 5iiir

li^j|^?t» '4i^ iir*^?m ^^!i^»t wrrsm u-^^^r xnw^wrrt juo^iml \t urmiiirrT
^j|»iiui^ ^^-Vr Mi*^ ii#»f:ijvc ^«f viiiflii nut Huniann iiff^rii**!:

^ ^tf*3% w*^4^ t!*^** iii'-z^-ajr *t»^ l»^.i.i\»ii* zsH^jr. i^vr* too'-jinr "^je-
>* -i^^ vfM^p^^ -f^r • .'•.*»5» >r i#v: *»VTj«i*ruf^ \^w-:2LiX v* taj*- latr: -iiac mmit-

COmFUCATtOHS IN OPERATIONS FOR FISTULA

TJ^ /y/r^^,;/:3^^♦v/^< **x:>r.r V/ airt*^ in f^ratkio* for fiiFtnIa maj be
4trt^M iu*'0 ;ffiff>^'^UiiU^, ikUfl H^:ftti^^n, Uie immeduiU are thoi«e that
//^yr«f *innu'/ th^ -^/f^fAfj///!, An/i th^ M^^ymdary thoie that occur after

IHflM^iaU C^mflumtimui. — Oi^M/ir^je of InUMinal Coni^U ortr Ike
OfM^raHr,^. f^i/'J/L Thtn i* ofu: of th^r rnr/itst annoying of the immediate
f'/fn$\f\u%iu/u*., Tht' htiriAn/^'thu of a lar;f*r »[>^^n^e into the rectum i&
a/lriwl t// \trfm*U* nifHtupX thin 9U'j:\(\t',ni, ^/fJt ^nfutiimm, notwithiftandiiig
(thin, IfM? inUnlihul tjfuU^uU will U? forcj^i through and soil the wound.
V/h^rfi iUi' »/'/'i/l<rfit han Usi\f\9*':uM \u of>^;ratin^ by ftxcmon with immediate
Hiiiiin*f nittfit'itiH Ufivi', ntkVcA wheth^;r it i« \nmM\j\i'. to obtain immediate
iirii//0 iiri/|<'f >iii/'b t'irt^tiuiHiJiucj^, lU^niMfmnfi from fiathology and the
kuim\t*A[fi* ihiii \ht' 'mU^XUw alwayn contains a certain number of septic
iuu\ \fyti[fyti'\t' i/t'nuHf ttiu* won Id ari«wr;r ihi« qucntion in the negative;
from t*%\U'ru'Ui'v, bow<*v<'r, it Im known that f»fcal contamination is not
always fafnl Ut \ir\umry union of woundH about the rectum. Such acci-
(Umin can be laff(cly jircvcnUid by thoroughly cleansing out the bowels.

i-olon and ibe sdxrnK^ ^xxity ^c-fccY ojoui^iu: i>«^ YMtrfes. *; iW ^ym^
time holding ibe anns <^f*«ft br a S;23f^"> ><ryv^^Gin axsi a tyvwi; to:i^''Tvc.
By ihes^ m^ms ihe coaiT«iTs of ihe >v*t*i arv all carnoi *>v*mTri ;^i*n iW
rectunu and can K- ma>^>od iv^* b> :TTyrft:>OT.. Th^r a*^7rn^i>i;T*i5t\r* ^-if a
hypodermic of nx^rphino aK^u: hilf ax: hoar V:\vrr iW ^-wraix^ft mill
mlso assist in prerentini: ihi> av\ ja^u;^ a pnxyiv*;?.^ iha* ha^t a *^>«>vly
beneficial effoci, in ihai ii Tvd«<i»> t^^t^^ ')a'rci\v ihr an>vv^rj: .^f *n**s:hcix^
neiV5«anr, and al5>o ix>nn\V]< lo a <iT:a^.n .^o.ctoo ;be :x^n>Jii>*v a^^is^
of the bowels;. When \hv iii^^-harsTi' oniv «vv;;t^ :ho ^'^;>'^7^ni^r. :sh^^v«\5 Si^
stopjvii, tho >|x>nire rt»movt>i, ana tho nvram ihoT\vi;i-h^.\ irr;4:^UM >n::b
a l-to-*2,(XH> biohloriiif <»^^]utK>n, The rtst of iho "»^T^vx^^*:TV shtM^,)*^ be
carried out under ix>n>iAnt irripition wiih a l-i*>-4.iW !a»>h;Ux\n of the
same dniir.

Hirm4frrha(K. — St-rious li><5S i>f Mixvi ir-irln*: ^n o:vra;ion for l^*sn)U
is rare at the pre^»ni ilay. There ;m^ >s*^ n^;4n\ iv.oAns of h,r^niVi:asi> il^at
it is seldom one will inoei with a h.TmorrhAjrt^ wliiih he can not \^^nn\^l
at onee.

If an arterx' lx» cut hiijh u]> m the Twninu i: van Iv i:r:^>|>*H? h\ louar-
pressure fonv}>s and held until a lic>»tui\^ i^n Iv thixnxn ar^^und it. If
the tying of this should W iTU|x\ssihh\ the fonv)v< n\a\ Iv left on for
t went v-f our or thirtv-six hours, and the hjeniorrha^^ will Iv \vtupletelv
contn>lKHl. If it is intendixi under suih eiTxnimstautvs to suturx^ the
wound, one will in\*ariably Iv able to stop the ha^ntorrhai^" hv }v>ssit\g
several sutures underneath the entin^ wound and tvinjr then\ t\irhtK\
Where suturing is not intendixK the aetual eautery applunl to the hUnHi-
ing surfacH:*s will etTivtually i\>ntT>>l the luvmorrhagt^ and it\ a settse
sterilize the wound.

In cases in which then* is a genei^l and fnv ^n^zing, it may Ih^
checked by the use of hot saline solutions appliinl hy i\unpn\^^^\>5 in the
wound. It is well to have such iH^zing cluvktHl Ivfon* applying the
permanent dressing, and exivpt in ntre instamvs the |>atient shotUd be
kept under anaesthesia until this has Ixvn ai\H>mplish^Mh

Spouting vessels should W (H>nt!X>lKHl hy torsion or ligjUun\ Matty
operators depend u|H>n firm }>acking of the wound to iH>i\t!\>l hKvding
after these ojx^rations, and it is usually satisfactory, hut gtvat caiv is
necessaiy in applying it to see that the pi>*ssui>* is exert ih1 upon tite
proper tissues, especially when the wound extends well up itt the ivetuttt.
It should be remembered that the chief blood-vessels lie in the mticoua
and submucous tissues and not in the deeper layers of the wound; ami
that if the edges are everted and the pressure is not brotight to bear tipon
them, the mouths of the vessels may be exposed in the nvtum, and thus
the bleeding will continue. The rectum should be held open during tho

408 THE ANUS, RECTUM, AND PELVIC COLON

through, their ends tied together and left in the wound as a sort of
seton. The sinuses can be washed out daily with antiseptic solutions;
the threads should be left in for ten days, at the end of which time
healthy granulation will develop and the sinuses will heal within four
or five weeks, the skin overlying them remaining perfectly healthy.
Where the lateral tracts burrow deeply upward instead of circularly
around the rectum, this method would not be advisable. Incision and
drainage after the method of Quenu and Hartmann, together with
cauterization by carbolic acid or iodine, or, if one prefers, by the sat-
urated solution of nitrate of silver, will be better.

There is no advantage to wait, as is suggested by Goodsall, for two
or three weeks after incising the fistulous tract before applying the
cautery. It is best to dry out the wound at the time of the operation
and apply the cautery then and there. The use of the thermo-cautery
in deep abscess cavities is not advisable owing to the fact that some-
times extensive sloughing follows this operation, and if the instru-
ment approaches too closely to the wall of the gut necrosis of the
tissues may take place, and a secondary and high opening may be
produced.

After the fistula has healed, if the retraction of the rectum causes
any great inconvenience, or there be any incontinence, the cicatrices,
may be dissected out, the anus loosened from its new attachment and
brought down and sutured in its normal position.

COMPLICATIONS IN OPERATIONS FOR FISTULA

The complications likely to arise in operations for fistula may be
divided into inmfiediate and secondary. The immediate are those that
occur during the operation, and the secondary those that occur after
it is finished.

Immediate Complications. — Discharge of Intestinal Contents over the
Operative Field. — This is one of the most annoying of the immediate
complications. The introduction of a large sponge into the rectum is
advised to provide against this accident, but sometimes, notwithstanding
this, the intestinal contents will be forced through and soil the wound.
When the accident has happened in operating by excision with immediate
suture, students have asked whether it is possible to obtain inmiediate
union under such circumstances. Reasoning from pathology and the
knowledge that the intestine always contains a certain number of septic
and pyogenic germs, one would answer this question in the negative;
from experience, however, it is known that faecal contamination is not
always fatal to primary union of wounds about the rectum. Such acci-
dents can be largely prevented by thoroughly cleansing out the bowels.

FISTULA 409

tlie day before operation and practising massage over the descending
colon and the sigmoid flexure before cleaning the parts, at the same
time holding the anus open by a Sims's speculum and a rectal retractor.
By these means the contents of the bowel are all carried down into the
rectum, and can be washed out by irrigation. The administration of a
hypodermic of morphine about half an hour before the operation will
also assist in preventing this accident, a precaution that has a doubly
beneficial effect, in that it reduces very largely the amount of anaesthetic
necessary, and also controls to a certain degree the peristaltic action
of the bowels. When the discharge once occurs the operation should be
stopped, the sponge removed, and the rectum thoroughly irrigated with
a l-to-2,000 bichloride solution. The rest of the procedure should be
carried out under constant irrigation with a l-to-4,000 solution of the
same drug.

11 ccmorrhage . — Serious loss of blood during an operation for fistula
is rare at the present day. There are so many means of haMiiostasis that
it is seldom one will meet with a haemorrhage which he can not control
at once.

If an artery be cut high up in the rectum, it can be grasped by long-
pressure forceps and held until a ligature can be thrown around it. If
the tying of this should be impossible, the forceps may be left on for
twenty-four or thirty-six hours, and the haunorrhage will be completely
controlled. If it is intended under such circumstances to suture the
wound, one will invariably be able to stop the haemorrhage by passing
several sutures underneath the entire wound and tying them tightly.
Where suturing is not intended, the actual cautery applied to the bleed-
ing surfaces will effectually control the haemorrhage and in a sense
sterilize the wound.

In cases in which there is a general and free oozing, it may be
checked by the use of hot saline solutions applied by compresses in the
wound. It is well to have such oozing checked before applying the
permanent dressing, and except in rare instances the patient should be
kept under anaesthesia until this has been accomplished.

Spouting vessels should be controlled by torsion or ligature. Many
operators depend upon firm packing of the wound to control bleeding
after these operations, and it is usually satisfactory, but great care is
necessary in applying it to see that the pressure is exerted upon the
proper tissues, especially when tlie wound extends well up in the rectum.
It should be remembered that the chief blood-vessels lie in the mucoua
and submucous tissues and not in the deeper layers of the wound; and
that if the edges are everted and the pressure is not brought to bear upon
them, the mouths of the vessels may be exposed in the rectum, and thua
the bleeding will continue. The rectum should be held open during the

400

THE ANTTS, RECTtTM, AND PELVIC COLON

them lo heal. After the tracts have been laid open the sphincters
should be thoroughly dilated and the treatment for simple rectal ulcera-
tion begun. In these cases rest in bed is imperative, the diet should
be carefiiUy regulated, and
the stools kept regular and
^■■luisolid.

No force should ever be
used in the introduction
of a probe or grooved di-
rector into a fistulous tract.
'I'be cellular tissues about
I Ik.' [larts are so soft that
tlirv may be easily pene-
Micd, and one may even
II i-u hoth the externa!
.J ml internal openings and
\<.'t leave a part of the fis-
Hdii intact (Fig. 144).

After the fistulous tract
has been laid open, it often
happens that the burrow-
ing around the rectum ex-
tends considerably above
the level of the internal
opening. Many operators
claim that it is wise to incise the recta! wall up to the highest pojnt
of such cavities. This, however, is rarely necessary. If the parts are
thoroughly drained and the sphincters put at rest by stretching and
incision, these cavities will rapidly fill up by healthy granulation, and
the cutting of the internal sphincter will be avoided. If, however, there
should be a burrowing tract involving only the mucous membrane of
the rectum, it is safer to lay this open. In order to avoid hiemorrhage,
the heated knife should be used for this purpose. All burrowing tracts
and diverticuli should he freely laid open into the main wound. Where
the fistiila is connected by burrowing tracts with the retro-rectal or
pelvi-rectal spaces, these cavities should bo opened into the general
wound and drained by the introduction of rubber tubes.

The dressing of the wounds after all these operations for fistula is
the same as that already described ; they should never be packed tightly,
inasmuch as this holds the tissues apart and results in delayed union
with extensive cicatrices.

Comphx Fistula. — Quite a large percentage of fistulas are of the
oomplei variety. Any perirectal abscess or fistula, if improperly drained.

(

FISTULA

401

I may resolve itself into this variety through burrowing and destruction
I of tissue.

They are described as fislulaa wilk lateral burrowing tracts, watering-
I P"^ fistulas, and horsenh-oe fistulas.

Fistula u-ilh Lateral Burrowing Tracts. — Any simple fistula resulting
[• from an absei?ss left to open spontaneously, or occurring in individuals
L with vitiated constitutional conditions, is likely to become complex
I ty burrowing tracts leading off from the abscess cavity. Goodsall
L pointed out many years ago the rules of extension of fistulous tracts.
[ Those in the anterior quadrant proceed directly into the anus or rectum,
I the aperture being found ahoost perpendicularly above the external
I opening. Those in the posterior quadrants extend circularly around the
[ Anus, and generally open at some point near the posterior commissure.

Subtegumentary fistulas at any point on the anal circumference may
I burrow subcutaneously in ail directions, because there are no connec-
I tive-tissue walls to obstruct them. Those situated anteriorly are likely
I to extend forward into the perineum and scrotum or upward into the
I cruro-scrotal fold. Those

■ situated posteriorly bur-
r row outward info the but-
[ , tocks, or upward behind
I the coccyx and sacl-um he-
Fneath the skin. The ex-
r tent to which these sub-
I cutaneous burrowings may
Itake place is very remark-

■ able. In one case a small
I anterior fistula burrowed
rforward through the peri-

■ nceum and crural folds and
upward into tlie iliac re-
gion, opening upon the
akin at a point near the
anterior superior spine of

I. the ilium. In another case

j (Fig. 147) a superficial fis-

I tula burrowed upward out-

Pnde of the sacrum and coccyx, turned anteriorly above the level of

f the fourth sacral vertebra, passed underneath the gluteal muaclea, and

['Opened at a point just below the greater trochanter.

An apparently simple, direct, subtegumentary fistula may have a
I'traet burrowing upwanl into the ischio-rectal fossa (Fig. 145) or even
[ entering the superior pelvi-rectal space. Submuscular fistulas [

402

THB ANUS, RECTUM, AMD PELVIC COLON

through the ischio-rectal fossa are very liable to have burrowing sinuses
leading off from them into the fosea of the opposite side, or into the
retro-rectal space (Fig. 146). Where they extend around the anterior
or posterior commissure of the anus they are called horseshoe fistulas.
It has frequently happened that small subcutaneous fistulas, after
having been laid open, continue to suppurate for long periods, and upon
close examination in these cases it has been discovered that small sub-
mucous tracts were burrowing upward beyond the internal opening of
the iistula.

The treatment of these variotieB of complex fistula has been prac-
tically described under those of general operations. It consists in
the incision and thorough drainage of every burrowing tract, whether
it be superficial or deep. In the superficial variety excision and imme-
diate suture may be applied. Where simple incision is employed the
cutting should always be
made beyond the limit of
the burrowing of the tract
for the reason that the
edges of the skin rapidly
retract and may very easily
form a pocket before heal-
ing from the bottom has
taken place. It is neces-
Siirj' to say something upon
the treatment of fistulas
opening at remote dis-
tances from the anus. In
certain of these cases the
large amount of tissue in-
volved and the extent of
the woimd necessary to lay
open the entire tract cre-
ates a condition entirely
out of proportion to the
gravity of the disease. In
the case opening near the
trochanter (Fig. 147) the
laying open of the fistulous
tract would have involved the cutting of the gluteus maximus and
medius, the gluteal artery and lesser sciatic norve, together with a wound
of DO less than 18 inches in length. In such cases it is advisable to
follow the fistulous tract from the external opening as far as possible
with a long probe, and at that place make a counter opening large enough

403

L this ineiaion the proho can
I secoml tountor opening luade

I to admit a drainage- tubo into it. Frt
J then be introduced still farther and i
I ae before, and so on untii

one is made at a site about

1 or 2 inches from the anal

margin. From this point

to the interaai opening of
I the (iatula all the overlying

tissues may be cut through,

and the condition treated

as one of complete listula

extending from the last

counter-opening. The fis-
tulous tract beyond this

last counter-opening ia

treated by curetting, atinui-

lating applications, am)

drainage. As a rule they

will close rapidiv and com-

P1....1,. Of c„„™ it ,hcre. '■"- "--"vrr T.::;r.r" "'" '""

should be lateral burrow-

ins tracts from this main fistulous canal, it would be necessary to lay
' these open and drain aa has been previously described.

Fistula with more than One External Ojmiiiuj; Water ing-pnt Fisttila. —
' When a fistula has existed for an indefinite length of time and the drain-
t age has been insufficient, numerous burrowing trai-ts may form and
I each open externally upon the skin. In this manner there will be eatab-
I lished what has been described as watering-pot fistula. The number of

Buch external openings is unlimited. Goodsall and Miles have described
1 case in which there were forty-three separate and distinct external
I apertures. This by no means implies a multiplicity of internal openings,
f for in the majority of these cases there is only one.

The nund)er of external openings, however, does hear some relation
I to the size of the internal opening, to the constitutional condition of the
1. patient, and the duration of the fistula (Goodsall and Miles, p. 117).
L Ordinarily in cases with numerous external openings one will find a
I large internal opening, generally between the two sphincters, and into
J which the ends of one or two fingers can be introduced. Sometimes a
[ Boft, flexible probe introduced through this internal opening will pass

directly out through the primary external opening, and where there is
I any donbt in the mind of the patient as to which of these occurred first,
r this may prove a practical solution of the problem.

The treatment of this condition will depend largely upon the conati-

404 THE ANUS, RECTUM, AND PELVIC COLON

Excision and suture are impracticable in cases of this kind. Many
of those which the author has seen have been associated with constitu-
tional syphilis, and, while not being complicated by any syphilitic
stricture of the rectum, they have proved obstinate to treatment
until the effects of mercury and iodide of potash have been well
established.

Fistula with more than One Internal Opening. — This variety is much
more rare than the preceding. There may exist two internal openings
connected with two distinct fistulas, or there may be two or more con-
nected with only one external opening. It may be caused through punc-
ture of the rectal walls by a sharp bone, needle, or other foreign body
caught crosswise in the rectum and setting up two distinct abscesses and
fistulous tracts upon opposite sides. These abscesses may burrow, coa-
lesce outside of the rectum, and open by one common external aperture.
It sometimes happens also that in a horseshoe fistula or double abscess
of the ischio-rectal fossae, an opening may occur within the rectum on
each side, whereas only one exists externally.

The treatment of this variety depends entirely upon the anatomical
character of the fistulas; if they are subtegumentary they should be laid
freely open or dissected out and the wound sutured; if, however, the
tract is submuscular it would be unwise to attempt an operation by incis-
ing both tracts at the same time. It is better to lay open one tract
thoroughly through the sphincter muscle, extend the incision laterally
so as to establish complete drainage, and at the same time cauterize the
other openings and tracts with a saturated solution of nitrate of silver.
If necessary secondary operations may be performed after the first has
healed, and ordinarily the remaining fistula will be so reduced that ex-
cision with immediate suture can then be performed with safety.

Horseshoe Fistula, — This consists in a fistulous tract surrounding the
posterior or anterior commissure of the rectum. Occasionally one finds

FISTULA 4,05

both conditions in the same patient, the fistula thus forming a complete
circuit of the rectum {Pig. 148),

The typical horseshoe fistula consists in a tract that runs from one

ischio-rectal fossa above the aponeurosis of the externa! sphincter and

around the posterior commissure of the rectum into the fossa of the

opposite side. It may have one or two external openings; it may have

one, two, or no inter-

I nal openings; as a rule \

I there is one external

\ opening upon one side

I or the other of the

. anus, and one internal,

usually at the posterior

I commissure of the rcc-

I iatn just above the

a of the external

incter.

; is said by com-

operatora tlial

[ this type of fistula is

[.rarely tubercular, ami

[my experience eoin-

I sides with this opinion.

FThe posterior variety

B generally submuacu- ^"'' "" ''■"■ "' l'"-"*--!"" ■'-'■■-a ...tii^iti. .,n m
I lar, in that it is above

I the level of the external sphincter and passes above its aponeurosis,
! anterior variety is generally eubtegumentary, owing to the fact
t there is no deep cellular tract between the perineal body and
anus. The fistulous tract may therefore be of considerable depth
t each side of the perineal body, hut is superficial as it crosses the
[■nterior commissure.

Treatment. — The anterior variety may be dealt with either by the

en method or by excision witli immeiliate suture. When there has

It been much burrowing and there are no tracts leading into the

Krotum and crural folds, they may be dissected out and the wounds

KjClosed. This is generally an easy operation owing to the fact that

stulas in the anterior quadrants of the rectum usually open into Ihe

3 quite low down, and ordinarily have no deep, burrowing tracts

J that extend up along the rectal wall. The tract generally consists in a

■ well-developed, more or less globular cavity on each side of the perineal

Ptiody connected by a narrow, superficial tract that runs underneath

B akin from one cavity to the other, and resembles a curved duml>-

THE ANUS, RECTUM. AND PELVIC COLON

■ Stttcral cavities are
le trianfTular ligament.
Excision and suture
are themfore practica-
ble, but it requires
skill and a complete
knowledge of the anat-
omy of the parts to
avoid the blood -vesBels
and nen-ea which trav-
erse this area. Where
the condition does not
M-Jiirant an attempt at
this method of treat-
ment, the fistula
should be laid open by
careful dissection, the ends of the sphiiicter muscle being cut squarely
across and pulled to one side while the cicatricial tissue is removed.
It is not safe to use the cautery freely in tliis area as the sloughing
which follows it may implicate the urinary organs, but gentle curetting
and the application of carbolic acid to the tract may be safely used.
After thiB the parts bIiouM be packed lightly with absorbent gauze
soaked in oil and balsam, or in glycerin and Ichthyol. In women great
judgment must be exereiaed in this class of cases not to destroy too
much of the perineal body; excision and iiuniediatc suture should al-
ways be performed i

postt
horseshoe fistula
internal opening
usually situated i
the posterior

: and between the
two sphincters. It is
generally of consideia-
ble size, and can bo
distinctly
by digital touch. The
lateral burrowings
may be superficial, but
generally they estend
deeply into the iscli
f be upon

FISTULA 407

sides. The cavities in such fistulas are generally so irregular that ex-
cision with immediate suture is not very practicable. In most of these
cases the entire fistulous tract around the posterior commissure of the
anus is laid open from one side of the rectum to the other, always carry-
ing the incision in the skin a little beyond the extremity of the burrow-
ing. After this has been done Jind the parts have been thoroughly
scraped out, a grooved director is passed from the incision posteriorly
through the fistulous opening into the rectum, and the intervening tis-
sues are cut tlirough. Frequently a considerable amount of dense,
nodular, cicatricial tissue is found at this point. When such is the
case it should be dissected out. Goodsall advises allowing the fistulous
tract between the posterior wound and the rectum to remain untouched,
and states that this method has three advantages, viz.: that haemorrhage
can be more readily controlled by plugging the wound; that when the
bowels move the wound will not be soiled by the escape of faeces or
flatus; that should the fistula be closed without the division of the ex-
ternal sphincter there can be no loss of power even in that muscle.
Neither }ia»morrhage nor division of the sphincter at this point are ever
serious, and soiling by faecal material is not so inimical to healing as
constant reinfection from a fistulous tract. This is the same old storv
which has been so often told in the treatment of fistula — an attempt to
cure the condition by leaving the pathological cause untouched. If it
were necessary to choose between leaving this portion or the lateral
tracts unopened, by all means select the latter, as complete healing
would be much more likely to take place.

Quenu and Hartmann advise laying open the fistulous tract leading
from the rectum to the transverse canal by an incision going well back
toward the coccyx, then introducing drainage-tubes into the lateral tracts
and keeping them washed out with antiseptic solutions. They claim
to have obtained excellent results by this method. The objection to
laying open all the lateral tracts at the same time that the fistula is
opened lies in the fact that sometimes the whole anus will be almost
surrounded by the incision, thus dissecting it loose from its lateral and
posterior attachments, so that retraction and deformity will follow.
While this deformity does not result in incontinence, it produces a sort
of funnel-shaped approach to the anus which it is very difficult to keep
clean. Besides this, the large cicatrices are occasionally tender and
painful.

Another method consists in cutting through the fistulous tract into
the posterior channel connecting the lateral cavities; a probe is then
introduced into each of these and carried circularly forward until the
end rests beneath the skin at its anterior limits; counter-openings are
made at these points and two or three strands of large-sized silk drawn

408 THE ANUS, RECTUM, AND PELVIC COLON

COMPLICATIONS IN OPERATIONS FOR FISTULA

The complications likely to arise in operations for fistula may be
divided into immediate and secondary. The immediate are those that
occur during the operation, and the secondary those that occur after
it is finished.

Immediate Complications. — Discharge of Intestinal Contents over the
Operative Field, — This is one pf the most annoying of the immediate
complications. The introduction of a large sponge into the rectum is
advised to provide against this accident, but sometimes, notwithstanding
this, the intestinal contents will be forced through and soil the wound.
When the accident has happened in operating by excision with immediate
suture, students have asked whether it is possible to obtain immediate
union under such circumstances. Reasoning from pathology and the
knowledge that the intestine always contains a certain number of septic
and pyogenic germs, one would answer this question in the negative;
from experience, however, it is known that faecal contamination is not
always fatal to primary union of wounds about the rectum. Such acci-
dents can be largely prevented by thoroughly cleansing out the bowels.

FISTULA 409

the day before operation and practising massage over the descending
colon and the sigmoid flexure before cleaning the parts, at the same
time holding the anus open by a Sims's speculum and a rectal retractor.
By these means the contents of the bowel are all carried down into the
rectum, and can be washed out by irrigation. The administration of a
hypodermic of morpliine about half an hour before the operation will
also assist in preventing this accident, a precaution that has a doubly
beneficial effect, in that it reduces very largely the amount of anaesthetic
necessary, and also controls to a certain degree tlie peristaltic action
of the bowels. When the discharge once occurs the operation should be
stopped, the sponge removed, and the rectum thoroughly irrigated with
a l-to-2,000 bichloride solution. The rest of the procedure should be
carried out under constant irrigation with a l-to-4,000 solution of the
same drug.

HcBfnorrhage. — Serious loss of blood during an operation for fistula
is rare at the present day. There are so many means of ha»mostasis that
it is seldom one will meet with a ha^morrliage which he can not control
at once.

If an artery be cut high up in the rectum, it can be grasped by long-
pressure forceps and held until a ligature can be thrown around it. If
the tying of this sliould be impossible, the forceps may be left on for
twenty-four or thirty-six hours, and the hannorrhage will be completely
controlled. If it is intended under such circumstances to suture the
wound, one will invariably be able to stop the haemorrhage by passing
several sutures underneath the entire wound and tying them tightly.
Where suturing is not intended, tlie actual cautery applied to the bleed-
ing surfaces will effectually control the haemorrhage and in a sense
sterilize the wound.

Spouting vessels should be controlled by torsion or ligature. Many
operators depend upon firm packing of the wound to control bleeding
after these operations, and it is usually satisfactory, but great care is
necessary in applying it to see that the pressure is exerted upon the
proper tissues, especially when the wound extends well up in the rectum.
It should be remembered that the chief blood-vessels lie in the nmcous
and submucous tissues and not in the deeper layers of the wound; and
that if the edges are everted and the pressure is not brought to bear upon
them, the mouths of the vessels may be exposed in the rectum, and thus
the bleeding will continue. The rectum should be held open during the

410 THE ANUS, RECTUM, AND PELVIC COLON

dressing by a duckbill speculum and rectal retractor, in order that the
pressure can be accurately applied.

Haemorrhage is very likely to follow operations done under local
cocaine anaesthesia. As is well known, this drug contracts the arterioles
to such an extent that they bleed very little; and so long as its effects
last one may have an almost bloodless wound, whereas after its influ-
ence wears away the parts sometimes bleed excessively.

It is important therefore when one operates with it to require the
patient to remain quiet for one or two hours until the influence of the
drug has entirely disappeared; after this the superficial dressings should
be removed, the parts examined, and if there is any evidence of bleeding
the wound should be more firmly packed or the vessels tied.

Another point which it is necessary to remember with regard to
haemorrhage is the possibility of a ligature's slipping after it has once
been applied. This may be due to the fact that a very slight hold has
been taken upon the vessels in the first place, or that the operator has
pushed the ligature off in crowding a dressing into the wound. There
is no necessity or advantage in the applications of alum, perchloride of
iron, or other styptics in cases of this kind; they all irritate the parts,
form a hard, fragile clot, which, when the dressings are removed, is
very likely to slip out and cause haemorrhage to recur ; they delay healing
and accomplish nothing which can not be done by plain hot water or
firm pressure from dressings properly applied.

Complications of Ancesthesia, — These are not peculiar to rectal opera-
tions, and need not be entered into in detail here. One precaution, how-
ever, should be mentioned, viz., in administering chloroform the mask
should always be removed when the sphincter is stretched, as this excites
deep respirations, and too much of the drug may be inhaled suddenly
and cause fatal results.

Secondary Complications. — The secondary complications in opera-
tions for fistula are described as early and late. Of the early complica-
tions the most important are retention of urine, involuntary faecal pas-
sages, shock, and sepsis.

Retention of Urine. — There is nothing peculiar in the retention of
urine following operations for fistula. It is of the same character as
that seen after almost every surgical procedure in the rectum.

In operations about the anterior quadrants of the rectimi one should
always remember the possibility of injuries to the urethra, and also the
fact that much manipulation and traumatism of these parts may result
in an acute congestion of the periurethral tissues, which will cause a
temporary oedema and constriction of the urethral canal. In such cases
it will sometimes be found impossible to pass an ordinary soft-rubber
or flexible catheter into the bladder, and one should always be proTided

FISTULA 411

with a sterilized silver catheter in order to be able to draw the urine.
As soon as the congestion subsides these symptoms of stricture rapidly
disappear. It is advisable to induce the patient to urinate if possible
before attempting to catheterize him, even if he has to stand on his
feet to do so. It is well to wait for from twelve to fourteen hours before
resorting to the catheter, only varying tliis rule in such cases as suffer
from distention of the bladder. A cei-tain amount of cystitis and atony
of the bladder may be developed by too long delay, but it very much
more frequently occurs as a result of too frequent and too early cathe-
terization, even under the most careful antiseptic precautions. The
catheter itself may be perfectly sterilized, the operator as clean as anti-
septics can make him, and yet the walls of the anterior and deep urethra
can not be sterilized, and the slightest traumatism or abrasion, such as
may be produced by the softest instrument, will sometimes set up
urethritis and cystitis which will require months to cure.

Firm packing may not only cause retention of urine, but also render
the passage of the catheter impossible. When this occurs the dressings
should be removed, and frequently after this is done the patient can
pass urine voluntarily. In all cases before the catheter is passed the
anterior urethra should be flushed with boric-acid solution. This sub-
ject is more fully discussed in connection with op#ations for haemor-
rhoids.

Involunfary Defecation. — If the bowels have not been thoroughly
emptied before the operation, the patient may have a pressing desire
to defecate immediatel}^ after recovering from the anaestlietic, or he
may even do so involuntarily before consciousness is restored. In such
cases, if excision and immediate suture has been practised, the parts
should be irrigated with a l-to-2,00() bichloride solution, gently dried,
and the dressings reapplied. If the open method has been practised,
only such dressings as are disturbed or soiled by the passage should be
removed.

When the patient after becoming conscious complains of a pressing
desire to defecate, one should not insist upon controlling it too long;
a concealed haemorrhage in the rectum will sometimes occasion this, and
if that is the case it is very important to find it out at once; therefore,
when the desire is at all pressing, the superficial dressings should be
removed and the patient allowed to relieve himself. Occasionally noth-
ing more than a small amount of gas or a little fluid will come away,
but no harm will result from this, and it will remove all doubt as to
concealed lucmorrhage.

Shock. — Surgical shock may follow operations for fistula; especially
is this likely if the patient is much exhausted from long suppurative
processes, or if the operation is an extensive one and done by the actual

412 THE ANUS, RECTUM, AND PELVIC COLON

cautery; a slight haemorrhage is not nearly so likely to produce this result
as deep and extensive cauterization. On account of this fact the use
of the Paquelin in large burrowing tracts with great destruction of tissue
occurring in weak and debilitated individuals is not to be advised.

The symptoms and treatment of this condition are laid down in
every work upon general surgery, and do not differ in cases following
operations upon the rectum, except in one point: it is not practicable
to employ rectal injections of hot saline solutions, because the dressings
would have to be removed and the impairment of the sphincter would
allow the fluid to come away at once. Hypodermoclysis and intravenous
infusion are the practical means of treating this condition in these cases.

The writer is a firm believer in the use of large doses of morphine
in surgical shock, excepting where the kidneys are diseased. It quiets
the nervous excitement, reduces the frequency and increases the depth
of the respiration, and is at the same time more or less of a heart stimu-
lant. Nitroglycerin is also an excellent remedy if administered in doses
sufficiently large to produce its physiological effect. Hot packs and
alcoholic stimulants are also useful. For general instructions upon this
subject, however, the reader is referred to the modern works upon gen-
eral surgery.

Sepsis, — Acute ♦epsis sometimes follows operations for fistula. It
may develop within the first few hours, and does not often do so later
than the third day. When it occurs it assumes the form of diffuse peri-
proctitis, a condition which has been already described. It is this com-
plication which renders it imperative to take every antiseptic precaution
in such operations notwithstanding the fact that pus is already present.
A mild form of sepsis which results in secondary abscesses is sometimes
seen. In these cases incision and drainage is the rule to be followed.

Late Complications. — Of the late complications in operations for
fistula the most important are incontinence of faeces, extension of bur-
rowing, irregularity of healing, persistent discharge, and partial pro-
lapse.

Incontinence of Fceces. — This condition has been discussed so much
that it has become a nightmare to the profession and a stumbling-block
to every layman suffering from fistula. It is the shibboleth of the
charlatan by which he frightens the sufferer away from the regular sur-
geon and induces him to be content with the palliative treatment of his
condition rather than submit to an operation accompanied by such a risk.

It does not occur with anything like the frequency that is generally
attributed to it. In a large number of observations the author has met
with only one case of partial incontinence following a successful opera-
tion for fistula in its early stages; other instances have resulted from
operations upon old, extensive fistulas with burrowing tracts or multiple

FISTULA

413

openings which have been long neglected, or whicli have been imper-
fectly operated npon in the beginniug and failed to heal.

Incontinence may result from simple divulsion of the sphincter, but
in such cases it is associated with some form of spinal or nerve disease
on account of which the tonicity of the muscles is not properly re-
established. A single irregular, diagonal, or jagged incision of the
sphincter may result in such vicious union that the patient will not
possess normal ftecal control, but such incisions will not be made if the
technique described above is carried out.

Some authors hold that if the internal sphincter is preserved, one
may incise the external in any direction without danger of incontinence

I (Fig. 151). While this may be true to a certain extent with reference to
unconscious frecal passages, it certainly is not so with reference to the
Toluntary control. A patient willi
the external sphincter destroyed
may never have a stool unconscious-
ly, but when the contents of the
intestine reach tJie ampulla of the
leetnin, it will be impossible to
control it long enough for him to

I reach the toilet if the stools are

' ihin and he is at an inconvenient

I distance. The integrity of the ex-
ternal sphincter is absolutely neecs-

I aary for the voluntary control of the

[ anus. This integrity does not pre-

[ elude the possibility of the muscle's

j having been severed and reunited.
It is only a question of the mus-

I cular fibers uniting end to end or

' through such a narrow plane of

I cicatricial tissue that their length

I Trill not be materially increased. It is on the same principle as a fibrous

I Tinion between two fragments of a fractured patella. If the fibrous

r union is narrow and firm, functional action will not be impaired. If,
however, the parts are united by long, fibrous bands, the functional
action of the vastus muscle will be practically destroyed. So in the
sphincter, when its fibers have been incised and are separated by wide
cicatricial masses, the length is so increased that sufficient contraction
to thoroughly close the anus is practically impossible. Oblique incisions

J of the muscle allow the divided ends to slide upon one another, thus

I lengthening the muscle and bringing the internal fibers of one end in
contact with the external fibers of the other {Fig. 152). This vicious

Fia. 151.

J. oblique incii'ion of BphinoLur which is fle-

qm^nlly ful lowed by iiicontimjiite, S,

Irnnxverw Ineution not likely tu rmalt In

414

THE ANUS, RECTUM, AND PELVIC COLON

iiiiion is always followed by more or less incontinence. The large ma-
jority of cases of incontinence following operations for fistula could be
avoided if the external sphincter were cut squarely across and the ends
sutured together, or the packing so applied as to separate the ends very
slightly.

WTiere the fistula passes through the external sphincter muscle,
involving only its lower portion, these fibers may be severed with im-
punity, and the necessity of suturing may
not appear; but where the entire external
sphincter is cut and the edges of the
wound retract to a considerable distance,
one must always be prepared to meet with
a certain amount of incontinence follow-
ing the operation.

It has been claimed that incontinence
never results from a single incision of the
sphincter muscle, but this statement can
not be substantiated. It is not a ques-
tion of one or two incisions of the muscle
so much as it is of a close and accurate
reunion. The muscle may be cut twice,
three times, or oftener, and if it be im-
mediately reunited no incontinence will
result. A number of cases have been re-
ported an which it has been cut at two or
three different points without immediate
suture, and without any incontinence resulting. The reports are all
too meager to prove that the entire external sphincter was severed; it is
probable that in the majority of them only the lower segment of the
muscle was cut. Where the muscle is completely severed in more than
one place, unless it be inmiediately sutured the retraction will necessitate
such a wide cicatricial union that functional activity will be much im-
paired. There are cases, it is true, in which both sphincters have been
severed at several points or entirely removed, and in which the anal
outlet and lower end of the rectum is left as a narrow, cicatricial canal,
and yet these patients suffer from no incontinence. These exceptions
only prove the rule.

When the external sphincter is incised more than once, or by oblique
incision, or where the ends are separated in union by a wide cicatrix,
incontinence will almost always follow. The question therefore arises
what is to be done in such cases.

Treatment. — Where the incontinence is partial, much relief may be
obtained without operative interference. Galvanism, hot fomentations.

Fig. 152.

On the left is sliown the Beparation
and lengthening of Uie muscle (i
to f) due to oblique incision. On
the right is seen the vicious union
of the fibers and the line of inci-
sion for repairing the muscle.

115

Effe persistent passage of medium-sizoil bougies have some influence
Tin hastening the abgorption of cicatricial depoeits, and will sometimes
rely cure these patients. They ehould be tried in all such cases
r before resorting to operative procedures.

Operative Trraimrnt. — The ideal method for the relief of inconti-
■nee c-onsistB in restoring the continuity of the muscular fibers. The
issibility of accomplishing this will depend first upon the amount of
I the muscle destroyed by the original operalion and subsequent sloughing
I of the tissues; and, secondly, upon the length of time which has elapsed
^ the operation. Where the destruction of tissue has been very
Lgreat, the muscular fibers left may be too short to be brought into eon-
Itact. This is fortunately not often the case. More frequently in-
F continence is the result of an imperfect and irregular union of the
I muscle, as exhibited in Fig. 152. It will be seen in such cases that
I the union of the libers allows only a few of them to act at all; that the
I distance between the fixed portions has been so increased that the ut-
[ most contraction will not close the anal aperture, and that the cor-
' responding fibers of the muscle which have been incised are ni)t in con-
tact with each other. The operation indicated in these cases is short-
ening the muscle and bringing into normal apposition its two ends.
The method usually advised to accomplish this consists in freshening
I the edges by taking a V-shaped piece out o£ the angle, as is shown in
I Fig. 153. and suturing the parts together. It is perfectly clear that
r such an incision will not shorten the elon-
gated muscle materially, neither will it
enable one to bring the corresponding
fibers into apposition with each other. If
\ the V-sliaped incision is inverted, as shown
■<is Fig. 152, causing the two legs to diverge
1 outward, thus cutting the fibers squarely
[•cross, the muscle will be shortened and
I the fibers can be brought into a eompara-
I (ively norma! apposition. This incision
1' having been made, the tissues intervening
I between the legs of the incision should bi'
I excised, the ends of the muscle dissected
k«ut and sutured squarely together bv chro- ' '

V . ■ , . . . ,, ■;, n , " , i'"- ISB. — Old Uetbod or re.

■ ^icized catgut. ;Vfter the ends have been kauii^o Spih.hktbr

1 sutured together, it is well to pass a silver

[ wire or catgut tension suture through the skin and sphincter muscle
distance from the incision, carrying it across the wound
I laid out through the muscle and skin on tlie opposite side. After
( the wound has been closed this suture should be tied over a pad

416 THE ANUS, RECTUM, AND PELVIC COLON

of iodoform gauze so as to prevent tension upon the sutures that
hold the ends of the muscle together until they shall have sufficient
time to unite; it is allowed to remain in position for five to eight days,
according to the amount of irritation it produces. Another plan to
accomplish this same end is by passing around the anus, on a level witli
the superior border of the external sphincter, a buried kangaroo tendon,
and, tying it firmly upon the index finger, introduce it into the anus
as is done in the operation for prolapse.

In this operation the mucous membrane should be dissected up from
the muscle before the latter is incised, and after its ends are brought to-
gether the membrane should be sutured back into position; none of it
should be destroyed. It is needless to say that it is important to check
all oozing and bring together the deeper portions of the wound from
which the segment of cicatricial and muscular tissues has been excised,
before closing the incision.

The patient's bowels should be confined for six to eight days after
such an operation, at which time they should be induced to move by
injections of oil and glycerin in the proportion of three to one. These
injections should be repeated twice daily until all the hard, fa?cal masses
have been removed, after which time the patient may be given a laxative
by the mouth. The fact that a patient develops an elevation of tempera-
ture of 1, 2, or 3 degrees during this period of constipation should not
alarm the surgeon, although it is necessary to carefully examine the
wound daily to be sure that no suppuration and abscesses form in
the parts.

A\Tiere sepsis does occur and a small abscess develops, it is not neces-
sary to lay the whole wound open; it should be treated simply by in-
oision and drainage in such a direction that the united ends of the
sphincter will not be separated.

Where the sphincter muscle has been divided in more than one place,
it is advisable to divide the operation into two or more steps, suturing
at the first sitting all the incisions upon one side, and leaving those
upon the other for a future operation. By attempting to unite all the
parts at once, too great tension upon the ends of the muscle may de-
velop, and too much inflammatory reaction may be set up in the parts
for proper healing. Where the operation is done upon one side alone
little tension will occur, and union will not often fail. The second
operation may be attempted at the end of three or four weeks after
the first.

The patient should be absolutely confined to bed after such an
operation, and the buttocks, after the dressings have been applied,
should be strapped together with a broad band of adhesive plaster in
order to prevent any traction upon the wound which might occur from

FISTULA

417

;hese parte^eing caught and dragged upon by the bed-clothing. If the
internal sphincter haa been divided, its ends should he dissected out
and sutured together, but here it will be impossible to use the ten-
_ aion suture.

Where incontinence has existed for long periods of time, the mus-
L eular fibers may become so atrophied that it will be impossible to reeog-
I Hize them and bring their ends together. Indeed, they become degen-
lerated into fibrous tissue, and there is no longer any real muscle. In
Lnich cases the only relief which cliii ho cxju'cti'd will h<- comparative.
} narrowing of the auul outlet l\ ,i ■:-■ ■ i ■. . ■ ■. ! benefit the

Fio. 154.— CHKTVtuuii'd Oi'l:

patient conaiderably, but restoration of function is improbable. This
k should be explained to the patient before the operation is undertaken in
|<order to avoid disappointment.

Chetwood, of New York, has succeeded in restoring the functional
I activity of the anus in a case of this kind by a most ingenious plas-
■iic operation. The patient suffered from absolute incontinence, and
■ external examination revealed no evidence of the existence of a
Rcphincter.

The doctor made a largo semicircular incision extending from one
mberoeity to the other, its convexity being directed backward toward
W-ibe coccyx and a little beyond it (Fig. 154). The flap thus made was

418

THE ANUS. EBCTUM, AND PELVIC COLON

Fio. 155.— Chstwood':

turned forward, and the fatty tissue dissected away until the lower end
of the rectum at the edges of the glutei muscles were exposed. A
ribbon-shaped piece of muscular tissue about J of an inch in breadth
and -ff of an inch in thickness was then dissected from the glutei mus-
cles on each side, leaving an attachment at the coccyx. These ribbon-
shaped bands were made
to cross each other be-
neath the ligamentous
attachment of the anus
to the coccyx; they were
then made to encircle
the rectum and meet
anteriorly beneath the
skin, the cellular tissue
having been perforated
by dull dissection. At
this point they were su-
tured with chromicized
catgut (Fig. 155). A
very small remnant of
sphincter was found on each side of the rectum, and to this the new mus-
cular strips were attached by sutures. The original flap was then sutured
back in position and the wound closed with aseptic precautions. Aside
from some alight sloughing in the edges of the wound there was no com-
plication following the operation. An improvement in the patient's
continence was established at once, and one year later the newly made
sphincter exercised sufficient control on the bowel to retain its contents
under all conditions.

This ingenious operation certainly merits further trial in these old
cases in which the sphincter has been destroyed.

Kelsey advises the narrowing of the anus in such cases by the appli-
cation of the thermo-cautcry at four or five points around the anus.
The cicatrices produced by the cauterization are often tender, irritable,
and occasion considerable suffering. ]t sometimes happens also that
this process of cicatrization involves a sensitive nerve, producing a peri-
neuritis, and is followed by persistent neuralgic pain. This method is
therefore to be avoided if it is possible to narrow the anal outlet by a
plastic operation.

Prolapse of Ha-morThoids and Mucous Membrane. — Occasionally fol-
lowing an operation for fistula the patient will suffer from prolapse of
internal hipmorrhoids or mucous membrane into the fistulous wound.
The hfpmorrhoids may be present at the time of tlie operation, or they
may develop afterward. Where the pile or the fold of mucous membrane

FISTULA 419

continually protrudes between the edges of the wound it will necessarily
retard or prevent healing.

It is the practice of some operators to remove them at the time of the
operation for fistula; ordinarily no complication follows it, but occasion-
ally the haemorrhoidal wound is infected by the pus from the fistula,
and the patients suffer from long, protracted ulceration. This has
usually been in the cases in which the fistula was very recent and there
was a considerable amount of pus in the abscess cavity. Therefore, it
is advisable to make this distinction in such cases: where the fistula is
comparatively acute, and there is considerable suppuration present, no
operation should bo performed at the time upon existing liaemorrhoids.
The stretching or cutting of the sphincter, together with the rest in a
recumbent posture, will probably prevent the piles becoming congested,
and obviate any interference with the healing of the fistula. If, how-
ever, one well-developed liaemorrhoidal tumor is situated right above
the angle of the wound, it may be removed by the clamp and cautery
at the time of operation for fistula, but it is better not to interfere with
the others.

Where the fistula is chronic and associated with very little suppura-
tion, if the operation of incision is to be done the ha?morrhoids may be
removed at the same time with impunity. The clamp and cautery is
by all means the best method to employ under these circumstances. If
excision and immediate suture are to be done, the haemorrhoids may be
removed at tlie same time by the Whitehead method, but no operation
resulting in granulation and suppuration such as the clamp and cautery,
or the ligature, should ever be employed under these circumstances.
If after an operation for fistula there should be a prolapse of the mucous
membrane or the folding in of the mucous flaps of the wound into the
fistulous tract, these folds sliould be removed as early as possible either
by the scissors or the clamp.

This second operation may be performed under the influence of
cocaine, but it is much better to chloroform the patient so that it may
be thorouglily done, and the excision carried as high as is necessary.

Protracted Svppiiraiioti and Extension of Burrowinff. — In a certain
number of cases after operation for fistula the discharge of pus will not
be materially lessened. Occasionally the suppuration will be protracted
on account of the general unhealthy condition of the wound. This con-
dition may be due to septic germs or to the constitutional state of the
patient due to syphilis, etc.

Bright's disease, diabetes, cardiac disease, and anaemia are also causes
of protracted healing in fistula. These conditions should always be
recognized before an operation is done, and where they exist in a marked
degree it should be limited to the least possible interference consistent

420 THE ANUS, RECTUM, AND PELVIC COLON

with the relief of the patient's sufferings. An incision into the external
tissues large enough to thoroughly drain the fistulous tract is all that
should be attempted under these circumstances. We have indicated
already the course of procedure in cases where tuberculosis is responsible
for delayed healing.

Occasionally after an operation for fistula, extension of burrowing
will take place in one or more directions; if careful examination is made
it will be found due to the fact that some small pocket or lateral tract
has been imperfectly laid open, and the dressings have acted as a plug,
preventing its drainage. Where the wound has been drained by very
light packing or by' drainage-tubes, such extension will rarely occur.
If, however, it does take place, the burrowing tracts should be freely
laid open upon the skin surface to a distance of ^ an inch beyond its
deepest portion, and drained as has been indicated heretofore.

Goodsall says: " The onset of pain in the wound after the first eight-
een hours following an operation upon an uncomplicated fistula is
always suggestive of extension of burrowing." The pain in these cases
is of a throbbing, aching character, and is associated with chill, fever,
and swelling in the neighborhood of the wound, resembling very much
the symptoms of acute abscess. Immediately upon the appearance of
such S3rmptoms early after the operation, the dressings should be re-
moved, and the burrowing tract or fresh abscess laid open and drained.

Premature and Irregular Healing. — Frequently after an operation for
fistula, where the patient is not carefully attended and dressed, the
superficial edges of the wound will unite before the deeper portions have
contracted and filled up by granulation, thus leaving a cavity beneath
them; or, owing to the imperfect application of the dressings the parts
will be drawn out of shape and an irregular, puckered imion will take
place. Many cases of fistula recur owing to these accidents. It is a
condition which should be prevented and not treated. There is no
operation done upon the rectum which requires so persistent and exten-
sive after-treatment as that for fistula, and the surgeon who is the most
successful in the cure of these cases will always be found to be the one
who gives his personal and individual attention to the dressing and care
of his patient.

If from any neglect or accident the upper portions of the wound
should unite before the deeper portions, they should be reincised or torn
apart by the introduction of the probe or index finger.

A good plan to avoid such an accident is, when operating for fistula
by the method of incision, to trim off well the skin and mucous edges
of the wound for the distance of ^ of an inch throughout its extent.
By this means better drainage will be secured, and the dangers of prema-
ture union of the edges will be practically eliminated.

CHAPTER XII
COMPLICATED FISTULA

This class embraces all those fistulas which connect the anus and
rectum with other organs, or which proceed from diseases of the bones
of the pelvis and spinal column. The recognition of these conditions
is very necessary, for the treatment is entirely different from that of
other types, and errors in diagnosis may end disastrously.

Fistulas originating in Bone Disease. — Tuberculosis, osteosarcoma^
and necrosis of the bones of the pelvis or spinal vertebraB result in
abscesses and subsequent fistulas which open in the perianal region or
into the rectum itself. Those which originate in disease of the sacrum
or coccyx find outlets in the posterior quadrants of the perinaeum, and
involve the retro-rectal space; while those from the other bones of the
pelvis or the vertebra? usually open in the anterior quadrants of the
perinaeum or into the rectum itiself ; but occasionally an abscess originat-
ing in the lower lumbar vertebrae burrows down between the folds of
the peritonaeum wliich form the mesorectum, and thus forms a fistula
leading into the retro-rectal space.

The symptoms in such conditions are never tho^e of acute abscess
with chill, fever, pain, and swelling. They develop as cold ahscesseSy
manifesting themselves by pain in the spine or legs with dull, heavy
aching in the pelvis, interference with the fapcal and urinary passages,
and finally present or break at some point around the anus or within
the rectum. After the abscess has broken into the rectum it may still
burrow downward and open upon the skin.

The point at which the rupture into the intestine occurs is very vari-
able. It may be anywhere, from the internal sphincter to the upper
limits of the pelvic colon. In a typical case of this kind the opening
was about 2 inches above the recto-sigmoidal juncture.

J. 8.; boy, five and a half years of age, suffering from tubercular coxalgia,
developed at first a small subtegumentary fistula at the margin of the anus. This
was laid open, cauterized, and appeared to be healing without complications,
when he began to suffer with distention of the abdomen, difficulty in fiecal move-
ments, and dull pains in the pelvic region. The tumor could be easily felt to the

421

422 THE ANUS, RECTUM, AND PELVIC COLON

left of the lumbo-sacral juncture through the abdominal wall. It increased
rapidly, and six days after it was discovered the child ^^felt something break/^
and shortly afterward had a movement of his bowels composed entirely of pus,
and measuring, according to the mother^s statement, fully two pints. She
brought the child to the clinic on the following day, and while the external sur-
faces about the anus appeared to be perfectly healthy and the previous wound
healing nicely, the rectum was found to be full of creamy pus. Under chloroform
the sphincter was stretched, the rectum cleaned out and searched carefully for any
point from which the pus might come, but in vain. With the tubular speculum,
however, at a point about 2 inches above the recto-sigmoidal juncture, a linear
rent about i an inch in length was found in the bowel, through which pus
could be made to flow by pressure upon the abdomen. The course of the
abscess was doubtful, and manipulation with the probe at so great a distance
might penetrate the peritoneal cavity, so the parts were irrigated as gently as
possible through the speculum, which was then withdrawn. The mother was
instructed to give the boy full enemata of saline solution daily, but not to purge
him under any consideration lest violent peristaltic action should tear loose the
adhesions and produce a peritonitis. The pus continued to be discharged from
the rectum, until four weeks later the child began to complain of pain in walking,
and careful examination showed a deep induration to the left, and in front of the
rectum. After several days^ poulticing and rest in bed, it was possible to make
out this swelling through the perinceum. After deep dissection, a large pus
cavity was found and opened. After this the discharge of pus from the bowel
became rapidly less, and ceased entirely within one week. Tuberculosis of the
vertebrae having been diagnosed in this case, the source of the pus was not difli-
cult to determine. Under constitutional treatment, continual drainage, and irri-
gation the patient^s health improved, and the suppuration largely decreased, but
not until three other burrowing tracts had occurred in the buttocks and around
the anus. The child lived for two years, seemed to be gaining in health and
strength, and all the fistulous tracts, save one, had closed, when he was attacked
with pneumonia following measles, and died at the age of seven and a half years.
The necrosis in this case was seated in the ninth and tenth dorsal vertebrae.

The writer has seen a ease of fistula passing downward and in front
of the rectum, originating in an osteosarcoma of the ilium. An autopsy
upon this case showed that the fistulous tract had burrowed downward
below the inferior fascia of the levator ani muscle, passing behind the
triangular ligament, and opened in the right anterior quadrant about 1
inch from the anus. The fistulous tract approached the rectal wall so
nearly that nothing more than the mucous membrane seemed to separate
• the two cavities. It is not possible to give any statistics in regard to
the frequency of fistula in diseases of the vertebra*, but to judge from
the number which appear at the clinic they can not be very rare.

Subtegumentary fistula posterior to the anus and burrowing upward
over the surface of the sacrum is not infrequent. It may sometimes
be due to necrosis of the bones, but in many instances it is not. It is
said by some authors to result from injuries during childbirth and falls
or blows upon the coccyx. The author has seen a case which resulted

COMPLICATED FISTULA 423

from a fall while skating that occurred in a man forty-five years of age,
and was evidently due to necrosis following fracture of the coccyx.

The white, creamy character of the pus, its profuseness and persist-
ency, notwithstanding free drainage and antiseptic irrigation, together
with the antecedent history of the case, will generally indicate the nature
of such fistulous tracts.

Treatment. — One must recognize in the beginning that the large
majority of these cases are tuberculous, and conduct the treatment upon
these lines. The only operative interference justifiable in such cases
is to keep the tract well open at its lowest point in order to maintain
drainage and prevent further burrowing. If the diseased bone can be
reached and the necrotic tissues scraped out, this may be attempted;
but at the present day this j)ractice is opposed by many competent sur-
geons, who hold that where the entire diseased area can not be radically
excised, it is better not to interfere with it at all, but depend upon
improving the patient's constitutional resistance to tlie pathological
processes. Thorough drainage, the support of the diseased parts by
proper braces, the administration of tonics, cod-liver oil, and creosote,
and change of climate will do more for these cases than local treatment
or surgical operations.

The lines of incision for drainage in such cases are the same as those
laid down for other types of fistula, and depend upon the location of
the external opening. The sphincter muscles should be sedulously
avoided, as their reunion is almost impossible with the constant flow of
pus through the wound.

Fistulas connected with Other Organs. — Ano-rectal fistulas connect-
ing with other organs have been very properly divided into the urinary
and the genital. The first class is always connected with some part of
the urinary tract: the urethra, the bladder, or the ureter. They are
largely confined to the male sex, owing to the fact that in women the
bladder and urethra are separated from the rectum by the interposition
of the uterus and vagina. ^Miile it would be practically impossible to
have a recto-urethral fistula in a woman, we do occasionally see recto-
vesical fistula in this sex. There is rarely a simple fistula between these
two organs, however, as it ordinarily involves the vagina as well, thus
forming a rccto-vosico-vaginal fistula. On the other hand the genital
fistulas are nearly all found in women. Occasionally one sees a sub-
tegumentary fistula burrowing fonvard into the scrotum, but such cases
have no distinguishing features beyond the fact that they are very rare,
and always superficial in the anterior portion of their course. They
may be dismissed with the remark that they should be treated by inci-
sion, or better still by excision with immediate suture, just as any other
subtegumentary fistula in ano.

424 THE ANUS, RECTUM, AND PELVIC COLON

TJrinary Fistulas. — These may be classified as perineal, reeto-
urethral, reeto-ureteral, and recto-vesieal.

Perineal Fistula, — Fistulas in the perinaeum that originate in the
urinary tract sometimes burrow backward and open at some point around
the anus, thus simulating ano-rectal fistula. They usually result from
some disease in the posterior portion of the bulbous urethra or in Cow-
per's glands. It will be remembered from our anatomical studies that
these parts are included between the layers of the deep and superficial
fasciae, and form a part of the anterior boundary of the uro-genital tri-
angle. Abscesses or urinary extravasation occurring in this space may
burrow forward around the anterior margin of the superficial fascia of
the perinajum, and thence backward beneath the skin and perineal fascia,
surrounding the anus and opening at points which make them appear
as ano-rectal fistulas. In the case illustrated (Fig. 123), the fistula ap-
peared to be of the horseshoe variety posterior to the rectum, and almost
completely surrounded this organ. Careful dissection, however, revealed
no connection between the fistulous tract and the latter organ. Two
days after the operation urine was found in the wound, and finally the
tract was traced around the anterior margin of the superficial fascia of
the perinaeum into the bulbous urethra. Such cases practically belong
to genito-urinary surgery, but it is very important to recognize them,
and thus avoid making incisions into the rectum when there is no con-
nection between it and the disease.

Etiology. — The causes of these fistulas are diseases of the urethra,
traumatism to the parts from a kick, blow, fall, or more frequently from
the forcible introduction of instruments. False passages made by sounds
or small urethral instruments in cases of stricture at the bulbous
portion of the canal may be followed by abscess of the perineal space,
as may also suppurative disease of this part, gonorrhoea, or tuberculosis
of CowpePs glands, and the extravasation of urine through a rent in the
urethral wall, and such abscesses often end in fistulas which simulate
those of the ano-rectal type.

Diagnosis. — In these cases there will nearly always be a history of
gonorrhoea, of stricture, or of traumatism. The patient will not com-
plain of any pain in the anus or rectum unless the faeces are very hard.
He may have difficulty of urination, and sometimes even inability to
pass urine at all; there will generally be a history of chill, fever, pain,
and swelling preceding the discharge of pus from the urethra or the
opening of the abscess upon the skin; the finger in the rectum will not
elicit any induration or abnormality in this organ, but if bimanual palpa-
tion be practised, induration in the perineal body can be easily made out.
Examination with the probe will show that the deepest portion of the
fistula is always anterior to the line between the two ischii, the abscess

COMPLICATED FISTULA 425

being limited posteriorly by the triangular ligament. The pus in these
cases is never feculent, but may have an odor of urine. Where there
is any doubt with regard to the opening in the urethra several methods
of diagnosis may be adopted. One may determine this by passing a
sound into the urethra and then introducing a probe into the fistula.
If the metals come in contact the urethral opening will be proved. The
urethra may be suddenly compressed during urination, and the urine
thus forced out into the wound can be recognized by chemical tests.
This method was employed in the case mentioned.

A simpler method consists in administering to the patient a small
capsule of methylene blue; after a few hours the urine will be stained
with this material, and if it discharges into the abscess cavity there will
be no difficulty in recognizing the fact. Where no urine passes into
the fistulous tract one may safely conclude that the disease has origi-
nated outside of the urethra, either in the glands of Cowper or the
perineal lymphatics.

The chief point in the diagnosis consists in determining the extra-
rectal origin of tlie fistula, and as a general rule for this, one may say
abscesses which develop anterior to the transversus pcrinei muscles
rarely have any primary connection with the rectum.

Treatment. — The abscess or fistulous tract should be treated by drain-
age, curettage, and cauterization, such as has been advised in the treat-
ment of ano-rectal fistula; but one sliould be careful in using strong
cauterizing agents lest they invade the urethra and bladder, and thus
set up an acute cystitis or urethritis. Where a stricture of the urethra
is present, it is important that this should be dilated or incised before
any attempt is made to heal the fistula. All suppurating conditions of
the urethra should be overcome, and the urine rendered as non-irritating
as possible. It may be a wise plan during tlie first two or three weeks
of such treatment to catheterize the patient at stated intervals, never
allowing any urine to pass through the urethra, and thus into the wound.
The frequent passage of the catheter, however, may do more to retard
the healing and keep up the inflammation than does the escape of a little
urine. What concerns us most in the present discussion is the fistulous
tract and its burrowing around the anus. With regard to this nothing
more need be said than that excision with immediate suture is not likely
to prove successful in these cases on account of the urethral discharge;
therefore they had better be treated by simple incision, or if the case
be of a tubercular nature, incision by the thermo-cauter}'^ and cauteriza-
tion of the fistulous tract would be the proper course to pursue.

Eecto-urethral Fistula. — This condition, as its name implies, con-
sists in an abnormal communication between the urethra and the rec-
tum. It always involves the membranous or prostatic portion of the

428 THE ANUS, RECTUM, AND PELVIC COLON

the resulting fistula will be indirect, long, and tortuous; in the second,
it will be short and direct.

Abscesses of the prostate, whether simple, gonorrhoeal, or tubercular,
may result in this form of fistula; the capsule of the gland will prevent
much burrowing, and the fistulous tracts will usually be direct and very
short. They may open into the urethra first, and afterward invade the
rectal canal, or the process may be reversed. Where they open into the
urethra the danger that recto-urethral fistula will result will be much
less than in those cases where the abscess breaks first into the rectal
cavity. This fact emphasizes the danger of opening such abscesses
through the rectum, if there were no other reasons for condemning the
procedure. Forgue (quoted by White and Martin) states that 43 out
of a total of 67 prostatic abscesses opened into the rectum, and in 21
of these pus was discharged by both rectum and urethra.* If these
figures are correct, it is surprising that we have so few rccto-urethral
fistulas. Sometimes there is burrowing in these cases, and the openings
into the rectum and urethra may be complicated by one in the perinaeum
or by blind lateral tracts.

Finally, calculi of the prostatic and membranous urethra or of the
prostate itself are also occasionally the cause of this condition. In these
instances the fistula may be produced by the sharp point of the stone
cutting through the urethro-rectal saeptum, or by pressure ulceration,
extravasation of urine, abscess, and breaking down of the walls.

Congenital recto-urethral fistulas have been observed, but they be-
long to the type of malformations. They are due to the absorption of
the recto-urethral instead of the recto-anal saeptum in foetal life. When
the normal anal orifice is established, the recto-urethral fistula will gen-
erally close spontaneously.

Symptoms and Diagnosis. — The characteristic symptoms of recto-
urethral fistula are the passage of urine into the rectum or of gas and
intestinal contents into the urethra. Both rarely occur in the same
individual. The direction of the tract will determine the nature of the
abnormal passages. The latter take place at the time of urination or
defecation. The amount of such discharges will depend upon the size of
the opening, the length and direction of the fistulous tract, and the
amount of obstruction in the natural channel. A tight stricture of the
urethra causes an excessive flow of urine into the rectum, and a spas-
modic sphincter will result in an increased amount of faecal matter being
passed into the urethra. Escape of the intestinal contents into this
canal is much less frequent than that of the urine into the rectum; this
is accounted for by the prevailing direction of the fistulous tract, which

* The same figures are attributed to Segond. As the author has been unable to
obtain the original articles, he can not state which reference is correct.

COMPLICATED FISTULA 429

is downward and backward; by the size of the orifice, which is generally
too small to admit any but fluid materials; and finally by the fact that
the sphincters are not frequently so contracted as to produce much ob-
struction to fluid or semifluid materials. Sometimes, however, gas and
faecal matter are forced into the urethra, and even solid masses have
been known to pass through the canal after much straining and pain.
In such cases there is always a large rectal opening, and the fistulous
tract is short. When the urine passes into the rectum it is generally
expelled immediately thereafter, owing to the intolerance by the rectal
mucous membrane of this secretion. Sometimes this is not the case,
and it is retained until the next defecation. In such instances it is
difficult to distinguish between this disease and recto-vesical fistula.
In the early stages there is always a discharge of pus from the rectum
and urethra, but later on these cease almost entirely. In short fistulas
the mucous membrane of the rectum becomes continuous with that
of the urethra. Bernard has reported a case that occurred in the
practice of Lallemand, in which the semen was expelled through the
anus without any previous erection; in one of the eases in which the
writer operated, spermatozoa were found in the pus collected from the
rectum.

Rectitis and urethritis are constant symptoms in this disease. There
is often diarrhoea and frequent micturition. According to Kichet, the
sphincter muscle loses its control, and Legueu states that the skin upon
the buttocks and perina?um becomes excoriated, though in the cases
which the author has seen neither of these complications has been ob-
served. In one case there was a marked cystitis, and a swollen, oedema-
tous condition of the urethral meatus.

Digital examination will always reveal the rectal opening, and where
this is large enough to admit the tip of the finger, a sound intro-
duced through the urethra can be easily felt. If the opening is small
it will generally be surrounded by a considerable mass of cicatricial
tissue; it may be in the shape of a pouting tubercle, or a depressed,
crater-like cavitv, but in either case the reed-like tract of the fistula
may be felt beneath the mucous membrane of the rectum, running
up to the urethra. By the aid of a fenestrated or Sims's speculum the
orifice can be brought into view and a probe passed into it. Usually
there is no difficulty in bringing the latter into contact with a metallic
sound passed into the urethra. Sometimes the orifice is hidden in the
folds of the rectum or within an anterior rectocele; in such cases the
lar^Tigeal mirror may be of service in discovering it. The only condition
with which this disease is likely to be confounded is that of recto-
vesical fistula. The diagnosis between these two conditions may be
thus stated.

430

THE ANUS, RECTUM, AND PELVIC COLON

Recto-urethral Fistula

Rarely congenital.

History of urethral or prostatic disease.

Contents pass from one channel to the

other only during functional action.
Amount of material passed is small and

irregular.
Discharge is generally from the urethra

into the rectum.
Cystitis and frequent micturition rare.

Opening in rectum generally small and

low down.
Sound in urethra can be felt by probe or

finger in rectum.
Colored fluids injected into bladder do

not appear in rectum until micturition

takes place.
Deposit of cicatricial connective tissue is

generally large and easily felt with

finger in rectum.

Recto- VESICAL Fistula

Comparatively often congenital.

History of peritonitis or intestinal disease.

Contents pass abnormally without regard
to functional action.

Amount of material passed is large and
constant.

Discharge is nearly always from the in-
testine into the bladder.

Cystitis and frequent micturition always
present.

Rectal opening generally large and al)ove
the reach of the finger.

Sound in urethra can not be felt through
rectum.

Colored fluids appear in rectum immedi-
ately after injection into bladder.

Deposit of cicatricial connective tissue
generally small and above the reach of
the finger.

The prognosis of recto-urethral fistulas is favorable in those cases
which result from operative procedures. Where they result from patho-
logical processes, however, there is little or no tendency to spontaneous
healing, and until recently all the methods advised failed in the large
majority of cases to close the communication between the cavities.

Treatment. — The treatment of recto-urethral fistula has been as vari-
ous as it has been unsuccessful. Writers of text-books upon surgery
and diseases of the rectum recommend methods with which they have
had no experience, and in which they have little confidence. Duplay
(Am. Encyc. Surg., vol. vi, p. 507) says: "While traumatic fistulas and
those which follow acute and tolerably circumscribed abscesses present
a good prospect of recovery, fistulas which follow in the train of diffuse
and extensive suppuration, either idiopathic or of a tubercular nature,
and which are accompanied by prostatic sinuses, are almost always incur-
able." And again (Traite de path, extern., t. vii, p. 180) he says: " On
the whole, if we had any examples of spontaneous cure of urethro-rectal
fistula we might counsel that it is best to wait, as the chances of surgical
interference are very slight.*'

Sir Henry Thompson concludes from an enormous experience that
surgical intervention is rarely of great benefit, and that constant cath-
eterization offers the best prospect of cure. He advises the use of the
galvano-cautery, but frankly admits that he has never cured a case with
it. Morris (Treves's Syst. of Surg., vol. ii, p. 898) advises, from a theo-
retical point of view, catheterization and the splitting and scraping of
the fistulous tract; he reports no cases as cured, but states that he has

COMPLICATED FISTULA 431

benefited one by suprapubic cystotomy. Quenu and Hartmann ascribe
excellent results to the operation of Sir Astley Cooper, but we have
found only 1 case in which it has ever succeeded.

The author (Mathews's Med. Quarterly, April, 1898) collected 25
cases of this condition, 8 of which were cured by operative methods,
and 4 by palliative methods. The latter 4 were all acute cases. No
chronic case, so far as can be learned, with possibly the exception of
Thompson's, has ever been cured by cauterization or stimulation, and
surgeons can expect little from this mode of treatment. In the paper
referred to, the writer reported 3 cases operated upon by a modified
technique, all successfully; since that time he has operated successfully
upon 5 others, and assisted in 1, thus makinor a total of 9 cases. In the
case in which he assisted, the operation was not so successful, owing
to a mistake of the house-surgeon, which will be detailed later.

The two principles upon which the successful treatment of these
fistulas depend are: first, the removal of all obstructions to the passage
of urine or intestinal contents through their normal channels; second,
the obliteration of the fistulous tract.

So long as a stricture of the urethra remains no hope can be enter-
tained of curing the fistula. For the method of treatment of stricture
the reader is referred to the works on genito-urinary surgery, and to a
brief article upon this subject by the author (X. Y. Medical Journal,
April 13, 1895).

Wherever there is hypertrophy and spasmodic contraction of the
sphincter ani, or obstruction to the passage of faecal matter by tumors,
strictures, or other conditions of the rectum, it is necessary to remedy
these before attempting any direct treatment of the fistula. Forcible
dilatation of the sphincter will overcome spasm temporarily, but its
results are too transitory' to be depended upon in the treatment of so
serious a condition. Absolute relaxation for a considerable period is
necessary in these cases, and this can only be obtained by incision of the
muscle. All obstructions having been removed, the parts should be
protected from the abnormal passages of urine into the rectum and of
faecal matter and gas into the urethra. Permanent or periodical cath-
eterization will accomplish the first of these. Many ingenious mechani-
cal appliances, such as a^sophageal tubes, cannulas with aprons attached,
and various methods of packing the anterior rectum and fistulous open-
ing with non-absorbent materials have been devised, but none of them
has proved successful in preventing the escape of gas and fa?ces into
the urethra. Allowing the bowels to move only once in four or 1\vc days
is perhaps the best method to prevent this, unless one wishes to resort
to the diversion of the faecal current through an inguinal anus. This
last measure has been considered too formidable, and is decried by most

432 THE ANUS, RECTUM, AND PELVIC COLON

operators and patients. Since it has been demonstrated that the opera-
tion is comparatively without danger, and the anus can be safely and
permanently closed without opening the peritonaeum the second time, it
is looked upon more favorably, and would be entirely justifiable in those
cases where other methods have failed, or as a preliminary measure to
other operations under certain conditions. As will be observed in the
paper referred to, this method was utilized by the author in one case
on account of extensive rectal ulceration; the result was satisfactory'
and permanent.

Treatment of the. Fistulous Tract Itself. — ^While the urethral stricture
is being dilated or otherwise treated, antiseptic washing and stimulating
applications by such substances as nitrate of silver, chloride of zinc,
iodine, or even the galvano-cautery, as advised by Sir Henry Thompson
and M. Dentu, may be used with the hope of narrowing the fistulous open-
ing, if not of closing it. In acute conditions these methods may suc-
ceed, but where the fistulous tract is surrounded by cicatricial tissue,
cauterization will be more likely to result in enlarging the orifice, as has
been pointed out by Ziembicki. If the stricture is in the deep urethra,
all this will be a loss of time, as operation on the fistula involves external
urethrotomy of this region, and this will overcome the stricture.

Three principal surgical methods have been advised and attempted
in the closure of these fistulas. The first consists in splitting open the
perinaeum, urethra, and rectimi up to and through the fistula, thus
forming one channel for the escape of urine and faecal matters. The
fistulous tract is then curetted, and the wound left to heal by cica-
trization. This operation has been done a number of times, but, so
far as can be learned, with only one reported success (N. Y. Med. Chir.
Bull., 1831, vol. ii, p. 37).

The second method consists in splitting the recto-urethral saeptum
laterally until the fistulous tract is cut across, thus converting the
condition into two fistulas. The posterior rectal fistula is then treated
either by incision, by suturing the opening, or by the use of an elastic
ligature. The urethral opening is left in this method to heal by granu-
lation, the urine passing out through the perineal incision.

Sir Astley Cooper^s method is a modification of this, and consists
in splitting the recto-urethral saeptum between a sound in the urethra
and the index finger of the left hand in the rectum for guides. The
division is carried well up above the fistulous tract, dividing the latter
into two portions. The wound is then packed, and whatever urine es-
capes through the urethral opening passes out into the dressing or
through the perineal incision. White and Martin modify this method
by dissecting out and suturing the urethral and rectal openings after
splitting the perinaeum.

COMPLICATED FISTULA 433

The operation most frequently employed consists in some modifica-
tion of Sims's operation for vesico-vaginal fistula upon the rectal wall.
It is much more difficult, and is less likely to succeed in these cases than
in the variety of fistula for which it was devised. It has been attempted
many times, but no more than 3 cases have been reported in which it
has succeeded. The methods of Wyetli, Kelsey, and Emmett are all
modifications of this method and open to the same objections. It has
been clearly shown that the passage of healthy urine over a sutured
wound does not materially interfere with union. It is necessary to
** seek for some other cause, therefore, to explain the numerous failures
by the suture method. When the urine collects in a pocket it decom-
poses, pyogenic bacteria develoj), and any healthy processes in the part
will soon be checked." The fact that this method of suturing results
in a depression or pocket upon the urethral side, thus causing retention
of a few drops of urine, easily accounts for its failures. Especially is
this true in cases where the fistula is of considerable length and is tor-
tuous, for in such the tract would be only partially obliterated, and the
urine infected with whatever bacteria exist in the urethral or bladder
cavities would collect in the remaining portion of the tract, infect the
wound and prevent union, or result in the formation of a second fistula.
The ideal operation for this condition consists in one which will immedi-
ately close the fistula without leaving any such pocket or unobliterated
fistulous tract and at the same time avoid the dangers of permanent
fa?cal incontinence.

Ziembicki (Cong. Franc, d. Chir. Proc. Verb., 1889, vol. iv, p. 295)
has applied a new principle in the treatment of this condition. The
operation consists in dissecting out the rectum from all its attachments
up to a point somewhat above the fistulous orifice. The edges of the
openings in both rectum and urethra are then freshened and sutured;
finally, the free end of the rectum is rotated upon its axis until the open-
ing in this organ is brought well off to the side, and thus out of line with
the opening in the urethra. The gut is held in this position by sutures
introduced around the anal margin. The idea is ingenious, and suc-
ceeded in the case reported, notwithstanding a small perineal fistula
formed through which urine escaped for a short time. It is a formi-
dable operation, however, and should not be undertaken except by a
skilful operator, and in cases in which less extensive dissections have
first been attempted. Fuller has reported a successful case done after
this method.

The combination of colotomy with suprapubic drainage of the blad-
der has been employed in these cases, but with no marked success. Even
if the method assured a cure of the fistulous tract, it would not be justi-
fied until all other methods had failed. The dangers of cystitis and
28

434

THE ANDS, RECTUM, AND PELVIC COLON

frequent failure of the Buprapubio opening to close after drainage lias
been continued for a long timp contraindicate this procedure uudor all
circumstances. The author's observations up to 18it6 had been limited,
but from them it appeared that the urethral side of the wound always
gave way first in suturing operations, and resulted in the reestablishnient
of the fistula. Inasmuch as all these methods formed a pocket capable
of retaining a few drops of urine at the site of the operation, it seemed
^Wlk it tilOB eoold be prevented, and strain on the sutured siirfnccs

avoided until union iiad taken place, the question of curing these fistulas
would be solved. The opportunity to test this offered Itself in a patient
sent to the clinic by Dr. Bodine; the fistula opened into the rectum about
J an inch above the external sphincter, and was large enough to admit
the tip of the index finger. It extended upward into the urethra through
a tract about 5 of an inch in length. There was considerable cicatricial
deposit about the opening, and a stricture of the membranous urethra
anterior to the fistulous opening. The pendulous urethra was normal.

COMPLICATED FISTULA

435

The p&tient was prepared for Ireatmeiit by clearing out the intestinal
canal, sterilization of the urinary tract through the administration of
horic acid and salol,
and daily irrigations of \^
the urethra and hlad-
dtir.

On August 30, 18I>().
the operation was pur-
formed as follows: The
rectum was ineiavd in
the middle line anteri-
orly, the cut being car-
ried through into llic
nrethra and extended
froin the scrotal junc-
ture of the perinaium
into the fistulous open-
ing, thus dividing the
urethral stricture (Fig,
157). The cicatricial
tissue around the en-
tire fistula was trimmed
away with scistiors,
Tlie intestinal wall was
then dissected from its
I anterior attachments
for J of an inch alHwe
the fistula, and i an
I inch to each side; a flap was then dissected from the soft tissues on either
[ Bide of the urethra large enough to replace that portion of the floor of
this organ which had been destroyed. A steel sound (So. 30 French) was
introduced into the bladder, and these flaps sutured together over it at
a slight tension. Secondarj' flaps were taken outside of the first fla|)8
I and entirely surrounding them, making a sort of cuff to the first area
, sutured (Fig, 158)- The edges of the rectal wall were sewed together in
I all their thickness with chromieized catgnt down to the external sphinc-
ter muscle, at which point the mucous membrane was dissected loose for
' a short distance to each side, and drawn together by stitches which did
not involve the muscle. The incision into the urethra from just below
the site of the fistulous opening was left unsuturcd (Fig, 159). A N"o. IS
Boft-rubher catheter introduced through the meatus into the bladder
was fastened there by adhesive straps attached to the head of the penis.
The anterior portion of the perineal incision was loosely packed with

436

THE ANUS, EBCTDM, AND PELVIC COLON

absorbent gauze, and a large sized drainage-tube introduced into the

rectum to facilitate the escape of gas. The catheter seemed to cause

the patient no inconvenience, and it was left in position for eighteen

days, the bladder and

^"^"^^i^^^^U^^^BI^^HH^^H perineal wound being

irrigated daily with

Thiersch's solution.

The patient, after
serving as an assistant
around the hospital for
several weeks, was dis-
charged December 1,
1896, perfectly curetl.
He presented himself
for examination in
February, 1902, and
was still well. The
success of the opera-
tion is ascribed to leav-
ing no pocket at the
site of the fistula, ab-
solutely free drainage
for the urine through
the perinjBum, and the section of the external sphincter muscle which
places the parts at rest and at the same time prevents any obstruction
to the passage of gas or fa'cal matter.

In one ease in which the autlior operated, there was ^o much cica-
tricial tissue and the opening into the urethra was so extensive, that it
was impossible to obtain suiRcient flaps of healthy tissue upon the sides
to restore the floor of this organ. In that case both ends of the urethra
were dissected loose and sutured together (Fig. 160), thus making a
practical resection of the urethra. Over this it was possible to drag
and suture a very thin fold dissected from the peri-urethral tissues.
The success in this case was remarkable from the beginning. There
was never a drop of urine passed from the perineal wound so far as
the patient was aware. The rectal wound liealed by primarv union,
and the patient left the hospital coinplctely well at the end of six
weeks. One year later, however, he returned to the workhouse, hav-
ing failed to keep up the dilatation of the urethra by the pa^a^c
of sounds as directed, and was found to be suffering from a stric-
ture at the point of suture in the urethra. By gradual dilatation
his symptoms disappeared, and he left the hospital at the end of
three months, once more apparently well. This was eighteen months

Fistula.

COMPLICATED FISTULA

437

after the operation, and no return of the recto-urethral fistula had
occurred.

Theoretically it is important to retain the catheter in the bladder
seven to ten days, and yet in those cases, three in number, in which this
was impossible, there were no unfortunate results. If it once slips out
there Is danger of reperforating the rectum in attempting to reintroduee
it through the meatus. This accident happened in a. case operated upon
by Percy Bolton after this method. The catheter, instead of entering
the bladder, perforated tlie sutured wound, and extended upward in the
rectum for about 4 inches; it was removed at once, and the parts left
to heal by granulation. Tliia was a very slow process, and it was not
completed at the end of four months when the patient left for home.
Subsequently It was reported that the opening into the rectum com-
pletely liealed, and that the patient only Buffered from a slight leak-
age from the perineal
wound at the time of
urination. The cathe-
ter in such instances
should be reintroduced
by passing it from the
meatus through the
perineal wound, and
then upward and back-
ward against the supe-
rior wall of tlie urethra
through this opening;
in this way it can he
introduced without im-
pinging upon the su-
tured wound. In case
the patient is unable
to bear the irritation
of a permanent cathe-
ter, the urine should
be drawn every three
hours by a skilful
surgeon with a well-
curved silver catheter *■"'" i*"'-K"^"'"« '■' ^^"^J^"^""^ '"" K^"'-^ ««""'*'■
held close to Ihe supe-
rior wall of the urethra during the first five days. It is important that
the bladder should not become distended and urine allowe<l to leak
over into the wound. While the number of cases, 9 in all, is very
few, they are sufficient to establish the fact that such cases can be cured.

438 THE ANUS, RECTUM, AND PELVIC COLON

Becto-vesical and Entero-vesical Fistulas. — The two conditions indi-
cated by the terms here used differ simply with regard to the portion
of the intestinal canal which connects with the bladder. They both
consist in an abnormal conmmnication between the intestinal tract and
the urinary viscus. They were more or less frequent in times past when
it was the practice to pimcture the bladder through the rectum in cases
of retention of urine. This having become obsolete, fistulas of this
variety have largely disappeared. They do, however, occasionally occur
as a result of accidents or operations upon the bladder and rectum in
the course of malignant disease, and through the process of destructive
inflammation.

Instances of wounds connecting the bladder with the rectum are
quite numerous, but these very frequently close spontaneously and no
fistula results. Thus, in the chapter upon accidents and injuries, refer-
ence is made to a number of cases in which bullet wounds and sharp,
puncturing instruments, such as bars of iron and paling-sticks, have
passed through the rectum and into the bladder, and yet the recto-
vesical communications have closed without any surgical interference.
Bartels (Archiv fur klin. Chir., Berlin, 1878, Bd. xxii, S. 519) collected
78 cases of wounds of the bladder in which only 5 resulted in fistula.
It is only after the communication has existed for a certain period that
it should be recognized as a fistula.

The Character of the Fistula. — This type of fistula may be direct or
indirect. In the first instance it is due to a matting together and direct
perforation of the intestinal and vesical walls. In such cases the tract
is very short and the openings absolutely opposite each other. The
mucous membrane of one organ, as cicatrization occurs, coalesces with
that of the other, and a mucous tract between the two cavities is formed.
This may occur at the base of the bladder in the neighborhood of the
trigone, when the communication will be with the rectum; or higher up
in the fundus, when it will be with the sigmoid flexure or small intestine.

The tract may also be indirect, owing to rupture of abscesses into
both organs. In such cases the openings will be separated by the abscess
cavity. Thus the fistulous tract will be more or less elongated and very
irregular in shape. The openings may or may not be opposite each
other; in all probability they will be considerably separated. The patho-
logical characters of these fistulas are practically the same as those of
ano-rectal fistulas; they may be inflammatory, tubercular, or malignant.
"While serious in all cases, the degree will, of course, depend upon the
pathological cause.

Etiology. — Traumatism or wounds are comparatively frequent causes.
Velpeau (Nouveaux 61em. de m6d. oper., Paris, 1839, t. iv, p. 564) esti-
mated that 20 per cent of them result from recto-vesical wounds. There

COMPLICATED FISTULA 439

are no statistics at the present day to establish or to deny these faets^
but inasmuch as all operations upon the bladder through the rectum
have been relegated to the surgery of the past, it is probable that the
percentage from these causes has been materially reduced. Dittel
(Wiener med. Woch., 1881, Bd. xxxi, S. 261, 293, and 321) relates 1 case
in which the fistula was produced by violent catheterization.

In one instance of carcinoma of the bladder, the sounding of this
organ with a Thompson searcher produced a communication between
the two cavities — at least the discharge of urine into the rectum and
fa?ces into the bladder had not been observed until after this examina-
tion; but that any surgeon should be violent and careless enough to
penetrate a healthy vesico-rectal saeptum in sounding the bladder is
incredible.

In gunshot injuries and puncturing wounds the fistula does not
always appear immediately after the injury, but it may follow some days
or weeks later, owing to slougliing around the edges of the wound, as is
stated by Bartels, or to an extravasation of urine into the saeptum be-
tween the two cavities, and subsequent rupture of the abscess.

Wounds due to foreign bodies in the rectum, as pins, needles, fish-
bones, rectal concretions, etc., may result in a perforation of the sjeptum
bet\*'een the two organs, and stone in the bladder has been observed by
Herczel (Beitriige zur klin. Chir., Tiibingen, 1889, Bd. v, S. 690) to result
in a recto-vesical fistula.

Inflammatorv conditions both of the bladder and the rectum are
accountable for the large majority of such fistulas at the present day.
Catarrhal inflammation of the bladder (^lercier, Gaz. m6d., 1836, pp.
257, 273; and Ballance, Lancet, London, 1883, t. i, pp. 411, 485), dysen-
tery (Herczel, Inc. n'f.), typhoid fever (Woodward, Med. and Surg.
Hist, of War of the Rebellion), appendicitis, and tubercular ulceration
of both bladder and intestine have been known to result in this con-
dition.

Prostatic disease, either suppurative or tubercular, may result in
recto-vesical fistula through the formation of an abscess between the
tunics of the two organs, which abscess ruptures first into one and then
into the other viscus, thus forming the indirect variety of fistula which
was mentioned.

Diverticuli in the walls of the bladder or rectum may enclose small
calculi or fjecal concretions, which result in inflammation, adhesion be-
tween the walls of the two organs, subsequent perforation, and fistula.
Malignant disease is one of tlie several causes of this condition, and
may proceed from either organ. This occurs largely in men, owing to
the close relationship between the bladder and the rectum; but it is
not unknown in women as a result of extensive pelvic and peri-uterine

440

THE ANUS, RECTUM, AND PELVIC COLON

r between the sigmoid

inflammations; in these the eommunications o
flexure or small intestine and the bladder.

The author has seen 2 cases, however, in which the bladder com-
municated with the rectum through fistulous tracts that passed around
the cervix just above the vaginal wall (Fig. IGl). One of these patients
was the victim of conatitution-
al syphilis; in the other it was
impossible to account for the
condition.

In that portion of the intes-
tinal tract in close apposition
with the bladder walls, tuber-
culosis may no doubt result in
ulceration, perforation, and the
formation of fistula, but it is
rarely the cause of such a com-
munication between the blad-
der and the movable portions
oi the intestinal canal, as ad-
hesive peritonitis is not a fre-
cjuent complication of tubercu-
lar ulceration of the intestine,
and it is absolutely necessary
lo the formation of an entero-
vesical fistula. The recognition
of the pathological causes of this condition is of the utmost importance,
as upon it will depend the advisabiJity of radical interference. It is also
important to know whether the rectum, the sigmoid fiexure, or the small
intestine communicates with the bladder, as the prognosis differs in all
these cases.

Cripps (The Passage of Air and Pieces from the Urethra, London,
) has collected 03 cases of entero- vesical fistula in which the intes-
tinal opening was twenty-five times in the rectum, fifteen times in the
sigmoid flexiu-e, twelve times in the small intestine, and five times in
both the small intestine and colon.

In the 18 cases collected by Quenu and Hartmnnn, the opening was
nine times in the rectiun, four times in the sigmoid flexure, twice in
the small intestine, twice in the vermiform appendix, and once in the
caecum.

From other sources 8 cases have been collerted in which the opening
was four times in the rectum, twice in the sigmoid flexure, once in the
small intestine, and once in the vermiform appendix.

So there are 8!) cases in which the opening was in the rectum in

COMPLICATBD FISTULA 441

38, showing that this is the most frequent site. A fact which should
be remembered is, that while a stone may exist in the bladder in
these cases, it is not necessarily the cause of fistula, but may be the
result of the same through some of the faecal contents escaping into the
organ and thus forming a nucleus around which the stone forms. Thus,
for instance, in the case reported by Kelsey, a stone which was supposed
to have caused a fistula proved to be the accumulation of urates about
the broken end of a catheter which had been introduced with a view
of curing the fistula.

Symptoms and Diagnosis, — The characteristic symptoms of recto-
vesical fistula are the presence of urine in the rectum with or without
the presence of fa?cal materials and gas in the bladder. The communi-
cation between the two organs may be sufficiently large, or the tract
may be in such a direction that urine can escape from the bladder into
the rectum and f^^cal matter can not escape from the rectum into the
bladder. The presence of gases in the bladder should not be taken as
a pathognomonic evidence of entero- vesical fistula; it is well known that
these may develop, owing to certain chemical changes in the urine, and
be expelled during the passage of the last few drops of this secretion.
Dittel, Hartmann, and Blanquinque have all reported cases of this kind,
which may be termed essential gas formation in the bladder. While,
therefore, there may be entero-vesical fistulas without gas or faecal mat-
ter in the urine they almost never occur without the escape of urine
into the rectum. The constant presence of urine in the rectum, how-
ever, does not necessitate a persistent dribbling from the anus. A cer-
tain number of cases have been observed in which the patients were
able to control the urine after it had escaped into the rectum (E. Monod,
Diet, encyc. des sci. med., and P. Blanquinque, Thdse de Paris, 1870,
p. 169).

The character of the faecal discharge into the bladder, and subse-
quently passed out through the urethra, varies according to the digestive
functions of the patient and the size of the aperture between the two
organs. Small pieces of meat, fibrous portions of vegetables, bone, fat,
and fruit seeds have all been found in the bladder and passed through
the urethra after much straining and pain. The nature of these ma-
terials has been said to throw some light upon the site of the intestinal
opening; but this is denied by the best observers, who state that solid
substances have been passed when the fistulous opening was in the small
intestine as well as when it was in the rectum; and liquid substances
are passed in both instances.

The diagnosis, therefore, depends chiefly upon the presence of urine
in the rectum; not only must the urine escape into the rectum, but it
must be constantly present and not alone at the periods of micturition.

442 THE ANUS. RECTUM, AND PELVIC COLON

Where the commiinieation exists between the bladder and some portion
of the intestine high up, it may be difficult to determine the constant
presence of urine in the rectum, inasmuch as the fluid then becomes
mixed with the intestinal contents. However, in such cases there will
usually be the corroborating evidence of gas and faecal matters in the
bladder.

The history of the case will always have some bearing upon the diag-
nosis, but this is generally meager. Cystitis or proctitis and the passage
of lumpy or dark-colored urine may have been observed, but more
frequently the symptoms first complained of will be diarrhoea, or rather
a constant desire to defecate^ which results only in the passage of a
small quantity of clear water. Pus and blood may be contained in
the discharges, especially if the fistula be the result of a pelvi-rectal
abscess. In such cases the history of abscess with its rupture and dis-
charge of pus, either by the urethra or the anus, can be clearly elicited.
In tubercular cases the general physiognomy and constitutional con-
dition will indicate the nature of the disease to a certain extent, but
not invariably. In malignant disease the history of pain, diarrhoea,
frequent micturition, loss of flesh, and general cachexia will corroborate
the evidences which may be obtained by the speculum and by digital and
cystoscopic examinations.

The differential diagnosis between recto-urethral and recto- vesical
fistula will be found in the preceding section.

Having determined the existence of a connection between the blad-
der and the intestinal tract, the next step in diagnosis is to learn the
site of the intestinal opening. If it is low down at the trigone of the
bladder, just above the prostate, it may be made out by digital touch;
if, however, the opening is small and is ensconced between the folds
of mucous membrane, it may sometimes escape notice. Moreover, if
it occur more than 4 inches from the anal orifice it will be practically
impossible to make a diagnosis in this way. The use of the pneumatic
sigmoidoscope is of great assistance in such cases. Not only may open-
ings into the rectum be detected, but also those into the sigmoid flexure
— something which was impossible except by uncertain inferences until
this instrument was devised.

The cystoscope is of advantage to demonstrate an opening into the
bladder, but unfortunately it gives no information as to the point of
the intestinal tract with which it communicates. Moreover, if the open-
ing be of any considerable size it will be difficult to distend the bladder
sufficiently to operate this instrument properly.

By the aid of a long, flexible probe through the proctoscope, one
may determine the course of the fistula, and a view of the parts will
indicate the pathological nature to a certain degree. The dangers of

COMPLICATED FISTULA 443

tearing loose the adliesions between the two organs and thus opening
the peritoneal cavity, should always be borne in mind when using the
probe.

The practice of injecting colored fluids into the bladder, in order
to determine if there is a communication between this organ and the
rectum, is practically useless as a diagnostic measure. Dumesnil has
advised the injection of a very weak solution of perchloride of iron into
the bladder while at the same time he introduced a sponge into the
rectum soaked in a solution of yellow prussiate of potash (1 to 500); the
combination of the two solutions produces a chemical reaction which
demonstrated to his mind the existence of a comnmnication between the
two organs. This chemical reaction must take place immediately, or
it may be assumed that it might occur through osmotic or circulatory
channels. Thus, if the fistula is high up in the intestinal tract, the
length of time which will elapse before the fluid from the bladder could
come in contact with the sponge below would necessarily invalidate the
importance of the chemical reaction obtained. The presence of uric-
acid crystals in the faecal discharges, and the reaction obtained from this
substance, will be better evidence of the existence of urine in the rectum
than can be possibly obtained by the injection of colored fluids into
either organ.

Prognosis. — The prognosis in these conditions is always grave.
While there is a certain number of cases which have resulted in spon-
taneous cure, the ho{)e of such a termination is most illusory.

The results of surgical interference are scarcely more encouraging.
Cripps estimated that the average length of life in this condition is
something less than two years, although there is one case reported which
lived as long as thirty years after the fistula developed. Blanquinque
has summarized the results of operative treatment in 30 cases as follows:
Four cured, 5 unimproved; 3 deaths from other diseases; 4 deaths in
which particulars were not given, and 15 from urinary infiltration, peri-
tonitis, exhaustion, suppuration and inflammation of the rectum and
bladder (Quenu and Ilartmann, op. cit., p. 232). In this enumeration
of the causes of death, the extension of the inflammatory condition
from the bladder upward through the ureter to the kidney seems to
have been omitted. The majority of observers refer to this as the
most serious complication, and it is probably the most frequent cause
of death in these ca^es. The cystitis and proctitis, while annoying
and irritating, are not of such a grave nature as to bring about a
fatal termination in themselves. In the majority of instances the rectum
becomes tolerant after a time to the presence of urine; and while this
does produce a chronic catarrhal inflammation of the organ, it is rarely
of serious import. The dangers are therefore upon the side of the

444 THE ANUS, RECTUM, AND PELVIC COLON

bladder, ureters, and kidneys in cases of direct fistula. In the indirect
variety, where there is an abscess cavity between the two openings, the
accumulation of urine and faecal matters in this is likely to result in
urinary infiltration or burrowing tracts which may perforate the peri-
tonaeum, extend down to the buttocks or around the anus, causing fatal
peritonitis or eventuating in lardaceous changes of the glandular organs,
exhaustion, and death.

Treatment. — In the treatment of this condition it is more important
to prevent the escape of faecal matter into the bladder than that of urine
into the rectum. Permanent or periodical catheterization and irrigation
of the bladder have failed, so far as can be learned, to produce a single
cure. In acute conditions due to accidents, injuries, or surgical proced-
ures, permanent catheterization, together with constipation of the bow-
els, may facilitate the healing. Certain positions, such as laying the pa-
tient upon his face or side, so that the secreted urine will gravitate in the
opposite direction from the wound, may also be of benefit; but, unless
faecal material is kept out of the bladder, these procedures will be of
little use. Where a fistula is once established the surgeon is brought
face to face with one of two procedures: either a direct closure of the
fistulous tract itself or the diversion of the faecal current.

Diversion of the Foscal Current. — ^Where the opening is in the rec-
tum or lower portion of the sigmoid, a temporary artificial anus may,
together with permanent catheterization, result in the closure of the
faecal fistula. At any rate, such a diversion of the faecal current will
contribute largely to the probabilities of successfully suturing the fistula.

Quenu and Hartmann advise making a permanent artificial anus at
once in these cases, but such a radical procedure can not be indorsed.
The temporary anus can be made just as effectual to protect the parts,
and it can be changed into the permanent form at any time if desirable.
Moreover, it can be closed without any particular danger to the patient,
provided the fistula heals.

The question of temporary artificial anus, the methods of making it,
and its final closure will be found in the chapter on Colostomy. WTiere
the communication between the bladder and the intestine is above the
sigmoid flexure, an artificial anus is not likely to prove satisfactory,
especially if it must be made in the small intestine. Here one should
open the abdomen, separate the two organs, and close the fistulous open-
ings, as will be described later.

After the fa»cal current has been turned aside, one may attempt to
close the recto-vesical opening by freshening the edges and suturing the
wound, just as in the operation for vesico-vaginal fistula. If it is high
up, the difficulties of approaching it may be overcome by the removal
of the coccyx and incision of the posterior wall of the rectum. Some

COMPLICATED FISTULA 445

attempts have been made to close these tracts by suprapubic cystotomy
and suture of the wound from the vesical surface. No case, however,
has been reported as cured by this method (Thompson; Le Dentu).

It has also been proposed, where the opening is low down, that the
anterior wall of the rectum be dissected from the bladder by lateral peri-
neal section to a point above the fistulous tract, thus cutting the latter
in two and converting it into a recto-perineal and vesico-perineal fistula.
If within reach the openings may be sutured from the perineal wound;
if not, this may be packed after having curetted the fistulous openings.
Where the fistula results from a pelvi-rectal abscess, unquestionably this
would be the proper procedure, because it would furnish complete drain-
age to the abscess cavity, and any burrowing tracts could be laid open at
the same time. The records show that suture of fistula from the rectal
surface has proved more successful in these cases than any other pro-
cedure. In the statistics of Monod (Diet, des scs. med., vol. i, p. 437)
and Dumesnil (Revue de chir., 1884, p. 24), 26 cases are collected in
which artificial ani were made for the cure of recto-vesical fistulas with-
out a single success. Amelioration resulted in some, and in two life
was prolonged five and six years. According to Brant, Dumesnil, and
Herczel, this operation should be reserved for fistulas due to malignant
growths. The author can not go so far as this, but would advise that
the temporary artificial anus be employed in these cases as a preliminary
to suturing the fistula from the rectal side. The diversion of the fa?cal
current is important for this purpose, but it is not curative.

In suturing tlie fistula, Czerny's method of employing catgut for the
deep row, and silk or silkwonn gut in the mucous membrane, appears
the most rational. The superficial sutures should be removed at the
end of the seventh day.

Where the fistulous opening is in the sigmoid flexure, or connected
with some higher portion of the intestinal canal, a more radical operation
through abdominal incision will be called for. In such cases it will be
necessary to open the abdominal cavity, separate the adhesions between
the bladder and the intestine, and then suture the openings separately.
Where the adhesion is extensive and the peritoneal covering of the
intestine has been destroyed by inflammatory processes, simply suturing
the o])ening is not likely to close it. In such eases it is better to resect
the portion of the intestine involved. The woimd in the bladder may
then be sutured by folding in the walls after the manner of Lembert.

Having accomplished the closure of the openings, a gauze wick, sur-
rounded by protective tissue, should be passed down to the opening in
the bladder and left there for several days. Where the intestinal opening
has been sutured without resection, a second wick should be carried dowTi
and held in apposition with this suture, but the space between the two

446 THE ANUS, RECTUM, AND PELVIC COLON

openings should be widened by a Mikulicz drain in order that the leak-
age from one cavity shall not affect the other. Terrier has adopted
this method without suturing either opening, but simply placing a drain
between the bladder and intestine; in his case the cure of the vesical
opening appeared to be immediate, and the faecal fistula which resulted
healed in a short time. Skene has also used this method with success
in one case (personal communication), but the combination of suturing
and draining afterward would appear to promise the best results.

Redo-ureteral Fistula. — A certain number of cases of ureteral fistula
have been reported, but none in which the opening was into the rectum
itself, except in malformations which have been already described in the
chapter upon that subject. Kelly, Kuster, Tuffier, Morestin, and others
have attempted the transplantation of ureters into the rectum in cases
of extirpation of the bladder for malignant disease. These cases, how-
ever, have been experimental, and have no practical bearing upon recto-
ureteral fistula. In one case reported by Bayard a communication be-
tween the ureter and the duodenum was found.

Simon has attempted the total extirpation of the bladder for car-
cinoma, and planting the ureters in the rectum. His patient, however,
died of peritonitis. The author has seen one case in which a recto-
vagino-ureteral fistula resulted from an operation for the extirpation
of a carcinomatous uterus, and, strange as it may appear, the fistula
closed spontaneously.

Becto-g^enital Fistula. — The term recto-genital is applied to all those
abnormal openings occurring between the rectum and the genital organs,
as distinguished from the urinary. They are practically confined to the
female sex, and should not embrace those communications due to mal-
formations. A perineal fistula, extending forward and into the scrotum,
may be termed a recto-genital fistula, but as it has no peculiar charac-
teristics differing from the ordinary subtegumentary fistula, it need not
be discussed in this connection. A prostatic abscess, or an abscess that
occurs as a result of suppuration in Cowper's glands, may break through
into the rectum without communicating with the urinary tracts; in such
cases they form blind internal fistulas, which have been described. As
a rule, both of these types either communicate with the urinary tracts
in the beginning or later in their course. The recto-genital fistulas
may then be described as recto-uterine, recto- vulvar, and recto-vaginal.

Recto-uterine fistulas are exceedingly rare, if, indeed, they exist at
all except as congenital malformations. Petit (Annales de gyn6col.,
Paris, 1882, t. ii, p. 401, and 1883, t. i, pp. 14, 90, 290, 353, 431) has
thoroughly reviewed the subject of entero-uterine fistulas. No case was
noted in which the rectum was involved. The writer has seen one case
in which a carcinoma uteri involved the posterior uterine wall, extended

COMPLICATED FISTULA 447

to the rectum and produced a communication between the two organs
through which a uterine sound could be passed; this was in an old
woman in the Almshouse Hospital, in whom curettage of the carcinom-
atous growth had been practised some months previously. AVhether
the neoplasm produced the fistula, or whether the opening was made
by the curettage, it is impossible to say.

It is possible that a pelvi-rectal abscess originating in the peri-
uterine structure might eventually break through into both organs;
but the uterine tissue being so tough and resisting, it is hardly reason-
able to suppose that the burrowing would extend through it when so
many lines of less resistance exist about it. ^lusilier (Bull, de la soc.
anat., Paris, 1874, p. 848) has reported a case of a woman who died
from albuminuria, in whom the necropsy revealed a communica-
tion between the ])us sac in a uterine fibroid and the rectum. There
does not appear to have been any communication between the uterine
and rectal cavities. In the ease reported by Lauers and Bidder (Revue
de chir., Paris, 1885, p. 1013, and Annales de gynecol., Paris. 1892, t.
ii, p. 118) a tnie fistula between the sigmoid flexure and the cavity of
the uterus has been established. Quenu and Hartmann report a similar
case (op. ciL, 214) which healed spontaneously, and the authors were
not able to state what portion of the intestine it was which communi-
cated with the uterus, though it was above the rectum.

From these observations one gains no practical information. The
fistula is a possibility, but is so exceedingly rare that operative interven-
tion to cure it has never been undertaken. In the one definite case
which the writer saw the malignant neoplasm was inoperable, although
the patient lived some four months after the fistula appeared.

ReciO'Vulvar Fistula, — Fistulas opening in the genital tract anterior
to the hvmen are tenned recto- vulvar. Thev occur ordinarily as a result

ft ft/ •■

of injury, infection, inflammation, and suppuration of the glands of the
labia and vagina anterior to the fourchette. They may be due to injuries
during labor and efforts at repair of the perina»um. Spencer Wells
(Med. Times and Oaz., 18G0, p. 61) and Barton Hirst (Am. Journal of
Obstetrics, 1886, p. 83) have reported cases due to violent coitus. Kelsey
(op. cit.y p. 135) reports a very interesting case of this kind in which
there were two oi)enings in the vulva and two in the rectum. This case,
however, originated from suppuration in the labial glands upon each
side.

Si/mptn7ns. — The disease ordinarily begins as a ])imple or slight in-
flammation in the labia of one side. It sometimes occurs simultane-
ously on both sides. If this is not opened promptly and drained, it may
burrow backward to one side of the perineal rhaphe and open into the
anus. It may also burrow into the ischio-rectal fossa after it passes the

448 THE ANUS, RECTUM, AND PELVIC COLON

transversus perinei muscles, but such is very rarely the case. The tracts
usually run directly backward beneath the superficial perineal fascia,
and open either into the anus or about its margin in the anterior quad-
rant of the same side upon which the labial abscess occurs.

The openings may be single or multiple. The writer has seen a case
in which there were four openings about the anus and one just within
the vulva. The patient will give the history of pain, especially upon
walking, a swelling about the genital organs, sometimes difficulty in
micturition, and always, if the fistula is incomplete, of a sudden relief
from these pains following a discharge of pus.

The opening is nearly always found in one labia or the other, or just
within the vulva in front of the hymen.

Treatment. — The treatment of these cases should not be carelessly
undertaken. Great care should be observed to preserve the perineal
body. Open incisions, such as those practised upon simple ano-rectal
fistulas, may result in disastrous consequences through the destruction
of the female perinaeum. Taylor advised passing a probe into the fis-
tulous tract from the vulvar orifice and cutting down upon it at a point
near the anal margin, thus converting the condition into ano-rectal and
vulvo-perineal fistulas. The rectal portion of the tract he treated by
the ligature, and the anterior portion by stimulating applications.

In the light of modern experience with excision and immediate suture
of fistula, it appears best that such uncomplicated tracts should always
be. dissected out and the wounds immediately closed. WTiere there are
two distinct fistulous tracts which communicate with each other in the
rectum, as in the case described by Kelsey, the ingenuity of the operator
will be exercised as to what course to pursue. It seems that in such
cases one might with safety excise and suture the two perineal tracts at
different sittings, or if there be only a slight dissection of the tissues,
they might both be done at one time.

The question as to the pathological nature of these fistulas and its
influence upon the operation differs in no wise from that in general ano-
rectal fistula. If the process be tubercular, the fistula should be entirely
excised and the edges sutured together; or else it may be treated by anti-
septic irrigation and the application of methylene blue, carbolic acid,
and iodine, or with pure carbolic acid alone.

Occasionally these fistulas have only one opening, and that in the
rectum, thus forming blind internal fistulas. In such cases the fistula
should be converted into a complete one, and if it fails to close after
injections of nitrate of silver it should then be excised. In suturing a
wound made after excising these fistulas, it is very important that ac-
curate apposition of the muscular tissues should be made. In order to
accomplish this one should in cutting down upon the fistulous tract

COMPLICATED FISTULA 449

isolate the ends of the muscle when cut, grasp them with fixation for-
ceps, and hold them to one side while the fistula is dissected out. After
the deeper portion of the tract has been closed then these ends should
be accurately brought together, and no time will be lost in searching
for them.

Recto-vaginal Fistula. — This is perhaps the most frequent of all com-
plicated fistulas. It consists in an abnormal opening between the rectum
and the vagina proper, or that part of the female genital tract posterior
to the hymen or its remains. It may be direct or indirect, depending
largely upon its cause and the size of the openings. It results from
a variety of causes, the comparative frequency of which it is impos-
sible to estimate. Kelsey states that it is nearly always due to the
imperfect repair of the perina?um after rupture during childbirth.
Munde (Boston Med. Journal, 1885) has reported a case resulting from
brutal coitus. It is frequently the result of an incomplete tear of the
perinajum, such as may be described as a submucous rupture of the
recto-vaginal sa>ptum. Sloughing of this sa?ptum, owing to prolonged
pressure by the fcetal head, is also a cause. The communication does
not take place until several days after labor, just as in the case of vesico-
vaginal fistula.

Syphilitic ulceration, with or without stricture, is a frequent cause
of this type of fistula. In one year the author observed 6 cases of this
condition in 4 of which tliere was stricture of the rectum; all of the
patients were syphilitic, and the ulcerations bore the indubitable evi-
dence of the disease. It has also been observed in cases of simple cica-
tricial stricture of the rectum.

Tubercular ulceration of tlie rectum mav result in a fistula of this
type, but certainly it is a very rare cause. Carcinoma of the rectum
or vagina frequently results in a communication between the two cavi-
ties. Sloughing of the sa^ptum, due to an operation for haemorrhoids,
has been mentioned by Quenu and Ilartmann as a cause, and one can
easily see how too large a bite witli a hasmorrhoidal forceps or with the
ligature may result in this condition. Prolonged pressure upon the
recto-vaginal sa»ptum from any cause may result in sloughing and the
formation of recto-vaginal fistulas. The writer has removed a glass
pessar}-^ from the rectum wliich had ulcerated through the sa?ptum and
left a large opening between the two cavities into which three fingers
could be easily introduced.

Fistulas of this type may also result from abscess developing in the
sa^ptum, from tumors of the perina^um, dermoid cysts, or from foreign
bodies in the intestinal canal, such as pins, fish-bones, etc., which pene-
trate the sa^ptum, especially in cases of anterior rectocele.

Large pelvi-rectal abscesses developing in women may burrow down
29

450 THE ANUS, RECTUM, AND PELVIC COLON

between the layers of this saeptum and open both into the rectum and
into the vagina, thns constituting a recto-vaginal fistula. The fistulous
tract in these cases may not be direct, but open at one level into the
vagina, and at another into the rectum with an irregular abscess cavity
intervening.

Symptoms. — Except in those cases resulting from abscesses, ulcera-
tions, and neoplasms, few subjective symptoms will precede the forma-
tion of the fistula. The history of traumatism or accidents in child-
birth, the prolonged retention of the head in the hollow of the sacrum,
rupture of the perinaBum and efforts at its repair, will all point to the
cause of the fistula.

The diagnosis is very simple. The escape of gas and faeces through
the vagina at the time of defecation, or involuntarily, leave no doubt in
the patient^s mind as to an abnormal communication. The presence
of faecal material in the vagina, the vaginitis and leucorrhcea resulting
therefrom, are the distressing features of these cases. They not only
cause pain and irritation, but mortification and uneasiness to the indi-
vidual, resulting sometimes in melancholia and even in suicide.

The opening can generally be seen in the vagina with the aid of a
Sims's speculum introduced into the anterior commissure. It may
also be felt with the finger in the rectum, or seen through the ordinary
fenestrated speculum. Ordinarily the opening is large enough to admit
the end of the finger, and frequently much larger. It is generally in
the median line and within the first 2 inches above the anus. The tract
is ordinarily short and direct. It may, however, be diagonal and some-
what elongated when it occurs from puncture, abscesses, or neoplasms
in the recto-vaginal saeptum. In the beginning of the condition there
is ordinarily a discharge of pus, and sometimes blood with the faecal pas-
sages or from the vagina. After a period, however, the pus ceases to
discharge, and the condition occasions the patient no pain except that
due to the vaginitis. In this state the tract will be found lined through-
out with mucous membrane, and it will be impossible to decide where
that of the rectum ends and that of the vagina begins, the epithelial sur-
faces gradually blending at an indeterminable point.

In cases where the tract is oblique the openings upon both surfaces
are flap-like, and it may be difficult to find them. If, however, the
patient frequently passes gas from the vagina, the diagnosis may be
considered established and the search should not be given up. Where
there is a stricture of the rectum the fistulous communication will
almost always be found below it.

Treatment. — The treatment of this condition has not been invariably
successful, and it is no unusual thing to see patients who have under-
gone three, four, and even more operations for the closure of these

COMPLICATED FISTULA 451

fistulas, and all in vain. A very small proportion of them may be closed
by cauterization and local treatment of the fistulous tract, but in the
large majority this will fail. The instruments and tampons devised for
carrying the fajcal current past the fistulous opening have not been suc-
cessful. Prolonged constipation of the bowels after cauterization of the
fistulous tract is more likely to be successful than any of these appliances.

As a rule, however, some surgical procedure will be necessary, and of
these there is a large variety. They may be divided into three types:
operations upon the fistulous opening through the rectum, operations
upon the fistulous opening through the vagina, and complete excision
of the fistulous tract combined with perinaeorrhaphy.

Operations through the Rectum, — Inasmuch as the fjecal and gaseous
passages which are supposed to keep these fistulas open proceed from
the rectum, it would appear more rational to close the fistulous open-
ing upon this side and thus obviate the escape of these substances into
the tract. If this could be successfully done, in all probability the rest
of the fistulous tract between it and the vagina would heal spontaneously.
The difficulties in this operation consist in the impossibility of absolute
asepsis, the constant mobility of the rectal wall on account of peristaltic
contractions, and, finally, the difficulty in reaching the opening through
the anus. Prolonged preparation combined with intestinal antiseptics
and frequent douches will do much to overcome the first. Opium in
large doses will practically control the second, but the difficulties of
approach, when the fistulous opening is high up in the rectal cavity,
are not so easily overcome. Terrier and Hartmann (Annales de gyn^c,
Paris, 1891, vol. ii, p. 192), Heydcnrcich {ihid., 1894, t. ii, p. 341), and
Demarquay have attempted to accomplish this by splitting the anus and
rectum posteriorly and removing the coccyx, or by doing a practical
Kraske operation. The seriousness of such operations is out of all pro-
portion to the gravity of the condition. If the opening can be reached
and sutured by an incision through the posterior commissure of the
anus no permanent ill effects will be likely to follow this. Upon the
whole, however, one must admit that the results of plastic operation
upon the rectal end of these fistulas do not justify either of these
procedures. Occasionally, when the opening is small and low down,
one may freshen the rectal opening and close it successfully by sutures;
but where the opening is large and some distance above the anus, opera-
tions through the vagina or through the perinaeum are more likely to be
successfid.

Operations upon the Vaginal Wall — The simplest of these is that
advised by Lauonstein (Fig. 162), which consists in denuding the fistu-
lous tract down to the rectal mucous membrane from the vaginal surfaces.
Stitches are then introduced from the vaginal side embracing all the

452

THE ANUS, BECTUM, AND PELVIC COLON

tissue of the reeto-vaginal sreptum except the nmcous membrane of the
rectum, and the wound is thus closed. The sutures should be of silver
wire, and introduced in whatever direction will bring the parts together
most accurately and with the least
tension. No effort is made to close
the opening in the rectal mucous
membrane. It is wise, however, after
having sutured the fistula, to stretch
the sphincter, introduce a rectal tube,
and constipate the patient in order
that no fluid fsfcal matter shall in-
fect the wound, and that tJiere shall
be -a free escape of the intestinal
gases through tlie anus. Fergusson
dissects u]> a c\iff of mucous mem-
brane upon the vaginal side about ^
an inch outside of and surrounding
the fistulous opening. This cuff is
dissected inward toward the fistula,
Ekcto-v*bi!14l KiJiTti-i. but Icft attached around the margin

of the opening: it is then caught to-
gether in the center and invaginated through the fistulous tract into
the rectum, where it is grasped by a hieniorrhoidal or narrow-bladed
clamp, and held in this position while the freshened surfaces around
the fistula in the vagina are brought together with silver or silkwonn-
gut sutures. The inverted flap closes the opening into the rectum
for the time being, and prevents the escape o£ gas and fiecal material
into the fistula until the freshened surfaces have had an opportunity to
unite. The same precautions should be exercised here as advised above
with regard to stretching the sphincter, constipating the patient, and
introducing a tube.

Various modifications of the flap operation have been devised. They
all consist in attempts to close the fistula by sliding or transplanting
flaps from the vaginal wall over the fistulous opening. In some the
tract itself is dissected out and sutured, in othere no attention is paid
to the tract, and it is attempted to close the fistula by placing a patch
of one or two layers of vaginal mucous membrane over the anterior aper-
ture. Among these operations may bo mentioned those of Montgomery
(Gymecology, p. 224), Saenger (Transactions of the Amer. Ass'n of Ob-
stet. and (Jyniecol., 1890, p. 359), Schauta ((.'entralblaft f. Gynakol., Leip-
zig, 1886, S. 485), Fritsch (Centralblatt f. Gynakol., Leipzig. 1888, S.
804), and Le Dontu (Annales de g,vn4col., 1890, p. 336). They are all
ingenious, but more or less complicated. The simple methods of Lauen-

COMPLICATED FISTULA

433

Btein and Fergiisson will accomplish all that can be done by these com-
plicated profedures. Where these plastic operations have failed, or
where the fistula is associated witli ruptured perinseum, Bonie operation
designed for its closure and the repair of the rupture at the same time
should be employed-

Complele Exriston of the Fistulous Tract comhintd with PeriiuFor-
rhaphy. — The technique employed by the author in this operation is
as follows:

The sphincter muscle should be thoroughly but gently stretched;
■ (he perinaeiun is then completely incised from the vagina into the rec-
l(t^,io>bat not ioeluding the fistula; a probe la then passed through

[ the fistula, and the latter, together with all its cicatricial tissue, is dis-
I Bect^ out m masse. The mucous membrane of the rectum is trimmed
off from Ihe edges of the wound for about \ an inch up to the level
of the fistulous opening, and above this it is loosened from its attach-
ments until it can be brought down to the marfcin of the anus; the
perineal steptum is then brought together down to and including the
I sphincter muscle with a continuous clinimicized catgut suture. Three
■ or four deep silver-wire sutures are then passed through the perinieum,
after the manner of Emmet. Before the latter are fastened, the mu-

454 THE ANUS, RECTUM, AND PELVIC COLON

cous flap in the rectum is brought down and sutured to the skin at
the margin of the anus (Fig. 163); the wire sutures are then drawn
together and made fast by twisting or by perforated shot, and finally
the edges of the mucous membrane in the vagina are sutured with plain
catgut and sealed over with iodoformized collodion. The operation con-
sists in doing practically a Whitehead operation upon the anterior wall
of the rectum combined with a complete perinaeorrhaphy. The mucous
flap closes all communication between the rectum and the perineal
wound, and thus protects the latter from faecal and gaseous passages. A
small drainage-tube is placed in the rectum to facilitate the escape of
gases, and the patient's bowels are constipated for six or seven days.
After this period injections of oil and glycerin may be given to soften
the faecal materials, but under no circumstances except real danger to
the life of the patient should a purgative be given until the hard faecal
accumulations have been removed or softened. The wire sutures are re-
moved on the eighth day. In 7 cases done by this method not a single
failure has occurred. In one instance, in which complete laceration
of the perinaeum and efforts at repair had resulted in great destruction of
tissue, it was impossible to bring the parts accurately together without
great constriction of the anus; this difficulty was overcome by incising
the rectum in aV-shape posteriorly (Fig. 108), thus relaxing the sphinc-
ter muscles fOid allowing the parts to be brought into more perfect ap-
position. No incontinence followed this operation, and from being one
of the most despondent and miserable of women, this patient was enabled
to enjoy society and travel without any fear of involuntary discharges
and the personal mortification consequent thereto.

In a certain number of cases the extensive destruction of tissue
renders it impossible to restore the rectal wall without causing a stric-
ture. In a patient from whom a glass pessary was removed through
the anus, inasmuch as she had passed the menopause, it was considered
wise to freshen the anterior lip of the cervix and suture this to the
freshened surfaces of the lower margin of the fistula, thus turning the
mouth of the uterus into the rectum. By this means the opening was
effectually closed. Simon has advised closing apertures of this kind
by a flap taken from the posterior lip of the cervix. The advice of
Rose and Czerny to precede this operation by inguinal colotomy, with
the hope that the recto-vaginal fistula will close spontaneously, is illu-
sory and apparently unjustifiable.

Episeiocleisis has been advised by Kaltenbach (Centralblatt f . Gynak.,
1883, No. 48) in these cases, but it has never met with great favor in
this country. One of tlie plastic methods, or the modified perinaeor-
rhaphy described above, will generally give the most satisfactory results.

CHAPTER XIII
STRICTURE OF THE RECTUM

Strictures of the rectum are spoken of as annular, valvular^ tubular,
and linear, according to the shape which they take. The annular stric-
ture is one which assumes the shape of a ring, involving only a very
small extent of the rectum, but completely surrounding it. The valvu-
lar stricture was formerly understood to mean that condition in which
a fold of mucous or fibrous tissue extended partially across the lower end
of the rectum or upper portion of the anus. This condition is con-
genital, and has been described in the chapter on Malformations. The
term has been applied of late to cases in which there was inflammation,
thickening and tension at the margin of the valves of Houston; these,
strictly speaking, are obstructions and not strictures. The tubular stric-
ture, sometimes called " cannular,^' consists in a tube-like contraction of
the rectum that extends for 1 inch or more in its length, in which the
entire circumference and all the tunics take part. The linear stricture
consists in a cicatricial or fibrous deposit over a limited area in the cir-
cumference of the intestine by which the caliber of the latter is les-
sened either througli the dimensions of the deposit itself or through
the contraction of the walls of the gut over the area which it occupies.

Strictures are spoken of as of large and small caliber according to
the amount of coarctation which they produce. We also read of con-
genital and acquired stricture, simple, cicatricial, spasmodic, soft, hard,
malignant, and benign strictures. The last term is a misnomer, for as
Cripps (op. fit., p. 215) has well said, every stricture if left alone eventu-
ally results fatally, if not from the disease itself, at least from the
symptoms which follow in its wake and shorten life. According to their
supposed etiology strictures are divided into congenital, neoplastic, trau-
matic, tubercular, sifphiUiic, gonorrhceal, dysenteric, and inflammatory.
All except the first two are included in the general term inflammatory
stricture, and we therefore adopt the following divisions:

Congenital Strictures, Neoplastic Strictures, Spasmodic Strictures,
Inflammatory Strictures.

455

456 THE ANUS, RECTUM, AND PELVIC COLON

The shape of the stricture may modify to a certain extent the surgical
procedures applicable to its management, but it has little if anything
to do with the pathological nature of the disease. Before discussing
these tjrpes, reference must be made to strictures which do not constrict,
or at least do so in a very slight degree.

Stricture of Large Caliber. — Every surgeon is familiar with the period
when it was the custom to introduce an ordinary steel sound of very
moderate size into the urethra, and if it passed backward without abso-
lute obstruction, pronounce the patient free from stricture. Later on,
cases arose with sjrmptoms referable to the urethra, and yet in which
the ordinary methods of examination failed to show any condition to
account for them. The invention of the bulbous bougie, and after this
the urethrometer, established the fact that aside from the normal coarc-
tations of the urethra there frequently occurred from pathological con-
ditions slight contractions in caliber that gave rise to certain neuralgic
and reflex symptoms which before this time were little understood and
not at all amenable to treatment. The discovery of this condition led
to new and revised methods of treatment, and the consequent cure of
many cases which had hitherto baffled the efforts of surgery. The same
conditions exist in the rectum. Small cicatricial or connective-tissue
deposits in the walls of such canals as the urethra and rectum are con-
stant sources of irritation because of the friction produced by the passage
of faecal matter and urine over them. It is not necessary that the caliber
of the canal shall be so contracted as to produce an absolute obstruction
in order to produce irritative symptoms. As an evidence of this the
following cases are cited :

Mrs. L. was operated for a small po8t-rectal fibroid on October 15, 1894, and
the operation was followed by some ulceration at the point from which the tumor
was removed ; but this healed, and the patient seemed to recover entirely within
due time. She sought advice five years later, describing herself as suffering from
a frequent desire to defecate, a slight discharge of mucus which stained her linen,
and constant aching pain in the back and pelvis. A careful examination showed
the existence of the cicatrix at the left posterior quadrant of the rectum, but it
was not painful ; and as it was possible to introduce a No. 10 Wales bougie, it
did not seem probable that the cicatrix was the cause of her suffering. A slight
hypertrophic catarrh existed, and she was also nearing the menopause with a sub-
involuted uterus. The treatment included rectal lavage, the regulation of the
diet, and occasional administration of such sedative and antineuralgic remedies as
her family physician had found to relieve her, in the hope that by tiding her over
the climacteric she would be relieved of her pains. Two years later the woman
consulted the author again, this time in desperation ; formerly she had positively
refused to consider any operation, but at this time her first remark upon entering my
office was, **I am here to do anything you say to get relief." Her neuralgia had
continued during the two years since she had been seen. An examination of the
rectum elicited the fact that the fibrous deposit had extended farther around the

STRICTURE OF THE RECTUM 457

rectum, involying about one-third of the circumference; the mucous membrane
over it was slightly redder than normal, but the caliber of the gut was very little
reduced. On September 19, 1900, this tissue was excised and the mucous mem-
brane was sutured over the wound. From the day of the operation this patient *s
neuralgia absolutely ceased, the pains in her hips and legs disappeared, and she
wrote three months later that she was perfectly well.

In another case of this nature in which there was no history of an operation,
but of a ** dysentery," as she called it, about fourteen years previously, the patient
complained of an inclination to go to the closet frequently, a feeling of pain and
dragging when her bowels moved, and an aching in the back and pelvis for some
time after stool. Examination of the rectum with the finger showed no abnor-
malities below, but about 3^ inches above the anus a narrow, submucous band
surrounding the lateral and anterior two-thirds of the rectum could be felt. It
was not a normal narrowing, but a distinct band surrounding the rectum, and
by pressure upon it it was possible to produce the same pains of which the
woman complained when she had well-formed faecal passages. There was no
cicatrization or evidence of preceding ulcerations in the mucous membrane of the
rectum, and so far as could be made out by palpation there was no great thicken-
ing of the tissues; full-sized bougies passed without difficulty, but did not give
much relief. The hand passed into the rectum felt this annular contraction, about
the caliber of a good-sized shoestring, entirely surrounding the intestine. By
gradually insinuating the palm of the hand through this portion and folding the
fingers so as to increase the circumference, the band gave way and the normal
caliber of the rectum was immediately restored. The patient was watched care-
fully for the next two days, but, so far from having any alarming symptoms, she
had immediate relief from the constant desire to defecate; and when on the second
day following the operation her bowels moved, she was delighted to find that it
was without straining, and accompanied with no pain whatever.

Some readers will attribute the result in both of these cases to the
divTilsion of tlie sphincter, but in neither was there any unusual con-
traction or spasm of this muscle, and more than that, both eases had
been treated by gradual and forcible dilatation of the sphincter before
they were finally operated on. Three other cases of this nature have
been seen at the clinic, in all of which the symptoms appeared to be
due to the irritation of the fibrous deposit and not to any actual nar-
rowing of the gut.

The cases presented are too few to base conclusions upon, but they
are suggestive at least of a possible obscure cause of many rectal 8\'mp-
toms which the ordinari^ treatment fails to relieve.

Obstructions to faecal passages from pressure by pelvic organs, tu-
mors, pessaries, etc., outside of the rectal wall, can not properly be called
strictures of the rectum, but they produce similar symptoms and may
excite an inflammation in its walls which will eventually produce
them.

458 THE ANUS, RECTUM, AND PELVIC COLON

CONGENITAL STRICTURES

The subject of congenital strictures has been already considered in
the chapter upon Malformations. At the risk of repetition, however,
we may say here that this condition is frequently unobserved until later
on in life, when, on account of change in food and habits, the patient's
stools become more solid, and difficulty in the passages begins to be felt.
Patients assume that this condition is simple constipation, and pay little
attention to it until the necessary straining produces fissure, haemor-
rhoids, or other inflammations of the rectum or anus. This usually
occurs about the age of puberty. Under these circumstances they con-
sult the doctor, and upon finding a strictured condition about the margin
of the anus, or just below the level of the internal sphincter, he is very
liable to be misled in regard to the nature and etiology of the same. A
very careful examination into the history of such patients will be neces-
sary to establish the true state of affairs. It is not to be supposed that
a patient will develop a cicatricial or fibrous stricture without the history
of some inflanmiatory or ulcerative condition having preceded it. These
cases can give no history of any rectal condition beyond that of gradually
increasing constipation. Many of them will be able to recall the fact
that constipation had existed from early infancy, that it was better for
a period during childhood, began again at the age of twelve or fifteen,
and after this time it gradually grew worse. The use of enemata and
laxatives will have become an established habit with such individuals
in early life. Ordinarily there will be no evidence of loss of tissue, but
rather an abnormal development. The stricture in such cases is usually
about i to J of an inch above the margin of the anus. It may consist
in one well-defined band, or sometimes a circular fold with an opening
in the center or on the side. The sphincter muscle may or may not be
hjrpertrophied, but it is absolutely distinct from the fibrous band which
forms the stricture.

When these strictures are seen after the age of puberty, they are
generally quite dense and difficult to dilate; in a young woman twenty-
three years of age it was impossible even by the exercise of considerable
strength to dilate the parts sufficiently to introduce a good-sized Sims's
speculum, and in order to accomplish this it was necessary to cut the
stricture. The fibrous tissue was removed by dissection, and was more
than i of an inch in thickness, dense, hard, and almost cartilaginous.
After having removed it, the mucous membrane of the rectum was dis-
sected up and sutured to the margin of the skin just over the external
sphincter. The patient made an excellent recovery, and all her symp-
toms were relieved. Ordinarily, however, such stricture will not be
found so dense, and gradual dilatation with small incisions at several

STRICTURE OF THE RECTUM 459

points in the circumference will accomplish a cure in these conditions.
It is unnecessary to repeat what has been said upon this subject in the
chapter on Malformations, but this will serve to call the reader's atten-
tion to the possible congenital nature of the strictures found low down
in the rectum.

NEOPLASTIC STRICTURE

The rectum may be obstructed by a new growth inside of it or within
its walls. Unless such a growth forms a true constriction of the rectal
caliber it can not properly be called a stricture; a pol3rpus may completely
fill up the rectal cavity, and yet it does not comprise in any way a stric-
ture; the same may be said of fibroids, of papillomata,and of condylomata,
they are obstructions but not strictures. Such growths will therefore
be considered in the chapters on Neoplasms of the Rectum. Malignant
growths, such as sarcomata and carcinomata, not only obstruct the rectal
caliber by protrusion into it, but they also narrow it by a fibrous con-
traction of the walls of the gut. Especially is this true of carcinomata;
they form a type of stricture which is both obstructive and contracting.
The fibrous portion of the stricture in these cases may have none of the
elements of the neoplasm in it, and is probably of an inflammatory
nature; but it is of small importance compared with the neoplasm that
causes it. When malignant growths have once been established, total
extirpation offers the only ground of hope for the patient, and the stric-
ture is always included in this. These strictures will therefore be con-
sidered in the chapter on Malignant Neoplasms of the Rectum. The
present chapter is limited to the consideration of that general type of
stricture produced by some form of inflammation. The cause and extent
of the inflammation, the amount of tissue destruction, and the method
of healing will determine the type of stricture.

Before beginning to discuss the special varieties of inflammatory
stricture, it will be well to take a hasty review of the anatomical con-
struction of the intestinal walls. It will be remembered that the rectal
wall is composed of four separate layers: the mucous, the submucous,
the circular, and longitudinal coats; and in addition to these, in its
upper portion and throughout the pelvic colon, it is surrounded by the
peritonapum. There jut out into the cavity certain folds of mucous mem-
brane between the lavers of which are included connective-tissue fibers
with glandular and cellular substances between them. These protru-
sions, called Houston's folds or valves, are fairly constant in certain
locations which are indicated by sulci upon the external surface of the
gut, and give it a convoluted form. The circular muscular fibers are
divided by bands of fibrous tissue which extend circularly around the
canal, and outward anteriorly, connecting with the fibrous meshes of

460 THE ANUS, RECTUM, AND PELVIC COLON

pelvic tissue, the ligament of the bladder, the broad ligaments of the
uterus, the prostate, and the fibrous sheaths of the levator muscle. These
facts are important in that they show how the rectum may be contracted
not only from inflammatory processes in the walls themselves, but also
by traction upon these circular fibers through the distention and infiam-
mation of the perirectal tissues. Moreover, any inflammatory processes
developing in these tissues may travel along the tract of these fibers,
invade the rectal wall, and result in a true submucous stricture, for
which no ulceration of the rectum or solution of continuity in the mu-
cous membrane need be evoked as the cause. The fact that these cir-
cular bands of fibrous tissue enter into the conformation of the valves of
Houston renders it easy of comprehension that contraction of these
valves may result from perirectal inflammations without any involve-
ment of the mucous membrane or the surfaces of the valves themselves.
The majority of cases in which the contraction of these valves has any
influence in the production of constipation will be found in cases that
have had pelvic, peri-uterine, or periprostatic inflammations.

SPASMODIC STRICTURE

Under the term spasmodic stricture two conditions have been de-
scribed which are entirely dissimilar. In one there is a stricture in
which there are no organic changes in the walls of the gut; it consists
in a spasmodic contraction of the muscles without any actual shortening.
In the other, a condition is described in which organic change and per-
manent constriction of the tube is produced through persistent spas-
modic contraction, resulting in shortening and fibrous transformation
of the muscular fibers involved, ^^^lile spasm of the oesophagus and
urethra are commonly admitted by every surgeon, the existence of a
purely spasmodic stricture of the rectum has been denied almost uni-
versally. Van Buren (Diseases of the Rectum, p. 318) said: " No mod-
em authorities admit the existence of pure spasmodic stricture of the
rectum, except in its lowermost portion where it is surrounded by the
external sphincter." He stated that the majority of the cases in which
such a stricture had been diagnosed were the victims of hypochondria
due to chronic constipation and dyspepsia; the difficulty in the move-
ment of the bowels suggested to them probability of obstruction or stric-
ture, and the fact that the passage of a rectal bougie stimulated the
organ to peristaltic action and thus facilitated the fnecal passages, tended
to confirm the erroneous impression. ^loreover, the fact that a rectal
bougie is very liable to be arrested by a fold of mucous membrane or by
the promontory of the sacrum, is also likely to convince the inex-
perienced surgeon himself of the existence of such a stricture. In sup-

STRICTURE OF THE RECTUM 461

port of these views Van Buren quoted 2 cases^ 1 in the practice of Syme,
and 1 in his own, in which patients suffered from symptoms of stricture
of the rectum, were treated for the same, and yet upon post-mortem no
stricture whatever was found. The cases cited are, unfortunately for
his argument, just the classs for which those who believe in spasmodic
stricture of the rectum contend. The facts that no organic stricture
existed, that the patients^ symptoms showed positively some obstruction
to the passage of faecal matter, and also that the rectal bougie after
having passed through the apparent obstruction was still grasped and
held tightly, show very clearly that ther.e existed during life a muscular
spasm resulting in a greater or less constriction of the rectal caliber.
There is no answer to the argument that, reasoning from analogy, one
may expect to find spasm of the circular fibers of the rectum even more
marked than in the oesophagus, the larynx, and the urethra. Contrac-
tion of the circular fibers of the intestinal canal may be excited by the
electric current, and it is not unreasonable to suppose that certain irri-
tating substances may do the same, and thus bring about a spasmodic
•constriction of the rectum. That such a condition is very frequent is
not asserted, but that it docs occur, and especially at the juncture of the
rectum with the pelvic colon, is absolutely certain. The author has time
and again attempted to introduce a cylindrical tube through this portion
of the canal, and notwithstanding that the direction of the cavity was
clearly in view, has been unable to pass the instrument upward until
after the spasm had relaxed. Upon withdrawing the tube in these con-
ditions the parts may be seen to contract like a rubber band, almost
entirely occluding the orifice. Whether there exists in these conditions
some sensitive area of mucous membrane or some irritable nerve-end, it
it not possible to say, but frequently in the same individual it is impos-
sible to introduce the tube on one day on accoimt of such spasm, whereas
on the next it is passed in without any difficulty; certainly there can be
no pathological or organic change varying from day to day which would
cause such an obstruction. While prolapse of the sigmoid into the rec-
tum would prevent the introduction of the tube, such a condition is not
difficult to recognize through the instrument, and therefore would have
no weight in this argument. The other condition which might possibly
account for the changes from day to day is the angle of flexure of the sig-
moid upon the rectum, which may vary. With the pneumatic sigmoid-
oscope, when no adhesions exist, the sigmoid may be lifted up by infla-
tion entirely out of the pelvic cavity, and yet the narrowing at the junc-
ture between it and the rectum will remain and appear larger at one time
than at another. Sometimes it will admit a Xo. 3 tube, while at others
it is difficult to introduce a Xo. 1. No one denies the fact that spasm of
the sphincters may be so marked as to interfere with stool or the pas-

462 THE ANUS, RECTUM, AND PELVIC COLON

Bage of instruments, and thus constitutes a type of stricture which may
be excited by small ulcerations, fissures, or foreign bodies. The proof
of this lies in the fact that the stricture disappears as soon as these con-
ditions are relieved. Whether they are called strictures, constrictions,
or muscular spasm is a matter of indifference, but the fact remains that
spasmodic contraction of the circular fibers does occur, and produces
symptoms that resemble those of organic coarctation.

Concerning the other type, that in which organic changes follow a
persistent spasm of the muscle, there seems to be considerable differ-
ence of opinion. No one claims that spasmodic contraction of the
rectum can be permanent; Cripps {op. cit,, p. 223), however, claims
that it may continue long enough to produce permanent shortening of
the muscles, and cites as comparable to this the contraction which occurs
in the hamstring muscles in cases of chronic inflammation of the knee-
joint, and goes on to argue that while such a contraction is at first an
intermittent one resulting from irritation in the joint, after a while
atrophy of the muscular fibers takes place, and permanent shortening
results. In this stage, he says: " The contraction ceases to be one of
muscular action, but the shortening remains permanent even after the
source of the irritation has been removed." From this analogy he
argues that any irritation in the rectum may produce a similar con-
traction of its muscular walls, and if such irritation continues it may
result in a permanent shortening of the fibrous elements of the muscle,
thus producing fibrous stricture. In support of this view he relates
the case of a woman in whom he found an ulcer in the posterior part
of the bowel with an annular stricture situated about 2 inches from the
anus, well above the sphincters; upon examining the patient a few days
later under ether the ulceration was unchanged, but the stricture had
practically disappeared. He afterward learned that by introducing the
finger somewhat roughly the stricture was immediately reproduced, but
by keeping it gently in contact with the part, a gradual relaxation took
place, so that the finger would lie comparatively easy in the narrowed
part; upon any rough movement it could be felt to be palpably and
immediately grasped and again relaxed in a few seconds. As the ulcer
healed the stricture gradually disappeared, and the woman left the hos-
pital apparently well. Two years later Dr. Cripps was called to see
this same patient. On examining the rectum he found at the site of
the previously soft and pelding stricture a firm, hard, unyielding fibrous
contraction narrowing the bowel almost to occlusion. In support of this
view Ball {op. cit., p. 139) reports a similar case. They both hold that
the irritation that occasioned the muscular contraction had resulted in
a permanent shortening and alteration of the muscular fibers, which
finally produced a fibrous stricture of the rectum. According to their

STRICTURE OP THE RECTUM 463

views both the circular fibers and those of the levator ani were involved.
The author has seen this spasmodic contraction of the rectum a number
of times in patients in whom there was ulceration of the mucous mem-
brane. It is always just above the point of ulceration, and it is reason-
able to suppose that the repeated contraction of these muscles due to
irritation of the fgecal passages may result in their shortening, but it
seems more rational to account for the stricture by the plastic deposit
which occurs beneath the ulceration and its known tendency to extend
and develop into fibrous tissue. It seems, therefore, that this type of
stricture is not spasmodic, but the result of inflammation, and should
be included in the latter class.

INFLAMMATORY STRICTURES

These include all those strictures due to simple^ tubercular, and syphi-
litic inflammations. The simple type comprises diffuse inflammatory,
cicatricial, and perirectal strictures.

The Location, — The site of inflammatory strictures varies greatly;
they may occur at any point from the margin of the anus to the upper
limits of the pelvic colon, though the large majority begin within the
first 6 centimeters of the anus. Excluding 258 cases collected by Perret
(These, Paris, 1856, No. 34), and 21 by Quenu and Hartmann (op. cit.y
vol. i, p. 253), 110 additional cases have been collected; of these the
sites were as follows:

Below 6 centimeters (2^ inches) 65

At 6 centimeters 5

F'rom 6 to 9 centimeters (2J to 3^ inches) 18

Above 9 centimeters (3^ inches) 12

In the pelvic colon 10

Quenu and Hartmann in 21 cases found only one stricture beginning
as high as 6 centimeters (2f inches) above the anus. In the author's
collection there occur no less than eight S3rphilitic and four tubercular
strictures above 9 centimeters (3 J inches). There is no question, how-
ever, that the majority of strictures of these parts are within the first
8 centimeters above the anus.

Diffuse Inflammatory Stricture. — These consist in an inflammatory
or fibrous deposit beneath the mucous membrane. Lesions of this mem-
brane may occur from various causes, and heal, leaving a perfectly nor-
mal surface with plastic deposit in the submucosa which continues to
increase, undergoing transformation into fibrous tissue until it partially
or completely surrounds the rectum, thus forming a stricture (Fig. 164).

In all inflammatory strictures, whether simple, tubercular, or S3rphi-
litic, the process must involve the tissues below the mucosa. Ulceration

464

THE ANUS, RECTUM, AND PELVIC COLON

or injury of ihe mucous membniDO alone «ill not produce a stricture,
and for this reason it is rarely ever caused by simple catarrhal diseases.
If the inflammation once involves the submucosa it is likely to extend
beneath the mucous membrane in all directions, owing to the distribu-
tion of blood-vessels and lymphatics in this tissue. This causes the
diffuse inflammation which ia followed by stricture or the reclilis
atenosanie of French authors.

CiCATBiciAL .Strictuhe. — If thoBe which follow surgical operations
are excluded, true eicatricia! atrictures will be found to be far leas fre-
quent than is generally
supposed. Wierever
the normal surface
membrane is restored
without intervening
fibrous tissue, no cica-
trix can be said to ex-
ist. Cicatricial stric-
ture, therefore, must
be confined to those
cases in which there
has been destruction
of tissues and replace-
ment by pure fibroife
or cicatricial material.
Phlegmonous tmd gan-
grenous ulcerations,
such as result from dif-
fuse gangrenous peri-
proctitis, may result in
cicatricial stricture of
the ■ rectum. Opera-
tions in which consid-
erable areas of rectal
tissue have been re-
moved, and healing
Fi- ■ -'■ "■ .1 I'F THE by granulation takes

place, will also occa-
sion them. All sorts of traumatisms which cause sloughing of the rec-
tal wall, as, for oxaniple, prolonged pressure of the head during child-
birth or the retention of large foreign bodies in the rectum, may result in
this type of stricture. Jtolliere has pointed out that gangrene of the rec-
tum or funis following certain forms of fever has resulted in the destruc-
tion of largo areas of the rectum and produced cicatricial stricture.

STRICTURE OF THE RECTUM 465

Kelsey, Tanchou, Curling, Esmarch, and others have reported eases
of cicatricial stricture that resulted from the introduction of foreign
bodies into the rectum; Krouse (Med. Record, 1892, vol. ii, p. 506) re-
ported a case of cicatricial stricture that resulted from a burn; Jeannel
has related a case in which cicatricial stricture resulted from the injec-
tion of pure tincture of iodine into the rectum; Qu6nu and Hartmann
state that other cases are due to accidental injections of caustic sub-
stances, such as nitric or sulphuric acid, into the rectum {op. ciL, p. 252).
The author saw a stricture of this type follow the accidental introduc-
tion of a strong solution of chloride of zinc into the rectum.

Cicatricial stricture is one of the complications or unfortunate se-
quences of operations for excision or resection of the rectum either by
the sacral or perineal methods; especially is this likely to occur if end-
to-end union is attempted in that region of the gut surrounded by the
levator ani muscle. Operations for fistulas and for haemorrhoids have
also resulted in this condition. Recently, owing to the attempts of in-
competent surgeons to perform the Whitehead operation, more cicatri-
cial strictures are seen than formerly. In the Medical and Surgical His-
tory of the War of the Rebellion there are reported 4 cases of stricture of
the rectum due to gunshot injuries; all of these, however, suffered from
perirectal inflammation and fistula, together with considerable sloughing
and destruction of tissue in the rectal walls themselves; in 2 the wound
of the rectum was complicated by that of the bladder, and in 2 others of a
similar nature the patients died from urinary extravasation before the
wound in the rectum healed. Wherever an extensive destruction of
tissue results in a granulating ulcer, an examination of this condition
during the ulcerative period will always elicit a loss of elasticity in the
rectal wall due to inflammatory infiltration, and, as Esmarch held, this
infiltration has more to do with the stricture than the actual contraction
of tlie cicatrix. Qu6nu and Hartmann state {op. cit., p. 24) that the
cicatrix is not so much the cause of the stricture as is the hyperplasia
in the submucous tissues. It may thus be stated that the majority of
so-called cicatricial strictures are really of the diffuse infiammatory type.
The cicatricial strictures which occur around the margin of the anus
following extensive ulcerations and operations in this region compose
a large percentage of those which one meets with at the present day;
there is no restoration of the cutaneous or muco-cutaneous membranes,
but a true, shining, cicatricial mass takes their place.

Perirectal Strictures. — By these we mean those strictures which
develop from conditions outside of the rectum. Displacements, enlarge-
ments, and tumors of the uterus, ovaries, bladder, prostate, or other
pelvic organs may cause obstruction in the rectum or sigmoid by pres-
sure, but these are not strictures. The writer has seen one case of abso-
30

466 THE ANUS, RECTUM, AND PELVIC COLON

lute occlusion of the rectal canal due to extra-uterine pregnancy; the
f cfitus broke through the intestinal wall and was delivered per anum, but
after this the caliber of the gut was at once restored.

Local or general peritonitis not infrequently produces rectal stric-
ture. The adhesive bands formed by these inflammations either pass
across the gut and bind it down to the bony structures like a ligature,
or they may narrow its caliber by holding it in an acutely flexed posi-
tion; this is illustrated by a case in which it was impossible to pass even
a No. 6 Wales bougie through the first loop of the sigmoid flexure on
account of the acute bend of the intestine at the recto-sigmoidal juncture
caused by an adhesive band holding it down in Douglas's cul-de-sac.
After the adhesion was broken up and the sigmoid flexure lifted out of
the pelvis, it was possible to pass without any difficulty a No. 12 bougie
its full length. Hartmann (Annales d'gyn., Paris, 1894) has related 2
* cases of this kind. Broca (Bull. soc. anat., Paris, 1852, p. 49) has de-
scribed a case in which two such adhesive bands embraced the rectum,
almost encircling it, and caused constriction. Inflammatory adhesion
of the uterus to the rectum or to the sacrum at one side or the other
may, by dragging the broad ligament of the opposite side across the gut,
cause stricture (Stone Scott, Med. Record, 1893, vol. ii, p. 264). The
stenosis in Scott's case was relieved by breaking up the adhesions be-
tween the uterus and the sacrum^ and thus lifting the broad ligament
from the rectum.

Another cause of stricture from extra-intestinal conditions is adhe-
sion of the appendices epiploica? to the abdominal walls, or, as has been
seen recently, to one another. The pedicles pass across the gut and
contract it to such an extent that it forms a perirectal stricture.

Many authors have recorded cases of peri-uterine inflammation that
involved the rectal wall and caused inflammation of the same with sub-
sequent stricture (Balzer, Bull, de la soc. anat., Paris, 1877, p. 402;
Biggs, Med. Record, 1893, vol. i, p. 153; Quenu and Hartmann, vol. i,
p. 247). Cases have been treated in which after the uterus was dissected
loose, the rectal wall remained thickened, indurated, and contracted in
its caliber. The passage of rectal bougies in such conditions occasioned
much pain, which was attributed to the pressure upon the uterus or the
ovary; while some of the pain was due to this, most of it was occasioned
by the inflammation in the tunics of the gut itself. The longer this
inflammation continues the greater will be the development of fibrous
tissue in the walls. The circular muscular fibers, owing to the fact that
they are held by adhesions and inflammatory plastic material and can
not contract, will become atrophied and transformed into fibrous tissue.

Prostatic disease may also cause perirectal stricture. The writer
once saw a case of this kind. The patient was sixty-one years of age

STRICTURE OF THE RECTUM

467

and had never suffered from venereal disease, but gave a history of
prostatie abseoss which discharged through the urethra. From that
time forward he began i t

to notice difficulty in \ ;/

stools and a hi'avineea
and weight in the sa-
crum: he had never
had any loss of blood
or pus from the rec-
tum, and no ha?mor-
rhoids had ever pro-
lapsed. The mucous
membrane of the rec-
tum, barring some
Iraumatitini made by
thtf forceps in efforts
to relieve an impac-
tion, was absolutely
healthy, but the organ
was bound closely to
the prostate, which was
large and indurated;
a circular fibrous band
con8tricte<l the rectum
at the upper limits of
the prostate and
seemed continuous
with the capsule of
the gland. It had evi-
dently been produced
by inflammation of
this organ. Kirmis-
son and Desnos (An-
nates des maladies des
organes genito-uri-
oaires, Paris, t. vii,
p. tt) have calle<l at-
tention to stricture of
the rectum resulting
from chronic inflam-
mation of the prostate.

A specimen (Fig. IfiS) taken from the body of an old man at the New
York Almshouse exhibited a remarkable condition of affairs. The rectum

468 THE ANUS, RECTUM, AND PELVIC COLON

consisted in a very narrow, tortuous tract surrounded by dense fibrous
tissue. About 3 inches above the anus was a perforation of its walls lead-
ing to an abscess cavity in which were several lemon-seeds. This cavity
appeared to be in the lobe of the prostate. Jeffries, who examined the
specimen microscopically, stated that the tissue all around the supposed
rectal canal was of a prostatic nature, and that careful study failed
to reveal any normal rectal tissue whatever. The fact that the lemon-
seeds were swallowed shortly before death and found in this narrow tract
proved its connection with the alimentary canal. The patient was
brought into the hospital moribund, and consequently no history was
obtainable. It is without doubt a remarkable stricture of the rectum
due to prostatic inflammation and hypertrophy. While stricture from
this cause is rare, there are numerous cases in which it has resulted from
pelvi-rectal abscesses originating in the prostate or in the broad liga-
ments.

Blind external fistulas may be the cause of perirectal stricture. They
do not involve the mucous membrane, but cause inflammation and fibrous
deposit around the gut, thus occasioning true stricture. Henry Smith
(Surgery of the Rectum, 1876) states that in such cases the stricture is
always the cause of the fistula, but he is certainly mistaken in this.
Cripps {op, city p. 230) cites a very interesting case in which he was
able to follow the patient from the time the abscess appeared until the
stricture formed. He examined her thoroughly in the beginning, and
found no contraction of the rectal canal. She was kept in the hospital
for twelve weeks, no internal opening of the fistula having ever devel-
oped. Eighteen months later she was readmitted to the hospital and
was found to be suffering from a well-marked stricture. He says: " It
is a matter of some surprise that the irritation of the fistula should so
seldom be followed by stricture, and I think it will probably be found
only when the fistula extends some distance between the coats of the
bowel, with a tendency to abscess formation, that the irritation is suffi-
cient to cause stricture.*^ The writer has seen a patient in whom a
small but deep perirectal abscess was opened early through the peri-
naeum, and was followed by stricture of the rectum; there was never any
lesion inside the rectum, and this abscess was the only discoverable cause.
One could argue that the stricture had been occasioned by a previous
ulceration of this organ, but there is not the slightest evidence of this.
With these facts in view, it must be concluded that true fibrous stricture
of the rectum may be occasioned by inflammatory processes and irrita-
tions entirely outside of the organ, without any infection from within or
any solution of continuity in the mucous membrane of the gut.

In an article entitled Phantom Stricture (Am. Jour. Med. Sci., Octo-
ber, 1879, p. 334 et seq,), Van Buren described 4 or 5 cases of this type in

STRICTURE OF THE RECTUM 469

which he states that the strictures are due to inflammatory deposits in
the pelvis and about the rectum, or to constricting bands resulting from
pelvic inflammations without involving the rectal wall itself in any
pathological changes. Illustrative of how pelvic growths and malposi-
tion of the uterus may simulate stricture of the rectum, he cites the
case of a young woman of twenty-five who could not relieve her bowels
while in the usual position, and was compelled to resort to the use of a
bedpan. As she lay in the Sims's position nothing abnormal could be
felt or seen in the rectum, but when she stooped in the squatting posi-
tion Van Buren was able to recognize a globular tumor forced firmly
backward into the hollow of the sacrum so as to completely occlude the
rectal caliber. This tumor proved to be a fibroma about the size of a
billiard-ball, which had developed in the posterior wall of the uterus.
These conditions, while not constituting stricture in themselves, may
produce it by exciting inflammation in the rectal walls through pressure
and obstruction.

Tubercular Stricture. — The existence of tubercular stricture in
the rectum or sigmoid is often denied. Pathological examinations have
positively demonstrated not only the inflammatory results of tubercular
ulceration, but the presence of giant-cells and tubercle bacilli in the
stricture itself. The fact that tubercular ulcerations of the rectum are
so rarely primary, and that when they occur in cases that have already
developed the constitutional disease they seldom heal before death takes
place, has led many to suppose that such a condition was impossible.

Recently the author had the opportunity to examine the bodies of a
number of patients who died from tuberculosis, and in four instances he
met with undoubted fibrous stricture existing beneath well-developed
tubercular ulcers; in 2 of the cases the stricture was in the pelvic colon,
and in the other 2 within the rectum; one was low down, and the other
4 inches from the anal margin. In neither of the latter instances
had the stricture contracted to such an extent as to greatly constrict
the gut, but in those in the sigmoid flexure the calibers had been
reduced to about one-fourth their normal size. Were the conclusions
with regard to the etiological influence of tuberculosis in stricture to
rest upon these post-mortem examinations alone, it would be well
founded; but there is more: two of these patients had distinct histories
of chronic, obstinate constipation alternating with diarrhoea, discharges
of pus and mucus, and all the concomitant sjTuptoms of true stricture.
Moreover, the histological examination of these specimens demonstrated
the existence of tubercle bacilli, giant-cells, and embryonic cells outside
the area of the ulceration.

In the section upon Pathology it will also be seen that the examina-
tions of Mitchell, Hartmann, Toupet, and others have demonstrated

470 THE ANUS, RECTUM, AND PELVIC COLON

these same characteristics, and thus proved beyond the shadow of a
doubt that tuberculosis may result in the formation of true fibrous stric-
ture of the rectum without the ulcers having healed. This is in har-
mony with the fact pointed out in the chapter on Tuberculosis of the
Rectum, that around every tubercular deposit there is a fibrous wall
tending to limit its extension. This fibrous deposit which causes the
stricture is inflammatory, but the inflammation is caused by localized
tuberculosis.

Syphilitic Stricture. — For many years the controversial war con-
cerning the influence of syphilis in the production of rectal strictures has
been waged. As far back as 1815, Richeraud (Nosographie chirurgicale,
t. iii, p. 428) spoke of " condyloma intemis " as a cause of stricture, and
from that time onward the subject has been more or less constantly dis-
cussed in medical literature.. Many of the early writers, as White, Mor-
gagni, Symes, Erichsen, and Talmann, failed to mention it in their
writings upon stricture; while others, as Bush, Copeland, and Curling,
absolutely denied its etiological significance.

As experience widened and observation became more exact, it gradu-
ally became established that a large number of patients suffering from
stricture of the rectum had been victims of syphilis, or at least venereal
disease. At this period we find such men as South (Chelius^s Surgery,
Am. ed., p. 47), Lansereaux, Hamilton, and Smith stating boldly their
opinions that syphilis is a cause of stricture.

The field of controversy then changed. Surgeons generally admitted
that venereal diseases, so frequently present in cases with stricture of
the rectum, must have some influence in producing it. They were un-
willing to concede, however, that it was through a constitutional pro-
cess. Thus we find Gosselin (Arch. gen. de med., 1854, p. 66) taking the
stand that the strictures in these cases were never due to constitutional
sjrphilis, but always to a local sore, chancroidal in its nature. This
theory was adopted by a large number of surgeons, such as Gross, Van
Buren, Bumstead, Mason, and Van Harlingen. Mason published a
series of 31 collected cases to prove this theory, but of these 15 had true
constitutional syphilis; Van Buren stated that he had seen chancroidal
ulcer followed immediately by stricture of the rectum. The facts, how-
ever, would not sustain this theory, for the majority of syphilitic stric-
tures occurred from 1 to 4 inches above the anus, and chancroids rarelv
extend above the muco-cutaneous margin. The initial sore of syphilis
accounted for it no better, because this was so seldom found in the rec-
tum at all. It was finally referred to some insidious process brought
about by the constitutional effects of this protean disease. This theory
was accepted, and at one time became so popular that every patient
suffering from stricture of the rectum was at once pronounced syphilitic,

STRICTURE OF THE RECTUM 471

whetlier there were any other evidences of the disease or not; but how
or why it produced stricture was not known.

Fournier (Lesions tertiares de I'anus et rectum, Paris, 1875) finally
advanced the theory that these strictures consisted in an interstitial
h3rperplasia ending in a fibrous degeneration and persistent contraction
of the walls of the gut, to which he applied the name ano-redal syphiloma,
which has been already discussed. This theory of Fournier has been
adopted by all syphilographers, and is admitted by rectal surgeons as
occurring occasionally, but it by no means accounts for the large major-
ity of strictures in the syphilitic which do not conform to this type of
the disease.

The question has heretofore been studied from a clinical point of
view, and each surgeon has drawn his conclusions from the sequence of
symptoms and the unreliable histories of his patients. With better
knowledge of the pathological changes which occur in syphilitic inflam-
mations, opinions are now based upon the actual alterations in the
tissues.

jVIicroscopic examination of a sufficient nutnber of these strictures
has been made to prove positively that they consist in the tissue changes
ordinarily seen in secondary and tertiary syphilitic inflammations, and
therefore it is concluded that while syphilis does not occasion so many
strictures as was formerly supposed, it nevertheless is accountable for a
considerable proportion of them. The question is no longer " Does it
produce stricture? " but " What is the process by which it does so? "

The writer has expressed his positive conviction that all these stric-
tures are preceded by ulcerations (p. 250). In order to understand this
subject he must anticipate somewhat his conclusions from the patho-
logical studies of this condition. Microscopic examinations of syphi-
litic stricture of the rectum show that the condition consists in a
chronic, inflammatory deposit characterized by nodular or gummatous
formations around the blood-vessels and distinct endarteritis. The
fibrous development or the stricture itself differs in no other way from
those strictures due to simple traumatisms and infective ulceration of
the rectum. There has been no histological examination of an ano-
rectal syphiloma in its early stages so far as is known. In a somewhat
extensive experience in rectal and genito-urinar}'' diseases no stricture
of this type has been seen in which the probability of previous ulceration
of the rectal wall could be eliminated. All the cases which have suf-
fered from this condition have either been ulcerative at the time, or they
have given the histor}' of previous discharges of blood, mucus, or pus
from the rectum, showing the inflammatory nature of the process.

The theory of Fournier was more attractive in 1876 than it is to-day,
because at that period local examination of the rectum was much neg-

472 THE ANUS, RECTUM, AND PELVIC COLON

lected in the secondary and early tertiary periods of syphilis, and there-
fore the ulcerations and inflammations of these periods were overlooked.
Many cases of syphilis develop a diarrhcBa and discharge of mucus during
the secondary stages which are generally attributed to the mercuric reme-
dies administered; whereas they are in fact the result of mucous patches
or ulcerative processes in the rectum itself. The writer has demon-
strated this fact more than once to the students at the Polyclinic Hos-
pital, and he believes that these early lesions of secondary syphilis are
always the beginning of Foumier's ano-rectal syphiloma. Under the
influence of mercury, which every layman knows for himself to be the
remedy for syphilis, these symptoms disappear, the ulcers in the rectum
heal, and the patient supposes himself to be well. The discontinuance
of treatment, however, results in the reestablishment of the pathological
process in the submucous tissue along the arteries and veins in the shape
of minute gummatous deposits around these vessels, and in the muscular
walls as an hypertrophy of the unstriped muscular fibers and connective-
tissue fibers which lie between them. Here there are two distinct pro-
cesses; one a specific involvement that extends in the line of the blood-
vessels, the other a purely inflammatory condition that extends in the
line of the submucous, muscular, and fibrous tissues. This submucous
inflammation, set up by the original ulcer and continued by hard faecal
passages and the presence of abnormal gummatous deposits, is really
the cause of contracture, and forms the true fibrous portion of the stric-
ture. It therefore seems probable that a very large majority of syphi-
litic strictures of the rectum originate in some ulcerative lesion of the
mucous membrane of the intestine, and that these lesions, due to second-
ary or tertiary syphilis, comprise most of the so-called chancroids which
were supposed at one time to account for so many strictures of the
rectum.

Fathology of Stricture. — We are indebted largely to Malassez, Comil
(Legons sur la syphilis, p. 412), Panas and Valtat (Bull, de la soc. de
chir., Paris, 1872, pp. 543, 572), Hartmann and Toupet (Semaine medi-
cale, 1895), M. Sourdille (Quenu and Hartmann, op. cit., pp. 278, 281,
283), Jeffries, and M. Girode for most of our information upon this por-
tion of the subject.

In the early stages of the disease macroscopic appearances show the
existence of an ulceration of the mucous membrane or a localized thick-
ening. Whether ulceration be present or not, there is always a lack of
elasticity in the rectal wall, a dense, leathery feel, and a decrease in the
distcnsibility of the organ. Where the ulceration has healed, the mu-
cous membrane is dry and has lost its normal shining appearance.
Quenu and Hartmann state that this condition is due to the transfor-
mation of the cylindrical epithelial cells into the pavement variety^

STRICTURE OP THE RECTUM 473

In our examinations we have not found thls^ but rather a stratified
columnar epithelium from which the goUet-cells are absent. Where
the ulceration exists along with the stricture, and there are many cases
in which this is the first symptom and continues throughout its course,
the rectum will be filled with a muco-purulent, sometimes sanious dis-
charge, and thus the dry, frictional condition of the mucous membrane
will not be observed. There is a tendency in syphilitic ulceration to
heal in its lower portions while it extends upward. The healed portion
appears as a bluish-white cicatrix, dense, hard, and almost ligamentous
to the touch. The condition may extend from the margin of the anus
to the pelvic colon, and even sometimes involve the lower loops of this
portion of the intestine. Occasionally the symptoms of obstruction will
be out of proportion to the actual fibrous contraction of the intestine.
In these cases we have to deal with the " rectitis proliferante " of Hamo-
nic (Annal. med. chir. trans., France et Etrang., 1886, vol. ii, p. 3). In
one case observed by the author the proliferating granulations almost
entirely filled the rectal cavity, obstructing the passage of faeces and
causing an abundant purulent and bloody discharge; after a colotomy,
and under specific and local treatment, they entirely disappeared, but
left a contracted stricture of the rectum.

The fibrous portion of the stricture is not always the narrowest;
sometimes the congestion and proliferating granulation cause greater
narrowing of the canal than the actual cicatricial contraction. Where
the ulcer is small, extending over a limited portion of the circumference
of the intestine, the diminution of the caliber will be at first propor-
tionately slight, and yet after such ulcerations as this have healed the
circular fibrous contraction may proceed and cause extensive strictures,
notwithstanding the fact that medication has controlled the syphilis.
In these eases tlie stricture possesses only the histological characteristics
of the inflammatory type. As has been frequently pointed out, in old
cases, especially where the stricture assumes the annular form, there
may be two points of ulceration, one above the stricture and the other
below it. That above the stricture does not present the character of true
syphilitic ulceration even in well-marked syphilitic cases, but assumes
that of a simple necrotic ulcer due to the irritation and pressure of
faecal materials that lodge at that point. The gut is always dilated and
tlie walls thinned above the stricture. The ulcer below is of the type
that produces the stricture, whether it be infectious, syphilitic, or tuber-
cular. The fact of an ulcer existing below the stricture has been said by
Ball to indicate that the stricture was caused through spasmodic con-
traction of tlie circular fibers, and their consequent h3rpertrophy and
shortening due to the efforts of the intestine to rid itself of the irritating
focus. This is an ingenious theory; it explains the fact that while the

474

THE ANUS, RECTUM, AND PELVIC COLON

mucous membrane is ulcerated above and below the strietured area, that
over the contracted portion appears apparently normal. Fistulous tracts
are occasionally found beneath the mucous membrane leading downward
from the stricture, and sometimes
outside into the perirectal tissues.
In women these fistulas may break
into the vagina, thus occasioning
recto-vaginal fistula (Fig. 166);
they sometimes pass through the
sphincter muscles or outside of
them, causing blind internal, or
even complete, fistula. Upon the
level of the stricture itself, espe-
cially where it is of the annular
variety, the mucous membrane
may not appear to the eye to be
at all altered. An examination
with the finger, however, shows
that it fails to move over the sub-
jacent tissues, that it is smooth
and fricttoBal to the touch, and
appears to be amalgamated with
the tissues beneath it. Thus we
have, as Malassez pointed out, three positive conditions or locations
to study in the pathological examinations: the stricture itself, the
parts above, and those below it. Hartmann and Toupet have studied
this subjeef very thoroughly following these lines. One constant fea-
ture in all the varieties of stricture which they describe is the absence
of ulceration at the level of the stricture and the substitution of pave-
ment epithelium with papillie for the cylindrical epithelium with glands.
The alteration they say is complete, and occurs in all strictures, whether
due to syphilitic, tubercular, or infective inflammations. This substi-
tution they also find in chronic catarrhal proctitis, a fact which is sig-
nificant in indicating the inflammatory nature of strictures, although
due to specifie causes. Quonu and Hartmann {op. ctt., p. 268) record
the case of stricture of the rectum in which this substitution of the
pavement for the cylindrical epithelium went on to such an extent that
a true pachydermatous condition of the mucous membrane of the rectum
was established.

Malassez says: "Just above the true stricture the tissue is formed of
new elements, is very vascular, and offers little resistance to the passage of
instruments; this part of the stricture is narrower than the true connec-
tive-tissue portion on account of the increased circulation and cellular

STRICTURE OP THE RECTUM 475

infiltration/' Lower down in the widest part of the stricture there are
fascicles of hard connective tissue surrounded by embryonic cells which
present the characteristics of true cicatricial tissue; sometimes the whole
rectal wall is involved in the sclerous process, and sometimes only the
internal layers. Even the circular muscular layer may be invaded while
the longitudinal layer is uninvolved and separated from the other by a
sort of callous infiltration. Ilartmann and Toupet say that when the
entire tliickness of the rectal wall has been involved, there may form
around it a sort of " callous fii)ro-lipomatous *' mass. In one case in
which they made a histological examination of the stricture removed,
the whole mass was composed of fatty cells dissected by fibrous bands
and ramifying blood-vessels with hypertrophy of the walls, thickness
of tlie intinia, and reduced caliber. The external coats were separated
by small round cells, the nuclei of wliich were easily stained. Here
we have no evidence of syphilis or tuberculosis, but simply a type of
inflaminatory infiltration. In another case, however, presenting prac-
tically the same pathological changes in other respects, they have dem-
onstrated the existence of typical syphilitic endarteritis and small gum-
matous deposits all along the course of the arteries and veins. In both
of these cases the blood-vessels are encroached upon until they are prac-
tically occluded at certain points. In the fibrous tissue there appear at
places certain new blood-vessels, but this collateral circulation is not
constant. The features which were always present in syphilitic stricture
are endarteritis and the small nodular developments about the arteries,
which are gummatous in their nature, some of them seeming to have
softened down in the center. The nodules are not so constantly situated
around the veins as around the arteries, but thev also occur in this
location.

In tubercular stricture one finds a different condition of affairs.
Ordinarily the entire epithelial surface of the mucous membrane will
be found destroyed. Quenu and Ilartmann state that the epithelium
destroyed is replaced by the pavement-striated variety. The examina-
tions made for the author by Ileitzmann and Jeffries do not demonstrate
any such substitution in these cases. They show that the epithelium has
entirely disappeared. The inflammatory infiltration extends considerably
beyond the ulceration. Upon the mucous membrane a number of papillae
are seen, and in the submucosa in the infiltrating fibrous tissue there
are here and there tuberculous follicles which show a tendencv to caseous
degeneration. The blood-vessels are crowded and somewhat occluded;
they are diminished in number, but they show no alteration in their
walls. Ilartmann and Toupet state that in 50 preparations they were
able to find only 2 in which they could demonstrate the existence of
an arteriole in the deep mucosa, and in this they perceived no appreciable

476 THE ANUS, RECTUM, AND PELVIC COLON

alterations. There were numerous capillaries, however, the lumens of
which were quite narrow.

The following report on a case observed by the author corroborates
the above observations, with the exception of the substitution of pave-
ment for cylindrical epithelium:

SyphiliUc Stricture of the Beetum — Histological Examination

by F. M, Jeffries

Six inches above the anus a stricture is presented. At this point the lumen of
the gut is greatly diminished so as to hardly admit the passage of a probe the size
of a lead- pencil. It is tortuous, and numerous crypts and pockets beset its course.
The walls here are generally thickened.

Above the stricture the colon wall is thin and distended and the gut is
engorged with faeces. Here again are numerous saccular diverticuli and pockets of
all sizes. Just above the stricture are two which are the size of hens* eggs. In
addition are numerous small saccular pockets the size of a pea which are filled
with faeces and are noticeable only from the outside. Viewed from the inside, the
sites of these pockets are hardly apparent, but upon close inspection it appears
that they are at the sites of solitary follicles. The follicle has disappeared and a
small channel has taken its place, givmg communication between the sac cavity
and the lumen of the gut. Macroscopic examination of these sacs gives the
impression that the peritonaeum constitutes the sole barrier between the contents
and the peritoneal cavity. Microscopically, however, the inner surface is lined
with a pyogenic membrane.

Throughout the extent of the large intestine are eight or ten small ulcers, and
in the caecum is a large ulcer which presents the appearance of a union of two
ulcers. At this point the walls are thickened and puckered in such a manner as
to markedly distort the contour of the gut.

The ulcers are of fairly uniform size and appearance, averaging 1.5 by 2.5 centi-
meters in diameter. The long diameter of all of them is transverse to the axis of
the intestine. (This is the course of the blood-vessels at this part.) Their edges
are abrupt and rough, and the mucosa turns downward and underneath. The
floors are rough and present slight elevations and depressions. The intestinal wall
around and beneath the ulcers is thickened and indurated.

Beneath the peritonaeum are numerous small miliary elevations which thickly
beset the indurated tissue. Microscopically these are found to be gummata.

At the site of the stricture there is no sign of inflammation either in the mucosa
or the remaining coats. There is a marked hypertrophy of the inner and outer
muscular coats, and associated with this change is an increase of flbrous tissue
conflned largely to the external muscular coat. The submucosa is closely studded
with blood-vessels most of which present thickened walls.

Microscopical examination of the tissues of the edge of one of the ulcers
resulted as follows :

Acute inflammation manifested by an exudative infiltration pervades the entire
thickness of the intestinal wall from the mucosa to the peritonaeum. The infiltra-
tion is of the small round-celled variety and is most marked in the muscular coats
and the submucosa. The arteries throughout are increased in numbers and present
thickened walls, in some cases with obliterated lumina. The thickening is con-

STRICTURE OF THE RECTUM 477

fined largely to the intima, and in many instances there appears to be an exfolia-
tion of endothelial cells which are embedded within the mass of blood-corpuscles.
These cells are somewhat swollen, but exhibit no further degenerative change and
stain nicely.

The intestinal wall is thickened, the increase largely confined to the sub-
mucosa. This is due in part to fibrous tissue, but principally to the fact that it is
thickly beset with gummata most of which are miliary in character.

One large gumma 8.20 centimeters by 1.76 centimeters (1| by f inch) in
diameter is situated just beneath the ulcer; another, external to the muscular
coats, is 1.60 centimeters by 2.80 centimeters (| by H inch) in diameter.

A few giant-cells are found. These are rich in nuclei, the latter being scattered
irregularly throughout the protoplasm of the cell.

The mucosa adjacent to the ulcer exhibits the small round-celled infiltration of
acute inflammation. The epithelium of the tilli is desquamated^ hut that qf the
crypts of Lieherkuhn is tntaet. At the edge of the ulcer the mucosa abruptly ends,
leaving but a thin layer of the deepest strata, including the ends of two or three
crypts, forming the floor of the ulcer. The muscularis mucosae remains intact
throughout.

The smaller giunmata are made up of aggregations of small round and epithelioid
cells which are somewhat loosely connected and present an appearance suggesting
a more or less fluid intercellular substance. The outer zone of these nodules is
made up of the usual small round cells with a few fibers of connective tissue inter-
mingling and rather numerous blood-vessels, some of which extend to the inte-
rior. Within this outer zone giant-cells are occasionally seen. In some of these
nodules necrotic changes have occurred, and their centers present an appearance
resembling cheesy degeneration wherein no nuclei are manifest.

The two larger gummata difler so in their structure that they will be described
separately.

The larger, situated in the submucosa, is surrounded entirely by fibrous tissue,
though it is scant in some portions. Within the fibrous coat is a thin layer of
small round cells, embedded in which are numerous capillary blood-vessels and
one or two large giant-cells. A few connective- tissue fibers are also found and
they are more abundant m the margin toward the center.

The greater part of the nodule is made up of necrotic substance thickly beset
with nuclei, most of which are fragmentary, the fragments of each nucleus remain-
ing grouped in close apposition.

The remaining nodule is situated external to the muscular coat and is sur-
rounded by a fibrous capsule which is thicker than the one just described. Within
this fibrous coat, sharply defined from it, is a thicker layer of epithelioid cells,
spindle-shaped and round, and with large intercellular spaces. This layer is devoid
of blood-vessels and presents one or two giant-cells. The interior is a necrotic
mass resembling complete cheesy degeneration, and contains minute fragments of
nuclei only, except at its periphery, where a few larger fragments are seen.

A succinct statement of the differences in the pathology of the three
typical varieties of inflammatory strictures will be found in the fol-
lowing table, which is briefly summarized from the works of Toupet,
Jeffries, Mitchell, Malassez, Hartmann, and Sourdille:

478

THE ANUS, RECTUM, AND PELVIC COLON

Simple Inflammatory
Stricture

The destruction of the
cylindrical epithelial layer
and the substitution of
the same by striated pave-
ment epithelium. (Found
only by French patholo-
gists.) Diffuse sclerosis of
the submucosa with amal-
p:amation of all the coats
of the bowel, excepting,
IKjrhaps. the external mus-
cular layer. Decrease in
the number of bloo<l-ves-
sels, but no marked
changes in the arterial
walls. Occasionally cal-
careous deposits or fibro-
li|>omatous infiltration
around the outside of the
walls.

Tubercular

The epithelium and the
superficial mucosa may be
entirely destroyed and the
whole strictured surface
ulcerated. Where the
mucous membrane cover-
ing tile strictured portion
remains intact, the colum-
nar e{)ithelium is trans-
formed or replaced by
the pavement epithelium
(Ilartmann and Toujwt).
Fibrous bands more or
less dense extend through-
out the submucosa. These
bands are .separated here
and there bv tuberculous

•

follicles. The blood-ves-
sels them.selves are only
altered in their external
walls bv infiltration with
embryonic round cells.
Giant -cells exist in the
more superficial portions
of the fibrous tissues,
gradually decreasing as
one extends outward from
the caliber of the gut.

TulxTcle bacilli are
found in the granulations,
but disappear altogether
in the sclerous portion.

Syphilitic

On the level of the
stricture the mucous mem-
brane may be absolutrij
destroyed and replaced by
true cicatricial tissue, or
the inflammatory process
having been due to spt-
cific inflammation withoat
great destruction of Uasiie,
the mucous membrane is
reformed over the stric-
ture<l portion. In such
cases we have still the
substitution of the pave-
ment for the cylindrical
epithelium (Hartmanoand
Toupet). The sclerous or
'fibrous degeneration of the
submucosa and muscular
walls of the gut is homo-
geneous throughout. The
blood-vessels show infiltra-
tion of all their walls with
distinct thickening of the
endothelium, narrowing of
the caliber, and all the
evidences of specific end-
arteritis. Around both
the arteries and veins are
gummatous nodules with
clearly defined outlines,
some of wliich present evi-
dences of softening in the
center.

Rieder states (Annales
depath.,1898. p. 545)thtt
sometimes the submuct)?!*
exists only as a thin con-
nective tissue and cellular
layer with miliary gum-
mata scattered throughout
it, and that the walls of
the veins alone mav be in-
volved. the arteries re-
maining normal. These
statements have not been
corroborated.

It is by no moans so easy to distinguish these varieties, even with
the microscope, as it would seem from the above. A chronic inflamma-

STRICTURE OF THE RECTUM 479

tory condition with endarteritis is ordinarily considered as an evidence
of constitutional syphilis, but endarteritis has been known to exist in
inflammations due to traumatism and caustic substances. It is not justi-
fiable, therefore, to base a diagnosis of syphilitic stricture upon the
existence of this condition alone. We must have other evidences of
the disease in the shape of gummatous nodules in the strictured area,
and at least a suspicion of the disease in the patient. A simple, diffuse,
inflammatory stricture may become infected with tubercle bacilli, and
yet not be a tubercular stricture. The finding of the bacillus is not
sufficient evidence upon which to base a diagnosis of true tubercular
stricture; in addition to this evidence one must have at least the pres-
ence of giant-cells with embryonic infiltrations of the perivascular re-
gion, and tubercular nodules with well-defined limitations. These con-
ditions may thus be so combined that it is very difficult to determine
the exact nature of a stricture even after it has been excised and a
thorougli histological examination made. Where the patient has a his-
tor}' of tuberculosis or syphilis, one may presume upon the possibility
of the stricture partaking of the nature of the general disease; but
he must always bear in mind that a syphilitic or a tuberculous individual
may be afflicted with a simple infiammatory stricture.

Etiology. — Diffuse inflammation of the intestinal walls is undoubt-
edly the chief etiological factor in the production of stricture. Trau-
matism, infection, syphilis, tuberculosis, and dysentery may all be the
exciting causes. In 313 collected cases, 216 occurred in women; this
preponderance of the disease in that sex has been the strongest argu-
ment against syphilis being the chief cause of stricture, for while women
suffer very much more frequently from the latter than men, men suffer
very much more frequently from constitutional syphilis than women.
This might be explained were it admitted that stricture of the rectum is
frequently due to the initial lesions of s}T)hilis or to chancroid, but as
has been already shown, this is not the case, and the more frequent
occurrence of these lesions about the anus in women will not account
for the preponderance of stricture in this sex.

The close proximity of the rectum to the genital organs in women
constantly subjects it to injur}' during childbirth and pressure from the
gravid or displaced uterus; constipation is also very much more frequent
in women than in men, thus subjecting the mucous membrane to more
frequent lesions from this source. It does not seem difficult, therefore,
to explain why strictures are more frequent in this sex, especially if
we concede the fact that the majority of strictures have their origin in
some lesion of the mucous membrane or some traumatism to the wall
of the gut.

Wallis (Brit. Med. Jour., 1900, vol. ii, p. 1002), who has seen a num-

480 THE ANUS» RECTUM, AND PELVIC COLON

ber of these eases, states that in his opinion most rectal strictures are due
to septic ulceration or to the pressure of the child's head during labor.
Pulton (Kansas City Med. Jour., 1894, p. 181) reports a very positive case
in which the stricture followed prolonged pressure of the child's head
in the hollow of the sacrum. Duplay (Semaine m6dicale, 1892, p. 461)
states that strictures of the rectum differ in no wise from those affecting
the urethra and the oesophagus, and that they are all due to inflamma-
tory processes, the causes of which may be simple infection, traumatism,
syphilis, tuberculosis, or any other condition which produces a rectitis
with cellular infiltration. Syphilis, as we have already seen and ad-
mitted, has an undoubted etiological influence in the production of the
disease. The fact, however, that the large majority of strictures show
no amelioration from antispeciflc treatment, demonstrates very clearly
that in these cases there is another factor. If the stricture were due
to gummata and syphilitic cellular infiltration alone, the specific medi-
cation would undoubtedly produce an amelioration of the symptoms.
In conclusion it may be said that the fact of a patient's having had
syphilis does not prove that a subsequent stricture of the rectum is
due to this cause; the syphilitic may have non-syphilitic stricture.

Tuberculosis is not duly appreciated as a cause of stricture. Refer-
ence has been made in a former chapter to the development of dense
connective-tissue walls around tubercular fistulas and ulcers, so it is not
surprising to find pathologists claim to have demonstrated beyond the
question of a doubt that tubercular infiammation is the exciting cause
of a certain number of strictures of the rectum. In the specimen
(Fig. 90) we have to deal not only with a tubercular ulceration but
also a fistula and a stricture of the rectum combined. Tubercle bacilli
and giant-cells, together with embryonic infiltration, were found in the
inner layers of the stricture with pure fibrous tissue in the outer layers.
RoUeston (Transactions of the Path. Soc. of London, 1890, p. 131) re-
ports 3 cases of stricture of tlie large intestine due to tubercular deposit,
1 of which was in the sigmoid fiexure. In the post-mortem room at the
Almshouse Hospital of this city, the author has demonstrated no less
than five strictures of the rectum and sigmoid in patients who died
from general tuberculosis; the strictures all showed the embryonic infil-
tration, giant-cells, and tubercle bacilli. This disease is therefore un-
doubtedly the cause of certain strictures.

In the section upon dysenteric inflammation of the rectum and
sigmoid, it was stated upon good authority that the majority of dysen-
teric ulcers occur in the sigmoid flexure and in the rectum. Wherever
ulceration occurs the possibilities of infection, hyperplasia, and fibrous
contraction are always present. Mathews, basing his conclusions upon
personal experience and the pathological studies of Ouchterloney, states

STRICTURE OP THE RECTUM 481

very positively that dysentery never produces stricture of the rectum.
He has many followers in this opinion, among them Comil, and Wood-
ward, who in his history of the War of the Kebellion found no case of
such a stricture either in the hospitals or upon the pension rolls. On
the other hand Gibbs, Allingham, Kclsey, Cripps, and Castex all afl5rm
just as positively that they have seen cases which dated from distinct
attacks of dyscnter}-; the author has seen 2 cases in which the patients
ascribed the condition to attacks of dysentery, but in these the only
proof of the disease consisted in the fact that they had suffered from
pain and burning in the rectum, tenesmus, diarrhoea, and the discharge
of blood and mucus, and such symptoms may be due to any inflam-
matory condition of the lower end of the intestinal canal. While it
is probable that these patients did suffer from dysentery, inasmuch as
they both came from Southern States in which the disease is very preva-
lent, and where the inhabitants are quite familiar with it, it is impos-
sible to say positively that either of the strictures resulted from the
dysentery itself. Certainly no case has tlius far been discovered in which
any of the typical bacteria to which dysentery has been ascribed have
been found in the stricturod area. AMiile, therefore, the possibility and
even the probability of dysenteric stricture is conceded, it must be
admitted that the condition is not absolutely proved.

Irritating injections, habitual constipation, and ptederasty have been
mentioned as causes leading to rectal inflammation, ulceration, and sub-
sequent stricture. In the Medical and Surgical History of the War
there are 4 cases of stricture of the rectum reported as resulting from
gunshot wounds of this organ. In 2 other cases death occurred from
the wound, but not until after a strictured condition had been discov-
ered. Any cause, therefore, which results in the destruction of tissue,
in inflammation of the submucosa, or the deeper tunics of the rectal
or intestinal wall, may bring about a stricture.

Symptoms, — The symptoms of stricture may be divided into those
of the latent, the ulcerative or inflammatory, and the obstructive periods.

Latent Period. — A certain number of classical writers deny or ignore
this period entirely (Quenu and Ilartmann, vol. vi, p. 297; Kelsey, p.
350; Allingham, p. 323; and Cripps, p. 235). In stricture due to malig-
nant neoplasms the disease may exist for long periods before any marked
symptoms will be noticed. There is also a latent period in strictures
due to inflammatory conditions, either simple or specific. An injury
occurs to the rectal wall through pressure of the head during labor,
through surgical procedures or foreign bodies, and a small ulceration
may develop which goes on for a certain length of time and finally heals.
From this time forward the patient has no symptoms of rectal disease
until months aftem'ard he begins to notice increasing difficulty at stool,
81

482 THE ANUS, RECTUM, AND PELVIC COLON

and an examination shows a well-developed stricture constricting the
caliber of the gut to a greater or less degree. This latent period is
very common in syphilitic strictures and those following surgical opera-
tions. It is well illustrated in the case quoted from Cripps (p. 233),
and in the stricture of large caliber described in the early part of this
chapter. It also occurs in cases due to perirectal inflammations and
pelvic cellulitis. In all these conditions the rectal symptoms in the be-
ginning are entirely subordinate to those of the primary condition, and
after the real cause of the stricture has been alleviated or removed there
is a period in which the rectal S3miptoms are absent. It is that period
between the acute inflammatory process and the time when the fibrous
bands begin to obstruct the caliber of the gut by persistent contraction,
which is called the " latent period," and in which no definite symptoms
occur.

The ampulla of the rectum is a very wide and distensible cavity,
and it requires a considerable amount of constriction to develop symp-
toms of obstruction in it. Until this degree of contraction has been
developed, therefore, the symptoms of stricture may not manifest them-
selves at all. The symptoms of the latent period may be elicited by
careful interrogation. Tlie patient will generally admit that for con-
siderable periods of time, or even dating the period back to that of
the original disease, he has suffered more or less distinctly from
heaviness, weight or aching in the rectum or sacral region, and pains
shooting down the legs. Dysuria or frequent urination of a mild degree
is often noticed at this time, and patients so affected have been treated
for cystitis, urethritis, and stricture of the urethra, whereas the actual
disease was in the rectum. Reflex disturbances of the uterine append-
ages, the digestive organs, and of the nervous system also occur in this
period. It is well, therefore, to bear in mind its possibilities whenever
there are obscure symptoms in patients who have suffered from rectal
ulceration, pelvic cellulitis, uterine displacements, tuberculosis, or syphi-
lis, and to examine from time to time to determine the possible devel-
opment of stricture.

Ulcerative or Inflammatory Stage, — The symptoms of the ulcerative
period previous to the formation of stricture differ in no wise from
those described in the chapter upon General Ulceration of the Rectum.
They consist in dull, constant pain in the perinaeum or sacral region,
diarrhoea, tenesmus, discharges of mucus, blood, and pus, together with
reflex disturbances of the genito-urinary and digestive organs.

These symptoms may entirely disappear and the patient feel per-
fectly well during the latent period of stricture formation, or they may
pass gradually into those of stricture before the ulceration heals. As
the causative ulceration heals, or the inflammatory tissue begins to con-

STRICTURE OF THE RECTUM 483

tract, the sjrmptoms of diarrhoea subside, and difficulty in obtaining a
movement grows more and more marked. At this period the reflex
disturbances of the genito-urinary organs will increase, the rectal dis-
charges will grow less, and while there will be tenesmus and frequent
desire to go to stool, the act can only be accomplished with great
straining.

Obstructive Period, — The symptoms of this period are the typical
signs of the disease. They consist in gradually increasing and per-
sistent constipation; from a simple irregularity the movements of the
bowels gradually become less and less easy, until a faecal passage is not
only a rarity but a real travail. Patients go one, two, five, ten, and
even thirty-six days without having a movement, and then after strain-
ing, employing injections and instruments for breaking down the mass,
a fa?cal explosion occurs, the intestines are cleaned out, and for another
period they may be comparatively comfortable. One of the writer's
patients devoted the Sabbath day to the movement of his bowels. The
process required about two-thirds of the day, and recovery from the
exhaustion occasioned by it took up the rest.

Godebert (Theses, Paris, 1873, No. 496) relates a case in which the
movement of the bowels only occurred once in a month or six weeks.
It was then a veritable labor: purgatives had no effect; the stomach was
much swollen, the appetite was lost, and the respirations very short.
When the symptoms became so severe that the patient could bear them
no longer, she retired to her chamber and with the finger introduced
into the vagina, and straining with all her might, she was able to relieve
herself little by little of the accumulated mass. The operation required
the greater part of a day; the fa?ces at first were extremely hard and dry,
but the later portion of the movement was soft and liquid.

The constipation in such cases is mechanical; it is an obstipation due
to arrest of the fgecal matter above the stricture. This arrest often
results in irritation of the mucous membrane and increased secretion.
Diarrhoea may therefore alternate with constipation, but what is more
frequently the case, the patient suffers from a diarrhoea and constipation
at the same time. There is a frequent discharge of mucus and semi-
fluid matter, while there still remains above the stricture large masses
of hard faecal matter. This condition is comparable to the dribbling
of urine in enlarged prostates, in wliich the patient supposes that he
suffers from incontinence when really it is from inability to empty his
bladder. One must not always conclude that the bowels are being thor-
oughly emptied because of frequent diarrhoeal movements. The tempta-
tion to give opium or astringents in order to control such a diarrhoea
should never be yielded to imtil one is absolutely sure that there is no
accumulation of fa?ces above the strict ured part.

484

THE ANUS, RECTUM. AND PELVIC COLON

Constipation, it should be remembered also, is a comparative term.
Some require movements every day, while others equally as healthy re-
quire them only once in a week or more, as was the case in a patient
who for forty years had a movement every Saturday night, and died
from pneumonia at the ripe age of ninety-five years. Gradually increas-
ing constipation, together H'itb greater and greater ellort to relieve one's
self, are much more important 3ym.ptoms than infrequent passages.
With this one observes abdominal distention and accumulation of hard
fffical masses in the intestine; above the brim of the pelvis, and all
o?er the abdomen, in fact, one may frequently feel hard, lumpy faices

through the distended abdominal wall. It is to these masses that is due
the greatest danger in the disease. Stricture rarely if ever obliterates
the lumen of the gut entirely, but foreign bodies, or hard, spherical
masses of fn'ces frequently become lodged in the strictured portion and
cause occlusion with rupture of the intestine and fatal peritonitis.

Intestinal indigestion, flatulence, and loss of appetite are common
in this condition, and occasionnllv patients are seen who suffer from
skin eruptions, fever, 00810^3 tongue, sallow complexion, jaundice, and
all the complications of auto-intoxication due to the accumulation and
decomposition of fiecal matter above a stricture of the rectum or sigmoid.

The straining necessary to overcome the obstruction is often so
severe that inguinal hernia may be produced, or, as in a case seen with

STRICTURE OP THE RECTUM 485

Dr. Ladinski (Fig. 167), it may result in prolapse of all the rectum
below the stricture. In this case there was a history of progressive con
stipation but no evidence whatever of syphilis or of tuberculosis. Ap-
parently it was a simple inflammatory process which had resulted in
great hypertrophy of the rectal walls and the development of fibro-
lipomatous tissue surrounding it. Hulke (Med. Times and Gaz., Lon-
don, 1879, p. 504) records a case of this kind, and also one in which
complete prolapse of the uterus was brought on by this straining.

With the diarrhoea there are sometimes discharged large quantities
of pus tinged with blood, and occasionally alarming haemorrhages occur.
These are due to the ulcerations above and below the stricture. The
discharges from that below are not usually mixed with faeces, being
purulent or sanio-purulent, and quite profuse; those from the ulcer
above the stricture are mixed with faeces. Thus patients will describe
being called to stool early in the morning and passing nothing but blood
and pus; within an hour or two they attend the closet again and have
a fircal passage with some pus, and later in the day various calls result
in passages similar to that of the morning.

The amount and character of the discharges from a stricture will
depend largely upon its cause. In syphilitic stricture the discharge
is very abundant, always sanious and dark-colored, and possesses a sort
of feculent odor. In those due to tubercular or simple inflammation the
discharges are not so abundant, they are not frequently mixed with
blood, and the color is more of a creamv white stained with faeces.

Skin-tabs, such as the French call condyloma, excoriations, thinning
of the perianal skin, and sometimes the development of papillomata
around the anus, may form the external manifestations of stricture of
the rectum. Henry Smith states that the skin-tabs and condylomata
are more frequently found in syphilitic stricture than in any other
variety, and that he had often made a diagnosis of this condition from
the external appearances alone, and found his opinion corroborated by
a more thorough examination.

The form of the faecal passages has been insisted upon as an impor-
tant symptom of stricture of the rectum. As such it has been greatly
exaggerated. It is a perfectly clear mechanical principle that the faecal
mass must assume the form of the last constriction through which it
passes; tlierefore it must take the shape of the anal aperture, and will
not represent that of a stricture higher up. Grooved or tape-like faecal
masses are often full of import to the inexperienced, who suppose
that they are always due to stricture, whereas they may be caused by
spasmodic sphincters, hypertrophied skin-tabs, or haemorrhoids. The
only circumstances under which the faeces retain the shape of the stric-
ture are when the latter is at the anus or is prolapsed so as to be outside

486 THE ANUS, RECTUM, AND PELVIC COLON

of this aperture. Kelsey was fortunate enough to see a case in which
the faecal mass retained the form imparted by the stricture, owing to
the fact that it prolapsed outside of the anus whenever the bowels
moved. In Ladinski's case this was also clearly demonstrated, because
the prolapse was constantly down, the stricture being at its lower end,
and therefore the faecal mass always assumed the shape of the stric-
tured caliber.

When the stricture is very low down, or at the margin of the anus,
the parts assume a sort of inelastic, tubular condition, the sphincters
lose their power of control, and the patient suffers from a condition of
incontinence and constipation at the same time. The fluid substances
constantly dribble away, whereas the formed faecal matter will be re-
tained until great effort or solvent enemas result in its removal.

Dilatation and weakening of the gut wall above the stricture always
occur, and cause danger of perforation or rupture. Tympanitic reso-
nance is present over this area one day and an absolutely flat sound
on another, owing to the periodic accumulation of faeces in, and empty-
ing of this portion of the intestine. Perforation of this thin and weak-
ened wall may occur without absolute obstruction, owing to ulceration
or straining. In fact it most frequently occurs in this way. When it
is preceded by obstruction the patient suffers from nausea, faecal vomit-
ing, or great belching of foetid gases, together with intense pain and
swelling of the abdomen, rapid pulse, and high temperature. After
perforation occurs the temperature may suddenly drop for a few hours;
if the patient does not die in this state of shock it will rise again, and
the condition will develop into local or general peritonitis. While per-
foration ordinarily ends fatally this is not invariably the case, as timely
operation may save the patient's life; or the area may become walled
off and a localized abscess formed, which of course terminates in a faecal
fistula.

Diagnosis, — In the diagnosis of stricture it is not only necessary to
determine its existence, but also its seat, its pathological character, its
extent, and the degree of constriction. When within 4 inches of the
anus all this information can be obtained witli comparative ease, inas-
much as the parts can be reached with the finger, can be seen through
the speculum, and sections can be obtained for microscopic examination.
Above this limit the diagnosis is more difficult.

The history and symptoms of the case will give valuable information
as to the existence and probable pathological character of the stricture.
Previous injury or operation, diffuse proctitis, pelvic cellulitis, a pro-
longed labor, the history of perirectal or pelvi-rectal abscess, syphilis,
fistula, or rectal ulceration, may all suggest the probable existence of
stricture, especially if associated with a gradually increasing difficulty

STRICTURE OF THE RECTUM 487

in movement of the bowels. A source of error in reading such symp-
toms lies in the fact that many patients, after having suffered from
inflammator}' conditions about the rectum and anus, develop the habit
of irregularity in fa?cal movements. They leam to restrain themselves
on account of the pain which stools occasion, and thus become accus-
tomed to visiting the toilet only once in two or three days.

Constipation, such as would indicate stricture, consists in the re-
quirement of great effort to secure a stool even though the desire for
defecation is urgent. In cases of infrequent defecation simply due to
habit, no unusual amount of straining or discomfort is required to
accomplish the act. The symptoms may lead one to suspect stricture,
but local examination alone can establish the diagnosis.

Examinaiion. — The patient should be placed upon his side in the
Sims's position with the hips flexed upon the abdomen and elevated
upon pillows. The external appearance of the anus is frequently quite
suggestive.

The existence of fistulous openings around the margin, especially
if they are multiple and preceded by progressive constipation, is always
suggestive of the probability of stricture. Where there is a discharge
from the parts, the character and odor should be carefully observed;
these have been described in connection with different varieties of
ulceration, but the odor is of great importance in differential diagnosis,
and may be referred to again. In cancer it is unique; once smelled
it is never forgotten; it is neither faecal nor feculent, but a combination
of putrefaction, gangrene, decomposing fa»ces, and rottenness to which
no other bears any resemblance. In simple inflammatory or tubercular
strictures the discharges may be comparatively odorless. In syphilitic
stricture it is feculent, but if ordinary' care is practised in the manage-
ment of tliese cases the odor will be entirelv subdued. In carcinoma,
however, nothing short of the incinerating box of a crematory will de-
stroy it. Aside from the odor, the discharges from carcinoma and syph-
ilitic stricture resemble each other very much; they are both compara-
tively thin, bloody, and purulent.

In simple and syphilitic strictures the anus is ordinarily not much
deformed; the fatty cusliions around it remain comparatively intact.
In malignant and tubercular strictures it is ordinarily sunken in, the
fatty cushions around it are absorbed, and it presents a sort of infundi-
bulifonn appearance. In carcinoma the condition of the anus will de-
pend largely upon the situation of the growth and the extent to which it
has developed; if situated high up and it has not gone on to consti-
tutional involvement, emaciation, and cachexia, the anus may give no
indication wliatever of the disease; if low down, however, the sphincter
may be hypertrophied, hard, and spasmodic, and the seat of constant

488 THE ANUS, RECTUM, AND PELVIC COLON

pain in the early stages, but later the spasm gives place to great relaxa-
tion, dribbling of the discharges occurs, and exuberant, cauliflower-like
growths may protrude from the anus.

The chief source of information in the diagnosis of stricture is
examination by the finger. Great gentleness and caution should be
exercised in such an examination, not only to avoid giving the patient
pain and to prevent such a spasm of the sphincter as would interfere
with complete, examination, but because it is altogether possible to break
down the soft and weakened tissues of the ulcerative portion and cause
rupture with dangerous ha>morrhage or perforation of the peritonaBum.
Even with the utmost gentleness this has sometimes happened (Bull, de
la soc. de chir., Paris, October 23, 1872).

Upon the introduction of the finger into the anus the changes in
the mucous membrane below the stricture which have been described
may be observed. If the finger is pushed upward it may enter a gradu-
ally decreasing cone-like canal which leads to the stricture, or it may
come upon a sudden decrease in the caliber of the gut formed either
by soft granulations, smooth, hard, cicatricial tissue, or nodular, in-
durated, malignant masses. The gradual coarctation from below up-
ward is usually associated with the tubular variety; the sudden and abrupt
diminution in the caliber of the gut is due to an annular or sickle-shaped
stricture. The sensation imparted to the finger by the touch of the
stricture is very important. Many clinicians believe that they can posi-
tively diagnose malignancy by this, and certainly no one will deny that
a surgeon of large experience can by this means alone obtain a fair
knowledge of the condition. If hard and nodular and bulging out into
the rectum, or broken down in its center and forming an irregular,
crater-like ulcer with friable, exuberant granulations, one may assume
with confidence that it is a case of malignant disease; if, on the other
hand, the obstruction is comparatively smooth, hard, and contains only
a few minute irregularities beneath the mucous membrane, is movable
upon the sacrum and surrounding tissues, and apparently confined to
the walls of the gut, it will probably belong to the inflammatory variety
of stricture. In malignant stricture the diminution in the size of the
gut is usually abrupt, whereas in the syphilitic type it is gradual. The
latter are more frequently tubular than annular, whereas those of the
simple inflammatory and tubercular type are ordinarily annular and
involve onlv a small extent of the rectum. When the stricture is
reached, one should never yield to the inclination to force his finger
through the aperture, especially if it be a carcinomatous or ulcerative
case. No good whatever can come from such a procedure, and there
is always danger that what appears to be the caliber of the gut may
possibly be the entrance into an ulcerative diverticulum, the dividing

STRICTLTRE OF THE RECTl'M

4S9

tissue between which and the peritoneal cavity is so thin that perfora-
tion may easily result. As Malossez has pointed out, there is a portion
(if almost every stricture which is composed of a sort of proud flesh, soft
and easily torn. ;\iiy undue force at this point may result disastrously.

Tlie thickness and height to which a stricture extends may often
be determined in females by the combined vaginal and rectal touch,
which should never be omitted. In men who arc not too fleshy, with one
hand upon the abdomen and the other in the rectum one may some-
times grasp a tumor or a long stricture between them, and thus deter-
mine its extent upward. Under amcsthesia it is possible to grasp a
tumor of the sigmoid between two fingers introduced into the rectun)
and the hand upon the abdomen; with the whole hand in the rectum
this can always be done. In these examinations one should always de-
tennine the mobility of the affected parts: it tlie stricture is freely
movable upon the sacrum and other
organs of the pelvis, it will be much
more favorable for operative inter-
ference than otherwise. Where it
is attached to the sacnim. the pros-
tate, the uterus, or other pelvic or-
gans, the operation will be difficult
and the prognosis grave.

When the symptoms indicate
the existence of a stricture and it
can not he made out by digital ex-
amination, search by instruments
will often succeed, but it must bo
remembered that instrumental e.t-
ploration is exceedingly dangerous
in stricture. A rectal bougie, how-
ever soft and flexible, may do great
damage in the hands of the inex-
perienced. There are so many
sources of error in examination by
this instrument that litlle weight i*
attached to it as a diagnostic means. hm i-rt.ir.iM.iM. ., Mnu-renE.

It may be caught in the nmcous

folds or in a diverticulum of the rectum and absolutely fail to pass
beyond this (Fig. 1U8); at the promontory of the sacrum it may be
arrested, and, owing to the acute flexure of the sigmoid upon the rec-
tum, may double upon itself, coming backward into the rectal ampulla
instead of passing into the sigmoid flexure; sometimes, even if the opera-
tor is skilful enough to appreciate when it is thus doubling upon itself.

I
I

490

THE ANUS, RECTUM, AND PELVIC COLON

he will be unable to introduce it any farther. A bougie which is stiff
enough not to double upon itself is also stiff enough to penetrate a dis-
eased rectal wall. Soft Wales bougies may be used by experienced
hands in these cases, but even they are dangerous. The author has
several times had these instruments introduced into the rectum, when
operating for abdominal conditions, just to observe the amount of pres-
sure exercised by them upon the intestinal wall, and from these experi-
ments he is exceedingly skeptical in regard to the wisdom of ever intro-
ducing them into chronic, inflamed intestines with symptoms of stric-
ture. Certainly no one who has ever seen the amount of pressure that
is exercised upon the gut wall by one of tliese instruments will take
the chances of attempting to force one through a strictured intestine in
which there is ulceration. Aside from this danger, the bougie reveals
nothing definite with regard to stricture. If it fails to pass, one can
not say whether the obstruction is due to this or to some other cause;
if it passes, one can not say there is no stricture, for, as Kelsey says,
" a bougie of good size will often pass a stricture small enough to pro-
duce great trouble ^' {op. cit., p. 357).

One may sometimes use it to advantage through the proctoscope by
bringing the strictural opening into sight and introducing the bougie
through it. Otherwise one works in the dark when they are used.

The reader should also be warned
against the danger of introducing
rectal instruments into patients
under the influence of anaesthetics;
the only guide there is in regard
to the amount of traumatism that
is being produced lies in the sensa-
tions of the patient, and one may
perforate the intestine uncon-
sciously if this safeguard is re-
moved. The pneumatic procto-
scope gives much more informa-
tion than the bougie and is not
nearly so dangerous; through it
one is able not only to diagnose
the stricture and its location, but often its caliber and pathological na-
ture as well. The condition of the parts below the stricture can be seen,
and if the obstruction consists in neoplasms, such as polyps or papillom-
ata, this can also be determined. The groat value of this instrument
is enhanced by the fact that there is practically no danger in its use.

It is introduced through the internal sphincter, and the gut is in-
flated so that one can see clearly every inch of the way before advancing

FlO. 169.— BODENHAMER^S BCLBOUS KeCTAL

Bougie.

STRICTURE OF THE RECTUM 491

the instrument. TVlien no stricture exists in the rectum itself, a few
pressures upon the hand-bulb will dilate tlie organ, and the tube can
then be advanced, its end always being clearly in view, out of touch with
the rectal wall. At the juncture of the rectum and sigmoid the direc-
tion of the gut above can be seen, and with skilful manipulation the
tube can be carried into the latter just as safely as into the rectum.
By this means it is possible to bring into view any contracted or stric-
tured portion of the gut without any undue pressure or danger of per-
foration. After this has been done and the end of the tube accuratelv
adjusted to its aperture, the external cap may be removed, and a prop-
erly adjusted bulbous bougie (Fig. 169) passed through the stricture
to determine its caliber and extent. These instruments and their uses
have been already described (p. 129).

Redometers, — Laugier and Tarnier have each invented instruments
whicli have dilating ends, and which may be introduced through the
stricture and then dilated and allowed to collapse gradually until they
can be easily withdrawn, on the same principle as an Otis urethrometer.
The author having had no experience with them, is unable to confirm
or denv their usefulness.

In the absence of the proctoscope, or where for any reason it can
not be applied, one may have resort to Simon's method of introducing
the whole hand into the rectum and examine the parts in this way. It
is a very dangerous procedure, however, where there is clironic inflam-
mation of the organ.

Laparotomy. — As a final resort in tlie diagnosis of stricture one may
liave recourse to exploratory laparotomy. Formerly such a radical
measure would have been looked upon unfavorably; to-day, however,
it is a most common procedure, and comparatively without danger.
Indeed, it is less dangerous than any instrumental examination of the
rectum in diseased conditions, if the use of the pneumatic proctoscope
be excepted.

In making such an examination the incision should always be made
similar to that employed for inguinal colostomy in order that an artifi-
cial anus may be made at the time if it is found necessary. Moreover,
this incision will be found the most convenient for operations upon the
sigmoid flexure and upper end of the rectum. After the incision has
been made, tlie sigmoid may be gently dragged out of the opening or
run tlirough the fingers until the strictured area or neoplasm is felt or
found absent.

The diagnosis between the several varieties of stricture is somewhat
more difficult; but the most important distinction to be made is that
between the malignant and non-malignant. In a general way one may
distinguish them as follows:

492

THE ANUS, RECTUM, AND PELVIC COLON

Malignant Stricture

Generally occurs in persons above thirty-
five years of age.

Runs its course ordinarily in two or
three years. Constitutional symptoms,
such as loss of flesh and strength, ap-
pear early in the disease.

Hereditary influence probable.

To the touch hard, nodular, without
pedicle ; protrudes into the rectum
from more or less of the circumference
of the gut, but not equably ; it may
occur as a deep excavating ulcer with
sharp edges and indurated base, or
sometimes as a fungous, granulating,
cauliflower growth. May be movable,
but is generally attached to the sacrum
and surrounding parts.

The odor is nauseating, gangrenous, and
unique.

XON-MALIGNANT STRICTURE

Occurs at any age, ordinarily between

twenty and fifty.
The patients may live for many years

with it. General health remains good

through long periods.

No hereditary connections.

To the touch it is smooth, hard, and
inelastic, but not nodular.

Rarely attached to the sacrum, but some-
times attached to organs in the ante-
rior portion of the pelvis.

The discharge may be abundant or lim-
ited, thick or thin, according to tiie
nature of the stricture.

The odor is ftecal or feculent, according
to the amount of ulceration.

A distinct cicatricial or fibrous appear-
ance upon examination through the
speculum.

In doubtful conditions microscopic examination of an excised por-
tion of the growth will be of service, but one should not rely too
implicitly upon it, especially if the result of the examination is nega-
tive. The author had one case in which three specimens removed from
a neoplasm of the rectum were reported as non-malignant by three
different microscopists; so convinced was he of the clinical diagnosis
which had been confirmed by tw^o other surgeons that he advised radical
operation, to which the patient consented. After the tumor was re-
moved more thorough examinations of its deeper portions revealed
clearly its carcinomatous nature. Hypertrophy of the other tissues,
tubules, and glands in the rectum may occur as a result of irritation
from a neoplasm, and the sections obtained for examination (during life)
may be only portions of these hypertrophied areas, and not a part of the
malignant disease at all. Between a careful, thorough clinical diag-
nosis and a microscopic examination of a small specimen the former
seems more reliable, though the value of the latter is not to be un-
derrated.

Between the varieties of inflammatory stricture differentiation is
much more difficult. Reference has been made to the microscopic ap-
pearances, the changes in the blood-vessels, the deposit of tubercles, and
the development of fibrous tissue which occur in the three different
varieties, but unfortunately such examinations can only be made after
the stricture has been removed. Wliat is needed is some method to

STRICTURE OP THE RECTUM 493

distinguish the different varieties in the early examinations in order
to determine positively the line of treatment most applicable to any
given ease.

Those symptoms upon which most reliance is placed are the follow-
ing: Syphilitic strictures are rarely abrupt, they show a gradual funnel-
like contraction, and around the edges of the ulcers there is a bluish-
white cicatrization.

The traumatic or simple inflammatory stricture is usually abrupt
and may be limited to one side of the gut as a falciform contraction;
it is generally smooth, covered with epithelium, and in the majority
of instances is near the anus. Tubercular stricture may occur at any
portion of the large intestine; it is always associated with tubercular
ulcers and caseating tubercular masses, and the scrapings from such an
ulcer will generally show the presence of tubercle bacilli and giant-cells.
The appearance of the ulcer is entirely different from that of the syphi-
litic ulcer, as has been described in the chapters upon these two diseases.
The nmcous membrane is always undermined and the base elevated,
whereas in the syphilitic ulcer the edges are never undermined and the
base is alwavs crater-like or excavated.

While the tlierapeutic test is of little value to determine the nature
of the stricture, it is of the greatest importance in that it checks the
extension and assists in healing an ulceration if it be specific. Not only
this, but it acts as a real alterative and tonic in cases due to tuberculosis
and simple inflammation.

Microscopic and culture tests throw light upon tubercular strictures,
but the finding of tubercle bacilli should not be taken as an absolute
proof of the tubercular nature of a stricture, because these germs may
be ingested, carried through the intestinal tract, and thus enter the dis-
charges or lodge upon the ulcerations without being the cause of the
same. The appearance of the ulceration below the stricture, the sensa-
tion imparted to the finger in digital examination, the history of the
case, and above all the concomitant symptoms, such as pulmonary tuber-
culosis or syphilitic manifestations elsewhere, are the important points
in differentiation.

Treatment. — Recognizing the fact that strictures are all due to in-
flammatory processes, it is conceivable that proper treatment in the
early stages may prevent their formation. The theory upon which
gradual dilatation has succeeded in curing a certain number of acute
strictures of the urethra is that it squeezes the blood out of the stric-
tured area, and when the instrument is withdrawn there results a state
of arterial hvpenemia which results in absorption of the newly formed
tissue. During the early stages of stricture the blood-vessels remain
intact, and are not materially diminished in number; the plastic deposit

494 THE ANUS, RBCTUM, AND PELVIC COLON

is soft and absorbable. Similar treatment may therefore be as successful
here as in the urethra. If the inflammatory process is syphilitic, proper
medication, along with local treatment, will control it and check the cel-
lular infiltration which results in stricture. If it is due to tuberculosis,
the administration of proper remedies and forced feeding, together with
local applications, may limit the extent of the ulcer as well as the fibrous
deposit aroimd it, and thus control to a certain degree the extent of
the stricture. If it is due to simple infection, careful antiseptic treat-
ment may often prevent the formation of a cicatrix or stricture. When
once a dense, hard, fibrous stricture has formed, the blood-vessels are
no longer normal in their caliber or number, and the probability of
exciting an absorptive hyperaemia is exceedingly remote; this stage once
reached there is no method that offers any certain hope of permanent
cure.

Dietary and Medicinal Treatment — The patient should be placed
upon a nourishing but non-irritating diet. A milk diet produces a hard,
leathery, insoluble stool; while it is non-irritating in the stomach and
upper intestine it is far from being so in the sigmoid flexure and rec-
tum, and it is particularly dangerous in stricture.

As a rule a nitrogenous is preferable to a carbohydrate diet, but
when there is no marked colitis this need not be insisted upon. A
mixed diet, consisting of chopped meats, soups, rice, hominy, ice-cream,
fruits, chocolate, fish, oysters, etc., may be allowed; with these a liberal
amount of cod-liver oil or olive-oil should be given. Where there is
marked ulceration rest in bed is always advisable; but one must be care-
ful not to carry this too far and develop general debility by long con-
finement and lack of exercise.

Where diet does not produce a regular movement of the bowels it
will be necessary to resort to some laxative. Strong purgatives are to
be avoided, inasmuch as they not only produce irritation and oedema,
which narrow the passage, but they may through excessive peristalsis
and tenesmus cause a rupture of the thin gut above the stricture. For
these cases there is nothing better than small doses of Epsom salts with
bicarbonate of soda in the proportion of three to one; the saline mineral
waters are also useful, but patients are very likely to develop the habit
of taking them in too large quantities, and thus induce a diarrhoea rather
than a normal movement. Castor-oil, cascara sagrada, glycerin, and
licorice powder may also be used with advantage. It is advisable in the
majority of cases to alternate these different remedies. The resinous
cathartics, such as gamboge, aloes, podophyllin, and senna should be
avoided. Enemata, if properly administered, are of benefit, but the
practice of introducing them through long tubes is not only dangerous
but useless. If the tube is stiff perforation may be easily produced; if it

STRICTURE OP THE RECTUM

495

is very limber it will pass up to the stricture, double upon itself, and
thus the fluid will be poured out into the rectal cavity just as it would
have been had the small nozzle of a syringe been used. It is better in
these cases to advise the patient to take cold-water enemata from a
fountain syringe raised about 2 feet above the bed or floor on wliich
he lies. He should be in the knee-chest posture and allow the fluid
to flow in slowly. The cold water will temporarily contract the blood-
vessels, reduce the congestion, and thus increase the caliber of the
etrictured portion for the tinie being. The sliglit elevation of the
syringe will obviate any danger from pressure, and the slow, gentle
current will not excite any immediate peristalsis. As much as 2 or
3 pints of cold water may be introiluced in this manner, and often
with the happiest results. Oecasionatly 4 ounces of olive-oil may be
injected about half an hour before the enema is given. Tliis lubricates
the parts, and sometimes produces a smooth, comfortable movement
of the bowels without the enema. Glycerin, turpentine, and salt may be
added to the cold enema, and will sometimes be of material assistance
to excite peristaltic action and proper fa-cal movements.

Diarrhuea connected with a stricture of the rectum is generally due
to one of two causes, viz., an impaction of fffices above the stricluretl
point or an acute ulceration of the intestine. The management of this
condition, therefore, consiste in the removal of any fjecal masses which
may be retained above the stricture and treatment of the ulceration.
The injections of oil, solutions of o.\-ga!l, and warm water may result
in the softening and removal of the arrested materials. When this
has been accomplished then the ulceration can be treated, as has been
described in the chapter on that subject.

Eelscy states that acute obstruction sometimes occurs in these eases
as a result of the spasmodic contraction and excessive peristalsis, and
claims (op. ril., p. 362) that several times he has been able to obtain
a movement, in apparent obstruction due to stricture, by the adminis-
tration of large doses of opium. Although with no experience of this
kind, the author would certainly hesitate to administer very large doses
of this drug to patients who are suffering from symptoms of obstruc-
tion unless there was great tenesmus, griping, and pain. Medicines, as
a rule, do little more than relieve the symptoms in the majority of cases,
and yet one would be verj' far from justified in omitting their use.
Especially is this true with regard to antisyphilitic remedies. Mercury
and the iodides have a positive influence in promoting the resolution of
all embryonic fibrous material, as Stills pointed out many years since
in hia lecture upon plastic adhesions of the pleura. Mercury when ad-
ministered in moderate doses has been shown by Keves to have a positive
tonic influence, to increase the red blood-corpuscles, and conduce to

496 THE ANUS, RECTUM, AND PELVIC COLON

the patient's general health. Therefore these drugs may act in a bene-
ficial way in non-specific as well as specific strictures.

LOCAL AND OPERATIVE TREATMENT

The chief local and operative methods used in the treatment of
stricture are:

Dilatation or divulsion; proctotomy; excision; entero-anastomosis;
colostomy; electrolysis.

Theoretically the ulceration should always be healed before any
surgical treatment is begun in order to avoid sepsis, but practically
this is impossible, for in many instances the ulcers can not be cured
so long as the stricture exists, iintiseptic precautions should always
be taken before any local or operative treatment of the stricture is
begun, whether it be dilatation, proctotomy, or excision.

Gradual Dilatation. — This method is that most generally employed
throughout the surgical world, notwithstanding the fact that it is not
often curative and entails periodic repetition throughout life. It is
carried out by the aid of bougies and rectal dilators of various types; it
requires a considerable amount of skill and judgment, and it is fraught
with danger even in the most skilful hands.

Bougies. — There has been devised a large variety of rectal bougies,
some of them useful and many of them positively detrimental. Those
of Wales, Cred6, Andrews, and Hegar (Figs. 81 and 170) comprise the

most useful ones for the treat-
ment of rectal stricture. The
old conical rectal bougie made

Fio. 170.— Cred6'8 Rectal Bougie. ^^ wovcn linen or silk and cov-

ered with shellac, is a most
dangerous instrument and no longer used by rectal surgeons. Tlie
methods of introducing the bougies, however, are of more importance
than the instruments themselves. The dangers of traumatism and per-
foration of the rectal wall from the use of stiff instruments have already
been described.

The Wales instruments were devised to obviate this danger, and
they are superior to other instruments in this respect.

Methods of Introduction. — The patient is laid upon the side in the
Sims's posture with the thighs flexed upon the abdomen. The bougie
is then gently introduced, if practicable using the left index finger to
guide its tip into the orifice of the stricture. In the majority of cases
this is impracticable, as the sphincter will not admit the passage of
the finger and the bougie at the same time without groat pain. Wlien
the bougie is arrested, a current of water is injected through it in

STRICTURE OF THE RECTUM 497

order to lift out of its way any folds of mucous membrane or other
obstruction.

If the stricture is at the margin of the anus or within an inch of
the same, it is an easy matter to introduce the instrument, but if it is
higher up it is always a matter of chance whether it enters the stric-
tured canal or not. In stricture above the levator ani there is generally
a sagging or procidentia of the constricted portion of the gut into that
below, thus forming a sort of cul'de-sac around it. The end of the
bougie is very likely to be arrested in this instead of entering the stric-
tured aperture (Fig. 168). Especially is this the case in malignant
and annular strictures, where the orifice may be in the center or at any
other portion of the circumference. In syphilitic strictures, in which
the approach to the orifice is funnel-shaped and gradual, this accident is
not so likely to occur. At any rate, it is always a matter of uncertainty
when the bougie is arrested whether its tip is engaged in the stricture,
in this sulcus, or in a nnicous fold, and in diseased conditions any exer-
cise of force at such points, even with these soft instruments, may result
disastrously.

The Author^s Method of introducing Bougies into Strictures, — In
order to obviate these dangers and be more accurate in the use of
the instalments, the author has for several vears been in the habit of
introducing a proctoscope up to the point of the stricture and locating
its end over the aperture; the bougie is then gently introduced through
it into the stricture. By this means it is known that the bougie is in
the right track; the proper size can be easily selected, and it may be
gently ])ushed upward with or without the use of a stream of water and
without any doubt of its being in the right track. The bougie which is
used for this purpose is a Wales instrument with no flange upon its end,
so that the s})eculum can be removed as soon as the former is engaged
in the stricture. It is best to introduce a small instrument first, pass
it through the stricture, and then introduce one size after another
until the largest one which can be passed without actual pain has been
reached. When this has been done, the speculum is withdrawn and the
bougie allowed to remain in position for five to fifteen minutes. By
this moans not only is the bougie accurately introduced into the orifice
of the stricture, but it is possible to see the condition of affairs at each
introduction, and also to realize how much of the friction and grasping
of the bougie is due to the stricture itself as distinguished from that
of the external sphincter muscle. The method is simple, accurate, prac-
tical, and far superior to the old uncertain methods.

The ap])lication of remedies to the stricture at the time of dilata-
tion was first eni|>loyed by Dessault, who introduced a tampon in-
corporated with mercury through the constriction and left it there.
83

498 THE ANUS, RECTUM, AND PELVIC COLON

This method is of no practical value, but in cases where there is ulcera-
tion, the bougie may be lubricated with such ointments as may be
thought beneficial to the condition. The author has sometimes used an
iodoform ointment in the strength of 1 dram to the ounce, and some-
times a mercuric ointment; but of recent years he finds it more satis-
factory to use a simple lubricant upon the instrimients, and depend upon
more accurate methods in the application of drugs to the ulcerated
areas.

The frequency with which the bougie should be introduced depends
upon the amount of reaction occasioned. At first it may be advisable
to introduce it every day, provided the patient's anus and rectum do
not become inflamed and tender from the proceeding. Often it will be
found necessary to allow several davs to intervene betw^een seancts.
Any haste in this regard may result in the development of acute inflam-
matory conditions which will not only retard the final result, but increase
the stenosis and add a real danger to the condition. It may be set down
as a rule, therefore, that wherever the bougie produces any tenderness
or considerable pain it sliould not be introduced again until all this has
passed away. Too rapid increase in the size of the instruments may
also produce this effect. One should never introduce more than three
bougies at one sitting; he should keep a record of the sizes used, and
always begin with one number lower than the largest used at the previous
treatment; if this passes easily and without pain, he may then introduce
the highest number used on the previous day, and if it passes freely,
introduce one size larger. Before removing the instrument a warm
solution of boric acid is injected through it, and thus everything above
the stricture is cleansed as far as possible.

The patient should be kept quiet for half an hour after the treatment,
and if any bleeding follows the withdrawal of the instrument he should
not be allowed to leave the office until his rectum has been examined,
to ascertain if any considerable luemorrhage is taking place, and if neces-
sary control it.

Eetention of Bougies. — The length of time a bougie should remain
in the stricture after it hai? once been introduced is a somewhat mooted
question. Kelsey (op. cit., p. 353) claims that it is advantageous to
allow the instrument to remain in the stricture several hours, or even
through the night. Crede (Archiv fiir klin. Chir., 1892, S. 175) says
that the bougie should be left in position as long as it is grasped by the
sphincteric contraction of the circular fibers, and that having been once
introduced it should be retained imtil it comes away without any fric-
tion or effort upon the part of the surgeon. Keyes, however, believes
in rapidly increasing the size of the dilating instrument, and in intro-
ducing a bougie with considerable force in order to accomplish this.

STRICTURE OF THE RECTUM

Ball (op. ciL, p. 173) maintainH that the length of time which the bougie
should remain depends largely upon the character of the stricture. In
dense, hard, cicatricial strictures he believes in allowing the instrument
to remain in silu for several hours; while in soft, flexible ones he ad-
vises not only the use of comparatively small instrumeuts, but their
immediate removal after liaving pa^ised through the strictured area.
MacMaater (X. Y. Med. Jour., 1876, p. 37G) and Qiicnu and Hartmann
iop. cU., p. 311) are atlvocatea of the immediate removal of the bougie
after it has once passed the stricture. The rule is as we have stated
above, but occasionally, where the stricture is very tight, having once
succeeded in introducing the bougie, it may be allowed to remain for
considerable periods of time, even for ttt-onty-four hours, in order that
its pressure may gradually soften the strictuit?, and by pressure upon
the parts reduce the congestion and osdema which narrow the orifice.
In strictures of moderately large caliber there is no advantage in main-
taining the bougie in position longer than is necessary to overcome what-
ever s[)aBm it excites.

Aside from bougies, numerous ingenious instruments have been de-
vised for the dilatation of stricture. Among them are sponge, tupelo, and
laminaria tents that have metallic tubes running
through their centers in order to facilitate the es-
cape of gas. These are introduced through the stric-
ture and held in position by tampons until the mois-
ture of the bowel causes them to swell and gradually
dilate the stricture. They are dangerous instruments,
however, inasmuch as there is no means of gaging
the amount of pressure which they exert upon the
weakened and sometimes friable intestinal walls. The
points at which stricture is generally located arc very
slightly sensitive to pain, and laceration or even rup-
ture of the gut may result without the patient being
aware that the injury has taken place. Such instru-
ments are therefore inadvisable.

Others, such as hollow dilating bougies made of
soft rubber and arranged so as to be dilated by the
injection of water or air after they are passed through
the stricture, have been advised by various surgeons.
Ball says that the ordinan,' Barnes's dilators are supe-
rior to any of these devices; he has used them a num- Rklt*!. Dilhok.
her of times for the dilatation of stricture, and with
excellent results; they are of hour-glass shape, and, after they have been
onct' introduced and distended, they will remain in silu as long as is
necessary. Wiere the stricture is within the lower 3 inches of the gut.

500

THE ANU8, EECTUM, AND PELVIC COLON

the author is in the habit of using the simple, old-fashioDed Cuscos's
speculum for dilatation. It is easy of introduction and very effectual
for this purpose.

Rectal dilators of various patterns have been devised for the treatment
of stricture, the best known of which are Sims's (Fig. 171), Mathews's,
N^laton's, and Durham's (Fig. 172). Recently Martin, of Cleveland,
has introduced one which he calls a
" coactor," There is no doubt that in
experienced hands these instruments
sometimes prove superior to the use
of the bougie to obtain rapid results.
The friction and pressure necessary
to dilate a stricture by the use of bou-
gies may result in dragging and tear-
ing of the tissues, whereas the rectal
dilators may be introduced through
the stricture and gradually widened,
thus avoiding any friction. The dan-
ger of these instruments is in our
inability to estimate how much pres-
sure is being exerted upon the rectal
wall; there is no means to determine
when laceration or rupture is about
to occur, and after it has once taken
place the damages can rarely be re-
paired. Such instruments shouhl
never be used except in the hands
of operators familiar with the amount
of pressure which they exert, and hav-
ing a knowledge of the friability of
the different classes of stricture. On
the whole one must conclude that the
bougie properly used is the safest and
most satisfactory instrument for grad-
ual dilatation.

Rapid DilalaHon or Divuhion. —
This method, so popular at one time
in strictures of both the rectum and urethra, has practically and juslly
become obsolete, Mathews still employs it in constrictions following
operative interference at the anus or very low in the rectum. At this
point the method may be employed, and no doubt one will obtain soniu
very rapid and oxcollent results, especially if bougies are passed regulai'ly
thereafter to maintain the dilatation.

STRICTURE OP THE RECTUM 501

The operation consists in a rapid distention of a fibrous or cicatricial
tube which is often friable and easily torn. When such distention takes
place, a rupture either complete or partial is the inevitable result, and
it is impossible to tell in which direction, where, and to what extent
this will occur. Naturally the anterior and lateral portions of the rec-
tum being the thinnest and least protected will ordinarily be the site
of the injury, and this being in the neighborhood of the peritoneal cavity
adds a double hazard to the operation; haemorrhage, peritonitis, infec-
tion, and abscess are the natural sequences of such an accident. They
have all been observed by Trelat (Jour, de la soc. de chir., Paris, 1872,
p. 573) (ibid., p. 450, and Jour, de la soc. anat., 1872, p. 400) and death
has not infrequently resulted either from immediate shock or sub-
sequent complications. The stretching of the stricture is done either
with the fingers or with specially devised instruments, such as the
dilators mentioned above.

The operation has nothing whatever to recommend it, save that it
produces an immediate increase in the caliber of the stricture, but it
does so at such risks that the end can not justify the means. Moreover,
these ends may be accomplished by simpler and less dangerous methods.

Electrolysis, Cauterization, and Baclage. — For a number of years
there have been frequent reports of strictures of the rectum treated by
electrolysis. Le Fort (Gaz. des hopitaux, Paris, 1873, p. 221) has re-
corded a number of cases, originating a method by which he claims to
liave obtained radical cures. Ilis method consists in the introduction
of an electrode shaped like a rectal bougie. It is insulated except near
its end, where there is a metallic contact through which the electric
current passes. The instrument is introduced until this metallic area
is brought within the grasp of the sphincter, and then with the nega-
tive pole attached to it and the positive pole held in the patient's palm,
or attached to some other portion of his body, a mild galvanic current
is turned on and allowed to flow for considerable periods of time. In
some cases the instrument is allowed to remain in overnight, and the au-
thor claims to have obtained most satisfactory results. Newman (Jour.
Amer. ^led. Ass'n, 1891, p. 701) describes another method of applying
this principle; he claims to have first used it in 1871. It was also used
by Beard in 1874 (Archives of Electricity and Neurology, vol. i, p. 98),
who described the process of decomposing a compound body by elec-
tricity, and claimed to obtain a " galvanic chemical absorption '^ of the
stricture. Ne\\'man's electrode consists in a metallic tip fastened to an
insulated stem. The shape of the tip may be cylindrical or olive, from
i of an inch to 1^ inch in length, and from 1^ to 3 inches in cir-
cumference.

The patient is placed in the Sims's position; the positive pole is

602 THE ANUS, RECTUM, AND PELVIC COLON

grasped in the palm of the hand or placed upon the abdomen; the rectal
electrode is then introduced up to the stricture and engaged in its orifice,
and the current of from 5 to 20 milliamperes is turned on. With ordi-
nary pressure he claimed that within five to fifteen minutes the bougie
will gradually pass through the stricture without any rupture or abrasion
of its surface. He reported 12 cases in which dilatation and other meth-
ods had been tried without avail, and claimed to have cured 9, the other
3 having been improved. In 1 case in which the method was \ised, he
states that he had the opportunity of making a post-mortem examination
some years afterward and found no evidence whatever of stricture; lie
advises the application of the current about once in two weeks. The
claims for this method have been frankly stated, but having tried it in
urethral strictures and found no benefit therefrom, the author sees no
reason to believe that it will cure those of the rectum.

Proctotomy. — This operation is the one generally recommended in
rectal stricture. It consists in partial or complete section of the stric-
ture. It is described in the text-books as internal and external proc-
totomy. The term external, however, is misleading, inasmuch as the
incision is not made from the outside, but simply extends from the upper
limits of the stricture downward through the rectum, anus, and post-
anal structures. It is better to describe the two operations as partial
proctotomy and complete proctotomy.

Internal or Partial Proctotomy. — This operation consists in cutting
or nicking the stricture with the view of facilitating dilatation by bou-
gies or other instruments. The first mention of this operation is that
by Stafford (London Med. Gaz., 1834, p. 607). The operation is com-
parable to that of internal urethrotomy, and is performed by incising
the stricture with a blunt-pointed bistoury, or with some specially de-
vised instrument similar to the urethrotome of Civiale or Otis.

The stricture may be cut deeply in the posterior region, or it may
be simply nicked at different points around its circumference. The
operation is a very dangerous one, especially when the stricture is situ-
ated at some distance from the anus. Haemorrhage is a possibility, al-
though there has been no fatal occurrence from this accident; the danger
lies in infection, sepsis, and diffuse periproctitis. It is unnecessary to
enlarge upon the possibilities and probabilities of infection from an im-
perfectly drained wound well up within the rectum where there are
always numerous bacteria present; the accidents which have followed
this operation and the false principle upon which it is based have ren-
dered the procedure practically obsolete. There are occasional cases of
valvular or falciform strictures situated at a distance from the anus in
which it may be justified, especially if done with some of the modern
appliances, such as the Pennington clip or hysterectomy forceps. In

STRICTURE OP THE RECTUM 503

such cases the clip or forceps is applied over the valve-like stricture and
made to grasp as much of the tissue as possible; it remains on until
it cuts its way through, thus widening the caliber of the gut. It re-
quires from five to six days for this to be accomplished, but there is
little danger of haemorrhage or sepsis by either of these methods.

Where the stricture is tubular, or involves any extent in the length
of the gut, these procedures will, of course, be impracticable. Internal
proctotomy by simple incision is no longer countenanced by operative
surgeons, for the slight benefits derived from it are out of all proportion
to the dangers incurred; therefore it need not be discussed further.

Compute Proctotomy, — This operation, called also linear posterior
and external proctotomy, consists in an incision in the posterior median
line of the rectum extending from the upper limits of the stricture down
through the anus and tissues posterior to it. The operation was technic-
ally first devised by Humphreys (Ass*n Med. Jour., London, 1856, p.
21), although, as Quenu and Hartmann say, it had been done practically
many years before in operations upon fistulas associated with stricture.
To Humphreys, however, belongs the credit of establishing the operation
as a procedure of choice.

In tlie early operations by this method the chain ^craseur or the
actual cautery was used to incise the parts. Both of these methods were
useful in that they avoided haemorrhage; but the fact that they are both
followed with denser cicatrization than simple incision, and that the
methods of controlling haemorrhage are so complete that it no longer
gives any great anxiety, have rendered the use of these instruments un-
necessary. The operation is performed by introducing a blunt-pointed
bistoury through the stricture and cutting downward and backward in
the median line through all the walls of the intestine, through the in-
ternal and external sphincter out into the skin. It is most important
that the incision through the sphincters and skin should extend back-
ward to the tip of the coccyx in order that there shall be no possible
point for lodgment of fjecal matters and purulent discharges. The dan-
gers of incontinence from this operation have been greatly exaggerated.
It will be remembered that onlv a few of the fibers of the external
sphincter around the very margin of the anus are circular, and that
those which extend backward and are attached to the coccyx do not
decussate; therefore, an incision in this line will not sever many of the
muscular fibers, but simply separate them and thus destroy their contract-
ile power. Occasionally where a large cicatrix is formed, separating the
ends of the internal sphincter, a certain amount of incontinence may
result, but this is rare. At any rate, the incontinence which follows this
operation is not comparable to the discomforts and dangers of a stricture,
and therefore the patient must submit to the lesser evil. On account

504 THE ANUS, RECTUM, AND PELVIC COLON

of the time required for the parts to heal, Weir suggested that the in-
cision be made through the stricture and down into the hollow of the
sacrum, from which point a drainage-tube is carried out through the
skin and the post-anal tissues without incising the sphincters. Kelsey
states that he has tried this in several cases, with the result of saving
much time. " The tube should be left in until all danger of periproctitis
has passed. If there is no rise of temperature by the fourth day, it may
be safely removed, and the wound caused by it will generally heal
promptly." It seems improbable that this operation would end other-
wise than in a fistula, which would eventually have to be cut — the very
proceeding which it is intended to obviate.

Another method of hastening the healing of the lower end of the
wound consists in freshening the surfaces and drawing the edges to-
gether by deep sutures after granulation has once begun. Both of these
methods are based upon theory. The fact is, the external wound nearly
always heals before the internal, and it is difficult to keep it sufficiently
open to secure proper drainage. Moreover, as the after-treatment con-
sists in persistent, thorough dilatation, it is perfectly plain that any
attempt to suture the anal wound together would not only be useless
but cruel to the patient. No effort should be made to narrow the external
outlet until the stricture has been obliterated, and until the wound or
ulceration about it has completely healed. The dangers in this operation
as in internal proctotomy, are sepsis, periproctitis, and haemorrhage. As
said before, the ha?morrhage can be easily controlled by packing with
gauze or charpie; the sepsis and periproctitis must be avoided by thor-
ough antisepsis before the opef^tion and complete drainage afterward.
It is well, after having incised the stricture and packed the wound, to
carry a large-sized drainage-tube into the gut above and fasten it in
this position so that gas and fluid faecal matter will not accumulate and
force the packing out of position.

The after-treatment of complete posterior proctotomy consists in
thorough antiseptic irrigation, followed by dilatation and loose packing
of the wound with iodoform or sterilized gauze. In these cases, as has
been said in fistula, great harm can be done by packing the wound too
tightly; simply introduce enough gauze into the incision to protect it
from faecal matter and to absorb its discharges. Of course this does not
apply to the original packing for the control of haemorrhage, which
should be introduced very firmly into the wound. The operation is not
applicable or advisable in cases of malignant stricture, although some
authorities believe that the patient's condition may be benefited by in-
cising a stricture even of this character.

The possibility of there being two or more strictures, one above the
other (Fig. 173), should always be remembered, and the operation should

STRICTURE OP THE RECTUM 505

not be concluded until one is able to introduce & full-sized bougie well
into the sigmoid flexure.

This operation, considered so simple and without danger, is aaid by
most authorities to give excellent results. In the author's experience
the results have not been uniform or satisfactory; notwithstanding com-
plete incieion, there has been no marked case of incontinence, hut re-
currence of the stricture has been
the invariable rule. This observa-
tion ia in keeping with those of the
statistics taken from the thesis of
Lachowski (Paris, 18!)4-'95). In
32 observations the results were as
follows: Three immediate deaths
from erysipelas; 4 deaths within
four years from cachexia or phthi-
sis; 21 recurrences, 3 of which oc-
curred during the first year and 4
during the second year; and 3 in-
valids were lost sight of. Only 1
case out of the 32 is noted as abso-
lutely cured (Vemeuit), Protracted
ulceration and recurrence of the
strictures, together with more or
less incontinence of faeces, were
the results in a large majority of
cases.

Bullard (op. ct(.) states that he "i;i,tiii

has rarely failed to obtain a com-
plete cure by this method of treatment. Kelsey also claims to have
had the most satisfactory results. The English siirgeons, Cripps, AUing-
ham, and Ball, all speak highly of the method; and so far as obtaining
an immediate enlargement of the rectal caliber, allowing the free pas-
sage of fa?ce8, and giving to the patient relief from symptoms of ob-
struction are concemefl, the operation is satisfactory; but in the author's
experience, the only permanent cures by it have been in a few cases of
annular or falciform contraction low down in the rectum.

It should be borne in mind that in certain cases where fistulous
tracts extend around the stricture, opening above it into the rectum,
and below either upon the skin or into the anus, these tracts may be
laid freely open, and thus the stricture incised without doing pos-
terior proctotomy. The more incisions that are made the more like-
lihood will there be of sepsis; nevertheless, all the fistulous tracts and
burrowings should be laid open, and the parts protected as well as possi-

606 THE ANUS, RECTUM, AND PELVIC COLON

ble by antiseptic dressings and frequent irrigations. When these pre-
cautions are carried out, there is not a great deal of danger of sepsis,
and cases of erysipelas and diffuse periproctitis are seldom seen. The
objections to the operation, however, remain: recurrence is rapid and
frequent, there is a certain amount of incontinence for an indefinite
period of time, healing is slow, and the patient can never expect to
discontinue the use of some dilating instrument. (Lachowski, Carre,
Qu^nu and Hartmann.)

Where the stricture is very tight, the operation is sometimes done
in two steps, first dividing the sphincters and the rectal wall up to
the stricture, and checking the ha?morrhage in these parts. Later the
stricture itself is incised by the introduction of a grooved sound for a
guide to the bistoury where it is impossible to introduce the finger for
this purpose. This is simply a matter of detail, however, and while it
may be a wise precaution it is not necessary.

Excision. — As far back ajs 1825 Lisfranc excised the rectum for stric-
ture. The reports of these cases by Carr6 (Thesis, 1893) clearly indicate
the inflanMnatory or syphilitic nature of two of them which were sup-
posed to have been carcinomatous. Glaeser (Archiv f . klin. Chir., 1867-
'68, Bd. ix, p. 509) in 1864 excised a cicatricial stricture of the rectum.
The patient made a good recovery, but the stricture recurred, and two
years later he was compelled to do a colotomy at the site of the stric-
ture. From this period on to 1890 there were a few isolated cases re-
ported in which the operation was performed.

The statistics and reports are somewhat contradictory owing to the
fact that writers and operators did not distinguish between resection
and excision and between the different types of strictures. Thus Qu6nu
and Hartmann claim that the first attempt at extirpation of a syphi-
litic stricture in France was made by Qu6nu in July, 1890, and was
followed by the operations of Richelot, Terrier, and others. On the
other hand, Carre gives the credit to Marchant, and states that Dessault
had done it as early as 1828. Pinault (Th^se, Paris, 1829) is also
known to have excised the lower end of the rectum for stricture in
1826. While these early operations are put down under the heading
of cancer, Carr6 says that it is clearly apparent from the cases cited by
Pinault that some of them at least were syphilitic. In the discussion
before the Societe de Chirurgie of Paris in 1891, Kichelot stated that
the operation of excision for syphilitic stricture of the rectum was a
success; that whatever the method, " the stricture is cured forever with-
out infirmity." Qu^nu indorsed this statement at the time, but, as
will be seen later on in his own statistics, its truth is questionable.

Strictures of the rectum may be removed by the })erineal or sacral
routes.

STRICTURE OP THE RECTUM 607

Perineal Method, — The perineal method is applicable to those within
6 centimeters (2f inches) of the anus. If the sphincters and the anus
are involved, the whole anal circumference is dissected out and the
rectimi amputated at the upper level of the stricture; if the constriction
is above these parts, the operation may be performed in several ways.
First, the sphincters are incised in the median line back to the tip of
the coccyx; a circular incision through the entire thickness of the gut
is then made around the rectum just above the internal sphincter; the
flaps containing the muscles are then dra^Ti to each side and the rectum
is dissected out to the upper level of the stricture; if possible without
too much haemorrhage or too prolonged dissection, the gut may be dis-
sected farther upward, dragged down and reunited to the edges of the
mucous membrane c6vering the sphincter muscles. If the amount of gut
removed renders this impossible, the wound may be left open to heal
by granulation, a large-sized rubber tube being introduced into the
caliber of the gut above for the purpose of conveying outside of the
wound as much fa?cal material as possible. If it has been possible to
drag the gut down and suture it to the mucous membrane, then it is
wise to suture the sphincter muscles together where they were divided,
otherwise this should not be done. Second, an elliptical incision is
made embracing f of the posterior circumference of the anus, and
deep enough to go above the sphincters; this flap is dissected forward,
thus amputating the rectum above the muscles; the rectum is then dis-
sected out up to the superior limits of the stricture and cut off; if
possible, the gut is then dragged down and reunited to the flap, including
the sphincters, and the latter is sutured in position. If this is impossible,
an opening is made on the side of the coccyx and an artificial anus
formed at this point. After the patient's general condition has im-
proved from the relief given by this operation, the gut may be dissected
out either by the sacral method or through the wound alongside of the
coccyx, and brought down and sutured to the flap, which, having been
allowed to lie loose in the perineal wound, will need to be dissected up
and freshened in order to obtain a suitable place for the reattachment
of the gut.

These are the methods of choice in strictures which do not extend
more than 6 centimeters (2f inches) above the anal margin. When
higher than this the sacral route is more satisfactory.

The Sacral Method. — The sacral method consists in some modification
of the Kraske operation for excision of the rectum. Where the stricture
is within the first 10 centimeters (3J inches) there is no necessity to
remove anything more than the coccyx in order to excise it. Abundant
room can be obtained by this procedure.

Where it extends higher than this, it may be necessary to cut off a

508 THE ANUS, RECTUM, AND PELVIC COLON

triangular piece from the sacrum, thus giving a wider operative field,
or to adopt Eydygier's method, in which the bones are all preserved
and restored to their normal position, and thus the floor of the pelvis
is not impaired.

Having exposed the rectum by this means, it should be clamped with
long-bladed forceps in order to control bleeding, and then the dissection
should be carried as far up as necessary to remove the entire stricture
and bring the portion of the rectum above the stricture down to the
healthy tissue below it. By proceeding in this manner, if it is necessary
to open the peritona}um, there will be little, danger from infection,
inasmuch as the gut will not have been opened until after all this dis-
section is completed. Having loosened the gut as high up as is neces-
sary, the peritoneal cavity should be closed either by sutures or by tam-
poning with iodoform gauze. The gut should then be cut off through
the healthy tissue above the stricture, and the diseased section dissected
out from above downward.

The point in this technique is, first, to control the haemorrhage, which
comes largely from the superior hsemorrhoidal vessels; and, secondly,
to accomplish all the intraperitoneal dissection and close this cavity
before the gut is opened, thus avoiding the greatest danger from sepsis
in this operation. Having dissected out the stricture down to the
healthy tissue below^ it should be cut off and the two ends of the re-
maining gut united by end-to-end suture, the ^furphy button, or by
invaginating the upper end through the lower, and suturing it outside
of the anus. The bone-flap is then sutured back in its normal position
with silkworm gut and the external wound closed, with the exception of
its lower angle, which is left open for drainage. The technique of this
operation is fully described in the chapter on Extirpation of the Rectum.
Where the stricture is in the pelvic colon it should be removed by the
abdominal route, with end-to-end union, as is done in cancer of this
region.

Results, — After the reports of Richelot, Qu^nu, and Carre in France,
Kelsey and Weir in Xew York, and Alberan and Kraske in Germany,
excision was hailed with great enthusiasm as having solved the treatment
of rectal stricture. The stricture being removed, the obstruction oblit-
erated, the patient was cured, notwithstanding the fact that they suffered
frequently from small fistulas and perineal phlegmons. The mortality
from the operation in the beginning was comparatively small, about 10
per cent. Longer observation of the cases began to show a recurrence
of the stricture even in a worse form than previously, and the enthu-
siasm subsided. Ijachowski (These, Paris, 1894-'9r)), in a careful study
of this subject, shows that the recurrences after this method are almost
as large in proportion as after complete proctotomy. Quenu and Hart-

STRICTURE OF THE RECTUM 509

mann (op. cit., p. 325) give a detailed account of 35 cases^ in which there
were 4 deaths directly due to the operation — a mortality of 11.43 per
cent. Of the remaining cases, 1 succumbed to pneumonia in about
six months, 1 was at the time of the report in a dying condition from
tuberculosis, and 10 were lost to view. In the 19 cases which they were
able to observe for some months to four years, the results were as follows:
One had been compelled to submit to a colotomy, the stricture having
returned; 18 others were suffering from rectitis and suppuration suffi-
cient to compel them to wear napkins; 1 had a stercoral fistula; 8 suf-
fered from incontinence of gas and liquid fa?ces; and 6 had a clear
recurrence of the stricture. In 8 only were the fiecal movements nor-
mal. It must not be presumed, however, that the 8 cases were radically
cured, for the authors state that they all suffered more or less from
suppuration, a thickening of the mucous membrane, and a rigid, cylin-
drical and abnormal condition of the rectum.

Lapointe (I^a presse medicale, 1898, p. 153), in reviewing the subject,
collected 69 cases with 10 operative deaths and 1 due to septic infection
of the sacral wound shortly afterward, thus giving a mortality of 14.5
per cent. Forty-seven were done by the perineal method with 8 deaths,
a mortality of 17.2 per cent; 20 by the sacral method with 2 deaths,
mortality 10 per cent; and 2 by the vaginal method, in both of which
the results were good. In addition to the 10 operative deaths, 4 others
died within the first year, thus leaving 55 cases. Of these, 31 were
observed for less than one year and 24 for more. In the 24 cases there
was a recurrence in 12, or 50 per cent. In 38 cases done by the perineal
method, 19 had more or less incontinence. In 15 done bv the Kraske
method, incontinence was noticed six times; thus in the 55 cases incon-
tinence has followed in 25. Prolapse occurred in 3 cases done by the
Kraske method, but no cases of this are reported in the operations done
by the perineal route. It is reasonable to suppose that the majority of
the cases which were lost to view were successful, inasmuch as they were
in favorable conditions when last seen. Therefore, one may state that,
barring a certain amount of inconvenience due to ulceration, small
fistulas, or incontinence, 50 per cent of these cases have been practically
cured. These results, while not satisfactory, certainly are an improve-
ment over the old methods of treating stricture by internal and complete
proctotomy.

Prodnplasty. — Where there has been great destruction of tissue
around the margin of the anus or the lower portion of the rectum, fol-
lowed by large, dense cicatrices, it will sometimes be impossible to
restore the caliber of the gut without resorting to some form of plastic
oj)eration. Xo rule can be laid down for these conditions. The ingenu-
ity of the surgeon will be put to the test in each individual case.

510

THE ANUS, RECTUM, AND PELVIC COLON

Krouse, of Cincinnati, has reported an interesting example of what
may be done by this method in the ease of an extensive stricture of the
anus following a burn. He dissected up a large triangular flap from
the buttock, swung it around into the space from which he removed

the extensive cicatrix, and sutured it in position.
The parts healed promptly, and the final result was
a comparatively normal anus.

Williams, of Melbourne, enlarged the caliber
by a plastic operation entirely within the rectum.
He incised an annular stricture from above down-
ward under rigid antiseptic precautions. The in-
cision was then sutured obversely in its long axis
so that the wound was made to extend horizontally
around the rectum. By this ingenious procedure
the caliber of the gut was increased by just the
length of the wound, and the immediate result
was a relief of the stricture. The case was re-
ported within a few months after healing, and
therefore the permanency of cure can not be
vouched for.

Swartz (Presse medicale, 1894, p. 304) modified
this procedure by approaching the rectum from the
outside through an incision made between the coc-
cyx and anus. He incised the gut longitudinally,
and sutured its walls together after the manner of
Williams. The wound in the skin was left open for
drainage, and a large-sized drainage-tube was in-
troduced into the rectum to facilitate the escape
of gases and liquid frecal matter. This case was
also reported within a month after the operation,
and the ultimate result can not be stated; it is mentioned simplv because
it has been referred to a number of times in literature as having cured
the stricture.

Skin-grafting and plastic operations about the margin of the anus
are practical methods known to every surgeon, and where there is an
intractable granulation associated with large cicatricial deposits, one
may greatly improve the patient^s condition by employing these.

Lateral Entero-anastomosis. — Bacon (Mathews's Med. Quarterly, vol.
i, p. 1, 1894) has described a most ingenious method for the relief of
stricture of the rectum when situated above the sphincteric region. It
consists in bringing a normal loop of the sigmoid down and anastomosing
it with the rectum below the stricture, as follows: After the patient has
been properly prepared and etherized, he is placed in the extreme

Fio. 174. — Trocar fob
Insertion of Female
Segment of Murphy
Button in Bacon'» Op-
eration FOR Stricture
OF the Kectum.

STRICTURE OF THE RECTUM

511

Trendelenburg posturu, and an abdominal section ia made from the
pubis to the umbilicus, Tbe sigmoid is then folded downward until
it readies well below tbe stricture, and thus tbe point at whiob tbe
anastomosis is to be made is measured. It is tben drawn well out of the
abdomen, and with Murphy clamps above and below tbis point, a
longitudinal incision is made into the gut between them and the male
half of a jrurpby button secured in this incision. After having scari-
fied tbe peritoneal surfaces of the sigmoid and tbe rectum, the female
half of the button is introduced into tbe wall of the latter in tbe fol-
lowing manner: an instrument carrj'ing a short trocar (Fig. 174), which
passes through the hole in the button, is pushed up into tbe rectum
by an assistant and pressed against the anterior wall of the gut just
below tbe site of the stricture, while tbe operator, with hia hand in the
abdominal cavity, presses down upon tbe trocar and causes it to pene-
trate the wall, carrying tbe neck of the button along with it. Tbe two

ends of the button are then seized by the operator and approximated,
and the anastomosis is complete. Two or three sutures are placed in tbe
peritoneal layer of the gut (Fig. 175) in order to fortify the anastomosis
made by the button and also to prevent any loops of the small intestine
coming in between those of the sigmoid flexure and the rectum. If the
operation has been carefully performed, no fa'cal extravasation or leak-

512

THE ANPS, RECTUM, AND PELVIC COLON

age will have occurred in the abdominal cavity, and the latter may then
be permanently closed. The button will be expelled in five to seven
days, after which an enema may be given by the rectum, and the colon
thoroughly washed out. After this a long clamp Is inserted through
the anus, one blade of
which is introduced
through the button-
hole into the sigmoid
while the other extends
through the stricture
and upward into the
rectum (Fig. 176). The
clamp is then firmly
closed, thus embracing
the stricture in its bite.
On each succeeding
day the handles of the
clamp are closed little
by little until the sseptum is completely severed, which usually oc-
curs upon the third day. By this means the caliber of the gut
will be increased to that of the sigmoid flexure plus the former cali-
ber of the stricture. Bacon states that where the stricture is low
down the operation may be done by the sacral method. The operation
has no advantages over resection and cnd-lo-end union in strictures of
the sigmoid flexure. He employed this ingenious method upon 4 dogs,
2 by the abdominal and 2 by the sacral method, and all were successful;
later on he applied it with success in an old, specific, rectal stricture
in a woman.

Cohiomy. — In non-malignant strictures colotomy is generally looked
upon as a last resort, one which patients and surgeons avoid until ob-
struction is imminent, and until recently the operation has only been
done when this has occurred or the pain has become unbearable.

As early as 1824 Martland performed a left iliac colotomy to over-
come obstruction due to a stricture, and thus prolonged his patient's
life for more than seventeen years (Edinburgh Med. and Surg. Jour.,
vol. xxiv, p. 271).

In 1865 Curling did a lumbar colotomy for the first time with the
deliberate intent of preventing obstruction in an incurable stricture
{Amer. Jour, of itcd. Sci.. 1873).

Allingham performed the operation in 18C7, and Olaoser (Archiv f.
klin. Chir., Berlin, 1867-68, p. 509) operated upon a woman for intes-
tinal ohstniction due to a stricture which he had already excised and
which bad recurred. Twenty years later (ibid., 1887, vol. xxxiv, p. 459)

STRICTURE OF THE RECTUM 613

he had the unusual opportunity of making an autopsy upon the body
of the patient, establishing clearly the specific nature of the original
stricture, and showing that the pelvic colon and rectum had been re-
duced to nothing more than a long, narrow, fibrous coW perforated by
a small canal which would admit only the finest sounds, and was sur-
rounded by inflammatory tissue. He says the "cavity of the cord is
lined with a membrane which seems more like a serous than a mucous
membrane." The interesting point of this case is, that notwithstanding
the strictured portion of the gut below the artificial anus had been
absolutely devoid of functional activity for nearly twenty years, it still
remained patulous.

From this period fom'ard operators in America, England, Grermany,
and France (Hochenegg, Arb. U. Hahresh. d. K. K. ersten chirur. Uni-
vcrsitiits Klinik zu Wien, 1888-'89, p. 122; Konig, Berlin, klin. Woch.,
1887, p. 17; Hahn, Archiv f. klin. Chir., Berlin, 1883, Bd. xxix, p. 395;
and ]Mason, Amor. Jour, of Med. Sci., Philadelphia, 1873, vol. ii, p.- 354)
have more and more resorted to colotomv in cases of stricture of the
rectum. Excellent results have been obtained, and long periods of life
have followed the operation in cases of non-malignant stricture. In a
case of the writer's, the patient survived eleven years after an artificial
anus was made for an intestinal obstruction due to syphilitic stricture.

Where the stricture is inoperable by excision or proctotomy, when
it has recurred after these operations or where obstruction takes placJ^i-*
there is no question as to the advisability of this operation, llecently
some operators, recognizing the fact that by functional rest and loQal
and constitutional treatment, much may be done to promote the ab-
sorption and disappearance of a stricture of the rectum, have under-
taken the cure by making temporary artificial ani, side-tracking the
ftvcal current, thus giving the opportunity of treating the strictured
canal from both ends. By this means complete drainage is obtained, the
distention and irritation are stopped, obstruction of the fa?cal current
at the point of stricture is avoided, and the dangers of infection from
the intestinal contents are practically eliminated in case it is necessary
to excise the gut or dilate the stricture.

Lowson and Kammerer were among the first fo employ this method
as a preliminary procedure for the extirpation of non-malignant stric-
ture, and Thiem (Verhandhmgen d. deutsch. Gesellsch f. Chir., Berlin,
1892, p. 46) first employed it as a preliminary to the treatment of stric-
ture in the sigmoid by gradual dilatation with bougies. After the
stricture was completely dilated and apparently cured, he closed the
artificial anus, and up to the time of his report the patient had remained
perfectly well, the intestines having resumed all their functions.

In 1897 the author made an artificial anus in an Indian woman aged
33

514 THE ANUS, RECTUM, AND PELVIC COLON

twenty-two, in the workhouse hospital of this city, with the view of
treating an extensive syphilitic ulceration and stricture of the rectum
that occurred within the first year after her infection. The stricture
was situated at 3^ inches from the margin of the anus, and barely ad-
mitted the tip of the index finger. The mucous membrane of the lower
anterior surface of the rectum was entirely destroyed, and it was impos-
sible to determine the extent to which the ulceration extended above
the stricture. With a view to treating the stricture and possibly ex-
cising it, a temporary ad:ificial anus was made in the highest point
of the sigmoid flexure. Under the use of antispecific medication, anti-
septic irrigation, and persistent dilatation, the ulceration healed, the
caliber of the gut was gradually increased, and finally resumed almost
a normal appearance. The artificial anus was closed by the extra-peri-
toneal method, and at the time that the patient left the hospital six
months later, her bowels moved regularly, there was no discharge, and
80 far as could be observed she was perfectly well.

The same method was practised in the Polyclinic Hospital in 1894.
In this patient, however, the stricture was of a dense, hard, cicatricial
nature, and it finally became necessary to incise it before any material
increase in the caliber of the gut could be obtained or healing of the
ulcer induced. After complete posterior proctotomy, the caliber of the
gut was restored and the ulceration healed, but the dense, hard, cica-
tricial tissue remained, and could be easily felt by the finger. My
impression was that this would be likely to recontract, and much more
rapidly if the fsecal current were turned again into its natural channel.
This was explained to the patient, and as he had learned to manage
the artificial anus comfortably, he declined to have it closed. He dis-
appeared from view after this, going upon the road as a traveling sales-
man, and the last heard of him (some two years later) was that he was
perfectly well and enjoying life.

In 1898 the author performed the operation for the treatment of
stricture for the third time in the Almshouse Hospital of this city. This
patient had been operated upon for supposed cancer of the rectum some
two years previous. She suffered a great deal of pain, and there was
a large ulceration in her rectum which did not appear malignant.

A temporary artificial anus was made, and the treatment by irriga-
tion and dilatation of the stricture was begun. After three months
the caliber of the gut seemed practically restored, and upon the pa-
tient's urgent request the artificial anus was closed in May, 1899. In
January, 1900, the patient returned to the hospital suffering from con-
stipation, difficulty in obtaining a movement of the bowels, pain in the
sacrum, and more or less purulent discharge. An examination of the
rectum revealed the fact that the stricture had recurred, this time more

STRICTURE OP THE RECTUM 515

dense and fibrous than before. For the third time in her case colotomy
was done and a permanent artificial anus made^ after the method of
Bailey. For some reason or other the patient had a severe haemorrhage
from one of the mesenteric vessels two hours after the operation, and
she came near losing her life from it. She still remains in the hospital
at the present day; she is obdurate with regard to the use of bougies,
and consequently the stricture has not received the attention which it
should. Notwithstanding this, the fibrous stricture has greatly sof-
tened, showing the effect of local treatment and functional rest upon
these conditions. With this limited experience the author is not pre-
pared to make any very positive assertions with regard to the effect
of colotomy as a curative agent in stricture of the rectum, but from
these cases and the experiences of Thiem and Lowson it is thought
that we may hold out to patients afflicted with strictures and excess-
ive ulceration of the rectum a reliable hope of relief from suffering,
and the possibility of a cure, with eventual restoration of the fa?cal
current to its normal course.

Resume, — In a somewhat detailed manner the different methods for
the treatment of stricture have been reviewed, and no very positive
preference has been expressed for one over another. Tlie fact is that
up to the present time a satisfactory treatment for this condition has
not been devised. The dangers of sepsis and haemorrhage in internal
proctotomy would certainly contraindicate its use in the large majority
of cases. Complete proctotomy, while less dangerous so far as sepsis and
haemorrhage are concerned, has the disadvantages that it results in pro-
tracted ulceration, prolonged incontinence, and recurrence practically
always takes place unless the use of bougies is continued throughout
life. Notwithstanding these disadvantages, the operation is the least
dangerous method for the radical cure of the disease, and often affords
the patient much relief for a considerable time. Many cases are re-
ported in which it has resulted in a radical cure, but such results can
not be looked fonvard to with any degree of confidence in the large
majority of cases.

The favorable results of the first few excisions done for non-malig-
nant stricture led manv to believe that the radical cure of this disease
had at last been found. The author has been able to gather from
private communications and the journals 25 cases in addition to those
collected by Lapointe and Quenu and Hartmann, thus making a total
of 94 cases of resection with 14 deaths, a mortality of 16 per cent.
When the fact is recognized that all strictures, whether malignant or
non-malignant, prove fatal in the course of time unless properly treated
or removed, this mortality should not offer any great argument against
the performance of an operation which promises a radical cure. Un-

616 THE ANUS, RECTUM, AND PELVIC COLON

fortunately the results thus far obtained by resection do not justify
the statement that a radical cure will be obtained in the majority of
cases.

Investigation shows that in one-half of the resections for non-
malignant stricture of the rectum there has been a recurrence in situ,
whether the stricture has been of a specific or of a simple inflammatory
nature. Assuming, however, that of the cases which have survived the
operation a radical cure may be obtained in one-half of them, it would
still be necessary to conclude that this method is superior to any which
is known for the treatment of stricture. Nevertheless, in cases with
extensive ulceration and suppuration, this operation is very dangerous
to life, and the formation of a temporary artificial anus, followed by local
treatment and dilatation, is a far safer procedure, and will accomplish
just as good results in a large number of cases of this type as attempts
at resection or proctotomy.

After the ulceration and suppuration have been controlled, and it
is found that the stricture persists, or has a tendency to retract, resec-
tion may be done without so much danger of infection, and with a
greater probability of immediate union between the sutured ends. In
brief, a temporary artificial anus, with gradual dilatation and local treat-
ment, and, if necessary and practicable, the eventual resection of the
stricture, seem to furnish the most rational as well as the safest method
of treatment.

CHAPTER XIV
COXSTIPATION, OBSTIPATIOy, AND F^CAL UIPACTION

Constipation consists in the passage of insufficient amounts, or
the abnormally prolonged retention, of fa?cal material in the intestinal
canal. A healthy individual passes upon an average 6 ounces of fjeces
in twenty-four hours. These figures, however, are only relative; the
amount of frecal material depends not only upon the food ingested, but
the quality of the food and the activity of the digestive functions.
Active, energetic individuals living an outdoor life consume large quan-
tities of food of a mixed variety, and therefore their ftvcal dejections
are much greater than those of individuals who lead a sedentary life
and consume small quantities of a limited dietary. Farmers and other
individuals who live chiefly upon vegetables, cereals, and the coarser
articles of food, pass larger quantities of faeces than the more pampered
classes who consume small quantities of concentrated and refined foods,
in which there is a minimum amount of indigestible detritus. Con-
stipation exists in both of these classes, but it can not be based upon
the amount of fa?ces passed. So also is the period of the retention of
fa?cal material in the intestine comparative. It requires from fifteen to
twenty hours for the food to pass through the intestinal canal. The
ordinary assumption based upon these figures is that every normal indi-
vidual should have a stool of adequate quantity once in twenty-four
hours. So imbued with this idea are the laity in general, that one who
does not succeed in having such a passage, or whose passages do not
appear to be normal in quantity, quality, color, or consistence, immedi-
ately considers himself the victim of constipation, and begins to take
drugs or enemata to remedy the condition.

Fa?cal movements, while more or less involuntarv, are matters of
habit and education to a large extent. One can accustom his bowels
to move twice a day, once a day, or once in three, four, or five days,
and ordinarily an individual whose fjecal periods are regular every three
days is just as healthy as another whose bowels move twice a day. A
child may be educated in infancy to have faecal passages twice a day,
and this will be maintained as long as there are no pathological condi-

517

518 THE ANUS, RECTUM, AND PELVIC COLON

tions and no mental diversions or preoccupations to interfere with
attention to the periodic calls. This periodicity can be established in
any healthy intestine, and often establishes itself unconsciously in ac-
cordance with the occupations and habits of the individual, as is shown
in the following case:

J. A., a railroad conductor, had a night and a day run from Philadelphia to
Chicago, leaving one morning and arriving the next ; on his return trip he left at
night and arrived the following night; thus he was at home every third night and
every third day. Without any conscious effort on his part, his bowels established
the habit of moving in the evenings of the nights he remained at home, and in the
mornings of the days which he remained there, and never, except under unusual
circumstances, had any inclination to move at other times.

Many instances of such irregularity and prolonged retention of
faeces could be cited, but it is enough to state that the length of time
between faecal passages is so variable in individuals that what consti-
tutes constipation in one is not in the least conclusive of such a condi-
tion in another.

Those extreme instances in which long periods of time elapse be-
tween the stools are frequently due to some idiosyncrasy or deformity,
and they can only be considered as curiosities in this connection.
Mathews (Diseases of the Rectum, p. 58) reported a case in which the
faecal movements occurred at first once in two weeks, and gradually
extended the time until finally the patient's bowels moved only once
in four months. In this case a movement of the girl's bowels was not
only an event in the family but to the entire neighborhood. He
states that there was no impaction, disease, or unnaturally contracted
condition in the intestine, that no odor emanated from the body, and
that little damage resulted to the general health. The extreme and
alarming reflex symptoms produced in this case by the introduction
of the bougie and flooding the colon with water, and the collapsed and
exhausted condition after faecal passages, clearly indicated some irri-
table or obstructive point in this canal which would account in a largo
measure for the girl's constipation in the first place.

The author had a patient who claiihed that he only had a move-
ment once in twenty-eight days, and always at the full of the moon.
These instances, however, are almost insignificant when compared with
the cases reported by Strong (Am. J. of Med. Scs., October, 1874, p. 440),
in which the movements occurred once in eight months and sixteen
days; Inman (Half- Yearly Abstract in Med. Scs., vol. xxi, p. 275), once
in two years; Valentine (Bull, de scs. med., t. x, p. 74), once in nine
months; Devillier (J. de med., 1756, t. iv, p. 257), once in two years;
Chalmer (Med. Gaz., London, 1843, vol. xxi, p. 20), once in three years,
and a case (Records of the Phila. Med. Museum, 1805, vol. i, p. 305)

CONSTIPATION, OBSTIPATION, AND FMCAL IMPACTION 519

where the patient had only one movement in fourteen years. Medical
literature is full of such eccentricities, and, strange to say, these individ-
uals in the majority of cases have maintained comparatively good health.

The only explanation of such facts is that they have lived upon a
diet in which there were small quantities of indigestible substances,
and that their digestive and assimilative functions have been sufficiently
active to appropriate all the ingested material, with the exception of
a very minute proportion.

Leaving out of account these phenomenal cases, and coming down
to the every-day individual with whom the physician has to deal, in
order to determine whether a patient is really constipated or not, one
must acquaint himself not only with the dietary of the individual but
with his habits from childhood in regard to fa?cal movements, and his
occupation and practices at the time of consultation.

Constipation is not a disease in itself, but a symptom or manifestation
of functional or pathological conditions. It is produced by whatever
conditions retain faecal detritus in or retard its passage through the
intestinal canal. In those cases in which the f»cal discharges are less
than normal on account of insufficient or improper food, the patient
usually suffers no inconvenience from the apparent constipation; under
such circumstances, if he can be convinced that the faecal passages are
entirely adequate in proportion to the amount of food taken, and per-
suaded not to indulge in laxative or cathartic medicines, the greatest
good will be accomplished for him. In such cases as suffer from oesoph-
ageal stricture, ulceration of the stomach, cirrhosis of the liver, stric-
tures, cancers or tumors of the pylorus, stomach, or upper end of the
small intestine, all of which prevent the ingestion of normal quantities
of food and limit that which is taken to the most concentrated forms,
the fa?cal passages will not only be very small in quantity but ordinarily
at widely separated periods. Such cases as these can not be called con-
stipated, for the intestinal functions are perfectly normal, in that they
act whenever there is sufficient material for them to act upon.

Defecation. — In order to understiind constipation, one must be
familiar with the processes by which the ingested material passes
through the alimentary canal, and the conditions necessary to establish
normal passages. Practically one may say that up to the last moment
at which the faecal mass is extruded from the body, the ingested ma-
terials are carried through the intestinal tract by what is known as
peristaltic action. The food is received into the stomach and the albu-
menoids are subjected to the action of the gastric secretions, thus being
converted into peptones; after this it is passed through the pylorus
into the other sections of the intestine.

The reaction of the contents of the stomach as they pass little by

520 THE ANUS, RECTUM, AND PELVIC COLON

little through the pylorus is acid; the secretions of the small intestine,
the bile, and the pancreatic fluid are all alkaline; thus, when the acid
contents of the stomach are poured into the small intestine, they pro-
duce a stimulation or irritation which causes a wave of muscular con-
traction constituting peristaltic action. At the same time the chemical
reaction of this acid substance upon the alkaline contents of the intes-
tine creates certain gases which serve to distend the caliber of the gut,
stimulate still further the muscular contractions, and thus facilitate
the passage of the semifluid substances through the tract.

These gases consist largely of carbonic-acid gas, nitrogen, carbureted
hydrogen, hydrogen, and sulphureted hydrogen (Planer, Sitzungsbe-
richte d. Akadem. d. Wissenschaften zu Wien, vol. xlii; S. J. Charles,
British Med. Jour., February, 1885). The presence of these gases,
therefore, is not abnormal or detrimental, but, on the contrar}% most
useful. It is only when they are found in improper proportions and
are more irritating than normal that they are unhealthy, in that they
produce too rapid and severe peristalsis and too great distention of
the intestinal canal, thus causing atony or paralysis of the circular
fibers and consequent inability to contract.

Ordinarily the gases are reabsorbed by the blood-vessels or discharged
with the faecal mass through the anus. If, however, there is any inter-
ference with such absorption or passages, either through catarrhal in-
flanmiation and consequent mucous coating of the intestinal canal or
through obstruction due to volvulus, acut^ angulation or stricture, the
gases will accumulate and cause overdistention, or pass backward along-
side of the fffical materials in the intestinal canal and into the stomach,
being discharged in this direction. Other sources of stimulation, aside
from acid peptones and the production of gases, are the harsh, undi-
gested particles of food which were not acted upon by the gastric secre-
tions. These also stimulate the muscular contractions of the small
intestine.

In addition to these intra-intestinal stimulants to peristaltic action,
there is another which is of great importance, and is generally disre-
garded in the discussion of this subject; it is the to-and-fro movement
imparted to the intestine by the processes of respiration. The up-and-
down movement of the diaphragm during every inspiration and expira-
tion imparts to the small intestine in particular, arid to the transverse
colon, a movement which accomplishes a churning, as it were, of the
intestinal contents, changes the position of the guts, and thus con-
tributes to the movement of the substances along the alimentary canal.
The importance of this stimulus can not be overestimated, for its im-
pairment, either by lack of exercise, improper clothing — such as tight
corsets — or disease, soon exhibits itself in inactivity of the intestinal

CONSTIPATION, OBSTIPATION, AND F-ECAL IMPACTION 521

functions, and the development of constipation or other intestinal
derangements.

Overstimulation of the intestinal mucous membrane by too large
quantities of acrid food, or by too much coarse, indigestible fiber, is likely
to result in decreased sensitiveness of the nerve-ends, and consequent
inactivity of the muscular contractions. While a certain amount of
these substances is desirable in one's dietary, an excess of them may
result in the very condition which they are intended to obviate.

The peristaltic action of the small intestine is accomplished largely
by the circular muscular fibers. There are some very fine longitudinal
fibers in this portion of the intestine, but their action is doubtful. As
the faecal material here is almost always fiuid or semifluid there is little
necessity for longitudinal fibers to draw the intestine up over the mass
v.'hich is squeezed down by contraction of the circular fibers.

The processes of digestion are practically completed in the small
intestine, and the absorption of chyle takes place at the same time
through the villi. By the time the food reaches the ca?cum, therefore,
a large proportion of its nutritive elements are absorbed. Its fluid
character, however, is not very greatly diminished, and on this account
it is easily pushed through the ca?cal or Bauhinian valve into the ascend-
ing colon. As this portion of the large intestine nms directly upward,
the faecal material must therefore travel directly against the force of
gravity, consequently its hitherto rapid movement is checked, and it
rests in this position for a considerable-time. As a consequence of this,
absorption of the fluids takes place largely at this point, and by the time
the faecal matter reaches the upper portion of the ascending colon it
becomes quite consistent. On this account it requires the mechanism
of the fully developed longitudinal muscular fibers to pull the intestinal
wall upward (with regard to the course of the intestine) over the mass
after it has been squeezed forward by the circular fibers. In conse-
quence of this hardening or solidification of the faecal material com-
posed largely of the fibrous and indigestible portions of the food, the
mucous membrane of the colon is constantly more or less irritated by
it, and becomes thickened and less sensitive than that of the small
intestine.

These facts are of considerable importance when one considers the
subject of artificial anus on the right side. The further the opening in
the colon is made from the caecal valve the more solid will be the faeces,
and therefore less inconvenience will result from their constant escape
through it.

Where there is too much fibrous or indigestible material taken for
considerable periods of time, and it accumulates in the colon, the mucous
membrane may become so insensitive that the gases and rough materials

522 THE ANUS, RECTUM, AND PELVIC COLON

fail to stimulate peristalsis; consequently the patient will develop a
tardy movement of the faecal mass and undue distention of the intes-
tine, which resolves itself into atony of the muscles, chronic constipa-
tion, and sometimes impaction.

The glands in the large intestine are not only absorptive but secret-
ing glands, being possessed of a large number of goblet or mucus-pro-
ducing cells. When the intestine has been overstimulated and irritated
by the prolonged presence of hard faecal material, an excess of mucus
is secreted, and we have developed what is known as mucous colitis
or hypertrophic catarrh.

After the faecal mass has been carried through the ascending colon
around the hepatic flexure into the transverse colon, if this latter por-
tion is in its normal position it travels through a horizontal tract in
which the movement is more rapid and less diificult. Here it is sub-
jected to the action of the abdominal muscles and the diaphragm. If,
however, the transverse colon be displaced, as it frequently is in en-
teroptosis, sagging downward in the abdominal cavity below the umbili-
cus and even to the pubis, the faecal mass will be arrested or retarded
in this portion of the tract.

When the mass has once been emptied into the descending colon,
it passes downward to the sigmoid flexure by the force of gravity and
peristaltic action of the gut. Unless there is some coarctation of or
pressure upon the intestine, it passes through this section rapidly
enough.

The sigmoid flexure when empty lies chiefly in the pelvic cavity,
its loops running horizontally downward, upward, and downward again
to join the rectum. Next to the caecum this is the most distensible
portion of the large intestine, and is the typical reservoir for the storage
of faecal material. When empty or partially filled, this portion of the
large intestine forms an acute angle with the rectum, which practically
closes the conununication between these two organs. Besides this, at
the junction of the two there is an aggregation of circular fibers upon
one side which act as a sort of valve to prevent the escape of the faecal
mass into the rectum so long as the acute flexure exists. When, how-
ever, the sigmoid becomes distended with faecal matter or gases, it rises
upward into the abdominal cavity, straightens out the flexure at the
junction between it and the rectum, thus opening up the passage be-
tween the two organs and facilitating the escape of the faecal material
downward. If from any cause, such as inflammatory adhesion, adhesive
bands, tumors, or other conditions, the sigmoid is prevented from rising
up into the abdominal cavity, the faecal mass will then have to be lifted
directly upward and forced past the contracted orifice connecting it
with the rectum in order that a movement of the bowels may take

CONSTIPATION, OBSTIPATION, AND P.SCAL IMPACTION 523

place (Fig. 177). Such conditions are among the most frequent causes
of constipation.

After the fsecal mass has been passed into the rectum from the sig-
moid, it is carried downward by the force of the rectal muscles. It
does not drop into a vacant cavity, as is sometimes described, but is
directed by the folds of Houston in a rotary course from one side
of the intestine to the other until it reaches the anal canal, which is
normally closed by the sphincter rauselea. When the fieeal mass reaches
this lower portion of the rectum, around which are distributed the
sensitive nerves, the inclination to go to stool becomes imperative. If
the place and season are appropriate, and there is no local condition at
the anus preventing the same,
a frecal passage occurs, but it
can generally he restrained by
voluntary contraction of the
sphincter.

Reverse Perislalsis. — It was
stated by O'Beime that when
the fieeal mass has been passed
into the rectum and is not im-
mediately expelled, a reverse
peristalsis takes place which
carries it upward into the sig-
moid again; also that the rec-
tum, except in its lower dilated
portion, is always empty of
firees. These statements have
been accepted by the large ma-
jority of writers upon this sub-
ject; but, after carefully study-
ing it, and examining many
cases with regard to these facts,
it is not possible to verify them. In 9 out of 10 cases examined at any
period from two to three hours after a movement, one will find a greater
or less quantity of fwcal material in the lower portion of the rectum.
If pledgets of cotton, plain, coated with vaseline or soaked with water,
are introduced into the rectum and left there for two, three, six, or
twenty-four hours, during which time the patient has no movement
of the bowels, at the end of the time the pledgets will be found in the
ampulla of tiie rectum just where they were left. When the rectum
has been thoroughly filled with ftecal material and there is an obstruc-
tion at the anal outlet, it is possible that muscular straining and con-
traction of the rectal walls may force the mass upward instead of down-

52i THE ANUS, RECTUM, AND PELVIC COLON

ward, because this is in the line of least resistance; there may also be
an apparent peristaltic action upon fluid materials and gases in cases
where there is a tight sphincter and voluntary resistance to the passage
downward. In such cases there is no absolute closure of the intestine
above, but simply a circular contraction of the canal which decreases
the caliber and capacity of the gut as it proceeds downward toward the
rectum in a wave-like manner; when the wave reaches this organ and
decreases its capacity, the contents are forced to move in some direction,
and they escape upward into that portion of the intestine which has
become relaxed by the passage of the peristaltic wave beyond it; thus,
wave after wave acting in a similar manner, the contents are carried
upward through a certain portion of the alimentary tract.

The author has examined the peristaltic action in a large number
of cases in which the abdomen was opened, and he has never yet seen
any reverse wave; fluid injected into the rectum while the sigmoid flexure
was exposed has not been carried up by any such motion. Moreover, if
there were such a reverse peristaltic action, it appears that it would
manifest itself in those cases in which an artificial anus is made for
tight strictures of the rectum, and in which accumulated fsecal masses
are left below the artificial opening. Within the past year this latter
condition was observed no less than four times, and in each case it
was necessary to remove the f»cal masses from the distal portion of
the sigmoid by mechanical means. There has never been the least
tendency toward retroperistaltic action to relieve this accumulation; it
seems, therefore, when the f»cal mass has once passed into the rectum,
it remains there until it is removed by natural or artificial means, and .
the longer it remains there the drier and harder will it become on
account of the gradual absorption of its fluid constituents by the glands
of the orgMi.

The process of defecation may therefore be briefly described as con-
sisting first in peristaltic action of the entire intestinal tract, which
eventually brings the fapcal material down and stores it in the sigmoid
flexure; as this organ gradually distends it rises upward out of the
pelvic cavity, unfolding its convolutions and the flexure between it and
the rectum, thus opening up to a greater or less degree this narrowed
aperture. When the sigmoid has been straightened out sufficiently to
bring its last loop in a more or less straight line with the upper seg-
ment of the rectum, the gas and faecal material pass into the latter
and are carried downward as before described until thev reach the lower
end or sensitive area of this organ; at this point the stimulation of
the cerebro-spinal nerves causes a closer contraction of the external
sphincter muscle, and the mass is arrested until the mental action of
the individual brings into play the inhibitory power over this muscle.

CONSTIPATION, OBSTIPATION, AND P^CAL IMPACTION 525

causing it to relax and thus admit of a fajcal movement. Under cer-
tain circumstances, however, the peristaltic force is so great that it
overcomes the resistance of the external sphincter and involuntary
movements occur.

At the moment of stool, if the mass is at all hard, the assistance
of the abdominal muscles and the diaphragm are brought into play
through the process called " straining.*' This straining compresses the
small intestines, the sigmoid flexure, the bladder, and through these
organs the rectum; owing to the protected position of the ascending
and descending colon, it has little influence upon these portions of the
intestinal tract.

Remission of Inclination to Defecate. — ^\Vhen the inclination to have
a passage is resisted, the desire often passes over, and may not occur
again until the next regular period for such a movement. This remis-
sion of desire lends a plausibility to the theory of O'Beime, but the
mass is never lifted back into the sigmoid. It simply adjusts itself
to the rectal ampulla, and the parts become tolerant of its presence.
If the rectum is inflamed or the faeces fluid, this tolerance vill not be
manifested.

From tliis description of the functional action of defecation, one
may infer that whatever interferes with the passage of the fjpcal mass
through the intestinal canal will develop constipation. On the other
hand, whatever exaggerates these functional actions, hastens the ingesta
through the intestinal tract, increases the amount of the fluid secre-
tion therein, or imduly stimulates the peristaltic action, will bring on
" diarrhoea."

At the heading of this chapter the terms constipation, ohstipatioUy
and impaction have been used; the distinction between these different
terms must be borne clearlv in mind.

By constipation is understood a condition of insufficient and tardy
faecal passages due to functional conditions or diseases of the intes-
tinal tract.

Obstipation refers to those conditions in which there is a sufficient
quantity of faecal material and adequate fimctional activity, but in which
there exists some deformity, growth, or contracture in the intestinal
tract tliat causes mechanical obstruction to the passages.

By impaction is understood an accumulation of fajcal material, usu-
ally hard, dr\', and stuck together in a mass, which is arrested at some
point througli an organic or spasmodic narrowing of the intestinal
canal.

The symptoms of constipation and obstipation so overreach one
another that it is almost impossible to clearly separate them without
much repetition, therefore we will describe them together.

526 THE ANUS, RECTUM, AND PELVIC COLON

Etiology. — The causes of these conditions may be defined as func-
tional and mechanical, predisposing and exciting; those cases due to
functional derangement are true constipation, while those due to me-
chanical obstruction are obstipation.

Predisposing Causes. — Heredity, — The influence of heredity in con-
stipation is very marked; the condition may occur in all the members
of a family, and frequently it occurs in three and sometimes in four
generations.

Predisposition to catarrhal conditions, the habits of life, carelessness
in attention to the activity of the bowels, the continuous use of laxa-
tives and their administration to children, account in a large measure
for this apparent heredity. Nevertheless there are a certain number
of cases in which the father and mother are constipated, and their
children inherit this tendency, notwithstanding the most careful hygi-
enic regulations and abstinence from the administration of laxatives.
In such cases, the children are born with deficient intestinal secretions
and peristaltic action. There is generally in these cases frequent urina-
tion, which accounts in a measure for the dryness of the faecal mass and
the difficulty in its movement along the intestinal tract.

Age. — Age has considerable influence in the production of constipa-
tion. Old people, owing to deficient exercise, relaxed muscular con-
ditions, and decreased peristaltic action, together with insufficient intes-
tinal secretions which render the fa?cal mass dry, are ordinarily the
victims of this disorder. The fimctions of the animal economy at this
period of life are less active, the appetite less voracious, and conse-
quently the faecal passages adequate to maintain good health are not
necessarily so abundant or so frequent as in earlier life.

Old people are seen frequently whose bowels move once in three
or four days without any artificial stimulation, and who are in perfect
health, with the exception that they suffer from a mild degree of haemor-
rhoids. Such can not properly be called constipated.

Very young children are more subject to constipation than those
aged two years and upward. This is due occasionally to malformations,
such as narrowing of the intestinal tract at some point. It is often
caused by artificial feeding, or by a deficient quantity of lactose in
the mother^s milk. The concentrated, uniform diet of milk unless freely
supplied with this laxative tends toward costiveness, whether in the
adult or in the child. Lack of exercise and deficient oxygenation will
also account in a measure for the condition in young children. The
fact remains, however, and is inexplicable, except upon the ground of
heredity, that a large number of children bom under similar circum-
stances, fed in a similar manner, with equal hygienic care and identical
environments, differ materially in the functional action of their bowels.

CONSTIPATION, OBSTIPATION, AND F.SX3AL IMPACTION 527

Some exhibit symptoms of constipation from their very birth without
any anatomic conformation to account for the same, while others pass
through infancy with perfectly normal physiological actions. In chil-
dren from three to twelve years of age constipation is raijier a rare
disease; the period of puberty or adolescence, from twelve to twenty
years of age, however, is frequently the time when this habit is devel-
oped. Especially is this true in the higher walks of life, where false
modesty or prudery with regard to the natural functions causes young
women and yoimg men to neglect the calls of Nature, or rather to refuse
to honor them lest they excite some thoughts not altogether refined
in the minds of persons present. This mock modesty and the absorp-
tion in school, society, and domestic affairs bring on the worst types
of constipation.

The normal stimulation of the intestinal mucous membrane and the
inclination to go to stool may be resisted so persistently that the nerve-
ends become insensitive to impressions, and the faecal masses may lie
day after day and week after week in the rectum, sigmoid flexure, and
other portions of the colon without any imusual desire for defecation.

A young woman, who went upon a sailing cruise for eight weeks,
had only three movements of her bowels during the entire time simply
because she was afraid that some gentleman would see her going toward
the toilet. The result was a severe proctitis and a constipated condition
which required a long time and much treatment to relieve. In such
eases it is habit and not age that produces the constipation. In people
of middle age it is ordinarily the result of neglect, improper diet, or
organic disease.

Sex. — False modesty in young women, the lack of outdoor exercise,
neglect of regularity, and after puberty the physiological phenomena
in a woman's life, tend toward producing constipation. Congestion of
the ovaries, and more or less enlargement of the uterus at every men-
strual period, the processes of pregnancy, resulting in prolonged pres-
sure upon the rectum and pelvic colon by the gravid uterus, a gen-
eral relaxation of the abdominal muscles, and the lack of support to
the intestines after childbirth, together with frequent displacement or
disease of those generative organs, render the female sex much more
subject to constipation than the male.

Occupation, — Occupation is another predisposing cause. A seden-
tary life, such as that of professional men, bookkeepers, office clerks,
seamstresses, etc., predisposes to the development of this condition.
Such individuals, unless they are systematic in the habit of going to
stool at re^ilar hours and allowing nothing to interfere with this func-
tion, are very likely to develop the chronic form. As Johnston says:
" Intellectual work, not only from the muscular inactivity which it

528 THE ANUS, RECTUM, AND PELVIC COLON

entails, but from the diversion of energy to the nerve-centers, develops
the constipated habit as well as indigestion."

Painters, workers in lead and other metals are predisposed to it.
Sailors, railroad men, and others whose occupations prevent regular
attention to these functions are subject to constipation; the large ma-
jority of them are habitual users of cathartics, the omission of which
results in acute attacks and sometimes in serious results. Here again
it is not the occupation so much as the habits which it entails.

The Exciting CauMS. — Food, — The normal action of the bowels de-
pends upon the character and quantity of the food taken.

Quality. — Highly concentrated foods produce little faecal material.
A vegetable or mixed diet gives rise to a larger quantity of faecal dis-
charge than does an animal diet, at the same time the stools are ordi-
narily less firm; this is owing to the fact that vegetables contain a
larger proportion of water and fibrous material. Within normal limita-
tions, therefore, a vegetable diet is less likely to be the cause of con-
stipation than is a nitrogenous one. On the one hand, vegetables taken
in excess produce excessive stools, and the accumulation of fibrous ma-
terial in the large intestine is likely to bring on an insensitive condition
of the mucous membrane, and hence a tardy action which-* results eventu-
ally in chronic constipation; on the other, a purely nitrogenous diet
furnishes a very small quantity of refuse material, and consequently
small fffical discharges which result in irregular or infrequent stools.

Quantity. — The amount of food taken is also an element in the pro-
duction of constipation. Cases suffering, as has already been said, from
intestinal, oesophageal, and stomachic conditions which limit the quan-
tity of food taken and necessitate its being of the most concentrated
varieties, will pass very small amounts of fa?cal material; such cases,
however, can not be considered as constipated. On the other hand,
patients may take too much food. People of sedentary habits, who live
in luxury and are fond of gastric indulgences, frequently develop the
habit of eating large quantities, more than their organs can digest or
assimilate, and the result is that they either have enormous passages
or there is an accumulation of such materials in the colon with over-
distention, atony, and chronic constipation. In such individuals tlie
limitation of the amount of food is frequently the most successful treat-
ment. The small amount of fluids taken is also frequently a cause.
It has been determined by physiologists that the average composition
of the faecal mass is, approximately, water 75 per cent, solid material
25 per cent. Whenever the liquid constituents fall ])elow 50 per cent
the fa?cal movements are retarded and difficult, and when they reacli
as low as 20 per cent (Illoway, Constipation, p. 39) the movement is prac-
tically impossible.

CONSTIPATION, OBSTIPATION, AND FiECAL IMPACTION 529

The drjTiess of the faecal material is brought about also by numerous
functional or pathological processes. Diabetes, nursing, excessive
diuresis, or perspiration reduces the fluidity of the intestinal contents^
and hence contributes to the production of constipation. This is also
noticed in cases of malarial fever, the night-sweats of phthisis, and
as a result of very hot weather in a great many cases.

Good and Everly (Braithwaite's Retrospect, vol. xvii, p. 152) ascribe
constipation to an excessive absorption of the fluids in the small intes-
tine. Johnston also states (Pepper^s System of Medicine, vol. ii, p. 643)
that constipation may be caused by exercises which produce excessive
perspiration, and by stimulating the functions in general cause the too
rapid absorption of fluids in the intestinal canal.

The necessity, therefore, of consuming a sufficient quantity of water
to keep the faecal passages soft can well be understood. As to whether
this water should be taken before meals, with the fooil, or afterward,
is a question to be decided by the condition of the patient's stomachic
digestion. Where there is a catarrh of the stomach and an accumula-
tion of mucus in this organ large drafts of water before meals, in
order to wash out this material and cleanse the walls of the organ, are
desirable. When there is feebleness or inadequacy of the digestive
agents in the stomach the patient should avoid taking fluids along
with his food, but under other circumstances, such as are found in
cases with excessive gastric secretions, a certain amount of water taken
at this time will have a beneficial effect. In the class of cases in which
water is contraindicated during meals, it should be freely indulged in
two or three hours afterward.

Chemical Causes. — The chemical reaction of the intestinal contents
is nonnally acid in a carboliydrate diet, alkaline in a nitrogenous diet,
and neutral in a mixed diet. Thus it is that patients who are in the
habit of living upon a mixed diet, if they suddenly change to a fresh
vegetable and fruit diet, develop a diarrhoea owing to the excessive and
unusual acidity of the contents of the large intestine. On the other hand
vegetarians, if they change their mode of life and begin to live upon meat
and nitrogenous materials, are likely to become constipated. Speaking
in a general way, therefore, the proper and normal regulation of intes-
tinal action demands a mixed diet, together with a sufficient quantity
of water to maintain the soft or semifluid condition of the stools.

Drvgs and Medicines. — In the same line with foods may be classed
certain vegetable and mineral substances, which being taken into the
intestinal tract bring about delayed or insufficient stools. An excessive
quantity of lime salts, lead, opium, tannic acid, alum, etc., all produce
this, either by their action upon the mucous membrane or upon the
nervous system.
34

530 THE ANUS, RECTUM, AND PELVIC COLON

The modern preparations of flour, baking-powder, and various cereals
contain greater or less quantities of alum. This powerful astringent
taken into the digestive tract results in a limitation of the normal secre-
tions, unnatural dryness of the fsecal mass, and subsequent constipation.

Workers in lead, metals, bismuth, etc., either by absorption through
the skin and their effect upon the spinal cord, or by the unconscious
swallowing of certain amounts of the metals, very frequently suffer
from constipation. It is unnecessary to enlarge upon the effects of
opium in its production. Every practitioner is aware of its influence
in this respect, and those who have had to deal with chronic opium
hahitu€8 know how difficult it is, even after the habit has been dis-
continued, to bring about normal defecation. In such cases where
the habit has existed for considerable periods of time, the secreting
glands of the intestine become atrophied, the intestines become greatly
distended, the walls thinned, the muscles atonic or degenerated, and
it is sometimes impossible to restore them to their normal condition.

Tobacco in excess is said by Johnston to be the cause of constipa-
tion; but the fact has been observed that where patients have relin-
quished the tobacco habit, they frequently suffered more from con-
stipation than from any other complication; in a number of such cases
it was advisable to have the patient return to his morning cigar or pipe
in order to overcome a condition to which drugs, enemas, and dietary
regimen afforded little relief. There are some individuals in whom too
many or too strong cigars invariably induce a diarrhoeal movement
of the bowels, so the claim that smoking has a constipating effect is
not tenable. There may be cases, however, in which the habit of chew-
ing tobacco and excessive expectoration bring about digestive disturb-
ances which indirectly cause constipation.

Digestive Disorders, — In a line with what has just been said, the
various disorders of the digestive system, gastric diseases, chronic
intestinal catarrh, ulceration of the small intestine, such as is found
in typhoid fever and sometimes in malaria, may all result in acute
or chronic constipation. In ulceration of the stomach, where the
food is either not taken or is ejected, in cancer, acute and chronic
gastritis, gastroptosis, and stricture of the pylorus, constipation is the
rule, owing, first, to the limited amount of food ingested, and secondly
to the tardiness or imperfection with which it is poured out into the
small intestine.

Acute inflammations of the intestinal tract are more likely to result
in a diarrhoea at first; as the acute symptoms pass away, leaving the
mucous membrane thickened and oedematous, reflex excitabilitv is
reduced, muscular contraction is decreased, and atony of the walk
follows.

CONSTIPATION, OBSTIPATION, AND P^fflCAL IMPACTION 531

Intense inflammation and ulceration high up in the intestinal tract
often result in constipation^ as is the case when corrosive substances
have been swallowed.

Diseases of the liver and pancreas may produce constipation through
a modification of their secretions or an inhibition of peristaltic move-
ments due to the pains which they induce. Hinrichs (Inaugural Dis-
sertation, Berlin, 1889) stated that diseases of the pancreas are very
frequent causes, and that they greatly increase the suffering. Johns-
ton stated that occlusion of the pancreatic duct, either by calculi or
catarrhal disea^ses, frequently results in a fatty diarrhcea, but that pan-
creatitis causes constipation. Inflammation of the liver, the gall-
bladder, or any of the biliary ducts through the suppression or reduc-
tion in the amount of bile, or alteration in its quality, no doubt results
in this condition and induces a type ordinarily called biliousness. The
inflammation of any of these organs ordinarily affects the peritonaeum
covering them, and consequently produces a certain amount of peritonitis
which is likely to extend in all directions, involving the intestinal coat,
and this contributes also to inactivity of the bowels.

Circulatory and Chronic Diseases, — Clironic diseases of the heart,
liver, and limgs are frequently the causes of constipation by their gen-
eral influence in the production of muscular weakness, decreased glandu-
lar secretion, and imperfect oxygenation. In cases of lung and heart
diseases in which exercise is prohibited, the respiratory movements are
limited, the abdominal and diaphragmatic muscles are weakened, and
constipation results.

Diseases of the Nervous System, — It is a question open to discussion
whether constipation of the insane is due to defective innervation of
the intestinal tract or to lack of sufficient mental power for proper
attention to the calls of Nature. It is one of the most frequent symp-
toms in all forms of chronic insanity, senile dementia, and progressive
myelitis.

In acute meningitis and encephalitis it also frequently occurs. In
the latter and in myelitis it is probably due to an interference with
the motor nerve-fibers. In meningitis and tetanus it is said that the
muscles of the intestinal and abdominal walls are in a state of tonic
contraction, and therefore the accompanying constipation is due to a
sort of enterospasm. In multiple sclerosis of the spinal cord it is a
very frequent complication, and is associated with mucous colitis in
many instances. In those patients with sufficient intelligence to remem-
ber their habits, a considerable number of them have reported that they
had suffered from constipation before their nervous symptoms devel-
K)ped. A certain proportion of them were perfectly sure that their
bowels had always been regular until after the nervous disease set in.

532 THE ANUS, RECTUM. AND PELVIC COLON

As a matter of fact, however, in all of these patients the change of
environment, habits, and dietary at the time, or after the. beginning
of their nervous symptoms, might account in a degree for their con-
stipation. These facts, however, do not explain the occurrence of con-
stipation in almost every case of ataxia, and in individuals with whom
there. has been no change of circumstances, environments, or dietary.
Whether the sympathetic ganglia and the plexus of Auerbach and Meiss-
ner take part in the sclerotic process or not, or whether it is simply
an involvement of the cerebro-spinal nerve-roots and centers which
control the inhibition of the circular muscular fibers, is not known; but
constipation is nearly always an accompaniment of the disease, and all
remedies directed toward it are of only temporary benefit unless there
is concomitant improvement in the nervous condition.

Under this heading one may group that type of constipation termed
spastic, and due, according to Rosenheim (Pathol, u. Therap. der
Krankh. des Darmes, 1893), Kaczorowski (Deutsche med. Wochen-
schrift, 1882, No. 1), and Illoway {op. cit., p. 88), to enterospasm.

It is due to partial or general tonic contraction of the muscles of
the intestine, the circular and longitudinal fibers contracting syn-
chronously and persistently, and thus preventing any .movement of the
faecal mass.

It is said to be frequent in basilar meningitis and pathological pro-
cesses that produce pressure upon the pons or medulla oblongata, and in
lead-poisoning.

The partial type of enterospasm is frequent in acute gastritis and
intestinal indigestion, and, according to Rosenthal, may be produced
by chronic gastric catarrh. The same author speaks of this condition
as " crises enteriques " occurring in the course of tabes dorsalis. The
constipation in this type of cases, as can be readily understood, is a
matter of no importance compared with the general condition which pro-
duces it. It increases or decreases, following the course of the disease
of which it is a symptom, and needs no therapy of its own. Entero-
spasm occurs during the course of neurasthenia, hysteria, and acute
nervous excitement. In such instances the management of the neurosis
is the part of the physician; the constipation will take care of itself.

Illoway states that partial enterospasm may be associated with atony
of the intestinal muscles, which opinion seems to be corroborated by
Reynolds's System of Medicine, Rosenheim {op. cit.), Fleiner (Berliner
klin. Wochenschrift, January, 1893), and Cherchewski (Revue de mM.,
October and December, 1883). He includes spasmodic stricture of the
rectum and contraction of the sphincter ani as types of enterospasm.
These conditions, however, being due in the large majority of cases to
local causes, can not be properly included in this category.

CONSTIPATION, OBSTIPATION, AND P^ECAL IMPACTION 533

Local and Mechanical Causes. — There are causes which act in a
nieehanieal manner by offering an obstruction at some point or- other
of the intestinal tract to the passage of the fsecal mass. The constipa-
tion produced by these has been termed obstipation. The impression
has gone abroad in certain sections that this term is applied only to
those obstructions found in the rectum, particularly those produced by
inflammation, hypertrophy, or malformation of Houston's valves. Such
is not the case. Obstipation consists in a mechanical obstruction to the
passage of faecal matter at any portion of the intestinal canal.

In children it is frequently due to the imperfect absorption of the
sa»ptum dividing the rectum and the anus in foetal life, to malforma-
tions in the rectum itself, and to imperfect development of the intes-
tinal tract either above or below the ca^cal valve. It mav also be due
to abnormal development of the sigmoid flexure and colon, both in
tlieir circumference and length, to sacculation in the large intestine,
or to true diverticuli, as has been pointed out by Treves and Osier
(Annals of Anatomy and Surger}% Brooklyn, 1881). Diaphragms or
folds of mucous membrane sometimes project into the lumen of the
bowel and reduce the size of the passage to a greater or less degree.
These diaphragms more frequently occur in the lower portion of the
intestinal canal, the rectum, and sigmoid flexure, but they also occur
in the uj)per portion of the colon and in the small intestine, as has
been pointed out by Illoway {op. cit., p. 78).

Martin, in his little work Obstipation, attempts to prove that the
rectal valves or Houston's folds are the cause of constipation in the
large majority of cases. After demonstrating the existence of the
folds, which were described by Houston, Kohlrausch, and Otis, he
says: " It may be the special property of the valves in certain abnormal
conditions to maliciously obstruct the descent of the faces." He de-
scribes three forms of valvular obstruction, as follows: " First, the ana-
tomic coarctation of the valves may afford an exaggerated physiologic
resistance to the descent of the fa?ces. Second, congenital hyperplasia
of the rectal valves is a condition classically described as diaphragmatic
stricture or membranous sa?ptum in the abdominal rectum. Third, hy-
pertrophy of the rectal valves constitutes the classical, annular stricture
of the abdominal rectum."

With regard to his first proposition, no one who admits the exist-
ence of the folds as anatomical structures can deny the possibility of
their retarding the descent of the faeces when they are abnormally
developed. The writer has studied this subject in an unprejudiced
manner with a mind open to conviction from every point of view. Hun-
dreds of cases, in many of which the valves were markedly developed,
and overlapped each other, have been examined, and yet no case haa

534 THE ANUS, RECTUM, AND PELVIC COLON

been seen in which anything more than a small particle of fa?ces has
been arrested above one of these valves. They have been as well marked
in many cases which did not suffer the least from constipation as tliey
were in constipated individuals. Nineteen valvotomies have been per-
formed, always following the direction of Martin, viz., that a hooked
probe introduced into the center of the valve shall not slide over its
edges when drawn downward, thus demonstrating the obstructive qual-
ity of the valve according to his theory; of these 19 cases, 7 were oper-
ated upon by incision — ^according to the methods of Martin — and 12
by the Pennington clip. In all of the cases a certain amount of benefit
was obtained for two or three months, but after this time, as the
patients discontinued the hygienic regimen and local treatment neces-
sary to the healing of the incised valve, the old symptoms returned to
a greater or less degree. Permanent relief was accomplished by tlie
operation in only 2 or possibly 4 cases. No ill effects, however, such
as stricture, protracted ulceration, or inflammation, have followed the
operation in any of these cases. Reasoning from the anatomical con-
formation of the parts, and from some post-mortem specimens which
have been observed — for example, the one from which Fig. 25 is taken —
the opinion results that obstipation from this cause may occur, but
clinical experience does not prove that it is the etiological factor in
any great number of cases. As to his second and third propositions,
that congenital hyperplasia of the rectal valve is what is ordinarily
known as diaphragmatic stricture or membranous sa?ptum of the rectum,
and that hypertrophy of these valves constitutes annular stricture of the
rectum, a general denial must be entered. In the first place, diaphrag-
matic strictures and membranous saepta occur at no regular locations ex-
cept at the juncture of the rectum with the anus, entirely below the site
of any of the valves; in the second place, the compositions of such sa»pta
are entirely different from those of the valves; and in the third place,
the classical, annular stricture of the rectum has neither the shape, con-
formation, nor anatomical structure of an hypertrophied valve. Hyper-
trophy of the valve does not cause it to extend entirely around the rec-
tum, but simply increases its anatomical constituents in the original
site. The classical, annular stricture of the rectum entirely surrounds
this organ, and is ordinarily as thick in one portion of the circumference
as it is in another; again, the annular stricture is composed almost en-
tirely of fibrous material covered by mucous membrane, and is developed
from the submucosa. Hypertrophy of the rectal valve consists in thick-
ening of the mucous membrane, an increase of the normal constituents
of the submucosa, and hypertrophy of the muscular wall of the gut.

While, therefore, the possibility is admitted that abnormally devel-
oped or hypertrophied valves may produce an obstruction to the passage

CONSTIPATION, OBSTIPATION, AND P^CAL IMPACTION 635

of the fapcal mass, it is not conceded that either hypertrophy or hyper-
plasia of these valves constitutes the diaphragmatic or annular stricture
of the rectum. This view is sustained by the elaborate studies of hyper-
trophied valves by Pennington and Edwards (Jour. Amer. Med. Ass'n,
December, 1900). A brief account of their observations is as follows:

" Mucosa, — The mucosa showed epithelial glands containing a very
large percentage of goblet-cells. No other pathological process was
demonstrated in these structures. They were slightly hypertrophied.
There was nothing to indicate an atrophic process in the mucosa, at least
at this time. Between the glands there was an increase of tissue which
was generally round-cells, though some spindle-cells and young fibers
were apparent. In two of the specimens there was evident local infec-
tion with a pus organism, the focus extending into the submucosa. The
muscularis nmcosa was thickened.

'' Submucosa. — The submucosa showed a great increase in the con-
nective tissue, which was in bundles. These bimdles usually ran across
the long axis of the valve. There was extensive thickening of the blood-
vessel walls. This thickening was the usual type of endarteritis ob-
literans. The sections removed from the valves in live subjects showed
no muscle except a very few circular fibers.

*' In a section made from a cadaver, in which the valves were coarse
and resistant, the following were found: the circular muscular layer
was generally hypertrophied; the longitudinal layer showed slight hyper-
trophy, and the adventitia external to the muscular layer showed an
increase of white fibrous tissue together with an extensive endarteritis
obliterans."

From these examinations it will be seen that there was no evidence
whatever of cicatricial material, such as goes to make up the ordinary
annular stricture. On the other hand, while these cases are said to have
been the victims of constipation along with colitis, there is no proof
that the colitis and proctitis, together with hypei-trophy of the valves,
were not produced by the retention of hardened faecal masses in the
rectum.

This idea that constipation is caused by the rectal valves or folds
is not at all new. Henauldin (Diet, des sciences med., 1813, vol. vi, p.
25T), C.'opeland, Kohlrausch, and Quain (Diseases of the Rectum, 1854)
all describe cases in which these diaphragms or folds have resulted in the
])artial or complete obstruction of fjpcal passages. There is therefore
no doubt that when they are abnormally developed or malformed, as
in the ca.sc of Renauldin, the folds mav become obstructive, but such
cases are rare.

Malformations. — The cases of Renauldin and others which have been
referred to above may be more properly classified among the malforma-

636 THB ANUS, RECTUM, AND PBLVIC COLON

tions of the rectum; with them one may ioclude other malformations,
such as congenital arrests of development, unusual narrowness at the
cecal valvo, and partial atresia of the anus.

A child who presented all the symptoms of a chronic constipation,
with recurrent appendicitis, was seen, in whom, upon opening the abdo-
men, there was no appendicitis whatever, but a congenital narrowing of
the caeeal valve and of the ileum for two feet above its entrance into the
caecum. To the eye there was an absence of muscular development in
the small intestine at this point. The Bauhinian valve was so tight that
a veiy small fiecal mass pushed forward through the narrow ileum
failed to pass. By the use of the finger and invagination of the small
intestine through the valve, the latter was divulsed, after which the
mass passed with ease. The vermiform appendix was removed, but it
was not diseased. Since the operation the patient's bowels have moved
regularly, and his health has
greatly improved. The chief
cause of constipation in this
patient was the abnormal nar-
/., ii rowness of the ileo-ctecal valve

/ » and imperfect development of

■V the ileum,

^i Notlinagel {Beitriige zur

^^V Physiol, u. dt's Qarmes, Ber-

^^E. ', lin, 18&4) describes a eondi-

^^^hH|^^^ ' >A tion which he culls congenital

^^^^^^^^^HL^ ^^^ll hyperplasia of the colon. The

^^^^^^^^^^^^^^^ ^H^^ whom ob-

^^^^^^^^^^^^^^■A^^^pr gave the eon-

^^^^^^^^^^^^^^^^^ from infancy. There

^^^^^^^^^^^^^^r an immense

^^^^^^^^^^^^^ of the colon and large accu-

Fw.]78.-M*i,o«,*T.o,orT>i.8.™omFL..„„. '""'^lioDs of fa-eal material in
it. The interesting case of
Fntterer and Mittcndorf exhibits a remarkable dilatation or divertieu-
Inm of the sigmoid flexure removed from a boy fourteen years of age in
which constipation was the most marked sj-mptom (Fig. 178. Illoway,
op. cH., p. 77). Such instances are curiosities, but less marked divertieuli
of the intestine are by no means unique, and they, too, cause consti-
pation.

Enteroptosis. — Displacements of the intestines are not infrequent
causes of constipation. Rosenheim claims that the most frequent dis-
placement of the large intestine takes plaee at the hepatic flexure.
This, however, is not the experience of a large majority of observers.

CONSTIPATION, OBSTIPATION, AND F.ECAL IMPACTION 537

Prolapse of the iransverBe L-olon is the most frequent type; it is car-
ried along witli the Btoniacli in many eases of gastroptosis. In such
the eoion forms a Uwp representing somewhat an inverted U or M.
Tiie fffical material after it has paBsed the hepatic flexure drops down

into the loop and must be

again liftwl directly up-
ward against the force of
gravity, as has been before
described, and consequent-
ly there is an obstruction
to its passage. Persons
with this condition invari-
ably sufTer from a greater
or less degree of chronic
constipation; and when the
bowels and stomach are
lifted up into their proper
places and held so by prop-
erly adjusted bandages, the
constipation is materially
relieved.

Acute Flexmei. — One
of the chief causes of con-
stipation, and one to which
more importance is at-
"tached than to any other
form of mechanical ob-
struction excejit stricture, is acute flexnre between the rectum and
sigmoid. In the normal condition the empty sigmoid lies in the pelvis
between the rectum and bladder or uterus, thus causing an acute flexure
between these two organs (chapter on Anatomy). In cases of pelvic in-
flammation, peritonitis, or cellulitis, it not infrequently happens that
it becomes adherent to the rectum or to the floor of the pelvis, thus
becoming limited in its motions and prevented from rising up into the
abdominal envity, thus straightening out the tract between it and the
rectum (Figs. 179 and 180), Under such circumstances an obstruction
to the passage of the fiecal mass at this flexure is inevitable.

This condition can be demonstrated by the iise of the pneumatic sig-
moidoscope. Where the pelvic colon is normally mobile, inflation
will cause it to rise up into the abdominal cavity and allow the straight
tube to pass easily into the canal. When, however, on account of such
adhesions, obstructions in the shape of tumors, or too short a meso-
sigmoid, this flexure can not be straightened out, it is with the greatest

538

THE ANUS, RECTUM, AND PELVIC COIjON

difficulty, and sometimes even impossible, for one to introduce a tube of
even moderate size beyond the locto-sigmoidal juncture.

In one ca«e operated upon, the sigmoid was prevented from rising
by the vermiform appendix passing downward across its anterior surface
and adhering to the i>eritona;um of the
pelvis, just to one side of the bladder.
Attempts were made during several
months to introduce a straight tube
into this woman's rectum, and they al-
ways caused great pain until after Hie
vermiform appendix was loosened from
its attachment and removed. As soon
as this was done, the sigmoid sutured to
the abdominal wall, and the patient had
recovered from the immediate effects
of the operation, it was possible to in-
troduce the tube without any diffieulty,
and the patient's bowels moved without
pain, an experience which she had not
enjoyed for many years. A similar
case to this, obeen'ed in a post mortem,
is represented in Fig. 181. Adhesive
bands from peritonitis occasionally pass
across the pelvic cavity and interfere
;igmoid flexure. There may be inter-
ference with this movement by the adhesion of ap]>endicea epiploicie
of the sigmoid to the pelvic wall. These adhesive bands not only
obstruct the movement of the sigmoid flexure and thus cause constipa-
tion, but they also sometimes cross the pelvic colon, forming diver-
ticuli above them, and thus occasion constiiwtion by their actual ob-
struction of the canal. These flexures and adhesions are among the
most frequent causes of obstinate constipation in women.

Spasm of the Sphincter. — Hyjtcrtrophy of the e.\temal sphincter and
levator ani muscles are causes of constipation. Ifathews lays great
stress upon the influence of the external sphincter in the causation of
this condition; he holds that the large majority of the cases of con-
stipation arise from spasm or iiypertrophy of this muscle, and states
that in many of the cases in which constipation has been apjiarently
relieved by operations upon hn-morrhoids, the real hcnelit has bi'en
derived from the divulsion of the sphincter. There is no doubt a large
amount of truth in what he says upon this subject, but the cause of
the hypertrophy or spasm of the muscle remain.'* to be explained. It
may be induced by pressure from a prolapsed uterus, tumor.s of the

with the movement of the ;

COSSTIPATIOX, oaSTEPATION, AND F.F.CAL IMPACTIOX

r.;i9

pelvis, infliinimatioa of llie rectum, deep urethra, or bladder; otlier
reflex disturbances may also occasion it, as will be seen in the chapter
upon the neuroses of the rectum.

Fissure in nno or irritable ulcers — in fact, ulceration of any kind
about the margin of the anus, or just within the rectum, will occasion
it. Under such circumstances the fmcal movements are retarded or pre-
vented by a twofold action. First, the actual obstruction caused by
the sphincter; and second, the disinclination upon the part of the
patient to have a movement which will occasion more or less distress.
It is this fear in the first place which occasions the constipation in acute
fissure, and when the fissure has once healed, the hypertrophy of the
sphincter which has been occasioned by it comes in to play the part
of obstructor to the
passage. The levator
ani muscle is also sub-
ject to similar irrita-
tions, and it may also
play a part in the pro-
duction of obstipation.

Spasm of the circu-
lar fibers of the intes-
tine at the juncture of
the sifrmoid and rectum
may have an influence
in the production of
constipation, O'Beime
and others have pointed
out that whenever a
bougie has once passed
through this aperture
it is ven,' likely to bo
followed by a fa'cal
movement; it e.^eites
an inclination to go to
stool, and uptm a sec-
ond examination a short
time afterward one will
almost invariably find
an increased amount of

faeces in the rectum, thus showing, according to his view, that the
spasm of the circular fibers had prevented the descent of the fieces.

Foreign Boilies. — The presence of foreign bodies in the intestinal
tract may also become the occasion of chronic or acute constipation.

640 THE ANUS, RECTUM, AND PELVIC COLON

The introduction of these bodies through the anus will usually result
in an acute type; whereas those which are formed in the tract, such as
concretions and enteroliths, are of slow development, and likely to result
in chronic constipation and eventual obstruction. Certain foreign bod-
ies which pass through the intestinal canal, having been swallowed,
may also occasion this condition. The swallowing of false teeth has
several times been reported as resulting in constipation. Prune-pits,
fruit-seeds, gall-stones, and small particles of indigestible food have fre-
quently formed the nucleus around which have accumulated the salts
found in the intestinal contents, until they have produced large con-
cretions or aggregations which obstruct the canal and thus occasion
either chronic constipation or complete obstruction.

Masses of hair have been found obstructing tlie intestinal canal.
Many suppose that these aggregations are dermoid cysts which have
ruptured into the intestinal canal, but such is not the case. They are
ordinarily foimd in patients who are in the habit of biting their hair
or mustache and swallowing it; in one case a mass of this kind had
formed just above the ca^cal valve, measuring 5^ inches in circumfer-
ence and 8 inches in length. Another mass of this kind which was
removed from the stomach measured 9 inches from end to end, and
4^ inches in circumference in its widest part. In both of these cases the
habit of biting the ends of the hair (which was worn in a braid) was
clearly made out. Many other foreign bodies have been found to cause
constipation, an interesting review of which will be found in Treves's
work upon intestinal obstruction, and in the cases quoted by llloway
(op. cit.).

Extra-intestinal Obstructions. — Finally, as causes of constipation one
should always bear in mind the fact that pressure may be exerted upon
the intestines in any portion of their tract, and thus occasion retarda-
tion of the faecal current. Hydatids of the liver, tumors of the spleen,
kidneys and stomach are nearly always associated with greater or less
constipation, owing to their pressure upon the transverse or descending
colon. Subinvolution and displacements of the uterus very frequently
cause it. It is needless to mention the fact that a fibroid or ovarian
tumor may occasion the same results. These conditions should always
be diagnosed in any search for the causes of constipation, and no favor-
able prognosis can ever be offered so long as they exist.

With regard to strictures of the rectum and sigmoid, as has been
described in the chapter upon that subject, they always produce a con-
stipation at first, and afterward result in a combination of this condition
with a nagging, teasing diarrhoea which masks the constipation. The
diagnosis of these and the differentiation between the malignant and
cicatricial type have been given in the chapters upon those subjects.

CONSTIPATION, OBSTIPATION, AND PuECAL IMPACTION 541

Intra-intestinal tumors, such as polypi, adenomata, papilloma,
fibroma, etc., may all occasion constipation, but in the large majority
of instances the efforts of Nature to rid herself of these neoplasms result
in an increase of peristalsis and diarrhoea.

Intussusception and Prolapse. — Intussusception of the intestine in
any portion of its extent results ordinarily in an acute obstruction.
Illoway and Johnston both include it under the causes of constipation,
and perhaps there are instances in which a mild degree of intussuscep-
tion may result in an acute, temporary attack which is relieved either
by the sloughing off of the intussuscepted portion of the gut or by
the reduction of the intussusception. A case of this kind was reported
to the writer in a private communication by Thomas, of Charleston,
W. Va. The patient was seized on January 12, 1901, with a high
temperature, intense pain and aching in the limbs and back, and a
severe diarrhoea, which continued for ten days in spite of treatment.
The patient suffered from great pain in the rectum, together with
nausea, vomiting, and distention of the abdomen to such an extent
that intestinal obstruction was feared. Under rectal irrigation the
patient passed, at the end of five days, a section of bowel about 6 inches
in length. Immediately after this the symptoms of obstruction sub-
sided, and the patient gradually recovered. Thomas states that the sec-
tion passed was a part of the sigmoid fiexure, as he could see the circular
line of granulation at the point where the gut sloughed off about 8
inches above the anus.

This condition is rarely so mild in its manifestations and symptoms
as to bo classed among the ordinary causes of constipation. On the
other hand, that form of procidentia of the rectum termed prolapse of
the tliird degree, which really consists in an intussusception of the upper
portion of the rectum or sigmoid into the ampulla, is quite frequently
productive of constipation. Patients suffering from this condition claim
to be constipated, and yet their bowels thoroughly empty themselves
at regular periods; the sensation of uncompleted defecation in these
cases is caused by the pressure of the prolapsed or intussuscepted gut
upon the sensitive margin of the anal aperture. This condition is dis-
cussed in the chapter on Prolapse of the Rectum.

Stone in the Bladder, Stricture, and Urethral Diseases. — Stone in the
bladder, stricture, and urethral diseases may all result in constipation
owing to reflex spasm and subsequent hypertrophy of the sphincter mus-
cles. In the same way an enlarged prostate, both by its refiex infiuence
and its pressure upon the rectum, may result in this condition.

Willy ^feyer has reported (N. Y. Academy of Medicine, February,
1901) the fact that in his series of operations for enlarged prostate by
the Bottini method he has seen several cases of obstinate constipation

542 THE ANUS, RECTUM, AND PELVIC COLON

relieved of that as well as of the dysuria. The author^s experiences
with that operation have not been so fortunate in the relief of the con-
stipation.

Diagnosis. — Constipation must be distinguished from ficcal impac-
tion and intestinal obstruction. Before deciding that either exists, one
must determine that the patient^s functional habits are abnormal, ^^^lat
constitutes constipation in one does not in another. Where a patient
has regular and satisfactory movements without any local or constitu-
tional disturbances, even if the periods are somewhat widely separated,
it is to be presumed that this is normal, and the habit should not be
interfered with.

Regularity without effort, and the discharge of faecal material pro-
portionate to the amount of food consumed, are the essential requisites
of normal defecation. The impairment of either of these features in
the line of inadequate amounts, or prolonged retention requiring in-
creased effort to obtain a passage, constitutes constipation. When these
have been determined, a search for the cause in some one of the condi-
tions which have been enumerated should be instituted. Careful in-
quiry, abdominal palpation, and digital and instrumental examination
are all necessary to come to a proper diagnosis in such cases.

When one or more of these conditions has been shown to exist, they
may be the cause, but in the local conditions about the lower end of the
rectum one should be very careful in his prognosis as to the results of
their cure upon the constipation, for frequently they are only complica-
tions and not its causes.

Between acute constipation, fa?cal impaction, and intestinal obstruc-
tion it is not always easy to draw the dividing line. They may all be
brought about by the same causes, and produce in the beginning similar
symptoms. In acute constipation there is at first simply an omission in
the regular movements of the bowels, which may persist for an indefinite
period without any marked symptoms. When constitutional symptoms
develop they consist in some griping, lack of appetite, bad taste in the
mouth, a little heaviness or disinclination to mental activity, and occa-
sionally symptoms of autoinfection, such as elevateil temperature, rapid
pulse, and more or less aching pains over the body.

In impaction the patient may suffer from all of these symptoms, and
yet at the same time have abnormally frequent passages. The author
has known a patient to suffer from a continuous diarrha?a for six weeks,
and finally develop acute mania with hallucinations and loss of memory,
apparently from no other cause than an impaction of faeces in the sig-
moid flexure. The impacted mass being lodged in a saccule or diver-
ticulum of the colon or ampulla of the rectum, permits fluid stools to
pass around or to one side of it. This causes an irritation, inducing

CONSTIPATION, OBSTIPATION, AND P^CAL IMPACTION 543

frequent stools, and thus the patient is often misled into the belief that
he is suffering from diarrhoea. In simple constipation and in impaction
there is always a channel for the escape of gases from the bowels. In
complete obstruction the lumen of the gut is entirely occluded by or-
ganic changes in the caliber, by some foreign substance besoming im-
pacted in a narrow portion of the channel, or by intussusception, volvu-
lus, or acute flexure in the gut.

In obstruction the constitutional symptoms manifest themselves
very early. The tonnina* are severe, the abdomen distends, nausea and
vomiting come on soon in the disease, the ejecta are at first fluid and
bilious and afterward fa»cal; the patient's pulse becomes very rapid and
feeble; he has cold perspiration and general weakness, and after one or
two enemas the fluid injected will return unstained by fapcal matter. The
importance of an early distinction between these different conditions
can not be overestimated. The utmost patience and dependence upon
natural functions is requisite in the treatment of constipation; in fiecal
impaction repeated enemas, faecal solvents, and gentle distention of the
gut by air is advisable, rather than to undertake radical surgical opera-
tions. If the mass is within reach from the rectum, ana3sthetization and
breaking it up are justifiable, but too great haste may be exercised in this.

In intestinal obstruction, however, prolonged manipulation and
efforts to overcome the condition by enemas, inflations of the intestine,
and therapeutic remedies are not only useless but seriously jeopardize
the patient's life. Radical measures must be undertaken at once, either
through the formation of an artificial anus above the point of obstruc-
tion or by the removal of the obstructing cause. In order for this to
prove successful, the diagnosis and operation nmst be done early in the
obstruction. A close study of the symptoms is therefore of paramount
importance.

Thus far we have discussed those features common to both the acute
and chronic forms of constipation. In the consideration of symptoms
and treatment we must separate the two.

Acnte Constipation. — Acute constipation is a temporary interruption
of the normal activity of the bowels usually produced by functional
rather than mechanical causes. It occurs in the course of acute con-
stitutional and infectious diseases, or during periods of excitement, great
mental strain, changes in business or environment, and in travel where
the conveniences are poor, and the diet, water, and habits of life are
irregular and changeable.

Symptoms. — In a few cases the omission of a stool causes a certain
amount of inconvenience, but in the large majority an interruption of
one, two, or three days may take place without any serious disturbances.
The symptoms, when any are aroused by such an omission, consist in

644 THE ANUS, RECTUM, AND PELVIC COLON

slight heaviness about the sacrum, heat and fulness in the rectum or
pelvis, and more or less hebetude. When the bowels move after the
interruption, the mass may be perfectly normal or it may be hard and
lumpy, requiring effort to pass it; the quantity expelled is ordinarily
much larger than normal, and frequently the first stool is followed by
two or three smaller ones before the sigmoid and rectum are emptied.
The feeling of fulness and tenderness in the rectum and anus may re-
main for some time after the first movement, and an examination at this
time will demonstrate a congestion of the haimorrhoidal veins and an
oedematous condition of the muco-cutaneous tissue around the anus.
All of these symptoms may disappear spontaneously, or it may be neces-
sary to flush the colon and have recourse to purgative medicines before
they are relieved. Elevation of temperature and accelerated pulse-rate
are frequently but not invariably present in acute constipation. There
may be tenesmus or violent paroxysms of pain, and occasionally symp-
toms of obstruction, but these symptoms are rare except in cases with
organic obstructions. Volvulus or intussusception may also produce
them. In simple acute constipation they all subside, and the patient is
relieved as soon as a good faecal movement is obtained.

Habitual negligence of the calls of Nature and recurrent attacks
of acute constipation result in a decrease of sensibility and atony
or loss of expulsive power in the rectum which ends in the chronic
form.

Treatment. — When the condition develops suddenly and has only
lasted for a day or two in patients whose bowels have previously been
regular, it is ordinarily wise not to interfere too actively at first. Espe-
cially is this true where mental absorption or changes in habits or
environment account for the condition; such cases almost invariably
right themselves. But when there are symptoms like headache, sleepiness,
tympanites, pain in the back, in the inguinal regions, or about the anus,
then it becomes necessary to move the bowels. If a simple enema does
not relieve the symptoms at once, a rectal and sigmoidal examination
should always be made to determine whether foreign bodies or me-
chanical obstructions are present. When it is simple constipation the
enema should be repeated, and after all the hardened faecal masses in
the rectum and sigmoid flexure are removed, some mild laxative may
be given in order to stimulate the peristaltic action of the small intestine
and upper colon, and thus empty them. There is nothing better in
these acute cases than minute doses of calomel, one-tenth to one-fourth
of a grain, with bicarbonate of soda in triturate tablets; the one-tenth-
grain tablets may be repeated every half hour, or the one-fourth-grain
every hour until the bowels have been moved. Neither should be con-
tinued longer than eight hours.

CONSTIPATION, OBSTIPATION, AND PiECAL IMPACTION 645

Another remedy which has acted well in such cases has been sulphate
of magnesia one ounce, and bicarbonate of soda one dram dissolved
in four ounces of water; a tablespoonful of this is given every half hour
until the bowels move.

Rochelle salts, citrate of magnesia, Seidlitz powders, phosphate of
soda, and the various saline waters may also be used, but the above simple
remedies will ordinarily effect just as good results as the most com-
plicated aperients. Where there is tenesmus, tympanites, pain, and
grij)ing, hot applications to the abdominal wall often give great relief;
and occasionally the constipation yields to a full dose of morphine ad-
ministered hypodermieally, thus indicating the spasmodic nature of the
condition. When a low enema is given by an ordinary syringe and fails
to produce a faecal movement, long rectal tubes (24 to 30 inches in
length) may be introduced, with the patient's hips elevated and his
shoulders lowered so as to allow large quantities of water to flow slowly
into the colon. In this way as much as 4, 6, or even 10 pints of water
may be introduced, and distressing symptoms are relieved either by the
loosening up of an impacted faecal mass, or possibly by the undoing
of a volvulus or intussusception. The syringe holding the water should
be elevated not more than 2 feet above tlie patient's body, so that the
fluid will run in very slowly. A little turpentine and milk of asafoetida
may be added to the injection, and they will materially aid in stimu-
lating peristalsis. In one case of acute constipation it was possible to
give immediate relief by the lifting up of a subinvoluted uterus which
had through a sudden jolt been carried do\^Tiward and backward, and
become impacted against the sacrum, thus occluding the rectum.
With a 8ims*s uterine repositor the organ was lifted into position, not
without some pain, however, and within a short time a full and free
action of the bowels resulted. Another case of this kind was relieved
by the evacuation of a large ha?matocele which developed in the pelvic
cavity and thus practically occluded the rectum. Large abscesses, either
of the ischio-rectal fossa? or the superior pelvi-rectal spaces, may occa-
sion acute constipation, which salines and other laxatives aggravate
rather than relieve. The evacuation of the abscess cavity results in
immediate relief. Acute inflammation and spasm of the bowels may
produce a tem})orar}' constipation, but ordinarily it is of very short
duration, and soon resolves itself into a diarrhoea. Morphine relieves
these cases. The slowly acting cathartics are not advisable in this
variety of constipation.

Chronic Constipation. — Chronic constipation consists in inade-
quate or abnormally infrequent faical passages, and prolonged retention
of tlie faecal materials in the intestinal canal. It occurs at all ages, in
every class, and is produced by a variety of causes, as has been shown.
35

546 THE ANUS, RECTUM, AND PELVIC COLON

Symptoms, — The typical symptoms of chronic constipation are grad-
ually increasing periods between the fa?cal movements, associated with
progressive hardening of the faecal mass, and decreasing desire to defe-
cate. In the beginning there are ordinarily no constitutional symp-
toms; the patient simply notices that his stools are smaller, harder,
drier, in lumps of various sizes, and generally of a dark-brown or green-
ish-black color. Later on he will observe, perhaps, that these masses are
coated with mucus, which may or may not be tinged with blood. Fre-
quently gelatinous masses of coagulated mucus will precede or follow
the faecal mass, and sometimes one will observe in such passages })arti-
cles of undigested food, like pieces of meat, fruit or vegetable material,
and foreign substances.

When this condition has existed for a greater or less period, symp-
toms of indigestion appear; there are flatulence, lack of appetite, coated
tongue, distention of the abdomen, and gaseous eructations. The tongue
is usually pale, flabby, furred with white in the middle, and indented
by the teeth at its edges; headache, drowsiness, and mental lethargy
gradually come on; the patient's rest is broken by bad dreams, and he
may gradually lose flesh and strength. Palpitation of the heart, dys-
pnoea, and occasionally vertigo and dizziness, accompany the condition.
There may be disturbances of vision, tinnitus aurium, cardialgia (Mel-
hose, Huf eland's J., 1841, Bd. xcii, S. 105), and various reflex symptoms,
as follows:

Uro-genital Symptoms, — Constipation is frequently the cause of
urinary disturbances through pressure of the fa»cal mass upon the ure-
ters, the neck of the bladder, or the prostatic uretlira; suppression of
urine is said to have been occasioned by it (Barnwell, Cincinnati Med.
News, 1875, p. 553). In chronic cases the urine is increased in quantity,
the color is darker, and the solid constituents are increased; it is often
loaded with urates, but oxaluria is one of the most constant features.
Occasionally cases are seen in which there is an excessive secretion of
urine with low specific gravity and clear limpid color. In these eases
there is no evidence of glycosuria, and it is reasonable to suppose tluit
the symptoms are purely reflex.

In young women constipation is frequently the cause of catamenial
disturbances, hysteria, and chlorosis. That which is often described as
chlorosis or anaemia is nothing more than auto-intoxication due to the
prolonged retention of fiecal material in the intestinal canal. Anteflex-
ion and painful menstruation (Thomas), together with chronic inflam-
mation of the uterus and its appendages, may all be caused by tlie pro-
tracted retention of fa?cal masses in the sigmoid and rectum.

Constitutional Effects, — Muscular rheumatism, stiffness of the joints,
and lack of tone in the general system sometimes result from ])r()l()nged

CONSTIPATION, OBSTIPATION, AND F^CAL IMPACTION 547

retention of faecal matter in the intestine. The hair and finger nails
become dry and brittle, the skin is sallow, covered with silvery, scaly
epithelium, or is often wrinkled and parchment-like. Sometimes there
is acne, prurigo, urticaria, or furunculosis.

Alterations in bodily temperature are not so frequently associated
with chronic as with acute constipation; there are persons who, upon
the omission of one day's faecal movement, will develop an elevation
of bodily temperature of 3 or 4 degrees, and children, from no other
apparent cause than accumulation of fajces in the intestinal canal, will
have temperatures of 104° to 106° Fahr.

(leneral i)ractitioner8 have frequently observed the fact that in
the course of continued fevers the temperature will be elevated when
the bowels have not been moved for two or three days, and it is a
constant experience in hospitals that the temperature of surgical cases
will gradually rise after operative procedures until the bowels have
been moved, when it will drop to normal, and remain so during the
whole course of convalescence. Johnston (Lancet, London, 1879, vol. ii,
}). 221)) has recorded a case in which there was a temperature of 104.0°,
pulse 180, and a delirium due to accumulated faeces in the intestinal
tract. Barnes (Med. Press and Circular, 1879, p. 477), Cabot and
Warren (Boston Med. and Surg. Jour., 1880, p. 1571) have also re-
])orted cases in which there was great elevation of temperature due to
fivcal accumulations. The explanation of this phenomena lies in some
influence upon the heat center through auto-intoxication or irritation
of the mucous meml)rane.

Xerrous and Mental Sympiorns. — In children, either acute or chronic
constipation may result in severe nervous phenomena, such as St.
Vitus's dance, epilepsy, and convulsions. In nervous and mental dis-
eases of adults, chronic constipation is one of the most frequent com-
plications. In hypochondria and melancholia it is almost always pres-
ent, and may act as an exciting cause through the depressing effect
of the accumulated fa'cal material, the auto-intoxication from its putre-
faction, and also through the overestimation upon the part of the
individual of the necessity of dailv faecal movements. As has been
said, this " daily movement " becomes the subject of unceasing thought
and anxiety. Pulitzer (Wien. med. Presse, 1866, S. 439) and Du-
jardin-Beaumetz (Hull, de therapeut., Paris, 1875, p. 179) have called
attention to serious hallucinations and loss of consciousness in indi-
viduals suffering from constipation. Mattel (Bull, de Tacad. de med.,
vol. XXX, p. 870) has reported a case of aphasia due to constipation
and faecal accumulation. Every alienist has probably seen cases of
temporary mental derangement associated with faecal retention. The
following interesting instance of this occurred in the au thorns practice:

548 THE ANUS, RECTUM, AND PELVIC COLON

Mr. A. T., lawyer, patient of Dr. Frederick Peterson, had been suffering from
delusions, hallucinations, and partial unconsciousness for several weeks without
any apparent cerebral disease to account for the same. His attack had begun in i
diarrhoea with severe pains and tenesmus, which continued more or less persist-
ently except when he was under the influence of opiates. This pain was at first
referred to the lower portion of the abdomen and to the rectum. An examination
with the pneumatic proctoscope established the presence of an impacted fecal mass
in the sigmoid flexure, together with a small ulceration at the juncture of the
rectum with the sigmoid. The f»cal mass was loosened and removed by the use
of solutions of ox-gall and oil, together with pneumatic distention of the bowel
Within a few days the patient *s mental condition cleared up and he became per-
fectly rational.

Such conditions are doubtless due to an alteration of the blood
resulting from the absorption of gases and putrefactive materials from
tlie intestine. Vostch, quoted })y Johnston (Pepper's System of Medi-
cine, vol. ii, p. 647), has reported 10 cases of suicide in which there
were displacements of the colon and evidences of chronic constipa-
tion. He also quotes Ijaudenl)erger of Stuttgart, who observed that
in 94 autopsies of insane individuals, one-seventh suffered from con-
stipation and displacements of the transverse colon.

Treatment. — The treatment of any individual case of constipation
will depend upon its cause. In children it is ordinarily due to malforma-
tion, imnatural diet, or some local disease of the rectum and anus, the
pain of which causes them to avoid having movements. Malformations
usually will manifest themselves in the first few days of infant life,
and sliould be remedied in accordance with the methods before described
(see chapter on Malformations).

Every accoucheur when he delivers a child should make it a practice
to introduce his finger into the infant's anus, and determine whether
the connection between it and the rectum has been perfectly estab-
lished or not. It does the child no harm to dilate the sphincter slightly
at this time; it stimulates the respirations, gives vent to the accumu-
lated meconium, and also relieves the physician of any responsibil-
ity as to future accidents through the possible malformation of these
parts.

In breast-fed children there will be less danger of constipation than
in those brought up by the bottle. In these days of modified milk
and artificial foods, it is presumed that the mother's milk is absolutely
duplicated. There is a difference, however, between normal breast
milk and chemically prepared reproductions of the same, which science
has been unable to solve, and while many infants are raised to a strong
and healthy childhood upon cow's milk and its modifications, it is very
frequently found more than difficult to regulate their bowels and pre-
vent constipation and diarrhoea under this regimen.

CONSTIPATION, OBSTIPATION, AND P^CAL IMPACTION 549

In many books on paediatrics it is taught that the mother should
place the child upon a vessel at a certain hour every day in order to
establish the habit of faecal movements at certain periods. The estab-
lishment of such a habit is devoutly to be desired, but this method of
doing it is a most fruitful source of fissures, haemorrhoids, and pro-
lapsus of the rectum. If, in order to bring about a daily stool, it is
necessary to stimulate the mucous membrane of the intestine, it is
better to give the child a small enema of cold water at a certain hour
every day. Ordinarily in bottle-fed infants the constipation is due
to a lack of sugar in the food; this may be relieved by adding certain
quantities of sugar of milk to it. Sometimes a lack of oil or richness
in the milk will occasion it; in such cases an increase in the cream
will frequently overcome the constipation and regulate the child's
bowels. The addition of lime-water to milk for feeding children is
very likely to result in constipation. The prolonged use of bismuth
and such salts in the treatment of summer diarrhoea is also likely to
develop it, and should always be followed by a laxative in order to
clean these substances out of the intestinal canal after the diarrhoea
is under control.

The use of castile-soap bougies or cones often stimulates a child's
bowels to movement in cases with a tendency toward constipation, and
if they are carefully introduced no harm is likely to follow; in fact,
they are among the best remedies. After children have begun to eat
solid food, the regulation of their diet is ordinarily all that is neces-
sary to overcome the condition. The modern refinement of foods has
a tendency toward the production of constipation in that it removes
all the indigestible and rough portions, thus taking away one of the
chief elements in the stimulation of peristaltic action in the bowels.
Feeding upon white bread, prej)ared starch, predigested foods, arrow-
root, and such substances as have no indigestible material is a most
proliGc cause of constipation in children from one to seven years of
age. Oatmeal and cracked wheat in moderate quantities, together with
a little sugar and milk, are most excellent foods for children, in that
they furnish an adequate amount of roughness to stimulate the bowels
to normal action. Fruits are useful, but they have too great a tend-
ency to produce fermentation, and consequently diarrhoea. After the
age of three to four years a diet containing a reasonable amount of
waste, cold baths, massage to the abdomen, and outdoor exercise are
the best methods of avoiding or treating constipation. There is noth-
ing like a ])risk run in the fresh air, with full, deep respirations and
chest movements, to induce a normal aption of the bowels. Cold baths
are also very stimulating to peristaltic action; at the same time that
the bath is given thorough rubbing and massage of the abdominal walls.

650 THE ANUS, RECTUM, AND PELVIC COLON

especially in the line of the colon, upward upon the right side, trans-
versely, and then downward upon the left, will be found beneficial.

The habitual use of drugs in constipated children should be avoided.
Occasional doses of calomel, rhubarb and soda, or glycerin and phos-
phate of soda act as useful bridges, but they should not be used too
often. Castor-oil, while an excellent remedy in diarrhoea, cleaning
out the bowel, and serving as a sedative to the mucous membrane,
always leaves a tendency to constipation behind it in whatever form
it is administered. Sulphate of magnesia acts just as well and does
not leave this tendency. The stronger cathartics should not be admin-
istered to children.

Constipation in school-girls is a question of the utmost im})ortance.
The little attention given to the regularity of the bowels in girls in
boarding-schools calls for the severest criticism. The rules and regu-
lations of the recitation-room are important, but they are not para-
mount to the proper functional action of the patient's bowels. If
teachers only realized that the call for a natural movement if resisted
passes over and does not recur again under ordinary circumstances for
considerable periods of time, and that any individual retaining faecal
materials for longer periods than normal begins to absorb the toxic
principles of those materials, and thus becomes heavy, sleepy, and
lethargic, they would understand the importance of granting excuses
from study or the recitation-room for such purposes at all times. No
person can do good brain work with an intestine full of old, decomposing
faecal matter. The large majority of cases of constipation in women
have been generated in school-rooms, boarding-schools, or through mock
modesty and the stringent regulations of polite society.

The proper location of the toilet-room is of more importance to a
family or school than the elegance of their parlors. This should be
so placed that neither weather, darkness, nor ])ublicity should ever
interfere with its use. The accommodations should also be adequate
for all necessities. One water-closet is entirely inadequate for a family
of five or six, and when one sees large boarding-houses or schools with
only two little dark water-closets one wonders how the inmates remain
as healthy as they do.

The tenements and public institutions of nearly all cities are
criminally negligent in these matters. In one institution with which
the author is connected he found upon beginning his service there one
toilet-seat for seven hundred men. They stood in long lines to await
their turn, many of them losing their desire before the opportunity
for relief came, and others were forced through the urgency of their
calls to use the buckets in their cells, thus fouling the atmosphere
of the entire hall. This is an exceptional instance, but the same con-

CONSTIPATION, OBSTIPATION, AND PJECAL IMPACTION 551

dition prevails only in a less degree in many institutions outside of
New York city. Its influence was exhibited in the large number of
rectal cases which had to be treated in the hospital of the institution
at that time.

In adult life the prevention and often the cure of constipation
may be accomplished by a change of personal habits. Lethargic in-
dividuals leading sedentary lives should be urged to take exercise in
the open air, and to avoid sitting too long in poorly ventilated rooms.
Those who are given to eating largely and to stinmlating their appe-
tites with wines, condiments, and a rich dietary, should be advised
to live more simply; a certain amount of fat with a meat diet should
always be taken; in vegetables the fibrous, indigestible material has
its uses, and should be eaten as well as the saccharine and starchy
portions. The eradication of those fibrous portions of the food often
results in such a decreased amount of refuse matter that an inadequate
faecal mass is formed; it is important that the food should contain a
sulHcient quantity of roughness to stimulate peristaltic action, and to
furnish a proper amount of faecal material for the intestine to act upon."

Alcoholic liquors, colTee in excess, and especially tea, should be
avoided in these cases, inasmuch as they all cause congestion of the
liver, with im])roper secretion of bile, and consequent constipation.

Attention to the functions of the skin is frequently of much benefit
in constipation. Cold baths, with shower or needle-baths to the abdo-
men, followed by vigorous rubbing, is often productive of great good.
The tem})erature of the water must vary, however, with individual cases.
Cold baths are depressing to some, and in such cases tepid water should
be used.

Stomachic indigestion is very frequently the precursor of constipa-
tion, and yet it is often the result of the same. At any rate the
digestive functions should always be looked into very thoroughly, and
properly regulated in every attem})t to cure a case of constipation.

With these general remarks one comes to the management of the
actual condition of deficient or retarded faecal movements. Assuming
that a patient's digestion is good, that he takes a sufficient quantity
of proper food, and yet passes an inadequate amount of faecal matter
and at too widely separated periods, the question arises. What is to
be done for him?

In the majority of eases the patients will have run the gamut of
cathartic medicines before the physician is consulted. The popular
and too often the professional treatment of constipation consists in
the administration of some drug, usually without any reference to the
cause. By referring to the section on Etiology one will see a very
large array of conditions which may produce constipation; they are

552 THE ANUS, EBCTUM, AND PELVIC COLON

functional and organic, chemical and mechanical. The food may be
improper in quantity or quality; peristalsis of the intestine may be
deficient through enervation, or it may be spasmodic; the secretions
of the intestine may be deficient, so that the mass is too dry to be
moved along the intestinal canal; the organs may be displaced; there
may be strictures, mucous folds, neoplasms, concretions, foreign bodies,
and a hundred other conditions either obstructing the fsecal passage
and delaying it, or giving rise to catarrhal diseases, ulcerations, or
other conditions of the bowel which limit functional activity, and thus
prevent the movements.

The treatment of chronic constipation therefore consists in the
treatment of the various conditions which cause it. By careful ex-
amination of the faeces one may learn whether the stomachic or intes-
tinal digestion is incomplete. For the treatment of these digestive
conditions the reader is referred to the works of Van Valzah and Nisbit,
Ewald, Nothnagel, and Hemmeter.

Where there are evidences that the constipation is due to impair-
ment of the intestinal, hepatic, or pancreatic secretions, drugs directed
to the alteration of these conditions are advisable. Minute doses of
calomel or protoiodide of mercury unquestionably stimulate the secre-
tions of the glands. At the same time one may administer some of
the modern aids to intestinal digestion, such as diastase, pancreatine
taka-diastase, peptenzyme, and lactopeptine.

Where there is evidence of fermentation and excessive flatulence,
some antiferment, such as bismuth, boric acid, salol, naphthol, or beta-
naphthol, may be combined with the pancreatin.

If the stools are hard and dry, thus indicating an insufficiency of
fluid, large drafts of water after and between meals should be ad-
vised. Occasionally this fluid may be administered before meals, es-
pecially if there is any evidence of excessive mucous secretion in the
stomach. Two or three tumblers of hot water before meals will some-
times succeed in overcoming a chronic constipation, in which the most
powerful laxatives of the pharmacopajia have failed. The fact that so
many patients are benefited by visits to watering resorts, where the
water itself has no particular medicinal value, is evidence enough that
it is lack of fluids in the system and regulation of habits that account
in a large measure for their constipation.

Where there is evidence of catarrhal conditions of the bowel and
intestine throughout, these should be treated according to the meth-
ods laid down in the chapter upon that subject. Change of climate,
regulation of diet, and outdoor exercise in moderation, are of the
utmost benefit in such cases as these. Where such changes are not
possible, exercise and regulation of the diet should be carried out at

CONSTIPATION, OBSTIPATION, AND F^CAL IMPACTION 553

home. If the stomachic digestion can not be made efficient, the food
should be predigested or the nitrogenous elements in the diet should
be reduced, and the patient put upon a carbohydrate diet. Where the
condition, however, is one of intestinal indigestion, as is the case in
the majority of instances, then the diet should consist largely of nitro-
genous elements, such as animal soups, broths, fresh meats, eggs, fish,
fowl, and oysters, with a sufficient quantity of green vegetables to pro-
duce an adequate faecal mass which will stimulate the colon to peri-
staltic action. The fresh vegetables should consist of spinach, aspara-
gus, kohlrabi, chicory, kale, onions, salsify, peas, cabbage, celery, string-
beans, etc. The best bread in these cases is that made of gluten flour;
but the crust of well-baked French bread, toasted bread, rye bread, or
bread made of Indian meal, are admissible in moderate quantities.
Potatoes, pastry, rich puddings, and confectionery should not be
allowed. Along with this diet the administration of a sufficient quan-
tity of glycerin to stimulate the intestinal glands to secretion, and
thus increase the fluid element of the faces, is often of great benefit.
Small doses of phosphate of soda also serve this purpose.

W. Gill Wylie says that in the majority of gynaecological patients
coming under his care, the constipation is due to a deficient amount
of fluid in the intestinal canal, and that he obtains the best results by
the administration of half an ounce each of castor-oil and glycerin be-
fore each meal, together with large drafts of water between meals; while
one would expect this treatment to produce a diarrhoea, after the first
few days it seems only to keep the stools soft and to continue com-
paratively normal actions. The one thing to be guarded against in
the method is that it should not be stopped too suddenly.

In cases in which the constipation is due to displacement of the
intestines or enteroptosis, the treatment is very difficult. The wearing
of an abdominal bandage, such as has been advised by Van Valzah, will
frequently accomplish a great deal of relief. Its use must be con-
tinued, however, for long periods, and the patient should be required
to eat very small quantities of food at any one time, and thus avoid
overloading the stomach and pressing it downward, for usually dis-
placement of the colon is due primarily to the displacement of this
organ. Displacement of the splenic flexure or of the descending colon
rarely if ever produces constipation, but that of the transverse colon
does. The question of opening the abdomen and suturing the trans-
verse colon back into position is one that has frequently suggested
itself, but the writer has never had an opportunity to put it into practice,
nor is he aware of any one who has operated for this purpose.

The influence of an acutely flexed, displaced, or adherent sigmoid
in the production of constipation has been fully discussed. As a natural

554: THE ANUS, RECTUM, AND PELVIC COLON

consequence, when this condition of affairs exists, the pelvic colon rarely
empties itself completely, and the patients all suffer more or less from
constipation, auto-intoxication, irritation of the gut, and frequent ulcer-
ation. Where the sigmoid flexure is normally movable and not con-
stricted, the sigmoidoscope should pass through the rectum and into it
without any great difficulty. In many cases of chronic constipation it
has been found to be almost impossible to introduce the tube on account
of acute flexures and adhesions; even after it has passed the constriction
of the flexure it can only be carried a short distance upward, because
the sigmoid can not be lifted up into the abdominal cavity and thus
straightened out.

In these cases the constipation is accompanied with flatulency, heavi-
ness in the limbs, and the patients are never completely relieved by
a movement. Some benefit is obtained for them by the passage of a soft
Wales bougie wliich is left in position for ten or fifteen minutes; the
elastic curvature of the instrument lifts the gut up, stretches the ad-
hesions, and partially straightens out the curvature. The same end may
be accomplished by pneumatic dilatation of the sigmoid, a method that
will be referred to later. These means often fail to give permanent
relief. Under such circumstances the patient should be advised to have
the adhesions broken up, and if necessary to have the pelvic colon
sewed to the abdominal wall so as to prevent a recurrence of the
condition. This operation, called colopexy, is described in the chapter
on Procidentia. The author has performed it fifteen times, and while
it has not always been done for simple constipation, u])on inquiry he
has learned that there has not been a single case in wliicli the move-
ment of the bowels was not free and comfortable after it. The pa-
tients in whom the operation was done for constipation alone have
all been perfectly relieved. One may say that opening the abdominal
cavity is not justified by the condition of constipation; but in these
days of aseptic surgery one does not hesitate to do this operation
for simple exploration, and it would seem to be justified as a
means of searching for the cause of constipation or of relieving
that cause when it has been discovered by other methods. In the
case in which the sigmoid was held down by the appendix, the patient
had not had a movement for years without pain and difficulty; she
had become accustomed to the use of all sorts of laxatives and cathartics
in large doses, and there was therefore a certain amount of atony and
insensibility of the intestinal walls which required some stimulation
in order to keep up the peristaltic action. Before the patient got out
of bed after the operation she was having regular stools daily upon
taking 3 drops of the fluid extract of cascara, and, at the present writing,
sixteen months later, she takes no laxatives whatever.

CONSTIPATION, OBSTIPATION, AND P^CAL IMPACTION 555

Insufflation of air into the sigmoid floxure will frequently lift it
out of the pelvis, especially if the patient be put in the knee-chest
posture, and the distention of the gut will often result in a free faecal
movement shortly thereafter. Not only is this the case, but it fre-
quently follows that the patient will have regular movements for two
or three days after the inflation.

The author had in his practice a woman who came to his office
twice a week on account of a most obstinate constipation; there was
no dryness of the faecal mass, and the quantity seemed to be compara-
tively normal, but the sigmoid flexure was always bent down
in the pelvis until it was inflated by pneumatic pressure
and thus lifted up. This treatment resulted in a movement
shortly afterward, and often on the two or three following
days. Two months' treatment in this way practically cured
her. In these cases the air is not allowed to escape through
the tube before the latter is withdrawn; in fact, it should
remain and the sigmoid be distended so that when the pa-
tient rises it will stay outside of the pelvic cavity and allow
the small intestines to fall down below it, thus keeping it
above and in a somewhat straight line with the rectum, by
which means the passjige of fa»cal matter into the latter organ
is facilitated. By flooding the sigmoid flexure with liquids,
such as saline solution, oil, oil and glycerin, boric-acid solu-
tions, and simple hot water, it may be made to rise upward
in the abdomen; such injections thus aid faecal movements
in a mechanical way as well as by local stimulation.

Where there is deficient peristaltic action of the intes-
tines, massage is one of our chief remedies; no method is as
satisfactory as that of rolling a heavy ball over the colon, Fio. 182.—
beginning at the ca?cum and carrying it upward and across ^
in the line of the transverse colon, and downward to the
sigmoid flexure. The patient should get a small cannon-ball weighing
3 or 4 pounds and cover it with chamois-skin, and use this as an
instrument of massage; balls of this size, however, have become very
scarce, and it is necessary to have them made to order. They can
be purchased from ^Ir. Judd, of this city, or they can be made at home
by pouring melted lead into a sand mold. An ordinary baseball will
do, except that it is not heavy enough to give the pressure necessary
upon the colon.

Electricity may be used in these cases; the positive electrode (Fig.
182) is introduced into the rectum, and the negative is applied along the
tract of the colon and sigmoid over the abdomen. No doubt some cases
have materially improved while the electric treatment was being carried

556 THE ANUS, RECTUM, AND PELVIC COLON

out, but it has been a question as to whether it was the massage pro-
duced by the rubbing, the irritation to the mucous membrane, or the
electricity itself which produced the benefit. A movement of the
bowels has not been caused immediately by the use of the electric
current, nor is any marked peristaltic action developed by its applica-
tion; at the same time in cases of obstinate constipation resulting from
deficient peristaltic action, and in atony of the intestinal walls, its
use is indicated.

In such cases strychnine, arsenic, phosphorus, phosphide of zinc,
and all the nerve tonics and stimulants which are at our command
should be made use of in turn. The massage, however, with the heavy,
covered ball has proved beneficial in more cases than any of these
remedies. In patients whose conditions do not permit of their taking
proper exercise, massage or mechanical movements have frequently
proved of great benefit; in old, stout, lethargic individuals they are
exceedingly useful. They are not " cure-alls,'' however, as some of
their advocates claim, and must be used in connection with proper
local and general treatment.

Ulceration and inflammation of the sigmoid and colon are spoken
of as causes of constipation, though it is likely that they much more
frequently produce diarrhoea. When the ulceration can be seen through
the sigmoidoscope, it should be treated locally by such remedies as have
been advised in the chapter upon that subject.

Thus far we have considered the treatment of constipation when
caused by conditions in the intestinal tract above the rectum proper.
Within this organ various conditions may cause it, such as fissure,
stricture, foreign bodies, fistula, neoplasms, etc. It is not necessary
to reiterate the principles of diagnosis and treatment of these dis-
orders in this place. There are a few conditions, however, which
demand special mention.

Spasm of the Sphincter, — Mathews (Diseases of the Rectum, p. 55)
holds that the large majority of the cases of constipation are due to
hypertrophy and spasm of the external sphincter. Admitting that
this may offer an obstruction to faecal passages, one must give some
account of the cause of such hypertrophy and spasm. The sphincter
muscle is not continuously in a state of spasm, such as can not be over-
come by the inhibitory power, unless there is some inflammation or
irritation present. WTienever this has been relieved, notwithstanding
it may leave the sphincter in a hypertrophied condition, the constant
spasm ceases. The nerves, however, may be left in such a sensitive
state that the pressure of the fiecal mass will occasion spasmodic action
of the muscle and thus prevent faecal passages.

The true cause of constipation then is not in the muscle itself

CONSTIPATION, OBSTIPATION, AND F^CAL IMPACTION 557

but in the inflammation or the sensitive nerve condition. The fact
that the stretching of the sphincter often relieves constipation is proof
enough that it is not due to the spasm, for we know that a sphincter,
however thoroughly it is stretched, if it is not ruptured, will resume
its tone and spasmodic contraction within a few days; stretching it
can not possibly reduce the hypertrophy, inasmuch as it is only put
at rest for a short time and a hyperaemia is induced, thus giving a
greater blood supply and all the elements for increase instead of
atrophy. At the same time it often does cure obscure fissures and
minor anal ulcerations through the temporary rest which it gives to
the parts, and along with these the constipation disappears. They
are the causes of the constipation and not the spasm of the sphincter.
There are cases in which there is abnormal contraction and fibrous
degeneration of the external sphincter muscle occasioning constipa-
tion, but when such is the case the condition is practically one of
stricture.

In all cases of constipation with this contracted type of sphincter,
either gradual or forcible dilatation of the muscle should be prac-
tised; at the same time one should not be too positive in his prognosis
as to the result upon the constipation. Where a fissure can be clearly
seen, and there is no other reason for the constipation, incision is
preferable to stretching, the relief is more permanent and far more
certain, and the operation can be done under cocaine without general
anaesthesia.

Hcpmorrhoids. — As a rule, haemorrhoids are the result of constipa-
tion rather than its cause, and operations upon them for the relief
of this condition are very likely to result in disappointment. A large
mass of inflamed or hypertrophied haemorrhoids may obstruct the pas-
sage of hard faecal masses and thus intensify the constipation, but
they are rarely the exciting cause. In cases where such exist in con-
nection with constipation due to local conditions higher up in the
bowel, it is advisable to operate upon the haemorrhoids before under-
taking the treatment of the other condition; or at least if the latter
requires operative interference, it should be done at the same time.
But little can be promised a patient so far as the cure of constipation
is concerned by the operative treatment of haemorrhoids alone.

Houston^s Valves, — Many cases of constipation have recently been
reported as cured by incision of the valves of Houston. Martin, of
Cleveland, first introduced this operation under the name of Valvotomy,
His method is as follows: The patient is placed in the knee-chest posture
and a tubular speculum of 30 millimeters diameter is introduced up to
the projecting valve. The resistance of the valve is tested by the use
of the hook (Fig. 183) bent at an acute angle. If the hook holds in

55S

THE ANUS, RECTUM, AND PELVIC COLON

the valve whea dragged down upon, the latter is said to be abnorinal
and to require section.

The patient is prepared for operation by having the bowels thorough-
ly cleansed and washed with antiseptic solutions. The valve to be di-
vided is first fastened by the volsella forecps or long tenaculum; the
hook of the tenaculum is made to transfix the mucous membrane and
fibrous portion of the valve only (Fig. 183). The depth to which the
valve should be cut is determined by the point at which a uterine sound
curved to three-quarters of a circle is arrested when introduced nbove
the valvr ;ini1 imltr-1 downward- When thi^ i^; done- the point sit which
the pi-..!"' iv.-[^ uill I... ^funvn l,v ii IJ;.ii>l.rd .:riiiti,.iin'. und the di>liiiice

Fin, 198. — Truiiku Ebwstani

between tiiis and the free border nf the valve should be either meas-
ured, or the valve should be transfixed by a curved bistoury while the
probe is in position, somewhat nearer the free edge than the point
at which the probe presses. After having determined the point at
which the incision is to be made, the valve is fastened by two lenacula
upon either side of this point (Fig. 184). The knife (Fig. 185) used is
a special device of Dr. Martin. The transfixion ought to be made
when the valve is at right angles to the intestinal wall, end not when
it is drawn down. In order to avoid pulling the valve downward in
this procedure. Martin advises the use of proctoscopes of different
lengths, so that they will just reach the valve, naving made a

CONSTIPATION. OBSTIPATION'. AND F.ECAL IMPACTION 559

first ineisitin, which is very shallow, with the sharp-curved histoury, he
then lakes a scalpel (fastened upon a similar handle to that of the
bistoury) and carries his incision deeper. In hiw first paper he stated
that if hemorrhage occurri"!. Ijv nas in ihc hiibil <>! contrulling it hy
the application of
tcinporarj- el amps.
Later on, however,
he modified this by
using sutures which
bring the cut edges
of the mucous
membrane together.
He lias devised
some ingenious in-
struments for in-
troducing them,
but even with these
the operation seems
quite difficult. It
is questionable
whether the sutur-
ing does any good,
as prinmry union is
not likely to take
place, and Jlarlin
says that he ha-
never seen a Ikviu-
orrhage sufficient u,
cause him any gi'rii(
unensincsB.

The after-trcHl-
racnt he dcseribus
as follows: "Eieiy
day the wound
is inspected and
dressed according
to the nature of its requirements, ami after the iiret two or three days
the valve should be carefully subjected to divulsion or massage by tlie
moans of a coactor. Should there ensue a rectitis or a granulating
wound, it may be treated by the means of an atomizer, hy the use of
topic applications otherwise admin istere*!. or by lavage."

Pennington, after having had 1 case of peritonitis and another in
which there was a severe hEcmorrhage following the operation as above

560 THE ANUS, RECTUM, AND PELVIC COLON

described, devised the ingenious clip (Fig. ISO) which severs or cuts out
an elliptical piece from the free border of the rectal valve. This clip
is applied while the vaWe is in its normal position {Fig. 187), and hy its
gradual pressure causes a necrosis of the tissues, thus cutting through

the folds with-
^^^^^=^=^^^ ^^^^W out any danger

^=^=^^^^^^^»=a^B^^^^^ of haemorrhage,
and if the peri-
tonaeum should
Fi<i.;i9.T— Maktin's Knivkh. by any possibil-

ity be involved
in the valve, it

causes adhesions between the two layers and thus prevents perforation
and subsequent peritonitis. Gant has devised a modification of this clip
(Fig. 18S) which does not require a special instrument for introducing
it, but it is larger and more likely to irritate the rectum. This is a safer
and simpler method of operating than that originally devised by Martin,
and appears to accomplish exactly the same end (Figs. 189, 190).

Martin states that he has operated upon more than a hundred
cases by this method, and has absolutely cured the constipation in
almost every one, Pennington relates a similar experience, as do also
Cook, of Nashville, and Beach, of Pittsburg. Earle, of Baltimore,
Gant, of New York, and the author have employed their methods in
numerous cases, but have seen permanent improvement in very few
cases. Earle states that recently he has seen 2 cases in which the
operation seems to have effected a cure. The author has seen some
cases in which there were inilammatory and connective-tissue changes
in these folds, thus constituting crescontic stricture of the rectum;
these were incised with mnch benefit to the patients, but they suffered
more from diarrhoea than constipation. In some cases in which he oper-

Fio. 188.— Piksikotob's Cli

ated upon the valves there was an immediate increase of frequency in the
fiecal movements; in fact, they became too frequent, and the patient
suffered from more or less tormina and griping. As the operative
wound healed, however, these conditions disappeared and the old-time
constipation returned. In 1 case in which he operated by the Pen-

CONSTIPATION, OBSTIPATION, AND F.ECAL IMPACTION

561

nington t-lip, the movementB were accelerated from the very day that
the clip was put on. In fact during the whole period that the clip
was cutting throngh the valve the patient had from oiiu to three move-
ments each day. Now it must be observed that these movements
occurred before the clip had cut through and while the valve was still

intact. The obstruction to the faecal passages could not therefore
have been relieved, and we must look to some other influence to account
for their increase. This influence consists in the irritation of the intes-
tine produced by the incision in Martin's method and by the pressure
of the clip in Pennington's. This stimulation continues to act until
the ulcer is healed, and therefore no conclu-
sions can be drawn from this period.

If, as is advised by Martin, the patient's
diet and habits be regulated, if his environ-
ments and methods of life be changed so as
to be most conducive to the regular action ' 'c7,.^|^u Re'ctal VALvKa. '"
of the bowels, this increased activity may be

maintained, and the patient by establishing systematic habits with
regard to stool during this healing period will be relieved of his
constipation. But these methods will often relieve it without cut-
ting the valves. The passage of bougies, rectal tubes, and instruments
for the treatment and examination of the operative field, the introduc-
tion of ointments, sprays, and antiseptic washings, are all conducive
36

502

THE ANUS, HECTUM, AND PELVIC COLON

to the prcHliiction of piTistalsis and iiiovunienls of the bowels. The
author therefore believes that the benefits which have followed valvot-
oiny are due in many cases uiore to the after-treatment than to the
mere section of the valves.
The permanency of the
refill Its, however, depends
largely upon the mainte-
nance of the habits which
are established during tliia
period.

Medicinal Treatmrnt—lt
is quite the habit among au-
thors to devote long para-
graphs to condemning the
use of laxative medicines in
constipation, and immediate-
ly follow them with favorite
forniuks for pills, powders,
and mineral waters. The
fact remains that whatever
treatment is adopt efl it is
necessarj- occasionally to have recourse to these remedies. The danger
consists in relying upon them entirely and failing to treat the real
cause of constipation. A wise selection of these usefid remedies marks
the true clinician. One should study the condition of patients and
determine those forms of laxatives which seem indicated by the char-
acter of the stool and tlie general symptoms. Where the stools are
too dry and hard, together with free adiiiinistralion of wtiter. one may
give some saline, such as sulphate of magnewia,
sulphate of soda, cream of tartar, or phosphate
of soda. Common salt sometimes acts very
well. These remedies may be given in one full
dose before meals, or in small broken doses
during the day, in order to stimulateHhe a
tion of the intestinal glands. They miay also
be administered in the form of laxative waters,
sueli as Itubinat, Apenta, Hunyadi, Congress,
llathom. or Friedrichsball. Glycerin is an ex- Fio.ii>o.-HEc:T«LV*iTi*F-
ccllent remeily jn this tj^K' of constipation, Kisomn's Clip

and may be given in doses of from 1 to 4

drams three limes a day. When there is simple atony without
much mucus in the intesfinal canal, caseara sagrada is one of the
best laxatives; in fact, it is the most generally applicable of all of

lion of wtiter. one may

CONSTIPATION, OBSTIPATION, AND P^CAL IMPACTION 563

them. There are many preparations of this drug upon the market,
but only three of them need be given any serious consideration.
The confections and aromatic extracts are utterly unreliable. The
})o\vder, fluid extract, and cascarine may be relied upon. The fluid
extract is best given either pure or in malt preparations: maltine
and maltzyme, with cascara, 2 to 6 drams, at bedtime, or from 1
to 2 drams after each meal. The fluid extract is best administered
by dropping from 10 to 40 minims in a half tumbler of water and
allowing this to stand for about fifteen minutes; when the resinous
constituents of the extract settle to the bottom of the glass, the clear
part of the solution should be decanted off; this contains all the laxa-
tive elements of the drug, and is generally efficient in its action. The
powder is given in doses of 3 to G grains. The administration of
strychnine, nux vomica, and other nerve tonics is quite important along
with cascara in these cases. Confection of black pepper is a favorite
remedy with some of the English surgeons, especially Dr. Cripps. It
is very difficult to get it properly made in this country, and therefore
it is little used. FranckV *' grains de sante " are often very useful in
simj)le atonic constipation. Where there is sallowness of the skin and
jaundiced conjunctiva indicating congestion of the liver, the following
triturate tablets may be given:

I^ Calomel gr. J;

Podophyllin gr. ^^ ;

Bicarbonate of soda gr. 1.

Ft. tab. No. 1.

Sig.: Take after each meal.

One of the best combinations for a temporary laxative effect is that
known as Cathcart's pill. It consists of

IJ Kx. colocynth col gr. jss.;

Aloin gr. i;

Ex. belladonna, ) ...

„ . y aa gr. i.

hx. nuxis vomica, J

^li. et fiat pil. No. 1.

One or two may be given at bedtime.

Citrate of magnesia, licorice powder, phosphate of soda, and the
various })ro])rietary laxatives are all more useful for cleansing out
the bowel and treating diarrhoea than they are for constipation.

In old people, with hearty appetites, the old-fashioned Lady Webster
pill given after the evening meal will frequently give more satisfac-
tion than anv other remedv.

ft ft'

Where there is congestion of the rectum or pelvic organs, cold-

564 THE ANUS, RECTUM, AND PELVIC COLON

water enemata should be used instead of laxatives for moving the
bowels. The use of glycerin suppositories for this purpose is very
popular, but they will produce rectitis if continued for a long time.
The above remedies alternated one with the other are useful adjuvants
to the local and constitutional treatment of constipation, but they are
simply adjuvants or helps, and should never be relied upon exclusively.
Useful as all such remedies are, they should be employed only for
temporary relief while the actual cause of the constipation is being
removed.

Fscal Impaction. — This consists in an arrest of the facal mass
at some portion of the intestinal canal; it usually takes place at the
caecum, the sigmoid flexure, or in the ampulla of the rectum. It may
also occur in sacculi or diverticuli of the intestine.

The causes are similar to those of constipation. Catarrhal dis-
eases and dilatation of the colon very frequently produce it, as do
foreign bodies in the intestinal canal, such as fruit-pits, gra})e-seeds,
enteroliths, and cestodes. The fajcal mass is hard, sticky, and ordi-
narily contains excessive lime salts; it is made up of small, round
lumps compressed together by the muscular action of the bowels. In
those cases in which the impaction takes place at the caecum, it is
often assumed that the mass is arrested above the ca^cal valve in the
small intestine, but this is not frequently the case.

Symptoms. — The symptoms of impaction are ordinarily constipation
or the sudden cessation of faecal movements, followed in a short time
by griping, heaviness or weight in the region of the impaction, and a
tendency to diarrhoea, with frequent teasing, liquid stools, sometimes
containing small quantities of mucus and blood; with these, symptoms
of auto-intoxication occur in the form of furred tongue, bad breath,
torpor, and mental derangements, such as hallucination, delusions, and
even mania; indigestion, flatulence, and faecal vomiting may be caused
by this condition, although the last symptom is quite rare. The diar-
rhoea is produced by the irritation of the intestine by the arrested
mass.

Reference has been made to 2 cases of mental derangement due
to retention of faecal material in the intestine; and a case of epileptoid
convulsions has been seen by the author, apparently duo to the arrest
of a mass of plum-stones in a child's sigmoid flexure. Nervous de-
rangements following constipation, rapidly succeeded ])y a diarrhoea,
are always indicative of faecal impaction. In children one always sus-
pects cestodes; thus in a child eight years of age a mass of him])ricoid
worms as large as the fist entirely obstructed the rectum (»xcept for
the passage of small amounts of fluid faeces around it. A frequent
inclination to go to stool with the passage of only wind or very small

CONSTIPATION, OBSTIPATION, AND FMCAL IMPACTION 565

quantities of fluid matter, aching in the left side, back, or pelvis, and
shooting down the left leg, constant spasm or pain about the anus, and
frequent or difficult urination, may all be occasioned by impacted
faeces. Where the impaction is in the sigmoid flexure or rectum the
diagnosis is comparatively easy, either by the aid of the finger or by
the sigmoidoscope, but when it is in the upper portions
of the colon this is sometimes very difficult, as it simu-
lates volvulus, intussusception, and intestinal neoplasms.

The length of time an impaction may exist is indefi-
nite; in 1 case it lasted from the end of May until the
middle of September. In another case in which the au-
thor was consulted in August, 1899, with regard to the
nature of a tumor about the size of a baseball in the right
iliac fossa, and supposed at the time to be a tumor of
* the ca?cum, the woman stated that the lump had been
there for over a year and had caused her little incon-
venience; her physician testified to the fact that it had
not apparently grown in three months; she suffered at
the time from tenesmus and frequent small fluid passages
which brought no relief. Under the use of large colon
flushings, with full doses of sweet-oil and glycerin, on
the fourth day the mass moved into the transverse colon,
and finally passed through the sigmoid and into the rectal
ampulla, where it was arrested. It was necessary to dilate
the sphincters to remove it. It was composed of faecal
and calcareous material, indurated, but smooth on its
surface, and weighed 1 pound and 3 ounces.

The diagnosis has been already discussed. In persons
with thin abdominal walls the doughy feeling of the mass
sometimes may be made out. Gersuny claims to be able
to distinguish it from neoplasms by the adherence of the
mucous membrane to the mass, but this seems incredible.
The acuteness of the attack combined with the general
symptoms above detailed are more reliable guides.

Treatment. — The treatment of impaction consists in
removing the impacted mass. Where it is low down in
the rectum and its passage is obstructed by spasm of
the sphincter, it may sometimes be necessary to stretch
this muscle and break up the mass by a scoop (Fig. 191) or by
Currier's forceps. The use of such instruments in the rectum
ordinarily results in more or less traumatism to the anus, and
occasions the patient considerable suffering afterward. It is better
before resorting to them to administer an enema of a half pint of

Fio. 191.— Kel-
bey's Rectal
Scoop.

566 THE ANUS, RECTUM, AND PELVIC COLON

warm water containing 2 drams of inspissated ox-gall and 1 dram
of glycerin; this should be retained as long as possible and repeated
four times within twenty-four hours; at the end of this time it will
usually be found that ordinary faecal impactions of the rectum will
have softened down so that the patient can pass them without assist-
ance. Where the impaction is in' the sigmoid flexure this same method
should be employed, except that the injection should be given through
a long Wales bougie and with the patient in the knee-chest . posture.

Drastic cathartics should never be given in impaction. While these
drugs increase the amount of fluid in the intestine and thus tend in
a certain way to soften the mass, the peristaltic action and spasm
which they produce are likely to result in traumatism of the walls of
the gut from pressure against the mass, and may sometimes occasion
rupture where the intestine is already thinned and inflamed. They may
also result in forcing a hard faecal mass into a narrowed or strictured
caliber of the gut, thus bringing on complete occlusion and all the
symptoms and consequences of obstruction.

After trying the injections for twenty-four hours, if the mass is
not softened and does not move, it is then wise to attempt its removal
by mechanical measures. When the im])action is in the rectum, it
is best to give the patient gas or chloroform and dilate the sphincters.
In many cases the mass will be passed spontaneously as soon as the
patient goes under the influence of the anaesthetic. Where the patient
is unwilling to take an anaesthetic it is best to introduce a bivalve
speculum into the rectum and through this try to break down the mass
by the use of forceps and scoop. The handle of an ordinary tablesjioon,
a dull uterine curette, and bullet forceps may take the place of Cur-
rier's forcei)s and the rectal scoop. In women the mass may be forced
out through the anus or held by two fingers introduced into the vagina
while it is being broken up.

When the impaction occurs in the sigmoid flexure it is almost
impossible to reach it with instruments. Here one must depend very
largely upon the use of enemas and massage. Impactions may be
dislodged by the use of the pneumatic proctoscope; twenty-four hours
after having injected glycerin and ox-gall the instrument is introduced
and the sigmoid flexure distended by air, thus lifting it up into the
pelvic cavity and dislodging the mass. This procedure has succeeded
in 3 obstinate cases, in one of which it was necessary to dilate the
sphincter before the hard mass could pass. Where sucli procedures
fail one would be justified in anaesthetizing the patient and introducing
his hand through the rectum and into the sigmoid flexure in order
to break up the mass and remove it; this should not be done, however,
by any one whose hand measures more than 7^ inches in circumference.

CONSTIPATION, OBSTIPATION, AND P^CAL IMPACTION 567

In all cases before dilating the sphincter or attempting to remove
tlie faecal mass by the introduction of the hand, a large injection of
warm sweet-oil should be given to lubricate the parts, and thus make
tlie mass move smoothly through the gut. Where the impaction occurs
above a stricture too much manipulation from below should be avoided,
as the gut may be very easily ruptured under such conditions. One
should not hesitate under these circumstances to perform an inguinal
colotomy, and in this way relieve the patient. If the stricture is a
benign one it may be treated afterward by dilatation or resection as
the surgeon may think best; but neither of these procedures should
be undertaken with a mass of impacted faeces arrested above the
stricture.

In all cases in which impaction has existed for any length of time
there will result a certain amount of inflammation of the mucous
membrane which should be carefully treated after the removal of the
impaction. Immediately following the removal, the colon should be
flushed with a large quantity of hot saline solution in order to wash
it out and also to stimulate the patient, as great exhaustion frequently
follows the removal of these masses. On the day following the bowels
should be moved by a saline laxative, after which they should be thor-
oughly irrigated with normal salt solution or some astringent, such as

•

fluid extract of krameria, hydrastis, or pinus canadensis. Mathews
advises the use of tincture of iron or tannin in solutions with glycerin
in such cases. The objection to glycerin is that it ordinarily produces
such a j)rompt movement of the bowels that the tannin does not have
the astringent effect which is desired. Strychnine and belladonna
should be administered to promote peristaltic action and overcome
the atony which the distention produces. As soon as the inflamed con-
dition of the parts permits, the patient should be required to take
regular exercise, such as horseback-riding, golf-playing, walking, etc.,
and his diet should be carefully arranged in order to prevent the
recurrence of impaction. It is not necessary to repeat the precautions
heretofore expressed with regard to the regular movements of the
bowels in patients who have once suffered from impaction.

CHAPTER XV
PRURITUS ANl

Pruritus ani is a symptom and not a disease. It is associated
with or caused by almost every known disease of the rectum and anus;
it is also produced in a reflex manner by affections of the uro-genital
organs and by certain constitutional conditions, such as gout, rheuma-
tism, and lithaemia. If, however, we consider it simply as a symptom
or complication of other affections, then logically it should be treated
of under those diseases, and the present chapter would not be written.
This, however, would cause confusion, for many still believe in a
pruritus ani essentialis — a disease without a pathology, an effect with-
out a cause.

There is, according to dermatologists, a variety of pruritus unas-
sociated with any pathological changes in the parts where the itching
is felt, and which is due to some central neurosis. This condition
is usually distributed over a large area of the body, although it may-
be limited to some distinct spot. It is often associated with neuras-
thenia, hysteria, and melancholia. The mind seems to have a dis-
tinct influence upon such cases, and they are frequently subjects of
delusions, in that they believe they find pediculi or irritating sub-
stances upon their bodies. Bronson describes this condition very
well, enumerating three forms of essential pruritus: pruritus seni-
lis, prurigo (of Hebra), and pruritus hiemalis. These forms of pru-
ritus, however, do not affect the anus. They attack the extremitiea
or the body itself, especially the thorax and abdomen. In classify-
ing pruritus ani, he says: " It is often due to irritations originating
from the rectum or regions high up, or possibly from a strictured
urethra, but it is much more apt to be associated with those general
conditions mentioned above. The appearance of the anus in this affec-
tion is characteristic. It has a whitish, sodden look that is usually
accompanied with a foul-smelling secretion. The folds are swollen
and the furrows deepened. Often the effect of scratoliing is to compli-
cate it with eczema. It is one of the most distressing forms of the
disease.*' This statement is in keeping with that of a large number
668

PRURITUS ANI 569

of dermatologists, surgeons, and writers upon rectal diseases. It will
be observed, however, that he describes pathological changes in the
appearance, structures, and secretions of the anus. Thus tacitly he
proves that there is an etiological agent for the itching in these condi-
tions. The very changes which he describes here as existing in cases
of pruritus essentialis are the products of established diseases of the
rectum and anus.

Allingham (loc, ciL, p. 249) insists upon pruritus always being due
to some pathological or functional cause. He does not limit it to some
simple local changes, conditions, or diseases about the margin of the
anus, but attributes it to constitutional and general conditions. It is
this latter class, in which no local affection or alteration of the parts
is observable, that has led the dermatologists and writers on this subject
to elaborate this doctrine of essential pruritus ani. Mathews takes
the stand that it is always a disease of local origin, and he explains
the fact that we fail sometimes to find alterations or accidents sufficient
to account for the symptoms upon the basis of reflex action, arguing
that the inferior haemorrhoidal nerves are distributed to the lower
inch (or more) of the mucous membrane of the rectum, as well as to»
the external surfaces around the anus; and that whatever irritates
these nerve-ends will also produce irritation and itching about the
anus. This asserts that those cases of pruritus in which no external
cause of the symptom can be found are due to some cause inside of
the sphincter and involving the lower inch of the rectum.

All of this is true, but there are still found cases in which no
disease can be located either in the anus or in the lower inch of the
rectum. Shall these instances be called pruritus ani essentialis? By
no means, because, as will be seen later on, there are several condi-
tions, both constitutional and local, which produce pruritus and yet
cause no pathological changes in the lower portion of the rectum or anus.
There is no such thing as pruritus ani essentialis, strictly understood;
but, on the contrary, every case of pruritus, however mild or severe, will
find a cause in some local or general functional or pathological change.

Pruritus ani is a condition characterized by many eccentricities.
To the student of rectal diseases it is simply a symptom referable
to sundry pathological conditions, but to the patient it means an agony
beside which pain would be a pleasure. Its marked feature is itching
about the anus, but this itching is different from that felt in any
other part of the body: it comes when at repose, it is not relieved by
scratching, and is out of all proportion to the changes in the parts.
It is also peculiar in that hyperaBsthetic, hysterical individuals rarely
suffer from it, and if they do they suffer less than phlegmatic, strong
individuals. Cases of dysaesthesia or hyposelaphesia, whose sensibility

570

THE ANUS, RECTUM, AND PELVIC COLON

to pain is below normal, are the greatest sufferers from pruritua ani.
It is also peculiar in that time docs not palliate it. The longer it lasts
the worse it gels.

Ckaracterislicx. — The characteristic feature of this iillection can be
described in one word — itching: remittent at times, but when it has
once begun, incessant, tormenting, tantalizing, distracting. Almost
every adjeelive in the Knglisli language expressive of irritation, dis-
comfort, and pain has been applied to this sensation. As to when
or how it begins, few patients can give any satisfactory account. They
all know tliat for ji long lime tliey have felt a sensation of uneasiness,
or rather a slight inclination to scratch about the anus; but they can
only (is the time when this sensation changed from that of senii-
jileasure to the maddening, unrelievable affliction which is termed
pruritus oni. In some the itching appears only at night after the
patient has retir<'d and becomes thoroughly warm in bed; in some it
occurs whenever they experience a sudden change from cold to heat;
in some the attacks are not influenced by cold or heat, by night or
day, but they are brought on by mental strain, overwork, and anxiety;
in some a change of diet or a
special article of food will cx-
' cite the most violent attacks; in
others removal from one cli-
mate to another, such as from
the seashore to the mountains,
or inland to the seashore, will
induce the affection. Under
whatever circumstances or from
whatever causes the condition
arises, it is never described as
anything else but an itching —
intolerable, painful, and mind-
racking.

After the condition has ex-
isted for some time, nervous
and physical )ilienomena begin
to appear as a resiilt of the irri-
tation and exhaustion due to
loss of rest and sleep. Fre-
quently the cart is put before the horse, and these conditions are
diagnosed as the predominant element in (be ease, ami assjgneii as
the cause of pruritus instead of rii-e rerm. Pruritus iuii is not a frequent
symptom of nervous exhaustion, but nervous exhaustion is a frequent
result of pruritus ani. Small scratcbos, denuded spots about the margin

PRURITUS ANI 571

of tlie anus, thickened and oedematous folds (Fig. 192), the disappear-
ance of the normal pavement epithelium about the margin of the anus,
a white and sodden appearance of the epidermis of this region associated
with a moist and foul-smelling secretion; or, on the other hand, a dry
and brittle condition of the mucous membrane, which cracks when it is
pulled apart or distended by large faecal masses, all of these conditions
have been described as symptoms of pruritus. They do exist with the
pruritus, but like it they are the symptoms and results of the same
pathological conditions.

Elioloffif. — The sources to which pruritus has been attributed are
without number. Almost every affliction to which the human flt^sh
is heir has been assigned as a cause of pruritus. Many of these are
witliout any foundation in fact, but have been lighted upon by searchers
for something to account for the itching with which their patients
suffered. The causes are external, internal, constitutional, and reflex.

Exlernal Causes. — Bv these one understands those affections or
diseases which are located upon and affect entirely the external anal
surfaces. Under this class may be enumerated j)ediculi, parasites,
eczema, dermatitis, herpes, and erythema. The forms of pediculi
which may affect the anus are the pediculi pubis and corporis; in fact,
neither of these very frequently locates itself about the anus. The
spores are not often found in this region, and the itching of the anus
which is associated with their presence upon the body is generally
refl('X. Xevertheless where they have been found upon the body and
an itching about the anus is complained of, one should carefully search
the parts for their presence, and whether they are found or not, use
those remedies which are known to destroy their spores, such as blue
ointment, fluid extract of larkspur, and solutions of mercuric chloride.

Of the visible parasites which cause itching about the anus, the
trichophyton is about the only one of any importance. This parasite,
which is tbe cause of eczema marginatum, is not infrequently found
upon the nates and about the anus. The fungus was discovered by
Hazin in 1854, and it is said to be identical with the parasite found
in tinea tonsurans and tinea sycosis. It is found in the superficial
layers of the epidermis, is said to be highly contagious, and may be
transmitted from animals to men. Some patients are very susceptible
to this disease, and when pruritus exists in men who have the care
of horses or cows, it is always well to take this condition into consid-
eration. The diagnosis is described in books on dermatology, b\it it may
be said that a microscopic examination will always disclose it if present;
a small scraping of the epidermis obtained from one of the little
hypernemic areas should be placed upon a slide, treated with diluted
liquor potassae, and then covered with a glass cover and subjected to

672 THE ANUS, RECTUM, AND PELVIC COLON

some pressure. The characteristic appearance of the fungus is that
it contains very numerous spores or rather mycelia. The spores exceed
the mycelia, and they are more numerous in the corneous layer and
around the bulbous roots of the hair. Failure to discover the mycelia
should not, however, be taken as a positive proof of their absence;
repeated negative examinations are necessary to be conclusive. When
they have been discovered the disease should be treated in the same
manner as elsewhere in the body. Sulphur in the form of an ointment,
or sodium hyposulphite (1 dram to the ounce), either as a lotion or in
the form of an ointment, will generally prove efficacious. Sulphuric
acid and chrysarobin ointment are also very effectual in inveterate
cases. Salicylic acid combined with ichthyol is also satisfactory.

True eczema of the erythematous form sometimes occurs about the
anus. One is very likely to mistake it for the erythema produced by
the local irritations of vaginal discharges, and harsh or irritating de-
tergent materials. This form of eczema is characterized by more or
less extensive red and whitish patches; there are no fissures, papules,
or pustules, but there may be some excoriated points and raw spots
due to scratching; it is an exceedingly rare affection of the anus, and
there is really no moans to make a positive diagnosis between it and
some other forms of true erythema due to such irritations as have
been mentioned above.

Herpes is another local affection which sometimes occurs about the
margin of the anus, and is said to produce pruritus, but it more fre-
quently produces actual pain than itching. When it exists, it is per-
fectly evident to the naked eye, and there is no difficulty in its diag-
nosis. Its treatment has been already described. It should be remem-
bered, however, that where herpes occurs upon the mu co-cutaneous
margins there is always reason to suspect malarial complications.

Local Causes, — Itching may be associated with or a symptom of
fissure, piles, fistula, ulceration, diseases of the crypts, foreign bodies,
constipation, catarrhal diseases, cestodes, neoplasms of the rectum,
gonorrhoea, and syphilis; but that aggravated cases of true pruritus
are ever due entirely to these causes is very doubtful. Fissures and
fistulas may be cured, haemorrhoids removed, ulcerations healed by
local applications, and yet the itching for which these operations were
done persists sometimes in a more aggravated form, so that one loses
faith in these conditions as causes of the symptom. It is only neces-
sary to say here that wherever these diseases exist in patients who
suffer from pruritus ani, they should be removed by operation or what-
ever treatment is necessary; but at the same time one should be exceed-
ingly guarded in promises to the patient with regard to the effect of
such proceeding upon the pruritus, as it may or may not be benefited.

PRURITUS ANI 573

Diseases of the crypts of Morgagni are frequently the source of
considerable irritation around the margin of the aiius. This irritation
may not amount to a pain, but cause more or less itching of a char-
acter distinct from that known as pruritus. It is made worse by
fajcal passages, and is not affected by heat or cold; neither does it
come on at night after the patient is comfortably covered and pre-
pared for sleep. Foreign bodies in the rectum, if they be small and
not cutting or pointed, may produce a certain amount of itching, but,
as will be §een in the chapter upon this subject, the symptoms occa-
sioned by these bodies are entirely different from those known as
pruritus. If, however, threadworms and lumbricoids are considered
as foreign bodies, an exception may be made to this rule; some of the
most exaggerated cases of pruritus ani are due to the presence of these
in the rectum. The diagnosis and methods of search for these little
parasites are described elsewhere, but no case of pruritus should ever
be prescribed for until they have been thoroughly eliminated as an
etiological factor. Constipation is considered by many authors as a
frequent cause of pruritus ani. Here, again, a symptom is discussed
as a disease; constipation, as generally understood, is not a disease in
itself, but a condition brought about by a variety of affections, and
it may be said to be frequently the result of the same class of patho-
logical conditions which produce pruritus; it is a complication but not
a cause of pruritus.

Tumors of the rectum may cause a certain amount of itching about
the anus, but, as a rule, they produce entirely different symptoms, such
as heaviness, weight, dull aching pain, and tenesmus. Catarrhal dis-
eases of the rectum and anus are among the most frequent ca\ises;
whether it be the atrophic or hypertrophic form, pruritus is one of
the commonest symptoms. The dry, brittle condition of the m\ico-
cutaneous membrane about the anus, described as a symptom of pru-
ritus ani, is nothing more or less than a part of atrophic catarrh of
the rectum and anus; and that moist, sodden, whitish condition seen
in chronic cases of this condition are the results of the hypertrophic
type.

Gonorrhcra of the rectum may be looked upon as a specific form of
catarrhal disease of the rectum. It is said to produce pruritus ani,
but in a number of cases of undoubted gonorrhoea of the rectum seen
by the author not one of them has suffered from any unusual itching,
much less the typical form of it, as considered in this chapter. Terti-
ary and hereditary syphilis may be the cause of pruritus, in that it
sometimes produces a condition similar to that caused by atrophic
catarrh, viz., a very brittle, dry mucous membrane, always easily torn
and becoming irritated upon the least provocation.

574 THE ANUS, RECTUM, AND PELVIC COLON

Constitutional Causes. — Digestive derangements, improper dietary,
rheumatism, gout, uricaemia, diabetes, and hepatitis may all be the
causes of pruritus ani. Many patients who are subject to periodical
attacks of pruritus ani go for weeks or months without suffering in
the least, when suddenly, after some derangement of the digestive
functions, especially the development of an acid or fermentative process
in the intestinal canal, the symptoms are lighted up and continue until
these functional conditions are readjusted.

Certain articles of food or drink, especially shell-fish, strawberries,
and highly seasoned condiments are all productive of attacks in indi-
viduals predisposed to pruritus ani. Overindulgence in the use of
tobacco may also produce it. In some persons any condition or indis-
cretion which causes a congestion of the liver is very likely to light
up an attack.

The constitutional conditions which produce pruritus ani most fre-
quently are rheumatism, gout, and uricaemia. The pathology and etiol-
ogy of gout are so obscure and little known that one hesitates to speak
positively concerning it, but undoubtedly it and pruritus are frequently
associated in the same individuals, and remedies which relieve the
attacks of gout also relieve the pruritus. Hheumatism and uriciemia,
if not identical, are intimately associated in the human economy; gas-
tro-intestinal fermentation is an important element in both. It is
often difficult to distinguish between the rheumatic and lithic-acid
diathesis. If any one will examine carefully a given number of patients
suffering from pruritus, he will elicit the fact that a large percentage
of them have suffered more or less from rheumatism or uricaemia; the
urine is nearly always extremely acid or loaded with urates, and the
itching is almost invariably exacerbated or relieved by an increase
or decrease of these phenomena. Excess in diet and drink, or any-
thing which produces an increase of uric acid in the system, or of
intestinal fermentation, is likely to bring on an attack of pruritus, and
when the constitutional condition has once been relieved the pruritus
just as promptly subsides. Sweet wines, champagne, pastry, and an
excess of carbohydrate foods will bring on attacks of congestion and
itching about the anus in individuals predisposed to uricaemia.

There is strong evidence in favor of the theory that muscular
rheumatism is produced by intestinal fermentation and excess of uric
acid in the system, and it is certain that cases predisposed to muscular
and subacute rheumatism are very frequently the victims of pruritus
ani. When they begin to suffer from vague muscular pains, it is always
a warning to them that the fires of pruritus are soon to be lighted
up, and just as soon as the rheumatic symptoms subside the others
are extinguished.

PEUBITDS ANI 575

Idiosyncrasies with regard to diet are always to be remembered in
studying eases of pruritus ani; in one case an attack was always caused
by drinking a cup of Java coffee, though the patient could indulge
reasonably in almost every other variety of this beverage. Another
was exempt from this disorder except during the strawberry season;
with him indulgence in this fruit was always paid for by an attack
of pruritus ani. Sea-food, salt meats, and certain fruits affect other
patients in the same maimer. These all act through disturbances
in the digestive tract, and thus prove the constitutional origin of
pruritus.

Reflex Cavses. — Urethral stricture or inflammation, phimosis, en-
larged prostate, stone in the bladder, pregnancy, uterine diseases, or
gall-stones may produce pruritus ani.

It is also caused by irritating discharges from the vagina, such
as leucorrhcea, gonorrhoea, and the watery secretions from malignant
disease. The condition also often follows the establishment of men-
struation or the menopause. One should, therefore, in searching for
the cause of pruritus, carefully eliminate all such affections before
coming to a conclusion in regard to the etiology of the condition.

Trentment. — In the whole range of medical science there is no
disease for which so many and various specifics have been recommended
as for this; there is hardly a drug in the whole materia medica, or a
procedure in the surgery of the rectum, that has not at some time
been advised and applied for the relief of this condition. The proof
of the real suffering produced by pruritus ani is confirmed by the
inconvenience and torture which these patients are willing to un-
dergo in order to be rid of it. It would require a volume to describe
the various nostrums, simple and complicated, which have been vaunted
as *^ sure reliefs for itching piles and pruritus.'^ As pruritus is not in
itself a disease, but only a symptom of some other pathological condi-
tion, the treatment will resolve itself into the management of that
condition, and efforts directed toward the relief of itching while the
pathological condition is being cured. If there be haemorrhoids,
fistula, fissure, condylomata, stricture, or other pathological con-
ditions about the anus which apparently demand operative inter-
ference, it should be undertaken at once, but always with a very
careful prognosis so far as the relief of pruritus is concerned. The
methods of procedure in such cases are fully described in their appro-
priate place and need not be repeated here. Where foreign bodies exist
in the rectum, whether they be organic or inorganic, their removal
will, of course, be necessary. The methods of treating intestinal para-
sites are described in books on general medicine, but one simple remedy
seems so often overlooked that the writer feels called upon to call

576 THE ANUS, RECTUM, AND PELVIC COLON

attention to it. Lime-water injected into the rectum and drunk freely
will invariably destroy threadworms in a very short time. From 4
to 6 ounces should be injected twice a day, and as much should be
drunk four or five times daily.

When evidences of reflex irritation are present, the attention of
the surgeon should be directed to the removal of their cause. Thorough
and persistent dilatation of the urethral strictures, the crushing or
removal of stone in the bladder, the radical and proper treatment of
uterine diseases, and the surgical treatment of gall-stones should all
be promptly and thoroughly carried out. It will often happen, how-
ever, that these procedures are insufficient to eradicate the pruritus
ani, and one will come back to the old conclusion that it is due more
to general conditions than to local or reflex irritations. As to rheu-
matic, uricaemic, and gouty cases, it is unnecessary to go into any
elaborate description of their treatment. Nitrogenous diet, composed
of meat, eggs, fish, leguminous and non-starchy vegetables, associated
with alkaline diuretics, such as lithia, citrate of potash, and benzoate
of soda, together with some form of salicylic compound, will compose
the general regimen. Some cases can not take salicylic acid or salicylate
of soda, and yet their stomachs bear salophen, salol, or salipyrine quite
well. In gouty and urica?mic diatheses piperazine acts remarkably well.

The habits and diet of these patients should be generally altered.
In those cases in which pruritus is associated with excessive energy,
athletic dissipation, or overwork, these habits should be suppressed
and a more quiet life enjoined. In phlegmatic individuals, where
there is a tendency to overeating, drinking, indulgence in tobacco
and other stimulants, such practices should be curtailed, and moderate,
regular exercise insisted upon. When the bowels are constipated they
should be properly regulated. If the stools are hard and lumpy,
enemata of oil should be given to prevent irritation and traumatism
of the margin of the anus. If possible, these patients should sleep
between two linen sheets, the bed-covering should be as light as is com-
patible with comfort, the room should be well ventilated and without
any artificial heat.

In those cases due to catarrhal conditions of the bowel, and the
number is large, the catarrh should be treated as indicated in the
chapter upon that subject. One thing, however, may be mentioned,
and that is the fact that the passage of a cold rectal tube through
the anus once or twice a day sometimes gives these patients the most
unexpected relief; whether this is brought about by dislodging some
small foreign body, or whether by a stimulating effect upon the cir-
culation about the anus, or by its reflex influence (as some have claimed
for the steel sound in urethral itching), it is impossible to say. AVliere

PRURITUS ANI 577

there is an excoriation of the mucous membrane inside of the sphincter,
the application of pure ichthyol, or sometimes a 10-per-cent solution
of argonin, will give rapid and effectual relief and hasten the restora-
tion of the parts to their normal condition.

In the pruritus of liver diseases pilocarpine in small doses some-
times acts almost as a specific; it should be given in triturate tablets
(«VT*(r grain) by the mouth.

Five grains of ichthyol three times a day is said to be very useful
in those cases due to the menopause, but the writer has had no experi-
ence with it. Bromide of soda has given better results than any other
remedy in the reflex types of pruritus. In the large majority of cases,
however, regulation of the bowels, nitrogenous diet, intestinal anti-
ferments, and some form of salicylates will comprise the general
treatment.

Local Treatment. — Local applications are the sheet-anchors during
the processes of removing the pathological conditions accountable for
pruritus; by them it is possible to relieve the patient's distress, quiet
the nervous condition, obtain the rest and sleep so necessary to the
restoration of general physical tone, and to retain his confidence during
a sometimes tedious and prolonged treatment necessary for the eradica-
tion of etiological factors. One of the several means of relief for
pruritus, and one which should be employed before any other applica-
tion is made, is hot water; the patient should be instructed to apply
to the anus sponges dipped in water as hot as he can bear for five
or ten minutes before retiring. If the itching recurs in the night, this
process should be repeated before making any other local application.
This will sometimes entirely relieve the symptoms and enable the
patient to obtain a comparatively comfortable night's rest. In the
majority of cases, however, something more will be necessary.

One of the simplest local applications is blackwash, which has
been used for many years as an application for pruritus, and by many
physicians is still considered the best and most reliable remedy. It
should be applied after bathing with hot water. Carbolic acid in some
combination is probably the most universally applicable of all drugs
for the relief of the itching; it may be applied in ointments, or solu-
tions in water of from 5 to 20 per cent. An excellent combination of
this drug with salicylic acid is:

IJ Ac. carbolici oij;

Ac. salicylici 5j;

(ilycerina? 5j.

M. sec. art.

Sig.: Apply to the parts by camelVhair brush or cotton swab after
bathing in hot water.
37

578 THE ANUS, RECTUM, AND PELVIC COLON

The solution should be perfectly clear. A milky cloudiness impairs
its usefulness, but a reddish tinge does not. It may be repeated sev-
eral times during the night, but it is very rare that two applications
will not secure a good night's rest, especially if the rectum is cleaned
out by a cold-water enema before retiring.

Mathews {loc, ciL, p. 499) recommends:

IJ Campho-phenique 5j;

Aquai dest 5j.

M. This should be applied as a lotion after the use of hot water,
repeating it frequently if necessary; this application is occasionally
very effectual but often disappointing.

Chloral hydrate in the strength of 10 to 30 grains to the ounce
of glycerin and water sometimes affords almost instant and prolonged
relief; and yet there are cases in which it makes the itching worse.
An ointment composed of ichthyol 10 parts, boric acid 5 parts, and
lanolin 85 parts will be found to act exceedingly well, especially in
those cases in which there is an erythematous or eczematous condition
about the margin of the anus. Diachylon ointment is also useful in
these cases. The following formula laid down by Adler in a recent
paper before the American Proctologic Society is an excellent combina-
tion and well worthy of a trial in obstinate cases:

IJ Fid. ext. hamamelis f5j;

Fid. ext. ergot f,^ij;

Fid. ext. hydrastis foj;

Comp. tine, benzoin f3ij;

Carbolized olive- or linseed-oil, ) «^.

Carbolic acid 5 per cent, j ^^'

Shake well before using.

Carson recommends 1 dram of powdered camphor to 1 ounce of
lard as a specific in pruritus ani, but experience with it has not been
favorable; sometimes the suffering was intensified rather than relieved.

Waugh commends very highly the following formula:

IJ Benzoini pulv 5j ;

Hydrarg. ammon 5ss.;

Lanolini ,^j.

Sig.: Apply twice a day, avoiding coffee, alcohol, and sweets.

In cases where there are fissure-like cracks in the mucous mem-
brane due to atrophic catarrh or specific affections, the following pre-
scription, recommended by Cripps (p. 278), has given great relief:

PRURITUS ANI 579

IJ Ex. conii 3j;

Oloi ricini 3j;

Lanolini 3j.

Nitrate of silver in solutions of from 2 to 25 per cent is often a
very useful application for the relief of itching. If applied too often,
however, it may produce inflammation or even sloughing of the super-
ficial skin. In a certain number of patients oily preparations, such as
ointments, seem to aggravate the symptoms; in such cases washes of
one kind or another may give relief. The following formula, recom-
mended by Allingham, is one of the best of these:

IJ Liq. carbonis detergens, ) -- f?-.

Wright's glycerina?, f ^^'

Pulv. zinci oxid., ) .. ,,.

., 1 . y aa 3iv;

C alamis prep., j

Pulv. sulphuri prep oss.;

Aqua) ad. fjvj.

Sig.: Paint over the parts once or twice a day.

■

Where there is much thickening of the perianal tissues the fol-
lowing is said to be very useful:

IJ Liq. potassa?, ]

01. cadini, V aa 5j»

Alcohol, j

Sig. : Rub into the parts once a day and follow it by a soothing oint-
ment, such as:

IJ Ung. zinci ox 5ii

Chloroform 3].

Sig.: Apply freely to the parts and allow the chloroform to evaporate
before covering with dressings.

Where there is a tendency to too great moisture about the anus,
some sort of desiccating yowder should be used during the day to
keep the parts dry and prevent chafing. Oxide of zinc and calomel
in equal parts, or aristol 10 parts with stearate of zinc 90 parts, are
very soothing and healing in this condition. Bismuth, boric acid,
resinol, calamine, and talcum pow^ders are also useful for this pur-
pose. The following formula is highly recommended:

IJ Listol 3ii;

Ac. borici 5j;

Talcum purificat 5i'

Sig.: Dust freely over the parts three or four times a day.

580 THE ANUS, RECTUM, AND PELVIC COLON

Where the parts are dry and fissured, as in eczematous or atrophic
catarrhal conditions, it is sometimes possible to obtain great relief by
painting them with flexible collodion. One per cent of ichthyol mixed
with this is advisable in cases where there is much thickening of the skin.

Ten grains of methylene blue in an ounce of collodion, or in aqueous
solution in obstinate cases, will be found very satisfactory. The aqueous
solution is preferable when there is much moisture about the parts.

In 2 cases in which the parts were irritated and tender orthoform
gave immediate relief.

With all these applications the parts should be protected from
rubbing on each other by pledgets of cotton or gauze. The fact is
that one is often compelled to run the whole gamut of local applica-
tions before the particular one is found which gives the individual
patient most relief. Every case of pruritus ani is a problem in itself,
and if by chance or good judgment the practitioner selects at his first
visit a remedy which will relieve his patient from the tormenting symp-
tom, he will have established his professional reputation in that quarter
at once and secured a faithful as well as grateful patron. There are
cases, however, reported by reliable authors, in which all these local
applications and constitutional treatments have been ineffectual to
relieve the intolerable itching.

Before the disease was treated upon a constitutional basis many
such cases were seen, and occasionally the most heroic measures were
employed for their relief. A strong galvanic current has been applied
to the parts, both through sponges and wire brushes, but it can not
be said that any radical relief was ever obtained by it. In one or two
instances the itching was relieved by the application of the actual
cautery at white heat.

Mathews, in a report to the American Proctologic Society, has
recounted some cases in which he had failed by all methods of local
application to relieve the symptoms, and finally resorted to the removal
of the superficial skin for about 1 inch around the anal margin. The
writer has done this operation once, not as a matter of necessity but
as an experiment for the relief of pruritus ani. Undoubtedly it relieved
the symptom, but the protracted healing of the parts, the suffering,
and the subsequent contraction of the anus indicated that the proce-
dure is only justifiable in the most desperate cases, and then only after
a thorough understanding by the patient of its nature and what it
entails.

One other method deserves to be mentioned, and tlint is deep and
persistent pressure upon the parts. Allinghani first discovered that
pressure over the anus would relieve the sensation of pruritus, and
advised the introduction of a specially formed plug into the anus at

PRURITUS ANI 581

bedtime, and keeping it there by a bandage throughout the night. This
has been tried with success at times, but the results have more fre-
quently been disappointing.

In conclusion it may be said that if catarrhal, constitutional, and
digestive diseases are recognized and treated as the causes of pruritus^
there will be little difficulty in the management of these cases. The
itching can be controlled in a large majority of cases by the applica-
tion of the carbolic and salicylic mixture, and although the conditions
which originate the pruritus may recur after having been once cured
and the pruritus with them, the same management and treatment will
effect their relief.

CHAPTER XVI

HEMORRHOIDS— PILES

Befobe the history of medicine began a knowledge of haemorrhoids
existed. In Egypt there were " pile doctors '' before Joseph was sold
into bondage. " The Lord will smite thee with the botch of Egypt,
and with the emerods " (Deut. xxviii, 27), is the threat of Moses against
an impatient and a rebellious people. " And he smote the men of the
city, both small and great, and they had emerods in their secret parts "
(I Sam. V, 9), " And he smote his enemies in the hinder parts: he
put them to a perpetual reproach " (Psa. Ixxviii, QQ), are quotations
from Holy Writ descriptive of the afflictions of the Philistines for
their desecration of the ark of God, and indicate the views of an-
tiquity concerninig a disease most prevalent among the civilized na-
tions of to-day.

The term hcemorrhoids, according to its derivation, signifies a flow
of blood, a hffimorrhage. It is not altogether appropriate in the sense
in which it is used, for frequently the disease exists without any bleed-
ing whatever. It has also been applied to various conditions. For
instance, we read of " urethral haemorrhoids/' which are simply papil-
lomas; " uterine haemorrhoids," a roughened and congested state of
the OS uteri resembling the mucous surface of an internal rectal haemor-
rhoid (Simpson); and "vesical haemorrhoids," a varicose condition of
the mucous membrane about the neck of the bladder. By common
consent, however, the word, when found in general literature and un-
qualified by any other term, means some hypertrophy or varicosity of
the vessels at the lower end of the rectum.

The term Piles, which means a swelling or tumor, and is always
applied to the rectum, is more correct. For some unknown reason
the latter has become a sort of vulgar expression, and is not frequently
employed at the present day, but in this work the two will be used
interchangeably.

Definition, — Haemorrhoids or piles are tumors chiefly composed of
dilated blood-vessels or blood-clots situated beneath the mucous mem-
brane or muco-cutaneous tissue of the anus or rectum. There may
582

HEMORRHOIDS— PILES 583

be constant or periodic bleeding or there may be none ;^ there may or
may not be pain, protrusion, and difficulty in defecation; the tumors
may be entirely outside of the rectum, they may be inside, or they
may be both inside and outside.

The cardinal features are, a dilatation of the veins, a swelling, and
an increase in the connective-tissue stroma by which the convoluted
vessels are supported.

ETIOLOGY

For a disease which has been known so long, studied so much,
and so thoroughly written about, it seems strange that no very defi-
nite and accepted theory as to its cause has been accepted. There
is scarcely a condition or disease that has not at one time or an-
other been said to produce it. Its causes are both predisposing and
exciting.

Predisposing Causes. — Age, — The disease is found at all ages. The
cases found in infancy are comparatively rare, and yet they are indis-
putable; Allingham has reported a case of venous piles in a child three
years of age. In the summer of 1892 the author exhibited at his
clinic two children, one two years of age with an inflammatory haemor-
rhoid, the other between two and three years having well-developed
internal venous haemorrhoids. More recently he has seen this con-
dition in a child six months old. Trunka reported 89 children below
the age of fifteen years who were affected with haemorrhoids; of these,
5 were less than one year of age.

At puberty and middle age haemorrhoids are very frequently mani-
fovsted. This is explained by the fact that the environments, habits,
and constitutional conditions at these ages are particularly inclined
to bring on engorgements of the hepatic system and of the pelvic
veins. The menstrual periods in women, the development and exer-
cise of the sexual organs in both men and women, the tendency to
overeating and to dissipation, child-bearing and childbirth, muscular
straining in exercise or labor, and the constitutional diseases which
are prone to attack at this period of life, all conduce to the formation
of haemorrhoids. This period of life, therefore, may be called a pre-
disposing cause.

As the patients grow older many of these influences disappear, but
the absorption of fat, relaxation of the muscles around the rectum,
constipation, hardening of the liver, and atheroma of the blood-vessels
contribute to the causation of the disease. For these reasons old
age may be considered a predisposing cause.

In women the menopause is looked upon as an etiological factor,
because a periodic loss of blood ceases and the haemorrhoidal flux some-

584 THE ANUS, RECTUM, AND PELVIC COLON

times appears as a sort of vicarious menstruation. The theory of
change of life, however, hardly sustains this doctrine.

Age, therefore, may be said to be a predisposing cause only insomuch
as it affects the patient's habits, environments, and physical conditionB.
The disease is most frequent in middle life, next in old age, and least
of all in children.

Sex.-^The majority of cases of haemorrhoids found in hospitals
and clinics is undoubtedly among males; the proportion is about seven
males to four females. This preponderance may be more apparent
than real, owing to the fact that women are more diffident about con-
sulting physicians for rectal troubles than men, and being accustomed
to the loss of blood at menstrual periods, do not attach so much
importance to it as do men.

There are some reasons why women should be more frequently
afflicted with haemorrhoids than men. The monthly congestion of the
pelvic organs, the pressure of displaced or pregnant uteri upon the
rectum, the traumatisms of childbirth, the frequency of fibroids and
ovarian tumors, and the habitual constipation in them, all tend to
cause dilatation and hypertrophy in the veins and produce haemor-
rhoidal disease. On the other hand, men are more given to muscular
and nervous strain; they more frequently indulge in overeating and
drinking; they are more often the victims of intemperance and excess-
ive venery, and from these causes, no doubt, the disease arises. Stric-
ture of the urethra and stone, which are more frequent in males, may
also predispose to the disease in this sex.

The causes which predispose women to haemorrhoids are somewhat
balanced by the monthly menstrual flow. This theory is borne out
by the fact that they suffer very much more frequently from haemor-
rhoids during periods of menstrual suspension, gestation, and after
the menopause, than at other times. Bodenhamer states that it is no
unusual thing to observe them at each recurring menstrual period,
both conditions coming on and subsiding together; and that he has
seen many cases in which the menses ceased for several months and
the patient had regular periodical bleeding from haemorrhoids during
this period. This compensating action between menstruation and
haemorrhoidal bleeding may account for the disparity between the two
sexes in this disease.

Occupations^ Habits, and Environments. — These have a strong pre-
disposing influence in the causation of haemorrhoids. The reason why
the disease is so rare among children is due to the fact that their
occupations and habits are regular and their diet is uniform; there is
no nervous or muscular strain, and therefore no cause for the haemor-
rhoidal condition except in rare instances.

HJEMOBBHOIDS— PILES 585

Those occupations which require severe muscular strain, heavy
lifting, constant standing or sitting in the erect posture, are very likely
to bring on the disease. Railroad and street-car conductors, truck-
men, laborers, and miners are frequently its victims. The desk-
worker is likely to become sedentary and phlegmatic; his duties con-
duce to constipation, and constant bending over crowds the abdominal
organs down upon the rectum, thus interfering with the circulation
and predisposing to haemorrhoids.

The habits, however, have much more to do with the production
of haemorrhoids than occupation. It is well known that the more
civilized nations become, the more frequently are they affected with
this disease. Sedentary habits, excessive eating, indulgence in stimu-
lants and the luxuries and comforts which are enjoyed by the higher
classes, all tend to the production of piles. The large amounts of
rich food and drink consumed by this class surcharge the hepatic cir-
culation, and sooner or later bring on a congestion of the haemorrhoidal
veins which ends in haemorrhoids. Good living, full diet, and moderate
drink are not necessarily productive of the disease, provided enough
active exercise is taken to use up the material absorbed. Frequently
patients live to a good old age amid luxuries, wealth, and self-indul-
gence, never experiencing any haemorrhoidal affection until they give
up business and begin to lead a sedentary life, when suddenly the
condition appears. The superfluous carbohydrates are not utilized,
they congest the liver, and through it the rectal veins.

It seems somewhat contradictory to these facts to find the disease
as frequently in thin, anaemic, temperate individuals as in the plethoric;
the explanation of this is that muscular and nervous exhaustion result
in general relaxation and dilatation of the venous system, and conse-
quently piles develop.

Heredity. — " That heredity predisposes to haemorrhoids is a fact
established beyond all doubt " (Bodenhamer). That successive genera-
tions of a family suffer from this disease is explained by the simi-
larity of environments, habits, and constitutional conditions. Their
diet, methods of life, and vocations are very much alike from one gen-
eration to another, and therefore they suffer from the same diseases.
While there seems to be some hereditary influence in the disease,
it is a heredity of predisposing causes more than of the disease itself;
if it were the latter, children would be frequently born with these
dilated veins and hypertrophies instead of developing them later
in life.

Temperament. — Patients suffering from hepatic diseases are often
the subjects of haemorrhoids. It is well known that melancholic,
choleric, sallow, depressed individuals generally suffer from some dis-

686 THE ANUS, RECTUM, AND PELVIC COLON

order of the liver. Teraperaraent is not the cause of piles, but the
same pathological condition which brings about one also causes the
other.

Climate and Seasons, — These have undoubtedly some influence in
the production of haemorrhoids. The disease is comparatively more
frequent in the very hot and cold than in the temperate zones. The
explanation of this lies in the fact that in hot climates the patient is
subject to congestion of the liver and malarial conditions, together
with a relaxation produced by heat and lack of exercise. In the cold
climates the people are active, subjected to muscular straining, and on
the move constantly to keep themselves warm; besides this, they use
alcohol and much external clothing to protect themselves from the rigor
of the weather; hence, the difficulties of removing the clothing and of
reaching convenient places for stool engenders a carelessness and
irregularity in this regard productive of haemorrhoidal disease. Here
again it is not so much the climate (hot or cold) as the habits of
the individual.

So also with the seasons. In the spring hemorrhoids are more likely
to develop than at other times, because the system can not consume
the amount of hydrocarbons in hot weather that it does in cold, and
when warm weather comes on suddenly the dietary habits can not he
adjusted, the portal circulation becomes congested, and hsemorrhoids
appear.

That haemorrhoidal disease is more marked and frequent in those
countries in which there are frequent and sudden changes in tempera-
ture is better explained by these facts than by the theory that the
blood is suddenly driven from the surface into the internal organs and
veins, thus causing piles. In the many cases in which cold packs have
been used for various conditions, not a single case has been reported
in which the sudden chilling of the surface has caused haemorrhoids;
if the sudden driving in of the surface blood would cause the disease
it certainly ought to be seen in these cases.

Anatomical Causes. — Man is the only animal in which this disease
is at all frequently found; occasionally dogs suffer from it, but it is usu-
ally in fat, lazy house dogs or very old ones that take no exercise, but
lie around, eat whenever opportunity offers, and are always constipated.

The one essential anatomical feature that distinguishes man from
other animals is the erect posture. He is always upright during the
larger portion of the twenty-four hours, and as the weight of the blood
column is proportionate to its height, and the cardiac force must be
sufficient to lift this weight, the distending force that is exercised
upon the veins can be realized. Valves in a vein relieve the disten-
tion to a certain extent by preventing backward pressure, but veins of

HwSMOBBHOIDS-PILES 587

the portal system have no valves; they are practically upright in all posi-
tions except when lying down^ and if one is sitting constantly and
leaning forward over the desk or sewing-machine^ the abdominal organs
are pressed downward and backward upon them, thus causing obstruc-
tion to the blood current.

The blood-vessels of the rectum puncture the walls of the gut about
3 inches above the anus^ passing through the muscular walls in little
buttonhole-like slits, and then divide into numerous branches which
are distributed to the lower end of the organ; Allingham claims that
these little slits serve the purpose of valves for the veins. Vemeuil,
on the other hand, claims that they act as obstructions to the venous
circulation, and whatever produces spasm or peristaltic action in the
muscles causes constriction of the veins, congestion, and haemorrhoidal
disease. The thickness of the arterial walls protects them from com-
pression, and thus the blood supply remains constant while its return
flow is obstructed. Verneuil's view is much more rational, because
in order to act as valves these muscles would have to be in a constant
state of tonic contraction, which we know is not the case. Moreover,
admitting for the moment that they do act as such, it is perfectly
clear that there would be but one valve between the liver and the
rectum, which would be very ineffectual. From these facts it appears
that the constant upright position of the human race, inducing thereby
a constant pressure from a blood column of 14 inches or more in height,
is the most plausible explanation of the prevalence of haemorrhoidal
disease among men. The weight of this column and the cardiac force
necessary to lift it, being constantly active, it is not at all surprising
that the thin-walled veins of the rectum are frequently varicosed.

The loose attachment of the mucous membrane of the rectum to
the muscular walls leaves cellular spaces between the two in which
the veins can be stretched in length and dilated in caliber, thus forming
the convolutions which go to make up a true ha?morrhoid.

Exciting Causes. — Constipation, — The passage of a solid faecal mass
along the intestinal canal distends it more or less, and thus squeezes
out the blood which is in its veins. In the sigmoid flexure and colon
the arterial and venous supply proceeds in a circular course around
the gut, anastomosing freely; faecal passages and peristaltic action here
simply empty the blood-vessels by forcing the blood out of the veins
in the proper direction; but in the rectum, where the blood-vessels
run up and down and are very superficial, the faecal mass sliding over
the mucous membrane presses upon and strips or milks them, as it
were, in the opposite direction to the venous current, thus not only
obstructing the circulation, but also by backward pressure producing
a mechanical strain upon the veins and the little blood pools in

588 THE ANUS, EBCTUM, AND PELVIC COLON

which they originate. TXiiB is probably the chief exciting cause of
the disease.

The increased amount of blood in the parts causes hypertrophy of
the connective tissues, new capillaries develop, and thus the hasmor-
rhoidal tumor is formed. After this has taken place, the distentioa
produced by straining, or the passage of the fsscal mass, causes rupture
of the thin vessel walls, and there results what is known as bleeding
piles. It is not traumatism or friction by the faecal mass, as a rule,
but distention which causes haemorrhage from piles. Not only does
constipation act in this mechanical manner, but it also produces a gen-
eral congestion of the rectum in which the haemorrhoidal vessels take
part. It necessitates straining at stool and resort to cathartics, the
habitual and injudicious use of which is frequently followed by the
development of piles. Especially is this true of the resinous drugs.

The old practice of attributing every disease to torpidity of the
liver and bowels, and beginning all treatment with a large dose of
calomel, salts and senna, gamboge, or aloes has frequently resulted in
attacks of haemorrhoids in patients who had no knowledge of their
previous existence. Warm injections are also productive of hemor-
rhoidal disease by causing an excessive flow of blood to the parts and
frequently failing to induce an active movement which would relieve
this.

Drugs. — In addition to the resinous cathartics other drugs are
known to be productive of haemorrhoids. Such substances as apiol,
cantharides, aloes and myrrh, and savin, all act by producing congestion
of the pelvic veins, more or less increased peristalsis, and consequent
distention of the haemorrhoidal vessels. Many haemorrhoidal fluxes,
called vicarious menstruation, are only the result of such drugs.

Diet. — Certain articles of food are active causes in haemorrhoidal
attacks. Substances which irritate the mucous membrane, excite peri-
stalsis, spasm of the sphincters, and bearing-down, are very likely to
induce them. Such articles as aromatic spices, peppers, mustard,
highly seasoned sauces, radishes, water-cress, tamales, and pickles will
frequently bring on or aggravate piles.

Bodenhamer claims that the habitual use of oatmeal is very effective
as an exciting cause, but the author is not able to confirm this state-
ment. Wines, malt or alcoholic liquors add largely to the mass of fluid
in the veins, produce congestion of the liver, and along with this a
similar condition in the rectal veins which results in haemorrhoids.
Tea, when used to excess, may produce haemorrhoids by its constipating
effects, but coffee very rarely does so.

Idiosyncrasies with regard to diet occasionally lead to the develop-
ment of ha?morrhoids from the simplest articles of food. What will

H^MOEEHOIDS— PILES 589

induce a haBmorrhoidal attack in one, hundreds of others may use with
impunity. As a rule, too many carbohydrates induce the disease, and
foods containing excessive amounts of refuse material do so through
the large hard stools which they produce. Such lines of diet, while
advantageous in certain conditions, are deleterious in patients predis-
posed to hemorrhoidal disease.

Strain. — Thrombotic haemorrhoids are nearly always the result of
muscular strain. They may occur from lifting heavy weights, from
a misstep or fall with efforts to recover one's balance, from bicycling,
dancing, sweeping, or various forms of muscular strain. All efforts
that require forcible action of the abdominal muscles are associated
with action of the pelvic and anal ones in order to counteract the
downward pressure of the intestines in the pelvis. This muscular strain
from above and below causes pressure upon and distention of the
Tcssels of the rectum, and may cause their dilatation or rupture. In
the latter case blood is poured out into the cellular tissues, where it
finally clots and forms a thrombotic hsemorrhoid.

Straining or long sitting at stool are very frequent causes of the
disease among city people where the toilet-rooms are luxurious. Men
who take their pipes and morning papers to the closet with them,
acquire the habit of sitting there and straining in a position in which
all support is removed from the veins. This habit persisted in from
day to day unquestionably brings on varicose external haemorrhoids,
and has more or less influence in the production of the internal variety.
The same effect is produced by habitually sitting upon a rubber ring.
The buttocks are pulled apart, the anus drops do\\Ti, there is no ex-
ternal support from the folds of the buttocks or from pressure upon
the seat, the veins consequently become distended, and haemorrhoids
ensue.

Clothing. — Constrictions about the waist, especially tight bands for
supporting the trousers, or undue lacing, the wearing of heavy skirts
supported by the hips, all have their effect in aggravating, if not in pro-
ducing, haemorrhoidal disease.

External. Causes. — Whatever causes congestion about the rectum or
anus may act as an exciting cause of haemorrhoidal disease. Wounds,
injuries or contusions, the use of rough and irritating detergent sub-
stances, such as newspaper, corn-cobs, etc., the presence of foreign
bodies, threadworms, and other larvae inside the anus, or pediculi and
parasites upon the external surface, may all produce the disease.

Other Diseases. — Haemorrhoids may be a complication or the result
of other pathological conditions in the rectum or intestines. Ulcera-
tion or stricture of the intestine or urethra may result in this disease,
either through the congestion which it produces or the straining neces-

590 THE ANUS, RECTUM, AND PELVIC COLON

sary for micturition or defecation. With regard to stricture of the
rectum as a cause of haemorrhoids, the fact may be recalled that the
most usual site for strictures is just about the point where the arteries
and veins penetrate the muscular wall of the gut; any inflammatory
condition about this region results in a constriction, due first to spasm
of the muscles, and secondly to the deposit of lymph and fibrous tissue
which obstructs the circulation. Such obstruction always affects the
veins more than the arteries, because the walls of the latter are stiffer
and do not yield so readily to the pressure; in the veins there is no
constant pulsation to prevent the constriction, but simply a steady,
gentle flow, and little by little they become encroached upon until they
may be almost occluded by the same processes which the artery has
been able to resist. Thus, the vein being constricted and the artery
still pouring blood into the ha?morrhoidal area, the force finally falls
upon the venous walls, causing distention, hypertrophy, and devel-
opment of haemorrhoidal tumors. Generally, however, in strictures
of the rectum the haemorrhoidal complication is a matter of such small
moment compared with the etiological cause that little attention is
paid to it; this is a proper view of the situation, because the cure of
haemorrhoids would be of no benefit to the patient if a progressive stric-
ture is left to take its course.

Other uterine and genito-urinary diseases, such as retroversion,
anteversion, procidentia, cystitis, prostatitis, urethritis, etc., may bring
on attacks of piles, but the latter generally subside as soon as the
cause is removed.

Diseases of the heart, liver, and kidneys must also be taken into
account in a study of the causes of haemorrhoids. Valvular insufficiency
of the right side of the heart no doubt has some influence in producing
piles through the backward pressure and congestion which it causes
in the liver, and feeble cardiac action induces them through sheer
lack of force to drive the stagnating blood through the vessels.

Congestion or cirrhosis of the liver by obstruction to the portal
circulation increases backward pressure in the haemorrhoidal veins,
causing their distention and the development of haemorrhoids. In this
class of cases haemorrhage from the tumors is very frequent and no
doubt often salutary. Where the liver is surcharged with blood, some
overflow is beneficial, and these bleedings act as spontaneous venesec-
tions. Those who suffer from hepatic disease and haemorrhoids often
feel buoyant and comfortable after a marked haemorrhoidal flux, and
when this does not occur every three or four days they become morose,
depressed, and suffer from digestive troubles; some patients of this
kind, in whom operations have checked the haemorrhages, grow worse,
develop anasarca, and die very soon. Some of the older surgeons, ob-

H^MOERHOIDS— PILES 591

serving this, suggested methods for the reestablishment of the haemor-
rhoidal flow. It is wise, therefore, in these conditions to allow the
periodic bleedings to continue so long as they do not immediately en-
danger life, and confine ourselves in treatment to those methods which
prevent inflammation and avoid strangulation.

In acute congestion of the kidneys and lungs haemorrhoids and
haemorrhage therefrom may occur. If a sufficient quantity of blood
were lost in the incipiency of these diseases, it might be of some
temporary advantage to the patient, or even abort the disease, but
after this time any loss of the vital fluid is a serious complication.
The occurrence of piles is easily explained in lung affections, but
between them and diseases of the kidneys it is difficult to make out
any etiological relationship.

Certain diseases of the spinal cord appear to have some causative
influence in the production of haemorrhoids. They are likely to occur
in patients who suffer from lateral and posterior sclerosis and who
are markedly constipated. Peristaltic action is almost always deficient,
and the accumulation of faecal masses in the bowels and rectum is a
very constant accompaniment of the spinal disease. It may be in this
indirect method, or through their influence upon the walls of the
vessels, that these diseases act, but in some way they certainly appear
to have an etiological influence in the production of haemorrhoidal
diseases.

In acute catarrh of the rectum there is a congestion, and a certain
amount of dilatation of the haemorrhoidal vessels, which results in capil-
lary hfemorrhoids. This inflammatory process, however, is diffuse, and
consequently fails to produce those localized dilatations and congestions
which characterize the true haemorrhoidal disease.

Chronic atrophic catarrh, however, may produce it. The inflamma-
tion rarely proceeds lower than the mucous membrane itself. There
is no submucous deposit constricting the blood-vessels and obstructing
the circulation, but there is atrophy of the follicles, deficiency in the
mucous secretions, increased friction in the passage of the faecal masses,
accumulation of these masses in the rectum, and a generally consti-
pated condition, all of which tend to the production of piles.

In the hypertrophic form these conditions are reversed, and conse-
quently in this disease hsemorrhoids are seldom seen unless they have
existed previous to the development of the catarrhal process. Unfor-
tunately the haemorrhoids are frequently mistaken for the chief cause
of offense in patients who suffer from these conditions, and operations
for their relief signally fail to cure.

Emotions. — The effect of the emotions in the production of haemor-
rhoids has been referred to by many authors. Grief, fear, anxiety, and

692 THE ANUS, RECTUM, AND PELVIC COLON

nervous strain have all been known to bring on attacks. No satis-
factory explanation has yet been given of this fact.

It seems probable that in the majority of instances the piles existed
before the emotional disturbance took place, and that through some
sudden cardiac activity or relaxation of the sphincter muscles pro-
trusion and haemorrhage have been brought on. A hsemorrhoidal tumor
is not simply a dilated vein, but an aggregation of varicose vessels
held together by a network of connective tissue; it is impossible to sup-
pose that it can be produced in an instant by any excitement. Throm-
botic piles may be so produced, but true venous haemorrhoids can not.
This fact is important in its bearing upon suits for damages in rail-
road and other accidents.

Spasm and Atony of the Sphincter Muscles. — The condition of the
sphincter muscles has sometimes been referred to as an etiological
factor in the production of haemorrhoids. One can understand how
atony of the sphincter would allow more room for dilatation and hyper-
trophy in the lower end of the rectum by the removal of its support
from the vessels; but how spasm of the sphincter can act as an etio-
logical factor, except in cases where there is a prolapse of the mucous
membrane of the rectum, is difficult to comprehend. Undoubtedly
such a spasm will produce a strangury, swelling and increased inflam-
mation in a prolapsing ha^morrhoid, but it does not produce the pile.
Where a fold of mucous membrane prolapses through a spasmodic
sphincter, it may be caught and its circulation be so obstructed that
the veins become dilated, the parts hypertrophied, and a haemorrhoid
may result, but such a condition is very rare.

In conclusion, one may enumerate the etiological factors in the
production of haemorrhoids in the order of their importance as fol-
lows: Erect posture, constipation, improper diet, muscular strain, and
diseases of the liver, spinal cord, gen i to-urinary and uterine organs.

Nomenclature. — In literature there are references to a large variety
of haemorrhoids described under special names, which, although super-
fluous, it is well to know. They are as follows:

External Hcemorrlioids. — Those located at the margin of the anus
entirely outside of the rectum.

Internal, Blind, or Occult Hcemorrlioids, Ilfpmorrhois Ccpca. — Those
seated above the muco-cutaneous border and entirely inside of the
anus.

Interno-external, Mixed, or Compound Ilcptnorrhoids. — Those situated
partially above and partially below the muco-cutanoous border.

Bleeding or Open Piles, JI (cmorrhoides Fluentes sue Coruenta, — Those
from which there is a loss of blood.

Accidental Hcemorrlioids. — Those which are produced by some acci-

a-EMOERHOI DS-PILES 593

dent or injury, either externally or within, but which develop sud-
denly and are cither cured or pass away spontaneously in a short time.

Constitutional Hcemorrhoids. — Those due to some constitutional con-
dition, such as cirrhosis of the liver, congestion of the lungs, or cardiac
insufficiency.

Arterial HcBmorrhoids. — Those in which the tumor is chiefly com-
posed of arteries instead of veins.

VenoiLS HcBmorrhoids. — Those composed chiefly of convoluted veins.

Capillary HcBmorrhoids, — These are small raspberry-like tumors com-
posed chiefly of small capillary blood-vessels covered with a very thin
and fragile mucous membrane which is easily torn.

Fleshy HcBmorrhoids, Connective-tissue HcBmorrhoids, Cutaneous Piles.
— These are composed chiefly of connective tissue without much vascular
development. They are always external, and generally the result of an
inflammatory condition in one of the muco-cutaneous folds about the
anus. Hypertrophy of the anal papillae is sometimes spoken of as fleshy
haemorrhoids, but this use of the term is incorrect.

Itching Piles, — This term is applied to a number of conditions, but
chiefly refers to those cases of pruritus ani which are associated with
haemorrhoidal disease. It implies that the itching is due to the piles,
a very unwarranted assumption, but one which is firmly rooted in the
popular mind.

White HcBmorrhoids, — Richet has used this term to describe a chronic
condition of piles in which the mucous membrane has assumed a muco-
cutaneous character and the haemorrhages have been supplanted by a
periodic or constant discharge of mucus (Irish Hospital Gazette, July
12, 1874).

Inflammatory HcBmorrhoids, — This term is applied to any haemor-
rhoids which are in a state of inflammation. It should be confined to
that variety which is due to an acute inflammation in the muco-cuta-
neous folds about the margin of the anus.

Classification. — Haemorrhoids are broadly classified as external and
internal Those above the margin of the anus and out of sight are
called internal, and those below and in full view are called external.
The terms, however, have a wider and more definite meaning from an
anatomical point of view. By internal haemorrhoids are understood
those which are developed from the internal or superior haemorrhoidal
vessels; by external, those which come from the external or inferior ones.
Piles do not develop from the middle haemorrhoidal veins. It will be
remembered that in the normal condition the superior haemorrhoidal
vessels are limited by the muco-cutaneous border of the anus; that the
little pools in which the veins originate are situated just above this
margin in the submucous tissues, and that their connection with the
38

594 THE ANUS, RECTUM, AND PELVIC COLON

external veins is through the most minute venous capillaries. So long'
as the sphincter is normally contracted even these small capillary com-
munications are practically occluded. When it is relaxed the veins of the
two systems can freely communicate. After this has taken place both
sets of vessels may become involved in the same tumor and the result
is a mixed hcpmorrhoid. Thus we have a third variety, the symptoms and
characteristics of which are simply a combination of those found in the
other two. They are usually treated as internal haemorrhoids, and we
shall so consider them.

External Hemorrhoids. — For the purposes of discussion and a
clear understanding, external haemorrhoids may be classified as throni-
botic external haemorrhoids, varicose external haemorrhoids, inflamma-
tory external haemorrhoids, connective-tissue haemorrhoids.

Thrombotic External Piks, — These are small oval or round tumors
situated just beneath the skin or muco-cutaneous surface. The color
of the overlying tissue may be unchanged, or it may be a light red, vary-
ing from this to a dark blue, according to the thickness of the covering
and the amount of distention. They vary in size from that of a small
pea to a walnut (Plate IV, Fig. 1), and may be single or multiple.

They come on suddenly with a sharp, cutting pain, gradually in-
crease in size, and usually attain their full growth within a few hours.
They may be perfectly round like a shot beneath the skin, or they may
be elliptical, pear-shaped, or erescentic. The shape and consistence of
the tumors will depend largely upon the density of the tissues in which
they occur. When they develop in the subcutaneous fatty tissue outside
of the margin of the anus they are generally globular and not very
dense or hard. When they occur in the muco-cutaneous folds they are
pear-shaped, hard, and painful.

They are produced by clotting of blood in a varicose vein, or more
generally by the rupture of a vessel and extravasation of blood into the
cellular tissue surrounding it. Their gradual enlargement is explained
as follows: a small rent occurs in the vein due to muscular straining,
traumatism, or shock; the blood continues to ooze from such an open-
ing, gradually distending the cellular tissue surrounding the parts, and
thus the tumor grows and the blood-clot becomes firmer until the pres-
sure is suflficient to check the haemorrhage. Where the pile is due to
clotting in the vein there is no real tumor but a venous stasis followed
by the formation of a small indurated mass at the spot, only recognizable
bv touch.

Si/mptoms, — The patient while straining at stool, at some athletic
or laborious exercise, while standing, or sitting on a perforated seat,
feels a slight pain, like the prick of a pin, about the anus, or has the
sensation of something having given way. If he examines himself short-

k PftCH.APSIHQ INTEMHAL

TYPES OF H>£MORRHOIDS

H.£MORBHOIDS— PILES 595

ly aftem^ard he will feel a small swelling in the region of the pain.
After the first sting the pain is not acute for a while, but as the tumor
increases in size a sense of tension followed by aching and throbbing
ensues. The pain and tension increase for the first few hours, the
patient is unable to sit down with comfort, and the movements of the
bowels are distressing. With the application of heat or cold, and after
twelve to twenty-four hours, the acuteness of the pain decreases, but a
sensation of weight and aching continues.

If the tumor is a small one and not situated within the grasp of the
sphincter, these symptoms will gradually grow less and less until they
entirely disappear, but if the haemorrhage has been of considerable size,
or if it is in that portion of the anus where the muco-cutaneous tissue
is closely attached to the muscle, the pain and tension will be greater,
exciting spasm of the sphincter, and the patient will not be so quickly
relieved.

If left alone these haemorrhoids may take one of three courses. The
whole thing may become absorbed and pass away, a very rare although
happy outcome; the clot may become organized, and remain as an en-
cysted body, which sometimes becomes calcified, giving considerable
inconvenience, and at others producing nothing more than a knowledge
of its presence; it may become infected, resulting in an abscess, or finally
in a fistula of some variety. The method of infection is through the
glands of the skin and muco-cutaneous tissue. The extravasation occurs
so near the surface that the mouths of these glands communicate with
the invaded area, and the infectious germs which are always present
in these glands and hair follicles, finding a congenial medium in the
clot and serum surrounding it, thus develop an infection with its conse-
quent results. Where this takes place the condition then assumes the
aspect of a perianal abscess, and no longer belongs to the category of
haemorrhoids; such abscesses when opened discharge masses of broken-
down clots clearly showing their origin.

Of these courses only the first can give a satisfactory result. WTiere
the clot is encysted or becomes calcified, it is always a source of irri-
tation; especially is this so if it is high enough up to be within the
grasp of the external sphincter. Here it acts exactly as a foreign
body, causing spasm of the muscle, giving pain when the bowels move,
and often creating distinct discomfort when the patient sits upon a
hard chair or rides horseback. It is not necessary to go into detail
with regard to the unfortimate results when they have become infected
and produce abscesses or fistulas.

Treatment. — Temporizing with this variety of piles is a very faulty
policy. There is but one sure and scientific method to deal with them,
and that is immediate enucleation of the clots; these are sometimes sin-

596 THE ANUS, RECTUM, AND PELVIC COLON

gle and globular, at others they are multiple, irregular in shape, and
distributed throughout the convolutions of the vein. The treatment,
however, is one and the same. The parts should be cleansed with anti-
septic precautions, and a 2-per-cent solution of cocaine injected hypo-
dermically into the swelling. An incision should then be made vertically
in the line of the radial folds well down into the tissues, exposing the
clot, which should then be carefully seized with a tissue forceps and
dragged from its seat.

Squeezing of the swollen and oedematous tissues in order to force
the clot out is wrong, inasmuch as the bruising and traumatism will
cause congestion in the parts and delay healing. Where there is con-
siderable hypertrophy and oedema of the connective tissues, and numbers
of these little thrombi, one may with advantage catch these tissues and
carefully dissect them out with scissors until all the clots have been re-
moved and the swollen mass reduced to its normal size. This, however,
is rarely necessary. Usually if one places his left forefinger within the
anus and presses down gently from above, while scraping the tissues
with a dull rectal scoop, the clots will slip out one after the other until
they are all removed. After this is done, a small piece of iodoform
gauze should be crowded into the cavity, and pressed well between
the lips of the wound; it may be covered with flexible collodion for
the first twenty-four hours, in order to protect the parts in case
of a movement of the bowels. This packing of the cavity is not
intended to check haemorrhage, for practically there is none; but it is
designed to prevent oozing and reproduction of the clot, which is very
likely to occur if the edges of the wound are sewed together or allowed
to become approximated inmiediately. The fear of producing fissure
by this method is absolutely imfounded; the incision rarely goes more
than a few lines above the lower margin of the external sphincter, the
wound is not within its grasp, and if asepsis is properly observed it
heals in two or three days.

Some authors advise cutting away these haemorrhoids and suturing
the skin together. Where the thrombus occurs in an already well-de-
veloped skin-tab this may be done. The objection to this method is that
which operative surgeons are urging against through and through sutur-
ing of skin wounds in other portions of the body. There is no doubt
that the skin and its emunctories are the hiding-place of many septic
and infectious germs, and the passage of sutures and needles through
this tissue is very likely to carry infection into a wound. This is espe-
cially true about the anus. Occasionally excellent results are obtained
in plastic operations in this region, but every operator must admit that
it is the exception rather than the rule that he fails to have a little pus
around sutures in these parts. Subcutaneous sutures are very difficult

HEMORRHOIDS— PILES 597

to apply here, and the few attempts to do so have proved unsatisfactory;
therefore, until a method is perfected which will avoid the dangers of
this infection, it will be better in the treatment of thrombotic haemor-
rhoids, whether large or small, to remove the thrombus and hypertro-
phied portions, and pack the wound as advised above.

The removal of the clot gives almost immediate relief to the pain.
On the following day, when the gauze is removed, the parts will ap-
pear perfectly clean and the wound like a fresh cut. The edges
being then allowed to approximate, they rapidly heal, sometimes in
two or three days, and the patient is perfectly well. This method
of treatment applies quite as well to the encysted and calcified
thrombi as to those just formed, and should be carried out at the
first examination. A patient with such a condition should never leave
the oifice-table until the clot has been removed. It is very simple to
say to them: "You have a little clot here which needs to be let out;
this can be done with no more pain than the pricking of a needle," and
no one will object to it. It may be thought wise by some operators to
impress their patients with the gravity of their condition by magnifying
this little procedure into a surgical operation, and thus justify them-
selves in charging a proportionately large fee for the same. The con-
scientious surgeon, however, will never descend to any such scheme or
trickery to augment his professional reputation or add to his bank
account.

These tumors being practically without the grasp of the sphincter,
it is unnecessary to dilate this muscle in their treatment. When there
are more than one they should all be treated in the same manner at one
sitting. When these piles exist in connection with internal haemorrhoids,
some authors advise leaving the former alone until an operation for
internal haemorrhoids can be arranged, and do them all at once. This
method of procedure seems inadvisaole in acute cases, because every day
that one of these little clots remains beneath the skin or muco-cutaneous
tissues about the margin of the anus, just so much longer is the patient
exposed to the dangers of infection, abscesses, and fistula. They have
no connection with internal haemorrhoids, and as the latter are treated
in the majority of instances by open methods, necessitating a certain
amount of suppuration, this is more than likely to infect the area from
which the thrombus has been removed, and cause delay in healing or ul-
ceration at these points. In such cases the clot should be removed from
the thrombotic ha^morrhoid upon the first examination, and the patient
advised to wait until the wound has healed before having anjrthing done
for the internal haemorrhoids.

Varicose External Hcemorrhoids. — This variety consists in a varicose
condition of the subcutaneous veins surrounding the margin of the anus.

598 THE ANUS, RECTUM, AND PELVIC COLON

Any one who has operated about the rectum, or who has ever observed
these parts while the patient was bearing down, must have noticed how
easily the external plexus of veins becomes dilated and distended under
these circumstances. This dilatation takes place at every movement of
the bowel when there is any straining.

It is therefore very common in people who are constipated or who
sit for long periods in one position, especially upon perforated seats or
at stool. The veins are equably dilated and the circulation continues,
although impeded somewhat by the loss of elasticity in the vessel walls.
Like varicose veins of the leg, they are only present when the patient
is in the proper position. If sitting, squatting, or straining with the
abdominal muscles they appear, and sometimes reach enormous dimen-
sions, forming as it were a regular crown of haemorrhoids around the
anus; and yet, immediately after the horizontal position is resimied and
the straining ceases they disappear entirely.

They may also be caused to disappear even in the sitting or squatting
posture by firm pressure upon the parts, showing that there is very
little increase in the connective tissue and no permanent hypertrophy.
This sometimes deceives the patient, causing him to think that they are
internal haemorrhoids which pass inside of the bowel.

Symptoms. — In this variety the growth is of an insidious and slowly
progressive nature. There is no pain, no sudden development or pro-
trusion, and no obstruction to the functional action of the bowels. The
majority of patients are rarely aware of their presence unless they be-
come quite marked. It is only in the hypersensitive, overparticular, and
nervous, who in the use of detergents become aware of an unnatural
condition of the parts, that much attention is paid to them. The un-
easiness which they produce is more mental than physical.

These piles do not conform to the folds of the rectum; they are not
lobulated or easily outlined; they form a general swelling or cushion-
like mass around the margin of the anus, and sometimes give one the
impression of an inflated rubber pessary covered with skin and muco-
cutaneous tissue, with a bluish tinge that indicates the venous origin.

Treatment, — These haemorrhoids, being brought about through habit
and environment, are amenable to treatment by the regulation of those
factors. As a rule they do not require any surgical operation. The pa-
tient should avoid prolonged sitting and straining at stool; the constipa-
tion which generally exists should be remedied before any attempt at
treatment of the piles; tight, spasmodic sphincters should be gradually
dilated, obstructive rectal valves, strictures, catarrhal diseases, and what-
ever causes constipation or obstipation should all be carefully treated
and removed if possible. If there be none of these pathological condi-
tions to account for them, their treatment may be based upon the lines

HEMORRHOIDS— PILES 599

of dietary and physical regimen. In order to avoid the necessity of re-
maining long at stool the patient should be instructed to take an enema
of about half a pint of cold water at some hour at which it is convenient
for him to attend to the movement of his bowels regularly. As soon as
he feels a strong inclination for this to come away, he should repair to
the toilet, and without straining he will generally be relieved of what-
ever fajcal matter is present in the rectum and sigmoid. He should be
instructed not to sit at stool any longer than two or three minutes, after
which he should go to his bed, lie down with his hips elevated, and
apply cold cloths to the anus for five or ten minutes. Night is generally
more convenient for men, but for women whose duties are at home, any
hour may be selected in which they are least likely to be interrupted.
The important thing is to have a regular time for this function, and to
hold it inviolable. After a short, conscientious devotion to these regu-
lations the bowels will soon become habituated to regular action, and
frequently the movement occurs without the enema. At bedtime these
patients should apply the following ointment:

ig. siramonii, ) ,.

^ r aa 5j.

'^ Vug, acidi tannice 3iv;

Ung. stramonii,
Ung. belladonnffij
M. et ft. ung.
Or,

IJ Ext. suprarenalis 3ij;

Ung. lanolini 3vj.

M. et ft. ung.

The ointment should be spread thickly over a wad of cotton wool,
and held in apposition with the parts by a T-bandage.

One should be warned against the use of drastic purgatives in this
<;ondition. They cause frequent stools and straining, and will aggravate
rather than relieve it. The facal movements should be kept soft but
without purgation. A diet of meat, fruit, fresh vegetables, and Graham
or whole wheat bread should be enjoined.

The patient should always lie down to make the cold applications,
and should have his hips elevated above the level of the chest. Doing
this in the squatting position accomplishes very little good. Outdoor
exercise, walking, golf, tennis, and such diversions are very beneficial in
these cases. Where there are no internal haemorrhoids, and where the
patient can be induced to carry out this regimen, the varicose external
hemorrhoids can generally be relieved in a period varying from three
to six weeks. Where there are internal haemorrhoids, however, and
inflammatory conditions of the rectum which cause straining, irritating

600 THE ANUS, RECTUM, AND PELVIC COLON

discharges, and other symptoms, we can hardly expect this variety to
be greatly benefited until those conditions have been relieved. If an
operation for internal haemorrhoids is thought necessary or desirable,
one may at the same time remove a certain amount of the varicose veins
which form this variety of piles, and cure them both at the same time.
One should be careful, however, not to take away too much skin from
around the margin of the anus lest a cicatricial stricture should follow.

The author has tried cauterizing these piles by a narrow-bladed
Paquelin knife, and has been quite successful in the cases in which it
was used; but the burning pain which follows this operation has caused
him to discontinue it. Kelsey has advised the use of a fine needle-
pointed cautery, by which he bums into the varicose veins at different
points; this instrument has sometimes caused severe abscesses on ac-
count of the external opening closing before all the necrosed tissues in
the deeper parts of the tract had been evacuated.

The treatment of these tumors by injection has been frequently advo-
cated. It is performed as follows: After having thoroughly cleansed
the parts with antiseptic solutions, the piles are made tense and pro-
truding by the patient's straining and bearing down; the most prominent
portions of the varicose mass are then injected at four or five points
around the margin of the anus with a few drops of Shuford's solution
(see p. 627), or some mixture of carbolic acid. As a rule, however, this
treatment is not successful in any form of external haemorrhoids.

Electrolysis has been recommended by a number of surgeons in the
treatment of this variety of haemorrhoids, but this method is not as
effectual as the others detailed, and is only safe in the hands of an ex-
perienced electrician equipped with an apparatus by which the strength
of the current can be absolutely measured. The ordinary office batteries
are unreliable for such purposes. It has been suggested that the current
be tested in the white of an egg, and used only sufficiently strong to
coagulate this substance, but this is a very indefinite test. The positive
pole is attached to a fine electrolysis needle which is introduced well
into the substance of the tumor, and the negative pole applied to the but-
tocks. The swollen tissues may be first injected with a solution of
cocaine if the patient is hypersensitive. There is some pain at the time
of the operation which increases during the first twenty-four hours, and
this is followed by considerable swelling and cedema of the parts; after
this the swelling is said to subside and the varicosities rapidly disappear.
After trying all these methods the author is convinced that the non-
operative treatment is by far the most satisfactory.

Inflammatory External Tlcemorrhoids. — This variety consists in an in-
flamed and swollen condition of the folds of the anus; they are also
described under the name of (edematous piles. They are pear-shaped.

BLEMORRHOIDS— PILES 601

their small end extending sometimes within the external sphincter^ and
have a muco-cutaneous and cutaneous covering.

They originate in some traumatism or irritation of the margin of
the anus. This may be mechanical or pathological. Anal or rectal ulcer-
ation, fissures, chancroids, improper detergent material, rough or too
vigorous wiping, paederasty, rectal masturbation, kicks, injuries, falls or
strains may all produce them. Grasping of the upper portion of the
tumors by the sphincter may cause considerable pain, but it never pro-
duces strangulation or sloughing, as in the case of internal haemorrhoids
when they become prolapsed. Sloughing may occur, but it is due to the
inflammatory processes and not to strangulation by the sphincter, as
their blood supply is outside of this muscle. Sometimes they originate
in a traumatism which causes haemorrhage and clot in the fold, and
there is a combination of the thrombotic and inflammatory types. In
such cases the color of the tumor will have a bluish tinge, especially
when the skin is drawn down and made tight over the globular mass.

When it is of a purely inflammatory nature the tumor will be pear-
shaped or elliptical, red, dense, swollen, and painful.

Symptoms. — They may be single or multiple, simple or complicated.
The patient, if he does not recognize a positive injury to the parts, or
has no history of previous rectal or anal affection, will generally notice
at first a sense of heat, uneasiness, or itching. Upon examination
he will feel at one or more points around the anus an increased prom-
inence or a sort of oval swelling. The pain at first will be moder-
ate, and when the inflanmiation is very mild it may pass rapidly away.
Upon the next irritation, however, the swelling returns and the pain
becomes aggravated. The parts ache and bum, there is spasm of the
sphincter, and sitting down is painful. Lying upon the side, with the
hips elevated, is the most comfortable position which can be assumed.
Defecation is dreaded, and constipation therefore ensues. If the case
be a severe one, constitutional symptoms will appear; the temperature
may be elevated two or three degrees, the tongue coated, and the pulse
rapid. Ocular examination of the parts will reveal one or more swellings
of the shape already described about the margin of the anus, varying
in size from that of a small hazelnut to a guinea-egg. They are not
so hard as thrombotic haemorrhoids, and sometimes give the sensation
of fluctuation. They are always very painful to the touch, and if they
be large, the mucous membrane will be dragged down from within the
rectum, thus forming a part of their covering.

At the base of each tumor, or between two of them, there will often
be found a small fissure, ulcer, or excoriation. Sometimes a pocket exists
ait this point, and in it may be found a hardened mass of faeces, a small
seed, or other foreign body; a shallow, subtegumentary fistula may some-

602 THE ANUS, RECTUM, AND PELVIC COLON

times be found, the tract leading downward beneath the muco-cuta-
neous tissue. These haemorrhoids may ulcerate and slough, or if the in-
flammation subsides, gradually shrink until they disappear or form con-
nective-tissue piles; the latter is their usual course.

If the patient should be in a low physical condition and susceptible
to infection, very grave constitutional symptoms may develop. As a
rule they are the most painful of all haemorrhoids, and one can hardly
credit the amount of distress which may result from them.

Treatment, — The treatment of these consists in subduing the inflam-
mation by antiphlogistic methods or in radical removal of the tumors.
Lying with the hips elevated and an ice-bag applied to the parts, will
often relieve them very quickly, but at the same time cold may cause
sloughing. Where there is much oedema and swelling, gauze soaked in
a 25-per-cent solution of boroglyceride should be applied, and a hot-
water bag laid over this. As a rule this simple measure will reduce the
inflammation and relieve the pain. The following ointment is also very
efiFectual in this condition:

'^ Morphine sulph gr. v-x;

Ichthyol 3iv;

TJng. belladonnae, ) .. ^.

Ung. stramonii, \ "''

Sig.: Apply two or three times a day.

Often the pain is so severe in these cases that patients are willing
to submit to anything for relief, and operative measures are the surest
way to obtain this. Some writers advise making an opportunity of the
patient's exigency under these circumstances, and to persuade them to
have an operation to which they are opposed by stating that it is the
only certain means of cure. Such methods are distasteful. A fair, frank
statement of what can be expected from both methods of treatment, and
recommendation as to which is better in the individual case is a much
more dignified and self-respecting position for the surgeon to take; he
should not deign to frighten a patient into a course to which his candid
advice does not persuade him. If the operation is decided upon, general
anaesthesia should be employed, inasmuch as this variety is often asso-
ciated with fissures, ulcerations, and internal haemorrhoids, and stretch-
ing of the sphincter is very important. Occasionally, where only one fold
is inflamed and the fissure is clearly in view, the haemorrhoid may be
removed and the fissure incised under cocaine anaesthesia. At any rate
the sphincter should always be divulsed or incised in operations for this
class of haemorrhoids, otherwise a fissure will result.

The tumor itself should be removed by scissors or by crushing with
the clamp. Neither the ligature nor the cautery should be used on the

HEMORRHOIDS— PILES 603

skin tissue covering them, as they are both very painful. After excising
the piles, the edges of the wounds may be sutured together, but it is
doubtful if any particular advantage is obtained by this, as infection is
nearly always present to prevent primary union. The only advantage
of the operation over local treatment in these cases is the radical cure
which is obtained. One method relieves the pain about as quickly as
the other, but after the non-operative treatment there are left skin-tabs
or connective-tissue piles which may reproduce the inflammatory variety
at any time.

Connective-tissure Hcemorrhoids. — This variety of piles, called also
cutaneous or fleshy piles and skin-tabs, consists in hypertrophy of the
muco-cutaneous tissue about the margin of the anus. They appear
when not inflamed as flat folds or tabs, more or less numerous, and
sometimes entirely surrounding the aperture; the longest axis may
run up and down or circularly around the anus, the base may be
broad or constricted. They are generally composed entirely of muco-
cutaneous tissue, with a stroma of connective tissue separating the
two layers of the dermis in which run one or two arteries with their
accompanying veins. The blood-vessels are more or less atrophied
(Cripps) and there is an hypertrophy of all the elements of the muco-
cutaneous tissues. Microscopic examination demonstrates, however,
that the chief hypertrophy takes place in the subcutaneous connective
tissues, and that the term " connective-tissue haemorrhoids '' is there-
fore more appropriate to the condition than any other. They may
also contain cyst-like cavities, the remains of obliterated veins that
give rise to a condition resembling cavernous tissue. Small mucous
follicles and masses of fat may also be found in them.

They originate in three ways: they may result from an acute inflam-
matory haemorrhoid in which the inflammation has subsided, leaving
an hypertrophy of the connective tissue and of the skin, which tissues
contract and obliterate to a greater or less degree the dilated veins;
they may originate in some chronic irritation about the anus, such
as fissure, mild ulceration, or catarrhal disease; they may follow throm-
botic or varicose external haemorrhoids. When they are developed from
the latter they assume the circular type and extend entirely around
the anus. It is not necessary for the production of this variety of
disease that the exciting cause should be low down in the rectum.
The condition, as has been seen, results from strictures, ulcers, and
malignant diseases as high up as the sigmoid flexure. It has been
claimed in such conditions that the connective-tissue haemorrhoids are
probably due to the irritating discharge of the original disease. The
French authors claim that these skin-tabs, or "rhagades" as they
call them, are indicative of syphilitic disease. When associated with

604 THE ANUS, RECTUM, AND PELVIC COLON

hard, inelastic stricture and ulceration of the rectum one may undoubt-
edly suspect this origin, but when not complicated by such a condition
they are no more indicative of syphilis than of malignant or chronic
inflammatory diseases of the rectum.

There are cases of this variety, however, in which there is no
condition in the anus to account for them; they occur in lads fourteen
and fifteen years of age, who have no recollection whatever of having
had any anal or rectal disease, and are absolutely free from syphilis.
It is possible that in these cases phimosis or sexual excitement may
have caused the congestion or hyperaemia which produced them.

Symptoms, — Haemorrhoids of this variety, when in their quiescent
stage, can scarcely be said to produce any symptoms peculiar to them-
selves. They are not painful, they do not bleed, pressure will not cause
them to disappear, they can not be kept inside of the sphincter, and
they have no peculiar outline or color. • They may be single or multiple,
thick or thin, pedunculated or broad and flat at their bases. They are
supplied by one, sometimes two small arteries; the number of veins
varies according to the stage of development. They become inflamed
by slight traumatisms, such as sitting upon a hard seat, horseback or
bicycle riding, the passage of constipated stools, and too vigorous
cleansing. Excessive eating or drinking, sudden exposure to cold
after being overheated, and chafing in hot weather, will also excite
inflammation in them. When this occurs the symptoms correspond
to those of inflammatory piles.

Treatment, — Where these piles are uncomplicated by fissure, ulcera-
tion, or internal haemorrhoids, they should not be molested unless they
become inflamed or their presence annoys the patient mentally; if
one finds it best to remove them, this can be done under cocaine by
crushing them off with the haemorrhoidal clamp. By this means the
edges adhere, and being sealed by collodion and iodoform, they gen-
erally unite as if sutured.

Perfectly satisfactory results may be obtained by simply clipping
off the hypertrophies with scissors and leaving the wounds to granulate.
It is very important, however, to cut flush with the skin and leave
no stump. When they are extensive, with broad bases, a more rapid
cure may be obtained by cutting them off and suturing the edges of
the wound together.

Internal Hemorrhoids. — While a great many varieties of internal
haemorrhoids have been described in literature, there are practically
but four varieties. They may be classified as thrombotic internal
haemorrhoids, varicose internal haemorrhoids, capillary internal haemor-
rhoids, and mixed haemorrhoids.

Hamilton (Clinical Lectures on Diseases of the Lower Bowel, p. 32)

HEMORRHOIDS— PILES 605

describes a variety which he calls columnar hoBmorrhoids, as follows:
" The second variety, for which I would suggest the term columnar pile
to denote its pathology, consists essentially in hypertrophy of the folds
of mucous membrane surrounding the anal opening, the pillars of
Glisson. They have a red, almost vermilion color, elongated form,
and contain within them one of the descending circular branches of
the superior haemorrhoidal arteries."

Ball states that this is the most common variety of internal haemor-
rhoids. According to his microscopic examinations they consist of
inflammatory hypertrophies in which there are no varicosities. It
appears, however, from the descriptions of these authors, that they
refer either to inflammatory external haemorrhoids or to simple inflam-
matory conditions of the rectal columns. Such conditions occasionally
occur, but they can not be classified as true internal haemorrhoids.

Thrombotic Internal Hoemorrhoids. — These consist in an extravasa-
tion and clotting of blood in the submucous tissues, and difiFer from
external thrombotic haemorrhoids only in the location and overlying
tissues. They may occur in an otherwise healthy rectum, but gener-
ally complicate varicose piles.

They are less painful than external thrombotic piles, but sometimes
produce an irritation and bearing-down in the rectimi. To the touch
they feel like small globular or elliptical tumors, movable beneath the
mucous membrane and over the muscular wall. They present to the
eye only a slight elevation, as the overlying tissues are never sufficiently
distended for the blue color of the clot to show through it.

They are so rare, except in connection with internal varicose haemor-
rhoids, that it is difficult to give any definite description of their course
and final results. The writer has seen 2 cases in which the clot became
encysted, and, when turned out of its capsule, appeared as an ovoid
mass, hard, smooth, shining, and of a deep purple. They very rarely
become infected or form abscesses. The treatment consists in evacua-
ting the clot or removing the varicose mass in which they occur.

Varicose or Venous Internal Haemorrhoids. — This is the most fre-
quent variety of haemorrhoids. It consists in a varicosity of the
internal haemorrhoidal veins with hypertrophy of the connective-tissue
stroma in which these vessels lie.

They originate in the little venous pools which connect the arterial
with the venous circulation. In the beginning they are simply con-
gestions of the vessels. Pressure of the blood-column, straining at
stool, the friction of faecal passages, and other causes produce dilata-
tion of the veins, hyperaemia of the parts, and hypertrophy of the con-
nective tissue, until veritable angeiomatous tumors are formed. These
are ordinarily located at three points in the circumference of the

606 THE ANDS, RECTUM, AND PELVIC COLON

rectum: one upon each side and slightly in front of the posterior com-
, and one upon the right side and slightly behind the anterior
Sometimes there is a fourth prominent one upon the
left side of the anterior commissure (Plate IV, Fig. 2), but this is not
ordinarily well developed.

Between these three prominent tumors there ie generally a varicose
condition of the veins, and sometimes Email hsemorrhoidal tumors may
develop. These, however, are of little importance from a surgical
point of view, with the exception of one, which sometimes occurs
immediately above the posterior commissure. Occasionally the whole
circumference is involved in the varicose process, and the anus when
it is dilated presents a veritable rosette of hsemorrhoidal tissue, only
slightly more prominent in one portion than another. They begin
abruptly at the ano-rectal line, and are covered entirely with mucous
membrane. In their early stages, when quiescent, they lie dormant
and collapsed within the rec-
tum, and can neither be seen
nor felt unless the patient by
bearing down protrudes them.
Except when inflamed and
swollen their surface is irregu-
lar, lobulated, and crossed by
numerous furrows running in
different directions, produced
by the attachments of connect-
ive-tissue stroma to the mucous
membrane. When they have
been prolapsed for some time
or become inflamed these fur-
rows practically disappear, and
the tumors present a globular
shape with smooth, shining sur-
faces (Plate IV, Fig. 3). When
the disease has become chronic
and the connective-tissue stro-
ma hypertrophied, the tumors
can then be brought into view
by separating the folds of the
buttocks and dragging down upon the margin of the anus, or they
may be felt by the finger. If the tumors are habitually prolapsed the
mucous covering may assume a rauco-cutnncoiis character.

Their shape is variable; they may be globular or cone-shaped, and
attached by a broad base; they may be pedunculated or semicircular.

HEMORRHOIDS— PILES 607

involving almost the entire circumference of the rectum. Sometimes
small polypi or condylomata are attached to them (Fig. 193). Their
lower margin is sharply delineated by the white line of Hilton, and
even where they are connected with external haemorrhoids this line still
marks the division between the two.

Pathology, — The tumors consist essentially of congeries of dilated
blood-vessels and connective-tissue stroma. Upon section they present
a sort of sponge-like or honeycomb appearance, due to the dilated veins
and a few arteries held together by a complicated network of connective
tissue in which are found epithelial and glandular cells. They resemble
very much the erectile tissue found in the spongy body. In the cavities
of the veins the section shows coagulated blood, thickening of the in-
tima, and sometimes an inflammatory deposit in the blood-vessel walls,
but generally these are thin and friable. The coagulation takes place
after the hajmorrhoid is removed, and is not an essential part of its
pathology. The arterial supply of the ordinary venous haemorrhoid is
not through one main branch, but through a number of arterial capil-
laries. Sometimes, however, one large artery runs into the tumor and
can be felt pulsating when the finger is pressed above it. The tumors
are connected with the muscular wall of the gut by very feeble adhesion,
and can be peeled off both in life and post-mortem with the greatest ease,
especially if the stripping be from above downward.

The muscles at this portion of the gut are supplied by the middle
haemorrhoidal arteries, and at two or three pointa around the circum-
ference of the rectum there is a more intimate adhesion to the mus-
cular wall, due to penetration by branches of these vessels. In the
early stages the mucous covering is normal, but in old haemorrhoids
it is thickened, more dense in its composition, and the Lieberkiihn
follicles are very much atrophied, or may have disappeared entirely.
Sometimes there are little areas of cicatrization indicating points at
which there have been haemorrhages or ulcerations. In the cases of
general varicosity associated with diseases of the heart, liver, or spleen,
the condition may occupy the whole length of the rectum and ascend
even up into the colon, as has been described by Ludwig, Petit, and
Valsalva.

The form of haemorrhoids called " arterial " by Allingham, and
described as being composed of congeries of arterial capillaries instead
of veins, is not admitted by the majority of authors. This idea came
from the fact that the blood sometimes comes in jets or spurts. This
is explained by Cripps, as follows: "The jet is caused by blood being
forced as a regurgitant stream through a small rupture in a vein by
the powerful pressure of the abdominal muscles. If it really came
from an artery, why did the jet only appear when the abdominal mus-

608 THE ANUS, RECTUM, AND PELVIC COLON

cles acted? " He holds that if the bleeding of an artery was the cause,
straining and pressure would diminish rather than increase the spurt-
ing. In one instance of this kind he was able to discover a clot ob-
structing a small circular opening in the vein itself, and when this
was removed to reproduce the spurting by causing the patient to strain
with the abdominal muscles. His experience and the examination of
many specimens of haemorrhoids removed during life and post-mortem
seem to justify his position; and, notwithstanding the authority of Van
Buren, Brodie, and AUingham, the author is convinced that aside from
the capillary variety there is no such condition as arterial haemor-
rhoids.

Symptoms, — The two cardinal symptoms of internal haemorrhoids
are bleeding and protrusion; it is difficult to say which symptom is most
frequently first observed. A slight oozing of blood very frequently
occurs unobserved by the patient, and his attention is not called to this
loss until he feels an unusual protrusion about the margin of the anus;
when this is felt he generally examines his faecal passages and the
loss of blood is discovered.

In uncomplicated internal haemorrhoids there is practically no pain
and no obstruction to the passage of the faecal mass. Bleeding may
recur from time to time, especially in the lower classes, who do not
watch themselves closely, and go on for long periods without its ever
being suspected; whereas protrusion, as soon as it occurs, will be noticed
arid excite the anxiety of the patient.

In the varicose variety the haemorrhage, while not so frequent as
in the capillary, is sometimes excessive in quantity, resulting in dizzi-
ness and fainting; such cases, however, are exceptional. The patient
generally observes a small amount of blood following a movement at
stool. At first this loss occurs only occasionally, but after they have
existed for some time and begin to prolapse, the haemorrhages occur
more frequently at stool, and may even come on at irregular periods
from straining or physical exercise. The amount of blood lost at any
particular time varies, and one must always take cum grano salis the
description of patients as to the quantity or extent of any individual
haemorrhage.

In deciding upon the source of bleeding from the rectum, one must
always bear in mind the fact that it may come from the stomach or
from some portion of the upper intestine. Blood from the upper intes-
tinal tract will be decomposed, dark, and tar-like in appearance; it
will be mixed with the faeces and contain more or less mucus. That
from hemorrhoids is brighter in color, not mixed with feces, but gen-
erally passes after the faecal mass. When it first appears it may
be of a dark, venous character, but if exposed to tlie air for a short

HAEMORRHOIDS— PILES 609

time it will become brighter in color by the absorption of oxygen. The
fact that the blood is mixed with fseces and is clotted does not preclude
the possibility of its coming from internal haemorrhoids; there are
patients who, from time to time, pass from the rectum large masses
of clotted blood that undoubtedly came from internal haemorrhoids
developed high up on the upper margin of the internal sphincter. In
all such cases the haemorrhages cease after the haemorrhoids are
removed.

The protrusion of internal haemorrhoids does not occur until after
the tumors have developed considerable size. They at first come down
only a very short distance and appear to the patient as an uncom-
pleted stool, a sensation of something more to come away. As the
condition develops, however, this increases, and the patient when strain-
ing at stool will feel at the margin of the anus one or more little
masses, soft and velvety to the touch but without pain. In the beginning
they recede spontaneously, but as they become larger and prolapse far-
ther the grasp of the sphincter obstructs the return flow of blood in the
tumors, they swell, the margin of the anus becomes oedematous (Plate
IV, Fig. 3), and the patient finds it necessary to reduce them by firm
pressure. In ordinary cases this reduction is a simple and easy process,
but at times it is very difficult. Where there is great hypertrophy both
of the vascular and connective tissue, the reduction is sometimes impos-
sible to the patient himself, and it becomes necessary to obtain surgical
assistance. In such cases rest in bed with the hips elevated and hot
applications will sometimes result in spontaneous reduction.

Ordinarily there is no pain at the site of the tumors, but in well-
developed cases there is a constant sensation of weight and aching in
the sacral region. Sometimes there may be sharp lancinating pains
around the margin of the anus when the haemorrhoids are low down
and within the grasp of the external sphincter.

WTien the tumors prolapse and there is strangulation by the
sphincter muscles, the pain may become very severe. As a matter of
fact, however, the longer the haemorrhoids have existed and the greater
the prolapse which accompanies them, the more relaxed and free from
spasm will the sphincter become. Thus, strangulation in old cases of
haemorrhoids or in patients beyond middle life is rather a rare occur-
rence. It occurs more frequently in acute cases in which inflamma-
tion has developed and in patients of middle age.

Mucus is very generally present, either with the haemorrhages or
during their intermissions. Sometimes after bleeding has occurred
periodically for a long time it ceases altogether, and is replaced by a
constant or periodical discharge of mucus from the rectum; this is the
<?ondition which Eichet has described as "white haemorrhoids.^' Ball
89

610 THE ANUS, RECTUM, AND PELVIC COLON

appropriately says of this: " It is a singularly inappropriate term to
designate what is nothing more than a catarrhal discharge resulting
from continued irritation of the rectal mucous membrane."

Kelsey describes as one of the symptoms of haemorrhoids a condi-
tion which he terms " rectophobia — the sense of impending evil, which
is so common in rectal troubles." He says: " There is hardly any variety
of pain or of functional nervous disease that I have not cured by the
simple removal of haemorrhoids, and this applies as often to men as
to women." There is no doubt that haemorrhoids and any other form
of rectal irritation may produce profound impressions upon the nervous
system. As has been described elsewhere in this book, delusions, hal-
lucinations, and marked mental aberration are by no means infre-
quently the result of rectal disease. Such impressions, however, are
more rarely produced by haemorrhoids than by ulceration, stricture,
and faecal impaction.

Among the symptoms of haemorrhoids one should bear in mind the
reflex disorders of the digestive organs, pain in the back and shooting
down the legs, constipation due to the fear of having a movement lest
a haemorrhage be brought on, and anaemia consequent upon the loss
of blood.

Capillary or Ncevoid Hcemorrhoids. — In Hamilton's division this
variety is described as a capillary naevus of the rectum. The facts
that naevi are usually considered as congenital growths, and this type
of haemorrhoids is never found in children, render this term some-
what inapplicable. " Capillary " is more appropriate, inasmuch as it
describes the anatomical condition. They consist in small, raspberr}'-
like developments of the arterial capillaries close to the surface of the
mucous membrane of the rectum. They are covered by a very thin
layer of epithelium which is easily ruptured, and are the source of
very frequent haemorrhages.

They do not protrude, and can not be located by the most delicate
touch; they constitute what is commonly known as "blind bleeding
piles"; they bleed upon the slightest contact with an instrument or
even from digital examination. The blood is of a bright-red arterial
nature, and comes as a sort of oozing or dripping after each defeca-
tion. The amount lost at any one time is never very great, but the
frequent recurrence soon depletes the system and brings on marked
anaemia. In 1 case death was imminent from this cause when the pile
was removed and the patient cured (Kelsey). lender the microscope
they resemble the congenital capillary naevus, and from this the term
" naevoid " has arisen.

When they have existed for some time the mucous membrane be-
comes thickened and the haemorrhages cease, but the tumor continues

HEMORRHOIDS— PILES

611

to grow, the venous and connective- tissue elements increasing more
rapidly tJian the arterial, and eventually they resolve themselves into
venous or varicose bteraorrhoids.

Pathology. — Macroscopically they present a soft, velvety, bright-red
appearance much resembling a raspberry, are slightly elevated above
the mucous surface, and covered with a thin layer of epithelial cells.
Ball says that the change in the mucous membrane may occur, without
any other manifestation of disease, in patches as big as a sizpenny
piece.

Pressure with the finger will cause them to disappear for the mo-
ment, but immediately it is removed the tumor recurs. Ulceration
does not result from the bleeding, and consequently there are no cica-
trices as in the varicose variety. Under the microscope they present
the appearance of a conglomeration of arterial capillaries cut trans-
versely and at different angles. The veins are few and the connective-
tissue stroma almost entirely absent. They are covered by a very
thin mucous membrane; sometimes only a layer of striated epithelium
separates them from the intestinal cavity.

Mixed Hwmorrhoidg. — In cases where internal and external hieraor-

rhoida exist together, the divisio:
by the so-called " white line "
of Hilton, or sulcus, which
marks the attachment of the
external sphincter to the lower
end of the gut.

The connective tissue is
denser at this point than else-
where around the rectum, the
mucous membrane is more
closely adherent to the muscu-
lar walls, and the vascular sup-
ply is most limited. It is only
after internal hsemorrhoids
have existed for some time,
and through their gradual
growth and downward pressure
have raised the membrane from
its close attachment to the mns-
cle and dilated the latter, that
the piles cover this line. When the
sis with the veins below occurs, and
or mixed haemorrhoids. They
cutaneous tissue (Fig. 194).

between the two is clearly demarcated

y have once passed it, free anastomo-

wc have what is called entero-intemal

covered by both mucous and muco-

and are composed of varicosities of the

612 THE ANUS, RECTUM, AND PELVIC COLON

internal and external haBmorrhoidal veins; they are of a pale opaqne
pink in their lower portions and bright red or purple in the upper.
They are smooth and globular in form below and lobular or grooved
above like varicose haemorrhoids. They never entirely recede into the
rectum, inasmuch as part of them belongs outside. Their symptoms,
pathology, and treatment comprise those of external and internal haem-
orrhoids combined.

Treatment of Internal Hemorrhoids. — The treatment of in-
ternal haemorrhoids may be classified as preventive, palliative, and cura-
tive.

Preventive. — The presence of predisposing causes may be recognized
frequently before the actual development of haemorrhoids, and it is
the part of the family physician to warn his patients of them. The
influence of heredity is very problematical, but the habits, environ-
ments, and avocations of families are inherited, and they cause haemor-
rhoids.

Constipation in children should always be looked upon seriously
and its causes removed. Dilatation of the sphincter will often accom-
plish wonders in this respect. Cold enemata, soap bougies, and
glycerin suppositories are all superior to the use of laxatives at this
age. At puberty and middle age, individuals with a haemorrhoidal
tendency should avoid indiscretions in diet such as would cause con-
gestion of the liver, constipation, and indigestion.

The avoidance of predisposing and exciting causes, such as sitting
long at stool, great muscular strain, excessive venery, improper diet
and drink, will do much to prevent the disease. A meat or nitrogenous
diet is the most effective in such cases. Wines, liquors, and the excessive
use of tobacco should be discountenanced.

The bowels should be regulated, but not by drastic or irritating
cathartics; small cold enemata at regular periods is very effectual for
this purpose, and they also tend to reduce any congestion in the lower
end of the rectum. Cascara combined with malt is one of the best
laxatives in such conditions, and should be administered in doses rang-
ing from a dram to an ounce at bedtime, according to the patient's
needs. Phosphate of soda is also an excellent remedy. The passage of
a medium-sized bougie to gently dilate the sphincter and at the same
time stimulate peristaltic action will often do much to prevent the
disease. This should not be done too frequently, and the instrument
should not be too large lest it should set up irritation and bring on
inflammation. Once in twenty-four or forty-eight hours is sufficient.
Such diseases as proctitis, hepatitis, uterine displacements, stricture
of the urethra, and stone in the bladder should be remedied, both
on account of their effects and to obviate the haemorrhoidal develop-

HAEMORRHOIDS— PILES 613

ment. If the rectum is dry and the faecal masses hard, injections of
sweet-oil, or glycerin, or liquid vaseline will prove of the greatest
benefit. Even where the haemorrhoids have already begun, these sim-
ple measures directed toward the rectum itself, and the avoidance of
habits and conditions which predispose to and excite the hsemorrhoidal
disease, will in many instances abort the attack and prevent its future
development.

Palliative Treatment. — Any resort to tentative or palliative measures
in conditions which may be radically cured by operations, little if at
all dangerous, is not considered conservative surgery to-day. There
are many patients, however, in whom radical measures are out of the
question on account of complicating circumstances and diseases. Physi-
cal and nervous conditions, business and social arrangements, and some-
times the absolute lack of moral courage, frequently render it impossible
or unadvisable to operate for haemorrhoids. Some hold that the pallia-
tion of haemorrhoids is unscientific and only done from sordid motives;
that radical removal is the only method of treatment. Aside from
the fact that operation is often contraindicated, the patient himself
has some right to choose whether he will be operated on or treated by
palliative means for conditions in which life is not endangered. It is
true that haemorrhoids are likely to recur after palliative treatment,
but it is also true that many patients treated by these methods go
for years without any recurrence, and some never have it. The fact
that the large majority of those who suffer from rectal diseases in the
United States to-day are treated by irregular practitioners is due to
the inability or refusal of the general surgeon to apply palliative meas-
ures properly.

If the disease were a malignant one, or one likely to endanger
the life or usefulness of the individual, such refusals would be justi-
fied; but this is not the case. Men and women go through life, live
to a good old age, and die from some other disease, carrying with
them from adolescence a bunch of haemorrhoids that become aggravated
from time to time, bleed and prolapse, and yet never disable them for
more than short periods. Where the haemorrhage is excessive and fre-
quently repeated, and as a result the patient is weak, debilitated, and
threatened with profound anaemia, a radical operation is demanded,
and one may be justified under these circumstances in refusing to take
the responsibility of doing anything else than radically and rapidly
putting an end to this exhaustive drain upon the system. But in ordi-
nary cases of simple, varicose, internal haemorrhoids, bleeding occa-
sionally, prolapsing to a slight degree, and causing their victims nothing
more than an uneasiness and slight discomfort, the palliative method
is not only justifiable but frequently the most advisable. No operative

614 THE ANUS, RECTUM, AND PELVIC COLON

method is without some immediate or remote danger; therefore, while
a patient may be told that there is practically no danger to his life,
there is always the possibility of results which are altogether unde-
sirable. Of course such results are very improbable, but they do occur,
and patients hearing of them become unalterably opposed to operative
treatment. With nervous patients such a conviction is a contraindica-
tion to operative procedures, and the radical methods have been fre-
quently brought into disrepute by being forced upon such individuals
who suffer from imaginary disabilities and discomfort in the rectum
forever afterward. In cases, therefore, with these exaggerated fears
and antipathies toward operative procedure, it is better to adopt the
palliating methods, explaining thoroughly that they are not radical
cures, but that by repetition they will give relief and maintain compara-
tive comfort as long as they are continued.

The cardinal principles in the palliative treatment of haBmorrhoids
consist in the prevention of prolapse and arrest '^f haemorrhage. The
haemorrhage is always the most alarming symptom to the patient, and
as it may be excessive it should be considered first. It is rarely diffi-
cult to stop the flow; rest in the horizontal position, cold applications,
injections of hydrastis, tannic acid and krameria, and pressure upon
the anus will usually accomplish this. The chief object is to prevent
its recurrence. In the first place, obstructions to the portal circula-
tion should be remedied at once, whether they be in the line of the
vessels or in the liver itself. The diet should be regulated as to quality
and quantity. Less food and more exercise is usually good advice in
these cases, but there are exceptions to this rule. Restriction in the
use of carbohydrates and alcohol is always necessary. If the patient
has been in the habit of taking a large quantity of liquor, and it is
impossible or unadvisable to cut it off altogether, a small glass of
sherry or a little Scotch or rye whisky two or three times a day may
be allowed. Coffee and tea should be taken in great moderation, and
the use of tobacco should be limited.

He should also be directed to take regular and prolonged exercise
in the open air. If the haemorrhoids do not prolapse so that they would
be irritated by horseback-riding, it is one of the best forms of exercise
for stout individuals. Sometimes, however, the separation of the but-
tocks in order to straddle a horse, and the strain of rising and falling
in the stirrups, induces prolapse of the tumors. Under such circum-
stances riding is harmful, and should be supplanted by walking and
moderate indulgence in outdoor athletics. Late hours and exhausting
cares, either of a business or social nature, should be avoided. A regu-
lar time for going to bed and rising should bo adopted, but too much
sleep and rest in bed are not conducive to the best feeling of such

H-ffiMORRHOIDS— PILES 615

patients. Eight hours is as much sleep as most healthy individuals
need, and rising at a moderate hour after this amount of rest, together
with a cool bath and a good rub, is much miore conducive to good feeling
and general functional activity than lying in bed covered and over-
heated for nine or ten hours. The regulation of the bowels is of great
importance; the fsecal masses should be kept soft and unirritating, and
abdominal straining at stool prevented. A certain amount of laxative
medicine is necessary in the treatment of all these cases, especially in
the beginning. Some remedy which will produce a soft, consistent
stool is therefore better than cholagogues or saline purgatives. The
following combination is excellent:

J^ Ext. colocynth comp., | .. ..,

Ext. cascarae, j ° ' ^'

Ext. belladonnaB, ) .....

T^ , . y aa gr. iii.

Ext. nux vomica?, j o w

M. Ft. pil. No. xii.

Sig.: One or two at bedtime.

Cascara given as heretofore advised is very satisfactory. Aloin,
gamboge, and the resinous cathartics are often harmful in this condi-
tion, but occasionally a combination of calomel, bicarbonate of soda,
and podophyllin in small doses two or three times a day for a week will
act like magic. Phosphate of soda or small doses of Rochelle salts in hot
water before breakfast are also very effectual at times. Cold-water ene-
mata are often more satisfactory than drugs. Any preparation which
produces straining and prolonged sitting at stool should be at once
discontinued. After the bowels have moved the parts should be gently
cleansed with cold water and a soft sponge, but never wiped vigorously
with rough or irritating detergent material, especially newspaper, as
printers' ink is very deleterious in this condition.

If the haemorrhoids prolapse and spontaneously recede, great bene-
fit may be derived from lying down and injecting a small quantity
of cold, even ice-water, into the rectum immediately after the move-
ment of the bowels, and retaining it as long as possible. If, however,
they have to be replaced, it is a good plan to cleanse them as above
advised, and before reducing apply some astringent ointment or solu-
tion. The following formula of the late Dr. Cathcart, of Philadelphia,
is excellent for this purpose:

^ Vng. acid, tannici 3iv;

Ung. stramonii, ) -- ?•

Ung. belladonnae, f ^^'

M. Ft. unguentum.

616 THE ANUS, RECTUM, AND PELVIC COLON

This ointment, applied freely at the time of stool and upon going
to bed at night, will not only check moderate haemorrhages but subdue
the active inflammation in the hamorrhotds. Evt-n where hamorrhoid*
are inflamed and partially strangulated by inflammation, its applica-
tion will frequently subdue the condition to such an extent vithin i
few hours that the patient will rarely consider the question of opera-
tion when he realizes the relief obtainable from such methods of

Fio. 195.— IliBD.

treatment. Where the ha?moiThoida do not protrude, the applia-
tion of the ointment may be made through a hard-rubber pile-pipe
(Fig. 195).

Another ointment which is popnlar in the markets, and said to be I
of great value in the treatment of hsBmorrhoids, is the following:

If Sulph. morphise gr. IJ ;

Tannin gr. 24;

Pine-tree tar gr. 36;

Wax gr. 36;

Benzoated lard gr. 383.

Fluid extract of wich-hazel is also a useful remedy in internal him-
orrhoids. For immediate control of hemorrhage most authors recom-
mend the application of persulphate or perchloride of iron; it produces
a clot which is very hard and irritating to the mucous membrane, and
is frequently followed by a secondary htemorrhage when this comes
away. The reduction of the hjeraorrhoidal mass and the injection of
cold water, or the application to the tumor of a pledget of cotton thor-
oughly infiltrated with iodoform or suprarenal extract, will check the
haemorrhage quite as well and does not leave any uncomfortable after-
effects. The latter promises to become the most reliable remedy for
this purpose. Where the haemorrhoids do not protrude it may be used
in suppositories as follows:

^ Ext. suprarenal Sij;

01. theobromic 5vj.

These can bo applied immediately after stool and upon going to
bed; they produce no irritation of the mucous membrane and no uncom-
fortable effects whatever. In cases where there is excoriation or ulcere-

H-MdORRHOIDS— PILES 617

tion of the haBmorrhoidal tumor, powders such as bismuth, calomel, oxide
of zinc, and aristol serve the double purpose of checking haemorrhage
and healing the parts.

Suppositories are sometimes a convenient method to apply drugs
to haemorrhoids, but they frequently slip up beyond the diseased area
and do no good. Eecently some have been put upon the market so
shaped that they remain in the haemorrhoidal area until they are dis-
solved. Iodoform in quantities of 5 to 10 grains in each suppository
sometimes gives much relief:

Ichthyol in combination with other drugs is an excellent remedy.
The following formula is very effective:

^ I^I^%«1' I aagr y

Tannic acid, J 6 • >

Ext. belladonna?, ) _. , ^

Ext. stramonii, j ^^ ^' *'

Ext. hamamelis gr. x.

M. Ft. suppository.

Opium in any form is rarely useful in the treatment of haemor-
rhoids because it causes constipation. The hypodermic use of morphine
is admissible where the pain is very great and where spasm of the
sphincter is annoying. This spasm of the sphincter is a matter of
considerable importance in the palliative treatment of haemorrhoids.
The occasional passage of a full-sized rectal bougie, which is allowed
to remain within the grasp of the sphincter for five or ten minutes,
usually overcomes the spasm, but occasionally it is necessary to admin-
ister nitrous oxide or ethyl chloride and divulse the muscle. Patients
submit to this who will not consider other operations at all, and it
sometimes results in radical cure.

The amount of relief that can be obtained and the number of cases
which can be practically cured through these palliative methods are
not appreciated by surgeons and practitioners in general. Thousands
of patients who have haemorrhoidal disease are yearly consulting irregu-
lar practitioners and quacks for non-operative treatment of these condi-
tions. It is useless to say that these " pile doctors " do not cure any-
body. In a given number of cases their methods would not be as uni-
formly successful as operative measures; nevertheless, they would suc-
ceed in relieving the large majority and in practically curing many of
them. It is wise, therefore, not to force an operation upon unwilling
patients, but to give them the benefit of whatever knowledge is pos-
sessed of this line of treatment. Frequently, if they have been re-
lieved in several attacks of hsemorrhoids by palliative measures only
to have recurrences, it will be possible to overcome their prejudices

618 THE ANUS, RECTUM. AND PELVIC COLON

and persuade them to have radical operations done, although they at
first, absolutely refused to do so.

Operative Treatment of Hcemorrhoids. — Of the many operations de-
vised for the cure of internal haemorrhoids only a few need be described
at the present day. They are all based upon one of two principles,
viz., the atrophy of the tumors by shutting off their blood supply, or
their radical removal by surgical operations. The principal methods
of accomplishing these ends are gradual or forcible dilatation of the
sphincter, cauterization, injection, the ligature, clamp and cautery,
crushing, excision.

Dilatation. — In the foregoing pages we have already referred to the
beneficial effects of gradual dilatation in the treatment of minor degrees
of haemorrhoids. Veraeuil was the first advocate of this method, and
in 1871 published an article in which he claimed that the use of cold
water, and either gradual or rapid dilatation of the sphincter muscles,
were the best methods for the cure of this disease. The fact that acute
internal haemorrhoids existing in women during pregnancy are often
relieved or cured by dilatation of the sphincter at the time of delivery,
is well known; but it is impossible to understand how this operation can
accomplish any good in old cases which prolapse at stool or upon the
slightest provocation, and in which the muscles are already too relaxed
to retain the parts in their normal position. Further dilatation in
such cases would only aggravate the condition. In this class of cases
it is not only necessary to get rid of the tumors, but also to restore the
tone of the sphincter muscles.

On the other hand, there are mild cases of the disease in which the
small tumors prolapse at stool and are grasped by the external sphincter,
thus causing much pain and annoyance. In these, divulsion often re-
lieves the symptoms, and if it is followed by cold injections and proper
regimen, it will result in a radical cure. Dilatation can be easily per-
fonned under the influence of nitrous oxide gas or ethyl chloride; the
operation does not disable the patient in the least, and may be done in
the doctor's office without any fear of bad results. The permanency of
cure by this method depends largely upon the faithfulness with which
the cold enemata and dietary regimen are carried out afterward.

Method of Dilatation. — Inasmuch as dilatation of the sphincter forms
an integral part of all radical operations for hjemorrhoidal disease, it
seems worth while to give the subject a somew^hat detailed description.
Numerous instruments and methods have been devised by different oper-
ators to accomplish this purpose; most of them are practically divulsors,
but they may be used as dilators instead. Tlie principle which underlies
all true benefit from dilatation consists in the fact that the muscles are
not torn but simply overstretched till all spasm is overcome. Where

H.EMORR QOl DS- PILES

619

the dilatation is carried on too rapidly, the mucous membrane is torn
and the muscular fibers are separated at the anterior and posterior com-
missures. When this takes place the muscles themselves are only par-
tially stretched and soon resume their spasmodic condition, which is only
exaggerated by the ilssure-like cleft which is made in the mucous mem-
brane. If, however, the dilatation is gently and slowly carried out the
muscles may be stretched and temporarily paralyzed without any tear of
the mucous membrane, except in cases where fissures or ulcei-ation al-
ready exist, and the results will be much more permanent in the relief
of the spasm. Kelly's anal dilator (Fig. 68, (f) is a useful instrument for
the accomplishment of this purpose. It is supplied with a register which
gives the operator a full knowledge of the amount of dilatation accom-
plished; it should be introduced with a boring motion, being withdrawn
occasionally for the operator to test by digital touch the amount of
relaxation accomplished in the nmscles. Four or five minutes should
be occupied in this method of dilatation, and, speaking in general terms,
it should be carried out until four fingers can be easily introduced
through the anus and into the ampulla of the rectum. By it all parts of
the anus are distended equably, and little danger of rupture exists.

Another instrument which is highly recommended for this purpose is
Mathews's rectal divulsor (Fig. ISO). The skilful hand, however, ia
better than any instruraent for this purpose. There are two principal

Fio. 1B6. — Matiiewi'b Skotil T>i

methods in vogue for manual dilatation of the sphincters: in the first
the two thumbs are introduced through the anus and slowly but firmly
separated from before backward and then from side to side, practising
massage upon the resisting muscles until a flabby, pulp-like condition
is produced. The time occupied by this procedure will differ according
to the development and apasm of the muscles; in some cases it can be
easily done in two minutes and with very little force; in othere, it
requires five to six minutes and all the strength that the operator pos-
sesses in his thumbs. The tendency is always toward too groat haste.
If carefully performed, it can be done without rupturing the mucous
membrane or causing bleeding, but there will always follow it a certain
amount of extravasation of blood in the cellular tissue around the anus.
The habit of putting the thumbs in the rectum and the fingers of one
hand upon the pubis and those of the other upon the sacrum, or upon

620 THE ANUS, RECTUM, AND PELVIC COLON

the tuber ischii, and stretching or tearing the rectum in ten or fifteen
seconds to the desired extent, is unsurgical and often disastrous; deliber-
ation and patience in the performance of this operation can not be in-
sisted upon too strongly. One should also be careful in stretching the
rectum from before backward not to press upon the prostate or crush
the urethra against the pubis, thus producing traumatism of these
organs; sometimes irritation of the neck of the bladder and deep urethra,
together with more or less bleeding from the urethra, follow violent
dilatation of the rectum in this direction. The second method of dilata-
tion consists in introducing one finger after another into the anus until
all four can be insinuated through the two sphincters; this is done with
a boring motion, and finally the body of the hand can be. inserted. With
the fingers and palm of the hand passed through the sphincter muscle,
the former are then doubled up, as in closing one's fist, and further dila-
tation thus occurs through the expansion of the circumference of the
hand. Care should be taken that the finger-nails are always short and
clipped round, so that cutting or scratching of the mucous membrane
will be avoided. The same time and deliberation should be exercised
in this method as in those previously described. This method of dila-
tation is that employed in Simon's operation of introducing the hand
into the rectum for the purposes of examination. If equal care and
deliberation are exercised, one of these methods is just as good as the
other.

Before attempting any operation, or allowing the patient to come out
from under the influence of the anaesthetic, the operator should remove
the dilating instrument or his hand for two or three minutes, to observe
whether or not there is a tendency in the muscle to recontract. In case
such a condition exists, he should carry the dilatation farther and retain
the dilating instrument or hand for a longer time. Thorough relaxation
having been accomplished, one may proceed with whatever operation is
necessary. If dilatation is all that is intended, a suppository containing
opium 1 grain and extract of belladonna ^ grain should be introduced,
and a compress of soft cotton wool applied to the anus.

Most operators advise confining the patient for two or three days
after this operation. Unless there be some haemorrhage or other reason
calling for this, it is unnecessary.

The use of cocaine, cither hypodermically or locally, for stretching
the sphincter has not proved satisfactory in my hands; the amount of
the drug necessary, the frequent punctures of the needle and consequent
irritation and cedema of the parts, are all objectionable. Reclus and
Bodine have each reported satisfactory results from the injection of large
quantities of a mild solution of the drug for this purpose, but in general
one will find some form of complete anaesthesia much more satisfactory.

HEMORRHOIDS— PILES 621

Treatment hy Cauterization. — Cusack and Houston (Dublin Jour, of
Med. Sci., 1843, p. 95) many years ago enthusiastically advocated the use
of nitric acid in the treatment of haemorrhoids. This and various other
cauteries have been from time to time exploited as cures for this disease.
The method is very useful in the capillary variety of piles but it has
become obsolete in all others.

In capillary haBmorrhoids, the application of nitric acid is one of the
safest and most effective means of treatment. In these cases a conical
speculum (Fig. 63) is introduced, and the slide is drawn out until the
little pile protrudes into the fenestrum; it should be wiped off dry with
absorbent cotton, and the acid applied all over its surface by means of a
wood or glass applicator. Some have advised the use of little spun-glass
brushes for the application of the acid, but, as Ball points out, there is
danger of small fragments of glass breaking off from these brushes and
penetrating or irritating the mucous membrane. The speculum should
be held in place for four or five minutes until the acid has thoroughly
attacked the tumor, and then the parts should be washed off with a
saturated solution of bicarbonate of soda in order to remove anv excess
of acid which may remain. The first application of the acid generally
checks the bleeding effectually, but in order to eradicate the tumor it is
necessary to repeat the application two or three times at intervals of
about five days or a week.

There is no necessity for cocaine or any other local anaesthetic in this
method, as it produces no pain in the mucous membrane; but great care
is necessary to avoid touching the margin of the anus with the acid.
That region should be smeared with vaseline before the application is
attempted. After the speculum is withdrawn, a suppository containing
i a grain of opium is advisable to overcome tenesmus and peristaltic
action.

Other chemicals have been employed for this purpose, such as nitrate
of silver, caustic potash, arsenical paste, acid nitrate of mercury, pyro-
gallic acid, and butter of antimony, but none of these is as effectual as
the fuming nitric acid.

Hamilton (Ball, op. cit., p. 255) recommends passing through the tu-
mor needles coated with fused nitrate of silver. A better method than
any of these, however, consists in the application of the electro-cautery.
The tumor is brought into view just as for the application of nitric
acid, and a 10-per-cent solution of cocaine applied as a precaution more
than a necessity. After two or three minutes a small, flat electro-cautery
is applied to the summit of the tumor and the current turned on; by this
the whole growth can be burned away at one sitting; the haemorrhage
is immediately checked and does not recur, and afterward an opium sup-
pository is introduced and the patient is allowed to go about his occupa-

622 THE ANUS, RECTUM, AND PELVIC COLON

tion after two or three hours' rest. This procedure has the advantages
of being aseptic, radical, and exact, in that one can govern absolutely
the area and depth to which the cautery bums, and a second application
is rarely necessar}'. The method is also applicable to small venous pil^
high up in the rectum.

Electrolysis. — For the class of tumors which have just been men-
tioned. Ball recommends electrolysis. His method is as follows:

" The pile being brought into view, the surface is well painted over
with a solution of cocaine hydrochlorate (4 per cent), and after the lapse
of five or ten minutes four or Rwe round sewing-needles mounted in a
handle are passed into the center of the tumor and connected with the
negative pole of the battery, 10 to 20 Leclanche elements being the most
suitable; the other (positive) pole being applied by means of a wet sponge
to the buttock. After a few minutes the surface of the pile will be seen
to become white, and minute bubbles of hydrogen gas will be seen es-
caping round the needles. As soon as this is well marked, the needles
are withdrawn, and if deemed necessary, reintroduced into another part
of the same or another pile. In a few days the piles shrivel up and dis-
appear painlessly. If the positive pole is used the needles stick tightly
in, and haemorrhage may result from their forcible withdrawal. It has,
however, in order to avoid this inconvenience, been reconmiended in the
case of na?vi to use the positive pole first attached to the needles, and
then, after a few minutes, to reverse the current for a short time previous
to the withdrawal of the needles. I have not, however, found this plan
satisfactory, and prefer to use the negative pole all through." It re-
quires one or two applications to complete the cure, it does not confine
the patient, and with the use of cocaine there is comparatively no pain.
This method is more difficult than electro-cauterization, and the results
are not quite so radical. The one advantage which it has over the other
method is that no ulceration is produced by it, and the patient is never
annoyed by the slight moisture and occasional backache which is asso-
ciated with all operations which depend upon healing by granulation.

Injection Method. — The injection treatment of haemorrhoids is said
by Andrews (Rectal and Anal Surgery, p. 34) to have originated with
Mitchell, of Clinton, 111., in 1871. The method was kept secret and
rights to practise it in certain districts were sold to drug clerks, farm-
ers, irregular practitioners, or to any one who had the money to pay
for them. It soon fell into the hands of uneducated and irresponsible
charlatans who traveled from town to town, recklessly performing the
operation upon all kinds of cases, sometimes injecting polypi and
even carcinomata for piles. Andrews's statistics upon this method
were gathered from the work of this class of practitioners, and the
great wonder is, not that he found many bad results, but that they

BLffilMORRHOIDS— PILES

623

were so few. He collected 3,304 cases {loc, ^iL^ p. 36) with the fol-
lowing results:

Deaths 18

Embolism of liver 8

Sudden and dangerous prostration ... 1

Abscess of liver 1

Dangerous haemorrhage 10

Permanent impotence 1

Stricture of the rectum 2

Violent pain 83

Carbolic-acid poisoning 1

Failed to cure 19

Severe inflammation 10

Sloughing and other accidents 85

The records are not suflBciently complete for analysis, but it is
safe to say that they show remarkably good results obtained by the
method under adverse circumstances. Any other surgical operation
for haemorrhoids in such inexperienced and unscientific hands would
have produced a larger mortality and a longer Ust of accidents. The
mortality of less than one-half of 1 per cent, and failures in about
one-half of 1 per cent, are certainly not alarming results. Can any
practitioner cite 3,300 cases of haemorrhoids operated by any other
method with only 2 strictures? The other accidents, embolism and
abscess of the liver, prostration, permanent impotence, carbolic-acid
poisoning, severe inflammation and sloughing, are too indefinite and
problematic in their etiology to merit a discussion. It is possible some
of them were produced by the injection, but certain that most of them
were not. These statistics, however, and the abandonment of the
method by Kelsey — who, having had over two hundred perfectly satis-
factory results, suddenly turned against the operation after one or two
accidents — created at one time a strong prejudice against it. Lately,
however, a better knowledge of the method and the class of cases to
which it is applicable have led many surgeons to give it a trial, and their
reports are very satisfactory. The method is well worthy of thorough
consideration.

The Class of Hemorrhoids in which Injection may he Used. — The
most enthusiastic advocates of this method no longer advise it in any
other than internal piles. Even Agnew, in the last edition of his book,
says: " Since the advantages of cocaine have become known, and the
fear of haemorrhage has been dispelled, there is absolutely no apology
for the treatment of external haemorrhoids by any method other than
excision " {loc. cit,, p. 24). This is the position taken by the writer
in a paper before the Academy of Medicine in 1894, and is almost uni-
versally accepted. Only those piles should be injected which can be
brought into view and made surgically clean; occasionally small tumors
may be treated through the conical fenestrated speculum, but it is not
so satisfactory as when they are brought outside of the anus.

The size of the haemorrhoids is no contraindication to this method
of treatment so long as they completely collapse when pushed up in

624 THE ANUS, RECTUM, AND PELVIC COLON

the rectum. Some claim that it is a matter of indiflference whether
the haemorrhoid is already ulcerating or not, but the author does not
consider it wise to inject under these circumstances. Mixed haemor-
rhoids and those complicated by fissure or spasmodic sphincter are
not favorable for the injection treatment. In a word, uncomplicated,
varicose, internal haemorrhoids are the ones to which this method is
most applicable.

There are two distinct schools in the injection treatment: the first
injects strong solutions in large quantities, thus causing a sloughing
of the entire haemorrhoidal tumor; the second injects small quantities
of weak or moderately strong solutions, and in this way produces an
inflammatory induration and choking of the circulation, which is fol-
lowed by shrinking and atrophy of the piles without ulceration or
sloughing.

Agnew, of San Francisco, represents the first school. He claims
that all the accidents following treatment by injection are due to the
use of mild solutions, which he says set up an inflammatory condition
with minute thrombi in the veins that are easily dislodged. He states
that the injection of strong solutions of carbolic acid in quantities
sufficient to permeate the entire substance of the tumor acts as an
escharotic, causing immediate death of the haemorrhoidal mass, and
this drops away as a dry eschar in a few days. He lays great stress
upon the mixture used, which he prepares as follows:

" The solution of carbolic acid found to be uniformly successful
in the treatment of haemorrhoids by injection is prepared by first mak-
ing a solution of the acetate of lead and borax in glycerin, in the
proportion of 2 drams each of the chemically pure salts to 1 ounce of
Price's glycerin.

!9 Plumbi acet., ) -. ^..

Sodii bibor., [ ^ -"'^^

Glycerinae 5].

" Mix in a graduate, pour into a 2-ounce vial, and let stand for twenty-
four hours. The solution of the salts is hastened by placing the vial
in a warm- water bath and letting it remain there for fifteen or twenty
minutes. The glycerin can be handled to better advantage and its
measurement more accurately made by warming it before it has been
poured into the graduate and the chemicals have been added.

" Select Calvert's No. 1 crystallized carbolic acid and pour a sufficient
quantity, liquefied by warmth, into a 2-ounce graduate to measure 1
ounce, and add 2 drams of distilled water. To this add enough of
the glyceride of lead and borax previously made to make the combina-
tion measure exactly 2 ounces.

HJSMORRHOIDS— PILES 625

IJ Acidi carbol. cryst Sj;

Aqua? destillati oij;

Sod. bibor. et plumb, glyc ovj.

Misce et Sig.: Solution for haemorrhoids.

" The object of the water in the formula is to lessen the sirup-like
consistence of the preparation. Should equal parts of crystallized
carbolic acid and glyceride of lead and borax be combined, the solution
will be found rather too heavy for convenience. It will not flow through
the hemorrhoidal needle as freely nor take hold of the tissues, when
injected, as quickly as does a solution containing a small proportion of
water."

Others of this school use mixtures of carbolic acid with olive-oil, or
other substances, and vary the strength from 25 to 75 per cent.

The famous Brinkerhoff method consists in injecting haemorrhoids
with the following mixture:

IJ Ac. carbolici Sj;

01. oliva; 5^;

Zinci chlorid gr. viij.

From two to eight minims are injected according to the size of the
pile.

Carbolic acid is the principal ingredient in them all, and the inten-
tion is to destroy the haemorrhoid by causing it to slough off. This
necessarily leaves an ulceration of the rectum which may give more
distress than the piles, especially if the sphincter is not dilated and
perfect drainage afforded. To avoid any misunderstanding, the author
would state that he has no sympathy with this method. If the treat-
ment of haemorrhoids by injection is to be followed by sloughing, ulcera-
tion, and granulation, and the patient is to be confined to his bed for
a week or more, then all its supposed advantages disappear. An ulcer
produced by diffuse cauterization and sloughing is never as healthy
or prompt in healing as a clean surgical wound, and can not be so
accurately limited to the diseased tissue. The pain during the period
of sloughing is greater than that following surgical operations, and
the dangers of abscess or sepsis by absorption from the necrotic area
are incomparably more. The patient escapes general ana?sthesia, but
at the expense of time, pain, uncertainty, and danger. If, therefore,
the haemorrhoid is to be removed, let it be done by scientific surgical
methods. If, however, the haemorrhoids can be eradicated without pain,
sloughing, ulceration, or confinement, it will be a distinct improve-
ment over operative measures; this ie what is claimed for the second
method of injection, and in properly selected cases it is believed that
the claim can be substantiated. The principle upon which this method
40

626 THE ANUS, RECTUM, AND PELVIC COLON

is based consists in the production of an inflammatory induration of the
h(Bmorrhoidal mass through which the circulation is retarded or partially
cut off, hut which does not go to the extent of cauterization or strangulation
so as to result in sloughing. The cases to which it is applicable are
those of uncomplicated internal haemorrhoids which can be brought
into view and sterilized, in which no ulceration and no external haemor-
rhoids exist, and in which the sphincters are comparatively relaxed.

The Operation. — The patient should be just as carefully prepared
for injection as for any other operation for haemorrhoids. The
sphincter should be gradually and gently dilated, a procedure that may
require two or three days if it is spasmodic. The bowels should be
carefully emptied the night before the injection by a laxative, and a
saline enema should be given one hour previous to the treatment. If
it is difficult to bring the ha?morrhoids into view, the patient should
sit upon a vessel filled with hot water and strain for a few moments
in order to bring the tumors down; when this is accomplished he is laid
uj)on the side to which the haemorrhoids to be injected are attached.
While he pulls uj)ward with one hand upon the upper buttock, an assist-
ant pulls downward on the lower one, and thus the tumors are steadied
and kept outside of the anus. They are then thoroughly but gently
washed with soap and l-to-2,000 ])ichloride solution, after which they
are dried and the injection is made. The needle is introduced at the
juncture of the tumor with the normal mucous mem])rane below, and
carried well across its base. The finger is then introduced into the
anus to ascertain that the needle has not penetrated or closely ap-
proached the mucous membrane above. Small amounts of the fluid are
then slowly injected, partially withdrawing the needle and reintrodu-
cing it in different directions so as to distribute the fluid as equably
as possible over all the base; after this the needle is carried upward
into the body of the tumor and a small quantity of fluid is injected
near its center. The needle is then left in situ for one or two minutes
in order that the fluid may become disseminated and not flow out
through the point of puncture. A small pledget of cotton soaked in
alcohol is placed around the needle so as to cover the puncture when
it is withdrawn and to prevent the fluid which may escape from irrita-
ting the surrounding tissues. The tumor is kept outside of the
sphincter for two or three minutes in order that the squeezing neces-
sary to reduce it will not force the fluid into other portions than those
into which it was injected; it is then reduced, a small compress of
cotton is placed upon the anus and held there firmly by a T-bandage,
the patient being required to lie still for ten or fifteen minutes. It is
best to keep him quiet for a few hours after the first injection, because
the inflammatory action produced in one patient is never any guide as

HEMORRHOIDS— PILES 627

to what will be produced by the same injection in another; after this
if there is no great pain or swelling he may go about his usual avoca-
tions. On the day following the injection the tumor will be found
to consist of a tense, hard mass, not particularly painful to the touch
and of a bright-red color. It remains in this condition for two or
three days, after which it begins to shrivel, and eventually there
is nothing left at its site but an apparently normal mucous mem-
brane somewhat more closely attached to the deeper tissues than is
normal.

The Number of Tumors to be Injected. — Where there are several
tumors it is well to select the one which is apparently causing the
patient the most inconvenience, either through prolapse or bleeding,
and inject this one first. It is not advisable to inject more than one
tumor at the first sitting. After this, if there is no unusual disturb-
ance, one may with safety prepare the patient and inject at the follow-
ing sitting two or three of the remaining tumors in the same manner.
The second injection should not be made sooner than five days after
the first. ^

The Repetition of Injections. — In the majority of instances one never
has to inject the same tumor more than once, but sometimes through
overcautiousness and the injection of too small a quantity of fluid,
sufficient inflammatory reaction to obliterate the pile is not produced
and then the injection must be repeated.

The Solution. — After having tried many substances, the following
modification of Shuford's solution has proved the most satisfactory:

IJ Ac. carbolici (Calvert's) .• 3ij;

Ac. salicylici ^ oss.;

Sodii biborate 3j;

Glycerina} (sterile) q. s. ad. 5J-

M. Sec. Art.

The fluid should be of a sirupy consistence and perfectly clear. A
milky-white appearance is due to imperfect solution, and invalidates
its usefulness. The action of the salicylic acid consists in softening
and destroying the epithelial and endothelial cells, thus producing an
inflammation of the venous walls which eventually causes them to ad-
here together and completely obliterates their caliber. The biborate
and carbolic acid act as irritants and antiseptics, causing the inflamma-
tion in the perivascular tissues.

Amount of Fluid to be Injected. — The amount of fluid to be injected
in any individual tumor will depend upon its size. It is difficult to
lay down any absolute rules for this; the largest tumor never requires
more than 10 minims, and the quantity must be graduated from this

Fio. 197. — Gant*8 Strinok roR ikjkctino H^morbhoids.

628 THE ANUS, RECTUM, AND PELVIC COLON

amount down to 2 or 3, the average injection being about 5 minims
of the solution.

The Instrument. — No special instrument is necessary to make these
injections. An ordinary hypodermic syringe with a metal plunger and
a Xo. 21 hypodermic needle are all that are required. Fine needles do
not allow the fluid to flow easily. It is convenient to have handle-bars

upon the g}T-
inge in order to
steady it, as it
sometimes re-
quires consider-
able strength to
force the fluid
through the
needle. Special

syringes and needles, such as those devised by Agnew and Gant, are
convenient, no doubt, but they are not necessary. The curved extension
on Gant's syringe (Fig. 197) can be attached to any ordinary hypodermic
syringe, and allows the operating hand to drop out of the line of vision,
and is therefore useful.

The After-treatment, — After a hsemorrhoid has been injected by this
method there is comparatively little pain, and no opiates, sedatives,
or local applications are required. A suppository of opium, belladonna,
and iodoform may be introduced for the first two nights to prevent
the bowels from moving, but it is not necessary for the relief of pain.
The bowels are confined for forty-eight hours, after which they are
moved either by a gentle laxative or a cold-water enema. This is
repeated every day, and thfe patient is allowed to go about his business
after the first twenty-four hours. Thus practically there is no after-
treatment. The inflammatory condition gradually subsides, and the
protrusion and bleeding usually cease from the first day.

Accidents and Complications. — Prolapse of an injected haemorrhoid
may occur within the first twelve or fourteen hours after the opera-
tion. The patient should be warned against straining or too long
standing until the danger of this has passed. If by any accident,
through passing gas or otherwise, the injected tumor should slip out-
side of the sphincter, it should be replaced at once by gentle pressure
with a soft sponge or wad of cotton; if the patient is unable to do
this he should send for a physician and have it done at once. If this
is not done strangulation and sloughing may occur.

Shvghing. — Since beginning this method of treatment the author
has had sloughing in 3 cases only; in these he was unable to account
for the cause unless it was due to his having injected the fluid too

H^MOBRHOIDS— PILES 629

close to the surface of the tumor. The condition in each of these
cases was simply a sloughing out of the central portion of the tumor,
leaving a sort of fissure between the hardened masses upon each side.
In 1 of them the tumor was low down and occasioned a great deal of
pain and annoyance; in the other 2 the tumors being high up gave the
patients no trouble whatever beyond the alarm occasioned by seeing
a little blood and pus secreted from the rectum. All 3 cases, how-
ever, recovered after five or six weeks, and the tumors entirely dis-
appeared.

As to abscess, sepsis, haemorrhage, thromboses, and affections of the
liver, which are said to follow this method of treatment, the author
has had no experience with any one of them; sepsis or abscess is hardly
possible if it is properly carried out. There is nothing in the solution
that is septic or capable of producing pus; if the needles and the syringe
are properly sterilized before they are used, and if the tumor is cleansed
with antiseptic solutions so that no infecting germs can be carried in
from its surface by the needle, it is not likely that an abscess or an
infection of any kind will ever be produced by it. Gant, who has
employed the method for a considerable time and with more or less
success, records one notable failure in his experience in which an abscess
and slough were produced by injecting a haemorrhoidal tumor. He
states, however, that upon careful examination he found in the abscess
a small focus in which there rested a minute mass of faecal matter
evidently carried in upon the end of his needle, thus accounting for
the infection of the tumor.

Haemorrhages can not occur when the mucous membrane is not
broken through ulceration or sloughing, and as the method does not
produce this, they will never be seen unless some other complication
appears.

Recurrences. — The strongest point in Kelsey's argument (op, cit,
p. 183) against this method of treatment consists in the statement
that the operation does not radically cure. He says that relief con-
tinues for about three or four years, after which the haemorrhoids
return even worse than before. Granting that this is true, the fact
remains that the haemorrhoids are in no worse condition for operation
upon their recurrence, and the large majority of patients would much
prefer to take this chance with respite from the operating-table for
so considerable a time. The author has had cases return to him for
treatment after he had injected internal haemorrhoids, but upon careful
examination it has nearly always been found that the haemorrhoid was
at a different part of the anal circumference from that at which the
original injection was made. In a very few cases recurrences in situ
have taken place, and in only 2 in which the injection treatment was

630 THE ANUS, RECTUM, AND PELVIC COLON

used has it ever been necessary to do a more radical operation. All
the recurrences observed have taken place in six to twelve months,
and many j)atients injected six to nine years since have never liad the
slightest return.

When the j)iles do recur, they may be treated again after the same
method quite as succes.-^fully as at first. The probability of such results
should be frankly stated to the patient before adopting this line of
treatment, but the majority will prefer periodic treatment of this
kind rather than submit to radical operations. It is not claimed
that this method is superior or even equal to the accepted surgical
procedures, but it is maintained that the accidents and complications
which follow it have been greatly exaggerated by writers upon this
subject, and that most satisfactory results can frequently be obtained
through it in properly selected cases.

In all the strictly operative methods certain preliminar}- procedures
are necessary, such as preparation of the patient, anaesthesia, and dila-
tation of the sphincter.

Preparation of the Patient. — In order to obtain the best results,
patients should be as carefully prepared for ha?morrhoidal operations
as for laparotomy. The bowels should be thoroughly emptied twenty-
four hours before the time, and only light diet allowed during that
period. Rochelle salts, or a full glass of Rubinat, Apenta, or Hunvadi
water, given early in the morning and repeated if necessary in three
hours, will accomplish this purpose. The evening before the opera-
tion a bichloride dressing should be applied to the anus and retained
by a T-bandage. If excision is to be practised, the perina?um and anus
should be shaved, but this is not necessary for the ligature or clamp-
and-cautery operations. The patient should have a quiet, restful night
before the operation, even if trional or chloralamine has to be given.
Three hours before the operation a salt-and-soap enema should be
given: when this passes the parts should be washed and the dressing
reapplied. After the patient is anaesthetized and in position on the
table the sphincters should be dilated, the rectum irrigated with a 1-
to-3,000 bichloride solution, and the external parts surgically cleaned.
The order of procedure in this is important, for if the external parts
are pre])ared l)efore the sphincter is stretched and the rectum cleansiMl,
faecal matter from the latter mav come down and soil the outer field.
The bladder should always be emptied before beginning any operation
on the rectum, and if necessarv this should be done with a catheter
before cleaning up the operative field.

^^^lile such preparation is advisable in all cases, it is sometimes
almost impossible, and those who have done clinical work know that
it is not indispensable in the clamp-and-cautery operation, for the hot

HAEMORRHOIDS— PILES 631

iron destroys germs and seals the lymphatics and blood-vessels against
septic absorption.

'J'he Ancesthetic. — Generally speaking chloroform is preferable to
ether in operations upon the rectum, because it is followed by less
nausea and straining. When ether is preceded by nitrous-oxide gas
or ethyl chloride, and very small quantities of it used, this disagree-
able feature is largely eliminated.

As the operation for ha?morrhoids is short and simple, one may gener-
ally use chloroform with comparative safety, although it is more danger-
ous than ether. Ethyl chloride takes the place of gas in the adminis-
tration of ether, and is much more convenient, but it is not satisfac-
tory alone, as it does not completely relax the muscles.

If *^ spinal anaesthesia " proves to be without danger, it will be
superior to either chloroform or ether in operations upon the rectum,
because the nausea disappears before the operation is completed, the
oozing is much less, and the anaesthesia is so prolonged and fades so
gradually that the patient is practically over his initial pains before
sensibility returns. The bowels, however, must be thoroughly emptied
before attempting plastic operations under it, as involuntary move-
ments are very likely to occur and soil the operative field. The remote
effects of puncture and injection of foreign fluid into the spinal canal,
however, remain to be seen.

The operations may be done painlessly by the hypodermic injection
of cocaine or eucaine. The difficulty lies in dilating the sphincter.
Reclus and Bodine both claim to be able to dilate the sphincter pain-
lessly by infiltration of the parts with very weak solutions of cocaine,
but the author has not been successful with this method.

Position of the Patient. — Tlie position in which one operates is
largely a matter of habit and early teaching. AUingham and the ma-
jority of operators prefer the lithotomy position, Mathews advises the
Sims's position, and some operators prefer having the patient swung
in the knee-chest posture. The lithotomy position is generally the
most convenient except in cases with anchylosed hij)s, and in these it
is necessary to select that which gives the easiest access to the parts.

The LrcjATrRE. — The ligature has been for manv vears the most
popular method among surgeons for the treatment of haMuorrhoids.
It lias num])ered among its advocates the most noted and scientific
men in the medical profession. It is perhaps to Allingham more than
to any other that this operation owes its popularity. It is applicable
to almost every variety, and whatever else may be said against it, no
one can denv its effectiveness in the cure of ha?morrhoids. In this
countrv Mathews has been the most brilliant and consistent advocate
of this operation. There are several methods of applying it. Tlie

THE ANUS, RECTUM, AND PELVIC COLON

three which will be described are those of Mathews, AUiiigham, and

Rickets.

Mathews's Method. — The patieut is placed in Sims's position, the
sphincters dilated, and forceps or small retractors are used to bring
the hipmorrhoids into view.
Small tumors are caught
and tied off with fine
thread, either linen or silk.
Where there are no skin-
tabs or hypertrophied folds
around the anns, no cutting
whatever is done. " The
large tumors are caught
well at their base, drawn
stoutly down by the for-
ceps, held there by an as-
sistant, and a curved needle
threaded with stout silk is
passed immediately through
the base. The needle is
now cut away and the liga-
tures tied stoutly, first on
one side of the tumor, then
on the other (Fig. 198).
Having the tumor tightly
tied on each side, the pile is now cut off with a pair of straight scissore,"
The amount of the tumor to be cut away is a matter of individual
judgment, although Mathews indulges in a somewhat extensive argu-
ment with regard to the danger of cutting ofE too much or too
little. Only so much of the mass should be left as will thoroughly
hold the ligature. After the tumors are removed, he places a piece
of iodoform or bichloride gauze against the stumps ami pushes them
back into the rectum, A large anal compress is placed in position
and held by a T-lwndage. "The patient is then given a hypodermic
injection of ^ of a grain of morpliine and -^^ of a grain of sulphate
of atropine before he is taken to his room. This is repeated in one
or two hours if necessary." He also uses sulpbonal in 15- or 20-grain
doses, to control the spasm of the sphincter. If the hsemorrhoid:* are
complicated by external connective-tissue growths, he makes an incision
in the skin around these growths, transfi.xi's them along with the in-
ternal tumor, and ties one ligature in the groove produced by this
incision and another on the mucous membrane. He then cuts off the
summit of the tumors, thus removing them all in one mass. With

HEMORRHOIDS— PILES

regard to the amount of exterual tissue taken off with external hsemor-
rhoids, he states that the danger is always in taking off too little rather
than too much; that one of tlie most annoying comijlications of this
operation consists in an inflammation of the superfluous flaps of skin
at the margin of the anus, and that if a good sweeping cut is made
entirely around the akin-tab to be removed, the patient wi!l be much
more comfortable afterward and there will he very little danger of
anal stricture.

AlHngkam's Method. — The operation generally known as Ailing-
ham's was devised by Mr, Salmon more than fifty years ago, and has
been almost invariably practised at St. Mark's Hospital, London, since
that time. The method, as described by him, is as follows:

" The patient, having been previously prepared by purgatives, is
placed on the right side on a hard couch in a good light, and is com-
pletely anEesihetized, and then the sphincter muscles are gently but
completely dilated. This completed, the rectum for 3 inches is within
easy reach, and no contraction of the sphincters takes place, so that
all is clear like a map before one. The ha?morrhoids, one by one, are
to be taken by the surgeon with a volsclla or pronged hook-fork and
drawn down; he then, with
a pair of sharp scissors,
separates the pile from its
connection with the muscu-
lar and submucous tissues
upon which it rest«; the
cut is to be made in the
sulcus or white mark which
is seen where the skin meets
the mucous membrane, and
this incision is to be car-
ried up the bowel, and par-
allel to it, to such a dis-
tance that the pile is left
connected by an isthmus
of vessels and mucous mem-
brane mih/.

" There is no danger in
making this incision, be-
cause all the larger vessels
come from above, nmning
parallel with the bowel just

ienralk the mvrovs viemhraiie, and thus enter the upptr part of the pile,
A well-waxed, strong, thin, plaited silk ligature (Turner's Xo. 6) is now

634 THE ANUS, RECTUM, AND PELVIC COLON

to be placed at the bottom of the deep groove which has been made,
and tlie assistant then drawing the pile well out, the ligature is tied
high up at the neck of the tumor as tightly as possible (Fig. 199).
One must be very careful to tie the ligature, and equally carefid to tie
the second knot, so that no slipping or giving way can take place.
We always tie a third knot; the secret of the well-being of the patient
depends greatly upon this tying — a part of the operation by no means
easy (as all j)raetical men know) to effect. If this be done, all the
large vessels in the pile must be included. The arteries in the cellular
tissue around and outside the bowel are few and small, as they do not
assist in the formation of the pile, being outside it. These vessels
rarely require ligaturing. The silk should be so strong that it can
not be broken by fair pulling. If the pile be very large, a small portion
may now be cut off, taking care to leave sufficient stump beyond the
ligature to guard against its slipping.''

After the piles have been tied, if they are small ones he does not
cut them off, but leaves them to be cut through by the ligature. Any
skin-tabs or superfluous muco-cutaneous membrane around the margin
of the anus are cut off with scissors, the bleeding being checked by
compression. A point which is well brought out by Allingham is the
necessity of making the pedicle of the hsemorrhoidal tumor as small
as possible without dividing the chief arterial supply. If it is large
and broad, and there are several ha}morrhoid8 about the rectum, the
ligatures will draw the mucous membrane together and produce con-
sidera])le contraction of the cali])er. In this way marked stricture may
be ])roduced. By making a narrow pedicle one leaves little strips of
mucous membrane around the rectum which conduce to rapid healing
of the parts.

Operators in this country are about equally divided in their prefer-
ences for the ^lathews and Allingham operations. In the latter the
amount of tissue to be cut through by the ligature is less and the
granulating surface smaller, but there is more danger that the liga-
ture will slip off the stump and cause secondary haemorrhage than in
the transfixion method of ^lathews. But haemorrhage, either primary
or secondary, from ha^niorrhoidal operations seems to be somewhat of
a bugaboo to frighten young operators and make them careful. In
an experienc(? of twenty years the author has never seen any serious
liaMuorrhage follow an operation for luTmorrhoids by injection, liga-
ture, clani]) and cautery, or dissection, save in 1 case, which will be
detailed later.

^^^latever else may be said against the ligature operation, two things
stand out in bold relief: it is slightly if at all dangerous to life, and it
absolutely cures the disease. Accidents and deaths have followed this

HiEMORRHOIDS-PILES 635

operation, as they have almost ever}' other surgical procedure. They
are so few, however, that one need hardly consider them when the
conditions justify the removal of the haemorrhoids. Copeland, Curling,
Sir Benjamin Brodie, Agnew, Van Buren, Ashhurst, Gross, Sands,
Cooper, Goodsall, and hundreds of other leading surgeons throughout
this country and Europe have expressed their preference for this opera-
tion over all others, and with few exceptions have seen no fatal results.
Alliugham lias recorded five deaths in over four thousand operations;
Curling reported one death; Agnew saw three deaths all due to tetanus;
and Mathews, up to the time he completed his thousandth case, had
never had one from this oj)eration in his own practice.

After-treatment, — AUingham attributes all the unfortunate results
which follow this method to the after-treatment, lie confines the
bowels for four or five days, and uses opium freely for this purpose
and for the relief of pain. On the day following the operation the
outside dressing is removed, the parts are dusted with iodoform or
some other powder, and after this only small pledgets of dry gauze
will be necessary. To some patients a dressing moistened in some form
of antiseptic solution is more grateful.

The bowels arc moved, according to the necessity of the case, after
four or five days. Whatever laxative is selected should be given in
sufficient dose to compel the movement of the bowels even against the
patient's resistance, for at this time the sphincter will have regained
its tonicity, and the fear of pain will cause the patient to hold the
movement back as long as possible. Wlien the inclination for a move-
ment begins to be felt, an injection of warm sweet-oil into the rectum
will facilitate it, and prevent any friction by the faecal mass upon the
stumps and ligatures. In the majority of cases the patient may sit
upon the commode for this pur])Ose; it makes the movement easier and
causes less straining than when the bedpan is used. As AUingham
savs, there are cases so ana?mic and debilitated that the recumbent
posture is desirable, and in these the use of the bedpan for several
davs will be necessarv. After the bowels have once moved, 8 ounces
of boric-acid solution should be injected into the rectum, and expelled
again in order to wash away any faecal material which may have adhered
to the raw surfaces. If there is any difficulty in obtaining a move-
ment of the bowels, the finger should be introduced at once to ascer-
tain if impaction has taken place, and if so it should be broken up.
AUingham advises the introduction of the finger into the bowel every
day after the first week in order to avoid any contraction; he confines
the patient to bed for one week or more, and does not allow him to
walk about until the wounds are healed.

After the bowels have moved for the first time, gentle traction

636 THE ANUS, RECTUM, AND PELVIC COLON

should be made upon the ligatures daily in order to withdraw them
when they have cut their way through. This should be very care-
fully done lest too much dragging should tear off a pedicle and thus
bring about secondary hieinorrhage.

The time required for complete healing by these two methods is
from twenty-five to forty days. The period of confinement to bed is
from five days to three weeks, according to the temerity of the
operator.

Submucous Ligature. — Merrill Rickette, of Cincinnati, has recom-
mended the submucous ligation of hfemorrhoidB. He claims for it the
following advantages: Impossibility of secondary hremorrhage; no tissue
ia destroyed or sacrificed;
the time of confinement is
very short; there ia no pro-
tracted ulceration, and in
liis experience up to the
ijitii' of the report, there
li;i(| been no infeetion of
.i:iy kind; the pain is less
■..111 by other methods of
.;_,iiion; there is absolute-
ly no eontraction in the
caliber of the gut.

His method is as fol-
lows: The sphincters are
dilated and the parts pre-
pared, as has been already
described. A needle curved
to rather more than a semicircle, and threaded with mode rate- si zed kan-
garoo tendon, is passed aubmucously around the base of each prominent
ha'morrhoid (Fig. 200). After the ligatures have all been passed, they
are then tied so that the knot slips through the aperture made by the
needle and buries itself in the submucous tissue, the ends being cut off
very short. After this the hitmorrhoids become very much distended,
and it ia sometimes necessary to puncture the larger ones and allow the
blood to escape in order to prevent sloughing. The tumors are then
replaced within the sphincter, and a firm compress placed upon the
anus to prevent their prolapsing.

Ricketts states that "after a few weeks" atrophy takes place to
such a degree as to completely destroy all the objectionable " varices **
which formerly existed.

The method sounds reasonable, and is no doubt effectual, but the
dangers of infection and subsequent abscess must not be ignored. Some

HEMORRHOIDS— PILES 637

little experience with the buried ligature in the treatment of rectal
prolapse has convinced the writer that this danger is less than is usually
supposed, and Ricketts's experience corroborates this view. If the
ligatures overlap or loop into each other the method will result in a
certain amount of contraction in the caliber of the rectum.

Clamp and Cautery. — This operation for haemorrhoids was first
suggested by Cussack about 1846. His method consisted in clamping the
haemorrhoid with a strong forceps, cutting off the protruding portion,
and cauterizing the stump with nitric acid. Mr. Henry Lee adopted
the method in England, and it was through his influence that Henry
Smith was led to put it into practice in 1861. He did not use nitric
acid, but cauterized the ends of the stump with the actual cautery.
He emphasizes the importance of having the blades of the clamps
mortised on one side and elevated on the other, with serrated edges,
and even in his early operations called attention to the fact that the
catching of integument in the clamp caused more pain than all the
rest of the operation. The principles upon which the operation is
based consist in the double protection against haemorrhage through
crushing and cauterization, the destruction by the actual cautery of
all septic germs which may be distributed over the parts at the time
of the operation, and in sealing up capillaries and lymphatics to
prevent septic absorption. The operation is completed at one sit-
ting; there are no ligatures to cut through by slow and tedious proc-
ess; there is no protracted irritation about the nerves, no sutures
to be removed, and, according to the patholog}' of Smith's day, the
operation was thus free from the dangers of tetanus. After a pro-
longed experience with this method, the author agrees with the state-
ment of Smith that there is no operation which compares with it for
universal application, ease of performance, certainty of results, and
freedom from after-complications. One objection to the operation is
that it requires a somewhat elaborate paraphernalia. The clamp, the
proper kind of forceps, the Paquelin or iron cautery with a heating
apparatus, are indispensable to its performance. The objections offered
by Allingham, Mathews, and some other advocates of the ligature,
that this operation is painful, subject to secondary haemorrhages, and
often produces stricture, are without foundation in the experience of
those who have used it most. If any operator should take up an ex-
ternal or mixed pile and apply a ligature around it without cutting a
groove in the skin or dissecting up a pedicle, these two eminent authors
would stamp him at once as a tyro in surgery, and would not hesitate
to disclaim such operations as representative of their own. Yet the
description and illustrations of Smith's operation in the books of the
surgeons just mentioned are equally as far from the correct technique

638

TUE ANL'S. RECTUM. AND PELVIC COLON

of the cluinp-aiKl-eauttrv oiHrraliuD. Its freedom frdin )uiin, thciliii-
gers i>f secondary ha?inorrhage, protracted ulceration, prolonged dj-sura,
and llie short con-
finement which it
necessitates, render
it one of the sim-
plest and surest of
surgical proceduifs.

The Forceps.— t J* Fi». ail.-T.n-LK
If the lumor be
taken off in a line parallel with the long axis of the gut. the eicatrii
M-ill tend to hold the mucous membrane in position, overcome any
inclination to prolapse, and if it contracts it can only shorten tliew
turn and not narrow its caliber. Appreciating this faet, the anlhor
devised, some yeare ago, the forceps illustrated in Fig. 201. As nill
be seen, the instrument possesses a linear bite of alwut j of an inch in
length, in each jaw of which there are four sharji teeth. The jaws ol
the forceps are parallel with the blades, and the handles are providal
with a lock catch, m
thai when the lia'inor-
rboid is once graspej
it will neither tear
out nor be let loose.
By immdueing th«
instrument panlH
with ihe long axis d!
the gut, it ts impofsi-
blc to catch the tu-
mor in any other line
(Fig. 302). and by ^
plying the clamp un-
der the forceps (Fig.
•iO:!(, it will alwav*
grasp the tumor in
this .«ame line. The
resulting cicatrix will
necessarily run ujJ
This instrument facili-
iplishing the given end,

Fio. SUl.-

and down the rectal cavity and not around it.

fates the operation greatly aa well as accon

and although not indispensable, it is a most useful adjuvant in ihi

clamp-and-cautery operation.

The Clamp. — Almost every operator who has relied largelr upon
this operation for hjpmorrhoids has at some lime or other deviswl a

n^MOKRHOIDS— PI LES

clamp after his own views. The original clamp of L<?e consisted in a
sort of curved fenestrated forceps by which the tumor was clamped
and crowded into a central pedicle or mass; that devised by Smith has
flat blades, on one side of which are ivory plates intended to prevent
the transmission of heat to the tissues beneath during the cauterization;
the blades are also verj' wide in order to protect the surrounding parts
from being touched by the cautery. These ideas are ingenious, but the
ivory plates are unnecessary, and the broad blades are inconvenient,
especially in stout people. Oant's clamp (Fig. 204) is a modification
of Smith's, and has the
merit that the blades
open and close abso-
lutely parallel.

The author uses the
original Kelsey modifi-
cation of Smith's clamp
(Fig. 305). It differs
from the latter in hav-
ing longer and more
convenient handles,
which afford an oppor-
tunity for a stronger
grasp; the blades are
narrower, have no ivory
plates beneath them,
and are provided with
a tongue and groove,
all three edges being
serrated in order to
prevent the tumor's
slipping as it is grasped
by the clamp. The in- " "" 'hViiokmiioii) ib DHAr.^in howm.

Btrument is a powerful

one, and affords the means of completely crushing a tumor, if necessary;
the older patterns had rubber handles, but these have been supplanted
by metallic ones which can be sterilized without injury.

The Cautery. — It consists in a reservoir containing benzine, which
is connected with a double hand-bulb upon one side and an ingenious
hollow platinum knife or bulb upon the other. The platinum point
is heated to a dull-red heat in the alcohol flame, and then the benzine
vapor is pumped into it, causing combustion and the maintenance of
heat to any degree required.

There are a number of modifications of this instrument in the shops.

Fio. 204.— OiflT's

G4II THE ANUS. liECTrM. AXD PELVIC COLOS

but in most of thfin the platinum knife is maile so light Uint it «i!t
not retain the heat when applied to a wet suriace, and one hiu coo-
tinually to wait and fin" it up again. In
of ihem the blade is hfated by the t)enzene bcin^
vaporized and burned upon the outsiik of
knife so that the alcohol-lamp is unnecMsai^
(Fig. 206). Gasoline may be used instead «i
benzene in these instrument!

The fact that those instruments so (retjufni—
ly get out of order renders a few words upoa
their management not inappropriate. The '
strunient is based upon the principle that highli
combustible gases ignite at a low lempersn
and, continuing to burn, increase the heal ii
the bulb or knife. There is one tube leading
into the bulb which carries the vapor anil
second one for the escape of any superfluoui
amount. Now, if the vapor is pumped into the
bulb before the latter is heated to a tempera-
ture sufficient to ignite it, carbon will be formed
which obstructs either the entrance or eiil lo
the blade, and thus prevents the proper aclion
of the instrument. A mistake is frequently made in pumping! the
vapor through the instrument after it has cooled off. As surely u
this is done, (he instrument will not work the nest time it is tried.
If one is careful always to avoid this and have the platinum lip
well heated before compressing the bulb, the instrument will rarely
be out of order. When the accident which thus disables the appa-
ratus happens to occur, it is well to know that by placing the in-
strument in the ilame of an alcohol-lamp or a Bunsen burner and
heating it to a
white heat, at the
same time pump-
ing air through it,
the carbon will be
consumed and the
instrument will be
restored to its
usefulness. An-
other point to be
remembered is, that in that variety of reservoir which consists in a
metal tank lined with sponge, one should always be careful to put
no more benircne in th;m the sponge will absorb. If too much

I. !ns.~-H.clI<>iiBi9niD,

n^MOERHOIDS— PILES

641

placed in the tank, it will be carried as a liquid into the instru-
ment and thuB obstruct it. Before etherizing the patient to operate
by this method, one should always carefully examine his cautery nnd
see that it is in working order, else he may be caught in the predica-
ment where the clamp has been applied, the hjemorrhoid excised, and
the cautery will not bum. If the precautions mentioned above are
observed, the Paquelin cautery will be found a most useful and reliable
instrument, not only for this operation, but for many other conditions
which one meets in a surgical experience. It should always be uaed
at a dull-red heat for controlling hsemorrhage, as the white lieat cuts
the vessels and does not shrivel and contract them as the red.

The use of the galvano-cautery in operating for piles is frequently
suggested {Cutler, Times and Register, November li, 1891). The heat

is too intense and too easily reduced to make it satisfactory even when
the street current is used, and in operations at the patients' houses it
is altogether impracticable.

The Operation Itself. ^-The patient having been antesthetized, is held
in the lithotomy position by a Clover's crutch (Fig. 130) or the up-
rights of a modern operating-table. The foot of the table should be
somewhat higher than the head, and on a level with the shoulders of the
operator who sits upon a stool. The patient being in position, the skin-
tabs should be clipped off flush with the skin before stretching the
sphincter, otherwise they swell up to such an extent that it is difficult
to determine how much ought to be removed. After this the sphincter
should be dilated and the parts prepared as already described.

After the sphincter is dilated and the piles brought into view, one
should carefully note the position of the prominent htemorrhoidal tu-
mors. Generally they will be found to consist of three large ones:

642

THE ANUS, RECTUM, AND PELVIC COLON

one upon each side of the posterior commissure, and one just to Uie
right of the anterior commissure, with occasionally a small hfrraor-
rhoid to the left uf the latter, and one directly opposite the poeturior
commissure. The important ones are the two lateral and one anteriw
tumors. If these three are removed the others will generally di»-
appear epontaneously, especially if they are very small. They should
also be removed if of considerable size. Having located the tumors, thej
may be allowed to recede if they do so spontaneously. The hi^mor-
rhoidal forceps (Fig. 201) is then introduced closed directly over one of
the lateral tumors, and as it is pressed outwanl in the direction of thft
latter, it should be jrently opened to the extent of about 1 inch, and
closed again. By this procedure the tumor rises into the grasp of the
forceps, it is caught directly in the line of the axis of the gut, and it can
be easily pulled down into view. Some little knack and practice are
necessary to accomplish this deftly, and the beginner in this opcratioa
will do well to intro-
duce a Sims'a duck-bilt
speculum upon the oi>-
posite side, or drag thft
tumor down and catch
it by sight instead of
by touch, as above de-
scribcd. WHien the tu-
4 been grasped
and dragged down, if
it is covered in its
lower portion by niuco>
cutaneous or cutaneous
tissue, a groove (Fig'^
2(17) should be cut into
these sufficiently deep
to prevent their beinp
grasped by the clamp.
The ajiplication of the
itamp and cautery to
the muco - cutaneous
tissues or the skin i%
the cause of almoet
all the pain associated,
with this operation, and if this little precaution is strictly adhered to
the suffering following this operation will be comparatively slight. Ths
clamp is now slipped over the forceps (Fig. 903), the heel being upward,
in reference to the rectum, for the reason that if by any accident part

of the tumor should slip out of its grasp, it would always be the lower
portion, which is the least tightly held. This will be within view, and
any bleeding from it can be easily controlled. The tumor having been
grasped by the clamp, with the blades of the latter fitting into the
sulcus cut in the
cutaneous covering, the
screw upon the clamp
should always be tight-
ened in order to pii-
vent any possible re-
laxation of the grasp
until the cautery has
been applied. The for-
ceps should then be re-
moved, and thi
mit of the tumor cut
off to about ^ of an
inch of the clamp (Fig.
208), thus leaving a
stump sufficient to be
thoroughly charred
without destroying
that part of the tu-
mor which is cm shed
by the clamp. This is
an important part of
the technique, as the
crushed portion of the stump forms the original barrier to hipmor-
rhage and should never be destroyed by burning down between the
blades with the edge of a Paquclin knife, as is sometimes done.
The tumor having been removed, the stump should then be cauter-
ized with a Paquelin or iron cautery heated to a dull-red heat; it is
not necessary to bum the tissue all away, but simply to char it thor-
oughly until it presents a smooth black surface; the grasp of the clamp
should then be slowly relaxed in order to observe if there is any point
at which there is bleeding from the stump. In case there is, the clamp
should be retightened and the cautery reapplied. Ilthei-e is no bleed-
ing, the clamp niav be removed and the stump will spontaneously recede.
The second lateral tumor and then the anterior one should be treated
in like manner, and if the operator deems it advisable he may also re-
move the two smaller tumors which sometimes exist upon the left an-
terior and central posterior quadrants.

The tumors having been removed, there are two methods of treating

644 THE ANUS, RECTUM, AND PELVIC COLON

the wounds: one is the application of a soft fluffy piece of gauze, infil-
trated with orthoform, to the external raw surfaces left bv cutting off the
external hemorrhoids; this is covered with a good pad of gauze or ab-
sorbent cotton, and held in position by a snug T-bandage. The ortho-
form is somewhat antiseptic in its action; at the same time it is a local
anesthetic to fresh and granulating wounds; it obviates the necessity of
administering opiates after the operation, and is by far the most com-
fortable dressing for the j)atient. If the sphincter is thoroughly relaxed
and has no tendency to recontract immediately, this dressing is quite
as satisfactory as any other. In some cases, however, it seems impossible
to thoroughly paralyze the sphincter by stretching; and, however com-
pletely the latter is done, one will find by the time the operation is com-
pleted that this muscle has already begun to show a tendency to recon-
tract. In such cases the operator should use a Pennington tube, which
consists of a piece of medium-sized stiff rubber tubing alwut 6 inches
long, attached to which is a sheath of very thin rubber; the tube
is wrapped with iodoform or plain gauze until its size is sufficient
to keep the sphincter well dilated, and the rubber sheathing is then
folded over this gauze. The whole is then introduced for about 4 inches
into the rectum with the open end of the sheath downward, orthoform
having been dusted upon the raw surfaces about the anus. The tuhe
sers'cs to allow the escape of any gas which may accumulate in the rec-
tum, to control bleeding by its pressure, and to maintain the dilatation
of the sphincter, while the rubber sheath prevents granulations from
forming in the meshes of the gauze, and allows the plug to be withdrawn
whenever it may be desirable without any adhesion or pain. Gauze is
then packed around the lower end of this tube and a snug T-bandage
is applied through which the end of the tube protrudes in order to pre-
vent pressure upon the latter. A large safety-pin is fastened through the
end of the tube in order to prevent its escape upward into the rectum,
and thus the dressing is completed.

As a rule the author is opposed to the use of any plug or tampon in
the rectum, but in the class of cases described above he has found this
method of Pennington's to be of great service; it can be removed on
the second or third dav, or it mav be allowed to come awav with the
first movement of tlie bowels. One must be governed in this matter hv
the sensations of the patient. When the tube is used it will generally be
necessary to catheterize the patient, and to administer one or two hypo-
dermics of morphine during the first twenty-four hours.

After-treatment. — Usually a liypodermic injection of morphine is
given before the patient leaves the table, and this is all that is necessair
during the whole course of treatment. On the second night following
the operation twenty to thirty minims of fluid extract of cascara should

H-^MORRHOIDS— PILES 645

be administered; when the bowels feel like moving two ounces of sweet-oil
should be injected into the rectum. This may be done through the tube,
if one has been used, and then the latter should be withdrawn. After the
movement lias occurred, an enema of about one pint of boric-acid solu-
tion should be given, which immediately comes away and clears the
operative field of any small faecal masses which may have adhered to it;
til is should be repeated daily for one week, regulating the amount of
laxative to the needs of the patient. After the bowels have moved, a
small piece of gauze or cotton infiltrated with aristol or some such pow-
der should be applied to the anus two or three times a day to keep it dry.
If there is a tendency to recontraction and spasm of the sphincter, the
introduction of a full-size Wales bougie daily will relieve it, but this is
very rarely necessary.

The time for complete healing after this operation varies from two
to four weeks, the average being about twenty-one days. Patients are
allowed to get out of bed after the bowels have moved on the third day.
They can generally walk about without any distress, but sitting will be
found uncomfortable. As a rule they leave the hospital and return to
their homes or to work on the sixth or seventh day. They are allowed
to use the commode even for the first movement of the bowels, and are
never required to use a bedpan unless there is some complication. There
is often some bleeding after stools for the first week, but it is never
alarming, and only comes from the granulating surfaces. It gradually
disappears, and, with the exception of a little moisture from the dis-
charge, the patient suffers no further inconvenience.

The Crushing Operation. — Crushing is an old operation for haem-
orrhoids. Formerly it was the practice to seize the whole tumor with a
powerful flat-jawed forceps and crush it, leaving the pulp thus formed
to slough away. This method is now obsolete.

Chassaignac conceived the idea of crushing off haemorrhoids with
his ecraseur, and practised it to some extent; but the operation never
became popular, and is not done at present. Later, several instruments
were devised for crushing off the pile at its base. Among them was
Benham's crusher, and in 1880, Pollock, of London, made a strong plea
for this method and instrument in the following words:

" It is now some two or three years since I commenced to put in prac-
tice these views. The earlier attempts to crush the base of the pile
were occasionally partial failures as regarded the perfect freedom from
haemorrhage. Either from want of proper construction the clamp did
not effectually spoil the tissues at the base of the piles; or, perhaps, from
too much of the protruding mass being taken up at a time to enable the
clamp to act efficiently, or from some other unexpected cause, some
bleeding would occur after the clamp was removed, the pile having been

646

THE ANUS. RECTUM, AND PELVIC COLON

cut away; and this had to be dealt with by ligature. Seldom, howeier,
were more than two or three ligatures necessary, and never was trouble-
some or recurring haemorrhage encountered. As successive cases con-
tinued to be treated in this manner, any defects of the clamp became
manifest, and gradual improvements were made. Still, the theor}- that
crushing the base of the pile should entirely obviate the occurrence o!
haemorrhage on the separation of the pile and subsequent removal of
the clamp, was not as yet fully realized by the results. Sometimes ve
had no bleeding; sometimes three or four vessels might be required to
be ligatured. But still the one satisfactory result obser\*ed in all cases
thus treated was that the subsequent pain was quite an insignificant
matter. It is not wished to imply in this statement that no one ever
complained of pain; but in contrast to the pain attendant on ligature,
or that noticed after the application of the hot iron, certainly that
which has been observed after this system of rapid crushing may alnw^t
be said to be a mitivs quantity. One patient complained of pain for
about three hours. In all cases patients have expressed themselves free

FlO. 209. — ALLINOnAM^S IliEMOBBHOID CrUSHEB.

from severe pain, and many have hardly complained of any after an hour
or two. One who had some years previously undergone an operation
by ligature, expressed his extreme gratification at the almost entire
absence of even discomfort after the first effects of the ether had gone
off " (The Lancet, vol. ii, p. 1, 1880).

Allingham states, after trying Pollock's method, that he found the
instrument did not crush the base thoroughly, and that more or less
bleeding always resulted. In one case a bad concealed hjemorrhage took
place. It was from the crushed ha?morrhoid, and flow^ed upward into
the bowel. Some hours after the operation the patient, being seized
with a desire to go to stool, evacuated a large quantity of arterial blmxl,
and this bleeding was continued until checked by cold-water irrigation
and tamponing of the rectum with wool and perchloride of iron.

After this he devised a crusher (Fig. 209) in which the power is
exorcised by a screw. To use this instrument a special form of forceps
is necessary (Fig. 210). He calls attention to the importance of crushing
tlie haemorrhoids lon<?itudinallv and not transverselv. Pollock crushtnl
both external and internal haemorrhoids by his method, but Allingham

HEMORRHOIDS— PILES

647

Fio. 210. — Allinoham's Forceps for Use in Crushing

Operation.

advised making an incision at the muco-cutaneous border, and only
crushing the internal piles.

Mr. C-harles John Smith, of Farrington Dispensary, has devised a
modification of Allingham's crusher (Fig. 211) which appears to have
some advantages over the latter in the application of the power, and in
the fact that the in-
strument is applied to
the pile instead of the
latter being dragged
through a fenestrum
in the instrument. He
advocates crushing the

pile transversely to the axis of the gut, arguing that dilatation being
in this line, there will be less danger of the wound being torn open.
This danger, however, is not to be compared with that of stricture,
which is never produced by the former method.

Ten years since, being impressed with'the idea that the clamp would
effectually control the bleeding following excision of haemorrhoids, and
that granulation would start up more readily there being no eschar
from the cautery to come away, the author made some experiments with
tliis method, using the old-style hremorrhoidal clamp with mortised,
serrated edges and long, strong handles. Both external and internal
piles were crushed off; they were caught with the ha?morrhoidal forceps,
dragged out, and the clamp applied at the point where the tumor joined
the mucous or muco-cutaneous tissue, then with a slow, chewing motion
the base of the tumor was crushed until a sort of pedicle or neck was
formed, outside of which it was cut off with scissors. Frequently it was
possible to remove the tumor by the crushing power of the clamp alone;
especially was this the case in external ha?morrhoids. The results justi-
fied in a measure all that Pollock claimed for the method. After opera-
ting upon '^5 cases by this method, a ha^morrhoid slipped out of the

clamp after the summit had been cut
off in an operation by the clamp and
cautery. It is true that the pile was
only partially crushed in this instance,
but the author was so impressed with
the possibility of such an accident oc-
curring after the crushing method that
he has never done the operation for internal hemorrhoids since. In
external, inflammatory, or connective-tissue haemorrhoids this method
is still employed. The operation may be done in these cases under the
influence of cocaine. The crushing brings the muco-cutaneous edges so
accurately together that one can hardly see that any tissues have been

Fig. 211. — Smith's H^MORRnoiD
Crusher.

648 THE ANUS, RECTUM, AND PELVIC COLON

removed. After having crushed the tabs off, collodion should be applied,
and the parts will often heal just as if they had been sutured by the
subcutaneous method. No hsemoirhage follows this method in external
haemorrhoids, and very slight inflammation ever occurs. The cauteriza--
tion of the stump, however, is a safeguard against haemorrhage and
adds an aseptic element which the crushing operation does not do.

Recently some operators have been using the angeiotribe in carrying
out the crushing operation. While this method is very effectual, the
size and weight of the instrument seem to preclude the possibility of
accurately applying it to anything except very large masses. If an in-
strument of this type, but less cumbersome, could be devised, there is no
doubt that it would prove verj' useful, but none of those in use at
present are superior to the old Kelsey clamp used in the method which
has been described.

Excision. — For many years there have been advocated from time to
time divers methods of complete excision of haemorrhoidal tumors. Es-
march, Dupuytren, Brodie, and Cooper practised it, and obtained com-
paratively good results. In their operations the bleeding vessels were
caught up and tied and the open wounds left to heal. Others practised
a different method, completely excising the tumor and sewing the mu-
cous membrane together afterward, thus closing the wound.

Whitehead Method. — In 1882, Mr. Walter Whitehead, of Manchester,
after a brief and unsatisfactory experience with the ligature, and clamp
and cautery, introduced total excision of the haemorrhoidal area — i. e.,
the lower inch and a half of the mucous membrane of the rectum (Brit
Med. Jour., 1882, vol. i, p. 149).

In his first operation (Brit. Med. Jour., 1882, vol. i, p. 149) he left
strips or islets of mucous membrane between the dissected areas in order
to prevent circular stricture of the lower end of the rectum if primary
union failed to take place. His final and perfected technique, that
which is now accepted and taught under his name, does not embrace
this feature. He described it as follows (the italics are ours):

" 1. The patient, previously prepared for the operation and under
the complete influence of an anaesthetic, is placed on a high, narrow
table in the lithotomy position, and maintained in this position either
by a couple of assistants or by Clover's crutch.

" 2. The sphincters are thoroughly paralyzed by digital stretching,
so that they have ^ no grip,' and permit the haemorrhoids and any pro-
lapse there may be to descend without the slightest impediment.

" 3. By the use of scissors and dissecting forceps, the mucous mem-
brane is divided at its juncture with the skin round the entire circum-
ference of the bowel, every irregularity of the skin being carefully fol-
lowed.

H.£MORRHOIDS~PILES 649

" 4. The external and the commencement of the internal sphincters
are then exposed by a rapid dissection, and the mucous membrane and
attached haemorrhoids, thus separated from the submucous bed on which
they rested, are pulled bodily down, any undivided points of resistance
being snipped across, and the haemorrhoids brought below the margin
of the skin,

" 5. The mucous membrane above the haemorrhoids is now divided
transversely in successive stages, and the free margin of the severed
laembrane above is attached, as soon as divided, to the free margin of
tht shin below by a suitable number of sutures. The complete ring of
pile-bearing mucous membrane is thus removed.

" Bleeding vessels throughout the operation are twisted on divi-
sion."

Mr. Whitehead lays stress upon the point that the incisions are
made entirely in the mucous membrane, but one may be misled by his
references to cutting and suturing the " margin of the skin." He says:
" It is important that no skin should be sacrificed, however redundant
it may appear to be, as the little tags of superfluous skin soon contract
and eventually cause no further inconvenience." He states that there
is little diflBculty in separating the piles from the sphincters, and that
during this separation and dissection there is practically no haemorrhage,
the dissection being made by a raspatory or dull, curved scissors, or with
the fingers. There are certain points around the rectum to which the
attachment is closer than at others, on accoimt of the passage of the
branches of the middle haemorrhoidal arteries through the muscle and
into the mucous membrane. These points have to be snipped with
scissors.

Mr. Whitehead uses no ligatures to control the arteries, but simply
seizes and twists them with artery forceps as he makes his transverse
section of the mucous membrane. He says: " I have often operated upon
severe cases and not found it necessary to twist a single vessel, and very
frequently only one or two." In the 300 cases reported, he did not have
a single instance of secondary haemorrhage, and therefore considers that
this complication need scarcely be considered in the operation. Before
closing the wound, he insufflates iodoform between the raw surfaces, in
order to control any oozing which may exist. He uses carbolized silk
sutures, and never takes out the stitches. An ice-bag is kept upon the
rectum for the first few days, and the bowels are moved upon the fourth
day. The patient sits up on the same day, and is allowed to resume his
work in two weeks. The pain following this operation differs according
to the personal equation. Some patients have absolutely none, while
others suffer from burning pain in the parts, aching in the back, or
throbbing and fulness in the rectum.

650

THE ANUS, RECTUM, AND PELVIC COLON

Ho elaims for the oporation, first, that it is the most natural method;
second, it requires no special ingtruments; third, it produces a railiual
cure; fourth, it is as free from risks as any other operation; fifth, the
pain following it is k'ss severe than that following other operations for
the same condition; and, finally, that the loss of blood at the time of ihe
operation is inconsiderable, and the dangers of secondary lutmorrhage
are decidedly less than after otiier operations. We have thus given
largely in Jlr. Whit eh fail's own words the description of hie operation,
the grounds upon which it is bused, and his conclusions. That his ex-
periences are not borne out by the majority of the operators in this
country and in Euro]»e is well known to the profession. His stattraent
that the time required is short and the ha>niorrhago at the time of ihe
operation is inconsiderable has not been the experience of those who
attempt the iiictliod according to his technique.

The large Tiuij()rity of operators object to the method on account
of the iimiiunt of hlood lost, the length of time it takes to perform it,
the uncertainly of primary union between the cut edges, the danger
of strieliire following, and, finally, on account of the fact that this

operation reii

■tTtain anatomical structures

vhich are supposed
to have fimetioDs
necessiirj- to the
healthy condition
of the n-ctuin. The
fact that it re-
moves the tactile
or sensitive mar-
gin of the anus,
the crj-jits of Mor-
gagni, and the pa-
pilla' of the rec-
tum, is held bv
some to take aw»y
the power of con-
trol, or rather fhe
sense of warning
as to when a inove-
ment of the bowel
is likely to occur;
this pamo rcsuh
may follow both the lipiture and the elamp-and -cautery operntionj,
and does not occur in any larger percentage nf operations done atlef
Whitehead's method. The lime it takes to do the operation and the
danger of subsequent stricture are the chief objections to it; the amount

H^MOERHOIDS-PILES

fi51

of blood lost, while not alarming, is annoying and excessive com[)areil
with that in operations by clamp and cautery or the ligature. Re-
cently, by modilying the technique, a great saving in time and loss
of blood has been effected.

Tliis modiiieatiou is based on the fact that the blood-vessels and
submucous tissue can be easily peeled off from the muscular wall of the
gut from above downward.

The sphincters having been thoroughly etretchod, an incision is
made through the mucous membrane at the posterior commissure of

the rectum (Fig. 812), and with a blunt-pointed scissors, cui-ved on Ihe
flat, dull dissection is carried upward to the superior margin of the
internal sphincter; with a boring motion the instrument is insinuated
between the mucous membrane and this muscle, and gradually worked
to one side and downward until it comes to the muco-eutaneous border
of the anus (Fig. 2t3); little by little the ha-morrhoidal mass is thus
loosened from its muscular attachment and peeled out of its resting-
place, just as an orange can be peeled from its skin. Having accom-
plished this upon one side, the instrument is turned to the opposite
side and the same process is carried out. Tlie only point at which
any difficulty will be met in this procedure is at the anterior comrais-
Bure of the rectum.

Having thus loosened the whole hiemorrhoidal-bearing area from
its attachment to the muscular wall, the mucous membrane is cut just

652 THE ANUS, RECTUM, AND PELVIC COLON

above the muco-cutaneous margin, and the hEemorrhoidal area will thus
be left loose in the rectiim. An incision is then made in the mu-
cous membrane at tlie posterior commissure, extending aa high up as
the haemorrhoids extend. Each flap thus formed is caught by clamps,
and the tube of nmcous membrane, with the liEemorrhoids attached,
is dragged down. It is loosened above by pressure with gauze or dull-
pointed scissors until the healthy portion can be brought down to the
margin of the anus without tension. It is then cut off transversely
above the hiemorrlioidal mass, step by step, and sutured to the edge
of the muco-cuttuieous wound below (Fig, 214),

The haemorrhage during dissection is very slight, and the blood-
vessels cut in the transverse section of the mucous membrane are easily
controlled by the sutures which are applied immediately thereafter;
thei'c is no occasion to cither twist or tie them, A inattress-stiteh thrown

Fio, 3U.— Tiiup Stkp is Moi.ii'i

around the artery will control it perfectly. Tho lisemorrhagc and the
time of the operation are mntcrlally reduced by tliis method, and the
same end is accomplished as is desijined by the AVJiitehead operation.
The close attachment of the miicoiis ini'inbr.ane to llie muscular wall at
the anterior commissure of the rectum ri'fjuires some dissection to
loosen it, hut this is never ditneult, Tlie wnuiiil is sutured with larpp-
sized catgut in continuous sutures running from the posterior to the

E^EMORRHOIDS-PILES

anterior commissure upon each side (Fig. 215). The larg(?-sized catgut
is of importance because it is less likely to tear through than lino
silk or small suturing material. Chroniicized gut and silk aro objec-
tionable, in that they both remain in the parts too long; they require
to be removed or must cut their way
out, leaving small fisaure-like cracks
about the margin of the anus, and
sometimes they cause little stitch-
hole abscesses which are very an-
noying and retard recovei^. In 107
operations by this method the re-
sult has been simply perfect in 10a;
the catheter has been used in only
8 cases, and morphia has been ad-
ministered only three times in the
entire series. In 1 case, through a
mistake of the house surgeon, an
unfortunate result occurred. Not
being present at the operation lie
supposed that the clamp and cau-
tery had been employed, and no- y^^ ■'r,—\[<,i,iiiLi. Whitehead o ■
tieing a somewhat unusual oozinff rwn Coupleteu.

from the parts, determined to pack

the rectum and control it. Without introducing a speculum, he
forced a large mass of iodoform gauze through the anus and thus
tore loose all of the sutures and forced the mucous membrane up-
ward into the rectum. This was done about two hours after the
operation, and an alarming secondary ha;morrhage occurred. The
author was called to the patient, and on learning what had taken
place immediately reantestbetized him, washed out the parts as well
as possible, and applied the sutures for the second time. As might
have been expected, primary union failed to occur, and a cicatricial
stricture resulted which required the use of bougies for a year after-
ward in order to prevent most serious contraction. In the other case
a result occurred which is inexplicable; the operation was performed
as above described, primary union took place, and the patient reported
himself as having no discomfort and feeling perfectly well for three
months thereafter. He disappeared from view, and at the end of six
months he was recommitted to the workhouse where he had been
treated. Upon examination of the rectum a cicatricial stricture of
marked character was found about 2 inches above the anal margin.
The dissection did not extend to any such height: the anus and the
rectum at the site of the suture were patulous and of normal caliber;

654 THE ANUS, RECTUM, AND PELVIC COLON

the patient had no specific history or other evidence of syphilis, and
therefore the condition could not be attributed to it. The author
is unable to explain it.

The design of this operation has in it no originality, it is simply a
short method of accomplishing what Whitehead advocated. The time
occupied in the operation varies from ten to fifteen minutes, which is
a matter of no inconsiderable importance, inasmuch as a large numher
of the operations mentioned have been done upon patients above the
age of sixty years. In a number of cases the wound failed to heal at
all points by primary union, and small granulating spots were left,
but these healed in due time, and there was no appreciable retraction
of the mucous membrane. When large skin-tabs are present they are
cut off with scissors and the edges are sutured together; or they are
crushed off with the clamp and collodion is applied, as before described,
after the operation on internal haemorrhoids has been completed. In
none of these cases has there been anv incontinence or loss of sensi-
bility in the rectum.

Earles Method. — Dr. Earle, of Baltimore, has proposed a modifica-
tion of the Whitehead operation which consists in the removal of the
hemorrhoidal mass and the suturing together of the edges of the
mucous membrane without any dissection whatever. This is accom-
plished by the use of an ingenious forceps (Fig. 216) as follows:

The sphincters are first thoroughly dilated and the haemorrhoidal
tumors are each grasped and dragged down as far as possible. A small
incision is made at the base of one tumor extending into the healthy

mucous membrane
above it. A suture
of large-sized cat-
gut is introduced
through the ends
of this wound and
tied, the long end
being left threaded
„ „, . „ _, »^ ^x through the needle.

Fio. 21fi.— Earle'8 Forceps. If x\ ^

The haemorrhoidal
mass is then grasped
by the forceps transversely with respect to the rectum and tightly
clasped; it is then cut off above the forceps, the suture is passed through
the two layers of mucous membrane beneath the forceps and carried
around and around the latter (Fig. 217) throughout the extent of its
grasp. The forceps is loosened and easily withdrawn from the sur-
rounding thread; the loops of the latter are then tightened and the
edges of the mucous membrane are thus held closely together. The

a/EMORRHOIDS— PILES

forceps is then reapplied to the next hiemorrhoidal mass or i
portion of the rectum and the same procedure carried out. In this
manner the hemorrhoidal masses are removed almost without any

1 frefih Burgicul wountl, the ed^'(

bleeding whatever, and there
of which are held in
close and accurate ap-
position by the con-
tinuous suture. Large-
sized catgut is used as
a suturing material for
the same reason that it
is used in the preced-
ing method.

Limited Excision. —
When the hemorrhoids
consist in isolated, well-
developed tumors, they
may be excised and the
edges of tlie wound
fie wed together. Re-
cently it has been
found that by the aid
of Earle's clamp,
slightly modified, this
can be done with great
celerity and satisfac-
tion. The hemorrhoid

is caught in the long axis ol' Ua' t;iit In- llic liaTimrrlmiilal I'lirfi'pa
heretofore described, and dragged downward; a gut suture is then
passed through the fold of mucous membrane above the forceps
and tied, leaving the long end threaded to the needle. By this
first suture a ligature is thrown around the blood supply of the
hjemorrhoidal tumor, thus making the operation practically blood-
less. The Earle forceps is then applied with the heel upward, in
the line of the long axis of the gut, and locked. The hemor-
rlioid is then cut off and the suture is carried around the clamp
and through the two folds of mucous membrane below it, time after
time, until the whole length of (he wound is encompassed. The clamp
is then withdrawn, the loops of fhe suture are tightened, and its ends
tied (Fig. 217). The haemorrhoid is thus removed without any undue
sacrifice of mucous membrane. Ha;morrhage is absolutely precluded by
the preliminary ligature and thorough suture of the wound. Rapid con-
valescence is assured by the fact that the edges are drawn together,

G56

THE ANUS, RECTUM. AND PELVIC COLOK

and, although primary union does not always occur, the line of grana-
lation is much lees than by any other opeo method. The operation
is particularly applicable to mixed haemorrhoids, as the vboU ms,
both interna] and external, can be included in the clamp, remored, and
EUtured at one time. The author has occasionally found some diffimlt^'
in puUinj; the loops of thread tight after the forceps has been re-
moved on account of their sinking into the tissues. To avoid this he
has added to the Earle forceps a small hook (Fig. 218), over which (ach
loop of the suture is thrown until all are placed in position. Bvthis
means the suture can be accurately and surely tightened without undue
dragging upon the wound.

In cases with one or two pedunculated bcemorrhoids and relaied
sphincters, this operation can be done under the influence of cooini:
in one's office, and the patient allowed to go home and aboni hit
business on the following day. The operation is not altogether appli-
cable to those cases in which there is a general varicopily of the entire

rectum. In properly selected eases, however, the results obtained by it
have been all that could be desired.

From a surgical point of view excision is certainly an attractive
operation, but it is not so simple as the ligature or the elanip oiid
cautery. The pain and dangers of hiemorrhage, either primary or
secondary, can not be considered as serious objections; the complica-

H .EMORR n 01 DR— PILES

(iri7

tioDB and dangers from tliu operation consist in failure of primary
union, the destruction of sensitive organs of the lower end of the
rectum, and in the production of circular stricture at the anus. The
writer has seen seven strictures caused hy thi;^ (ipcriitinn. und lins cume
to the conclusion that it is
not a safe one in the hand-
of general practitioners,
howcvLT sueeeasful it mav
l)e in those of an expert,
rapid operator. He has
also seen two other acci-
dents follow it which were
distressing indeed, but can
not be properly attributed
to the operation ilaelf.
The first consisted in a
sort of exstrophy of the
mucous membrane of the
rectum due to the oper-
ator's having earned hia
dissection too far out upon
the skin and attached the
mucous membrane then'
(Fig. S19). Owing to this
faulty method the mucous
membrane is constantly
exposed to the friction of
the clothing and of the
buttocks in walking, the

parts are constantly moist and excoriated, and there is a persistent
feculent and disgusting odor from the parts. The only remedy for
it is the complete excision of the mucous membrane and allowing
the parts to heal by granulation, which generally results in a limited
stricture at the margin of the anus. The other condition, which was
exactly the opposite to this, in which the raucous membrane had not
been dissected sufficiently high up, the skin had been loosened around
the lower edge of the incision, and when the parts had united the
cutaneous tissne was dragged upward into the rectum, where it was
kept moist by the mucous accretion, and a sort of sodden, washer-
woman's-hand condition of the skin was produced, which soon became
excoriated, and discharged a feculent secretion which burned, stung, and
irritated the patient until life was almost unbearable. The author has
flperated upon 2 cases for this complication by dissecting the skin and

658 THE ANUS, RBCTUM, AND PELVIC COLON

mucous membrane loose and cutting off that portion which was drawn
upward into the rectum, afterward bringing the normal mucous mem-
brane down and suturing it to the healthy skin about the margin of
the anus. The results have been an improvement in the patient's
condition, but not altogether satisfactory.

The American Operation. — There has been a great deal of confusic^n
with regard to the use of this term. Some authors apply it to ik^
transfixion method of ligature. In the western part of the Unitecl
States it is understood to mean a modification of the Whitehead opera.^
tion introduced by Pratt, of Chicago. This procedure differs fromtli^s
ordinary Whitehead operation in two features: first, the mucous raem. ^
brane is cut transversely above the haemorrhoids and dissected dowiL —
w^rd; second, it premeditatedly removes all the redundant skin an
muco-cutaneous tissue around the margin of the anus. The operatio
thus done drags the internal sphincter downward, forming a collar o
roll around the lower end of the rectum, and it also brings the mucous
membrane outside of the anus, producing a sort of exstrophy ani-
The whole procedure is a bad modification of the WTiitehead opera-
tion; it does not represent the oj)inion or practice of American sur-
geons, and is in no wise entitled to this name.

The injection method might very properly be called the American
method, for it originated in this country. Roux, of Lausanne, speaks
of it as such. He describes it, however, as a major operation done
under anaesthesia and after forcible divulsion of the sphincters. The
particular features of the operation as done in America are: it requires
no anaesthetics, it gives little pain, and does not confine the patient after
the first few hours. Were the method always as carefullv and thor-
oughly carried out with regard to its antiseptic details as is described
by Roux, this operation would be a credit to America or any other
country. It is certainly more entitled to the appellation than is that
parody on excision described above and so often called the American
operation.

Strangulated H^morwhoids. — Strangulation of haemorrhoids may
occur in two ways: first, by the prolapsed mass being grasped by a spas-
modic sphincter which constricts the circulation; second, by an inflam-
matory action set up through abrasion and infection of the mucous
membrane of the rectum, through which the vessels of the htemor-
rhoidal tumor are obstructed. The distinction between these tvro
causes is very important, as in one we are able by dilatation of the
sphincter to relieve the strangulation, while the other, being due to an
inflammatory process, must be treated upon an entirely different basis.
In the first method it may occur as an acute condition in patients
whose piles have never prolapsed before, but have been brought dovcn

n-^MOIiKHOI OS— PILES

*;5!>

at the time by unueusi straining, in lifting, or in the efforts to have
a movement of the bowels. Again, the hfcniorrhoids may have been
in the habit of prolapsing for years. At first, perhaps, they are spon-
taneously reduced; later on the patient finds it necessary to reduce
them himself; hut finally, after a period of constipation, or some irrita-
tion at the margin of the anus, tlie sphincter becomes spasmodic, the
tumors are constricted by it, and strangulation ensues. Strangulation
occurs in only internal and mixed haemorrhoids (Fig. 220); in the former
it is not very painful, and sometimes proceeds to gangrene before the
patient realizes there is any serious disturbance; in the mixed variety
it is very painful. Efforts at reduction in tlie latter cases should
be very careful-
ly nia<le, because
only a part of the
swollen and con-
stricted mass can
be put inside of
the rectum, and
any attempt to put
the rest above the
external sphincter
will not only he
useless, but will
aggravate the con-
dition. Where the
strangulation hai*
persisted for some
time, the tumors
may slough off. In
this way spontane-
ous cure may re-
sult, hut general- Fm Sai— RTmsorLATFn IlHii^MHiuimn.

ly it is very in-
complete, because only portions of the mass slough away, and little, irri-
table, hleetling stumps remain which arc the si>urce of much annoyance,
and sometimes of considerable lucmorrhage. This rusult may occur just
as well in cases of inflammatory strangtdation as in those due to constric-
tion of the sphincter muscles. The author does not agree with the au-
thorities who hold that if sloughing has once commenced in a hmnior-
rhoid nothing more is to be done except to place a charcoal poultice on
the parts and let the gangrene proceed; the best results are obtained in
these cases by immediate radical operation at the very earliest possible
time after strangulation has occurred, whether there be gangrene or

HAEMORRHOIDS— PILES 661

operative methods for haemorrhoids. They are more frequent in some
than in others, but practically of the same nature in all.

Pain. — There is a wide variation in the statements of different
authors regarding the pain following one operation or another. AUing-
liani, Mathews, Goodsall, and Bacon state that after the ligature the
pain is very slight and of short duration. A careful inquiry from
tlie internes in ten large hospitals, instituted some five years ago, es-
tablished the fact that, in these institutions at least, patients having
undergone operation by ligature require four times as much morphine
as those operated upon by the clamp and cautery or the \Vliitehead
operation. There seems to be little difference in this respect whether the
AUingham, Bodenhamer, or Mathews o})eration is employed. Where a
deep groove is cut entirely through the skin and umco-cutaneous tissue,
and the ligature fits accurately into it, the pain is less than where these
tissues are tied with the pile; unless this is done, the operation can
not be said to have been properly performed. Notwithstanding this
j)recaution, the ligature operation always occasions a great deal of pain.
The clamp-and-cautery method, if properly done, is followed by con-
siderably less pain than the ligature; nevertheless, there are cases in
which it produces great suffering, and it is sometimes difficult to
determine the cause thereof. It is not due in either operation to
spasm of the sphincter, otherwise restretching of this muscle would
relieve it, and it does not do so. The most probable explanation of
the excessive pain which some patients suffer after either the ligature
or the clamp and cautery lies in the supposition that some nerve-end
is caught in the ligature or in the charred surface. The personal ele-
ment, however, must be reckoned with in every operation; some patients
will bear without complaining what others describe as intolerable
agony. As a rule, there is not a great deal of pain following the clamp-
and-cautery operation after the first twenty-four hours, and if the
parts are dressed with orthoform there will be very little even during
this })eriod. It is a rare thing for cases operated on by this method
to require more than one hypodermic injection of morphine.

Following the method of excision the pain is very great for eight
or ten hours; after this it subsides, and, unless there is some other
complication, it practically ceases. ^lorphine is the best remedy to
control it after all operations, but occasionally large doses of bromide
of soda will act more satisfactorily in cases of extreme nervous irrita-
bility. The smarting ]min which follows a movement of the bowels
in either operation may be relieved by the application of pure iodoform,
a 10-per-cent ichthyol ointment, or tlie insufflation of orthoform just
before the stool.

Dysuria, — Strangur}' and dysuria are almost inseparable from the

662 THE ANUS, RECTUM, AND PELVIC COLON

ligature operation. The writer does not remember a single ease wh.^r'
this method was used in which it was not necessary to cathete
the patient for some days or even weeks afterward. This is
times necessary after the clamp-and-cautery and excision methods, l>i
not nearly as frequently so as after the ligature. The closer the
turn is packed the more likely catheterization will have to be employ
One should not be in too great a hurr}', however, in drawing off the
urine, for sometimes hot applications over the pubis and allowing the
patient to stand on his feet will enable us to obtain voluntary uma-
tion. Unless there is great distress it is best to allow the patient to
go for eight, twelve, or even sixteen hours before resorting to the
catheter. Either a sterilized, soft-rubber, or Van Buren silver instru-
ment should be used for this purpose; woven instruments with sharp
ends are very objectionable. The urethra should be washed out with
boric-acid solutions before any instrument is introduced.

Period of Confinement. — According to the most enthusiastic advo-
cates of the ligature operation, the patient must be confined to his
room for two or three weeks, and be kept quiet in bed from seven
to fourteen days, until the ligatures come away; the period at which
this happens is very indefinite; it varies from five to thirty-five days.
as the writer saw in one case in 1899. It is therefore impossible to
tell with any degree of certainty how long a patient will be confined
by this method. Some surgeons allow their patients to get up and
go about before the ligatures come away, but this is dangerous and
should not be done.

After the clamp-and-cautery operation the patient is only con-
fined to his bed for the first three davs, after which time he is allowed
to walk around tlie room, and generally returns to his business in
seven days from the time of the operation, although the parts are
rarely completely healed under three weeks. The time consumed in
healing over the granulating surfaces is on an average about one week
less by this method than by the ligature.

Following the methods of excision the patient must be confined to
bed for seven or eight days. If primary union has then taken place,
the parts will be completely united and practically well, but if failure
in union has occurred at any point in the circumference, the patient
should be kept quiet until the granulated spot has healed. In this
respect, therefore, the clamp and cautery has the advantage over all
other operations, in that there is no necessity for the patient to lie
in bed after the first seventv-two hours.

Secondary IIcBmorrhage. — The danger of secondary haemorrhage is
greatly exaggerated by quacks and charlatans who do not operate for
haemorrhoids. If a blood-vessel is thoroughly tied off, crushed, or

HEMORRHOIDS— PILES 663

cauterized, there is very little danger of haemorrhage from it. If a
ligature should slip within the first few hours after operation, bleeding
may occur, but such an accident is so rare that one need hardly con-
sider it as a serious complication. Thorough packing of the rectum
with gauze will check it in any case. If one has at hand a conical
sponge, such as is used by Allingham, and will introduce it into the
ampulla through a tube, and then drag down upon it by the cord
run through its center, the bleeding may be quickly stopped. The
gauze, however, is always at hand, is more easily sterilized, and more
likely to produce general compression than the sponge. The introduc-
tion of astringents, other than cold or very hot water, is absolutely
unnecessary, and is injurious in these cases; perchloride of iron not only
irritates the parts but it forms a hard, brittle clot which may break off
when the dressing is removed and thus cause the bleeding to recur.

Where these methods do not check tlie haemorrhage in a very short
time, the operator should not hesitate to reanaesthetize the patient,
stretch the parts open, and tie the bleeding vessels. In the very many
cases operated upon by the clamp-and-cautery method the writer has
seen only one haemorrhage, and this was due to the fact that he allowed
the stump to slip out of the clamp before it was cauterized; this acci-
dent occurred through not running down the screw which holds the
clamp together, and since that time this little precaution has never
been neglected. In this case the crushing by the clamp controlled the
bleeding for the time being, but the pulsation of the artery overcame
this obstruction and a concealed haemorrhage occurred which nearly
cost the patient his life. It should be distinctly stated that this acci-
dent was due to an error of the operator and not of the operation.

In the excision method the primary bleeding is considerable, but
secondary haemorrhage is almost unknown. The case related above,
where the sutures were all torn loose and the cuff of mucous mem-
brane turned up into the rectum through a misapprehension on the
part of the house surgeon, can not be charged to the operation. If
the operations are properly done there is practically no danger what-
ever from secondary haemorrhage.

Erysipelas, Tetanus, and Infection. — Erysipelas may occur in any
of the operations for haemorrhoids owing to infection by streptococcus,
but it is a most unusual occurrence. It is less likely to follow the
clamp and cautery simply because the hot iron not only kills the germs
and bacteria about the parts at the time, but it also seals the mouths
of the blood-vessels and lymphatics in the stump, thus preventing infec-
tion through these channels. It should be prevented by proper anti-
septic precautions, but if it does develop, Crede's ointment is almost
a specific for it.

664 THE ANUS, RECTUM, AND PELVIC COLON

Tetanus has frequently followed the ligature operation. Alrawt
every fatal termination in operations for ha?morrhoids has been due
to this disease, and in every one of them the operation has been by
the ligature method. Whether this is a coincidence or is due to the
fact that the absorbent silk ligature attracts and retains in its meshes
small particles of faecal matter containing the bacillus, thus keeping
them in close contact with the parts, can not be determined. As a
matter of fact, however, no case of the disease has yet been reported
as following operations by the clamp-and-cautery or excision method?-

The treatment for this condition is laid down in works on general
surgery. Recently some eases have recovered under serum therapy, but,
so far as tlie writer knows, no case developing from a rectal operation
has ever been cured.

Abscess and Fistula. — These conditions have been known to follor
operations by the ligature, by the clamp and cautery, and by the excision.
metliods; they do not n»sult from the operations themselves, but from
traumatism produced by stretching the sphincter. The operations are
usually done in n(m-supj)urating cases, and, the sphincter being thor-
oughly stretched, there is no reason why the complete drainage thus ob-
tained should not prevent any burrowing and abscess formation from
the wound in the rectum.

If, however, some small perirectal blood-vessel should be ruptured
and a ha*matoma formed in the cellular tissue, this may necrose or be-
come infected and cause perirectal abscess. The writer has openel
three abscesses of this kind, and evacuated quantities of sero-pus anA
broken-down clots, which appear to prove that they originated in peri-
rectal ha»morrhages. Two of these abscesses followed the ligature'
method, and one the clamp and cautery. The only treatment in these-
cases is to open and drain as soon as the perirectiil swelling is dis-
covered.

After the methods of excision small stitch-hole or burrowing ab —
scesses may occur, but they should not attain any great size. As soor»-
as the evidences of such appear, the surgeon should cut the stitches at
this point at once, and thus drain it. The writer has done this in twr^
instances, and in each case htis obtained primary union, with the excep —
tion of the small area which was opened to drain the abscess. It is »►
complication above all others which makes careful watching and dail}*'
examination of the ])atients having undergone operations for hferaor —
rlioids important. The first quickening of the pulse or rise of tem-
perature after the twenty-four hours following operations should excite^
suspicion and suggest immediate and thorough examination of the parts.

Stridure. — Stricture has been frequently spoken of as the result
of all operations for haemorrhoids. Allingham states that following

HEMORRHOIDS— PILES 665

the ligature operation it is due to tying off of too large masses of mucous
membrane in one ligature, and shows in his drawings that by this method
a large raw surface is left partially surrounding the rectum. He does
not think, however, that the stricture is due to cicatricial contraction
from the large granulating area, but that it is caused by the massing
together of folds of mucous membrane which causes adhesions that do
not readily give way, an explanation that is very plausible. He also
attributes these strictures to patients getting up before the wounds are
healed, and in order to avoid them, advises the daily passage of the
finger or a moderate-sized bougie into the rectum until the wound is
completely healed over.

Following the clamp-and-cautery operation, stricture is certainly
one of the rarest complications. If the hiemorrhoid is caught in the
line of the long axis of the gut it will never occur, but if it is caught
trans verseilv so that the cicatrix runs around the lower end of the rec-
tum, contraction may result. Smith and Kelsey, after operating upon
thousands of cases by this method, have failed to see a single case of
stricture following it. The author has seen only one.

After the Whitehead operation, however, stricture is likly to occur
even when primary union is obtained. There must be a circular cicatrix
at the line of union, and if there is a deposit of fibrous tissue beneath
this, contraction will take place. This may be caused by too deep dis-
section or not loosening the mucous membrane high enough up, so that
when it is drawn down it produces a sort of roll or tuck in the walls of
the gut, which narrows the caliber, and becoming matted together by
inflanmiatory processes forms a true stricture.

A large number of strictures of the anus are seen to-day as the result
of this operation. While the writer has only seen 2 in over 200 opera-
tions in his own practice, he has seen 7 in cases where the Whitehead
operation was said to have been done by other surgeons. This compli-
cation is much less likely to follow the ligature or clamp and cautery
than the Whitehead operation.

Ulceration and Fissure. — Protracted ulceration or chronic fissures
have been known to follow the Whitehead, clamp-and-cautery, and liga-
ture o])erations. Wliile Mathews is honest when he says that he has
never seen an unfortunate result follow the ligature method, the author
has seen 1 patient upon whom this eminent surgeon operated, and who
is still suffering, after nearly three years, with chronic ulceration at
the posterior commissure of the rectum, together with a slight contrac-
tion in the caliber of the gut. In 10 patients under the writer's care,
the ulceration following this operation has persisted from three months
to two years; such a result is rare in comparison with the number oper-
ated on, but it occurs more frequently after the ligature than after the

666 THE ANUS. RECTUM. AND PELVIC COLON

clarap-and-cautery or excision methods. The constitutional condition
of the patient will account for this in the majority of cases, and in those
cases in which it has occurred, it might have done so had any other
method been used.

In summing up the accidents and complications following operations
for luviiiorrhoids, it is fair to say that untoward results occur occasionally
in all of them, but they are less frequent and less severe after the clamp
and cautery than after any other method.

Eecapitulaticm. — After this prolonged discussion one may be some-
what confused as to the method to be used in an individual case. Ex-
perience only can teach this. In the early stages of the disease the
palliative treatment will always relieve, frequently results in pennanent
cure, and ought to be given a trial. In uncomplicated varicose internal
haemorrhoids, with relaxed sphincters, the injection method is compara-
tively safe, and its results are very satisfactory in the majority of in-
stances. In strangulated, mixed, and ulcerating piles, or those with
considerable connective tissue in their substance, the clamp and cautery
is by far the best method. In haemorrhagic cases, or those with atherom-
atous arteries, the ligature is probably the safest method. In cases
with only one or two marked haemorrhoids, partial excision by the aid of
Earle's clamp appears to be an ideal operation. Where there is a general
varicosity of the lower end of the rectum, with prolapse of the mucous
membrane, excision with immediate suture will give the best results. On
account of its applicability to all varieties, the ease and celerity with
which it can be applied, and its uniformly good results, the clamp and
cautery easily stands first among the operations for haemorrhoids.

CHAPTER XVII

I^ROLAPSE OF THE RECTUM, PROCIDENTIA INTESTINI RECTI

Prolapsus and procidentia, both of Latin derivation, are identical in
their meaning, and signify a falling down. Some authorities have at-
tempted to establish a distinction between the two, limiting the term
prolapsus to a descent of mucous membrane, and procidentia to those
conditions in which all the coats of the gut come dowTi. Allingham
(Diseases of the Rectum, 1896, p. 209) goes further than this, and says:
*^ By prolapse is meant a protrusion outside the anus of a portion or
portions of the mucous membrane, not in its entire circumference and
unaffected by piles. The term procidentia must be confined to a descent
of the whole circumference of the rectimi." This limitation of the term
prolapsus is entirely too restricted, and there is no authority for it in
etymology or literature. Cases occur in which the mucous membrane
prolapses in its entire circumference with one or two haemorrhoids at
different points, and yet these would be excluded under the definition of
this gifted surgeon. Prolapsus has been applied for centuries to all
degrees of falling of the rectum, and it is too late to put such a restriction
on its use. It is the generic term, and applicable to all types of the con-
dition, and will be so used in this work. Procidentia, however, has not
been so generally employed, and is practically always applied to those
cases in which all the coats of the bowel descend. It will be so used here.
It is not so important that the prolapse does or does not involve the
entire circumference of the gut, as it is that it involves only a part or the
whole of its thickness. Prolapsus is divided into incomplete or partial
prolapse, in which the mucous membrane alone descends; and complete
prolapse or procidentia recti, in which all the coats of the bowel — the
mucous, submucous, muscular, and even the peritoneal — take part. Ac-
cording to this division the term prolapse may signify any form or degree
of descent, while procidentia applies only to the different degrees of com-
plete prolapsus.

Incomplete Prolapse. — This variety, called also partial prolapse by
Cripps {op. cit,, p. 120), consists in a sagging down, or protrusion from

t>(>S

THE ANUS, KECTUM. AND PELVIC COLON

the nnuM, of Ihe miul-ous iiieiiibmne oi lliu rt?(.-tuiii (Fig. 281). It is an
exiiggeration of the normal physiological eversion whidi occurs at every
stool. In health the loosi' fibrous and i:lastic tissues allow & certftin
ajiiount of pi'otrusion of the membrane which facilitates the ejiftiou of
the fnecal mass, and when the act of defecation is completed retract it
by their elasticity. In pathological conditions these tissues become
stretched and permanently elongated; they lose their elasticity, and thus'

not only allovr tha
mucous membrane to
extrude to an Blmor-
mal degree, but fail
to draw it up ajfain.

This is the moet
frequent form of
prolapse, and occurs
constantly in acute
proctitis with oxlfr-
nia. in hwrnorrhoiilB,
and in .superficial
nvn|i!asms of tli<*

Etiohijif. — Aye. —
The disease is found
most frequently in young children and in the very old. In adulta it
is not at all frequent, but iwcasionally occurs in women who have suf-
fered from complete rupture of the perinmum or after prolonged, ex-
hausting iliseascs. Those states in which there is relaxation of tint
sphincter muscles and reduction of the fatty cushions which surrotind
the lower end of the rectum and anus are all predisposing causes.
The exciting causes are:

1. Wliatever separates the mucous from the muscular wall of the
gut, such as cedema or inflanmiatory effusion into the submucosii, Mol-
li^re (/>ii. lit., p. 1EI9) proved this, and produced the disease artificially
by introducing a blow-))ipe beneath the nmeous membrane and inauf-
flating air into the subnmcous tissue, thus separating the miiciiiis from
the muscular wall of the gut, and causing the former to extrude from
the anus.

2. Tliose conditions which produce weakness or dilatation of the
aphintcer muscles, such as exhausting diseases, panilysis, incisions, over-
distention, sodomy, and traumatic injuries to the sacral plexus of nvrvoe.

3. WHiatever mechanically drags down upon the mucous membmne
— i. p., hiemorrhoids, tumors attached to the membrane, poly|i», and
hard costive stools.

PROLAPSE OP THE RECTUM 669

4. All those diseases and conditions which produce increased peri-
stalsis and straining efforts at stool, suoJi as pinwornis, foreign bodies
in the rectum, ulcerations, proctitis, urethritis, stricture of the urethra,
cystitis, stone, phimosis, and enlarged prostate.

5. Prolonged sitting and efforts at defecation. The pernicious habit
of seating little children on vessels and compelling them to sit there
until the bowels move is one of the most frequent causes. Old men of
leisure, who are accustomed to take their pipe and morning paper to the
toilet with them, often suffer from this form of the disease.

6. Diarrluea, especially the summer diarrhwa of children, dysentery,
and cholera morbus, with excessive vomiting, may all bring about this
condition.

Symptoms. — The syniptoms of incomplete prolapse are at first very
meager. The condition never comes on suddenly, and in the beginning
is not accompanied by pain, itching, or discharge of any kind. There is
simply an exaggeration in the normal protrusion of the mucous mem-
brane at the time of stool. This gradually increases until it becomes
perceptible and annoying. The extent of the incomplete prolapse is
limited by the distensibility of the fibrous attachment between the
mucous membrane and the muscular walls. One to 2 J inches may be said
to represent the possible extent of such a prolapse.

At first the prolapse is spontaneously reduced or recedes under gentle
pressure, but as it increases and the membrane grows thicker through
infiammatory changes, it is grasped more or less firmly by the sphincter
muscle, and reduction becomes more difficult. In this type of the dis-
ease, however, strangulation of the prolaj)sed gut and sloughing, such
as takes place in the complete variety, are rarely seen.

The color of the prolapse is at first like that of the normal mucous
membrane. It gradually assumes a bright-red or scarlet as the irrita-
tion from sliding up and down increases, and when constricted by the
sphincter it may assume a dark-purplish or gangrenous hue.

The prolapse may involve the entire circumference of the anus or
only a ])art of it. When it involves the entire circumference, it will be
composed of longitudinal folds which radiate from the center to the
circumference. This direction of the folds or sulci distinguishes the
incomplete from the complete form of prolapsus. The surface of the
protrusion may be smooth or lobulated according to the inflammatory^
ha^norrhoidal, or neoplastic conditions complicating it. Excessive
ha?morrhoidal disease is always associated with more or less prolapse of
the mucous membrane, and in these cases we observe the three or four
cardinal tumors with a sagging down of the mucous membrane of the
rectum between them. Pain, haemorrhage, ulceration, and suppuration
occur later in the disease as the result of friction due to the slipping up

670 THE ANUS, RECTUM, AND PELVIC COLON

and down of the prolapsing membrane, to constriction by the sphincter
muscle, or irritation by the passage of hard faecal masses. These symp-
toms, however, are secondary complications of the disease and not &
part of it.

Treatment. — The treatment of this type of prolapse is ver}' simple.
The removal of the cause, where it is apparent, is alw^ays the first step.
Haemorrhoids, polypi, and other neoplasms should be excised, and the
operations accomplishing this will ordinarily result in the cure of in-
complete prolapsus.

In children and old people the habit of prolonged sitting at stool
should be discontinued. A cold enema should be administered just be-
fore going to the toilet in order that defecation may be accomplished
promptly and with ease. Such reflex causes as phimosis, stone, urethral
stricture, etc., should be eliminated before attempting any operative
treatment for this condition. In children a very large majority of these
cases can be cured without any surgical operation. Active tonic treat-
ment, careful attention to the movement of the bowels, cold applications
and electricity to the anus, and plenty of fresh air will generally accom-
plish a cure.

In elderly people, however, the organic changes in the fibrous attach-
ment of the mucous membrane are not so easily overcome, and operation
is very frequently called for.

The operative methods employed in this type of disease consist in
cauterization of the mucous membrane, and in partial or complete ex-
cision. AUingham advises cauterizing the entire surface of the prolapse
with fuming nitric acid^ and believes that this will set up an inflam-
matory conditicm of the submucosa which will shorten the fibrous
connections between it and the muscular wall, thus overcoming the
prolapse. The method of Van Ruren is based upon a similar view,
and consists in cauterizing the prolapse with the actual cautery,
heated to a red heat, in lines about ^ inch apart throughout its en-
tire extent.

It is difficult to understand how either one of these methods acts
through producing a submucous inflammatory condition, for whatever
incre»ases the separation between the mucous membrane and the muscular
wall tends to produce prolapsus. It does not seem to the writer, there-
fore, that the method of repair follows the course laid down by these
eminent authors; the results are more probably due to the spasmodic
contraction of the sphincter and the prolonged constipation produced
by these cauterizations, together with the actual narrowing of the lower
end of the intestinal canal. If the prolapse is overcome by the production
of submucous inflammation between the mucous membrane of the rectal
wall, the same can be set up by hypodermic injections of chemical sub-

PROLAPSE OF THE RECTUM 671

stances into this space without the necessity of ulceration and inflam-
mation in the mucous membrane itself. Occasionally this condition haa
been cured by such methods, and the author would certainly advise their
application before any attempts at cauterization by the Allingham or
Van Buren methods.

The injection treatment of incomplete prolapse consists in the intro-
duction of 3 to 5 minims of modified Shuford's solution into the sub-
mucous tissue at several points around the circumference of the anus.
After this injection has been completed, a rubber drainage-tube should
be introduced into the rectum, and the rectal ampulla packed thoroughly
with gauze so as to hold the gut in position. The drainage-tube will
serve for the escape of gases, and the bowels should be confined for
seven to ten days. A firm compress should be kept over the anus at first
in order to prevent the mucous membrane from coming down, and the
patient should be kept under the influence of opiates sufficiently to
control peristalsis and efforts to expel the rectal packing. If care-
fully performed with proper antiseptic precautions, there is no dan-
ger of suppuration or sloughing in this method, and the percentage
of cures is fully equal to that by the cauterizing methods mentioned
above.

The radical and certain cure of these conditions, however, consists
in partial or complete excision of the prolapsing mucous membrane.
Partial excision consists in taking out elliptical portions of the mu-
cous membrane at three or four points around the circumference of
the prolapse. This may be done in two ways: first, by excising the
mucous membrane with scissors and suturing the edges of the wound
together; secondly, by grasping strips of the membrane in the hapmor-
rhoidal clamp, and removing them just as one would a ha?morrhoidal
tumor. The latter method is far simpler, and accomplishes just as good
results, for in the large majority of cases the sutured wounds do not
heal by primary union, and in the end we have to deal with a granu-
lating wound such as follows the operation by the clamp and cautery.
In applying the clamp and cautery to this condition, one should always
observe the same rules as are laid down in the operation for haemorrhoids,
viz., that the muco-cutaneous tissue should never be embraced in the
part cauterized, and the long axis of the portion removed should be
parallel with that of the rectum. This method, employed entirely by
Henry Smith, gives uniformly good results, and can be performed by
any surgeon.

The method of complete excision of the prolapsing mucous membrane
consists in nothing more nor less than a Whitehead operation. This
has already been described in the chapter upon haemorrhoids. The only
precautions necessary to be repeated here are, first, the necessity of care-

672

THE ANUS. KKCTUM. AND PELVIC COLON

m ami twhnique, of keeping the iucision entirely
aibrane, and tlie iinportanci.' of careful ailjust-
ihii wmind so as to avoid tension and tearing

f td antiseptic prepai-at

within the mucous m

mcnt of the edges of

throiigli of the suturei

The same objections may be urged against the operation in prolapsus

as have been urged under the subject of ha-morrhoids. The non-operative

and the elanip-and-cantery methoits laid down above will prove the most

satisfactory treatment

in a large majority uf
the cases. In this
minor degree of pro-
lapsus the nTitcr haa
not found any advan-
tage from strapping
the buttocks together
or requiring the pa^
tient to lie in the tv-
i-umbeut posturi- when
his bowels move. The
i rncin brain? will
prolapse in this posi-
tion just sa much m
if the patient sits upon
the commode.

The ligature opera-
tion in the treatmvnt
of this condition,
ihough it is advised by
MalhywB, Allingham,,
aud other ofKrators, is

rMHyy Jf ^t \[\\^^'^^ ""^ "" witisfactory aa

"' ~/fitl pi ■Rv'^' till' clamp and cautery,

flH HI n! although it will cure

'H'/fllH] ^ I hose cases which ar»

"VBL'Kr V '''"^ ^" bypurtrophied

T I'njiPi.ETK Pho-

■ i, \r S li , PnOCIDRNTIA

Pio. aas.— ConpLETK Pnoi'.i.KVTT, Hk.t. — ^..'..M, iii:.i.,i>:. I\'riii»Ti\i Recti. —

There are three degre«a

of complete prolapse of the rectum, all of which involve a descent of

the rectnin in all its coats to a greater or less extent. They are dia-

tinguished as follow:

PBOLAI'SE OF THE RECTUM

6T3

First Degree: In litis the prolapse begins at the margin of the anus,
and its external surface is continuous with the skin surrounding this
aperture (Fig. 222).

Second Degree: The prolapse begins at a point more or less above the
anus, and, descending through that portion of the gut which remains in
posilion, protrudes through the anal orifice (Fig. 223).

Third Degree: The prolapse begins high up in the rectum or sigmoid
flexure and extends down into the nmpnlla iif the rectum, but does not
protrude through the
anal orifice (Fig. 224).

These three de-
grees vary consider-
ably in their syiu|n-
toins and treatnuTit.
and therefore mciit
separate coasl d em-
tio n.

The First Deijice.
— This variety of |>ro-
cidentia is brought
about by the siaine
causes as incomplctr
prolapsus; it is I'm'-
quentlya sequeiicr nf
the latter. Partial
prolapse can only ex-
tend to a limited de-
gree before the fibroii:^
attachment of the mu-
cous membrane to the
muscular wall begins
to drag forcibly upon
the latter, and event- Fiu. a^4.— (■..mplete I'h.«ii.e.\th Hei;ti— Thjuu hh-hh
ually cnrrieB it down-
ward, thus bringing about a complete prolapse of the first degree. This
form, however, rarely occurs in connection with hrcmorrhoidfi, owing to
the fact that these growths are situated at a very short distance above
the mu co-cutaneous margin and only drag the mucous membrane down
to that limited extent that will be permitted by the stretching of the
elastic bands in the submucosa. When the attachment of the neoplasm
which causes a prolapse reaches the lowest point of the latter, it then
drags upon the external nttachmcnt around the margin of the anus as
well as upon the mucous membrane of the gut above, and conse(|uently

«»

THE ANUS. RECTUM, AND PELVIC COLON

the prolapse can not prot-eed any farther. Tlierefore, as the hfetnor'fl
rhoids are attached low down iii the rectum, prolapse from this eau8*1
can never bo excessive. When, however, the condition is due to polypi-l
or neoplasms higher up in the rectum, tiie organ may be draggtMl out-
side of the rectum to the extent of the height of their attachment.

The distinguishing feature of this degree of prolapse consists in the 1
fact that its external surface is continuous with tlie cutaneotis surface '
Burromidiag the anus. There is no sulcus between the prolapse and the

anal margin. The mucous folds which run up and dott-n in tlie iocom-
plole variety change to a circular direction in the complete tj-pea, and
surround ihe prolapse in irregular, crescentie folds (l''ig. 225).

The condition may come on gradually, or in rare instances it may
be suddenly produced by crushing accidents or excessive straittiiijf ta
lift some heavy object. When the prolapse is first protraded its color
is a bright red, but after it has been don-n for a short time it assumea-
a dull puqilish hue due to venous tui^gescencc. If there is cnnsideisble
obstruction to the return circulation, it may become tense, swollen, and
shining, thus obliterating the circular folds.

In the beginning the prolapse occurs only at stool, and retires spon-
taneously. Where the sphincters are relaxed or disabled, however, it

PROLAPSE OP THE RECTUM 675

may remain down all the time unless held in position by compresses or
supporters of some kind. Occasionally where the prolapse is produced
suddenly, it may be constricted by the sphincter muscle, and its reduc-
tion may be quite difficult. In the early stages the mucous membrane
is not altered in any marked degree, but after repeated prolapsing and
reduction it becomes excoriated, inflamed, and ulcerated at times. There
is nearly always a mucous discharge, and occasionally quite serious
hivmorrhages occur in this condition.

The Second Degree. — The prolapse begins at a point more or less
removed from the anus, and the rectum protrudes through this orifice,
thus leaving a sulcus or space between the protruding gut and the
anal margin into which can be introduced a probe, or sometimes even
the linger, to the height at which the prolapse begins. This degree
never results from incomplete prolapse, nor from haemorrhoids or tu-
mors attached within the first inch and a half of the rectum. It may
be due to stricture, ulceration, or neoplasm of the gut at any point
above an inch and a half. Whatever causes persistent peristaltic action,
abdominal straining, and prolonged efforts at stool may bring about this
type of procidentia.

It may occur gradually, or it may be produced suddenly by some vio-
lent strain, crushing accident, fall, or other injury. The author has
seen it occur during operations for haemorrhoids after the sphincter has
been dilated and the patient, only partially etherized, begins to strain
inordinately. Under these circumstances, however, it has always been
very temporary. The extent of prolapse of this degree is limited only
by the length of the colon itself, or even the small intestine. Cases
have been reported in which the whole colon, ileo-caecal valve, and sev-
eral feet of the ileum have protruded through the anus. As a rule,
however, 3 to 6 inches is the average amount of protrusion. When the
prolapsus does not exceed 3 or 4 inches it will be straight, and its orifice
will point in a line parallel with the long axis of the gut. When it ex-
ceeds this amount, traction upon the mesorectum begins to draw it
backward, and thus producing a curve with its concavity toward the
sacrum, drags the orifice in this line. In excessive cases of procidentia
the mesosigmoid and mesocolon, each in its turn dragging upon the
prolapsed organ, twist it into a sort of corkscrew shape, sometimes
making as many as two or three circuits.

Symptoms. — The symptoms of procidentia of the first and second
degrees are practically the same. In children the mass protrudes only
at stool, as a rule, but in old people, where there is atony and relaxation
of the sphincters, it may remain down all the time. Constipation is the
rule in young and old alike until the rectal mucous membrane becomes
excoriated or inflamed, after which a teasing, irritating diarrhoea may

«76

THE ANUS, RECTUM. AND PELVIC COLON

begin. Discharges of mucus, sometimes tinged with blood, aro nearly'
always present. Owing to the relaxed and overstretched condilioii of the
spliincters, the loss of sensibility in the nmcous membrane, and per-
sistent peristalsis kept up by the irritation in the rectum, a mild form
of incontinence of freces often exists in these eases. Pain is not a
prominent symptom unless there is ulceration in the lower portion of the
rectum, or spasm of the ephinctei- constricting the prolajise.

The one persistent symptom upon which the diagnosis rests, consists
in a protrusion of the entire thickness of the gut during defecation.
The condition can only be confoumled wilh hicmorrhoids and neoph

of tlie rectum which
prolapse. The irrt-gi*'
hir, tubulated shape^
Ihe varicose comlition
of the vessels, and the
fact that at cprtata
portions of the cir-
cumference of the rec-
I the

Itrane remains in silUf

servo to distia^uish

these conditiotiA front

procidentia.

The excoriation and
jrrnnulation of a chron-
ic procidentia of cither
the Hrst or second dfr-
ijree sometimes resuli
in a hypertrophic, nod-
ular condition wbiclii
rcseiublcs ver>' niitcll
I'pithelioma of the rec-
tum, and can only be
distinguished from
this condition by mi-
croscopic cKRininstion.
.As will he e.'cn from the illustrations, these varieties are pnme tO<
be complicated by a descent of the recto-vesical or Douglas's cul-de-sac,
in which may be conlainetl loops of the small intestine, thus confiH-
tuting II rectal hernia or archocele.

In thf early stages of this condition these loops arc contained only
in the anterior portion nf the prolapse, and produce a smooth, round
pnmiinence al this portion (l''ig. 23(1)- Hut where the prolapse has ex-

PROLAPSE OF THE RECTUM 677

tended to a distance of 5 or 6 inches the peritoneal cul-de-sac and its
hernial contents may entirely surround the gut, with the exception of
the narrow portion to which is attached the mesentery. Under such
circumstances the entire circumference of the prolapse will appear much
thickened, soft, and pliable.

The diagnosis of this condition may be made in several ways. Per-
cussion with the pleximeter will sometimes give a tympanitic note en-
abling one to say that there is air between the two layers of the prolapse,
but this does not positively denote the existence of a loop of intestine
therein. If, when the prolapse is down, the patient is placed in the
knee-chest posture and the parts manipulated, tlie gurgling and feel of
the returning gut can be easily distinguished, just as in the case of
inguinal hernia. Occasionally attachments will occur between the small
intestines and these hernial sacs, making it impossible to reduce the
hernia without the prolapse being carried along with it; in such cases
strangulation is very likely to occur. Several instances have been re-
ported in which the rectum has ruptured and the small intestine has
burst out from the peritoneal cavity under these circumstances. Strange
to say, wherever this has occurred, the prolapse has at once been sponta-
neously reduced, and only the small intestine remained protruding from
the anus. No satisfactory explanation of this fact has yet been given.

Other complications, such as strangulation and gangrene, with
sloughing of the prolapse, have been noted in medical literature, but
these cases chiefly occurred before the use of anaesthesia became so gen-
eral. With it prolapses can be almost invariably reduced, and no prac-
titioner hesitates to employ this means at once.

Third Degree. — This degree of procidentia consists in a falling down
or intussusception of the upper portion of the rectum and sigmoid into
the lower portion or rectal ampulla. It differs from ordinary intussus-
c(»ption in that it does not cause strangury or complete obstruction, prob-
ably on account of the wide distensibility of the rectal ampulla; and
secondly, the peritoneal coats which come in contact with each other
do not adhere and become fixed as in cases of typical intussusception of
the bowel higher up. In this degree the gut prolapses, but it does not
protrude from the anus. The sphincter muscles and the anal aperture
remain nonual. The patient has no sensation of any protrusion when
at stool, nor is there any soreness or pain about the margin of the anus.

Speaking from a mechanical point of view, this degree is only the
first step of the second degree of procidentia, only it is higher up, and
in the large majority of cases never proceeds to actual protrusion through
the anus.

Symptoms. — The symptoms of this condition are quite obscure. The
patient will nearly always give a history of having suffered from con-

678 THE ANUS, RECTUM, AND PELVIC COLON

stipation, but after a protracted period of this disorder he may develop
an irregular diarrha?a. In whichever state he is found, one can always
elicit the fact that when he goes to stool the act is never satisfactory.
There always appears to be something more to come away. This sensa-
tion is similar to that produced by the presence of a foreign body, and
often results in straining and prolonged sitting at the toilet.

I^axatives are never satisfactorv in their effects. Enemas are essen-
tial to a comfortable movement of the bowels, and these act more b?
raising the prolapsed gut upward and thus relieving the intussusceptioD
than by stimulating peristalsis. Heaviness and weight in the sacral re-
gion associated with dull, aching pains radiating to the thighs, are fre-
quently complained of. At other times there is aching in the perinaeum
with dvsuria and disorders of the sexual functions. In some cases the
author has observed a dragging upon the lumbar and lower abdominal
n^gions. The sym[)toms are very likely to be mistaken for ovarian or
tubal diseases in women. Flatulence, intestinal indigestion, and mn-
cous colitis are almost constant accompaniments of this disorder.

At first the mucus discharged is clear like the white of an egg: after-
wanl it becomes tingeil with blood and contains a small quantity of pus.
These latter changes are produced by the friction and irritation of the
mucous membrane due to the prolapse and recession of the gut, causing
first a stimulation and then excoriation, and finallv uleemtion. In
Plate I, Fig. i>. a typical ulceration occurring upon the crest of sneh
a pn>lapst^ is represent eil.

iKvasionallv there is assi>ciated with this condition a so-called mem-
branous i^^litis acctmi|>anied by marked exhaustion, and sometimes seiw
abdominal |vains after stool. None of these svmptoms is unifonnly
prwont, however, with the exception of the feeling of unfinished busi-
noss, tlatuloniv. and irregularity in the movement of the bowels.

Afff<>?»vv. — The causes of this tyj>e of [irocidentia are various. Any
n\H>pla>m i^f tlu* sigmoid or u]>per jwrtion of the re<-tuin may iadwf
«i jjmdurtl dt^ivnt until the growth reaches a nesting-place in tht* aic-
puJU of tho nvtum. Whatever causes constriction of th<- gut and
oK>tru\tu>n to tho faval jviSiSiiges will also result in this type of pn>
l^\v<o. rhxis, unusual i^mtracture at the recto-sigmoida] juncnn?.
?\U^>n;;v or maHgnant strictures, perirectal strictures or Il]<1e«I>'n^
\\'U',>'<^U s\vi>uuxlic o^ntraction. will cause the arrest oi the f«<*l rassie?
>^N^^o ;)\o>c |H>inls, and oonsiH]uently a sagging down or inrD?4?iisf^<n<«
*Nl O^o ni^osnno alnwe into that Mow. Chronic constipttiou iln»o?i
in\,*^r";;^M> pnvtxles this condition, and we have ass<x-iait*d iniii ii «
h>|vrtr\Aphic catarrh of the mucous membrane with bvjwTHiai ^
thiokotunc of the walls. The ulcerations which are oc<«si«xaIlT UeA
in this \>Muiition are in all probability the result of it, and att ikt

PROLAPSE OP THE RECTUM 679

cause, being produced by the constant friction of the gut's slipping
up and down. In the cases in which the abdomen has been opened
for the purposes of fastening the gut so as to prevent its prolapse,
the author has always found an abnormally elongated mesosigmoid and
mesorcctum. Elongated, peritoneal supports, associated with intra-
intestinal neoplasms, inflammation, or obstructions, are in general the
causes of this condition.

Dr. F. Sehmey (Centrbl. f. Kinderheilk., 1897, Bd. ii, S. 41), after
an extensive experience in this line, states that the large majority of
prolapses of the rectum in children is due to rhachitis. In elderly
people progressive atony of the intestinal muscles may also be con-
sidered as a predisposing cause.

Pailwloqy. — To understand the organic changes which the prolapse
itself involves, it is necessary to refer the reader once more to the
supports of the rectum (Chapter I, p. 47). It will be remembered that
the latter is held in position by several different classes of supports.
The lower portion is maintained in position by the levator ani and
external sphincter muscles, the perineal fascia and fibrous attach-
ments to the coccyx, and the prostatic or vaginal walls; the middle
portion is supported by the loose fibrous tissues which pass off from
the sacrum along the course of the lateral sacral arteries and line the
iipj)er surface of the levator ani, thus connecting the organ with the
osseous frame of the pelvis. The superior portion is held in position
by the j)eritoneal folds which connect it with the pelvic walls upon the
sides, the bladder or uterus in front, and with the sacrum behind,
where the mesorectum and mesosigmoid comprise the chief support
of the gut.

In order for procidentia to occur there must be a weakening or
destruction of these supports as well as some force capable of dis-
lodging the organ from its position. The passive supports, composed
of fibrous and elastic tissues, lose their efficiency through gradual elonga-
tion or rupture; the active supports, composed of muscular tissues, lose
theirs through atrophy, injury, or paralysis. In procidentia of the first
and second degrees the pathological changes consist in alterations in
the muscular apparatus and fibrous attachments of the lower end of the
rectum to the surrounding parts; in that of the third degree the altera-
tions take place in peritoneal, vascular, and connective-tissue supports.
The latter condition is alw^ays of a gradual and slow development; the
former may come on suddenly from accident or injury, or it may develop
gradually from the extension of a procidentia of the third degree. In
the case seen with Dr. I^adinski (Fig. 167), where the prolapse was due
to a marked fibrous stricture 6 inches above the anus, this gradual devel-
opment was undoubtedly the course of the disease.

080 THK ANUS, RECTUM, AND PELVIC COLON

In traumatic cages the prolapse occurs first, and the atony or weak-
ening of the muscles is secondary. In old people and sodomisu. and
in children that have suffered from exhausting diseases, the relaxa-
tion of the sphincters is primary and the prolapse secondary.

Along with the other changes which occur, there is the absorption
of the perirectal fat in the retro-rectal, superior pelvi-rectal, and isdiio-
rectal spaces.

Treatment. — The rational treatment of complete prolapse of the
rectum will depend upon the exciting cause, the type, and the actual
pathological changes which have taken place in the organ itself and the
surrounding tissues. It is useless to suppose that a procidentia can be
cured by restoring the rectal supports if the exciting cause reraaifls
active. Such conditions as haemorrhoids, neoplasms, strictures, and
ulcerations must all be eradicated before a permanent result can bf
obtained. All the methods of accomplishing this have been described
in their proper places. Assuming, therefore, that this has been done
and the prolapse persists, the surgeon must proceed to restore the
rectal supports to their normal condition.

In children and old people in whom this condition is the result of
constitutional debility, exhausting diseases, summer diarrhoea, dysen-
tery, rhachitis, or general senile muscular relaxation, together with de-
creased sensitiveness to normal stimuli, one will obtain the best results
by the treatment of these conditions. Schmey states that nearly all
prolapses in children may be radically cured by the administration of
phosphorus in increasing doses. He recommends the following pre-
scription :

^ B. phosphor 0.01;

01. jecoris aselli 100.0.

Ft. sol.

Sig.: One to three coffee-spoonfuls daily.

The author has long taught that procidentia in the young is ordi-
narily amenable to very conservative methods. Many of the cases
occur in weak, debilitated children suffering either from rhachitis or
the result of some exhausting disease, and constitutional treatment,
such as has been advised by Dr. Schmey, will be necessary in all of
them. Phosphorus in some form, strychnine, hypophosphites, cod-liver
oil, and arsenic are useful adjuvants in the treatment. These all act,
however, in restoring the muscular supports by toning up the levator
ani, the sphincters, and the longitudinal muscles of the gut. It is *
matter of the utmost importance that the prolapse should be kept m
position as much as possible while these drugs are restoring the re-
tentive powers.

PROLAPSE OF THE RECTUM 681

It is a well-established fact that if an intestine is held in one posi-
tion for several weeks, it will become fixed at that point, and only
be removed from it by some unusual force. The secret of success
in the treatment of prolapsus recti in children lies in our ability to
maintain the organ in its natural position while the general consti-
tutional conditign and muscular tone are being restored to normal.
In addition, therefore, to the constitutional treatment of these cases,
local applications, such as^ stimulate contraction of the sphincter mus-
cles and retraction of the prolapsed gut, should be frequently made.
Cold water is one of the best of such applications; solutions of alum
or tannic acid applied to the prolapsed gut often act with good effect.
Where the prolapsus is (edematous and swollen, excellent results may
be obtained from the application of an absorbent pad soaked in a 25-
per-cent solution of boroglyceride.

In order to prevent the prolapse of the gut during the act of defeca-
tion, the child should be forced to use the bedpan, or, what is better
still, to have its movements while lying on the side, the bed or table
being protected by pads of cotton, oakum, or some other substance which
can be destroyed. In order to facilitate these movements and avoid
straining, it is better to give the child an enema just before laying it
in position.

Where the prolapsus occurs at other times than when at stool, or
when it remains down except when replaced by manual efforts, some
method will be necessary to maintain the gut in position while the
alterative processes are going on. There is no better means of accom-
plishing this than broad adhesive straps used in the manner advised
by Dr. Powell, of New York. The application of these straps is made
while the bowel is reduced and while the child is lying upon its side;
they should be about 3 inches wide, and should pass from one trochanter
to the other, the buttocks being drawn closely together and folded in;
the posterior edge of the strap should pass just in front of the margin
of the anus. Ordinarily these straps are applied directly over the
anus, so that they must be removed every time the child defecates;
this is a mistake, because frequent reapplications bring on an irritation
of the tender skin, and it soon becomes ulcerated. If the strap is
placed in front of the anus, the child may lie upon its side or upon
the bedpan and defecate without soiling it or necessitating its removal
more than once in a week or ten days.

Compresses for supporting a prolapsed anus are not satisfactory in
accomplishing the result, and at the same time by their pressure upon
the sphincter they cause dilatation and relaxation of this muscle, and
thus practically prevent the very end that is sought. In old people,
who constitute the greatest number of cases of prolapses, with the ex-

682 THE ANUS, RECTUM, AND PELVIC COLON

ception of children, there is a different cause for the condition. Often
there are neoplasms, haemorrhoids, strictures, chronic constipations,
and other diseases of the rectum associated with an absorption of fat
from the perirectal spaces, a general decline in muscular tone, and a
decrease in nervous sensibility. Khachitis is not an element in these
cases so much as general muscular atony.

The constitutional treatment is of importance, but one can not
expect to restore the waning powers of age and accomplish such favor-
able results by it as in children. At the same time, it should be used,
and especially in the forms of strychnine and arsenic. The local appli-
cations mentioned above are useful in these cases, and adhesive straps
mav also be of benefit.

Allinghain and others recommend the use of rectal plugs for the
retention of prolapsus, and claim to have obtained good results from
them; but they can only be of temporary benefit in retaining the rec-
tum in position, and must ultimately do injury, as they constantly
dilate the sphincter and by their presence reduce its response to normal
stimulation.

Electricity, both galvanic and faradic, has proved useful in these
cases. A number of cases have been reported in which this agent
has produced a complete cure of the disease, both in children and
old j)e()j)le. General massage is also of benefit.

In old people it is a matter of great importance to regulate the
bowels, and to obviate, as far as possible, prolonged sitting at stool.
If the prolapse is of recent occurrence, it is well to have the patient
use a bedpan or lie upon the side, as advised for children, for the
movement of the bowels. Laxatives may be employed, but they should
not be drastic or griping cathartics. Small enemas of cold water will
generally serve to produce an action without much peristalsis or strain-
ing. The patient should be taught to have a regular time for going
to stool. He should take his enema lying down, and repair to the
toilet only when he feels an urgent call for relief.

The length of time which these non-operative methods should be
continued will de])end entirely upon the history of the case and the
extent of the prolapse. Two or three months will suffice to test them.

In children there som(»times occurs an extensive prolapse, coming
on suddenly and involving considerable lengths of intestine. This may
be brought on by accident, such as great pressure upon the abdomen,
being run over by carriages, or falls from considerable heights, and
also from acute enteritis with great tenesmus and straining. If seen
early and the parts are restored and held in position by straps, the pro-
lapsus may not recur. If, however, it continues to do so, some radical
operative interference will be necessary. In general, one may say that

PROLAPSE OP THE RECTUM 683

where the parts are irritated, causing the child distress, and where
the prolapsus is increasing instead of decreasing, operative interfer-
ence should be undertaken. One other condition also demands immedi-
ate interference, and that is where there is a large extent of pro-
lapsus, spasm of the sphincter, and great turgescence or strangury of
the prolapsed gut. Under such conditions delay is unjustifiable, and
operative interference should not be put off.

Strangury and sloughing from prolapsus of the rectum is very rare
in children and old people. It occurs in adults and middle-aged indi-
viduals, and the sloughing even then is generally limited to the mucous
membrane. There are cases, however, reported in which the whole
prolapsed gut has sloughed off, and thus a spontaneous cure of the
procidentia has resulted. In these cases there has always followed a
cicatricial contraction or stricture which has been very difficult to
manage. The dangers from such a process, and the unsatisfactory
final result, absolutely forbid dilatory action in these conditions.

B eduction. — Ordinarily prolapses of the rectum are reduced spon-
taneously or can be easily replaced by the patients themselves. Some-
times, in excessive cases or in those produced by accident, the patient
is unable to reduce the gut, and the surgeon is called in for this pur-
pose. If the procidentia has been down for any length of time and
the sphincter is tightly contracted around it, there may be great swell-
ing and (edema of the tissues, and the difficulties of reduction will be
found by no means slight.

The methods to be employed in such cases are various, and each
case will present a problem in itself. It is advisable that the replace-
ment should be made without general anaesthesia, if possible, in order
to avoid the subsequent nausea and straining which will tend to repro-
duce the procidentia. If, however, after due manipulation the reduc-
tion can not be accomplished, one should not hesitate to administer
it, stretch the sphincter, and reduce the procidentia.

When called to a case of unreduced prolapsus, one should carefully
examine the parts to determine whether it is complete or incomplete.
The condition of the mucous membrane should also be carefully exam-
ined to note if strangury, ulceration, or sloughing has taken place.
These conditions will depend, of course, upon the length of time which
the gut has been down and the amount of constriction. If there is
great congestion or oedema, firm pressure with hot cloths should be
made for some time before any attempt at reduction. Cold is never
advisable in these cases, as the circulation is always deficient, and one
may bring on sloughing by its use.

Applications of cocaine and suprarenal extract will assist in con-
tracting the blood-vessels and reducing the volume of the prolapse.

684 THE ANUS, RECTUM, AND PELVIC COLON

The patient should be placed in the knee-chest posture or in Sims's
position, with the hips well elevated, the former being by all means
the best to reduce the amount of blood in the parts, and also to obtain
the influence of gravitation upon the upper end of the intestine, thus
assisting in its reduction. By this position a hernia, if present, will
be reduced, and often after this the prolapse will retire spontaneously.
After gentle and continued pressure with hot compresses and the appli-
cations mentioned, one will generally find that the circulation of the
parts is improved, and the oedema and congestion will have greatly di^
apj)eared. Efforts at reduction may then be begun, and they should
always be directed through the lumen of the bowel at the end of the
prolapse. Allingham states that whenever this lumen points backward
toward the sacrum one may conclude that there is hernia of the small
intestine along with the prolapse. This is not always so, for the author
has seen one case in which the lumen was twisted almost to the sacrum,
and yet in which there was no hernia present. Great care should be
exercised in the nuinij)ulation that one does not bruise or irritate the
parts. In order to carry the inner layer of the prolapsed gut upward,
the finger or a bougie should be gently introduced into its lumen and
carried upward, thus undoing the outward invagination and shortening
the prolaj)sus. In order to accomplish this the bougie should not be
oiled, as it will then slide over the mucous membrane and not cam
the gut upward. An ingenious device is to wrap a small piece of
tissue paper around one's finger, introduce its end into the lumen of
the prolapse, and gently push upward. By this means the inner layer
of the prolapsus is carried upward, while the outer layer is little by
little enfolded on the finger. Having reduced the prolapsus thus far
by a boring motion, the finger is released from the tissue paper and
withdrawn; the paper remains and assists in preventing the prolapsus
from recurring. This procedure is repeated until the entire prolapsus
is reduced. The same method may be applied with a small rectal bou-
gie, but in the writer's experience the finger has been all that Ls neces-
sary to accomplish the reduction. A full dose of morphine adminis-
tered hypodermically is sometimes of great assistance in the accom-
plishment of the reduction. Where the sphincter is so tight that it
constricts the gut and prevents its return, one should not consume
valuable time in lengthy and vigorous taxis, but resort to the use
of general anjesthesia, stretch this muscle, and accomplish the re-
duction.

Reduction in Gangrenous Conditions. — When sloughing has taken
place, one should be very careful to determine its depth before attempt-
ing to reduce the prolapsus. If the walls of the gut have become gan-
grenous, or likely to perforate, it will be very dangerous to reduce

PROLAPSE OP THE RECTUM 685

such a condition, inasmuch as it might open into the peritoneal cavity
and thus produce a fatal peritonitis. In such cases immediate amputa-
tion should be resorted to instead of waiting until the slough comes
away spontaneously, because under such circumstances the upper end
of the gut may retract and thus open the peritoneal cavity and allow
all the contents of the bowels to be emptied into it. By immediate
amputation the upper end can be caught and fixed by sutures or for-
ceps until inflammatory adhesion shuts of! the peritoneal cavity, and
such dangers are avoided.

After the reduction of the prolapsed mass, the question of future
treatment will arise. If the procidentia is acute, whether due to acci-
dent or to other sudden causes, a compress may be applied to the
anus, the buttocks strapped together, the patient confined to bed, and
his bowels moved iii a reclining posture, until it is seen whether the
prolapsus will recur. Sometimes it happens that the gut remains in
situ, and no further treatment is necessary. But if the case be one
of long standing and gradual increase, some operative method for its
retention will be necessary.

Operative Treatment. — As will be recognized from the foregoing
description of the kinds and causes of prolapsus, the method to be
selected will depend upon the j)oint at which the prolapse begins and
the extent to which it descends. In procidentia of the first degree, in
which only a small portion of the lower end of the gut comes down,
those methods which narrow the anus and thus obviate the protrusion
will be effectual. But if the prolapsus begins high up, and there is a
cul-de-sac between it and the anal margin, such methods, while pre-
venting the protrusion, will simply convert a procidentia of the second
degree into one of the third degree, and will in all probability prove
of no permanent benefit. The principles upon which the cure of proci-
dentia depends are, first, the removal of any exciting cause; and,
secondly, the restoration of the supports which have been altered or
destroyed. It can therefore be seen that if the prolapse be due to
stretching or rupture of the passive supports, it will be necessary to
restore these or to devise others to take their places before the pro-
lapse can be radically cured; and if it be due to relaxation, overstretch-
ing, dilatation or paralysis of the muscles, the treatment must be
directed to the restoration of the normal condition in these parts.
In complete prolapsus of the first and second degrees, w^e have to deal
with rupture or elongation of the adhesions between the lower end of
the rectum and the surrounding tissues, especially its attachments to the
coccyx, sacrum, and prostate or vagina, together with muscular atony
or relaxation. Appreciating these facts, Allingham and Van Buren
devised methods for restoring the adhesions between the rectum and

686 THE ANUS, RECTUM, AND PELVIC COLON

these parts by setting up an inflammation in the walls of the gut, and
thus causing agglutination with the perirectal tissues.

Allingham^s Method. — This consists in the application of nitric acid
or acid nitrate of mercury to the prolapse. The patient is anaesthetized
and the gut brought down, washed off, and dried. " The acid must
be applied all over it, care being taken not to touch the verge of the
anus or the skin. The part is then to be oiled and the rectum stuffed
with wool. A pad must after this be applied outside the anus and
kept firmly in position by a strapping plaster, the buttocks being by
the same movements brought closely together; if this precaution be
not adopted, when the child recovers from the chloroform (the strain-
ing being urgent) the whole plug will be forced out and the bowel will
again protrude. When the pad is properly applied the straining soon
ceases and the child suffers little or no pain." The bowels are eon-
fined for four days; after this the strap is removed and castor-oil is
administered to move them. He states that the treatment is chiefly
applicable to procidentia in children, and rarely fails if properly car-
ried out, but sometimes it is necessary to apply the acid more than
once. The author has never had the temerity to emplo}' this method
as advised by Allingham.

Theoretically, it appears that so strong an agent applied to the
entire mucous membrane of the gut would produce a sloughing and
subsequent ulceration which would result in stricture. There is abso-
lutely no control over the action of the acid and the depth to which
it will burn. Whether this burning is any more severe in the tender
tissues of the child than in the adult is questionable, but certainly
the walls of the intestine are thinner in children, the blood supply is
more feeble, and sloughing, it seems, would be more probable. The
author has used nitric acid, however, as follows: A very small quantity
of absorbent cotton is wrapped around a long platinum or wooden ap-
plicator and dipped into the acid; this is laid upon the prolapsing gut at
points about \ an inch apart around the rectum, so as to produce linear
cauterization and leave healthy strips of mucous membrane between
them. These are carried from the margin of the anus to the highest
portion of the prolapse, the lumen being held open by small retractors
while the applications are made. The dressing and after-treatment em-
ployed have been the same as Allingham's, except that a drainage-tube
extending above the packing was introduced to allow the escape of gases.

Van Buren's Method. — The patient is anaesthetized, the prolapsus
is dragged down as far as it will come, thoroughly washed off, and
dried; the actual cautery is applied in lines about \ an inch apart
all around the circumference of the gut, extending from the margin
of the anus to the highest point of the prolapsus. A cauterizing iron

PROLAPSE OP THE RECTUM 687

or a Paquelin cautery, heated to a bright heat, may be used. Van
Buren says that the latter instrument is not suitable for this purpose
on account of its not maintaining its heat long enough. The author,
however, has found it very satisfactory for this purpose. A narrow
blade should be used so as to make the cauterization deep but not
wide. The tissues should be burned down to the muscular wall of
the gut, care being taken not to perforate this layer, especially on the
anterior surface of the gut, because in this region the peritonaeum
may be involved, and too deep cauterization might penetrate its cavity
and thus produce a peritonitis. After the cauterization has been ac-
complished, the parts should be well oiled and reduced. A drainage-
tube should be introduced above the height of the prolapse, and around
it there should be packed a mass of wool or gauze, well oiled, in order
to retain the rectal walls in close apposition with the surrounding
parts. A compress should be applied to the anus and held in position
with an adhesive strap which draws the buttocks together. The
bowels siiould be confined for four or five days and the patient kept
in a recumbent posture. At the end of this period an enema shouJd
be given through the drainage-tube, and the patient's bowels moved
while on his side or back. The gauze packing will be expelled with
the movement of the bowel, and generally the prolapsus will not recur.
The patient should be required to move his bowels in the reclining
posture for two or three weeks.

These methods are often successful in the treatment of prolapsus
of the first degree if they are applied in the early stages; but if the
condition is neglected until the prolapsus becomes very large and the
walls thickened and hypertrophied, they are not likely to result in per-
manent cure. In grown people, Allingham himself does not place much
confidence in his method. He states that the applications do good,
but that the relief is only temporary. The free application of acid
to old people with broken-down constitutions, he says, is likely to pro-
duce deep sloughing and subsequent haemorrhage. He also admits that
it may produce stricture, and he cites the case of a girl in whom such
a result did occur, although the prolapsus was cured. The Van Buren
method is more frequently successful, but it is only applicable to cases
of the first degree. If the prolapse involves the upper portions of
the rectum, those surrounded by the peritonaeum, it is perfectly clear
that methods which depend upon inflammatory adhesion of the gut
to the surrounding tissues will be comparatively useless.

Where the prolapse is of small extent, the removal of folds of
mucous membrane at four or five points around its circumference by
the clamp and cautery, as advised by Mr. Henry Smith, has frequently
proved entirely successful. One may also, in this class of cases, dissect

flSN xnK ANUS, KEfTUM. AND PELVIC COLON

off elliptifal slri]i6 <jf mucous iin'inbrune, bringing the edges logethtr
wiih silkworm-gut or chromieizt-d sutures, thus narrowing thi; \mv!
end of the rectal eanal. and overcome the prolapBe for the time Wing.
The permanency of such rcHi'f is very douhlful.

Duret's operation (Bull, et mem. de la soc. de chir., Paris, 1900, p,
470). known as rectorrhaphy, first reported in a thesis by Mssmiii,
181)4, is similar to that done for prolapsus vagina?. V\ion the An-
terior and posterior surfaces of the prolapsus an elliptical flap of
mucous membrane is dissected out, extending from the suminil In
the liase, thuri leaving two lateral pillars of mucous membrane. The
muscular walls arc folded in by buried silk sutures and the cdg« (>I
the mucous membrane approximated by 8Ui>erficial ones. By this means
the cavity of the aiii|iii)l;i is flmn^'cil into a rcpilar cylinder of imtll
ealiliL-r (the same is a
done in colporrhsphrl.
Finally, he rcmntw
triangular flaps uf ekia
from the margin of the
anus and sutures tht
edges of the wounils
together, thus nami»-
ing this orifice both
anteriorly and posteri-
orly. Ill a case oper-
ated on in 18(I4 after
this method, and ex-
amined twenty months
later, the result WM
pirfeet. This opera-
tion is only a modifi'
cation of the Dupiiy-
trcn method, and ffill
accomplish nothil^
more than the clamp
and cautery.

Ill minor degrew
of procidentia the
*■"■ ''I ui.v I'll I'liiiiu.KMn Tifi'Ti. dition mav sometime*

be relieved by some
uicHiiiuiniiin u\ ilic W Intchead operatjon. The mucous membrane is
dissected from the prolapse, excised, and the cut borders sutured to
the margin of the anus, thus tucking or folding in that portion of the
gut which wa-s prulapecd. nelorme (Bull, et menioiivs de la soc. de

chirur., Paris, 1900, p. 49S) advises this opuration even in large pro-
lapses of 4 to 6 inches in extent. He gives an elaborate description
of how the mucous i
brane is dissected from the
prolapse (Fig. 227), prac-
tically denuding the entire
rectum. It is cut off and
then sutured to the
cutaneous border. Thi'
thickened and freshened
surfaces of the gut aro
thus in vagina ted above
the line of sutures. He
claims that Ihis reduplica-
tion (Fig. 228) not only
produces a narrowing of
the canal, but also in-
creases the sphincteric
action, which is beneficial
to the patient. He re-
ports 3 cases in which he
removect 80, 30, and 80
centimeters (about 8, 13,

and 30 inches) of the mucous membrane, obtaining excellent results in
the first 2 cases and death from septic peritonitis in the third. It
is impossible to conceive that such a method would not result in stric-
ture at the lower end of the rectum. It has this one advantage, how-
ever, that in cases due to hernias through the rectal cul-de-sac, this
thickened ring will furnish an obstacle to the descent of the peritoneal
pouch, and thus effectually prevent the recurrence of the prolap.se.

These operations, limited to the mucous membrane, have often
proved ineffectual, and many procedures involving the deeper tissues
have been devised. The priucipal ones are those of Roberts, Dieffen-
baeb. Lange, Vemeuil, and Peters.

The Dieff en bach-Roberts operation consists in the removal of a
section of the gut at it.* posterior commissure, extending about 3 inches
upward. The entire thickness of the intestine with the sphincter mus-
cles are removed, and the caliber of the lower end of the rectum and
anus is thus greatly reduced. The success of the operation depends
upon primary union of the parts. If this fails, it is liable to result
in an increase of the prolapse, together with incontinence of freces.
The operation is not applicable to prolapses beginning high up, as it
does not affect the original cause.

690 THE ASUS. BECTUM, AND PELVIC COLON

Ijangc has advised infolding the rectal ampulla from the outside^
thus narrowing the canal so as to prevent the prolapse. His open-
tion coDsista in making an incision from tlie jiosterior margin of

anus itpHanl alongside of the co&
cyi, and deep enough to
the posterior wall of the rectum.
The levator am muscle ia dissectei
olf, and the walls uf the gut
theu infolded by a line of eutan*
introduced through the muscHljr
layer, thus narrowing the caliW
and stitfening the wall to such
extent as to prevent the proU|Me.
Vemeuil ((Jaz. des hOpitaox, May
8, 1892) modified Lange's method by gathering the gut in horiiaatal
folds, thus shortening it, after which he sutured it to the sides of tbt
coccyx and sacrum by buried sutures and closed the external wound.
Peters (International Text-Book of Surgen) advocates an operetioit
similar to this upon the
anterior wall of Itn'
rectum. He makes :in
abdominal incision in
the mwlian line large
enough to admit of tlie
manipulation of the an-
terior wall of the rec-
tum in the peritoneal
pouch. The prolapj=p
having been drawn up-
ward by dragging on
the sigmoid, the iiri-
terior wall of the ^nn
is infolded by Leml^iit
sutures (Fig. 229). ih..-
ends of which are left
long, and pass through
the muscular layer of
the abdominal wall,
thus forming a sort of
sling to support the

rectum (Fig. 230). The adhesion of the peritoneal surfaces
rows the caliber of the rectum and thus obviates the recurrence of
the

PROLAPSE OF THE RECTUM

691

None of thpse methods, with the exception of Verneuil's, accom-
plishes anything more than narrowing of the anal outlet and an inflam-
matory adhesion of the estreme lower end of the rectum to the sur-
rounding parts. Ab a consequence they all fail to retain prolapses of
considerahle magnitude. George R. Fowler (Med. News, N. Y., Feb-
ruary 27, 189'i) first practised suspending the rectum by sutures car-
ried around the coccyx. He is therefore entitled to priority in the
application of a principle which the author employs as follows:

Rectopexy or Suspension of Ike Rectum upon the Sacrum. — The patient
is prepared (ly thorough cleansing of the intestinal canal, shaving the
pcrinaium and sacral region, and applying an antiseptic dressing the

night before the contemplated operation. After being ansesthetized he
is placed in the semiprone position on the left side with the hips elevated
on pillows and the thighs well flexed on the abdomen. The prolapse is
then dragged down to its full extent and held forward by an assist&nt.
A curved incision about 2 inches in length is made midway between the
coccyx and anus (Fig. 231). This is carried through all the tissues
into the retro-rectal space. With the fingers or a dull instrument
introduced through this incision, the rectum is separated from the
coccyx and sacrum posteriorly as high up as the attachment of the
mesorectum and on the sides as far as the attachment of the lateral
ligaments. The latter should be sedulously preserved. The anterior

692

THE ANUS, RECTUM, AND PELVIC COLON

surface of tliD hone is then gently curetted to remove all the fatq
tissue and freshen it. At this point the assistant reduces the prolapi
and with his fingers inside the gut inverts and brings it out through th^

inc'i^irni M-'ii:, ^y■'^!^: th'- '■t'itUim- r;itclirs the protrusion and drags theM

gut down as far as it will come, usually a little less than the amount
prolapsed through the anus. The external surface or muscular w»l
of the gut thus exposed is then curetted as was the sacrum. Sillcwomu
gut or silver-wire sutures are then passed Iransversely through thi
muscular layer, embracing as much of the circumference of the gv
as pofleihie; they arc placed ^ inch a[«rt, and the ends left 6 to I
inches long. After the sutures have been placed, the ends of tbi
upper ones are each in turn threaded on a long, curved Peaslev^l
needle and carried up through the wound to the highest point of thi
separation between the rectum and sacrum, where they are made I
penetrate the tissues, and are brought out through the skin on oppoeita
sides of the bone. The other sutures are treated in like manner, i
being brought out J inch lower than the preceding one (Fig. 333).
The ends are then drawn taut, and the prolapse is thus dragged up
into the hollow of the sarrnm where it belongs. A pad of gauze it
laid over the sacrum, and the sutures tied over this to avoid their
cutting into the skin (Fig. 234). Before tying the sutures the space

PROLAPSE OF THE RECTUM

between the rectum and sacnini should be freed from alt clots and
the oozing cheeked. The gut is thus anchored in close apposition with
the sacrum, to which it unites in due time. The external wound is
closed by buried catgut and subcutaneous sutures. If the sphincters
are much relaxed or overstretched, a ligature of kangaroo tendon
(Fowler) is passed around the anus at the upper margin of the external
sphincter, and tied over the index finger introduced through the anus,
as has been advised by Piatt, This narrows the anal ouilet and causes
contracture of the muscle, thus contributing to the cure. The bowels
are confined for eight days, when they are moved by enemata. The
patient is required to remain in bed and use the bedpan for three weeks,
after which time he may be allowed to go to the toilet. The anchoring
sutures are left in from ten to fourteen days.

Up to the present writing the operation has been employed by the
author in 10 cases; 3 of them have been in old people, 5 in people of

middle age, and 2 in children. In 8 of these the procidentia bad existed
for fifteen and eighteen years respectively. Seven of them have re-
mained cured from one to three years. Three have been done less than
a year, but so far there has been no recurrence. In the case of a woman
of thirty-five years of age, operated on tlirough the courtesy of Dr.
Liisk, several other methods had been tried, and among them the

694

THE ANUS, RECTUM, AND PELVIC COLON

Bieffenbach-BoULTts oporation, which resulted io incoDtiiience
large cicatrices at the iwsterior cominissure of the auus, uecessitntin
a plastic operation to restore the sphincter after the prolapse had b
sutured to the sacrum. It has now been eighteen monthH since I
operation was done, and beyond a slight prolapse of the mucous mctn
hrane at the anterior commissure there has been no recurrence. T
is certainly one of the severest tests to which the operation could be f
The method ia only effectual in those cases in which the prolapse if J
confined to the rectum, and below that portion which is entirely sur-^
rounded hy |ipriti)!i!Knim. It would he useful, no doubt, in all i

of prolapse of the first or second degree to whatever length they ex-
tended, hut it is perfectly clear that it could not overcome a procidentid
of the third degree. For a prolapse, however, of 5 or 6 inches, it will
prove entirely satisfactory.

In complete prolapsus of the second and third degree, in whicV
the upper portion of the rectum and sigmoid flexure are involved,]
there is an entirely different problem to solve. The anus and lower
end of the rectum may be narrowed and thus obviate the protrusion '
of the prolapse; but this simply shuts out from view the displaced
organ, and in no wise restores it to position. These conditions depend
upon the giving way of the superior supports or upon an abnormally'
long mesenterj', and their treatment consists in a restoration of these

PROLAPSE OP THE RECTUM 695

supports or the substitution of others for them. The exciting cause
should be removed; if there be stricture of the gut, it should be dilated
or resected; if neoplasms, they should be removed; and ulcerations
should be healed if possible. The methods accomplishing this will
suggest themselves to the operator in individual cases. Inasmuch as
most of these prolapses occur at the time of stool, and are associated
with constipation and difficulty in defecation, restoration of these func-
tions, so as to produce regular and easy stools, should be always first
attempted. This may eradicate the cause and alleviate the suffering,
but it can not restore the supports of the intestine. Persistent re-
placement of the prolapse, retaining it inside by adhesive straps across
the buttocks, the movement of the bowels in a reclining posture, and
the injection of astringent fluids, may sometimes prove effectual in
procidentia of the second degree in children and in people of middle
age; but in old people and in debilitated constitutions, such methods
are not likely to prove permanently beneficial.

In prolapse of the third degree great relief to the symptoms may
be given by persistent, periodic introduction of long Wales bougies,
by which the gut is carried back into position, and the movement of
the bowels greatly facilitated. This is only a palliative treatment,
and while the author still recommends it as the most conservative and
satisfactory non-operative method, he can not say that its effects are
at all permanent.

In view of the fact that many cases of prolapses only occur at the
time of stool, it has been suggested that absolute physical rest of the
rectum would result in the organ's resuming its normal position and
becoming fixed there. In order to accomplish this an artificial anus
must be made and borne for a sufficient time for these changes to
take place. This method was employed first by Jeannel in 1889, and
afterward by Bryajit in 1893. Jeannol's case, however, was not a fair
demonstration of the principle, inasmuch as he dragged the sigmoid
and rectum from below up into the wound until the lower segment
was taut, and suturing it in this position thus held the gut up and pre-
vented recurrence of the prolapse. lie afterward closed the artificial
anus without dissecting the gut loose from its attachment, and ob-
tained a permanent cure of the prolapse. The result in this case was
undoubtedly due to the adhesion between the gut and the abdominal
wall. In Bryant's case, however, no effort was made to drag the pro-
lapse upward. A classical inguinal anus was established, the gut being
pulled down from above in order to prevent its prolapse through the
artificial opening. The result in this case was very good at first, but
after some months the prolapse began to recur, and Dr. Bryant was
finally compelled to resort to sigmoidopexy in order to overcome the

696 THE ANUS, RECTUM, AND PELVIC COLON

prolapse. Jeannel, recognizing the facts in his case^ suggested that
the results would have been just as good had he simply sutured the
gut in the abdominal wound and made no artificial anus whatever.

Acting upon this suggestion, Verneuil performed in 1889 the first
typical colopexy, as he termed it. Inasmuch as the sigmoid was the
portion of the intestine sutured to the abdominal wall, it appears that
the term sigmoidopexy would be more appropriate, and we shall adopt
it in this work.

The operation consists in drawing the sigmoid and rectum upward
until the prolapse is entirely overcome and the lower end of the intes-
tinal tract is made comparatively taut between the anus and the ab-
dominal wound. The sigmoid is then sutured to the abdominal wall,
where it adheres, and thus prevents the recurrence of the prolapse.
Thus far 51 cases (15 of which occurred in the author's practice) have
been collected in which this procedure has been adopted with almost
uniform success. The technique of the difTerent operators varies con-
siderably, and increased experience alone can determine which is the
best. Most surgeons advise suturing the gut to the parietal peri-
toneeum. In one case in which this operation was done the prolapse
recurred after four months. The abdomen was then opened for the
second time, and it was found that the adhesive bands between the
gut and parietal peritonaeum had stretched out to the length of 6
inches, thus demonstrating the fact that the adhesion between two
peritoneal surfaces was not sufficiently firm and inelastic to perma-
nently support a large procidentia recti. In this case the peritonaeum
was stripped ofT from one side of the abdominal wound to the extent
of about 1 inch, and the gut sutured to the transversalis fascia. The
result remained permanent for three years, after which the patient
disappeared and has not been heard from since. In all subsequent
operations, therefore, the author has sutured the gut to the fascia
instead of the parietal peritonaeum. The technique employed is as fol-
lows:

The patient having been prepared for laparotomy, an incision of
about 3 inches is made through the body of the left rectus muscle,
beginning 2^ inches above the pubis and extending upward toward
the umbilicus. The peritoneal cavity having been opened, the patient
is placed in the Trendelenburg posture and the parietal peritonaeum
is stripped off from the sides of the lower angle of the abdominal
wound to the extent of about ^ inch. The sigmoid flexure is then
caught and dragged upward into the wound until the entire prolapse
is overcome and the gut between this point and the anus is drawn
comparatively taut. Fine silk or chromicized catgut sutures are then
passed first through the transversalis fascia upon one side, then

PROLAPSE OP THE RECTUM 697

through the longitudinal muscular band of the intestine, and finally
through the fascia upon the opposite side. Three of these sutures
are used to fasten the gut to the fascia over a space about 1^ inch
in length. The gut thus having been anchored, the upper angle of
the peritoneal wound is sutured with catgut, and the abdominal walls
are closed by suturing the rectus muscle and its sheath with buried
kangaroo tendon, the edges of the skin being brought together by sub-
cutaneous or continuous silkworm-gut sutures. The wound is dressed
antiseptically, and the patient is placed in bed, the foot of which is
elevated about 2 feet. This position is maintained for five days, at
the end of which time the foot of the bed is let down, and the bowels
are moved on the seventh day.

The operation has been performed 15 times; in 7 cases for proci-
dentia, and in 8 for adhesions and acute flexure of the sigmoid upon
the rectum. The results have been good in every case with the excep-
tion that some patients complain of an annoying, dragging pain at the
side of the adhesion. In no case has the prolapse recurred.

Dr. Mathews (Jour, of Amer. Med. Ass'n, 1901, vol. i) has reported
a case in which he overcame a very voluminous procidentia by sigmoido-
pexy. In this case the gut was sewed to the parietal peritonaBum, and
the adhesions seem to have been firm enough to support it, as the pa-
tient has remained well since 1899.

The method of MacCleod, of Calcutta ,( recommended by AUingham
in the sixth edition of his book), consists in introducing the left hand
into the rectum and carrying it upward until the finger becomes prom-
inent above Poupart's ligament. A steel needle is then passed through
the abdominal wall, •penetrating the cavity of the gut, and, guided
by the finger, is carried outward until it emerges upon the abdominal
wall about 3 inches inside of the point of entrance. A second needle
is then passed in the same direction about 3 inches above the first;
the gut being thus temporarily fixed, the hand is withdrawn and an
incision is made in the abdominal wall between the two needles and
at right angles to them. A careful dissection is made through this
incision until the peritonajum is reached. The left hand is then rein-
troduced into the bowel, and " two series of silkworm sutures are
inserted, four on each side, at a distance of about 1 inch apart, so as
to attach the serous and muscular coats of the intestine to the ab-
dominal wall. A series of these loops also penetrating the outer wall
of the intestine will pass between the several points of these rows^ which
are made to bring the lips of the wound together, and between them
small horsehair stitches are inserted; antiseptic precautions are em-
ployed; after the operation a morphine suppository is introduced into
the bowel, and opium is given every three hours."

698 THE ANUS, RECTUM, AND PELVIC COLON

The whole operation seems to be based ui>on a fear of entering
the peritoneal cavity, and yet that cavity is penetrated with a needle
passed through the skin and through the cavity of the gut, not only
once but four times. There is not a single step in the whole procedure
that should not be condemned by every scientific surgeon. This promi-
nence is given to it simply because it has been frequently quoted as
an example of sigmoidopexy. It is a most dangerous, unscientific, and
uncalled-for operation. The bibliography upon this subject has been
carefully covered in the article of Bryant (N. Y. Med. Jour., 1898, vol. i,
p. 164).

WTien the procidentia is not due to neoplasm or organic stricture
and can be completely reduced, sigmoidopexy will usually result in its
permanent cure. If it be a voluminous case of the first degree, in
which the lower and active supports of the gut have given way, the
sigmoidopexy may be supplemented by suturing the rectum to the
sacrum after the manner which has alreadv been described. When
the prolapse can not be reduced, or when it is in such a condition
of inflammation or gangrene that it is not wise to do so, some other
method of treatment must be undertaken, and in these cases the removal
of the strangulated or diseased intestine will naturally suggest itself.

Excision. — Amputation of the prolapsed rectum, while simple
enough in itself, may prove a very serious operation. The chief danger
lies in the existence of archocele or rectal hernia, which necessitates the
opening of the peritoneal cavity through the mucous membrane of
the gut. This condition will be discussed among the complications of
prolapsus. It is sufficient here to mention the fact that in every proci-
dentia of more than 2 inches, one is likely to meet w^ith a peritoneal
pouch in which there may be a hernia of the small intestine. Any
operation upon such a prolapse may penetrate this cul-de-sac and bring
on peritonitis, adhesion, or strangulation of the gut contained in it.
Amputation of the prolapse, where the gut is perfectly healthy, can
not be considered a very dangerous operation, but it is certainly more
so than sigmoidopexy, and is never necessary when the procidentia
can be reduced. When the tissues are so unhealthy that it is not safe
to reduce the prolapse, amputation through them involves great danger
of septic peritonitis. In a certain number of cases where the proci-
dentia is due to organic stricture, which stricture has reached the lowest
point of the prolapse, the whole may be excised, and thus the stricture
and procidentia cured at the same time. This has been done by Dr.
Louis Ladinski in a case which the author had the opportunity of see-
ing. The procidentia extended 7^ inches outside of and below the
anus, and the stricture at its lowest end would barely admit the little
finger (Fig. 167). The whole mass was amputated, the edges of the

PROLAPSE OP THE RECTUM 699

gut being sutured together, and a most happy result obtained. Where
large areas of the sigmoid and colon protrude through the anus, amputa-
tion may be successful, but it should not be employed if the gut is
healthy and can be reduced, for under such circumstances the intestine
may be sutured to its normal position with less danger than is involved
in amputation.

In amputating a prolapse of the second degree involving the sig-
moid flexure, the point at which the union of the two segments is
made will be retracted, and it is very likely to leak and cause infection of
the peritoneal cavity. The conditions which seem to justify ampu-
tation are: the existence of neoplasms involving the entire thickness
of the gut wall, organic strictures, gangrene or sloughing of the pro-
truded gut, and adhesions such as prevent reduction.

Numerous methods of performing this operation have been devised.
Those advocated by Treves, Lange, Kleberg, Mikulicz, and Fowler have
been most frequently employed. Only the last two methods will be
described, as they seem to possess all the advantageous features of
the others.

Mikulicz's Method. — The technique as here described differs slightly
from that originally laid down by Mikulicz (Deutsch. Gesellsch. f.
C'hir., Bd. xvii). The patient having been previously antiseptically pre-
pared and anaesthetized, is placed in the lithotomy position with the
hips well elevated. The prolapse is then dragged down as far as possi-
ble by traction forceps. It is then clamped by two volsella forceps
and held in this position by assistants. The elevated position of the
hips allows any coils of small intestine to slip out of the peritoneal
pouch, and thus avoids the danger of wounding them. After the intes-
tine has been dragged down, it should be surgically cleansed and dried
by sterilized gauze. A sterilized conical sponge should be carried up
through the gut in order to avoid, as far as possible, any contents of
the bowels coming down upon the field of operation. After these
preparations, an incision is made through the mucous membrane upon
the anterior surface of the gut at the margin of the anus. Dissection
is carefully carried through the entire thickness of the intestine, all
bleeding being checked as it occurs, until the peritoneal cavity is
opened. When this has been done, the serous membrane of the intus-
suscepted portion of the gut will be brought into view. This mem-
brane should be cut through, and its upper edge sutured to the peri-
toneal edge of the wound in the anterior layer of the prolapse. Thus,
step by step, the peritoneal pouch is closed. This having been accom-
plished, the entire thickness of the intussuscepted gut is then cut
through, little by little, and its muscular and mucous layers are sutured
by interrupted silk or chromicized catgut to the mucous membrane

too THE ANUS, RECTUM, AND PELVIC COLON

surrounding the margin of the anus at the site of the original incision.
In this manner the entire prolapse is excised, and end-to-end union of
the gut is accomplished. The ends of the sutures in the muscular and
mucous layers should be left long in order to steady the parts and
prevent their retraction while the operation upon the other portion of
the circumference is being made. All bleeding points should be caught
and twisted or ligated during the operation. After completing the
excision, if the edges of the mucous membrane are not in accurate
apposition a fine running suture of catgut should be applied around
the entire circumference to accomplish this. The long ends of the
sutures should* then be cut off, the w^ound dusted with iodoform or
boric acid, and over this several layers of flexible collodion should
be applied. The sponge should then be removed, a good-sized drainage-
tube introduced into the rectum, and the parts dressed around it with
sterilized gauze. The bowels should be confined for seven or eight
days, and opium should be freely administered to quiet peristaltic ac-
tion. The advantages of this operation consist chiefly in the careful
opening of the peritoneal cavity, and emptying it of any prolapsed loops
of small intestine or omentum, thus obviating the dangers of cutting
or puncturing them, as exists in both the Treves and Kleberg
operations.

Oeorge R. Fowkr^s Method. — In this operation a row of fenestrated
forceps or common artery clamps is placed just in front of the juncture
of the mucous membrane with the skin of the anus in such a manner
as to pinch up a circular fold from the outer cylinder of the prolapse
for the entire circumference of the gut. Half an inch in front of
this fold an incision is made through the mucous membrane only, ex-
tending entirely around the prolapse. The proximal edge is then dis-
sected back for half an inch. Two clamps are then placed, one on either
side, at the lower end of the prolapse, or the place where the outer
cylinder of the gut returns to form the inner cylinder, by means of
which the mass is steadied. The index finger of the left hand is then
passed into the inner cylinder, and, with this as a guide, the circular
incision already made is deepened so as to include the entire walls of
the two cylinders. This incision is about i inch long. A suture of
catgut is now passed so as to include the entire thickness of the two
cylinders at the point of this incision, with the exception of the mucous
membrane of the outer cylinder which has been turned back at the
anal margin. This step of the operation is repeated until the entire
circumference of the prolapse is traversed, save that the subsequent
sutures are first introduced before the incision is extended. Fowier
states that when the posterior portion of the circumference is reached
and the mesenteric attachment of the gut encountered, no difficulty

PROLAPSE OF THE RECTUM 701

is met in securing the blood-vessels of the mesentery in the suture.
He treats this portion exactly as the anterior portion. After the pro-
lapse has been amputated, the cuflE of mucous membrane which was
dissected back at the beginning of the operation is replaced and sutured
in position over the first row of sutures. The operation is performed
under a continuous stream of borosalicylic solution, the parts are
dressed with a light tampon of zinc-oxid gauze, and the bowels moved
on the third day.

He states that the cuflE of mucous membrane which is dissected back
in the first step of the operation preserves the normal conditions at
the anal outlet, and also provides a covering for the sutured edges of the
stump, thus diminishing the dangers of subsequent infection (Med.
News, 1900, vol. Ixxvii, p. 879).

In the second degree of procidentia it will be seen from the illus-
tration (Fig. 223) that amputation will accomplish the removal of only
a part of the prolapsed gut. It is questionable whether the operation
will result in the retraction and cure of the entire prolapse. There is
little question that it will do so in those cases in which the procidentia
is due to a stricture or neoplasm, this being removed by the amputa-
tion. But where the procidentia is due to simple inflammatory causes,
with hypertrophy and thickening of the intestinal wall, it is very prob-
able that the cure will not be complete.

Several cases of stricture resulting from amputation have been
reported, but no satisfactory observations have been made as to the
final results of amputating large areas of the bowel for prolapsus.
The large intestine is one of the chief absorptive organs of the body,
and amputation of any considerable portion of it may seriously inter-
fere with the nourishment of the patient. This fact should always
be considered where the operation of excision is contemplated. The
amputation of rectal prolapses has been remarkably free from fatal
results, considering the magnitude of the operation. Only three deaths
have been reported from this cause, while a large number have oc-
curred from the so-called conservative or proctoplastic operations.
Thus far no deaths have occurred from colopexy or sigmoidopexy;
therefore, where the latter operation is feasible, it should be the method
of election. Amputation should be considered a method of necessity
and not of choice.

Complications of Prolapse. — The different forms of procidentia are
not only complicated at times by the existence of neoplasms which have
been described as etiological factors, but also by inflammatory condi-
tions, ulcerations, strangulation, archocele, and rupture of the rectal
wall. The inflammatory conditions are found in cases brought on by
acute inflammatory diseases of the rectum, such as dysentery, summer

702 THE ANUS, RECTUM. AND PELVIC COLON

diarrhoea, or infectious proctitis in children. They are also found in
old cases of extensive procidentia in which the gut remains down much
of the time and suffers from friction by the clothing or the opposing
buttocks. In the first class of cases the inflammation is a cause rather
than the result of the disease, and the subduing of it will finally end
in the restoration and cure of the prolapse. In these cases the bowels
should be sponged off with a warm solution of hamamelis or fluid extract
of hydrastis, a little of the solution being injected well up into the
intestine. The prolapse should then be restored and held in position
by a properly fitting compress, the patient being kept upon the back.
Sufficient oj)iates should be administered to control the peristaltic ac-
tion, and a licjuid, concentrated diet should be given.

In the second class of cases, inflammations, ha?morrhages, erosions,
and ulcerations are due to mechanical irritations and interference with
the circulation.

The hiemorrhages are best checked by applications of cocaine or
sui)rarenal extract. The application of cold for this purpose is unad-
visable, inasmuch as it is very liable to be followed by sloughing of
the parts. The use of persulphate of iron is objectionable, l>ecause it
forms a hard clot and irritates the intestine. The fluid extract of
hydrastis aj)plied in a 50-per-cent solution contracts the blood-vessels,
and will prevent the recurrence of haemorrhages for some time. Where
the surface is eroded, a mild solution of nitrate of silver or a 2-per-cent
solution of ichthyol in oil, painted all over it, will form a sort of pro-
tective coat and give much relief. Where the ulcers are well defined
and isolated, a 20-to-50-per-cent solution will be of benefit to stimulate
healthy granulation and hasten the cure.

Xone of these remedies, however, will be permanently useful unless
the patient is kept in bed and the prolapse retained inside of the anus.
The interference with the circulation caused by the constriction of
the sphincter and the oedema of the parts militates against the heal-
ing of the erosions and ulcerations. Firm compresses kept upon the
anus will sometimes prevent the prolapse from coming dowTi; at other
times strapping the buttocks together by adhesive straps is more
effectual.

The author has never seen any good come from rectal plugs which
pass up through the anus. They increase the relaxation of the
sphincter muscles, and simply add to the difficulty which they are
intended to cure.

Strangulation is a very rare complication of procidentia. The
instances which have been reported have occurred chiefly in traumatic
cases in which the procidentia was brought on very suddenly by acci-
dent or injury. Ordinarily the procidentia coming on and increasing

PROLAPSE OF THE RECTUM 70S

gradually, dilates the sphincter, overcomes its spasmodic tendency, and
therefore the latter does not produce any constriction. This is true
in children as well as in elderly patients. Occasionally, however, acute
inflammatory conditions set up in the protruded gut, causing an unusual
cedema and swelling, and thus the prolapse is constricted not through
any spasm of the muscle, but through the processes going on in itself.
Under such circumstances the entire mucous membrane may slough
off, or the gut itself may become gangrenous. The reduction of the
prolapse under such circumstances is a difficult procedure, and, more-
over, it is exceedingly doubtful whether it should be attempted. If it
were certain that the mucous membrane alone were involved in the
gangrenous processes, it might be perfectly safe to reduce the prolapse.
But if the submucous and muscular walls are involved, they will be so
weakened that manipulation at reduction may result in rupture; or even
if reduction is accomplished without this accident, the gangrenous
processes may extend into the peritoneal cavity and thus cause fatal
peritonitis. The author is of the opinion that immediate excision of
the gangrenous gut is a safer procedure in such cases than attempts at
reduction. Where the case is seen before sloughing takes place, efforts
at reduction should be made according to the methods heretofore
described.

Age is sometimes spoken of as a complication contraindicating at-
tempts at permanent cure of procidentia. Old people cling to life as
tenaciously as the youthful, and whatever worries, irritates, or dis-
tresses them shortens their days. The author has reported elsewhere
a large series of operations upon patients above sixty years of age,,
and has shown conclusively that in the absence of marked organic dis-
ease these individuals stand aseptic surgical operations quite as well
as those of forty years (Jour, of the Amer. ^led. Ass'n, vol. i, 1901). The
radical cure of procidentia, therefore, should be undertaken in this,
class of patients whenever the circumstances call for it.

Another complication is that in which excessively large areas of
intestine prolapse through the anus. Instances have been reported in
which almost the entire colon and 6 inches of the ileum were pro-
truded. Cumson records the case of a child in which the procidentia
extended down below the popliteal space, and Esmarch a case in which
the entire large intestine, including the caecum, protruded through the
anus.

The treatment of these extensive procidentia or invaginations isi
very difficult. They may sometimes slough off at the point where the
upper portion of the gut enters into the lower and thus be cured spon-
taneously. A specimen in the author^s possession shows a portion of
the gut which came away in this manner after an extensive procidentia;

704 THE ANUS, RECTUM, AND PELVIC COLON

it was from a patient of Dr. Thomas, of Georgia. Sixteen inches of
the gut came away.

Peacock (Path. Transactions, vol. xv, p. 113) reports a case in which
it is believed that 40 inches of the intestine came away piece by piece,
and yet the patient recovered. Such a result, however, can not be
relied upon, as 85 per cent of the cases which have pursued this course
have proved fatal. Reduction of these extensive procidentia, even
when seen in their early stages, is rarely possible from the outside.
Nevertheless, it should be attempted by gentle taxis and suspending the
patient in the knee-chest posture. The author has been able to reduce
1 case, in which the procidentia exceeded 14 inches, after suspending
the patient in tliis position for over two hours. In fact, the procidentii
was reduced spontaneously, it being supported and covered with warm
cloths during this period. Such results, however, can not be ex-
pected with any confidence. Prolonged and violent taxis is likely to
inflame the gut and increase its swelling, or it may result in rupture.
The question therefore arises, Shall the procidentia be amputated, or
shall a laparotomy be done and reduction accomplished through the
peritoneal cavity?

Where the condition is seen before sloughing and gangrene take
place, the latter course is without doubt the proper one. Under sudi
circumstances amputation not only involves a danger in itself, but also
that which would follow upon the removal of so large a portion of the
digestive tract. It appears to the author, therefore, that this opera-
tion ought never to be resorted to under such circumstances until
efforts at abdominal fixation of the gut have been made.

Lambotte (La presse med., Beige, 1896, p. 25) has demonstrated
the possibility of fixing these intussuscepted guts in their normal posi-
tion. In a child in whom the small intestine prolapsed through the
caecum for at least 15 centimeters (about 6 inches), and the colon and
sigmoid prolapsed through the rectum, he made an abdominal incision,
reduced the intussusceptions, and sutured the colon in its proper posi-
tion at the hepatic and splenic flexures, fastening the small intestine
along the border of the ascending colon so as to shorten its mesentery,
and thus prevented the recurrence of the prolapses. Three months
after this operation the patient was seen and was perfectly well. Such
an operation as this, or suturing of the colon to the abdominal wall?
should be attempted in these cases of extensive procidentia. It is less
dangerous, and the probable results are certainly as promising as the
excision of large areas of the intestinal canal.

WTiere gangrene has already begun, cutting away the diseased and
protruding portion may be advisable, and may possibly save the patient
from septic infection. It is evident, however, that the entire proci-

PROLAPSE OP THE RECTUM 705

dentia can not be removed by this method except in cases of the first
degree, and the extensive invaginations are rarely of this variety.
Operations through the abdomen and peritoneal cavity after gangrene
has occurred are not advisable.

Archocele or rectal hernia is one of the most frequent and serious
complications of complete prolapse. Ludlow has attempted to show
that the majority of prolapses of the rectum are due to rectal hernia;
that the cul-de-sac of Douglas, being low down and pointed backward,
causes an infundibulum into which the small intestines gravitate, and
through abdominal pressure sink lower and lower until the gut is
invaginated and procidentia is produced. This doctrine has not been
established by clinical observations, but every careful observer must
have seen cases in which this cul-de-sac bulged backward into the rectal
ampulla when the patient sits and strains, almost occluding this cavity,
and interfering with the fa?cal movements (Fig. 226). Sometimes in
such cases it is necessary for the patient to pass his finger through
the anus and press forward the bulging mass before a satisfactory evacu-
ation can be obtained. With such cases in view, one can not positively
deny the possible truth of Ludlow's theory.

Kelsey (op. cit., p. 255) says: " In the external form the sac is first
formed and remains ready at any time for the reception of its con-
tents," thus indicating his belief that the hernia has nothing to do
with the production of the procidentia. This, however, can not be
proved or disproved. The fact that rectal hernia? protrude into the
ampulla without ^ appearing outside of the anus, certainly indicates the
possibility that they may gradually increase just as do scrotal herniae,
overcome the resistance of the external sphincter, and finally cause a
procidentia of the gut. The extent of the circumference of the pro-
laj)se which is involved by the hernial sac will be determined by the
length of the prolapse.

The existence of hernial sacs, however, in all cases of prolapse
protruding more than 2 inches through the anus is undeniable. The
farther the procidentia protrudes, the larger will be the sac, and the
more of the intestinal circumference will it involve. In limited proci-
dentiae the hernial sac is restricted to the anterior quadrants, but in
extensive ones it mav involve the entire circumference with the ex-
ception of that part occupied by the mesentery. Herniie of this type
resemble those of the inguinal region, inasmuch as they come down
upon walking or straining, are reduced by pressure or position, may
become adherent to the sac, or may be strangulated either through
spasm of the sphincter or contraction of the hernial neck.

The diagnosis of hernia in procidentia may be made from the thick-
ness of the walls of the procidentia, the gurgling sound upon reduc-
45

I 706

THE ANIIS. RECTDM, AND PELVIC COM

tion, the tympanitic note upon percussion, dragging and griping sensa-
tions in tile abdomen when the hernia is down, anci the tact that (he
aperture in the prolapse points either forward or straight downirard
from the anus. The importance of recognizing this condition in tb*
treatment of ])rocideniia can not he overestimated, for too vigor<>ttg
manipulation may injure the intestines, and in the operation of smpaia-
tiiin llie gut might be wounded unless preeautione were taken to reduce
it beforehand. It is for the purpose of reducing the hernia that llw
Trendelenburg posture is advised in the operations of Mikulicz uiil
Fowler.

The contents of these hernial sacs arc variable. Ordinarily tlir^
contain the gmall intestine, the sigmoid, or omentum. Cases, bon-
ever, hflve been reported in which they contained ovaries and tubes,
the uterus, the bladder, and the vermiform appendix. All these orgiifls
may become adherent to the sac. and thus obviate reduction. The pro-
lapfic itself may be pushed inside of the anus, but the hernia will slill
be unreduced. Brunn (Casper's Wocbenschrift f. d. gesammie Ilcil-

I kunde, It^^A. i;.:. :.. :.,, i-, .>. ;;J1, „:.>; [\,. ..,:.. uaulog. Day's Col-

I legium Anatomical Chirurg., Braunschweig, 1S54) have reported into

I esting cases of this kind.

I A verj' unusual type of rectal hernia is shown in the illustratJan

{Fig. 23.1). It was in the person of an old woman in the .Almshouse
Hospital, and was supposed to be a case of simple rectocete when first

PROLAPSE OF THE RECTUM 707

observed. Careful examination of the tumor, however, showed it to be
a hernial sac. When the woman strained to move her bowels the tumor
would appear, gnnietiincs through the anus and sometimes through the

ina (V'i'^. 'i'M\). Tlu; photograph of the tuuiur prokp-in^' thmnirli the

anus was obtained by pressure upon the posterior vaginal wiiU while the
patient strained as if to move the bowels. The patient died, and an
autopsy WHS not permitted by her friends, so it is impossible to state
exactly what portion of the intestine was included in the hernial sac;
but the gurgling sound upon reduction, the tympanitic note, and the
fact that the tumor entirely disappeared when the patient was placed
in the knee-chest posture, left no doubt as to the nature of the pro-
trusion.

The chief danger from these hernias is strangulation and rupture
of the intestinal wall. Strangulation may occur from constriction by
the sphincter, the levator ani, or finally by the longitudinal muscular
fibers of the gut wall itself. Sometimes these fibers separate, allow-
ing the hernia to protrude between them, the sac being thus composed
of only the mucous, submucous, and serous tissues. The spasmodic
contraction of the longitudinal fibers, therefore, may cause constric-
tion of the neck of the sac and strangulation of the hernia. Strangula-
tion from spasm of the sphincter is exceedingly rare, and only occurs
when unusual amounts of intestine prolapse into the hernial sac and
become distended with gas, or when the procidentia becomes inflamed,

708 THE ANUS, RECTUM, AND PELVIC COLON

oedematous, and thus unnaturally enlarged. It is thus a question of
the procidentia becoming too large for the anal aperture rather than
one of spasm of the sphincter.

The treatment of such cases consists in reduction of the hernia, if
possible, by gentle taxis under the influence of general anaesthesia or
large doses of morphine. Some surgeons prefer the latter, holding that
it will cause less nausea afterward, which would tend to the ^ep^odu^
tion of the hernia. The sphincters should be stretched, or, if neces-
sary, incised, and one should always remember that reduction of the
procidentia does not mean complete reduction of the hernia. After the
procidentia has been carried upward, a hand should be introduced into
the rectum and the parts thoroughly examined to see that no hernial
sac containing strangulated intestine protrudes into the rectal ampulla.
Where such means fail to reduce the hernia, laparotomy should be per-
formed at once, the contracting bands severed or dilated, and the hernia
reduced by the intraperitoneal route. Incisions through the rectal
wall under such circumstances are fraught with the greatest danger.
The intraperitoneal route is not only less dangerous, but it affords
the opportunity for resection of the gangrenous loops of intestine and
the breaking up of any adhesions which may have caused the incarcera-
tion of the gut. It also has the further advantages that the hernial
sac can be obliterated from this side by accurate suturing, and the
procidentia can be overcome by abdominal fixation of the sigmoid
flexure.

Rupture of the Hernial Sac, — Aside from inflammation, incarcera-
tion, and strangulation, cases of rectal hernia may be complicated bj
rupture of the sac through the rectal wall. This may occur whether
the hernia protrudes through the anus or whether it is confined to the
rectal ampulla. Kelsey (Diseases of the Rectum, 4th ed., p. 240) gives
a most interesting collection of cases of this kind. To those interested
in the detailed cases, this resume will prove most interesting.

The rupture may occur spontaneously, as has been described by
Quenu (Revue de chirur., March 10, 1882), through injury, as in
Brunn's case, or through efforts at reduction of the prolapse and hernia.
In the case of Smith it occurred during his efforts to cure the pro-
laj)se by taking away longitudinal strips of mucous membrane with the
clamp and cautery. After the strip had been removed, the patient
began to vomit, and the straining upon the parts resulted in a rupture
with protrusion of the hernial contents.

Spontaneous rupture due to straining while at stool, vomiting, or
lifting heavy weights, is the ordinary course of events. If the prolapse
is down, the small intestine or other contents of the hernial sac will
protrude from the body itself. If the rupture occurs when there is

PROLAPSE OF THE RECTUM 709

no prolapse or protrusion outside of the anus, the gut may prolapse
tlirough the wound into the rectal ampulla until this cavity is entirely
filled. In either case the appearance of the small intestine or sigmoid
with their serous coverings will make the diagnosis clear. The symp-
toms of such a condition are sudden, acute pain followed by collapse,
shock, and protrusion of the gut either into the rectal ampulla or outside
of the body.

It requires no elaborate discussion of the pathology of the condi-
tions to account for such ruptures. Whatever weakens the wall of the
intestine will predispose to it. Inflammation, erosion, ulceration, fatty
degeneration, varicosity, and other pathological changes of the intes-
tinal wall which are likely to occur during the course of protracted
proeidentiae, will easily account for the weakening of the hernial sac
and its giving way under any extraordinary strain.

Where rupture occurs while the prolapse is outside of the anus,
it has been found that the prolapse itself will be spontaneously reduced.
This fact indicates that the hernia has something to do with bringing
down and maintaining the procidentia. The rent is variable in the
different coats of the rectal walls, generally being longer in the serous
than in the muscular coats, and least of all in the mucous membrane.
In the cases of Englisch there was marked extravasation of blood be-
tween the mucous and muscular coats, and between the muscular and
serous coats. In Smith's case the protruded gut was immediately re-
placed, the rent sutured, and the pafient made a good recovery. As
a rule, however, strangulation of the protruded gut occurs before opera-
tive interference can be employed.

The mortality in such cases is very high, but Smith's experience
teaches that, if the parts can be reduced at once, a favorable result
mav be obtained.

The wonderful case of John Xedham (Philosophical Transactions,
1755, vol. xlix, p. 238), quoted in full by Kelsey, is one of those
unique accidents in surgery which it is impossible to explain. A boy
was thrown underneath a cart (turned upside down), and found in this
position with a very large portion of his intestines forced through the
anus, a part of the mesentery hanging down between the legs. He
was in an intense condition of shock. After hot fomentations the
doctor reduced the parts, but the vomiting immediately returned and
forced them out. On the following day signs of mortification in the
protruded intestine appeared, and on the third day the surgeon cut
off the intestine, with the mesentery-, close to the anus. Very shortly
after this operation there was a discharge of black, offensive, fsecal
matter, the pain-? grew easier, the nausea and vomiting ceased, and the
patient proceeded to an uneventful recovery. For a while he had six

710 THE ANUS. RECTUM, AND PELVIC COLON

or seven stools daily, and had some difficulty in retaining them. The
doctor is not exactly certain as to what point in the circumference
the rupture had taken place, but thought he felt an opening through
the posterior wall of the rectum just above the internal sphincter. The
intestine cut off measured 57 inches. Three months afterward the
boy walked seven miles to dine with the doctor. Such cases as this
are surgical curiosities which throw no light upon the etiolog}' or treat-
ment of the condition.

Attempts at reducing the protruded gut in these cases of rupture
usually result in crowding the small intestine up into the rectum with-
out restoring it to the peritoneal cavity. Suspending the patient in an
exaggerated knee-chest posture may possibly cause the retraction of
the gut and enable one to restore it to its proper position. After
it has become strangulated and gangrenous, such a restoration would
not only be useless but surgically dangerous. If the gut is much dis-
tended with gases, large hypodermic needles may be inserted to allow
their escape.

In the gangrenous cases it is better to thoroughly cleanse the parts
and incise the protruding mass, tying off the segments of gut which
are left outside of the anus. Laparotomy should then be performed,
and end-to-end union of the healthy gut attempted. The fortunate
results of Xedham should not tempt any one to leave the part^ pro-
truding, as was done in his case.

If the gut is not gangrenous, it is the duty of the surgeon to per-
form laj)arotomy at once and reduce the procidentia from the peritoneal
side, having washed off the protruding gut thoroughly with borosalicylic
solution before it is withdrawn. After the protruding gut has been
restored by this method, the rent in the rectal wall may be sutured
from the peritoneal side, if possible; otherwise a gauze drainage should
be introduced down to the site of the rupture, and the abdominal wound
closed. A fivcal fistula may follow this latter course, but it is a matter
of small moment, as the large majority of these fistulas heal spon-
taneouslv.

The most important point in connection with these ruptures is the
likelihood of their ])eing produced by unwise and too vigorous efforts
at reduction of the procidentia, and by the cauterizing or denuding
operations devised for their radical cure. The likelihood of such acci-
dents should always be borne in mind, and in cases in which the rectal
wall is at all diseased, or in which there is evidently a hernial sac in
the prolapse, such methods had better be avoided.

CHAPTER XVIII
BENIGN TUMORS OF THE RECTUM

The lower end of the large intestine may be the seat of a variety
of neoplasms that occur at the margin of the anus, in the rectum, or
in the pelvic colon; they are broadly classified as benign and malignant,
but it is often a very difficult matter to say just where the one ends
and the other begins. Growths which in themselves are not dangerous
to life may be so gradually transformed that one finds both the benign
and malignant types in the same tumor.

From a histological point of view, tumors of the rectum may be
classified as follows:

The Connective-tissue Type, — Fibroma, enchondroma, lymphadeno-
ma, lipoma, myxoma, and sarcoma.

The Muscular Type, — Myoma and fibromyoma.

The Epithelial Type, — Adenoma, papilloma, and carcinoma.

In addition to these well-defined types, teratoma or cystoma, fungi,
vegetations and excrescences are met with.

Among the tumors of the connective-tissue type are sarcoma, and
among those of the epithelial variety, carcinoma. These growths, uni-
versally considered malignant, contain no histological elements not
found in other growths. The peculiar characteristic upon which their
malignancy depends is not understood. The fact that the epithelium
in one, and the embryonic cells in the other, develop out of their usual
order and location, will not account for the toxic or fatal results in
either case. Recent experiments with regard to their bacteriological
origin soem to point to a possible solution of this question, but so far
the pathologists have not agreed upon whether they are the results of
spores, germs, parasites, or toxins. At present only those tmnors will
be considered which, occurring in the rectum or sigmoid, produce no
constitutional disturbances beyond those due to their mechanical irri-
tation and the reflex eiTects of the same.

Polypus. — The term polypus or polyp is applied to any pedunculated
growth. The latter may be of any histological variety so long as it is
attached to a surface of the body by a pedicle narrower than the tumor

711

712 THE ANUS, RECTUM, AND PELVIC COLON

itself. It is sometimes applied to sessile, pyrif orm, and pendulous neo-
plasms in which there is no pedicle, but this use of the term is rapidly
becoming obsolete. When one speaks of a polyp of the rectum, there-
fore, he means a tumor attached to the rectal wall by a pedicle.

Seat and Manner of Development. — Polypi occur with greater or less
frequency throughout the intestinal canal. Wellbrock, who has searched
the literature on this subject, states that in four-fifths of the cases
they are found in the rectum and sigmoid. It is a question whether
this preponderance is not more apparent than real, inasmuch as this
portion of the intestine is the only one that can be satisfactorily ex-
amined during life, and therefore the tumors are seen here when it
would be impossible to observe them higher up.

Leichtenstem states that about 60 per cent occur in the rectum, 25
per cent in the ileum, about 12 per cent in the colon and ileo-c«cal
valve, and 3 per cent in the small intestine.

In children they are generally observed as isolated growths, one, two,
or three in number; most frequently there is only one. In adults, how-
ever, we find them multiple in the majority of cases. Their seat is
ordinarily about 1 or 2 inches above the margin of the anus, but occa-
sionally they are found much higher. Some have been seen with pedi-
cles as long as 6 inches attached within the sigmoid flexure. The
nature of the development is explained as follows: A closed follicle or
gland, becoming distended from inflammatory or other causes, protrudes
into the cavity of the rectum, carrying the mucous membrane before it,
and sometimes dragging a small portion of the submucosa after it
Through its weight, and the contraction of the circular fibers of the gut
in Nature's efforts to rid herself of the enlargement, the follicle is forced
downward, stretching the mucous membrane, and eventually dragging it
out into the shape of' a pedicle. The irritation and hyperaemia caused
by this sagging, and the obstruction to the return circulation from the
growth, bring about an oedema and hypertrophy of the follicle and its
surrounding tissues, and thus the polypus is produced.

This method of formation applies to all types of polypi, with the
exception that the original growth may be a fibroma, an adenoma, a
cystoma, or a lipoma instead of a solitary follicle or gland.

Histological Types. — The neoplasms which most frequently take on
this polypoid form are hypertrophied solitary follicles, adenoma, fibroma,
and lipoma. The most common form (that which is generally found in
children) is of the soft, mucous variety, probably originating in an
inflamed solitary follicle. It consists of alveolar tissue, the meshes of
which are filled with a thick, viscid fluid; the surface is covered with
cylindrical epithelium, and sometimes it contains true Lieberkiihn
tubules. Occasionally the mucous glands of the intestinal wall are

BENIGN TUMOES OF TBE KEUTUM

dragged into the tumor in the processes of formation, and they may
appear therein as small cjatB. These glands, however, are accidental,
and compose only a very small portion of the growth.

The specimen (Fig, 237) was taken from a tumor of this tj-pe,

Hutdogkal Etatnination by Loit'u Heilznuinn. — The tumor is composed of a
delicate fibrous reticulum, holding chiefl; at its points of interecclion obloog or
round bodies resembling nuclei. In the mealies of the network a gelntinoua, at
times apparently homogeneous basis substance la found. Id the spaces, raostlj their
centers, lie single, double, or
multiple corpusoleB of vary
ing aizes, the larger of n hicb
contain nuclei. This tumor
is rather freely supplied nith
blood-vessels, most of which
are broad and lined with
Urge endothelia, and in their
neighborhood the reticu-
lum is narrowest and sup
plied with a larger number of
blood-vessels. Glandular for JV
mations are here verj scanty
Diagnosis: Boft rectal polyp
or myxoma of reticular struc

This class of polyp
differs from the multiple
polypi of the rectum in
that it contains less
fibrous and glandular
ti^ue, and more of the
gelatinous or myxoma-
tous material. They are
softer to the touch, and
are rarely found except
in young children.
They are more pedun-
culated, and bleed less
easily.

Course and Sj/mploms.
— The longer a polyp re-
mains in the rectum, the
more elongated will be the peditle, aometimea it passes outside of the
anus and is grasped by the iphincter muscle during the act of defe-
cation. They may be torn off and pas&ed along with the freca! mass.

(MDmifled 100

F deUonle fibrous rariiuluin »Uh nuclei at
iniernei-lion eiiLlosine spBccs uhioh eonli
baiiU substanm N i-orpitaLled mostly
the basin Bubstuice L. \jmpb i-orpum.)
C rapillBry

1 Jolly-Uka
oleiW in

714 THE ANUS, RECTUM, AND PELVIC COLON

a slight ha?morrhage resulting, which is rarely if ever serious. There
are frequent instances in which children have thrust them out throu«^
the anus, and pulled them off, under the impression that they were
foreign bodies or something adherent to the anus. So long as they re-
main well up within the rectum they do not produce any marked symp-
toms. Patients are not ordinarily aware of their existence until they
come down within the grasp of the sphincter or rest upon the sensitive
area of the rectum. When they prolapse to this extent they produce a
sensation of fulness, with frequent desire to defecate, spasm of the
sphincter, and various reflex symptoms.

In one case of this kind which the writer saw with Dr. Lewis, of
Jersey City, tlio woman suffered from constipation, vague symptoms
pointing to ovarian disease, and intense nervous exhaustion; the little
growth was removed by crushing the pedicle with a haemorrhoidal clamp,
and within a few weeks all the symptoms, except the constipation, dis-
appeared.

To the eye these growths present different appearances according
to their pathological nature. The soft mucous polypus or myxoma with
reticulum, as Ileitzmann describes it, is pinkish or sometimes yellowish-
gray in appearance; at other times it appears as a raspberry-like growth
with soft, velvety surface. The lipomatous polyp appears as a light-
yellow lobulated mass covered by a smooth, shining mucous membrane
which may sometimes be ulcerated, but the color of the tumor shows
through the membrane. The fibroid polypus is spherical or ovoid in
shape, is not lobulated, and is covered either by normal or bright-red and
congested mucous membrane (Plate V, Fig. 3). Any of these tumors, if
protruded from the anus so that the pedicle is constricted, will present
a dark, purplish-red appearance due to the obstructed circulation.

Diagnosis. — The diagnosis of the existence of polypi is very simple;
they either protrude from the anus and can be seen, or by examination
with the fmger they may be felt and recognized. A precaution ordi-
narily given in examinations with the finger consists in the advice to
pass the finger as far up into the rectum as possible, and examine from
above downward in order to prevent pushing the tumor upward before
it. Generally the tumor will be felt in the ampulla of the rectum just
above the sphincter, and, if the rectum is normally collapsed, it may
be difficult to pass the finger upward without carrying the tumor along
with it. This can be avoided by sweeping the end of the finger rapidly
around the rectum so as to excite muscular spasm of the circular fibers,
which will force the tumor down while the finger glides up alongside
of it. After the finger is once above the growth, if the pedicle is long
enough one can bring it into view by pressing it firmly against the
side of the rectum and slowly dragging it downw^ard.

BENIGN TUMORS OP THE RECTUM 715

When polypi are above the reach of the finger, or slip up in front
of it, they may be seen and grasped through the proctoscope. Through
the instrument and by electric light they appear as pink or gelatinous
masses attached to the wall by a bright-red cord. This cord is usually
about the size of an ordinary shoestring, but it may be much larger.
Grasped between the fingers they usually feel soft and pliable, but occa-
sionally firm and fibrous. One can generally feel the pulsation of the
afferent artery, but this is not uniformly the case.

Treatment. — The treatment of these growths consists in snaring them
off with an ordinary rectal snare (Fig. 238), or if they can be grasped
and pulled down, a ligature may be applied around the pedicle and the
tumor snipped off below it. If the patient is anaesthetized, the pedicle
may be crushed with the haemorrhoidal clamp, the tumor cut off, and
the stump cauterized. In children, however, anaesthesia is frequently
unnecessary, inasmuch as the pedicles are devoid of nerve fibers, and
one may drag down
the tumor and apply ^
a ligature or crush
the pedicle without
any pain. Occasion-
ally these little tu-
mors are attached
by a broad band of
mucous membrane,
which, if it is simply cut off, will leave quite an ulcerative space; in
such eases it is better to cut the tumor off and suture the edges of the
mucous membrane together with fine catgut. This is a very rare con-
dition in single or mucous polypi, but in papillomata and adenomata
with broad attachments, the precaution is ver}' important, inasmuch
as it is the only method by which the entire growth can be removed,
and the danger of recurrence in a malignant form be reduced to a
minimum.

Where the pedicle is very slender it may be caught and twisted with
little tension until it is loosened from its attachment, but there is al-
ways risk of tearing the mucous membrane of the gut by this method,
and if there should be an invagination of the peritonaeum into the pedi-
cle this might' be opened.

No dressing is necessary after such an operation. The bowels
should be encouraged to move regularly, and the rectum should be
irrigated with antiseptic solutions daily for one week, after which time
the parts will probably be well.

The other typos of tumors which assume the polypoid shape will
be considered under their proper histological classification. The pedun-

Fio. 238. — ^Ladinski^s Rectal Snare.

716

THE ANUS. RECTUM, AND PELVIC COLON

culated form is ouly a tnurphulogicnl charaoteristic due to the elasticity
and mobility of the tissues in which they develop, and to the peristaltic
efforts (if Ihe bowel to rid itself of an abnormal object. Thus the sig-
nilieiinee ami importance of a tiiitior of tin.' ructnm depends entirely upim
tlie growth at the end
of the stem, and not at
al! upon the polypoid
>hape.

Fibroma. — True
fibromata of the anus
and rectum are exceed-
ingly rare. They hare
thi'ir origin in the con-
nective tissue of the
submucosa, sometimes
;rrow to considerable
siKe (Fig. 239). and
may be sidid or cav-
iinous. They may re-
main in the recta] wall
they may assume
tho form of poIypL

Inwlby (Transac-
tions of the Patholog-
ical Soc. of Ijondon,
1HS3, p. 107) has re-
corded the case of a
woman who, while at
stool, forced out from
licr anus a tumor of
(bis variety as large as
a ftetal head. It vnm
attached by a pedicle
to the anterior wall of
the gut 4 inches above the anus, and weighed nearly 2 pounds. On
microscopic examination it was found to be composed almost entirely
of pure fibrous tissue. The pedicle was simply ligated anil clampwl off
below the ligature, and the patient made an excellent recovery,

Barnes (Rrit. Med. Jour.. 1879, vol. i, p. 551) described a tumor of
thi.s variety as largo a^^ an orange, which he removed by means of a
galvanic loop. Tlie tumor itself was composed of fibrous tissue, and
was cavernous in enrne portions.

I'alhohgy. — A pure libroma consists of librons tissue arranged ia

BENIGN TUMORS OP THE RECTUM 717

wavy bundles, and ordinarily containing very few blood-vessels, but in
this respect there is considerable variation. Most of those removed are
of the mixed variety, and contain more or less muscular, glandular, and
connective tissues.

Thus what is ordinarily known as a fibrous polypus of the rectum
is not in reality a true fibroid, but a polypoid tumor in which the fibrous
tissue in varying amount is mixed with glandular and other elements.
In these cases the fibrous tissue does not riin in wavy bundles, but ex-
tends in all directions, and gives to the tumor its density, hardness, and
weight. Owing to the size and heaviness of such growths, the pedicle is
much dragged upon, and consequently becomes very weak and slender.
It may be ruptured, and the tumor brought away by the friction of the
fsecal passages or by the peristaltic action of the intestines. The size
of the tumors varies from that of a small hazelnut to that of a coconut;
ordinarily they are somewhat elongated, and about the size and shape
of a small olive.

Symptoms, — Fibrous tumors of the rectum as a rule do not occur in
children; they are hard and sometimes nodular; the mucous membrane
covering them is somewhat thickened, and occasionally it may be ulcer-
ated, owing to the pressure of the faecal mass or to the friction produced
by the tumor moving up and down in the intestinal canal. Sometimes
the glandular elements in these tiunors contain more or less fluid or
jelly-like mucus; when this condition exists, the tumor is termed a
colloid polypus. The transformation or degeneration of these tumors
is very rare, but it is said to occur, and when it does, a sarcoma is the
result.

When the fibroma remains in the intestinal wall it assumes the form
of a spherical or ovoid mass closely attached to the muscular coat, and
the mucous membrane is movable over it. Its seat may be anywhere
in the tract from the margin of the anus to the stomach. Fig. 239 is
drawn from the photograph of a case of multiple fibroids of the anus
occurring in the writer's practice.

The other symptoms are similar to those of mucous polypi. Those
in the wall of the gut give rise to dull, aching pain, tenesmus, frequent
defecation, and sometimes ulceration of the mucous membrane. The
absence of haemorrhages and mucous discharges distinguishes these
growths from other types of polypi.

Enchondroma. — One of the rarest tumors of the connective-tissue
variety occurring in the rectum is that known as enchondroma. Only
two instances have been reported. Van Buren (op, cit,, p. 268) recorded
a case of this type, and recently Dolbeau (Bull, de la soc. anat., t. v,
p. 6) has reported a case. The tumor which was removed from the rec-
tum of a man aged twenty-seven was about the size of a small walnut.

718 THE ANUS, RECTUM, AND PELVIC COLON

Histologically it was composed of cartilaginous and fibrous tissue. In
some portions, however, it appeared to be of an adenomatous nature,
and therefore could not be considered a pure enchondroma.

Lipoma. — Tumors composed of adipose tissue are found in the rectal
cavity, and also higher up in the intestinal canal; when they occur
in the rectum, they ordinarily develop from the submucous layer of the
intestinal wall; higher up, however, they sometimes arise from the
subperitoneal fat.

Ordinarily these tumors are closely attached to the rectal .wall, but
they may also assume a polypoid shape, and the pedicle may attain the
length of 5 or 6 centimeters (2| inches). They are composed of moder-
ately firm, lobulated masses, consisting of fatty cells enclosed in a
fibrous stroma varying in amount; they are only very slightly vascukr,
and may grow to a size which may obstruct the canal.

Castellane (Gazette hebd., 1870), quoted by Molliere, records the
case of a man aged forty-three, who passed from his rectmn an ovoid
tumor 12 centimeters (4 J inches) in length by 6 centimeters (2f inches)
in width, of a firm consistence, pink color, and lobulated. The tumor
was attached by a pedicle 3 centimeters (1^^ inch) in length, and com-
posed of pure lipomatous tissue.

Tedenat (Montpelier Med. Jour., 1885) operated upon a lipoma of the
rectum 13 centimeters (5 J inches) in length and 6 in depth, which was
attached by a pedicle the size of the index finger inserted 12 centi-
meters (4} ifiches) above the anus. This tumor, which entirely oc-
cluded the rectum, was removed by an 6craseur. The mucous membrane
covering the growth was thickened, oedematous, and ulcerated. Bernard
(Mollic^re, op. cit., p. 525) has recorded a similar case.

Virchow (Path, de tumours, vol. i, p. 379) has recorded a case in
which there was an invagination of the colon into the rectum due to
two submucous, pedunculated lipomata. Each of these tumors was
about the size of an ogg. Esmarch, Bose, Broca (Archiv f. klin. Chirur.,
187G), Afezon (Bull, de soc. d'anat., Paris, 1875), have all recorded
similar cases. Voss has reported a case in which the tumor, situated in
the rectal wall, caused a prolapse of this organ, and was thus protruded
through the anus when the bowel moved. He split the mucous mem-
brane and enucleated the tumor, after which the prolapse disappeared.

Spencer Wells (Transactions of the Path. Soc. of Ijondon, vol. xvi,
p. 277) speaks of the occurrence of lipomata in the recto-vaginal saeptum.
Molk (Thesis, Strasburg, 1868) described a number of perineal lipo-
mata, some of which were pedunculated and others not. Roberts (An-
nales de therap., 1844) gives the history of a man upon whom he oper-
ated for what he considered a perineal hernia, but which he found to
be a lipoma originating in the ischio-rectal fossa.

BENIGN TUMORS OP THE RECTUM 719

The author has seen two cases of lipoma of the rectum and one of
the anus. One of those in the rectum assumed the polypoid form, and
was attached to the anterior wall about 4 inches above the anus. The
other tumor was located in the rectal wall just in front of the sacrum.
This tumor was lobulated, about the size of a small hen's egg, and was
supposed to be a dermoid cyst. An incision was made in the mucous
membrane, and the tumor enucleated; it proved to be a pure lipoma, and,
so far as could be judged, was confined between the muscular and
mucous layers of the gut.

Tumors of this class occasionally occur outside of the rectum, and
yet attached to its walls, occasioning by their pressure tenesmus and
obstruction of the canal.

Vorchung (Transactions of the Path. Soc. of London, vol. xv, p. 100)
has reported a case of this kind seen in a woman who had suffered during
life from retention of faeces and difficulty in urination. She died from
mechanical obstruction to the passage of urine. Upon post-mortem
there* was found a lipoma in the pelvis completely surrounding the
rectum, and firmly attached to its outer walls. The growth en-
tirely obstructed the two ureters, and almost completely occluded the
rectum.

When such tumors are attached by pedicles inside of the rectum,
they are very likely to be torn off as other polypi are; the pedicle may
be twisted, and on accoimt of the circulation being impaired becomes
friable and easily ruptured.

Where the tumors are large and the pedicles extensive, there may
be funnel-shaped invaginations of the peritoneum into them. This, of
course, occurs when the pedicle is attached to the anterior or lateral
portions of the rectum or sigmoid. Ball {op, cit,, p. 298) states that this
fact, together with the history of most of these tumors having descended
from the sigmoid flexure, tends to show that they originate in the appen-
dices epiploicae, which have become inverted, and are thus carried down-
ward into the rectum in the shape of polypi. There is little ground for
this theory, as the tumors have never been shown to be surrounded by
the remains of a peritoneal membrane, which would necessarily be the
case were their origin such as Ball suggests.

Treatment. — The removal of these tumors when pedunculated should
always be carried out by the use of the ligature, owing to the possibility
of peritoneal invagination into the pedicle. If they are cut off with
scissors or torn loose recklessly, these little infundibular invaginations
may be opened, and thus connect the peritoneal cavity with that of the
rectum, which must inevitably result in septic peritonitis.

The snare and wire ecraseur and the clamp are none of them suitable
in such cases. Where the tumor is situated in the rectal wall and is

720 THE ANUS, RECTUM, AND PELVIC COLON

not pedunculated, it should be removed by incision of the mucous mem-
brane, enucleation, and, if possible, suturing of the wound.

Hyoma. — Tumors composed of muscular or combined muscular and
fibrous tissue occasionally occur in the rectum. They arise from the
muscular coat — ^generally the longitudinal layer — and assume a nodular
form supplied with a pedicle, or sometimes they exist as broad tumors
lying in the muscular wall of the intestine and covered by the submo-
cous and mucous coats. They are ordinarily classed among the leiomyas,
and are composed of unstriped muscular fibers. Microscopically they
consist of great numbers of muscular fibers separated by a connectiTe-
tissue network. WTiere the fibrous tissue exists in any considerable
quantities, the tumor may be called a fibromyoma. They are not mark-
edly vascular, the capillaries ordinarily running in the fibrous stroma
of the growth.

Tedenat (op, cit.) has described myomata which he removed from
the rectum of a man in whom they caused haemorrhages and mucou*
discharges. De Carlier (Jour, de med. chirur. and pharm. des Bmielles,
1881, p. 140) successfully removed a tumor from the rectimi which was
found to be a pure myoma. Heurtaux (Archives provincials de chirur.,
1896, p. 189) has recorded similar cases.

Berg and Senn, cited by Westermark (Centralblatt f . Gynak., 1896),
have reported cases in which they have removed fibromyomata from out-
side of the rectum, but closely attached to this organ. In Berg's case
the tumor filled the hollow of the sacrum, and was closelv attached to
the rectal wall, the mucous membrane of the gut being inflamed, thick-
ened, and ulcerated. The growth was removed by the Kraske operation.
In Senn's case the tumor partially filled the pelvis and was closely at-
tached to the anterior wall of the rectum. Westermark himself reports
a similar case in which the anterior wall of the rectum was ruptured
during the operation, and death followed on the fourth day from peri-
tonitis. In his case, however, microscopic examination showed the
tumor to be a pure fibromyomata, originating in the longitudinal,
muscular fibers of the gut. McCosh (Annals of Surgery, 1893, p. 41)
operated upon a tumor of this kind which was situated outside of the
gut and attached to its posterior wall. He found it necessar\' to per-
form a preliminary colotomy, after which he removed the growth bv a
shallow incision, at the same time excising the coccyx and removing a
part of the wall of the gut to which the tumor was attached. His patient
made a good recovery.

These tumors, however, are quite rare, and it is impossible to deter-
mine their nature without a thorough microscopic examination. If thev
are small and confined to the rectal wall, the hard, nodular surface may
frequently lead one to the diagnosis of scirrhous cancer.

BENIGN TUMORS OP THE RECTUM 721

Treatment, — The only thing to be done with such growths is to re-
move them. If feasible, this should be done from the outside of the
rectum. When the mucous membrane is freely movable over the tumor
and the latter is not more than 4 inches above the anus, this can gener-
ally be accomplished. After it is done, the muscular wall of the gut from
which the tumor is excised should be sutured as accurately together as
possible. If done within the rectum, great care should be exercised to
furnish free drainage to the parts even if complete posterior proctotomy
has to be performed to accomplish this.

Lymphadenoma. — This type of growth is occasionally found in the
rectum. It develops from the lymphoid tissues or solitary nodes which
exist throughout the large intestine. It is soft to the touch, and may
attain a considerable size. It consists of a reticulum formed by branch-
ing cells united by their prolonged extremities. Within the meshes thus
formed there lie round cells with circular nuclei. Stengel states that
the cells are less uniform in size than those of the normal lymphatic
glands, and large cells are in abundance.

Felizet and Brancha (Traite des malad. de Tenfance, 1897, t. ii, p.
747) state that in these tumors there are two zones, the peripheral, com-
posed of mucous membrane from which the glandular cuk-de-sac have
disappeared, and the central, composed of irregular lobules separated by
connective-tissue bands. In the delicate reticulum are found various-
shai)ed leucocytes and capillaries, the lumen of which is separated from
the adenoid tissue by a thin ring of connective tissue.

Quenu and Hartmann state (op. cit,, vol. ii, p. 361) that these growths
are usually pedunculated, and cite cases from Schwab (Beitr. z. klin.
Chir., Bd. xviii, S. 2), M. Broca, Shattock (Trans. Path. Soc, J^ondon,
1890, p. 137), and Branca (Bull, de la soc. anat., Paris, 1897, p. 158)
to corroborate this view. In the author^s case there was no peduncula-
tion whatever. Ball (op, cit,, p. 321) describes a tumor of this kind, but
states that upon minute examination it proved to be a lympho-sarcoma.
He states that a number of such growths have been recorded in connec-
tion with Hodgkin's disease. It is important, therefore, to know that
we are not dealing with sarcoma before giving a prognosis in such cases.

Symptoms. — Lymphadenpma present no other symptoms than those
of a single polyp. They may prolapse ahd produce mechanical irritation
of the rectum, but they do not bleed freely, and discharge no mucus or
pus. A glairy mucous discharge may be associated with them, but this
is due to a catarrhal proctitis excited by the pressure of the neoplasm.
The tumors are slightly lobulated, always single, of a bright-red color
and soft consistence.

Treatment. — The treatment consists in their radical removal by sur-
gical measures. The cases recorded are too few from which to draw
46

722

THE AKUS, BECTUH, AND PELVIC COLON

any general conclusions, but bo far those not exhibiting sarcomatous
changes have shown no tendency to recur, and the parts have healed
promptly after operation.

These tumors have been put down by authors generally as of a benign i
nature, but both Stengel and Ziegler consider them as frequently malig-
nant. Complete and wide removal should therefore be made.

Xfzoma. — This tyjie of tumor consists of a soft and more or less
flabby growth enclosed by a thin capsule, and has a spherical outlioe.

It may assume the polypoid shape, or occur as a semispherical pro-
tuberanco in the rectum. It is composed of stellate, irregular cells and
a gelatinous intercellular substance.
Occasionally it is lobulated, but or-
dinarily its surface is quite smooth.
It is rare that a pure mjiomi
is ever found, the myxomatous be-
ing usually mixed with fibrous, fil-
ty, cartilaginous, or sarcomatous
tissue. Microscopically these tu-
mors consist in a homogeneous,
somewhat glandular tissue, vith
surfaces due to the refraction of
the light. An excess of the round,
granular cells sometimes gives the
appearance of a myio-sarcoma.
Within this mass of myxomatous tissue there lie stellate, spindle-shaped,
connective-tissue cells (Fig. 240). According to Stengel, the vaamlar
supply is poor, and the blood-vessels are only partially developed. Zieg-
ler, however, states that the tissue is translucent, and the blood-vessels
arc plainly visible when they are filled with blood.

The soft rectal polypi of children are practically myxomata. Hulke
(Mod. Times and (Jaz., vol. ii, p. lOCfi) has recorded a case of myxoma in
which the tumor surrounded the rectum and anus, almost occluding
the canal. It was entirely outside of the gut, however, and occupied
the perinnpum and ischio-rcctal fossie.

Adenoma. — The term adenoma as applied to the rectum is ordinarily
considered synonymous with polypus. The fact that a large number of
rectal polypi are of the adenomatous variety, and that even multiple
adenomas assume the polj-pojd shape, has led many to consider these
two conditions identical, but this is not the fact. Almost every tumor
of the rectum may become polypoid, but this has nothing to do with its
patholof,'ical nature. It is only one variety of polymorphism to which
neoplasms are subject in a movable and loose tissue. All polypi are
not adenomas, neither are all adenomas polypi.

A (SWugel).

BENIGN TUMORS OP THE RECTUM 723

The earliest descriptions of adenomas of the rectum date back to
the sixteenth century. Leautaud, Lange^ Schmucker, Felizet, and Bran-
ca described them in 1760; the first accurate description was given by
Stoltz in 1841, who afterward published a most interesting article on
the rectal polypi of children (Gaz. m6d. de Strasburg, 1859, p. 157, and
1860, p. 7).

In recent years Ball, Bardenheuer, Cripps, Kelsey, Luschka, Tan-
chard, Weichselbaum, Dalton, and others have made careful pathological
examinations and studies of these conditions. Quenu and Hartmann
have gone very carefully into the subject, and to those interested in
the minute pathology their work will be of exceeding interest. It is too
detailed and technical, however, for the general practitioner, who must
depend finally upon the pathologist to decide upon the histological na-
ture of neoplasms.

Adenomas develop from the mucous and submucous coat of the rec-
tum. Quenu and Hartmann state that they do not extend below the
muscularis mucosa; Cripps, on the contrary, holds that they involve the
entire thickness of the mucous membrane and submucosa. At any rate
all the elements composing these layers, the epithelial, the tubular, the
fibrous, and the glandular constituents, are found in them.

The tumors may occur singly or multiple. In children there are
ordinarily only one or two, and these are of a distinctly polypoid form
with pedicles of considerable length. In adults, however, they are gener-
ally multiple, and the pedicles are not so marked.

Histologically, the single tumors found in children consist of a
greater amount of connective or fibrous tissue in proportion to the
glandular and epithelial structures. In the multiple tumors, found
chiefly in adults, the proportion is reversed, and there is an excess of
the epithelial and glandular elements in proportion to the connective-
tissue stroma. On this account adenomas of the multiple variety ap-
proach more closely the epitheliomatous or cylindrical carcinomatous
type than do the single adenomas of childhood.

Simple Adenomas. — They occur most frequently in children from
one to twelve years of age, although they are occasionally seen in adults.
The tumors vary in size from a small cherry to that of a hen's egg,
or even larger; there may be only one or there may be three or four.
Between this number and multiple adenoma there is no middle ground.

Cases have been reported by Kaemm, Ball, and others in which a
single adenoma reached enormous size and weighed as much as 4
pounds. Quenu and Hartmann, in an examination of 15 cases, observed
none of them larger than an ordinary nut. In the author's experience
one single adenoma as large as a hen's egg has been seen; the rest of
them varied in size from a small pea to that of an English walnut.

724 THE ANUS, RECTUM, AND PELVIC COLON

In a case of multiple adenoma, however, one of the growths absolutely
filled up the caliber of the gut. In the single variety, in which the poly-
poid form is marked, the pedicles may measure from 1 to 4 or 5 inches
in length; in 1 case, after ligating it 3 inches above the anus, the pedicle
could be felt dangling down in the rectum from above. Although no
accurate measurement was made, it was apparently 5 or 6 inches long.
The size of the pedicle varies with the age and size of the tumor.
Where the latter has existed for a long time, and has been gradually
dragged upon and stretched, the pedicle becomes much attenuated. Or-
dinarily it may be said to be about the size of a round shoestring, or in
proportion to the tumor, about ^ of its diameter. The tumors appear
to the naked eye as spherical knobs upon the end of the stems. They
are oval in form, bright red, and resemble very much a large red rasp-
berry. The mucous membrane covering the stem or pedicle is nonnal
with the exception that the tubules are decreased and the epithelium
is somewhat atrophied. Within the pedicle the fibrous core or center
passes in longitudinal layers through its tissues until it reaches the
tumor, at which point these fibers branch out, forming a sort of arbo-
rescent growth. These branches form the center or base of the lobes
composing the tumor. According to the observations of Qu^nu and
Hartmann, this fibrous stalk and branches appear to grow from the
septa between the Lieberkiihn follicles, and not to proceed from the
submucosa. From the fact that we very rarely find muscular fibers
in the stalks, it would seem that these observations are correct, but
Cripps does not accept them. He believes that they grow from the
submucosa. The blood-vessels proceed directly from the submucosa,
and can be traced downward into this tissue. From each of the fibrous
stalks which branch off to form the lobules, fine branches pass outward,
forming a sort of reticulum upon which the epithelial cells that prac-
tically compose the tumor rest.

The epithelium covering these stalks is always of the colunmar
variety, and comf)osed of goblet and cylindrical cells, the nuclei of which
are ordinarily near the base. The epithelium is arranged in a single
layer more or less closely packed together, and, according to Cripps
{op. cif., p. 288), is always continuous with the epithelium covering
the stalk, and through this with that lining the intestinal canal. The
firmness and vascularity of the tumor will depend upon the amount
of fibrous tissue in the stalk and the length of its ramifications. Where
the fibrous tissue is small and the ramifications very long, the tumor
will be soft, vascular, and bleed verv easilv.

Alterations in the volume, diameter, and shape of the tubules occur
owing to inflammatory processes and pressure. Those nearest normal
will be found at the pedicle, and gradually increasing alterations will

BENIGN TUMORS OP THE RECTUM 725

be more and more marked as one proceeds toward the periphery of
the tumor. Variations in form and height, the predominance of mucip-
arous cells and degeneration of the protoplasm and nuclei, characterize
the changes in the epithelium of these growths. In some cases the
outlines of the cells are not at all visible, they are simply recognized
by numerous nuclei surrounded by an indistinct protoplasm (Qu6nu
and Hartmann, vol. ii, p. 34).

The surface epithelium is frequently absent, owing to the friction
of the faecal masses and the rubbing up and down of the tumor against
the rectal wall. In the depressions and near the attachment of the
pedicle, the normal epithelium of the rectum is ordinarily found. The
connective tissue of the tumor itself presents a fibrillary appearance
composed of young cells, and resembling very much the chorion of the
mucous membrane. It varies greatly in quantity. In some it is very
marked and gives the tumor a firm, hard feeling; in others the glandular
acini and tubules are relatively large, and give it a soft, cystic ap-
pearance.

These tumors may undergo secondary degenerative changes, such as
hyaline, myxomatous, or cystic degeneration, under which circumstances
they would be called cylindroma, adeno-myxoma, and cystadenoma.

While adenomas are ordinarily considered benign growths, they are
said in some cases, even in their pure form, to give rise to metastasis.
Th(7 liave no effect upon the general health in themselves, although
til is may be influenced through their local irritation and interference
with the normal functions, or through ulceration and ha?morrhage.

Symptoms. — Simple adenomas nearly always assume a polypoid
form, and the symptoms are identical with those of other polypi, except
that they bleed more easily. The important points are, that in adults
where one is found many others are likely to exist, and after removal
thev are likelv to recur.

Treatment. — The treatment of this type of tumor is very simple.
They may be twisted, tied, crushed, or snared off. It is not necessary
that the pedicle should be caught close to the wall of the gut. Any
remaining stump will atrophy and disappear if all the adenoid tissue
is removed. If the growth is sessile or attached by a broad pedicle,
it should be removed by wide incision through the mucous membrane
down to the muscular wall, and the edges of the wound should be
sutured together by catgut.

The possibility of invagination of the peritonaeum into the pedicle
should alw^ays be remembered, and on this account, if the tumor is high
enough for this to occur, it should be tied off with a strong silk ligature.

Multiple Adenomata. — In adults, and occasionally in children, the
rectum, sigmoid, and the entire colon may be the seat of multiple ade-

726 THE ANUS, RECTUM, AND PELVIC COLON

nomata. The sjTnptoms, course, and pathology of this condition differ
in many respects from those of simple adenomata, and justify a distinct
consideration. Virchow (Die krankhaften Geschwiilste, 1863, Bd. i, S.
243-244) has described it under two titles: " Polypi of the large intes-
tine " and ** polypoid colitis." In these papers he does not seem to
have recognized the rectum as a seat of the disease. Cripps speaks of
it as disseminated polypi of the rectum, but does not connect it with
the sigmoid or colon.

There have been very numerous reports of cases of this type, esp^
cially during the last few years (Whitehead, Cripps, Gterster, Kelsey,
Ball, White, etc.). We are indebted to Quenu and Landel (Revue de
chirurgie, 1899, tom. xix, pp. 465^94) for the most exhaustive review
of the subject, and an excellent pathological report of 2 cases occurring
in their own practice. In their paper 42 cases are collected, most of
which have been observed since 1884; previous to their studies, surgeons
generally considered these tumors as identical with simple adenoma or
polypus of the rectum. They have pointed out, however, not only a
difference in the ages at which the two conditions occur, but also cer-
tain histological and pathological variations between the simple and
multiple growths that render this view of identity untenable.

Etiology, — A certain number of surgeons and pathologists seem to
believe that multiple adenomata originate in the simple t3rpe; there is
no case reported, however, in which a single or simple adenoma, recog-
nized during childhood, has ever developed into the multiple variety in
after years. In all the cases observed so far, not one has been reported
in which a single isolated tumor was found in the beginning and fol-
lowed by tlie development of numerous others afterward. Wherever a
clear and distinct history is furnished, there has been observed in the
beginning numerous neoplasms similar in size and stage of development.
There is therefore no ground to believe that the single or simple
adenomata of children are predisposing causes of multiple adenomata
in adult life.

Age. — While there are a few cases of the multiple type rej>orted in
children, it is especially a disease of adult life. Of the 42 cases col-
lected by the authors mentioned, over 50 per cent of them were between
twenty and thirty-five years of age; 4 cases occurred below sixteen, and
8 above forty-five years of age. The author has observed 6 cases, 3 in
his own and 3 in the practice of colleagues, all of which were between
twenty and forty years of age; it seems, therefore, to be a disease of
middle life.

Sex, — There appears to be a slight preponderance in favor of the
female sex. In the author's cases, 2 were in women and 1 in a man; in
those seen through the courtesy of Drs. Gerster, Ladinski, and Thomp-

BENIGN TUMORS OF THE RECTUM 727

son, all were in women. There is no reason, however, to believe that
sex exercises any etiological influence.

The exact cause of adenoma is not well known. They consist in an
inflamed hyperplasia of the normal glands of the rectum. Whether this
inflammation may occur in utero has not yet been determined; but in
view of the fact that they are sometimes observed very early in life, it
would seem that such was possible.

Heredity has some influence, as was pointed out by Esmarch, but
inflammation or irritation is generally accepted as the chief cause. The
action of certain parasites, such as distoma haematobium, and microbic
infection of the glandular tissues, have also been accused of having an
etiological influence. Francis Huber, of New York, has recently made
an elaborate study of this subject, and shows that a large number of
children suffering from postnasal adenoids also suffer from rectal
polypi. He argues that they all belong to that class of cases in which
there are lymphoid hypertrophies and " other manifestations of the
constitutio lymphaticus, status Ijrmphaticus."

In children there is no doubt that there is some ground for such
belief, but, so far as adults are concerned, there is no proof that adenoids
of the intestinal canal are in any way related to those of the respiratory
apparatus. While the growths in the rectum and in the nares resemble
each other somewhat, this resemblance does not amount to an identity
by any means. The fact that rectal adenoids are so frequently trans-
formed into carcinoma, and this transformation is rarely if ever seen
in the postnasal growths, would lead one to conclude that there was
a very distinct difference between them.

Huberts argument is interesting, but it will require a very much
larger series of cases to prove that all adenoids of the rectum are the
result of general lymphatic hypertrophy.

Distribution of the Growths. — The condition is said by some to be an
affection of the colon and not of the rectum; yet, as a matter of fact, they
are rare in the intestinal canal unless the rectum, and pelvic colon are
also involved. In the majority of cases they are as numerous and large
in these portions of the tract as elsewhere. In 50 cases, adenomata
existed in the rectum in at least 48; they were confined to this portion
in 15; in 11 they wore only in the rectum and sigmoid; in 13 (Quenu and
Landel) they occupied all of the colon; in 3 the entire intestine and
stomach, and in 2 the colon only. From these figures it would seem
that the rectum is the portion of the intestinal canal most frequently
affected.

Fink states that they begin in the rectum and gradually multiply
upward; they are sometimes grouped in certain regions, and seem to
be restricted to these; in some cases aggregations exist in the rectum or

P^VI^''

728 THE ANUS, RECTUM, AND PELVIC COLON

in the sigmoid and in the traosverae colon, with three lengths of per-

fectly healthy mucous membrane betweim them.

The sites at which they most frequently occur in great abundance

an> Ihoso at wliii-h ilie f;ecal mass is accustomed to be arrested. This fact

gives color to the tlifoiy that Ihej arc due to irritation or infection of

the glands by the fecml

material.

Cooformatian.—rhD

Jb^n^^

tumors vary exceeding-
ly in size, forni, and
appearance. They may
be smooth, round, and
shiny, or rough and

w-ai't-like, resembling a

raspberry (Fig. 241);
they may be sphericsl,
elongated, or even cy-
lindrical in their shspe,
sometimes resembUnj,
the tail of a larg*
lumbricoid worm {Fig.
24a). and their siz*
varies from that of a
hcmpseed to a good-
sized egg. In eoroe

■

■ I VJidiJS^^BH^H 1

cases the pedicles of

■

the dillerent tumons

may he conflnenl.

forming one general

stem from which sev-

eral tumors ehoot out

^^^I^^^^^PHL

like grapes in a buiich.

The author saw a
case of this kind some

-^j />*MJi

years ago, in which the

■

^M vaaas of adenoids waa

^H as large as one's fist, and the pedicle as large around as the wrist.

^P though soft and without induration. It was attached about 2i inches

^^ above the anal margin, and the mass was bo large that he was unable

^H to introduce his finger far enough to determine whether there were

^M any other adenomas above it or not. The patient was a timid goul.

^H and, refusing an operation, disappeared from the clinic.

The tumors may also occur in the papillary form in which the villi

BENIGN TUMORS OF TUE RECTUM

729

are very much exaggerated, bulb-shaped, and resemble the so-called
villous tumor.

Color. — The color of the growths depends very largely upon the
stage and the part of the intestine in which they are seen. It they are
loose in the rectum and of comparatively young growth, they appear
bright-red, yellowish, or sometimes, owing to their being coated with
mucus, a sort of reddish gray. If they are old and inflamed they as-
sume a dark, purplish-red color, and one frequently sees points of abra-
aion or ulceration upon their surfaces.

ttTien they are protruded from the anus, owing to the torsion or
strangulation of their blood-vessels by the sphincters, they appear dark,
purplish-red, or even black, approaching the stage of gangrene.

Coiifislcnce. — The tumors themselves may be soft or hard, according
to the amount of eonneetive-t issue stroma and the extent to which car-

cinomatous transformation has taken place. The harder the tumor, as
a rule, the more likely is it to have undergone such transformation;
but occasionally this is not true, because these little growlhs may un-
dergo cystic degeneration, in which the malignant transformation as-
sumes the type of colloid cancer; they may also be very firm from inflam-
matory or fibroid changes. Transformation can not therefore be predi-
cated upon consistence alone.

The Pedicle. — This is formed by mucous membrane, fibrous and
submucous tissue, and blood-vessels. The medium-sized tumors have
longer and narrower pedicles than the small or large ones. The very
small tumors are generally sessile, wliile the large ones are attached by
thick, short pedicles which render them almost so. The pedicles are

730 THE ANUS, RECTUM, AND PELVIC COLON

never so long in the multiple as in the simple variety. When trans-
formation has occurred they become dense, hard, and short.

Condition of the Mucous Membrane. — There is always more or less
proctitis or colitis along with this condition. Authors differ with re-
gard to the nature of this change in the mucous membrane. Desnos says
that the mucous membrane is reddened and thickened, while Hauser
states that it is injected and atrophied. Qu^nu and Hartmann eiplain
this by saying that in the case of the former it was a simple undegen-
erated adenoma, whereas in the latter they were all cases in which
carcinomatous transformation had taken place.

The pathological examinations of Quenu and Landel show that in
the whole extent of the colon, and far away from the carcinoma, there
was an atrophy with a partial destruction of the glands of the mucous
membrane and infiltration of the connective tissue. The capillaries
were dilated and the glandular epithelium had almost disappeared.
Strange to say, these lesions were less accentuated in the neighborhood
of the polypi themselves.

In the cases which the author has examined personally, there have
always appeared clinical evidences of hypertrophic proctitis, with an
increase of the secretions and general congestion of the mucous mem-
brane. Until he had read the report of the authors above mentioDed,
he had supposed this catarrhal condition was due to the irritatioD of
the mucous membrane by the neoplasms; but, accepting their report as
true, one must conclude that the changes are of a trophic nature rather
than due to anv mechanical irritation.

Symptoms. — The symptoms of multiple adenoma of the rectum may
be stated in four words: diarrhoea, haemorrhage, pain, and exhaustion.
Tlie diarrhoea, which is at first slight, is always annoying by its fi^
queney, tenesmus, and griping pains. It is not ordinarily associated
with fever or constitutional derangements, but it is uncontrollable by
any remedy short of complete narcosis.

Camphor, tannic acid, opium in moderate doses, and all the astrin-
gent medicines are absolutely powerless to control this condition.

The stools are small, soft, and always contain mucus, with more or
less fresh or decomposed blood. In the latter case the color is black
and the odor very disgusting.

The lurmorrhages are at first very slight, occasionally there is only
a tinge of blood to the mucus, but as the disease progresses these be-
come more marked, and the stools may be composed almost entirely
of blood and mucus. Occasionally mucus alone is discharged, slightly
tinged with blood.

The amount of pain which the patients suffer depends upon the
location, number, and size of the adenomata. Where they are dis-

BENIGN TUMORS OP THE RECTUM 731

tributed throughout the colon, tenesmus, bearing-down pain, and digest-
ive disturbances are common. Where they are largely confined to the
rectum and sigmoid, the patients do not suffer very much. When the
tumors grow to be so large that they obstruct the passage of faecal
masses, then the pain becomes more severe. This is not only due to the
mechanical obstruction, but sometimes to the carcinomatous change
which takes place in these neoplasms, and the consequent fibrous narrow-
ing of the caliber of the gut.

Prolapse of the rectum is occasionally associated with these growths,
and, when dragged down and strangulated, may be the source of a great
deal of pain, and even a fatal toxaemia. The constant diarrhoea, loss of
sleep, loss of blood, continuous pain, and irregularities of digestion in-
evitably result in marked anaemia and general debility. With this
develops the characteristic cachexia of the malignant neoplasm when
the tumors undergo carcinomatous transformation; and death is the
ultimate result of the disease when radical operation is not practised.

Diagnosis. — The diagnosis of multiple adenoma depends upon the
subjective symptoms, together with the local manifestations of the dis-
ease. There is no occasion for a patient with a protracted and in-
veterate diarrhoea to be treated for months and then suddenly told that
he has a neoplasm in his rectum.

The modem treatment of diarrhoea, when it persists longer than a
day or two, demands a local examination of the rectum and sigmoid
flexure. Under such circumstances adenoids will be seen or felt and
the diagnosis made. Where there are more than one or two in the rec-
tum, associated witli tenesmus and griping pains, diarrhoea and haemor-
rhages, it may ordinarily be assumed that there are others higher up.
By the use of the pneumatic sigmoidoscope these may be seen up to
the extent of the sigmoid flexure.

Palpation of the colon will sometimes reveal a thickening, but it
is impossible to determine by this means the height to which the
growths extend. It is important to determine this fact, however, and
in these cases one need not hesitate to advise immediate laparotomy for
examination of the colon throughout its extent, so as to determine the
limitations of the disease.

Whether or not the tumors have undergone malignant transforma-
tion can be told by the induration, which is apparent to the touch when
the tumor is within reach, by the odor of the discharges, or by the gran-
ular, ulcerative condition seen through the proctoscope. The micro-
scopic examination of a section of a tumor is the most reliable evidence
of such degeneration. Unfortunately the fact that one or two of these
tumors does not show any malignant transformation, proves nothing
with regard to the others. It has been shown by Hauser and Quenu

732 THE ANUS, RECTUM, AND PELVIC COLON

and Landel that a perfectly benign adenoma may be almost contigu-
ous with one which has undergone marked epitheliomatous transforma-
tion. A positive negative opinion, therefore, with regard to malig-
nancy can never be given in these cases. The chances are that in about
3 out of 4 cases of multiple adenoma malignancy occurs in some of the
growths sooner or later.

In an examination with the finger one may feel a variety of growths
ranging from a small pea-like protuberance to a well-developed tumor.
The fact that the growths have or have not pedicles can not materially
influence the diagnosis. In their earlier stages they are comparatively
soft, but, being inflamed, or having undergone malignant transforma-
tion, they become hard, so that the sense of touch, so far as these charac-
teristics are concerned, is not reliable.

Whore the tumors are large, or the cancerous degeneration has gone
on to such an extent as to cause a contracture of the caliber of the gut,
one will find stricture or rectal occlusion.

Whitehead (op. cit.) lays stress upon the thickened, sausage-like feel
of the sigmoid flexure in these conditions. The author has not been
able to observe this in multiple adenomata, but has seen it a number of
times in true carcinoma of the sigmoid unassociated with them.

Rotter has employed exploratory laparotomy as a means of diagnosis;
and Sklifasowski and Lilienthal have made artificial ani in order to
determine the upper limits of the growths. From Lilienthal's case it
seems that where such a course is followed, the artificial anus should
be made in the right inguinal region instead of the left, inasmuch as
the growths, if they extend beyond the sigmoid flexure, are likely to go
well into the ascending and transverse colon.

Pafhology. — The tumors are seated, as a rule, upon the summit of the
mucous folds, rarely growing from the grooves between them.

Macroscopic Appearances. — These have been described in the section
on conformation. Quenu and Landel state that they sometimes appear
as deformed, hypertrophied mucous folds.

Where they have undergone myxomatous changes they appear elastic
and gelatinous to the touch.

The color varies from a dark purplish-red to a yellowish-gray, but
these characteristics can not be observed in post-mortem pathological
specimens.

Microscopic Examination. — ^Microscopic examination shows these
growths to be composed of hypertrophied glands and connective tissue
covered with cylindrical epithelium.

Microscopic Examinntion hy L. Heitzmann.^^^ The tumor (Fig. 243) is composed
of a myxomatous connective tissue containing a large number of lymph corpuscles
and newly formed glands of varying sizes. These glands are partly of the tubular

BENIGX TUMORS OF THE RECTUM 733

and partly of the acinous variety, lined by culjoidal and columnar epithelia,
arranged mostly in a single layer, though in some places stratified. The blood-
Tesscla art: (ound in small numbers only."

In some of the specimens examined the glands were very much elongated, and
their lumen greatly enlarged. Sometimes they were transformed into actual
cystic cavities.

Qu^nu and Hartmann state that the connective tissue is of the loose,
fibnllan variety infiltrated nith Ijmphatic cells It contains smooth
muscular fibers
and 19 rich in
blood \esstlB which
extend to the per
iphery of the poly
pus This seem
ing diha^eement
with regard to the
vascular supply of
theie grow ths is
dependent upon
the actual tumor
examined home of
them have a laige
number of blood
vessels while
others are very
scantily supplied
In I ilienthal s case
(Fig 34^) the pol
yps are said to have
been composed of
hypertrophied soli-
tary follicles, but
this appears to be
unique.

Malignant
Transformation. —
The benign epithe-
lial tumors of the

rectum derive an immense importance from their great tendency to
transformation into cylindrical carcinoma. In two of the cases observed
by the writer this change had already occurred at the time of the
examination. In the other the tumors were removed from the rectum,
and three months later the patient returned with a marked adeno-car-

Fi8. a

IS.— IrMFHt-ADRl.

. fMBKiiifled 200 dl

B. lirpenrophted. newly R
rontniniuj: numo

ud cinndfl; CC.wim

734 THE ANUS, EBCTUM, AND PELVIC COLON

cinoma at the site of one of the largest growths. In the 42 cases col-
lected by Quenu and Landel (op. ciL), 20 of them either had at the
time, or developed afteni'ard, true cylindrical carcinoma. While man?
of the growths contained typical adenomatous tissue, at the same time
they presented an increase in the epithelial structures with the irregular
disposition thereof characteristic of carcinoma. Hauser, Bardenheuer,
Wulff, and Bickerstett have noted these changes in multiple adenomau
scattered throughout the intestine and complicated by carcinomatous
neoplasms. It is an established fact that a very large percentage of
the cases of multiple adenoma, if left alone, will in time develop malig-
nant transformation at some point or other. The fact that a micro-
scopic section of a tumor of this type shows a benign structure is some-
times most deceptive, for one may very easily obtain the specimen from
a benign growth, whereas the adjacent tumor has undergone malignant
transformation. Even in the same growth one may find parts of it per-
fectly benign, while other parts have undergone epitheliomatous trans-
formation. Wulff states that only the multiple variety of adenomata
undergo this transformation. This agrees entirely with the writers
experience. There are no authenticated cases on record where a single
pedunculated, adenoid polypus has recurred in the form of a carcinoma.

This predisposition to malignant change along with the diarrhoea,
hcTmorrhages, and exhausting mucous discharges makes this type of
neoplasm one of the most serious with which we have to deal. The
difficulty of entirely eradicating the growths when scattered throughout
the course of the rectum, sigmoid, and colon renders anything short of
the most radical and extensive operations worse than useless. The
prognosis in all these cases is therefore exceedingly grave.

Treatment. — The treatment of multiple adenoma is very unsatisfac-
tory. Diets of all kinds have been tried without any particularly good
effect upon the diarrhcea and the discharges; in Lilienthal's case the
meat diet seemed to have a very bad effect; in the author's cases chopped
meat and meat broths, together with a small amount of starchy food,
gave the patients more comfort than any other; the milk diet has
not been satisfactory, as a rule; in some cases cereals with egg albu-
men reduce the number of stools.

^fedicinos are utterly unable to control the symptoms, with the
exception of opium, which, if given in large enough doses, quiets the
pain and controls the diarrhoeal movements to a certain extent. Ergot
and tincture of cinnamon, together with fluid extract of hydrastis, have
a beneficial effect upon the haemorrhages, but even this is only tem-
porary.

Czomy (Qn^nu and Hartmann, vol. ii, p. 76) stated that the com-
bination of opium and tannic acid, together with injections of salicyl-

BENIGN TUMORS OP THE RECTUM 735

ated oil, gave a temporary amelioration; the same is the ease with other
astringent irrigations.

Surgical procedures have proved but slightly more successful; only
temporary benefits have been derived from the removal of the adenomata
from the rectum. In a case seen with Dr. Ladinski, from time to time
for over two years, the growths were snared off from the surface of the
bowel, giving considerable relief to the diarrhoea, pain, and haemor-
rhages; within two or three months, however, new ones developed, and
other operations became necessary.

The operations which have been advised consist in the removal of
the tumors from the intestine as high up as can be reached by ligature,
cauterization, and radical resection. It is important before undertaking
any of the procedures to determine if possible the existence of malignant
degeneration. If such a condition exists, no operation short of radical
removal of the affected area should be undertaken.

When the tumors are confined to the rectum and sigmoid, they may
be removed through the cylindrical proctoscope and with a wire snare
quite as effectually as by the more serious operations. Gerster in 2
cases did posterior proctotomy, laying the rectum open as high up as
the fourth sacral vertebra, and leaving it thus open while from time
to time he etherized the patient, and either snared or burned off the
numerous tumors; he states in a private letter to the author that in both
of these cases he succeeded in obtaining a cure by persistently repeat-
ing the operation, and believes this is the only means of doing so.
Malignant transformation did not occur in either instance.

Guyon performed a like operation, removing 30 to 40 tumors by
ligating the pedicles; his patient, however, died from vomiting and
diarrhoea shortly afterward. Richet by the use of a rectal speculum
removed between 80 and 100 polypi by seizing them with forceps and
twisting their pedicles. Considerable haemorrhage followed, which was
checked by the injection of ice-water, and later by the application of
the actual cautery to the stumps. A few months afterward the diar-
rhoea and haemorrhage returned, and the patient was found to have
developed other polypi in the field of operation. The difficulty of apply-
ing the cautery to the stumps through a speculum will be apparent to
all. Whitehead, by applying his method of operation for haemor-
rhoids, succeeded in removing along with the mucous membrane of
the rectum a considerable number of adenomata. The relief, how-
ever, was only partial and temporary. Fochier (Lyon medicale, 1874)
divided the mucous membrane of the rectum into five portions, dis-
sected up the sections, and ligatcd them at the top, thus removing
most of the growths. Within a year he had to intervene a number
of times, adopting the methods which Kelsey, Smith, and Whitehead

736 THE ANUS, RECTUM, AND PELVIC COLON

have more recently advised, viz., curettage and cauterization of the
tumors.

Thomas Smith (St. Bartholomew's Hospital Report, 1887) operated
in this manner five times within the space of as many years to control
the haemorrhages in one of these cases; the patient finally died from
peritonitis, having developed a cancer of the sigmoid flexure.

In Ladinski's case, operations by excision and cauterization had been
tried before he began the method of snaring off the tumors. During
the two years which he observed the patient, he removed at different
sittings between 40 and 50 tumors from the rectum and sigmoid flexure.
The patient is still alive and the tumors have not apparently undergone
malignant transformation.

Lilienthal's case is perhaps the most remarkable of all those reported:
A young woman twenty-one years of age had for years suffered from
diarrhoea, haemorrhages, and the passage of foul mucus; she finally be-
came so weak and anaemic that left inguinal colostomy was done to give
the pelvic colon and rectum rest. At this operation it was seen that
the mucous membrane of the colon was covered with small polypoid
growths extending above the inguinal anus. Notwithstanding this fact,
she was much benefited, the haemorrhages ceased, and the artificial
anus was closed. It was only a short time, however, before all her old
symptoms returned, and it became necessary to do something for her
relief. On December 30, 1899, he performed a right inguinal colotomy.
and found the colon at this height covered with large and small papillo-
ma-like excrescences, which the pathologist, Dr. Mandlebaum, described
as hypertrophied solitary follicles. The patient's haemorrhages almost
entirely ceased, although the visible mucous membrane seemed to be un-
changed. The girFs impatience with the artificial anus and the fact
that all her symptoms were almost sure to return if the same were
closed, determined the surgeon to exclude the faecal current from the
entire colon. This oj)eration he did on March (>, 1900, making an end-
to-end union between the ileum and the lower portion of the sigmoid
fiexure. From this time on the patient's general condition was clearly
improved, although she continued to have from 9 to 15 stools a day.

The artificial anus upon the right side was left open in order to give
vent to the secretions of the diseased colon. The patient's insistence
upon having the artificial opening close<l, and willingness to assume all
risks connected with the operation, led him to attempt the removal of
the entire colon, which he did on June 15, 1900. After various com-
plications of a most interesting nature, and associated with the most
wonderful recuperative power, the ])atient recovered from this most
remarkable and skilful operation.

The ca.<?e was presented at the Xew York Academy of Medicine,

BENIGN TUMORS OP THB RBCTUM 737

January 14, 1901, perfectly well, with the exception of a small sinus in
the right iliac region, which, according to LilienthaFs report, entirely
closed by April 16th. She was having then two movements a day;
the stools were ordinarily semisolid, but sometimes well formed. The
appearance (Fig. 242), the histological findings, and the results in this
case are unique.

Kelsey states, after having operated nine times upon one patient by
raclage and tearing away of the growths, that the only method which
offers any prospect of a cure is a radical excision of the affected area.

Where the tumors are limited to the rectum or to any single portion
of the colon, this may be accomplished, and even as in the case of
Li lien thai, the whole organ may be removed, but it is a desperate resort.
Where malignant transformation has taken place, this method certainly
offers the only hope. It is useless, however, to attempt to remove one
section of the gut, even if it contain a well-marked carcinoma, and
leave a greater or less area above it affected by the adenomata. The
diarrhcea, haemorrhages, and discharge from these will almost surely pre-
vent the union of the segments, and even if this should take place the
recurrence of the epithelioma in them is almost inevitable. If the
epitheliomatous change has taken place in the rectum or sigmoid flexure,
an artificial anus may be made upon the left side and all of the gut
below this portion removed after the method of Weir or Qu6nu. By
such means the dangers of non-union between the two ends of the gut
may be averted, and carcinomatous transformation in the parts above
be indefinitely deferred.

As a palliative means, either an artificial anus upon the right side
may be made, thus relieving the colon from the irritation of the faecal
passages, or, what is better still, the faecal current may be diverted
through anastomosis between the ileum and the rectum, as was done
by Lilicnthal, Rotter, and Holtmann. In the latter 2 cases the affected
area was not removed, and both patients died — one from " cachexia '^
and the other from peritonitis. Qu^nu and Hartmann were more suc-
cessful in a like case in which they made an anastomosis between the
ileum and the last loop of the sigmoid flexure. This patient was greatly
improved in health at the time of the report. The operation, however,
does not aim at a cure, and can only result in an amelioration of the
patient's symptoms. In Lilienthal's case the tumors showed no atrophy
or decrease after the faecal current had been diverted; it may obviate
the carcinomatous transformation by the prevention of irritation from
the faecal passages. When such an operation is undertaken, the anasto-
mosis should be made in the lower loop of the sigmoid flexure after
the rectum has been practically cleared of the adenomata. When the
disease is limited to the rectum, Gerster's method appears to offer the
47

738 THE ANUS. RECTUM, AND PELVIC COLON

best chance for cure; otherwise excision or entero-anastomosis should
be done.

Villous Tumor: PapUlnma, — ^Under the title "villous tumor," Quain
and AUinpham have described a neoplasm consisting of a "lobulated,
spongy mass with long, villous-like groups studding its surface." The
same growths have been described bv different authors under different
names: (Handular Pai>illomas (Gosselin), Villous Cancer (Bokitansky).
Papilloma (Virchow), and Paj)illarv Tumors (Forster). They are said
to resemble verv much tlie tumors of the same name found in the
bladder, although the ends of tlie villi are generally more blunt or club-
shaped (Plate V, Fig. "i). They arise from the superficial surf ace of the
mucous membrane of tlie intestine, and are attached by a broad bue
rather than by a j)edicle; tliey may occasionally become pedunculated,
the broad, flat attachment to the mucous membrane being dragged oat
to the extent of "Z or 3 inches. Allingham states that this pedicle is
api)arent ratlier than real; that the tumors grow from the surfice of
the gut, and by their weight drag the folds of the bowel down and give
rise to the ap])ea ranee of a pedicle. They ordinarily grow well up
within the bowel, and more frequently from the posterior wall, but
they have been seen both on the anterior and lateral walls of the gut.
When they arise from that portion of the intestine covered by peri-
tominim and become elongated or dragged down, it is possible for them
to drag along with them a fold of this membrane, thus forming a sort
of cul'de-sac in the wall of the gut (Allingham, op. <ri7., 1896, p. 465).
This fact ap])ears to be inconsistent with the view taken by this author
with regard to the origin of the growth upon the superficial surface of
the mucous membrane; if the submucosa and muscular wall of the in-
testine are not involved in the growth, it is difficult to understand
how it can drag down a fold or cul'de'Sac of the peritonaeum. The
precaution, however, which he suggests with regard to the possibility
of opening the ]x»ritoneal pouch by cutting off one of these tumors is
well worth remembering.

These tumors are exceedingly rare; Allingham has collected in all
30 cases, 17 being in his own j)ractice; Quenu and Ijandel have addei
7 cases to this number, 4 of which they have observed personally, and
have described minutely (Kevue de gynec. et de chirur. abdom., Febru-
ary, 1890) under the name of villous tumors or superficial vegetating
epitheliomas of the rectum. It is to these authors that we are in-
debted for a ])athological study of these neoplasms.

They make a very clear distinction between these vegetating, super-
ficial growths and those cases of secondary vegetations which develop
at a late period upon the surface of true cancers. The cut (Fig. 244)
is an excellent illustration of the appearance of these growths, and give?

a clear idea of the distinction betiveen them aod the cylindrical epi-
thelioma as it first develops in the rectum. In one ease thev observed
a villous tumor compli-
cated by tuberculous ul- i'fr'~
cerations below, a colloid ,
cancer above, together ^.
with a recto-vaginal fis-
tula, and in which an
ablation of the rectum
was made and a c
suited.

The macroscopic ap-
pearance, as described by
these authors, differs very
little from that given by
Allingham and Quain.
TJie tumors are red in
appearance, soft and vel-
vety to the touch,
vary in size from that
of a pea to a small egg,
althougb they are not
ordinarily spherical but
plaque -like; they are
composed of large numbers of villi or papillie, free at their surfaces but
conjoined at the base, thus forming a sort of lobulated tumor.

Tbe French authors state that in each lobe the papilla? group them-
selves anew in order to constitute lobules of a second or third order;
that if the tumor be plunged into water the different lobules and papil-
lae float, and their divisions and subdivisions are easily perceptible.

These tumors may become ver)' large; Allingham stales that one of
those which he observed was as large as a fretal head, and Cripps has
reported one as large as his fist. Ordinarily, however, they do not
exceed that of on English walnut. Hauser, quoted by Qu^nu and Hart-
niann, states that these neoplasms are seated exclusively in the mucous
membrane or in the superficial layers of the subraucosa; that they are
formed of a greater or less number of excrescences, red, and of a medul-
lary consistence. The French authors, however, state that they have
never found the tumor to go deeper than the muscularis mucosa. While
Hauser states that the tumors are ordinarily pedunculated, the French
writers and Allingham claim that they are more frequently sessile, and
that the villosities which constitute the tumor are directly implanted
upon the wall of the intestine and united at their base. They say:

((Ju^nu and HarU

Fla. MS.— SoiiEitj

TiO THE ANUS. RECTUM, AND PELVIC COLON

" The soft consistence of these tiunors, their euper6cial relation lo ilie
intestinal mucosa, and their peculiar papillary structure constitute, fmni
a macroscopic point of -new, the
fundanicntal characters which per-
iiiit us to distinguish them fmni
all other tumors."

The schematic cut, taken frnni
t^ufnu and HartmaoD (Fig. 243),
npresents the pedunculated lom
of ihese growths. The pediclt- is
composed of connective tissue, small
vessels, smooth muscular fibers, li>-
gether with some migratorj eelk
and young connective-tissue cpII*..
It is surrounded by a superficial foU
consisting of interstitial tissue en-
closing tubes of glandular apixar-
ancv; the surface of the tuniur is
covered with cylindrical epithelium; the interstitial portion is campo»ed
of fibrous tissue of new growth, constituting a sort of retieulum, uf
containing a large number of migratory cells and young CDnnectlTft-
tiaaue cells, together with numerous small vessels (Fig. 216). Accord*'
ing to Heitzmann, the structure of these growths is as follows:

" The tumor consists of a delicate connective-tissue stroma rich ia
blood-vessels and infiltrated with partly round and partly spindle-shaped'
lymph or inflammatorj- corpuscles. The surface is ?narkedlj papillatx
in nature, and the epithelial covering consists of eitJier a single layer-
of columnar or comparatively thin layer of stratified euhoidal cells."

QuSnu and Landel state that in the connective tissue there are ia*
eluded a large numl>er of epithelial tubes extending to the extremitia
of tlie papilliform prolongations. These tubes are more or less rstnifiod
and irregular, and one recognizes in them some small cystic caviliM
lined with epithelium.

The alterations of the epithelium, according to them, present charac-
teristics resembling both the adenoma and tlie cylindrical epithelioma.
They note a gradual change of the epithelium in going from the base
toward the peripherj- of the lobules, from an adenomatous type to a
cylindrical epitheliomatous type, and also a predominance in a well-
established tumor of the epitheliomatous tj^pe of these cells. This
change in type consists in a gradual decrease in the mucous cupules mi
an increase in the granulation of the protoplasm, together with oilier
more obscure changes, such as an increase in the reaction to coloring
agents, in richness of chromatine, etc.

BESIGN" TUMORS OF THE RECTUM

Their conclusioos, after these extensive stiirlies, is expressed in the
iollowing summary: " The villous tumors are, from a histological point
of view, cylindrical epitheliomas presenting a remarkable tendency to
maintain in a greater or less degree the primitive characters o£ the
elements from which they are derived. This tendency manifests itself
in the interstitial tissue, of which the primitive structure is not sensibly
modified, and in the epithelial tissue which embraces a mixture of the
«pitheliomatous and glandular elements, more or less normal, with nu-
merous forms in transition between these two tj'pes."

Etiology and Derelopmenl. — The etiology of these growths is not un-
derstood. So far as age is concerned, it appears to he one of adult and
advanced life. In 16 eases, 13 were found in patients above the age of
forty years. In 3 eases it was found below the age of thirty years.

There seems to be no predominance in cither sex; 8 have been observed
in men and 8 in women (Qu^nu and Hartmann, op. cit., p. 107).

As to the previous conditions causing the development of these
tumors, little can be said. Constipation is the only habitual condition.
The loss of blood and the existence of hemorrhoids has been stated by
Allingham to have existed in a number of patients, but no connection
can be traced between these and the production of the growths. Some
cases, even though the tumors have been discovered late in life, give
the history of having had a loss of blood for many years, and the patients.

742 THB ANUS, RECTUM, AND PELVIC COLON

supposing they suffered from ordinan^ internal haemorrhoids, gave the
matter little concern. Inasmuch as the haemorrhoidal development was
not marked in any of these instances, it seems fair to presume that the
blood came from the tumors which had existed for much longer periods
than was supposed. No germs or bacteria have been discovered in the
growths, although upon the surface and in the lacunae numerous leuco-
cytes have been found, together with colon bacilli and the various bac-
teria of the intestinal canal.

Symptoms, — The first and most prominent symptom connected with
this type of the growth is the frequent and abundant discharge of a
peculiar gluey mucus resembling the white of an egg^ but staining the
linen faintly yellow.

While there is a condition of costiveness, there is a frequent desire
to defecate, which results only in the passage of mucous discbarge.
AUingham states that this discharge is simply an excessive secretion
of the normal mucous membrane of the rectum due to the proliferation
of the villi and mucus-producing cells. He considers it the most im-
portant symptom of the disease. The mucus escapes involuntarily at
times, and it is impossible in many cases for the patients to keep their
clothing clean.

This loss of mucus is weakening and debilitating, and shows itself
in the pallor and loss of flesh in the patient, just as excessive purulent
discharges do.

Haemorrhages from these growths are very variable. Occasionally
they come on only once in long periods of time, in others there is a
constant oozing, and the mucous discharge is tinged with blood. Or-
dinarily the blood is fresh, and may continue to drip and ooze for some
time after stool. At other times it is clotted, or black and decomposed.
Large ha?morrliages may occur from these growths, exsanguinating the
patient, and bringing on extreme anaemia or syncope.

In one case described by Cripps {op, cit,, p. 301), the patient only
noticed that she had a free, watery discharge from the bowel, together
with a sensation of the bowel's not being completely relieved. Careful
examination, however, proved this discharge to be a very thin mucus,
which rapidly decreased when the patient was kept in the recumbent
posture. The discharge came from a large villous polyp attached about
3^ inches from the anus.

Constipation has been mentioned as a typical sjrmptom or prodrome
of the condition. In the cases reported there seems to be no fixed
rule concerning this, many of them suffering from constipation and
others from diarrhoea. In the case referred to the author by Dr. Teagiie,
of Xorth Carolina, diarrhoea, tenesmus, and recurrent haemorrhages
were the important symptoms, together with a cachexia indicating ma-

BENIGN TUMORS OP THE RECTUM 743

lignant disease. This case is apparently well four years after the re-
moval of the tumors. Two other cases, in which constipation was marked,
died from carcinoma after the papillomata were removed.

Quenu and Allingham state that the descent or protrusion of the
tumor when the bowels move, or even at other times, is one of the prom-
inent symptoms; but in examining the reported cases, it is found that
this does not take place in anything like the majority of them. The
growths develop usually at a considerable height from the anus, the
pedicles are not long, and therefore protrusion must be an exception
rather than the rule. The authors quoted state when this occurs it is
difficult to replace, and that it is during such a protrusion that the ex-
aggerated haemorrhages occur. In one case reported by Allingham, a
haemorrhage producing a syncope occurred under these conditions, but
immediately ceased when the tumor was reduced.

Pain is not at all a prominent symptom. The patient's chief com-
plaint is concerning the haemorrhage and mucous discharges, together
with a feeling of incomplete action of the bowels, a fulness of the
pelvis, and weight or aching in the sacral region.

The constitutional symptoms are dependent upon these discharges
and haemorrhages, together with the irregular action of the bowels; they
consist in a loss of flesh and appetite, digestive derangements, pallor,
anaemia, and sometimes actual syncope after the haemorrhages or diar*
rhoeal attacks.

Mechanical interference with the passages may result in faecal impac-
tion, inducing tenesmus, flatulence, swelling of the abdomen, and all
the symptoms due to obstruction, but such accidents are exceedingly
rare.

To the touch the tumors present a soft, slimy, velvet-like feel, slight-
ly elastic, and particularly wanting in that solidity which characterizes
adenoma. The end of the finger can be insinuated between the lobules,
and a villous-like feel can be made out.

If the tumor has been dragged down and its attachment to the wall
of the gut can be reached, a broad, flat fold may be made out. The
surface of this pedicle differs from that of the tumor itself in that
it is soft, smooth, and has none of the villous-like characteristics of
the tumor.

A point to which Quenu and Landel call particular attention in
regard to these pedicles is that, even at the point of their insertion into
the rectal wall, there is absolutely no induration, and the mucous mem-
brane preserves its suppleness and normal constituency. It is this one
point which distinguishes these growths clinically from cylindrical epi-
thelioma, and gives them any right to be classed among the benign neo-
plasms of the rectum.

Through the speculum they apjjear as bright or dark-red mamillated
masses, granular in appearauce, aud composed of lobules separaie<l b;
deep sulci- In some casus their surface appears b:« a sort of shaggj'effions-
cence, resembling more or less closely the villous polypi of the bladder,
but ordinarily the liranches have club-ahaped extremities (Fig. 811).

Diagnosis. — Papilloma or villous tumor may be confounded with
mucous polypi, myxomata or fibromata of the reclmn. The distinction
bohveon them and mucous polypi lies chiefly in the fact that the latter
are found almost entirely in children, while papillomata are nearly ■!-
ways seen tn elderly people; tlie pedicles of the former are much smaller
than those of tbe latter,
while the discharge of
nmcus and blood from pt-
pillomata is much grealtr
than that from the poly-
|iL The consistence o(
papilloma is much lf«s
marked than that of fibro-
niu, while its peduncula-
fion is also less maTkoi
Papillomata and multiple
iidcuomata, while they
lioth occur iu elderly peo-
ple, may be distinguished
Ijy the fact that the ade-
nomata are 6rmer to tht
touch, and much more nu-
merous as a rule. The
surface of the papilloma
is more irregular and lobulated; and, while there is a persistent gluey
mucous discharge in these cases, there is never that uncontrollable diar-
rhcea, with muco-purulcnt dejections, such as is seen in multiple adeno-
mata.

The distinction between these tumors and the vegetating form of
carcinoma lies in the fact that there is no induration at the point of
their implantation in the mucous membrane, and they are much \eti
friable than the carcinoma.

Maeroscopically and microscopically they resemble very closely the
adeno-carcinomas of the rectum. Allingham has reported their recur-
rence after removal in the shape of carcinoma, and Qu^nu and lAndel
claim to have observed the transformation of one of these tumors into-
a malignant neoplasm without any surgical interference having taken
place.

£ Keoti-h IBsII).

BENIGN TUMORS OP THE RECTUM 745

The following histological report of a case which gave every clinical
appearance of being benign papilloma is corroborative of the theory of
Hartmann and Quenu, that these growths are transformed into malignant
neoplasms, and nothing short of complete removal and microscopical
examination of the entire field can eliminate the possibility of such a
change in any given case.

The macroscopic appearance of this growth is well delineated in
Plate VII. Through the speculum the tumors gave every appearance
of being benign. The constriction and induration of the gut above
the base of the tumors, however, led to a clinical diagnosis of papil-
loma and carcinoma adjacent to each other. Microscopic examination,
however, showed that the supposed papilloma had undergone malignant
transformation.

HUtologieal Beport "by Louis HeiUmann, — ** The pedunculated growths in the
lower portion of the tumor were found to consist in many places of connective
tissue, partly fibrous, partly myxomatous in character, filled to a varying degree
with lymph and infiammatory corpuscles, generally quite abundant and coarsely
granular. Besides these groups^ individual, large, irregular, coarsely granular
multinuclear epithelia are found.

'^ The blood-vessels are quite abundant. In a number of sections, a few large,
irregular, convoluted glands are present, the original layers of polyhedral nucleated
formations filling the calibers to a greater or less degree.

'* The diagnosis of these growths is adenoid cancer, changing to medullary, in
all probability onginally benign.

^ Specimens from above these tumors show connective tissue greatly infiltrated
with medullary corpuscles, while in the upper portions there are numerous irreg-
ular, coarsely granular, multinuclear epithelia of various sizes arranged in nests
and tracts as well as irregularly scattered, and a large number of inflammatory
corpuscles crowded with micro-organisms. The connective tissue here is generally
scanty.

^* The diagnosis of this portion of the tumor is medullary cancer in a state of
ulceration and of a very malignant type.^'

This tumor was seen three months previous to operation, and there
were no clinical evidences of malignant transformation at that time.

Treatment. — These tumors, while exceedingly rare, demand when
once diagnosed a radical and prompt removal. The possibility of their
transformation into malignant neoplasms, the certainty of their gradual
increase in size, and the debilitating effect of the mucous and haemor-
rhagic discharges from them, together with their mechanical obstruc-
tion to the normal action of the bowels, and the reflex irritations which
they produce, render such a course mandatory.

The fact that the tumors may sometimes be spontaneously torn from
their attachments and cast off (Allingham) should never be relied upon,
or even mentioned, to excite an illusory hope in the mind of the patient.

Radical surgical interference is the only rational means of dealing

746 THE ANUS, RECTUM, AND PELVIC COLON

with such growths. Any compromising or palliative treatment, such as
cauterizing with chemical cauterants, or even the actual cautery, will
only result in temporary benefit and eventual injury to the patient.
Recognizing the fact, as stated by Allingham and corroborated by Cripps
and Quenu and Landel, that these tumors may drag down into their
pedicles or bases little pouches of the peritonseum, one should be very
careful in their removal that a method is employed which will absolutely
prevent the opening of such a cul'desac.

Where the pedicle is of moderate size it may be encircled by a strong
ligature and thus tied; the constriction of the ligature closing the peri-
toneal sac, if such should exist, will cause adhesion between its walls,
and thus prevent an opening being made after the tumor is cut off.
This method of applying the ligature, however, is somewhat dangerous,
owing to the fact that it may slip off in a short time after it is applied,
and thus allow the peritoneal cavity to open, or permit serious haemor-
rhage. In order to avoid this, Quenu and Hartmann have advised that
the pedicle be transfixed and then tied upon either side. This is a
wise precaution, and would be perfectly acceptable were it not for the
fact that the needle passing through the mucous membrane must also
pass through the peritoneal sac and thus may carry infection into that
cavity. Moreover, the threads passing through the pedicle and through
the sac, if such be included in the pedicle, act as a sort of wick for the
first few hours; and if there be septic material in the rectum will carry
it into the peritoneal cavity, and may thus set up a peritonitis.

It seems better, therefore, where the tumor is of small size to tie the
pedicle tightly by the ligature and leave the tumor in situ until it
sloughs away; by this procedure there is little danger of the ligature
slipping off.

Where the pedicle is broad and large, and the tumor is obstructing
the lumen of the gut, this method is not altogether satisfactory. It
is important in such cases that the tumor be removed at once. One
should therefore take every antiseptic precaution and apply the trans-
fixion method, taking the chances of infection as mentioned above. In-
stead of passing the ligature through the center of the pedicle, it may
be passed through the mucous membrane at each border, and tied as a
mattress suture. One might also apply hysterectomy forceps to the
stump in such cases, leaving them on for two or three days.

Where the tumor has no pedicle, and its base is as large as it^ ex-
tremity, it should be excised, and the edges of the wound sutured to-
gether with catgut sutures.

In the case described by Cripps (op. cit., p. 303) the pedicle was
very broad. He transfixed and tied it at several points in order to
perfectly control the haemorrhage, taking the chances of infecting the

BENIGN TUMORS OP THE RECTUM 747

peritoneal pouch by the needle and the wick-like action of the ligature.
As these growths are not multiple, resection of the gut is rarely if ever
called for until transformation is observed.

Cystoma. — This general term, indicating cystic neoplasms, embraces,
so far as the rectum is concerned, all those tumors which have undergone
cystic degeneration, as well as dermoids and hydatids.

Reference has been made to the cystic degeneration of adenomas,
fibromas, and other neoplasms of the rectum; in all of these cases the
cyst is of secondary consideration, the true histological nature of the
tumor being preserved more or less in the walls of the cyst and the
solid portions of the growth.

Simple Cysts, — These growths are very rare in the rectum. Prideaux
(London Lancet, August 18, 1883) has recorded a very interesting case.
A woman who had suffered from a very difficult labor complained of in-
tense pain in the pelvic region; her abdomen became distended and
tympanitic, and she exhibited all the signs of intestinal obstruction;
she described herself as unable to pass gas on account of something
closing up the rectum.

Digital examination of this organ elicited a tumor almost as large as
a foetal head resting low down in the ampulla of the rectum. It was
soft and elastic, and gave the impression of an intussuscepted intestine.
" The tumor was not covered by mucous membrane, its surface being
rough and much injected."

It was dragged down and out of the anus, and was found to be at-
tached by a pedicle 6 inches in length, which was tied in two places and
cut off. The tumor itself contained half a pint of albuminous fluid, and
its walls measured from ^ to ^ of an inch in thickness. No pathological
examination was made to determine the histological nature of the
growth. The external covering having been described as different from
mucous membrane, one would have expected to find evidences of a der-
moid cyst, but from the description one can only conclude that it was
a simple cyst in which the characteristic elements of the mucous mem-
brane had been destroyed by pressure or distention. Cripps describes
two other cases of a similar nature. The benign nature and extreme
rarity of this type of tumor render a prolonged discussion superfluous.

Dermoid Cyst. — ^Here one must clearly distinguish between true
dermoids of the rectum and those which develop in its walls, the recto-
vaginal sjpptum or the retro-rectal space. Such tumors are not at all
infrequent in these regions, but true dermoids of the rectum are ex-
tremely rare.

Those which originate outside of the rectum may break through into
it by ulceration or rupture, and thus protrude in a polypoid-like man-
ner into the gut, giving the impression of a growth originating within

748 THE ANUS, RECTUM, AND PELVIC COLON

the organ. Such a case has been related by Jardine (Glasgow Med,
1893, p. 50): A little girl aged ten years suffered from a discharge of
blood and pus with her stools, and during defecation there protruded
from her anus a mass of tufted hair matted together. A careful exam-
ination of this child^s rectum showed a rent in the wall with ulcerated
€dges, through which the discharge came and the tumor protruded. It
was clearly a case of a dermoid cyst originating outside of the rectal
wall that was forced through by straining and abdominal pressure.

Port (Transactions of the Path. Soc. of London, 1880, p. 307) relates
the case of a girl aged sixteen, from whom he removed a tumor appar-
ently originating in the rectum. It was composed of skin covered with
hair and sebaceous follicles; its central mass was chiefly composed of
fat and fibrous tissue, and within the central cavity there was found
a well-developed tooth growing near the pedicle. There were also em-
bedded in this tumor two masses of bony substance, one hard and the
other of a spongy consistence. WTiile the patient is said to have ex-
perienced the protrusion of a tuft of hair frequently when at stool,
no account is given of such a tuft being found upon the surface of the
tumor after it was removed.

Bazel (Langenbeck's Archiv, Bd. xvii, S. 442) related the case of a
woman who suffered from a protrusion of hair from the anus when
at stool. He removed from her rectum a tumor the size of an orange,
w^hich was attached by a pedicle to the posterior wall of the rectum
about 2^ inches above the anus. Upon an examination of the tumor
it was found to be composed of a sort of dermoid covering from which
were seen growing long tufts of hair, and at one place a small tooth.
Inside there was a distinct development of brain substance surrounded
by a sort of bony capsule, together with fibrous and fatty cells.

Barker (Med. Press and Circ, 1873, p. 208) described a tumor of
the rectum composed of bone, sebaceous matter, and small hairs. This
was in all probability a dermoid cyst, but the description is so imperfect
that one can not tell whether it originated within the rectal wall or
outside of it.

Glutton (Transactions of the Path. Soc. of London, 1886, p. 552)
has reported a case of a girl nine years of age, who suffered extremely
with constipation, tenesmus, and the presentation of a tumor at the anus
whenever the bowels moved. She also complained at times of fever and
loss of blood. An examination of the abdomen showed a distinct ten-
derness over the sigmoid flexure, and also the existence of a tumor in
that region. After a short time the sphincters w^ere dilated, and the
tumor was seen to come down well into the rectum within reach. An
examination elicited the fact that this tumor was attached bv a double
pedicle which originated about the juncture of the rectum and sigmoid

BENIGN TUMORS OP THE RBCTUM 74»

flexure. A ligature was placed upon each of the pedicles as high up aa
the fingers could reach, and the tumor was removed. An examination
of the growth showed it to be a typical dermoid cyst, covered with true
skin tissue and hairs, and containing all the elements usually found
in these growths.

Gant has also reported a case of this kind. No explanation has
yet been offered of the method of development of these tumors within
the rectum. While those posterior to the rectum have been said to
originate in the remnants of the neurenteric canal, it seems impossible
for those developing in the upper regions of the rectum to have so
originated.

Golding-Bird (Lancet, 1894, vol. ii, p. 1482) removed a tumor
from the walls of the rectum by incising the mucous membrane over
the growth and ligating the pedicle. An examination of the tumor
showed it to be cystic, filled with a clay-like fluid, and containing all
the structural elements found in the wall of the large intestine. The
author considered it without doubt a dermoid cyst originating in the
walls of the rectum. Huntt (Med. Repository, 1821, p. 79) relates the
case of a little girl, twelve years of age, who had become weak, anaemic,
and her abdomen swollen and tympanitic. One day she felt something'
give way in the left side, and immediately thereafter she passed a con-
siderable quantity of bloody water by the rectum. This was followed
in a few days by a discharge of pus, blood, and mucus. Some four
weeks later a spherical tumor presented itself at the anus, partially
protruding. As its presence caused the patient much pain and an un-
controllable desire to defecate, an immediate removal became necessary.
A ligature was placed as high up as possible, and the greater part of the
tumor was cut away. The rest of it eventually sloughed off, and the
child made a good recovery. The growth was covered with hair and
a sort of dermal tissue, and in its center there were found two teeth,,
together with fibrous and fatty tissue.

Van Duyse (Bull, of Anat. Royal of Belgium, Brussels, 1896, p. 583)
has reported a case of a woman thirty-two years of age who passed spon-
taneously from her rectum during labor a tumor which, on examination,
proved to be a dermoid cyst partially encephaloid, and containing a
rudimentary eye. The patient developed no unusual symptoms, and
made a perfect recovery. Xo examination was made with regard to the
source of the tumor, or whether it originated in the rectum or within
the recto-vaginal saeptum. The description given leads one to believe
that it originated in the wall of the gut or entirely outside of the
rectum proper.

In the summer of 1899, Prof. A. R. Robinson showed the writer a
tumor the size of a foetal head which had been passed from the rec*

750 THE ANUS, RECTUM, AND PELVIC COLON

turn of a patient during labor. The tumor had evidently been torn
from its capsule or attachment within the pelvis, had broken through
the rectal wall, and had been forced out through the anus in advance
of the child's head. Its pedicle was tied and cut off by the midwife.
It proved to be a dermoid cyst. He was unable to induce this woman
to enter the hospital and have proper treatment, notwithstanding there
was a rupture in the wall of the gut large enough to introduce several
fingers through it; she entered another hospital, was treated for puer-
peral peritonitis, and recovered.

From these experiences one must admit that, while true dermoid
cysts within the rectum are exceedingly rare, one not infrequently finds
tumors of this type in the walls of the gut or attached to their outer
surface. These walls may be ruptured by various processes, especially
during labor, and the tumor be brought down within the gut or de-
livered through the anus.

The etiological factor in them all is similar to that of dermoid cysts
elsewhere in the body. They are nearly always found in the female sex.
It is perfectly clear that they are congenital from the number of cases
found in young children. That they are not discovered until later in
life is due to the fact that some patients are not susceptible to reflex
irritability, or the tumor remains of small size and occasions no incon-
venience until it offers an obstruction to the foetal head or to a large,
hard stool.

Extra-rectal Dermoids. — Dermoid cysts may occur just outside of
and attached to the rectal wall either in the perinaeum or in the retro-
rectal space. Calbet (Thesis, Paris, 1893) stated that these tumors were
comparatively frequent. The writer has removed from the retro-rectal
space a tumor about the size of a pigeon's egg which bulged out into the
rectum and led him to believe that it was in the rectal wall. It was
removed through the rectum by dilating the sphincter and then making
a longitudinal incision through the wall of the gut. The tumor was
found to be situated in the cellular substance posterior to the rectum,
and attached to the rectal wall, but not in it. It contained a lock of
hair, some sebaceous material, and a mass of partially developed bone.

In another operation upon a similar tumor situated just beneath the
peritonaeum in the recto-vaginal sa?ptum, the woman had complained
very much of irritation and pain when faecal passages were hard, and
had a distinct hypertrophic proctitis, which was the cause of an aggra-
vated pruritus. An examination of the rectum showed this little tumor
about the size of a small olive situated 2^ inches above the margin of
the anus. There was also an adhesion of the uterus to the rectum, and
obstruction to the fa?cal passages had been noticed for a long time.
The vaginal cul-de-sac was opened, the adhesions were broken through,

BENIGN TUMORS OF THE RECTUM 751

the uterus was lifted up with gauze packing, the peritonaeum was
stripped upward, and the little tumor, which had a distinct pedicle, was
enucleated and the pedicle twisted oflf. It was composed of a dense,
fibrous capsule enclosing a soft, yellowish, semifluid substance, together
with three pieces of bone and a partially developed eye-tooth.

Manuel (Senn on Tumors) refers to 2 cases of dermoid cysts which
were situated between the peritonaeum and the levator ani muscle.

Konig reported the case of a suppurating cyst found enclosed in this
same locality. Ord (Med. Chir. Transactions, vol. xlii, p. 1) found in
the pelvis of a man twenty-eight years of age a dermoid cyst weighing
14^ pounds; but he does not state whether this was within the peritoneal
cavity or extra-peritoneal.

Page (Brit. Med. Jour., 1890, vol. i, p. 406) removed a dermoid cyst
weighing 3 pounds from the hollow of the sacrum in a woman thirty-
eight years of age. These cysts may also develop outside of the anus,
as in the case of Duret related by Fourneaus (Jour, des scs. med. de Lille,
1893, p. 346). The patient in this case was thirty years of age, and had
carried this cyst at the margin of the anus supposedly from birth. The
tumor was of a dark-red color, which extended down even into the ped-
icle by which it was attached. Its surface was richly vascular, and cov-
ered with a thin, smooth skin continuous with the skin of the anus. The
tumor was removed by incising the skin around the pedicle, dragging
down upon the latter and cutting it off, the edges of the skin being su-
tured together. Duret was under the impression that this tumor was
a melicerous cyst. Microscopic examination showed that it was one of
the rare types of dermoids.

Treatment. — These tumors should be removed either by ligature or
dissection under the most rigid antisepsis. Cauterization, curettage, and
local treatment are worse than useless in such cases.

Postanal Dimples. — Along with dermoid cysts one may consider
" postanal dimples " which, according to histologists, are due to similar
imperfections in the development of the embryo. They occur chiefly in
the region of the sacrum, coccyx, and posterior margin of the anus, and
are said to be caused by imperfect union between the two lateral halves
of the foetal body.

They occur as slight, fissure-like (Fig. 247'a), or cylindrical depres-
sions (Fig. 2476) in the skin, varying in depth from several inches to a
mere depression upon the surface. They are lined with true epithelium,
and contain sebaceous glands and hair follicles.

A distinction should be made between these and the sinuses which
occur in the sacro-coccygeal region as a result of obstructed sebaceous
follicles. In the latter hairs frequently accumulate, being broken off
from the surface of the body, and working their way inward through

THE ANUS, RECTUM, ASD PELVIC COLON

■T

H friction of the clothing; but these can be easily drawn out, and do not

^^ show any roots. In congenital dimples the hairs grow down within the

^1 sinus, and when pulled out not only give pain, but have di&tinct nwU

^M at the end.

^M These little dimples from irritation, lack of clcaoliness, or otba

^M causes may become closed at the surface and present the appearance nf

^M small cysts. When pressure is exerted upon them under such circunh

^^^ stances, sebaceous material and epithelial debris may be squeezed out,'

^P iMarkue uid Scliler. Am. Jour, Med. Sc. Mar, 19U2.)

and sometimes even pus appears, produced by inflammation and infee^
tion, giving the impression that one haa to deal with an external blind
fistula.

Occasionally where suppuration takes place it may burrow downward

coming close to the anus or even entering the rectum. W. Tran*
Gibb related a case of this kind in which the tistula extended from the
middle of the posterior surface of the coccj^x downward and fonrard,
ending near the rectum between the external and internal sphincters.
A lock of hair extended almost through the tract. ^TiHien this was pulirf
out the fistula appeared to be of the ordinary external blind variety, with
the exception that the external end was infolded and lined with tie-
normal skin. It was laid open, curetted, and healed, leaving a small
depression in the skin.

Trealmeiit. — It a dimple is deep and irritating, it may he welt t«
dissect it out and suture the edges of the wound together. If, however,
it is simply a depression and not irritating, it is better to leave it alone^
and impress upon the patient the necessity of keeping the parts clean
without any undue irritation. Squeezing and digging at them is harm*.
ful, and should he avoided.

Occasionally pulling the hairs out and cauterizing the tract witt

BENIGN TUMORS OP THE RECTUM 753

nitrate of silver will result in their obliteration, but if a small piece
of adhesive plaster is worn over the opening, the dimple will be kept
clean and rarely give any inconvenience.

Sacro-coccygeal Tiimors. — Certain sacral and sacro-coccygeal growths
develop upon the anterior surface of the sacrum or coccyx, and may be
mistaken for tumors of the rectum, or may originate outside of these
bones and extend inward, and thus seem to be connected with the gut.

In discussing them it may be well to refer to Sutton's theory of
«mbr}'ological formation of tumors in this region. He says: " In the
early embryo the central canal, spinal cord, and alimentary canal are
continuous around the caudal extremity of the notochord. The passage
which unites them is known as the neurenteric canal. When the
proctodaeum invaginates to form a part of the cloacal chamber it meets
the gut at a point some distance anterior to the spot where the neuren-
teric canal opens into it. Hence there is for the time a segment of the
intestine extending behind the anus, and termed, in consequence, the
postanal gut. Afterward this section disappears, leaving merely a trace
of its existence in a small structure at the tip of the coccyx, known
as the coccygeal gland or gland of Luschka."

The embryonic tissue thus left is a fertile sourqe of tumors of the
congenital cystic variety. In this region, therefore, we may meet several
different forms: dermoid cysts or foetal inclusions; tumors of the coccyg-
eal gland arising from the remains of the postanal gut; and tumors of
the neurenteric canal.

Calbet, Braune, Molk, and TaneflS have made special studies of these
cases, and their results are extremely interesting. Calbet reports 111
cases and Molk 115.

The most common point of origin is upon the anterior surface of the
coccyx and sacrum. The next most common point is upon the posterior
surface of the sacrum. The neoplasms found here are various, consisting
of mixed tumors, lipomata, sarcomata in different forms, carcinomata,
dermoid cysts, fibroids, and simple cysts. The most common type of the
tumors seems to be a sarcomatous degeneration of the fibrous tissue.
They are largely found in children, and are nearly all congenital. Many
in which the growths have been found were still-born, and others died
soon after birth. In Calbet's statistics 60 per cent died before the end
of the second year.

In 83 observations by this author the tumors were composed of
foetal tissue; there were 50 deaths and 23 cures or ameliorations. As
results of operative treatment, Molk collected 31 cases with 14 recov-
eries, and Calbet 53 cases with 37 recoveries, a total of 84, with 33 deaths,
or a mortality of 39.3 per cent. From these statistics one can not but
conclude that the prognosis of such tumors is very grave, and much
48

754 THE ANUS, RECTUM, AND PELVIC COLON

more so because one includes among these those distressing cases of
spina bifida occurring in the anterior wall of the sacrum^ and producing
what appears to be a tumor of the rectum.

While sarcoma is the ordinary form of malignant tumors found in
this location, it is not the only one. Fletcher and Waring (T^aIlsa^
tions of the Path. Soc. of London, 1900) relate the case of a child aged
two years who was operated on for the removal of a tumor in the^coc-
cygeal region, which had been present from birth. It was removed bj
a perineal incision. The coccyx was excised, owing to its attachment to
or involvement in the tumor, and the patient made a very good recov-
ery. An examination of the growth showed it to consist of two parts:
one a dense, hard, semisolid substance and the other soft and com-
pressible. The soft part proved to be an adeno-carcinoma, while in
the dense part there were numerous tubules of various sizes lined with
columnar epithelium, with a considerable quantity of vascular, connect-
ive tissue. Two and a half months later this patient returned to the
hospital, and died shortly afterward. The autopsy revealed the fact that
the pelvis was filled with recurrent masses of adeno-carcinoma. The
writers assume that the origin of this tumor was in the postanal gut.
They also report the case of a child who died on the seventh day after
an operation for an adeno-cy stoma originating in the neurenteric canal.

Spina bifida may also occur in this region, not only alone, but as
a complication of other tumors; this is a fact which is not ordinarily
appreciated. The writer came very near mistaking such a tumor for
an ordinary cyst some years ago, and was only deterred by the wisdom
and kind advice of L. Emmett Holt, who had seen the ease before,
and warned him to carefully exclude anterior spina bifida before under-
taking the operation. A very careful study of the case demonstrated
that Dr. Holt was right in his diagnosis. The proposed operation would
almost surely have proved fatal.

Treatment. — The fact that most of these tumors are malignant in
character renders the prognosis very unfavorable. Excision offers the
only hope of cure, but it should never be undertaken without a perfect
knowledge on the part of the patient, or the parents, of the probable
outcome. The operation should be done under the strictest aseptic pre-
cautions entirely outside of the rectum, even if the coccyx and a part
of the sacrum have to be removed to accomplish it. In anterior spina
bifida, either simple or complicated, the prognosis is so grave that it
is doubtful whether any operative interference is justifiable.

Angeioma. — This type of tumor, consisting of dilated venous capil-
laries bound together with connective-tissue bands, occasionally occurs
in the rectum, forming a sort of njevoid mass. It is derived from the
submucosa, and is ordinarily congenital. Barker (Med. and Chir. Trans-

BENIGN TUMORS OP THE RECTUM 755

actions, 1883-^84, p. 229) records the case of a man forty-five years of
age who died of anaemia, the result of severe rectal haemorrhages. !Mi-
croscopic examination after death showed that the tumor from which
the bleeding occurred was an unmistakable angeioma or naevus.

iVnother case of this kind is reported by Marsh (Med. and Surg. Soc,
1883). A little girl ten years of age had suffered with rectal haemor-
rhages for eight years; an examination with the speculum showed a
naB\Tis entirely surrounding the rectum and ascending 1^ inch above
the anus. In this case the neoplasm was treated by the use of Dupuy-
tren's cautery, which gave relief but did not cure the condition. ^Mar-
tin, of Cleveland, has also seen a case of this type in an adult.

In all of these eases the history of the disturbances dates back many
years, and it is presumable that they were congenital.

Treatment. — The rarity of these cases renders it impossible to speak
from experience with regard to their treatment. It seems reasonable to
suppose, however, that the Whitehead operation would effectually re-
move these growths if low down in the rectum; if high up, electrolysis
would probably be the safest procedure.

Verruca. — These gro\ii:hs, known also as warts, vegetations, condy-
lomata and papillomata, are found frequently around the margin of tlie
anus, especially in stout individuals. So frequently are th«'y assf>ciated
with genito-urinary affections that they are frequently calleil venereal
warts. Aside from the type known as condylomata lata, which is a
variety of mucous patch, the growths are in no wise venereal in the
strict sense of the word. They consist of a simple h\7iertrophy of the
papillary layer of the skin. This hypertrophy may Ix* eaus^,'d by any
chafing or irritating discharge. It depends e^^'Utially ufxjn moisture,
and therefore the condition is never obsen-ed in jn.'Ople'who are strictly
attentive to personal cleanliness.

The gro^i:hs sometimes develop upon the summit.-* of mixed Iwrnor-
rhoids, but here they attain only a small ^ize. Around the margin of
the anus they may grow to enormous proj^irtion-f. ^-ntirely -urrounding
this organ and extending forward over the [^erina-uin. ujkju i\u'. vulva
or scrotum, and upward into the inguinal njrion (Plat*- \', Fi/. \).

Careful research has failed to determine any •i\tf'<:\i\o ba/illu^^ or para-
site to account for them. They begin as =niail wart-like ex^r^'r^-'-ne^'H,
and develop rapidly in proportion to the amount and irritating qualiti^'H
of the discharges which bathe them.

The color varies from pale white to that of br:;rhr red, and KOfn"-
times the condition much resemble? a v^';reta*in;r e:/;*fj'-!ioriia. 'J'fie dis-
tinguishing feature between these condition- i- *r.e a^i'^ufM of any in-
duration in the deeper tissues at the V/a-^-- of V'.^r v^-;'M.Jition-;, SofH"
are covered with a firm epithelial layer, and rtihy r/'; hand Jed wiUi Itti-

756 THE ANUS, RECTUM, AND PELVIC COLON

punity 80 far as pain and bleeding are concerned. In others, wiping
or cleansing them will result in quite considerable and obstinate
bleeding.

The growths are not painful, as a rule, but when they involve the
muco-cutaneous margin they may result in such dragging upon the
mucous membrane as to produce anal fissure, and this becomes a source
of great pain.

Treatment, — The treatment of these growths may be operative or
non-operative. Certainly the most radical and quick method of eradica-
tion consists in clipping them off at their bases with scissors, and using
hot compresses to control the bleeding. This method is always effectual,
and is without any particular danger if thorough antiseptic irrigation
is employed during the operation. It requires general anaesthesia, how-
ever, in extensive growths.

The non-operative treatment consists in checking the discharges
from whatever sources they may come, in keeping the parts absolutely
dry by the application of such powders as oxide of zinc, calamine, starch,
tannic acid, calomel, etc. The tumors may be cauterized from time to
time with chromic or nitric acid, or better still with monochloracetic
acid. The chief point, however, in the treatment consists in keeping the
parts absolutely dry, and this is essential after operation by excision,
as the vegetations will undoubtedly recur unless the parts are protected
from the irritating discharges which originally caused them.

Fong^s of the Eectnin. — Under the name of " fungus recti " a num-
ber of distinctlv different conditions have been described: some of them
are merely inflammatory excrescences, some true papillomata, and others
syphilitic vegetations.

MoUiere has described under this class of cases a form which he de-
nominates " benign fungus of the rectum." It is in reality only a mass
of granulation tissue due to constant irritation. He observed it always
in children suffering from prolapse or inflammation of the rectum. The
fungus was nothing more or less than an hypertrophy of the villi or
granulation tissue over the ulcerated areas. Around the anus, however,
a true fungoid growth may be met with. This consists in the ray fungus,
technically called actinomycosis. The condition is extremely rare. Do-
lore (Lyon medical, 1898, July 10) gives a clear description of this con-
dition, and states that it is the only case reported in French literature:
A man fifty-six years of age had suffered twenty years previously from
an ischio-rectal abscess which healed rapidly. Marked induration was
obsers'ed in the ischio-rectal fossa, and masses of fungoid growth sur-
rounded the anus, through which ran many fistulous tracts. The rectum
was not affected, nor was the bladder or urethra, the condition being
perirectal and periurethral. A flaky, yellowish-white discharge exuded

BENIGN TUMORS OP THE RECTUM 757

from the mass, and on examination it was found to contain the spores
of actinomycosis. The presence of these peculiar-looking, yellowish-
white granules, resembling somewhat the crystals of iodoform and
consisting of a center of fine granular matter, generally calcareous,
grouped about which were numerous club-shaped bodies composed of a
limiting membrane with a clear, homogeneous, refractile protoplasm,
were considered pathognomonic evidences of the ray fungus. It is
spoken of by dermatologists as the cause of pruritus ani, but it is cer-
tainly a very rare cause of this condition, as we are unable to find a
single case of it recorded in the records of St. Mark^s Hospital, and none
has appeared at our clinic.

Hydatids. — This variety of tumors does not occur within the rectum,
but a number of cases have been reported in which the tumors occurred
in Douglas's cul'de-sac, in the mesorectum, and in the recto-vaginal saep-
timi, and could be felt through the rectal wall. In some instances this
wall has been so thinned by the pressure of the tumors that they have
ruptured through into the gut.

About 4 per cent of these tumors occur in the pelvis. According
to Jensen, Madelung, Freund, and Villard, they are found in women,
as a rule. An interesting case of this type has been recently reported
by Bangs (Annals of Surgery, May, 1900); the timiors seemed to involve
the bladder and prostate, but were afterward found to be in the recto-
vesical pouch and crowding the pelvic organs; they were removed by
an operation through the abdomen, and the patient made a successful
recovery.

Diagnosis. — The diagnosis of these timiors is extremely difficult.
There is nothing characteristic in their feel, shape, or symptoms to
distinguish them from other tumors found in the same location. Or-
dinarily the diagnosis is only made after or during an operation for their
removal. The hydatid thrill is said by some to be of assistance in
distinguishing them, but when the timior is situated in the pelvis it is
impossible to make this out. Practically the diagnosis can only be made
by the microscopic examination of the fluid. If the tumor is within
reach this may be obtained through an aspirating needle, under strict
antiseptic precautions, the presence of a single hydatid booklet being
pathognomonic evidence of the nature of the growth. Should the cyst
rupture into the rectum the booklet may be found in the faecal dejecta.

While the seat of these tumors is usually in the peritoneal cavity,
between the rectum and the uterus, or the rectum and bladder in males,
this is not always the case. Meyer, quoted by Piecheldt (Commentatio
de Tumoribus in Pelvi, Heidelberg, 1840), performed a laparotomy for
a tumor of the pelvis which he supposed to be a steatoma, but it proved
to be a mass of hydatids between the rectum and the upper vaginal wall.

758 THE ANUS, RECTUM, AND PELVIC COLON

Unfortunately his patient died forty hours later from peritonitis. Blot
(Compte rend, de la soc. de biol., 1859) and Roux (Jour, de med. de
SMillot, 1828) both relate cases in which the hydatids were found in
the recto-vaginal sa?ptum.

Obre (Transactions of the Path. Soc, 1854) reported a very inter-
esting case in which rectal obstruction was due to hydatid cysts in the
mesorectum. Madelung has collected 66 cases of pelvic hydatids, 5 of
which were between the vagina and the rectum, and 7 in the connective
tissue about the rectum. Although these cases are rare, they are suffi-
ciently well authenticated to put us upon our guard when diagnosticat-
ing tumors of the pelvis involving the rectum. They are quite im-
portant, because they are more dangerous than almost any other form
of cyst in this region.

Treatment. — The results of operations have not been very satisfac-
tory. The majority of writers believe, where the diagnosis is once made
and the tumor does not seem to cause much annoyance or to give great
pain, that they had better be left alone. If it should be necessary to
interfere with them, however, a radical and complete removal of the
cyst is the only safe method. If possible they should be removed un-
broken.

The injection treatment, whether by iodine, carbolic acid, or Mor-
ton's fluid, and tapping, are not only ineffectual, but may cause actual
harm by allowing the fluid of the tumor to escape into the cellular
tissues or into the peritonaeum, which accident is nearly always fol-
lowed by a rapid fatality.

Hypertrophied Anal Papille. — In connection with the benign neo-
plasms of the rectum we may call attention to certain hypertrophies of
the papillae about the margin of the anus. They can scarcely be tenned
neoplasms, being only excessive growths of normal tissues. They con-
sist in marked hypertroj)hy of the anal papillae normally found upon the
borders of the semilunar valves; it may take place in one or more of
them, and they may attain considerable size and length (Fig. 248).
While these growths are said to be highly endowed with sensitive nerve-
ends, they rarely produce any pain. They occasion, however, a great
deal of uneasiness in the rectum, spasm and hypertrophy of the sphinc-
ter, and consequently constipation, associated sometimes with neuralgia
of the rectum. They appear like little white fibrous teats or warts: they
can be seen through the speculum, and sometimes by dragging down on
the buttocks. They are also appreciable to the touch.

A marked s}Tnptom of this condition is the feeling of incompleteness
in the faecal movements; the patient is never perfectly relieved by the
same imtil, through pressure and gradual retraction, the papillae resume
their normal position and the desire for further stool then passes away.

BENIGN TUMORS OF THE KECTUM

759

The amount of disturbance and annoyance occasioned by theae little
teats can hardly be appreciated by those who have not observed them.
Occasionally they grow to siich an extent that they are mistaken for
polypi of the rectum or connective- tisane hiemorrhoids.

The treatment of this condition consists in the absolute removal of
the papillie. This may be done by scissors or crushing with the liiemor-
rhoidal clamp. As the bleeding is very slight there is no necessity for

ligature or eauterj-. If there is much hypertrophy of the sphincter, this
should be done under general aniesthesia, and a large Pennington tube
should he retained in the anus for several days in order to obtain com-
plete relaxation of the musele; otherwise the papillae may be removed
by the use of cocaine or eucaine, and the patient need not be confined
to bed. While there is little to be said with regard to the pathology
and treatment of this conditionj it is one of the most fertile sources
of rectal neurosis.

CHAPTER XIX

MALIGNANT NEOPLASMS— CARCINOMA AND SARCOMA

In our general divisions of neoplasms of the rectum they were
classified as connective-tissue, epithelial, muscular, and irregular
growths. Those in which the cellular elements are normally arranged
and fully developed have been described as benign neoplasms, and
those in which these elements are irregularly arranged, growing outside
of their normal sites and imperfectly developed, as malignant. Car-
cinoma of the epithelial and sarcoma of the connective-tissue type prac-
tically comprise all the malignant tumors of the rectimi. That doubt-
ful variety of epithelial growths, villous tumor, might "properly be classed
with the former on account of its extreme tendency to carcinomatous
transformation, if indeed it has not always some epitheliomatous foci
in it; but its exact status is not definitely settled, and it has seemed
wise to follow in the tracks of the large majority of writers who consider
it benign.

CARCINOMA

Vital statistics show an alarming increase in the prevalence of carci-
noma throughout the civilized world. Williams (Liverpool Chirurg.
Jour., 1895, p. 56) has shown that the disease has increased in Eng-
land and Wales from 1 in 5,646 in population in 1840 to 1 in 403 in
1894. The proportion of deaths from cancer to those from all other
causes in 1840 was 1 to 129, and in 1894 it had increased to 1 in 23.
In the city of New York, in 1890, the death-rate from cancer was
1 to 1,679 in population; in 1900 it had increased to 1 in 1,394 (statistics
compiled for the author by Dr. Roger S. Tracy). Parke (The Practi-
tioner, 1899, p. 378), in discussing this rapid increase in malignant dis-
ease in the State of New York, says: " If for the next ten years the
relative deatli-rates are maintained, we shall find that ten vears from
now — viz., 1909 — there will be more deaths in New York State from
cancer than from consumption, smallpox, and typhoid fever combined."
This alarming prophecy has practically come true in the adjoining State,
New Jersey, the authorities of which have recently announced that
deaths from cancer during the year 1900 were more than those from
either tuberculosis or typhoid fever. Newsholme (The Practitioner,
760

MALIGNANT NEOPLASMS— CARCINOMA AND SARCOMA 761

1899, p. 370) attempts to prove that this increase is more apparent than
real. He practically admits, however, that modem methods of examina-
tion and improved diagnostic means will account for only a very small
proportion of the increase. It is an incontestable fact that the disease
is becoming more and more prevalent, and bears dach year a larger and
larger proportion to the general mortality.

Two other facts which are equally as discouraging appear to be
clearly proved by the statistics upon this subject. First, the increase
is most noticeable in the civilized and prosperous districts; and, second,
the death-rate in proportion to the cases observed has shown no material
reduction. Modem science has developed no immunizing or preventive
means to check the onward march of this most fatal malady. State
and national health boards have devised all sorts of quarantine and
other methods for the control of typhoid fever, tuberculosis, and other
contagious diseases, but no practical steps have been taken with regard
to cancer, if we except the State of New York, in which there has been
recently established a fund for the study and development of methods
for its cure.

Seat of the Disease, — Carcinoma may develop in any tissue or organ
of the body where epithelial cells are found. Certain locations, such as
the mammse, the uterus, and the skin, are particularly prone to be at-
tacked. The older statistics of Williams (The Lancet, London, 1884,
vol. i, p. 934), Jessett (Cancer of the Alimentary Tract, London, 1886,
p. 238), and Leichtenstem (Cyclopaedia of the Practice of Medicine,
1877, vol. vii, p. 635) show that 3 per cent of all cancers occur in the
rectum, and that 80 per cent of all those found in the intestine are
located in this organ. More recent statistics, however, show a some-
what higher percentage of the neoplasms in the rectum. Zemann
(Bibliothek d. medicin. Wissenschaften, Bd. iii, H. 1 and 2, S. 49) found
in 21,624 autopsies at the Vienna General Hospital 1,744 cancers. Of
these, 912 involved the digestive tract, 9 of which were in the small,
and 156 in the large, intestine. Of the latter, 30 were in the sigmoid
flexure and 81 in the rectum. Heimann found in 20,054 patients who
died of cancer in the general hospitals of Prussia that 10,537, or over
50 per cent, involved the gastro-intestinal tract. Of these, 2,910 were in
the intestine, 1,204 being confined to the rectum. Combining the figures
of Heimann, Zemann, Kronlein (Deutsch. Zeitsch. f. Chir., 1900, S. 53),
and De Bovis (Revue de chirur., Paris, 1900, tome i, p. 679), we find that
in a total of 45,906 cancers, 2,177, or 4.8 per cent, occurred in the rectum.
If we add to these the cases occurring in the sigmoid flexure, the per-
centage is raised to 6.2 per cent. From these figures one must conclude
that cancers of the rectum and sigmoid form a somewhat larger per-
centage of the total than is generally admitted.

762 THE ANUS, RECTUM, AND PELVIC COLON

The site in these organs at which the disease occurs most frequently
is somewhat difficult to determine. For the purpose of studying this
feature the organs may be divided into four portions — the anal the
infraperiinneal, the supraperitoneal, and the sigmoidaL The anal portion
includes all that part of the rectum below the internal sphincter; the
infraperitoneal portion extends from the internal sphincter to the tip
of the coccyx, and is about 2 inches in extent; the supraperitoneal por-
tion extends from the tip of the coccyx to the recto-sigmoidal juncture
opposite the third sacral vertebra; and the sigmoidal portion from this
point to the lower end of the descending colon.

In a collection of 1,029 cases of cancer in these organs, the disease
was located in the anus and rectum 901 times, and in the sigmoid
flexure 128 times. Of those in the anus and rectum, the seat of the
disease has been quite definitely stated in 602 cases. The anus was
chiefly involved in G.7 per cent, the infraperitoneal portion in 26.3 per
cent, and the supraperitoneal portion in 67 per cent. In many cases,
however, two or more portions of the gut were involved in the same
growth. The following table, compiled from 32 personal observations
(27 carcinomas and 5 sarcomas) shows the proportionate frequency with
which different portions of the organs are chiefly affected:

Number'of cases.

Percentage.

Anal Dortion

3
6

18
5

9 . 4 per cent.
18.7

Infraperitoneal portion

Supraperitoneal portion

56.2 *

Sigmoidal iK)rtioii

15.6 "

In all but 7 cases the recto-sigmoidal juncture was involved to a
greater or less degree in the disease.

These figures are practically in accord with those of Quenu and
Hartmann (op. cit,, vol. ii, p. 120), who insist upon the frequency with
which carcinoma involves the supraperitoneal portion of the rectum.
This fact is of great importance, for it demonstrates that a ver}' large
proportion of cancers of the rectum can not be extirpated without open-
ing the peritoneal cavity, and that, while many involve the lower por-
tion of the organ, very few of them are confined to it.

The types of neoplasms found in these various sites may be stated
in a general way as follows: The squamous or pavement epithelioma is
found in the anal portion; adeno-carcinoma and medullary cancer are
found in the infraperitoneal and in the lower portion of the supraperi-
toneal areas; medullarv and scirrhus carcinomas are chieflv found in
the supraperitoneal portion and in the sigmoid flexure. These rules are
not absolute, however, as we may occasionally find cylindrical epithelioma
or medullar}^ cancer in the anus, and, as Quenu and Hartmann state,

MALIGNANT NEOPLASMS— CAECINOMA AND SARCOMA 763

squamous epithelioma may be found high up in the rectum following
prolonged chronic proctitis.

Etiology. — The cause of cancer is one of the most mooted questions
in all surgical pathology. After centuries of discussion it is yet unsolved.
Age, heredity, occupation, climate, locality, diet, mechanical and chem-
ical irritants, animal and vegetable parasites, have all been accused of
producing the disease, and yet pathologists have not been able to settle
upon any of them as the exciting factor. Certain of them seem to have
a predisposing influence, but no one can positively be shown to produce
the disease.

Recent statistics seem to show substantial ground for belief in the
parasitic origin of the disease, and yet many of the most careful and
logical observers hold that the observations upon which this theory is
based are open to so much criticism that nothing has yet been proved.

Heredity. — The influence of heredity in the production of cancer is
firmly grounded in the popular mind. The fact that the disease occurs in
the same family more or less frequently lends color to this belief. In
comparison with the number of cases observed, the instances of hered-
itary taint are very few; especially is this true if the comparison is
confined to the direct relationship between parent and child. Very
often the evidence of heredity is based upon the fact that some distant
relative, such as an aunt or a cousin, third or fourth removed, has at
some time in the past suffered from this disease. The fact that the
malady is one of middle or later life would contraindicate the hered-
itary influence, for it seems impossible that an inherited taint should
lie dormant for forty, fifty, or sixty years and then suddenly become
active at a time when all the vital processes are in a state of decline.

In recent years a number of cancers have been seen in comparatively
young people, and among these heredity seems to be somewhat more
clearly established. In 5 cases observed by the author under twenty-five
years of age, 4 of them gave a very clear history of direct heredity in the
fact that one of the parents in 3 cases had died from cancer, and in
the fourth a grandmother and brother had both died from the same
disease. In the fifth case the patient lost his parents very early in life,
and could therefore give no information as to the cause of their death
or his own hereditary tendencies. Quenu and Ilartmann have observed
this same fact with regard to young people. Stierlin established hered-
ity in 12.5 per cent of his own cases, and Heuck in 4.6 per cent. Eecog-
nizing the fact, however, that cancer is particularly prone to develop
in certain regions, and that generation after generation of the same fam-
ily are born and reared in these districts, it is more rational to assume
that the cancer is due to some local influence connected with the soil
or water than to heredity.

764

THE ANUS, RECTUM, AND PELVIC COLON

Age, — Age has always been considered a predisposing cause to cancer.
Its maximum frequency is between forty and forty-five years in all sta-
tistics, but it is found at almost every age. The following table, com-
piled from tRree sources, exhibits this fact remarkably well:

Finet's colIecUon.

Qu^DU aod Hartmanii*8
personal cases.

Author's <mn«etias.

Under 20

• •

I 25

• •

Prom 20 to 25

From 25 to 30

From 30 to 35

Prom 35 to 40

Prom 40 to 45

Prom 45 to 50

Prom 50 to 55

From 55 to 60

Prom 60 to 65

From 65 to 70

From 70 to 80

The decreasing frequency of the disease after sixty years of age may
be attributed to the comparatively small number of people living at
this age.

With the increase of cancer, however, it is observed more and more
in young people. In the vital statistics of New York city for the yetr
1900 there were reported 6 cancers in patients between five and ten
years of age, 4 in those between ten and fifteen, 6 in those between fif-
teen and twenty, and 20 in those between twenty and twenty-five. The
author has observed within the past two years 7 cases of carcinoma
of the rectum and 3 of the sigmoid flexure in patients under thirty
years of age. Schoening (Deutsche Zeitschr. f . Chirur., 1885, Bd. xiii,
and Annals of Surgery, 1885, vol. ii, p. 343) has collected 13 cases
of cancer in individuals under twenty years of age. Allingham and
Czerny have each reported cases in children of thirteen years. Maj
has reported 1 in a child of twelve and Godin 1 in a child of fifteen.

In the cases observed in children, it has appeared to be not so mud
a question of age in years as age in tissues. Where there is a tendenqr
to early retrograde processes in the animal economy, where the patient
matures prematurely, carcinoma is likely to develop early in lif^. In
all the cases in which the disease has been observed bv the author below
thirty years of age, there have been evidences of premature decay in the
patient, such as gray hair, parched and wrinkled skin, loss of suppleness
in the joints, and^ obstinate constipation with dry, hard stools. It is a
question, therefore, whether the modem stress of life may not tend to
an earlier retrograde movement in the tissues and consequent develop-
ment of carcinoma. Certainly, the proportion of cancers occurring be
low the age of thirty-five years has greatly increased, and this seems
to be the only rational explanation of it.

MALIGNANT NEOPLASMS— CARCINOMA AND SARCOMA 766

Sex. — While cancer in general is incontestably more frequent in
women than in men, that in the rectum is undoubtedly more frequent in
men. Kronlein, Brandt, Stierlin, and Quenu and Hartmann found that
€6 per cent of cancers of the rectum occur in males. In Finet's statistics
63 per cent were foimd in males. Williams found the disease in 130
males and 129 females, but his experience is exceptional. In the cases
collected by the author, 60 per cent were in males. This does not include
cancers of the sigmoid flexure, of which 80 per cent were found in men.
No satisfactory explanation is given of this fact. Those who believe in
mechanical and chemical irritants as the exciting cause of carcinoma
attribute the frequency of the disease in the generative organs of women
to the frequent traumatism to which these parts are subjected. This
same school claims that the preponderance of carcinoma of the intestines
in men is due to coarser diet, more rigorous life, dissipation, and con-
stant traumatism to which the intestines are subjected by straining at
heavy labor and athletic exercises.

The influence of constipation and the resting of the faecal mass at
certain portions of the intestinal canal would seem to have some influ-
ence in the production of the disease, inasmuch as those portions of the
gut at which the mass is arrested are by far the most frequently affected.
This theory, however, meets an offset in the fact that women are pro-
verbially more constipated than men, and therefore we would expect
to find cancers of the intestines more frequently in this sex, whereas
the opposite is actually found.

The parasitic theory of disease offers a more acceptable explanation
of these figures. Men travel very much more widely than women. They
are subject to the influence of changing climate, soil, and waters, and
are therefore more frequently exposed to whatever infectious or con-
tagious elements these may possess. If this theory as to the etiology of
cancer is proved, it will easily explain the preponderance of intestinal
cancer in the male sex; at the same time it will cast just as much doubt
upon the cause of its frequency in the generative organs of women.
The fact that men suffer more frequently than women from cancer of
the rectum is established, but why we do not know.

Occupation, — Vocation is frequently spoken of as a predisposing
cause to cancer, chimney-sweeps being cited as marked illustrations of
the fact. Experience and the studies of Newsholme (The Practitioner,
1899, p. 370) convince us that occupation has, if any, a very slight eti-
ological influence in the disease.

Previous Diseases. — The influence of previous diseases of the intes-
tinal canal in the production of carcinoma seems to be well established.
Volkmann, Qu6nu and Hartmann, and Stierlin claim that 15 per cent
of all carcinomas of the rectum are preceded by haemorrhoids. These

766 THE ANUS, RECTUM, AND PELVIC COLON

figures, however, are not convincing, for it is an established fact that
15 per cent of the individuals suffering from any class of diseases known
to human nature are affected with piles. Dysentery, colitis, and ulcer-
ative diseases of the intestinal canal have been frequently known to
precede the development of cancer. Prolonged irritation of the epi-
thelial tissue in these organs, as in the lip or throat, will no doubt eon-
tribute to the development of the disease, and this may be induced by
constipation of long standing or the lodgment of a foreign body at some
portion of the canal. While it is stated farther on that constipation
is one of the first symptoms of cancer, may it not be that cancer is the
last symptom or result of constipation? Multiple polypi, adenoids, and
villous tumors frequently precede the development of cancer, and in
one instance the author has seen the neoplasm develop in a syphilitic
rectum. Mucous or membranous colitis is frequently a precursor of
rectal cancer, and thus derives a greater importance.

Histological Types. — There are four elementary types of cancer
found in the anus, rectum, and sigmoid, viz., epitheliomatous, ade-
noid, medullary, and scirrhous carcinomas. All of these are subject
to colloid, myxomatous, mucous, cystic, and ulcerative changes which
alter their clinical, macroscopic, and histological features to such an
extent that the modified neoplasms are often described as distinct
types. These subdivisions only serve to confuse the reader, and the
author will confine his descriptions to the simple. types enumerated
above.

From the point of view of malignancy, cancers found in these parts
may be mentioned in the following order: medulla^, adenoid, epitheli-
omatous, and least of all scirrhus.

Carcinomas are all composed of two essential elements, the epithelial
cells and the stroma, the latter forming series of alveoli in which the
former rest. The different varieties are distinguished by the character
of the cells and amount of stroma. The epithelial cells are of the embry-
onic type, and of every shape and form — squamous, cylindrical, oval,
caudate, round, etc. They contain single or multiple nuclei, with prom-
inent nucleoli. The character of the epithelium is usually that found
in the tissue in which the carcinoma develops; the shape of the individual
cell, however, is governed largely by the pressure to which it is exposed
in the alveolus.

Cancer begins by the epithelial cells invading the lymphatic spaces^
which they distend so as to form alveoli, but do not attach themselves
to the fibrous walls. The stroma is composed of the fibrous or myxoma-
tous tissue of these spaces containing more or less of the histological
elements of the parts in which the growth is found. In the rectum it
frequently contains tubules, follicles, and unstriped muscular fibers; it

MALIGNANT NXOFLASHS— OARCINOMA AND SARCOMA

767

reaches its highest development in slowly growing tumore, such aa scir-
rhua. and its lowest in the fulminating variety of neoplasms, such as
medullary cancer. The alveoli, which connect with each other, are the
original lymph spaces of the tissue, and are therefore freely connected
with the lymphatics of the parts. This fact accounts for the spread of
the disease along the lymph channels. The blood-vessels and nerves
ramify in the stroma, but they do not enter the alveoli, hence the dis-
ease seldom follows these tracts.

EpUhdioma (Squamous Epithelioma, Skin Cancer). — The term epi-
thelioma is often applied to all types of cancer. In this work, however,
it will be limited to
the squamous variety,
which occurs chiefly
at the muci
neous margin of tlie
anus. Histologically
the growth is charac-
terized hy the pres-
ence of cuboidal or
flat epithelial cells ar- "' ;_
ranged in concentric p
layers. A transverse
section of these
masses exhibits the
so-called epithelial
pegs or nests (Fig.
249). When the cen-
tral portion of the
epithelia undergo fat-
ty degeneration
(Heitzinann) or liiin!
ening (Coplin), piu.
shining, irre^zii, .
masses are produced
known as the cancer
pearls. These pearis
are also seen in other
pathological condi-
tions, and are not
therefore pathogno-
monic. The epithelial cells invade the lymph spaces from the surface.
The stroma is comparatively slight, and is composed of connective tissue,
partly fibrous and partly myxomatous, in the specimen shown. It con-

FiD. 249.— ErirnKUOMA. (MiiKHiaed 300 diunetsra.)
ipilhellnl next with uonceatric iirrangutnunt nf Bpltbsliai E,
epithelial peg; F. oarer pearl; C. connective timue *ith
inflamiiuitorT ourpUKclcs ; B, blood-vesael.

768

THE ANUS, RECTUM, AND PELVIC COLON

>, and is iufi)trated with inflam-

^^^

tains a moderate number of blood-
matory corpuscles.

As clinically observed, epitheUomas are largely confined to the anal
margin. They begin as slight nodular elevations in the skin or jast
beneath the epithelium, over which the skin ia not movable. WTien fully
developed they appear as irregular wart-like elevations with indurated
bases. The ulcers may discharge a watery or ichorous fluid; thev have &
diritinet tendency to scab over, and each time the scab drops oft the ulcer

increases in circuiii'

es^ r ^/-H-T--. J ^1^^^^) f^rence. Around tha

cdftes of the ulceratioD
distinct nodules
ob.scrved. The rourso
of the neopli
'iurround the anus and
extend into the skttt
of the pcrinsum aai
vacnim rather than op
into Ihe rectxim. The^
tissues around the ul-
always indu-
rated, but, as CopIlB
says, '' this iuduralioii
does not limit the ex-
tcut of the tumor."
The growth and ex-
tension of tliL-so neo-
])lasms is very slow.
Squamous <<pitheli
mas are soinkaimtM
very painful, at others
not at all so; they
casionally bleed slight-
ly from traumatism or
abrasion, but rartlv if
ever occasion severe
haemorrhages; thoyare
distinguished from n>-
and excessive graDulationa

Fio. Wi>.— Adixoid Canl-ir. (Magnifled BOO diamuluni.)
EE, mnvoluted epitheliul Uactn eucloHiDg culibora of varyltiK
dluueton: CC,canii«ctlvotissijii crowded iritti inflDmmii'
toiy corpusclea; BB, Uood.vasBela.

dent ulcers by the nodular, elevated
(Plate VI, Kig. 2).

Adenoid Cancer (Cyliiidrical or Colvmnar E pilhelioma : Malifttaid
Adenoma). — This ia the most frequent variety of cancer in the rectum
proper. It consists of tubular cavities of irregular form arranged in

MALIGNANT NEOPLASMS— CARCINOMA AND SARCOMA 769

manifold convotutiona, and lined by cylindrical or columnar eyithetium.
The tubules are separated by a fibrous or myxomatous stroma; tiie convo-
lutions are arranged in groups; the epithelia are similar to those lining
the Lieberkiihn follicles
arranged at right angles
to the stroma and possess
no basement membrane:
they are short, nucleated,
and in many places
broken up into medul-
lar)' corpuscles which
partly or completely fill
the caliber of the tubules
<Fig. 250). The stroma
is infiltrated with these
corpuscles, and contains
comparatively few blood-
vessels. The more rapid
the growth, the more
atypical is the glandular
formation and the small-
er are the cells and lu-
mina.

Clinically these
growths appear as soft,
sometimes gelatinous,
elevated, lobular masses.
Upon squeezing or sec-
tion they exude a watery
secretion — the so-called
cancer juice — which,
dropped into water,
turns milky white. They may grow very rapidly and protrude into the
rectum to such an extent as to obstruct its caliber; they are associated
with abundant discharge of mucus, and often bleed very freely.

Early metastasis is the nile, especially in the liver, and the secondary
nodules possess the characteristics of the primary growths. They are
distinguished from simple adenoma by the irregular arrangement of the
cylindrical cells and the absence of a basement membrane, but the fact
that simple adenoma may undergo transformation into adenoid cancer,
renders it very difficult to make a diagnosis between them. Certain
tumors on the border-land between the two often exhibit the char-
acteristics of benign adenoma in one portion and indubitable carcinoma

NN.

ru. (Ui«i>ifliHl 400

ncOT epithelU; 0. remnant of ilniid; T,
conneotive tiMue croirdtid wllh Inflatiimatory corpui-
cIcb: S. blgod.vcMcl.

770

THE ASrS. RECTUM, AND PELVIC COLON

in another. Small sections of such growths are therefore unreliable I
the making of positive diagnoses. On this account it ig always best to
treat them as if they were well-developed carcinomas.

Medullartj Cancer {Sofl Cancer, Encephaloid Carcinoma). — -This is
the most malignant of all types of rectal carcinoma. It consists in &
soft, pulp-liiii growth characterized by large ami irregular epitheha,
coarsely granular and multinucleated, with scanty stroma, fibrous in its
character and di'Dsely infiltrated with inflammatory corpuscles. The
epithelia are arranged in an irregular manner, sometimes in nests (Fig.
251); the alveoli are large; the stroma is often embryonic or myxomatous
in character, and is abundantly supplied with blood-vessels. Clinically
the growth occurs in the
•*' -' ' ^ ^ — _ T-iftiim as a soft, nodular

. I lilting mass, sealed up-
fir surrounded by dense
ilMiiius tissue. It bleeds
easily upon touch, discharg-
es abundant pus, grows rap-
idly, and soon involves the
nuiyiiboring organs. It oi^
dinarily occurs earlier in
ife than scirrhus, but it
may result from degenera-
tion of the latter. Glandu-
lar involvement is earlier
than in any other form of
cancer, although remote
'■ I lawtiitic deposits are not
fri'<iuent as in adenoid
I' iT owing to the fact
It it usually kills before
■ -1' take place.
Srirrhuus Cancer {Ft--
iinnis Carcinoma, Hard
Cancer, Acinous Cancer). —
This type of careinonis is
the least frequent and
slowest growing of all can-
cers of the rectum. It is
composed of dense fibrous
stroma and epithelial cells. The stroma is so arranged as to form a aeries
of alveoli which contain the epithelial cells (Fig, 252), The alveoli are
small, and f he epithelial cells are atrophiid, compressed, or degenerated.

Fia. Sfit.— SomiiHUB ur Ihtkbtink. (Mvulfled Sm

diameton.)

CT. derue. flbroiu Ntine«tlvo tlMoe; A. alveoli fllled

with «ii(wr eliitliKlli : a cIUBter of conni.-cMve-tis-

■ue oorpuwle*: £, rov of vancur ei)itlieliu; B,

blood-vo«el«.

MALIGNANT NEOPLASMS— CARCINOMA AND SARCOMA

771

iser port inns of the tissue,
f which are thickened and

There are few blood-vessels in the

but more in the periphery, the walli

more or less fibrous. On

being cut, the tumor pre

seiita to the naked eye the

appearance of a bluish

white gristly mass, con

taining here and there

patches of fatty tissue,

which are more numeroub

near the center of the tu

mor. If the cut is made

through the center of the

growth, the central part of

the cut surface will ri

tract, causing a cup-like

depression, constituting the

so-called cancer cup.

Clinically these tumors
appear in the shape of a
gradually contracting stric
ture of the organ. Thei
cause no pain, very littk
discharge, and no hsemor
rhages from the rectum
Gradually increasing and
intractable constipation ia
the salient feature. Ca-
chexia and sepsis are prac-
tically absent, and unless
the tumor is transformed
into acme other type, the
final end occurs through intestinal obstruction or rupture of the gut
above the growth,

Scirrhus ia subject to hyaline, mucoid, colloid, and fatty degenera-
tions. The chief change to which it is prone is transformation into
medullary carcinoma. ifelanoBia has been observed, and calcareous in-
filtration of the tumor is not infrequently seen. Coplin has described a
type of atrophic scirrhus in which the fibrous tissue predominates, and
the epithelial cells are therefore pressed upon and often disappear from
many areas of the growth. Under such circumstances the tumor grows
smaller instead of larger. These growths, however, have not been ob-
served in the rectum.

(MngnlHed SSO dlaiueten> )
F, coiuiective.tiiieue IViuiiiiwork , £, cancer opllhuliu
pkitlf filling ulveolua; C. HlveoluB flilud with col-
loid aubstince, a, number of eplChella onobaiiKed :
C T. oonnBcrtve tianiu with medullary corpusclBB ;
JV, mealullary conniHcloa; M'. iiicdu1tiir7 corpuncles
dumging to colloid aubatatiw.

772 THE ANUS, RECTUM, AND PELVIC COLON

Colloid carcinoma may develop from any of the four types which we
have ahove described. It consists in a degenerative change in the epi-
thelial cells and in the stroma (Fig. 253). When the substance that dis-
tends the alveoli is more viscid than gelatinous, it is called mucoid de-
generation. It is said that the colloid change occurs in the cell itself,
the mucoid in the intercellular substance. Chemically these two condi-
tions may be distinguished, but clinically they can not. As Coplin
says: " Until our methods of differentiation become more accurate and
we know more of the evolution of mucoid and colloid carcinoma, it
would probably be best to consider them both under the head of gel-
atinous or gelatiniform types of cancer."

Symptoms. — The s}'mptoms of cancer in these organs depend upon
the stage of the disease, the type of neoplasm, and its site in the canal.
In all carcinomas which do not result from the transformation of other
tumors or pathological conditions, there is a latent period in which no
symptoms appear that can not be accounted for by other causes. The
local and constitutional manifestations at this period do not in anv
wise indicate the serious nature of the disease. The existence of cancer
is therefore compatible with a perfect state of health for considerable
periods of time. Frequently patients with well-developed carcinomas
of the rectum or sigmoid recall that for long periods they have noticed
vague, indefinite discomforts in the regions of the sacrum or aroimd the
pelvis, with increasing constipation or a tendency to diarrhoea and some
slight derangements of the digestion, none of which were severe enough
to attract any particular attention. Gradual loss of strength, increased
pain, or unusual bleeding from the rectum induces them to consult a
surgeon. Ordinarily the disease is well developed before this, and it is
absolutely impossible to state just when or how it began.

The fact that the first manifestations of carcinoma may be a vague
discomfort in the pelvis, symptoms of intestinal or gastric indigestion,
constipation, or a colicky tenesmus, with or without the passage of mucus
and flecks of blood, emphasizes the importance of early local examina-
tions in patients with such symptoms. It is not suflBcient to introduce
the finger 3 or 4 inches into the rectum and, if no neoplasm or patholog-
ical condition is observed, exonerate the rectum and the sigmoid from
any part in the production of these symptoms. A more careful and
extensive examination is necessary. By the pneumatic proctoscope
and specimen forceps (Fig. 254) it is possible to bring into view
and take sections from every portion of the sigmoid flexure and de-
termine almost in the earliest stages of this disease its existence and
its site. The author has by this means diagnosticated and afterward
removed 5 carcinomas of the sigmoid flexure in which frequent digital
examinations and abdominal palpation had failed to determine any path-

MALIGNANT NEOPLASMS—CARCINOMA AND SARCOMA 773

ological condition to account for the diarrhoea and constipation. In the
early stage, where the carcinoma is within reach, it may appear as a
small plaque-like deposit beneath the mucous membrane of the rectum,
slightly movable upon the muscular wall, and decreasing the supplene^
of the tissues. These deposits are chiefly found in the anterior and pos-
terior segments of the circumference, although they are occasionally
seen in the lateral segments. They involve only a small portion of the

Fio. 254. — RxoTAL SpKcufEN Forceps.

circumference, and have a tendency to extend in all directions. Such
deposits generally indicate the development of adenoid or medullary
cancer.

In other cases the first appearance of the disease is in the shape of
little papillary excrescences protruding into the rectal caliber, but con-
nected with the mucous and submucous tissues by an indurated base.
These tumors always result in adenoid cancer. They bleed easily from
the beginning, and can be clearly seen through the sigmoidoscope. In
the first or plaque-like form, ocular examination reveals only a slightly
congested, thickened, and smoother condition of the mucous membrane
over the deposit. In scirrhus one observes in an early examination a sort
of annular deposit in the submucosa resembling very closely a simple
fibrous stricture of the gut. It is almost impossible to diagnose car-
cinoma of this type in the latent stage. The symptoms are those of
obstipation, gradually increasing, with or without bloody or mucous dis-
charges. The history of the case may be of diagnostic importance, for
inflammatory strictures are nearly always preceded by some traumatism,
ulceration, and suppuration, whereas this type of carcinoma is not ordi-
narily preceded by such processes. While in this latent period the diag-
nosis of malignant disease is often quite uncertain, wide clinical experi-
ence and careful observation over certain periods of time will enable
one to recognize the condition before it arrives at an incurable stage.

In the active or proliferative stage the symptoms are more marked.
In scirrhus or annular carcinoma, which is chiefly met with in the upper
rectum and sigmoid, gradually increasing constipation is the typical
symptom. There may be colicky pains in the stomach or upper portions
of the intestine, aching in the sacral region, and occasionally there is a
sharp, cutting pain at the seat of the growth. As a rule, however, pain
is not a prominent feature at this period or in this type of the disease.

774 THE ANUS, RECTUM, AND PELVIC COLON

A slight mucous discharge, occasionally tinged with flecks of blood,
appears in this stage, and there may be an accumulation of gases in the
intestine causing tympanites. As the growth increases and the caliber
of the gut is more and more encroached upon, obstruction to the faecal
passages becomes more marked, friction is more noticeable, and the
amount of blood in the discharges becomes more abundant.

At this time a certain amount of procidentia or intussusception of
the affected into the lower portion of the gut will occur. This practically
produces a procidentia of the third degree, in which the neoplasm forms
the lowest portion of the prolapse, and around it there exists a circular
cul-de-sac or sulcus into which the finger or bougie will slip instead of
into the caliber of the gut. Examination with the proctoscope under
these circumstances exhibits a mass in the center of the intestinal caliber
resembling very much the cervix uteri. The lumen of the gut at the
strictured point usually appears as a lateral slit, and the mucous mem-
brane may or may not be ulcerated according to the stage of the disease
and the amount of traumatism to which it has been subjected by the
passage of hard faecal material. When within reach such a growth im-
parts to the finger the sensation of a dense, inelastic, nodular mass, in
the center of which there is a greater or less lumen. With the finger
of one hand in the rectum and the other pressing down upon the
abdomen, such growths may sometimes be brought within reach, whereas
they can not be felt by the ordinary methods of digital examination.

The adenoid or medullary cancer presents an entirely different pic-
ture in this second stage. Constipation may or may not be one of its
features. Exasperating, frequent calls to defecate, resulting in the
passage of small amounts of gas and mucus, with or without blood, are
the principal symptoms. The patient may have to attend the toilet
fifteen or twenty times a day and as many times at night, and yet have
no satisfactory movement. Ordinarily this tendency to diarrhoea is
quiescent during the night, but the patient must repair to the toilet
immediately upon rising in the morning. This constitutes what is
ordinarily knoi^Ti as morning diarrhcea, and it is one of the most char-
acteristic features of malignant disease of the rectum and sigmoid.
The first one or two passages after the patient arises consist in nothing
more than mucus, blood, and pus; after this the patient may have a
very satisfactory faecal movement, and then during the rest of the day
he is annoyed by the teasing, unsatisfactory calls to stool. • The haemor-
rhages may be constant and slight, or periodical and exhausting; the
blood is sometimes black and decomposed, at others bright red. In the
first instance it generally comes from neoplasms of the sigmoid or high
up in the rectum; in the latter from those in the ampulla or sub-
peritoneal area.

MALIGNANT NEOPLASMS— CARCINOMA AND SARCOMA

775

Pain in these cases is marked. It may be intermittent or constant;
dull, vague, and shooting through the pelvis or down the extremities,
or it may be sharp, stabbing, or burning. It is often influenced by
posture. Some cases are only comfortable when lying down, others can
not sit with any comfort, and still others are more free from pain when
standing up. It may only occur at or after defecation, but in certain
cases this function seems to have no influence upon it. In cases in
which the sphincters are involved, the pain is ordinarily greater than
where the cancer is higher up. In these instances incontinence of fieces
is sometimes noted, owing
to the infiltration of the
muscle and its consequent
inability to contract.

Constitutional symp-
toms, such as loss of appe-
tite and weight, anjeniia,
rapid heart action, and in-
creasing sallowness of the
skin, begin to manifest
themselves at this period,
and local examination ex-
hibits a variety of con-
ditions. Sometimes u
amooth, hard, lobulated
mass protrudes into the
rectum, involving the en-
tire circumference of the
gut, and almost occluding
its caliber; at others the
mass is equally as promi-
nent, but attached to a
limited portion of the cir-
cumference. Sometimes the

finger comes in contact with a proliferating cauliflower-like growth,
slimy to the touch, and between the lobes of which it can be in-
sinuated; at other times there is no protrusion into the gut, but a
distinct narrowing of its caliber by an indurated deposit extending
around the gut or involving only a portion of its circumference, in the
center of which is a deep, excavating ulcer, the edges of which are sharp,
hard, and scalloped (Fig. 255).

In the medullary type the symptoms are more severe, the pain is
greater, the discharges more profuse, the loss of flesh and strength more
rapid, and the involvement of neighboring organs occurs at earlier peri-

776 THE ANUS, RECTUM, AND PELVIC COLON

ods. Digital examination in these eases reveals a dense ulcerated mass,
the edges of which are sharply defined and surround a deep crater-like
cavity. Occasionally the finger comes in contact with a soft, pulpy,
brain-like mass, more or less isolated, friable, and easily breaking down
upon pressure. Finally, one observes at times a moist, slimy, soft con-
dition of the mucous membrane, accompanied by a fluctuation in the
walls of the gut, together with a distinct reduction in its caliber. All
of these conditions are associated with a foetid, gangrenous, disgust-
ing odor, which AUingham states is pathognomonic of the disease. The
proctoscope reveals the appearance of these conditions in a remarkable
manner, and in sites in which it is impossible to feel them with the
finger. It may show in the adenoid variety a smooth, lobulated tumor
protruding into the rectum, covered by dark-red congested mucous mem-
brane with enlarged veins and bathed in viscid mucus, or a condyloma-
tous growth, grayish-white in its appearance, secreting a muco-purulent
fiuid and bleeding easily upon touch. In medullary cancers it exhibits
a dense, irregular, ulcerated mass protruding into the rectum, or a deep,
excavating ulcer, with sharp, well-defined borders and bright-red prolif-
erating granulation, or dull, grayish, and sloughing. Finally, in the
gelatiniform or colloid types one sees a grayish or bright-red oedema-
tous mucous membrane, lobulated or elevated at points by nodules under-
neath, and secreting an abundant sanious mucus.

In the third or degenerative stage, the symptoms are all more marked.
The digestion is exceedingly deranged, the anaemia becomes excessive,
the skin is pale, dry, parchment-like and covered with fine silvery scales.
General debility progresses, and the countenance of the patient exhibits
an anxious, foreboding appearance. The haemorrhages become more
frequent and abundant, the diarrhoea is more distressing, and the faecal
passages less satisfactory. The pains are more acute and more constant,
the mucous discharges are supplanted by excessive purulent secretions,
and the odor from the parts becomes more and more offensive. On the
whole, the patient presents a typical picture of mild septicaemia.

With these one observes in this stage other symptoms connected with
the different organs of the body, such as the genito-urinary, glandular,
and secretive organs. Anuria and dysuria are very frequent complica-
tions, either constant or periodical. The total suppression of urine may
occur through involvement of the ureters or of the kidneys themselves.
Irregularities of the menstrual functions are frequently observed, and
hepatic derangements are among the most frequent complications. Ab-
solute obstruction of the intestine rarely if ever occurs from carcinoma
of the rectum itself. This may be due to the amplitude of the rectal
ampulla, to the marked tendency of growths to ulcerate in this portion,
or, finally, to the fact that the parts are most directly influenced by

MALIGNANT NEOPLASMS— CARCINOMA AND SARCOMA 777

enemata. In the writer^s opinion^ it is chiefly due to the fact that the
types of cancer which occur most frequently in the rectum (adenoid
and medullary) are soft and compressible or friable, and they degen-
erate or ulcerate chiefly upon the surface, thus keeping the caliber of
the gut open. He has never observed a case of complete obstruction
from carcinoma of the rectum. On the other hand, this accident is
always imminent in carcinoma of the sigmoid flexure, owing to the fact
that the type of growth which occurs in this location is often scirrhus,
which does not ulcerate or degenerate easily, but constantly and per-
sistently contracts the caliber of the gut in which it occurs. The ob-
struction even here is not usually absolute, but due to the impaction of
some foreign body or hard faecal mass in the narrowed caliber. Above
and below carcinoma in the intestine the wall of the gut is inflamed
and very thin. Ordinarily marked ulceration is found above the
stricture, and it is at this site that rupture or perforation takes place,
if at all.

Aside from the reflex disturbances of digestion referred to hereto-
fore, there are other complicating symptoms which arise in the course
of carcinoma of these organs; among these auto-infection or mild septi-
caemia is the most constant. This may be brought about by retention
and putrefaction of faecal material above the neoplasm, or it may be
induced by traumatic lesions of the mucous membrane from the passage
of hard faecal material, which lesions become infected. In the first in-
stance this sepsis manifests itself as a sort of malaise with slightly
elevated evening temperature, lack of energy, and loss of strength. In
the second, it occurs as periodical crises with chill, fever, and great
exhaustion. This type resembles very much the sepsis of surgical kid-
ney in its early stages. In other cases perirectal abscesses develop, which
sometimes result in fistula or perforation into other organs, such as the
bladder, vagina, or peritoneal cavity. These cases are also accompanied
with high temperature, chills, and septic symptoms. They have a tend-
ency to result in extensive gangrene and sloughing similar to that seen
in idiopathic periproctitis.

Aside from these septic complications, inflanunatory conditions
around the neoplasm and between the rectum and other organs are
frequently met with. The bladder, prostate, and seminal vesicles may
all become attached to the carcinomatous rectum through inflammatory
processes without being involved in the neoplastic change. The author
has twice removed portions of the prostatic gland and seminal vesicles
in excision of cancer of the rectum, and found that these organs were
entirely free from carcinosis. The same may be said with regard to the
vaginal saeptum. Inflammatory deposit here may cause a matting to-
gether of the walls of the two cavities without any carcinomatous change

778 THE ANUS, RECTUM. AND PELVIC COLON

taking place in the parts; indeed, this saeptum may be perforated through
simple destructive ulceration below the carcinoma. In one instance in
which this took place the author was unable, after various examinations,
to find that the rectum or vaginal wall at the site of the ulcer was in-
volved in the carcinomatous process which existed at a higher leTel.
The peritoneal cul-de-sac may also become obliterated by this perirectal
inflammation; under these circumstances the opening of the cavity dur-
ing extirpation is rendered very difficult. These facts are important,
because they indicate that the attachment of a carcinomatous rectum
to any of these organs is not pathognomonic evidence of their involve-
ment in the malignant processes. Thus, the author has seen 3 cases in
which the rectum, uterus, and ovaries were all removed for carcinoma,
and yet upon the most careful examination no involvement whatever
of the uterine organs could be determined. In two other instances in
which the peritoneal cul-de-sac was obliterated and the rectimi attached
to the uterus, this adhesion was broken up and the rectum extirpated,
and no carcinosis of the uterine organs followed. It is admitted that
all of these organs may be involved by extension in continuity of the
-carcinoma, but adhesion does not always indicate involvement in the
malignant ])rocess.

Lines of Extension, — Carcinoma of these organs extends, by continu-
ity, through the lymphatics, and possibly through the blood. The
lines and method of extension are largely governed by the seat of the
■disease.

In anal cancer the disease usually extends, by continuity in the skin
surrounding the anus, into the scrotum, vulva, vagina, the ischio-rectal
fossa, and sometimes upward into the rectum. Occasionally in these
-cases fistulous tracts develop which are found to partake of the epitheli-
omatous nature of the growth. Lymphatic extension of cancer from this
region travels in the line of the inguinal vessels and glands. Both the
superior and inferior chains may be involved. Quenu and Hartraann
have called attention to the fact that when these cancers invade the
ischio-rectal fossa, they may extend along the line of the middle hasnior-
rhoidal lymphatics, thus involving the hypogastric chain of glands. The
glands always partake of the nature of the original growth, which is
usually squamous epitlielioma in this region, but it may be of the adenoid
type. Occasionally the glands become enlarged and tender through
infection without presenting any carcinomatous changes.

Cancer in the subperitoneal portion of the rectum extends by con-
tinuity to the prostate, urethra, seminal vesicles, bladder, vagina, utenis,
and coccyx (Quenu and Hartmann, Pasteau, Schoening, Leube, Fayard,
Rabe). Ganglionic extension occurs in the retro-rectal and hypogastric
-chains. The lateral vertebral lymphatics may also become involved

MALIGNANT NEOPLASMS— CARCINOMA AND SARCOMA 779

from cancer in this location (Ball, Fayard). In some cases the ureters
seem to become involved through this process, and not by extension
(Fayard, Thesis, Lyons, 1891, p. 60); Babe, Bull. soc. anat., 1898, p.
106; Morefetin, Thesis, Paris, 1894).

Cancer of the supraperitoneal portion extends by continuity to the
bones of the pelvis, to the peritonaeum, and to the uterus, bladder, or
omentum. In one instance, in which the abdomen was opened to deter-
mine the extent of the disease, the whole peritonaeum and greater omen-
tum were studded with myriads of little gelatinoid nodules, which proved
to be colloid cancers. Ganglionic extension from these growths is not
frequent. When it occurs it extends along the antero-vertebral chain,
involving sometimes the hypogastric glands.

Metastatic deposit or generalization of the cancer may occur from
carcinoma in any of these locations. It is not the rule, however. The
liver is the organ generally affected. Whether this occurs through the
blood-vessels or through the lymphatics is not positively known. Hoche-
negg and Rinne (Wiener klin. Woch., 1889, Nos. 26, 27, 28) have col-
lected a number of cases in which this organ was attacked both before
and after extirpation. The author has observed it in 6 cases, 2 of which
were recurrences after operation. The pancreas (Cripps, op, cit,, p. 372),
the lungs (Luys, Soc. anat., February 5, 1897; Quenu and Hartmann,
op, cit., vol. ii, p. 137), the ovaries and skin, the kidneys (Schuh, Ab-
handlung d. Chirurgie und Operat. Lehre, Wien, 1867), and the axil-
lary and subclavicular glands may all become involved. Sometimes the
small intestine becomes attached to the rectum or sigmoid affected with
carcinoma, and may become involved in the growth. The author has
seen one case in which this occurred from carcinoma of the rectum, the
small intestine becoming adherent and involved in the peritoneal cul-
de-sac; and another in carcinoma of the sigmoid, in which both portions
of the intestine were attached to the brim of the pelvis, the periosteum
of which was involved in the growth, together with tlie left iliac ves-
sels. Kirchoff and Beckel (Quenu and Hartmann, op. cit,, vol. ii, p. 139)
have related cases in which this complication has occurred.

Diagnosis. — Carcinoma is not likely to be confounded with any other
condition of the rectum and sigmoid than multiple adenomata, papilloma,
sarcoma, proliferating proctitis, and fibrous stricture. The extreme tend-
encv of the first two to be transformed into, or when removed to recur
in the form of carcinoma, renders it wise to treat them as such in the
beginning. From these facts differentiation in these cases derives a
reduced importance so far as treatment is concerned. For the purposes
of prognosis, however, the neoplasms should be distinguished as far as
possible, for one is much more justified in giving a favorable opinion
in cases in which malignancy has not already appeared than where it

780

THE ANUS, RECTUM, AND PELVIC COLON

has. The distinctive features are briefly enumerated in the following
columns:

Adenoma

Generally in adult life,
but mav occur in children.

More frequent in fe-
males.

Distributed over large
areas, even the entire
colon.

Tumors vary greatly in
size, and rarely coalesce.

They are soft and elastic
to the touch.

Attached to the rectal
wall by a j)edicle or base
of normal raucous or sub-
mucous tissue.

Diarrhcea and hemor-
rhage are the earliest
symptoms.

The odor of the secre-
tions is not unusually of-
fensive.

Papilloma

Occurs in adult and ad-
vanced life, rarely if ever
seen in children.

No predominance in
either sex.

May be single or two or
three in number closely
aggregated.

May attain very large
proportions.

Soft and shaggy or vil-
lous to the touch.

Attached to the rectal
wall very superficially.
The pedicle may be long
and the base indurated.

Discharge a peculiar
gluey mucus. Hapmor-
rhages are irregular and
periodic. Constipation is
more frequent than diar-
rhoea.

Anfemia and physical
exhaustion come on quite
early.

No particular odor.

Carcinoma

Usually in adTanced
life, but may occur in
youth.

More frequent in men.

Is generally limited in
area, but may invohe the
entire rectum.

Base is always indon-
ted, and involves the en-
tire thickness of the gnt

Constipation is the rule
in the early stages ; diar-
rhoea in the later. Mu-
cous discharges precede
those of pus and blood.

Constitutional srmp-
toms appear after tumor
ulcerates.

Extension takes place
by continuity, metastaas,
and through the lymphat-
ics.

Odor 8u% generis.

WTiile some of these symptoms are similar and overlap one another,
to the experienced clinician there is rarely any difficulty in distinguish-
ing the typical growths. In those transitory stages, where the benign
is undergoing transformation into the malignant tjrpe, nothing short of
complete extirpation and thorough examination of the entire growth
can absolutely distinguish one from the other. In doubtful cases, indeed
in all cases, it is wise to remove a section of the growth for microscopic
examination, but one should not place too much confidence in negative
reports with regard to malignancy. The growth may be perfectly be-
nign in that portion from which the section was taken and markedly
malignant in other portions. The fault is not with the methods of ex-
amination or with the pathologist; it lies in the nature of the neoplasms.

MALIGNANT NEOPLASMS— CARCINOMA AND SARCOMA 781

The most prominent and accessible portions of these growths are often
benign, while the deeper portions are absolutely malignant. We main-
tain this from numerous experiences, notwithstanding it is claimed that
the transformation begins on the surface. While, therefore, microscopic
examination is of great assistance in corroborating clinical evidence, it
should not shake the clinical conviction of an experienced surgeon as
to malignancy in one of these cases. The author has removed 5 neo-
plasms of the rectiun which had been pronounced benign from micro-
scopic examination of the sections taken for diagnosis, and has in each
instance found his clinical conviction corroborated by more complete
and thorough microscopic examination of the growth after its removal.

It is important in obtaining specimens for microscopic examination
not to crush them. This can be done by use of nasal scissors (Fig. 256)
or the specimen forceps (Fig. 254). The bite of the latter consists in

Fio. 256. — ScissoBs kmplotbd fob obtainino
SpKoiMKirs OF Rectal Gbowtus.

two elliptical Volkmann spoons, which cut out the specimen and hold it
in the cavity formed by their approximation; the instrument is 12 inches
long, and was devised for operation through the sigmoidoscope. By it
specimens may be obtained from any part of the pelvic colon.

Between carcinoma and proliferating proctitis the diagnosis is not
very difficult, although many of the symptoms are similar. In the latter
there is generally a history or other manifestations of syphilis; the dis-
ease is uniformly distributed throughout the rectum; diarrhoea is present
from the beginning, and the discharge of muco-pus is abundant; there
is little pain, and the protruding granulations are soft to the touch and
without any indurated edges. These sjTnptoms are sufficient to distin-
guish it from carcinoma, but one may still further rely upon the pathog-
nomonic odor in the latter disease.

782 THE ANUS, RECTUM, AND PELVIC COLON

Between scirrhous cancer and fibrous stricture it is almost impossible
to make a diagnosis, except by complete excision and microscopic exam-
ination. The early symptoms of the two are practically the same. In
fibrous stricture there is usually a history of inflammation or ulceration,
but this may also be true in scirrhous carcinoma. Scirrhus rarely occur
in the rectum, and fibrous stricture is quite as rare in the sigmoid. Thus
the site of the disease may be of importance, but it is not absolutely
diagnostic. Where the growth can be easily reached a nodular condi-
tion may be felt in scirrhus which is not present in pure fibrous stricture.
Glandular involvement is sometimes spoken of as a diagnostic symptom,
but this occurs very tardily even in scirrhus. Through the proctoscope
the mucous membrane over scirrhus appears congested, thickened, or
ulcerated; over fibrous stricture it is pale, smooth, shining, and rarely
ulcerated.

The fact that carcinoma may present so few subjective s}Tnptoms,
all of which are explicable by other conditions, emphasizes the impor-
tance of local examination in all cases in which diarrhoea, constipation,
obscure digestive derangements, pain in the sacral region, and discharges
of mucus, blood, and pus from the anus exist. The means of such
examinations are the finger and pneumatic proctoscope. So far as it
goes, the finger is by far the most satisfactor}', but above 4^ inches one
must depend upon the instrument. Ordinary tubes, specula, sounds,
and bougies should never be employed in these cases, for the operator
should always be able to see the space into which the instrument is
directed. Even the introduction of the finger should be made with the
greatest gentleness, for the weakened walls of the gut may be easily torn.
With the pneumatic proctoscope, after the sphincter has been passed,
the gut is distended by air and the tube is pushed upward through the
dilated caliber without coming in contact with the walls of the gut until
the tumor or contraction is reached. The degree of distention is never
so great as to endanger the integrity of the walls, for the air either
escapes upward into the intestine or outward through the anus when-
ever any tension is produced. By this means the exact location and
appearance of the disease may be determined up to the highest limits
of the sigmoid flexure. In Plates VII and VIII are illustrated the ap-
pearance of two carcinomas of the sigmoid. The small, round figures
show the growths as they appeared through the proctoscope; the larger
ones show their appearance immediately after excision. The importance
of this method of diagnosis in tumors situated above the reach of the
finger can not be overestimated.

In the diagnosis of cancer, either by the finger or the proctoscope,
it must always be borne in mind that the integrity of the mucous mem-
brane does not in any wise indicate the limits of the disease. Carcino-

MALIGNANT NEOPLASMS— CARCINOMA AND SARCOMA 783

ma spreads in the submucous and muscular walls of the gut, and the
mucous membrane may be perfectly healthy over large areas in which
the deeper tissues are involved in the carcinomatous process.

Epithelioma of the anus may be mistaken for fissure, condyloma, or
tubercular deposits. From fissure they are distinguished by their indura-
tion, their tendency to scab over and extend in area, and by their seat,
which is usually upon the folds and riot between them. From condyloma
they may be distinguished by their density, disposition to bleed, and
indurated base. From tubercular deposits they are distinguished by
their irregular shape, bright-red color, and lack of any tendency to un-
dermine the skin. Occasionally, where an epithelioma develops from a
prolapsing hemorrhoid, it may be difficult to distinguish it from the
granular condition which is sometimes seen on these hypertrophies.
Finally, as Quenu and Hartmann have pointed out, one should bear in
mind the resemblance between these neoplasms and the condition pro-
duced by actinomycosis. The diagnosis in all these anal cases may be
positively established by microscopic examination, which will reveal the
epithelial nature of the cancer whenever it exists.

It has been recommended from time to time that in cases of cancer
situated high up in the rectum, the entire hand should be introduced
for the purposes of diagnosis. The author is convinced that this is not
only a dangerous, but useless procedure, and does not hesitate to con-
demn the practice. Instrumental examination has reached such a stage
of perfection that this method can no longer be countenanced.

Finally, one should not forget to mention and recommend laparotomy
as a means of diagnosis in these cases. This procedure is not of so much
importance to determine the existence as the extent of a neoplasm. It
is, in fact, one of the chief means of deciding upon the operable character
of high carcinomas. It not only furnishes an accurate knowledge of the
condition of the growth and the extent of its involvement of other or-
gans, but enables one to determine the ganglionic extension along the
vertebral chains. The incision for such an examination should always be
made in the same line as that for inguinal colotomy, in order that if one
deems it necessary he may at the same time produce an artificial anus,
either temporary, with a view to excise the growth, or permanent in case
the conditions demand it. It is not sufficient simply to introduce the in-
dex finger in these cases, but the incision should be made large enough to
admit the whole hand, which should be introduced in order to examine
the entire pelvic cavity, the prevertebral glands, and also the surface of
the liver. By this means the author has been able twice to determine
the uselessness of any attempts at removal of the carcinoma, and under
modem aseptic precautions the procedure may be said to be practically
without danger.

784 THE ANUS. RECTUM, AND PELVIC COLON

Treatment, — The treatment of carcinoma of these organs is the most
serious problem that the rectal surgeon ever has to face. The majority
of these cases in the past have ended fatally regardless of what method
has been employed. In a few an apparent cure has been obtained, but
the percentage is small. The following questions must be answered in
every case: Is there reasonable hope of cure by extirjjation? Will the
patient's life and usefulness be prolonged by this operation, and his
sufferings be relieved? Or will these ends be attained in a greater meas-
ure by palliative methods, such as irrigation, curettage, opium, and, if
necessarv, an artificial anus or entero-anastomosis? Between these
methods of treatment the profession has vibrated for the past three-
quarters of a century.

Before the introduction of aseptic surgery the immediate mortality
from extirpation of cancers of the rectum and sigmoid was so high that
many surgeons claimed the operation was never justifiable. More re-
cently this mortality has been much reduced, and many of those who
formerly condemned the operation now favor it in properly selected
cases. If the ultimate were proportionately as good as the immediate
results, few surgeons would deny patients the opportunity of radical
cure with four chances out of five in their favor. Unfortunately, re-
currences in situ or generalization of the disease has proved so frequent
after these operations that one can not promise with any degree of
certainty that the growi;h will not return within one or two years, even
if the patient survives radical and complete extirpation. The experi-
ence of any one surgeon is always too limited to establish reliable con-
clusions; some few have operated 40, 50, or even more than 100 times,
while a large majority who report their cases have operated from 1 to
15 times. The only just estimate of this procedure must be deduced hy
collecting large numbers of operations done by different surgeons. By
this means the average results, in average hands, and in an average class
of patients, are obtained.

One set of operators confine themselves to carcinomas low down and
removable by perineal dissection; the mortality in these cases is com-
paratively low. Another class pays less attention to the elevation of the
tumor, but confines its operations to those cases in which the growth
is absolutely confined to the rectal wall, is freely movable, and has not
presented local symptoms longer than six months; the mortality in these
cases is still comparatively small. A bolder and more ambitious class,
however, attacks cases regardless of the attachments of the tumors to the
pelvic organs or the bony frame; in this class the immediate mortality
and the percentage of early recurrences are exceedingly high. The
actual facts are only obtained by combining the results of all.

The author and his associate, Dr. George H. Wellbrock, have col-

MALIGNANT NEOPLASMS— CARCINOMA AND SARCOMA 785

lected from literature and private communications a total of 1,578
cases of extirpation of the rectum done since 1880, with a mortality of
319, or 20.2 per cent. With slight differences this is practically the
conclusion of Finet (Exer^se dans le cancer du rectum, Paris, 1896), who
collected 375 cases, Carl Vogel (Deutsch. Zeitsch. f. Chir., April 19,
1901), and Hupp (Med. News, September 28, 1901), who have made
similar compilations. In a summary of cases made in 1896 (Jour. Amer.
Med. Ass'n, 1897), drawn largely from private communications and num-
bering 249 in all, the author showed a mortality from these of OTily 13.5
per cent, and firmly believed at that time that this mortality would be
materially reduced as the technique of the operation improved and our
knowledge of how to select operable cases increased. He is compelled
to admit at present that these hopes have not been realized. The mor-
tality from this operation in the past five years appears to have increased
rather than decreased. This may be explained by the following facts:
More difficult cases are operated upon, wider dissection for the removal
of glands is employed, less experienced surgeons are attempting the
operation, and our aseptic technique has not kept pace with the boldness
of operators. Assuming, however, that these records are correct and
that 1 in every 5 cases of cancer of the rectum dies from the operation,
there would still be few who would hesitate to take four chances in five
if promised a radical cure, or even a prolonged extension of life. But
how many cases are actually cured by extirpation, and to what extent
is life prolonged in those not cured? The first question it is impossible
to answer, because there is such a diversity of opinion in regard to the
period after extirpation at which a patient may be said to be cured.
Formerly it was held that when a patient, having been operated upon
for carcinoma, had survived three years without any recurrence, he
might be said to be well. Recently, however, recurrences have been ob-
served six, eight, and more years after the operation, and these cases
are added to fhe mortality from recurrences. It is a question whether
such tardy recurrences, except when in situ, ought not to be considered
new developments and not returns of the old disease. These cases may
be left out of account from the fact that if such prolonged freedom
from so malignant a disease can be obtained, the results will be so far
in advance of anything which can be accomplislied by any other treat-
ment that no comparison can be instituted.

WTien it is recalled that the disease is absolutely fatal when left alone,
and with few exceptions within one year, any procedure which prolongs
life two, three, or more years must be considered most favorably, espe-
cially if it brings comfort and relief of suffering to the patient. Treat-
ment by extirpation arouses hope of a radical cure, and thus adds buoy-
ancy and comfort to the patient's mind; this hope, it is true, is bought
50

786

THE ANUS, RBCTUM, AND PELVIC COLON

at a price, consisting of one chance in five of death, but this is four
times as many chances as he has by any other treatment. It offers a
prolongation of life, as the average length of life following extirpation
is two years and seven months, calculated from 602 cases which have
been followed; this is nearly three times as long as that given by non-
operative treatment, and almost twice as long as that furnished by the
palliative methods of colostomy and entero-anastomosis. It offers a dis-
tinct chance of radical cure, of life without recurrence for a certain
number of years. The percentage of such cures is very diflBcult to de-
termine; that observed by various operators is far from uniform, as the
following table, taken from Hupp's article, will demonstrate. This is
based upon the assumption that three full years without recurrence
constitute a cure of the disease:

Table

Namb.

Number of operations.

Cures.

Percentage.

K(K'her

35
109
63
46
53
80
95
93
66

28.5

Czcrn V

U 6

Kronleiii

fier^mann

Ma<lclung and Garre

17.4
11.8

Kraske * . .

13.7

Kuster

16.8

Hoenefifff

13 9

Mikulicz

Average percentage of cures.

14.8

It is to be observed that this percentage is based upon the total
number of cases operated, and not upon those that survived the imme-
diate effects of operation. To these may be added the experiences of the
author, who has operated upon 32 cases, with an immediate mortality
of 6 — 18.7 per cent. Of the other 26, he has been able to follow 16 of
them for one year or more. Of these there are living without recurrence,
1 ten years, 1 eight, 1 six, 2 (1 sarcoma) five and one half, 2 four, 9
between two and a half years and one year; and 4 have died from re-
currences— 1 in six months, 1 in eleven months, 1 in fourteen months,
and 1 in two years. In this list there are found 7 out of the total 33
cases (21.8 per cent) who have survived the period of four years or more.
From these facts, it may be concluded that on an average 1 in 5 cases
will live three vears or more without recurrence.

WTiat does the operation offer in relief of pain and maintenance of
normal functions so long as the patient lives? The relief of pain is
complete in the large majority of cases. In the statistics furnished bv
Hupp absolute sphincteric control was retained in 30 per cent, relative
control in 60 per cent, incontinence in 10 per cent (taken from the
personal experience of Kronlein). In the writer's experience in 2^ cases

MALIGNANT NEOPLASMS-CARCINOMA AND SARCOMA 787

which survived the operation, complete incontinence was observed
in 2, partial incontinence in 7, and comparatively perfect sphincteric
control in 17. All the latter cases were instances of resection by the
sacral or abdominal methods without involvement of the muscles. Other
complications, such as stricture, posterior fistula, and abnormally placed
ani do occur, but they are of such minor importance compared with the
disease itself that they need scarcely be considered except in relation to
the different methods of operating.

A\Tiile the average length of life made up from the entire number
of operations performed is comparatively small, there are numerous in-
stances in which the operation has been followed by no recurrence in
long periods. The following table brings this out in an interesting
manner:

Table

Name.

Number of cases.

Number of years without recurrence.

Cripps

2
2

6
12

8
10
14
16

3
10

5i
4

X. «.| 1^^

i 4

Quenu

< (

6 months.

J. Bocckel

t (

Koc'htT

t •

10 **

5 "

% %

(•

( t

« f

Ball

• «

Koiiitr

Ilildcbrand

Reclus

Caspersolin

Labe

Richelot

Keen

t i

6 "

Author

t <

1 1

t <

There are no statistics to determine the comparative results of opera-
tions done early in the course of the disease and late in its development.
Personal experience and the meager reports in published cases show that
the longer the S3rmptoms have existed the less chance will there be of

788 THB ANUa, RECTUM, AND PELVIC COLON

immediate or permanent recovery. A fact of much more importance
than this, however, in regard to prognosis is, that the younger the pa-
tient the less are the chances of recovery, and each year we are seeing
more cases in early life. In the 1,578 cases studied, those in which the
age is given show a gradual decrease in mortality and recurrence as the
ages increase. Not a single case of radical cure has been reported under
the age of twenty-five years. Under thirty years of age the immediate
mortality is over 30 per cent, and the recurrences approximate 60 per
cent. Fifty to sixty years seems to be the most favorable age for opera-
tion. The mortality in these cases is about 12 per cent, and the recur-
rences are less than 40 per cent.

Causes of Death following Extifpation, — A study of the causes of
death shows tliat there is reason to hope the high mortality from this
operation will some day be reduced.

The causes of death, as determined by Hupp in a collection of 881
cases with 171 fatalities, are as follows:

Se|)8i8 and pyaemia 46, 26.8 per cent

Peritonitis 37, 21 .6

Collapse and heart failure 32, 18.7

Pulmonary afflictions 21, 12 **

Miscellaneous causes 35, 20 *•

(Archiv fQr klin. Chir., 1900, S. 309.)

In the collection of Finet there were 76 deaths due to the following

causes:

Peritonitis 24. 31 per cent.

SepticiiMnia 13, 17

Pya?mia 2, 2.6

Collapse 16. 21

Gangrene of the rectum 3, 3.9

Pulmonary complications 4, 5

Haemorrhage 1, 1

Diarrhoea 1, 1

Iodoform poisoning 1, 1

Miscellaneous causes 11, 14

• <

Quenu and Hartinann say, in discussing the latter figures, that if
the cases of peritonitis, septicaemia, gangrene, and pya?mia were all
united under one head of sepsis, we would have a mortality from this
cause of over 60 per cent, and even this is below the reality. They
believe that all cases dying within the first thirty-six or forty-eight
hours and diagnosed collapse, succumb to a form of acute sepsis charac-
terized by low or subnormal temperature, quick pulse, and suppression
of urine. The pulmonary complications, either early or late, they claim
are due to the same cause; and on the whole they do not consider it
an exaggeration to state that full 80 per cent of the mortality from

MALIGNANT NEOPLASMS— CARCINOMA AND SARCOMA 789

operations of this kind are the result of some form of sepsis (Chirur.
du rectum, t. ii, p. 132). The author is entirely in accord with the
views of these eminent surgeons; indeed, he believes that if gangrene
and chronic exhaustive suppuration be added to the category of sepsis,
the deaths from this cause would amount to more than 90 per cent of
all fatalities. The high mortality from this operation, therefore, is due,
not to the magnitude or diflBculty of the procedure, but to infection;
we have not arrived at that stage of perfection in aseptic technique in
this variety of operations that we have in many others. Carelessness
in detail is the cause of much of this. The author has seen various
operators do extirpation of the rectum, and time after time during the
procedure introduce a finger into the gut and back into the wound.
It is absolutely impossible to sterilize the intestinal canal, however much
care is taken, and if this practice is followed by many surgeons, it will
account for the high percentage of infections and the great mortality
due to this cause. Much of this is avoidable. Another cause of high
mortality is too great boldness in operating, undertaking impossible
cases. It is a question how far this cause can be avoided. Had the
author refused to operate in 2 such cases instead of yielding to the
importunities of the patients, the mortality in his series of cases would
be 12.5 per cent; but if the patient demands it, has the surgeon a right
to refuse him even one chance in a thousand for his life?

While extirpation offers a much smaller probability of permanent
cure than could be wished, and while even this prospect must be pur-
chased at the price of one chance in five of death, it still offers to these
unfortunate sufferers relief from pain, a surcease from the inveterate
and uncontrollable diarrhoea, a cessation for considerable periods, at
least, of the excessive discharges and frequent haemorrhages, and, finally,
a hope, though feeble and faint yet far-reaching in its influence, of
eventual cure. In contradistinction to this, what has the palliative
treatment to offer? A relief from pain through the administration of
opiates or through diversion of the faecal current, either in the form
of an artificial anus or through entero-anastomosis. There is absolutely
no proof that either of the latter procedures retards the extension of
the disease in continuity or by metastasis. In certain instances they
relieve the pain to some extent, but never to the same degree as extirpa-
tion; they undoubtedly improve the digestive functions and control the
diarrhoea, which is annoying and exhausting; they reduce septic ab-
sorption, and consequently prolong life, and the mortality from the
operations is very small. They offer, however, no hope beyond a lethal
end in about one and a half years. The modern methods of performing
colostomy make it a less disagreeable and disgusting feature than for-
merly, as will be described later on; but the very fact that the faecal

790 THE ANUS, RECTUM, AND PELVIC COLON

movements must be discharged from an abnormal aperture; that band-
ages, trusses, or fascal receptacles must be worn at all times in order to
prevent accidental faecal escape and mortification to the patient, keeps
constantly before his mind the fact that the fatal malady still exists,
and it has therefore a depressing rather than an encouraging influence.
In short, these methods oflfer the patient and his friends absolutely no
hope of cure, only a relief from some of the disagreeable symptoms, and
then resign him to fate and the euthanasia of opium until the end
appears.

Indications and Contraindications to Different Methods of Treaiment.
— It is clear from the foregoing paragraphs that the author is in favor
of extirpation in all suitable cases of carcinoma of the anus, rectum, and
sigmoid: It is believed, however, that a more careful discrimination
should be made in the cases selected; to this end the reader is invited
to a closer studv of the indications for radical treatment.

ttr

Indications for Extirpation, — In a general way it may be said that
extirpation is indicated when the growth is movable and does not in-
volve other organs; when no metastasis or ganglionic extension has
occurred; wlien the patient's physical condition is such that he is able
to withstand the shock of operation, and when marked cachexia is
not present.

It is contraindicated when other pelvic organs or the bony frame
are involved; whenever the disease has extended to the remote l}Tnphat-
ics; when there is positive indication of the generalization of cancer
exemplified in nodules upon the liver, in the skin, or in other remote
organs; in low physical conditions with rapid pulse, cachexia, and
periodical elevations of temperature. It is specially contraindicated
in cases with marked digestive disturbances. Recovery after these opera-
tions depends largely upon the ability to assimilate food and resist in-
fection, and if the digestive functions are deficient these indications
can not be met.

It is not always wise, however, to adhere too closely to these indica-
tions. The rectum may be adherent to the prostate, bladder, or uterus
through simple inflammatory processes, and the latter organs may be
absolutely free from malignant disease; the liver may be enlarged from
congestion or other causes in cases with carcinoma of the rectum, and
yet not be involved in the malignant process; the growth may be firmly
bound down to the sacrum by inflammatory bands without the perios-
teum partaking of the malignancy. On this account, Quenu, Czemy,
and Bardenheuer (Quenu and Ilartmann, op. cit., w)l. ii, p. 237) do not
any longer hesitate, when it is only a question of adhesion to the prostate
and seminal vesicles, to extirpate the growth with parts of these organs,
always respecting the urinary tract. Kelsey (Surg, of Rect. and Pelvis,

MALIGNANT NEOPLASMS— CARCINOMA AND SAECOMA 791

1897, p. 287), however, says he has ceased attempting even these eases.
The author is in accord with the French surgeons on this point, and
would not hesitate to operate on account of such adhesions. Frequently
it is impossible to determine the ganglionic extension through rectal
examination and abdominal palpation. One of the many advantages
of preliminary colotomy consists in the opportunity of closely examining
the parts and determining whether or not this has occurred. It also
enables one to examine the bladder and uterus so thoroughly that it is
possible to determine whether the malignant process has extended to
these organs, or whether the adhesions are simply of an inflammatory
nature (Schwartz, Revue clin. ct de therap., 1890, No. 42; Adamski,
Th. de Paris, 1899, No. 97; Quenu and Hartmann, op, cit,, vol. ii, p.
237). When the latter is the case, extirpation may be attempted with
fairly good prospects of success.

The type of the tumor should always be considered in determining
for or against operation. The prognosis is much more favorable in scir-
rhus and adeno-carcinoma than in the medullary and squamous varieties.
In the latter, ganglionic and metastatic extension occur at an earlier
period than in the former, and recurrences are therefore more frequent.

With regard to involvement of the vaginal wall, it would seem that
this should not form a very strong contraindication to extirpation of
carcinoma of the rectum. As a matter of fact, however, experience
teaches us that in the majority of such cases generalization has already
occurred, or it comes on early after operation. This complication should
therefore be considered a very serious one.

The rule formulated by Van Buren that no cancer of the rectum
should be removed, the upper limits of which could not be made out
by digital examination, is no longer followed. The tolerance of the
peritonaeum to invasion under ordinary aseptic precautions renders any
limitations with regard to the height of the tumor no longer necessary.
Those low down may be removed by perineal methods, those in the
ampullary or upper portion of the rectum by the sacral route, and those
high up in the rectum or sigmoid by the abdominal or combined methods.
The area involved by the tumor may be a contraindication, from the fact
that the more extensive the growth the more likely is there to be in-
volvement of the neighboring organs, ganglionic extension, or general-
ization of the disease. Long sections — 20, 25, and 36 centimeters — of
the rectum and sigmoid have been removed, but death or early recur-
rence has almost invariably resulted. The author has successfully re-
moved 12 inches of these organs, and the patient still lives twenty-six
months after the operation, but such results can not be expected often.

Two other things need to be considered in determining for or against
extirpation of carcinoma of the rectum: the desire of the patient and

792 THE ANUS, RECTUM, AND PELVIC COLON

the preparation of the surgeon. If it is one's ambition to obtain a record
for low mortality in these operations, he will adhere closely to the lines
laid down above, and decline to operate on any complicated cases. The
patient, however, has certain rights which should be respected. He ii
entitled to know that he is afflicted with a fatal malady and exactly wk;
chances he has for a radical cure of the same. With this knowledge he
should have the privilege of deciding for himself whether he will take
the one chance of life in comfort, and failing put an end to all his suffer-
ings, or adopt a waiting course, obtaining what relief he can from pallU-
tive methods. It is the author's firm conviction that no surgeon is
justified to refuse the one chance to be cured of this disease even in the
most desperate cases, if the patient elects to take the responsibility of i
fatal termination. Such action will not conduce to a lowered mortality
in this operation, but in the majority of cases death is preferable to life
with such a malady ever slowly and painfully progressing toward the
end. One might just as well say that a man has no right to jump from
a burning building and thus take the one chance of living, even though
a cripple, as to deny these patients the right to choose for themselves.
It is the author's practice in such cases to present the facts and probabil-
ities to the patient and his friends, and leave them to decide whether
they will choose a palliative or radical course of treatment. In three
instances he has been persuaded to operate where it was his positire
conviction that no possible good could be achieved; two of these patients
died shortly after the operation, the third ^and most desperate one was
restored to health, and when last heard from, over three years after the
operation, was supporting his family in spite of the unfavorable prog-
nosis. Thus the end was hastened in two hopeless cases and a useful life
was rescued in the third. This case is worthy of particular mention:

Amputation of the Bectumy including the Entire Fro&tate and ParU of the Uretkrn
and Bladder. — R. G.,- thirty-five, entered the Polyclinic Hospital, January 9, 1899.
He gave an indefinite history of constipation, hflemorrhages, gradually increasing
pain, and protrusion from the rectum. The symptoms had existed for over one
year, during which time he had been treated for piles almost constantly. From
the anus there protruded a wart-like mass, and as far up as the finger could be
introduced the rectal caliber was filled by similar neoplasms. The patient was in
a most emaciated condition ; his pulse was 140, temperature subnormal, and he
required thirty-six grains of morphine per day to be made comfortable.

January 15th. — Left inguinal colotomy after Maydl-Reclus method, sphincter
dilated, and protruding epithelial mass clamped off. Examination of the peKis
through the abdominal opening demonstrated involvement of the lower posterior
wall of the bladder and prostate in the neoplasm. The prevertebral glands were
not involved apparently, and the liver was perfectly smooth. The patient improved
greatly following the operation ; and. after the bowel was opened, he was compar-
atively comfortable. He was advised against having any further operation done.

February 7th. — Yielding to the patient^s importunities, an attempt was made to

MALIGNANT NEOPLASMS— CARCINOMA AND SARCOMA 793

extirpate the carciDoma. Six inches of the rectum, 1} inch of the urethra, the
entire prostate, and nearly 1 square inch of the posterior wall of the bladder were
removed in doing this. The patient became very weak during the operation, and
it was necessary to shorten the procedure as much as possible. It was therefore
impossible to accurately close the bladder wound and make any attempt at restora-
tion of the urethra at this time. Length of operation, forty-five minutes.

February 14th. — The patient recuperated rapidly, and gained strength every
day.

February 21st. — An attempt was made to close the wound in the bladder and
restore the urethra by freshening the edges and drawing the parts together. It
was impossible to bring the ends of the urethra together, therefore a drainage-
tube was passed along the perineal wound into the bladder, and around this the
neck of the latter organ was sutured. Comparatively good union was obtained in
this, and the patient was left with a perineal urethra. After the parts healed, the
bladder could retain about 2 ounces of urine, but no more, and it was found
necessary for the patient to wear a perineal urinal.

The upper end of the rectum, where it was cut off, was not closed or sutured
in any way, but simply packed with gauze. At the time the patient left the hos-
pital, March 18th, there was only a slight fistulous tract leading up from the site
of the anus to this point. The patient entirely relinquished his morphine habit
within three weeks, and was on his feet walking about the ward in two weeks
after the second operation.

The results in such cases as this render us bolder to undertake appar-
ently impossible operations. Such attempts are justifiable upon the in*
sistence of the patient, but they should never be urged by the surgeon.

The capability and preparation of the surgeon are of the utmost im-
portance in determining upon this operation. While asepsis is the chief
feature in the technique, the time occupied and the control of ha?mor-
rhage are major considerations. Every minute and every drop of blood
saved in such a procedure add to the patient's chances of life. Absolute
familiarity with the anatomy of the parts and every step of the operation
are necessary to success. Blind groping in an unknown field, feeling
one's way step by step, results not only in useless loss of time and blood,
but frequently in injury of the adjacent organs, such as the urethra,,
bladder, and ureters. The surgeon who proposes to do this operation
should certainly practise it on the cadaver many times before he under-
takes it on a living subject.

Indications for Palliative Treatment. — These methods of treatment
are indicated when from one cause or another extirpation is not advis-
able, and as preliminary preparations for the latter operation. Where
great weakness and excessive digestive disturbances exist, it shoijld be
employed with the view of improving the patient's condition sufficiently
to justify extirpation. It should always be employed in some form for
eight to fifteen days before extirpation, and it will therefore be de-
scribed first.

794 THE ANUS, EECTUM, AND PELVIC COLON

Palliative Treatment. — This consists in diet, antiseptic and astrin-
gent irrigation, curettage, cauterization, colotomy, entero-anastomosis,
and the free use of opium. The chief element in the prolongation
of life in inoperable cases is the ability of the patient to resist in-
fection. Wherever the digestive functions remain good and the patient
is properly fed, this resistance is maintained and the constitutional
effects of the disease are retarded. Forced feeding with predigested
food, milk, egg albu^nen, meat extracts, and small quantities of well-
cooked cereals are always indicated.

Sweets, uncooked starches, fibrous vegetables, and articles contain-
ing much detritus should be avoided. Milk diet alone has not been
found advisable in these cases, but associated with other aliment it is of
the greatest benefit.

Irrigation. — Irrigation of the affected part is indicated, especially in
those cases in which there is much discharge associated with a frequent
diarrha'a, or in which there is a tendency to hard, lumpy stools. The
substances which have been found most satisfactory for this purpose are
solutions of boric acid 5 per cent, hydrastis 1 per cent, krameria aq. ext.
5 per cent, bichloride of mercury 1 to 10,000, and carbolic acid 1 to 100.

The method of employing irrigation in these cases depends upon
the site of the growth. In those cases low down about the margin of
the anus, the solutions may be sprayed upon the parts, a certain portion
being carried up into the rectum simply to act as an enema in unloading
the bowels. Where the tumor is in the ampulla of the rectum an
ordinary rectal irrigator (Fig. 83) should be used with the patient
lying upon the side. Where the growth is higher up at the jimction
of the rectum with the sigmoid or in the latter organ, the irrigation
should be carried on by placing the patient in the knee-chest posture,
allowing the fluid to run in slowly from a fountain syringe so that it will
find its way above the affected area and thus wash out whatever mucus,
pus, and fcTcal material have accumulated above or below the growth.
In cases which are too weak to assume this position long enough for
the fluid to pass in slowly, a small Wales bougie, Nos. 3 or 4, which
is practically a soft-rubber catheter open at the end, may be gently
introduced by an expert nurse, and thus the fluid can be carried above
the growth. Of course it is always possible that this tube may bond
upon itself, and, as said before, there is a certain amount of danger in
introducing such instruments, but with a soft bougie of small size this
is not very great.

The amount of good which can be accomplished by this dietary
and antiseptic treatment does not seem to be appreciated by most
writers upon this subject. The author has seen a number of inoperable
cases not only hold their own, but gain flesh and strength under it.

MALIGNANT NEOPLASMS— CAECINOMA AND SAECOMA 795

In several cases he has seriously doubted his own diagnosis on account
of the remarkable improvement. In some cases in which the local
condition indicates operative interference, the patient's general con-
dition contraindicates it. In these instances one may occasionally im-
prove the general condition to such an extent that extirpation will
become feasible where it was not so at the first examination.

Drugs, — As to therapeutic remedies, little can be accomplished except
by the artificial aids to digestion, tonics and stimulants to circulation,
and such remedies as prevent fermentation in the intestinal tract. The
author is opposed to the administration of opium by the mouth, as it
interferes seriously with the digestion, produces hard, lumpy stools
which are dangerous in this disease, and it accomplishes nothing in
the control of the irritative diarrhoea that can not be accomplished by
irrigations and proper diet. For the relief of pain, hypodermics of
morphine are admissible, but they should not be too freely used until
the disease has progressed to its latest stages. When the hopeless, bed-
ridden stage has been reached, then the unlimited administration of the
drug should be employed to relieve suffering and quiet mental anxiety.

Curettage, — Where there are no great septic symptoms, but the pa-
tient's life is drained by frequent and exhausting haemorrhages from
large, soft, pulpy, inoperable tumors attached to the posterior wall,
we may have recourse to curettage for the relief of this condition. If
the growth involves the anterior or lateral wall of the gut, this opera-
tion is not safe, as one may very easily penetrate the peritonajum; at
the same time, in expert and careful hands, the anterior cancerous
excrescences may be twisted or crushed off with pressure forceps, and
scraped out posteriorly so as to greatly increase the caliber of the gut
and check for considerable periods the dangerous bleeding. Where the
haemorrhages are not accompanied with much pain, the author believes
this method will give quite as much relief as an artificial anus, and it
will render the after-care of the patient less burdensome to the attend-
ants. After the curettage, hot or cold irrigation should be employed
to check the bleeding, and afterward a drainage-tube should be intro-
duced into the rectum and firmly packed around with sterilized gauze
infiltrated with suprarenal extract or dried persulphate of iron. It is
not safe to pack such large cavities with 10-per-cent iodoform gauze
on account of the toxic effect of this drug.

Cauterization, — In the same class of cases as those just mentioned,
one may employ the actual cautery to control the bleeding. It is slower
in its action than curettage, and more likely to result in peritonitis
through heat radiation.

A\Tiere the growth is low down and the excrescences are of a papil-
lomatous or polypoid nature, they may be grasped with a haemorrhoidal

796 THE ANUS, RECTUM, AND PELVIC COLON

clamp, crushed off and cauterized, thus accomplishing the control o
haemorrhage and widening of the rectal caliber. The author is opposes
to the use of chemical cauteries in such cases, and believes the Paqueli]
knife is the only agent which should be employed if this method o
treatment is adopted.

Colostomy in Malignant Tumors of the Rectum. — The opinions ani
experiences of surgeons vary greatly with regard to the employment o
colostomy in cancer of the rectum and sigmoid. Some believe that i
is never justifiable, others that it is the only justifiable operation whicl
affords these unfortunate sufferers any relief. It is employed to avok
obstruction, prevent haemorrhage, control diarrhoea, check sepsis, anc
as a preliminary operation to extirpation. Some surgeons, notabl]
Allingham and Kelsey, claim to accomplish all these ends by thi:
procedure; in the hands of others the operation has not been so satis-
factory.

Where the growth is low down and involves the sphincter, an artificial
anus will prevent the intense suffering which follows every stool. Id
some cases it controls the diarrhoeal movement, but in others it fails
to relieve the unceasing desire to defecate; in these cases small mucous
and bloody passages continue from the anus after the colostomy has
been done. Usually it checks the septic manifestations, although this
is not invariably the case. It undoubtedly improves the digestive func-
tions, and for the first three or four months after its performance the
patient gains in strength and flesh. In the control of hsBmorrhage i1
has no distinct advantages over curettage, dietary regime, and recta!
irrigation. It may check the inflammatory processes around the can-
cer, but there is no reason to suppose that it inhibits the growth of th<
neoplasm. That it prevents intestinal obstruction can not be denied
but, as has been stated already, this is a very rare accident in carcinonu
of the rectum. In the sigmoid, where scirrhous cancer is somewhat
more frequently observed, obstruction is more likely to occur, but ii
these cases the condition of affairs is usually recognized at a tim(
when extirpation is altogether feasible, and therefore colostomy is not
called for.

The writer is not among those who hold that an artificial anus is
the most disgusting and distressing condition to which a patient can
be subjected. He believes that in many diseases, such as chronic ulcew-
tion of the rectum, syphilitic stricture, multiple polypi, complicated
fistulas, etc., it is one of our most useful aids. The modem methods
of colostomy have rendered the faecal control so complete that many
of the most disgusting features have been obliterated. At the same time
it does not appear indicated in carcinoma of the rectum except in the
rarest instances. The writer has never seen a case of obstruction from

MALIGNANT NEOPLASMS— CARCINOMA AND SAltCOMA

carcinoma of the rectum, and in 20 colotomies for this disease he has
never seen a patient live longer than one year after the operation.
It has always been necessary to resort to loorphine almost as freely
as before the colotomy, and in most of the cases periodical hiemorrhagea
have occurred long after the fiecal current had been turned aside. He
therefore employs it only in inoperable cases where the sphincter is
involved. As a preliminary to extirpation of the rectum, colostomy
can not be too highly praised. The operation is of such great im]>or-
tance in rectal surgery, and applicable to such various conditions, that
it has been deemed advisable to devote a special chapter to its con-
sideration.

Erilero-anastomosia. — Under the same conditions as those stated for
colostomy, one may employ entero-anastomosis in cases where the tumor
is high up in the rectum or in the sigmoid flexure. Where there is
sufficient healthy gut below the growth to admit of a union between
the upper loops of the sigmoid, the Ciecum, or the ileum with the
rectum, the portion of the intestine involved in the neoplasm may be
thus eliminated from the
faecal tract and all the ad-
vantages of an artificial
anus obtained without any
of its disgusting features.

The operation possesses
one great recommendation,
in that it produces no con-
stant reminder of the pa-
tient's actual condition in
the shape of an abnormally
placed anus. The fffical
current apparently passes
throngh the normal chan-
nels, it produces no irri-
tation of the neoplasm, and
is thus far more satisfac-
tory than the permanent
artificial anus. It is a more
serious and difficult opera-
tion to perform than colosto-
my, hut the death-rate from
it is not particularly high.

This operation, first performed by Wallh (St. Petersburg med. Woch.,
February IS, 1889), is chiefly employed for inoperable tumors of the
largo intestine above the sigmoid flesure. We are able to find but three

Fio. 25T.— Lateh

798 THE AJJUS, RECTUM, AND PELVIC COLON

instanees in which it has been employed in neoplasms of the sigmoid
flexure (Stinison'a. Darling's, and the author's). It coDsists in anas-
tomosing a healthy portion of the intestine above the growth with one
below it. There are two methods employed in its performance. One
consists in a lateral anastomosis of two segiHents, either by the use ot
Senn'a bone platea or the
Murphy button (Fig. 257),
By this method the portion
of the intestine involved in
the neoplasm retains its
conneetion with the rest ot
the intestine, and a (.-ertain
amount of the intestinal
contents escapes into it or
probably through it. By
the second method the por-
tion involved is entirely ex-
cluded from the fsecal cur-
rent. The intestine is cat
through above the growth
and below it under projier
aseptic precautions. The two ends of the diseased portion are then
invaginated and closed by Lembert sutures. The healthy seginenta
above and below the growth are then united by end-to-end suturing or
a Murphy button, thus establishing a tract for the fipeal current whieJi
has no connection whatever with that portion of the intestine iuTolred
in the growth (Fig. 258). The section thus eliminated from the intes-
tinal tract atrophies and appears to occasion no inconvenience, hut th«
neoplasm continues to grow, and eventually ends in death through
metastasis.

In the author's case the sigmoid flexure, the ascending transventi
and descending colon, and about 18 inches of the ileum were eliminated
from the intestinal tract on account of a tumor involving the sigmoid
and ileum. The upper end of the rectum was then invaginnted and
closed, a longitudinal incision was made in its anterior wall, and the
upper end of the ileum was then dragged down through this slit, after
the manner snggested by Kelly (Fig. 259). The new fwcal tract was
perfectly established, and the patient's bowels moved regularly and
without pain until his death, which occurred from rupture of \ht
left iliac artery, which was involved in the disease, 45 days after the
operation.

While the results from this procedure are comparatively satisfadonr
in tumors of the colon above the lower loops of the sigmoid, it is rarely

MALIGNANT NEOPLASMS-CARCINOMA AND SARCOMA

applicable to tumors of the rectum and pelvic colon. In the ease re-
ferrL'd to, the ileum was involved with the sigmoid in the neoplasm.
This would have necessitated an artificial anus being made in the ileum
in order for it to be of any benefit, and it is well known that ani made
in this portion of the intestine are not only distressing to the patient
on account of the fluid condition of the fseces at this point, but also
followed by rapid eshaustion through the constant diarrhtea which they
occasion. In such an in.stance, tlierefore, where the tumor can not
be removed, this operation is called for; but complications like this in
which the sigmoid, the small intestine, and the iliac vessels were all
involved, are exceedingly rare.

In addition to these forms of treatment, one should not forget to
mention the interesting experiments which are now being made in the
treatment of cancer by the X-ray and phototherapy. Most encouraging
results have been obtained by the use of these methods in carcinomas,
especially of the epithelial
type, in other portions of
the body, and it is not un-
reasonable to suppose that
the same can be obtained
at least in the tower por-
tion of the rectum. Thus
far the author has had no
experience in their use, and
must therefore refer his
readers to Williams's ex-
cellent work upon this suli-
ject and the extensive
journal literature of the
day. Subjecting the meth-
ods to the same test which
we apply to surgical pro-
cedures— viz., three or four
years' freedom from recur-
rence — it has not been
shown that they have ef-
fected a single permanent
cure; but the period during
which these methods have
been employed is entirely

too short for the practical application of such a test. We can only
hope that they will prove as effectual as some of their advocates,
predict.

800 THE ANUS. EECTUM, AND PELVIC COLON

SARCOMA

These occur under the t^'o general types of melanotic and non-
melanotic sarcomas; the latter are much more rare in the rectum than
the former; the collected cases include 29 of the melanotic and 14 oi
the non-melanotic sarcomas.

This pigmentation or melanosis is not the all-important element in
these tumors, for it may complicate any variety of sarcoma, and has also
been seen to occur in carcinoma of the rectum (Roecke, Inaug. Dissert,
Freiburg, 1895). This latter is exceedingly rare; there is not another
instance recorded of such infiltration of carcinoma of the rectum, and
were it not for the very minute report of Roecke, one would feel in-
clined to doubt the accuracy of the histological investigation. The
only plausible reason for its comparatively frequent occurrence in sar-
comas is the thinness of the blood-vessel walls, and this explanation is
only partially satisfactory.

Form. — Sarcomas occur in the rectum as irregular deposits beneath
the mucous membrane. Their shapes are round, elliptical, and some-
times they resemble hypertrophied tonsils. They rarely if ever assume
the smooth, plaque-like form of deposit beneath the mucous membrane
of the gut, such as is seen in carcinoma.

Their surface is always rough, unequal, " muriform," and the mu-
cous membrane is movable over the growths in their earlier stages, a
condition which distinguishes them from carcinoma.

They originate in the submucosa, and at first appear as slightly
elevated protrusions into the gut. As they grow they may appear as
sessile tumors, and eventually through their own weight, friction of tht
faecal mass, and the detrusive influence of the intestinal muscles, develop
a distinctly polypoid shape.

They may also aj)pear as a general fibrous thickening of the wall ol
the gut, and thus be mistaken for simple inflammatory stricture (Gremb
Thesis, Paris, 1887, No. 231). Ball also records a case of this kinc
found in the Dublin Hospital Museum.

The mucous membrane covering sarcomas is at first comparative!}
normal. When the tumor has grown so large as to distend it and sub-
ject it to pressure and friction from the fa?cal passages, it may beconu
congested, (pdematous, or ulcerated, or it may adhere to the growth
through inflammatory processes.

Niwiher. — Sarcomas occur in the rectum singly or multiple. Ball
(op. cit., p. 325) has related a case in which there were three distinct
growths, and Heaton (Path. Soc, London) and Bowlby (Brit. ^Nfed. Jour..
1891) liave recorded cases in which the growth appeared in the form
of a large number of small, disseminated tumors. In one of the author's

MALIGNANT NEOPLASMS— CARCINOMA AND SARCOMA 801

cases there were two tUmors: one polypoid and protruding from the
anus, the other submucous and involving about half of the circum-
ference of the rectum.

The tumors vary in size from that of a hazelnut to a good-sized
orange. Peterson has described one as 10 centimeters (3^ inches) long
and 8 centimeters (3^ inches) wide, almost entirely occluding the lumen
of the gut. In a patient of Dr. Ladinsky^s, in which the tumor involved
the sacrum and rectum, the rectal portion was as large as a coconut,
and so filled up the gut that it was impossible to pass the finger beyond
it. In the case from which Plate VI, Fig. 1, was made, the growth
was very extensive, but did not protrude into the bowel to any great
extent. The chief obstruction which it produced was at the anus.

Consistence. — To the touch, rectal sarcomas are comparatively hard,
but have not the density felt in scirrhous cancer... In the spindle and
round-cell varieties, this is not so marked as in the fibro-sarcoma and
osteosarcoma, which are very hard and firm to the touch.

In the polypoid form they are elastic, with a firm center resembling
very much the adenoid polyp.

Color. — To the eye, sarcomas of the rectum present various colors.
Most frequently they appear like the normal mucous membrane; in
other cases they are of a dark-red or grayish color, and when the melano-
sis is accentuated they appear as black gangrenous masses.

Where more than one tumor exists, they may differ materially in
appearance, owing to the changes in the mucous membrane and to the
fact that melanosis is rarely uniform in multiple growths.

As stated elsewhere, in a case reported by Ball, one of the tumors
was black, while the other was pale and blanched. The first was infil-
trated with melanin, while the latter exhibited no trace of it.

Site. — Sarcomas may occur at any portion of the rectum or sigmoid,
but the large majority of them are situated low down near the anal
margin. In all of the author's cases the growths were within the lower
2 inches of the gut, with the exception of the large one involving the
sacrum, which was as much as 2^ inches from the anus.

The growth may therefore be said to be one of the lower end of
the rectum, and is very rarely foimd above the last 3 inches of the gut.

Course. — Sarcomas differ from other neoplasms of the rectum in the
rapidity of their growth. They increase in size much more rapidly
than do carcinomas, and their fatal termination occurs much sooner.

Differing from sarcomas in other portions of the body, those of the
rectum are said to have a distinct tendency toward ganglionic infection
(Gillette, Union medicale, 1874, p. 629, and Tuffier, Arch. genl. de med.,
1888, p. 28). Early in the disease the lymphatic glands become en-
larged. In those cases in which the tumor involves the margin of the
51

802 THE ANUS, RECTUM, AND PELVIC COLON

anus, the inguinal glands will be the first to become involved; in thos
situated higher up in the rectum, the sacral, mesenteric, and hypo
gastric chains will be the first attacked. ^leunier (Bull. soc. d' anat
1875, p. 792) reports a case in which there was a black, tar-like infil
tration of the vertebral ganglia, and Tuffier {op. ciL) describes hiTJnj
found a pigmentary granulation in the blood in cases of melanotie ni
coma. This latter author, together with Gillette, insists upon th
glandular involvement as a diagnostic symptom of the disease. Ec
march, Grenet, and Tedenat deny this tendency to glandular imdn
mont. In the author^s cases it was present in 2 and absent in S.

ISIetastasis is one of the chief characteristics of sarcoma of the i«
turn, and should always be borne in mind in considering any «tteni|
at removal. The growth in the rectum may be a metastatic depod
itself, or, being primary, it may be associated with secondary develoj
ments in other organs, either of which conditions would contraindiGal
operation. This metastasis is sometimes very widespread, as in tl
case of ^laier, where the lung, the pleura, the peritonffum, and the liv<
were involved; in that of Peterson, the liver, the intestine, the kidne
and j)ancrea.s; and in that of Hamonic, the gums and the skin.

In one of the author's cases, in which an autopsy was not permitte
small sarcomatous nodules occurred over the abdomen, and extendi
almost as high as the axilla; before death the patient became jaimdice
apparently indicating the involvement of the liver, and one nodule d
veloj)ed on the inferior maxilla. On the other hand, these cases occ
sionally go for considerable periods without any metastatic deposits.

Histology. — There are several different varieties of this growth knoi
as round' or glohe-cell, spindle- or fimform-ceU, giant-cell, alveolar, iz
mixed sarcomas.

The round-cell, spindle-cell, and alveolar sarcomas are the ones th
occur most frequently in the rectum, although instances of the oth(
types have been seen.

There is a general impression that the so-called melano-sarcon
represents a distinct variety of this neoplasm. As a matter of fact, an
one of tliose enumerated may take on the melanotic change, which
due to the deposit of melanin in the tumor, giving it its color an
name.

Sarcomas of the rectum, as elsewhere, consist of embryonic, coi
nective-ti.ssue cells embedded in an intercellular substance which vari(
in amount and character. They contain, as a rule, very little fibroi
tissue, the mass being chiefly composed of embryonic cells. These eel!
are either uninucleated or multinucleated, and rarely possess a limitin
membrane (Fig. 200).

The variety of the tumor is determined by the shape, size, and ai

MALIGNANT NEOPLASMS-CARCINOMA AND SARCOMA

803

rangement of the colls. The consistence of the tumor depends upon
the character of the cells, the intercellular substances, and the presence
or absence of a fibrous stroma. Where there is an exeeas of fibrous
elements, the tumor is spoken of as a fibro-sarcoma.

The blood-vessels are very numerous, and are usually in direct con-
tact with the cells themselves or soparntcd therefrom by a thin layer
of fibrillary tissue. _

Their walls some- ^^gj^^^^J^ ^
times vary from fho
normal, being cen,-
posed of dcii^-'
packed embrjoi. >
cells, which, becom-
ing detached, are
carried along the
channels, thus ix-
plaining the s]iri,i '
of sarcomata in f.
direction of tl,
blood current.

^Vhen the tutim.
is of slow growth,
an apparent capsule
of thin, fibrous tis-
sue may be formed
around it. The
round-, giant-, spin-
dle-cell, and mixed
forms of sarcoma are
usually easily recog-
nized by the micro-
scope. The alveolar
variety is, however,
often confounded
with carcinoma. It
consists of a fibrous
stroma resembling
that of cancer, which

separates the sarcoma cells into groups. The cells are perfectly distinct
from the fibrous network, and are loosely adherent; the blood-vessels
follow the course of the fibrous tissue, and rarely if ever enter the cell
groups (Fig. 261). The chief method of distinguishing it from carci-
noma is by a close examination of the blood-vessels, the walls of which.

Fib. seo.— Boinnt- Am Sninii»«uuD Samxiiu. (HiciiUtad

I BpidenniH ; P, pnpill*, cul
C, rounii. nuclMled aai
spindWIiapfU rorpuiwlea

tnmsvamols ; it
; B, blood.vesBtl

804

THE ANCS, RECTUM, AND PELVIC COLON

in sarcoma, are generally absent or very thin, while in the carcinoma
we find them either nornml or in the thickened state.

Melanosis does not alter the type of the tumor or change the c-liarai-
ter of its component parts. It may involve but one part of the tumor,
while the other portions remain perfectly exempt. Where there are
several tumors or nodules In the part, one may be thorouglily impn^-
nated with the melanin, while the other remains perfectly free,

Occa onallv hTmorr! a^es occur m tl ese tumors owing to the thin-
ness of the blood vessel vails nh ch g vc them a dark appearance, atui

n ay mislead one
Wd L^ ^^^^^il^^'^^iMM^ '"^ supposing thai
fWf> *^^^^^^^^^^^^ the^ are melanotic.

that the hsenioglo-
hin of such extrafs-
sated blood mar
cause the pigmenta-
tion Ziegler, Sten-
l* gel and other an-
thers do not con-
sider this as possi-
ble, and account for
the pigmentation In
other ways.

Sarcomas of the
intestine develop
from the submaco-
sa, and ordiDarily
\L do not affect thi'
mucous membrane
except by pressure,
tension, and ulcera-
tion through trau-
matism and infec-
tion by the fa'cal
mass. In its earlier
stages, and fre-
quently after it haji
attiiincd consider-
able size, the mu-
cous nienihrnm- covering it retains its normal characteristics, and iniiy
be easily moved about over t)ie tumor, '

Eliiil'i'jy. — The causes and inllucncos which bring about the produc-

Moitn H 1 40( a iu n
I in c Cfl rorpuKLl h / pis ont cluKteiH
CO an unil. >ii hIIi; and pcur-HluiiK 1

C. I'ui'illury ; A, uriery : T, enliiioi'live li»iie.

OF MEOULLAHV CARCINOMA

MALIGNANT NEOPLASMS— CARCINOMA AND SARCOMA 805

tion of a sarcoma are as little known as those of carcinoma. Owing
to the recent results in the serum therapy there seems to be some reason
to believe that this neoplasm is the result of certain germs, to the life
of which the antitoxins used by Coley are destructive, though Coley has
not specialized any of these germs as causative influences. Inasmuch
as sarcoma of the rectimi originates ordinarily from the submucous tis-
sue, it can hardly be said that it is the result of superficial irritation,
as has been stated concerning cancer. What excites the hyperplasia
and development of the embryonic tissue is yet to be determined.

Age and Sex, — Age can not be proved to have any direct influence,
notwithstanding the fact that the majority of cases seen have been be-
yond the period of middle life. Nevertheless all are aware that sar-
comas occur in children of very tender years.

Of 29 cases collected, 12 were females and 10 males, practically
showing that sex has no etiological influence. The ages were given in
only 22 cases. Of these, 4 were below forty, 5 between forty and fifty,
10 between fifty and sixty, and 3 above sixty years of age. From this
one would conclude that the tumor was one rather of later years than
middle life, as is held by the majority of writers.

The tumors may originate in the rectum, thus being primary, or
they may occur here as a result of metastasis from tumors elsewhere
in the body. Grenet (Thesis, Paris, 1887, Xo. 231) related the case of
a young man who was operated on in August, 1880, for a small sarcoma
of the gum, and died five months later in a state of cachexia, showing
sarcomatous growths in the rectum and numerous other portions of the
body. He also cited one in which, he says, the eye was first involved
and later on the rectum. There is no positive proof in either of these
cases, however, that the rectal condition was not primary, and that of
the other organs secondary, the only evidence being that the first
symptoms elicited were those of the gum in one case, and of the
eye in the other. The practical absence of symptoms in the early
stages of this disease in the rectum renders it impossible to decide this
question.

Symptoms, — The symptoms of sarcoma of the rectum are at first
very vague. A sense of fulness or feeling of the presence of a foreign
body is sometimes described by patients as having existed for a long
time before consulting the surgeon. Sometimes the first noticeable
symptom is t)leeding or discharge of mucus. Cases differ exceedingly
with regard to haemorrhages. In one case with a very large tumor
there was no loss of blood; in another, in which there were two tumors,
the woman had bled until she was almost exsanguinated and pulseless.
The author operated with the patient in this weakened condition, and
she succumbed to the shock. Perhaps it would have been wiser to

806 THE ANUS, RECTUM, AND PELVIC COLON

have packed the rectum and tried to control the haemorrhage by styptics
until her circulation could have been restored in a measure, but inef-
fectual efforts had been made in this line before she was brought to
the clinic^ and it seemed imperative that this haemorrhage should be
checked at once.

In the large melanotic sarcoma shown in Plate VI, there was some
haemorrhage in the first few weeks of the disease, but after that there
was no loss of blood whatever. In the case of J. S., in which the sarcoma
recurred at the site from which an adenoma had been remoYed, there
were profuse haemorrhages and a considerable discharge of pus. In the
case of Mrs. P., there was a marked discharge of mucus tinged with
blood, but never any haemorrhage.

One would expect on account of the thin blood-vessel walls to meet
with excessive hsemorrhages from sarcoma in the rectum, but as the
growth is covered with normal mucous membrane, which remains intact
until the later stages of the disease, the true sarcomatous tissue is not
exposed to the friction and traumatism of the fa?cal mass, and conse-
quently the haemorrhages are not very frequent, especially in the early
stages.

The discharge of mucus is occasionally seen with these tumors, but
it is not so marked as in ei)ithelial tumors, because the hypertrophy is of
the submucous tissue and does not involve the mucus-producing cells.

Protrusion, — Protrusion is more frequent in sarcoma than in car-
cinoma, but less so than in adenomata and villous tumors.

Where the growth assumes a polypoid shaj)e and the pedicle is suf-
ficiently long, it may come entirely outside of the anus. Even where
it is sessile and situated just at the margin of the anus, eversion or
prolapse of the lower end of the gut may cause the tumor to protrude.

Where the tumor is pedunculated and tlius protrudes, severe hapinor-
rhages may occur on account of its being partially strangulated by tlie
sphincter muscles.

Where the growth is of tlie melanotic variety, it may be mistaken
for a gangrenous htvmorrhoid. On the other hand, even though mela-
notic in its center, the surface of the tumor may have a pale, yellowish-
red color, resembling an e])ithelionia. Such was the case in one of tho
author's patients, in whom Dr. Jeffries and he both mistook the growth
for an epithelioma.

Odor. — There is no odor peculiar to sarcoma. Before ulceration of
its nuieous surface takes place there is nothing more than the ordinaTT
normal fiecal odor to the ])arts. After the ulceration has oocurri'*!.
however, and there is a ])rodu('ti()n of ])iis, it changes to that of decom-
]K)sing tissue, but never assumes that peculiar characteristic and dis-
gusting odor which one finds in carcinoma of the rectum.

ePlTMELIOMA OF SIOMOID

a^^

MALIGNANT NEOPLASMS

MALIGNANT NEOPLASMS— CABCINOMA AND SARCOMA 807

Pain. — The amount of pain which a patient suffers with sarcoma
depends very largely upon its site. If it is low down and involves the
sphincter, thus inducing persistent contraction and pressure, the patient
will suffer greatly, but if it is high up in the rectum and of an infil-
trating form, he may go on almost to the very end without any knowl-
edge of his grave condition. This symptom is therefore a very un-
reliable one.

The State of the Bowels. — The state of the bowels in sarcoma of the
tectum also varies according to the type of the tumor; in some cases
"Constipation is complained of persistently, whereas in others diarrhoea
is almost uncontrollable.

In the large melanotic sarcoma, from which the plate was made,
ihis woman restrained the movements of her bowels on account of the
pain, and thus developed an inveterate constipation. In the case in
which the sarcoma followed the removal of the adenoma, this patient
suffered from a diarrhoea which one could not say positively came from
the sarcoma, because the man had two adenomas higher up in the rec-
tum which might have accounted for it.

General Symptoms. — Flatulence, indigestion, loss of appetite and
weight are associated with sarcoma of the rectum, as they are with all
other neoplasms of this organ.

Cachexia is not so marked as in carcinoma and villous tumor. The
reflex digestive disturbances are quite as severe. Decrease in strength,
loss of flesh, swelling of the feet and abdomen rapidly succeed one
another when the sarcoma is once well developed.

Dysuria is frequently present, and complete suppression due to
involvement of the kidney may occur. The lungs and pleura may
become affected, presenting symptoms of acute pleuro-pneumonia,
and the patient finally succumbs to progressive anaemia and ex-
haustion.

Diagnosis. — Sarcoma is to be distinguished from carcinoma, adenoma,
fibroma, and villous tumor. It is more pedunculated than carcinoma,
and less so than adenoma. It is more firm than the adenoma and less
so than carcinoma.

In its attachment to the gut it does not involve so large an area,
And it does not spread out, producing that wide infiltration of the
walls like carcinoma. Its attachment is very abrupt, and one can gen-
erally limit the extent of the growth very positively and clearly.

To the touch it is more undulating and spherical than carcinoma,
and the dendritic divisions which one finds in villous tumor and ade-
noma are absent. One may recall the fact that simple adenomas occur
largely in children, whereas sarcoma is a disease of middle or advanced
:age; nevertheless, it is occasionally found in the young.

808 THE ANUS. RECTUM, AND PELVIC COLON

When it is a question between saxcoma and multiple adenoma, the
very multiplicity of the growths, the excessive diarrhoea, together
with the comparatively fair condition of the patient's health, may be
mentioned upon the side of adenoma. Between sarcoma and carci-
noma the distinct odor of carcinoma is enough to make the decision
positive.

In the early stages of sarcoma, the fact that the mucous membrane
moves easily over the growth distinguishes it almost positively from
carcinoma. The final test, however, depends upon the microscopic ex-
amination of a section of the growth. It will not do, however, to depend
upon any superficial portion in order to make this diagnosis. The
growth is a submucous one, and the section to be reliable must be
taken from the substance of the tumor itself and not from the super-
ficial mucous covering. It is inadvisable to make any incision into these
growths for the purpose of obtaining a section, unless the case is an
operable one and the patient consents to a removal, if the microscopic
examination should show a necessity for the same.

Any meelianical irritation or interference with such growths only
stimulates their progress and hastens the end, unless they are radically
extirpated.

Treatment. — The treatment of these tumors consists in their radical
removal. A ligature to pedunculated sarcomas ought never to be con-
sidered for one instant. The growth extends into the submucosa, and
the ligature is sure to leave behind it portions of the disease. The
tumor should be removed radically and widely at its base. If it is
situated in the ampulla and limited in extent, posterior proctotomy may
enable one to excise it thoroughly and bring the edges of the wound
together; but if it is extensive and diffused, involving much of the cir-
cumference of the rectum, total excision or resection of the organ is
the only recourse available. The technique of these operations will be
described in the chapter on Extirpation.

While there seems to be some evidence in favor of the effective-
ness of the serum therapy in sarcomas elsewhere, the advocates of this
method give no encouragement in the treatment of this condition in
the rectum. Recent experiments in the use of the X-ray in the treat-
ment of sarcoma give some encouragement to hope that this line of
treatment may prove successful in this disease. In the present state
of our knowledge the author believes that it would be a wise precaution
in inoperable cases, or even after the tumor has been removed, to apply
the rays to the seat of the disease. If cautiously employed, no harm
can result from it, and it is possible that recurrence may thus be pre-
vented.

Prognosis, — The prognosis in sarcoma of the rectum is exceedingly

MALIGNANT NEOPLASMS-CARCINOMA AND SARCOMA 809

grave. Its tendency is toward a wide metastasis and rapid fatality. Very
few of the cases survive more than one year after operation. Paul (Brit.
Med. Jour., 1895, vol. i, p. 519) has reported a case living without re-
currence one year, Bemays (Jour. Amer. Med. Ass'n, April 3, 1897) one
five years, Ball (Brit. Med. Jour., 1895, p. 693) one nine years, and
Esmarch (Deutsch. Chirurg., Bd. v, S. 516) one five years. The author
reported a case to the Chicago Academy of Medicine in January, 1897,
which is still free from recurrence five and a half years after operation,
and in perfect health. The patient from whom the extensive melano-
sarcoma shown in Plate VI was removed September 21, 1899, was living
and well two years after the operation. The microscopical examinations
of these cases were made by Drs. Heitzmann, Vissman, and Jeffries, and
there can be no doubt as to the pathological nature of the growths. One
was lympho-sarcoma, the other melanotic spindle-cell sarcoma. These
cases, while few, show that extirpation of these growths is not utterly
hopeless.

CHAPTER XX

EXTIRPATION OF THE RECTUM

The operation of removing the rectum is now almost two centuries
old. Faget performed it in 1739, but Lisfranc first successfully ex-
tirpated the rectum for cancer in 1826. The results of the operation
in 9 cases were embodied in a thesis by one of his students (Pinault,
Thesis, Paris, 1829, No. 167), and in 1833 the great surgeon himseli
gave to the world a complete accoimt of his operation and method,
thus establishing the procedure as a surgical measure (Memoires de
Tacademie royale de m^decine, 1833, t. ii, p. 296). The results ii
these cases were not calculated to create any great enthusiasm, for the
mortality was high owing to the lack of aseptic technique; nevertheless,
; surgeons oscillated in their opinions between this operation and thera-

I peutic measures for the next half century. As late as 1876 Sir Henn

Smith said: " I should have thought this " (excision of cancer of rectuml
" " was entirely a part of the surgery of a bygone age, and that th(

i recorded experience of those who had performed these operations in

;j France and in this country would have sufficed to put an end to al

I such barbarism."

Up to this period the operation had been confined to growths lo^

down in the rectum, and was performed either through perineal in

cision or through the anus itself. Vemeuil, adopting the suggestioi

of Amussat, first practised the removal of the coccyx to obtain bette:

^ access to the tumor, but the operation attained only slight popularit;

j[ imtil Kraske's epoch-making paper before the fourteenth congress o

• German surgeons in Berlin in 1885. His suggestion to remove a portioi

of the sacnmi, in order to reach neoplasms involving the upper portioi
' of the rectum, revolutionized the surgery of these parts, and gave ai

- impetus to the operation of extirpation which has probably carried u

for a time bevond the limits of true conservatism. Soon after the an
nouncement of Kraske, many surgeons, notably Hochenegg and Bai
denheuer, advocated removing larger portions of the sacrum so as t
widen the field of operation. This tendency reached its maximum i
the method of Rose, which practically obliterated the entire bony floe
810

EXTIRPATION OP THE RECTUM 811

of the pelvis. In order to obviate this feature, Levy, Rehn, Rydygier,
and Billroth proposed to make bone-flaps containing the coccyx and
lower segments of the sacrum, which would be sutured back into posi-
tion after the rectum was extirpated.

About this time Desguins first employed the vaginal route in extir-
pation of rectal cancer (Annales de la soc. de m6d., D'Anvers, September,
1890). Price (Med. and Surg. Reporter, May 16, 1896) and Arthur
[Amer. Jour, of Obstet., 1881, vol. xxiv, p. 567) had previously made
use of the vagina as a point for the implantation of the gut after extirpa-
tion of the rectum where it was impossible to bring it down and suture
it to the margin of the anus, but neither of them suggested attacking
the growth through this canal.

Later on in 1894 and 1896, Giordano and Quenu (Clinica Chirurg.,
Vlilano, 1896, f. 463; Chirurgie du rect., t. ii, p. 290) found it difficult to
control haemorrhage and dissect out the enlarged ganglions above the
sacral prominence by the foregoing methods, and advocated opening the
abdomen, loosening the attachments of the upper rectum and sigmoid,
and the establishment of an artificial anus; after this the rectum was
dissected out from below either through the perineal or sacral route.
These efforts created what is known as the combined method for extir-
pation of the rectum. They were preceded, however, in this method
by Maunsell, who advised in 1892 a laparotomy to loosen the upper rec-
tum and sigmoid from their attachments to the sacrum, the invagina-
tion of the growth through the anus, and resection of the neoplasm
thus brought outside of the body. Recently extirpation through the
abdominal route alone has been advocated by Mann and Edebohls.

Prom this brief sketch it will be seen that there are five general
methods of accomplishing extirpation — the perineal, the sacral, the
vaginal, the ahdominal, and the combined.

Preparation of the Patient. — Before describing these methods in de-
tail it may be well to consider the preparation of the patient, which
is practically the same in each. In order to obtain the best results it
is necessary to increase the patient's strength as far as possible by
forced feeding for a time, to empty the intestinal tract of all hard and
putrefying fjecal masses, to establish as far as we may intestinal anti-
sepsis, and to check in a measure the purulent secretion from the growth.

It requires from seven to ten days, or longer, to properly prepare a
patient for this operation. The diet best calculated to obtain a proper
condition of the intestinal tract is generally conceded to be a nitroge-
aous one. The absolute milk diet is not so satisfactory as a mixed diet
composed of meat, strong broths, milk, and a small quantity of bread
md refined cereals. The patient should be fed at frequent intervals,
md as much as he can digest. Along with this forced feeding one should

812 THE ANUS, RECTUM, AND PELVIC COLON

administer daily a saline laxative which will produce two or three tl
movements, and to disinfect the intestinal canal one should give throu
the stomach three or four times a day either sulphocarbolate of zi
grs. ijss. in the form of an enteric pill ; naphtholene, grs. xv in a capsn]
beta-naphthol, grs. x, or salol, grs. x, in the same manner. The recti
should be irrigated three times a day with solutions of bichloride
mercury 1 to 5,000, permanganate of potash 1 to 1,500, or, as has be
recommended by Quenu (Soc. de chir., February 23, 1898), peroxi
of hydrogen. This solution is made by mixing one part of the peroxi
of commerce with three to four parts of boiling water. Qu^na stal
that it causes no irritation in the mucous membrane, that it deodorii
the cancer in a few hours, that its action is persistent, and that it c
stroys the micro-organisms more effectually than any other substani
On the day previous to the operation the perinaeum, sacral regie
and pubis should be shaved, dressed with a soap poultice for two hou]
then washed and dressed with a bichloride dressing, which should
retained until the patient has been anaesthetized. Notwithstanding i
these preparations it is impossible to obtain absolute asepsis of tl
affected area, and so many fatalities occur from infection, either durii
the operation or through the giving way of the sutures and pouring a
of the intestinal contents into the wound, that it is deemed wise 1
many surgeons to make an artificial inguinal anus as a preliminary pr
cedure in all extirpations of the rectum. Schede (Deutsch. med. Wocl
Leipzig, 1887, S. 1048) first took this precaution, making the colotoi
at the same time that he extirpated the rectum, thus diverting the f»c
current from the operative field and reducing the chances of sepsis fro
this source. This method has been largely adopted by surgeons all ov
the world; some make a permanent inguinal anus to begin with, closi
up the distal end of the sigmoid and dropping it back into the intestin
cavity, where it is either left or removed along with the cancer (Kec
Jour. Am. Med. Assoc, 1898); others make a temporary inguinal am
which is closed later on if it is found feasible to restore the faecal e3
to its normal position at the anus. Some advise making this anus
the sigmoid, others in the transverse colon, and still others in t
ascending colon just above the caecum. The wisdom of this precauti
can not be questioned in very many cases, but its necessity is open
debate. It involves either a threefold operation or the establishme
of a permanent inguinal anus, both of which are to be avoided if pes
ble; and if it is made in the sigmoid it may prevent the gut being broug
down sufficiently to reestablish the intestinal canal. The question thei
fore arises, When is this procedure necessary? It appears to the autb
that where the cancer is low down and the caliber of the gut is sufficien
great to enable one to thoroughly empty the intestinal canal of all fae^

EXTIRPATION OP THE RECTUM 813

accumulations above it, where it is perfectly clear before beginning the
operation that one will be able to bring the gut down from above and
suture it to the margin of the anus, this procedure is not indicated.
When there is any doubt with regard to the possibility of accomplishing
this latter operation, the preliminary artificial anus ought always to be
made. The author is opposed, however, to making a permanent colos-
tomy except in those cases where the extent of the growth renders it
certain that the normal faecal tract can not be restored. A preliminary
artificial anus that may be readily closed can be easily made if, after
manual examination of the pelvic cavity, one is persuaded that he can
extirpate the cancer and restore the intestinal tract. In the chapter
on Colostomy the manner of accomplishing this is thoroughly explained.
If after extirpation it is found that the intestinal tract has not been
restored, it is always possible to convert the temporary into a perma-
nent artificial anus with comparatively no danger to the patient. In the
32 cases operated upon by the author, artificial ani have been made in
10 cases. Of these, 3 resulted fatally, thus giving a slightly higher
mortality than that obtained in operations without preliminary colot-
omy. It is not meant by this to claim for one instant that the arti-
ficial anus increases the mortality from extirpation. The author firmly
believes that if it were consistently employed in every extirpation of
the rectum, the mortality from this operation might be slightly reduced;
but he also holds that in the class of cases mentioned above the two
additional operations can be avoided with comparative safety. Where
the artificial anus is employed, one should not be in too great haste to
carry out the extirpation. A period of ten days or two weeks should
be allowed to elapse between the two operations. During this time
the rectum should be irrigated through the lower end of the artificial
anus and through the anus with antiseptic solutions, and at the same
time one may take advantage of this period to employ forced feeding,
tonics, and stimulating remedies to improve the patient's general con-
dition and better prepare him to withstand the shock of operation.

It has been suggested by E. II. Taylor (Ann. of Surg., 1897, vol. i,
p. 385), that where the cancer is soft and ulcerated, one may employ
curettage to remove the sloughing and suppurating portions of the
growth, following this for a few days by frequent irrigations, and then
carrying out an extirpation by whatever method is deemed best. This
procedure has not been generally adopted by surgeons, and possesses
no advantages over the preliminary artificial anus.

Perineal Method. — Under this method mav be included certain
operations for small epitheliomas low down in the rectum done through
the anus. The procedure is carried out as follows:

The patient having been properly prepared, the sphincter is thor-

814 THE ANUS, RECTUM, AND PELVIC COLON

oughly dilated; a circular incision through the entire wall of the
is made 1ml f an inch below the neoplasm; this incision may entii
surround the rectum, or it may be limited to half the circumfere
when the growth is confined to one side; the upper segment of the gu
then caught with traction forceps and dragged upon by an assistant wj
the operator frees it by scissors and blunt dissection to a point at 1(
half an inch above the cancer; it is then cut transversely well above
growth, the upper segment being caught by forceps to prevent retracti
finally, this end is brought down and sutured to the lower edges of
original incision (I^edru, Cong. Franc, d. chirurg., 1891, p. 319; Hi
mann, ibid., 1893, p. 698; Routier, Exerese dans le cancer du recti
Finet, p. 204). The cases to which this method is applicable are v
rare; moreover, the procedure is open to the objections that it is v
likely to be followed by septic infection, and furnishes no opportui
to remove any aifected glands.

Numerous methods have been devised by various surgeons for
tirpation of the rectum by the perineal route proper. The old operatic
of Lisfranc, Dieffenbach, Velpeau, and Vemeuil are no longer e
ployed. The V-shaped incision of Schelky (Berlin, klin. Woch., 18
No. 32), the lateral incision of Hartmann through the ischiatic fo
(Quenu and Hartmann, op. cit., t. ii, p. 249), and the H-shaped
cision of Depage (Ann. d. 1. soc. Beige d. chir., 1893, No. 6), are
to be rejected on account of the vast areas of tissue laid open and 1
unsatisfactory access to the rectum which they give.

The methods of Cripps and AUingham have long been very popu
in extirpation of cancers in the lower portion of the rectum.

Cripps* s Method. — A long, sharp-pointed, curved bistoury is int
duced through the anus and made to penetrate from within outward
the tip of the coccyx; all of the intervening tissues are then cut throu]
thus Laying the rectum open up to this point; lateral incisions are tl
made around each side of the rectum, either through the skin outsi
of the sphincter or through the mucous membrane above the muse
according to whether the anus is involved in the neoplasm or not; th(
incisions should be made deep and boldly at one sweep, the woui
being immediately packed with gauze to control haemorrhage; after tl
the rectum is freed from its lateral and posterior attachments by sciss(
and dull dissection to a point well above the cancer; these parts of t
wound are then packed with gauze and the rectum is dissected off a
teriorly from the perina^um, urethra, and prostate; this step is soir
what difficult, and a good-sized sound should be kept in the ureth
during the procedure in order to avoid wounding this organ. If t
growth is limited to one side of the rectum, only this portion is d
sected out. After the dissection is completed the gut is amputat

EXTIRPATION OP THE RECTUM

815

above the growth by a wire eeraseur or a galvano-cautery loop. Unless
the growth is very low, no attempt is made to bring the gut down and
suture it to the anus, but a drainage-tube is introduced into the upper
segment, and after the ha?morrhage is controlled the wound is packed
with sterilized gauze. The gap between the anus and excised gut is
left to heal by granulation.

Allingham's Method, — The chief feature of this procedure consists in
a deep dorsal incision; with the left index finger in the rectum, a long,
narrow bistoury is introduced through the skin just posterior to the
anus and carried through the post-rectal tissues above the upper limits
of the growth entirely outside of the rectum; the tissues between this
and the sacrum
and coccyx are in-
cised from this
point downward at
one stroke ; the
wound is packed
with sponges to
control the bleed-
ing; an incision is
then made all
around the rec-
tum (Fig. 262) and
between the two
sphincters if the
anus is not in-
volved, and the external muscle is incised at the posterior commis-
sure; the muscle is thus left in the skin-flaps; with the finger in the
rectum one blade of a long scissors is introduced into the posterior
wound, the other is thrust into the ischio-rectal fossa, and the in-
tervening cellular tissues cut through. Each side is treated in the
same manner, and the wounds packed with sponges. The outer edges
of the wounds being held apart by broad, flat retractors (Fig. 263),
the surgeon then proceeds to dissect the anterior portion of the
rectum loose from its attachments. A sound should be held in the
urethra in men and an assistant's finger in the vagina in women to
prevent wounding these organs. After the gut has been dissected out
well above the tumor, it is caught by rectangular clamps and cut off
below these. Bleeding is controlled by ligatures and equal parts of hot
water and alcohol. AUingliam states {op, cit,, p. 358): " In most of our
eases it was absolutely impossible to bring down the stump of the rectum
to the skin; if, indeed, these parts could be brought together, the ten-
sion would be so great that the sutures would be torn out in a few

Fio. 262. — Line of Incision in Perineal Proctectomy by

Allinoham^s Method.

THE ANUS, RFXTUM, AND PELVIC COLON

Fjo. 263.— Secui

Mmuuu (MMIiewH).

hours," The rapidity with nhieh this operation can be done aod the
preeorvation of the external sphincter comprise its chief advantages.

Tliese operations are open to the same objections; thev do not remove
the affected f,'an{;li(>ns, they leave a section of the rectum to be repro-

EXTIRPATION OF THE RECTUM

S17

dueed Ly granulation, and they inevitably lead to infection and pro-
longed suppuration. For this reason the writer no longer practises
them.

Kecognizing the facts that the mortality from extirpation of the
rectum by the perineal route is much lower than by any otiier method,
and that the deaths are largely due to sepsis following the operation,
surgeons have long sought to devise for this measure some eiHcient
antiseptic technique. Infection occurs during the operation from intro-
ducing the finger into the rectum and then into the wound, or from
cutting or tearing the recta! wall so that its contents flow out into the

fcpei

srative field; after the operation it occurs from the passage of faces
'er the fresh wound. In order to avoid tlie latter, a preliminary arti-
ficial anuB may be employed. To avoid the former, one must absolutely
close the lower end of the rectum and keep well away from the wall of
the gnt in his dissections. These ends are largely accomplished by the
technique of Qu^nu (Rev, de gynec., September and October, 1898).
"With some slight modifications introduced by the writer, this proceeding
is as follows:

The patient, after being properly prepared, is anFcsthetized and
ilaced in the lithotomy position, the hips being well elevated above the

818

THE ANUS, EECTUM, AND PELVIC COLON

shouldors by cufihioim or inclination of the table; the rectam b i
irrigiited, dried out, and loosely packed with gsiize in order that
may rccoj^ize a cioac approach to its walla during dissection; a circ
incLjiuu is then made tlivough the akin around the anus, and thia is

eectc<i up inaide of the sphincter to the extent of about J an ii
Around the cylinder thus dissected loose a strong silk suture is li
the ends of which are left long for purposes of traction (Fig. 261);
extremity of the anus below the ligature is then cauteriztKl wit!
Paquelin blade to destroy any infectious germs which it may eontJ
The external sphincter is then inciseil anteriorly and posteriorly
tirely outside of the rectum, the posterior incision being carried b<
to the tip of the coccyx and well into the retro-rectal space; the twli
is then dissected from its attachments laterally and posteriorly, I
sphincter being left in the skin-flaps, if it is not involved in thegmwi
in doing this the levator ani muscle should be cut off as close to t
rectum as possible {Fig. 265). The skin and sphincter muscle Iwri
been incised in the median line anteriorly as far as tlie junction in
the scrotum, the rectum is drawn backward and dissected loose i
teriorly up to the level of the levator ani, which is much highfT he
than poetcriorly. The finger is then introduced from behind fnrwK

EXTIRPATION OF THE KECTUM

819

above the anterior fibtTS of the levator and tlie deep perineal fascia,
and by gently ilragging downward these are separated from the rectum
in the lines of cleavage; when this has been aceoinplished on hoth sides,
the anterior attachment of the levator and ano-bulbar rhaphe to
the rectum are cut through U[>on the linger, and the organ is thus
freed in its entire circumference. This accomplished, the operator
reaches the superior pelvi-rectal spaces filled with cellular tissue, from
which the rectum can be separated by the finger until the peritoneal
cul-de-sac is reached in front (Fig. StiC). At this point the lateral con-
nective-tissue folds which support the rectum on the sides must be
clipped with scissors, and then the gut will descend well outside of the
wound. Sometimes the pcritonseum can be stripped off from the rectum
and its cavity need not be opened; it is better, however, to open the
cavity at once when the growth extends above this point. Before doing
this it is well to disarticulate the coccjs and fold it backward in order to
obtain more room, nm! r^cpiirutf llir rei-lum from the sacrum by break-

F,o. 2«,-I*iuii>EAL EII1E1-ATIOH-TI.Z Pkritokea:. T.

ing up the cellular and fibrous attachments with the fingers. The peri-
tona>um is then incised (Fig. 267), cut loose from its attachments close
to the rectum back to the mesorectum (Fig. 2fi8), which should be cut
close to the sacrum in order to avoid wounding the inferior mesenteric
artery. When the gut has been loosened sufficiently above the tumor

820

THE ANUS, HECTUM, AND PELVIC COLON

to be brought down and sutured to the anus, one should proceed to clos*
the peritoniL'um and restore the planes of the pelvic floor down to the
levntor ani by fino cat{,'ut Buturos. Afti?r this has been iiccomplishcd the

P, lawral poritonettl lolds ; V, (rkiidulur unliirBOniiiut bulwcan foUa of mesorrctain.

the gauze should he romoved, and the gut flushed with a solution c
bichloride of mercury or peroxide of hydrogen. It is then ampubitcd
through healthy tissue above the tumor, and its upper end sutured at
the original site of the anus. Qu^uu advises that in amputating, eack
layer should be cut separately in order to avoid ha:?morrhagi\ bul thvrt
appears to be no advantage in this; in fact, we are much more likely
to meet with deficient blood supply, causing subsequent sloughing of
the gut, than with haemorrhage. The posterior and anterior portions
of the perineal wound are packed with gauze and left open to set
drainage (Fig. SC9), and the parts arc covered with aseptic pads held
in position 'by a well-fitting diaper or broad T-bandage. A large drainagi?*
tube is passed well up into the rectum, its lower end extending outsiiit
of the dressings in order to convey the discharges and gases beyond thff
operative wound. This procedure is applicable in the female, lint it
is somewhat diflieult to avoid wounding the vagina, and llierc is alwajB
danger of infection from this organ during and after the operation. It

EXTIRPATION OP THE RECTUM

821

does not appear to possess any advantages in women over the vaginal
route.

In incising the peritonieum, it is the author's practice to begin at
the lowest portion of the anterior cul-de-sac and cut close to the in-
testine up to the niesorectuni. From this point upward he incises the
peritoneal fold as close to the sacrum as possible; first, because il
avoids the danger of wounding the superior hiemorrhoidal artery, and,
second, because it removes along with the growth all glandular enlarge-
ments in the mesorectuin. As can be well understood, the operation
is not applicable to those cases in which the tumor is isolated well
above the rectum, and can be resected, leaving a healthy area of 8 inches
or more between the anus and the growth. In other words, where resec-
tion is feasible, the perineal route is not to be advised; where amputa-

tion is necessary, this route should be employed. The author has suc-
cessfully removed 5 inches of the gut by this method.

Sacral Method: Kraske's Operation. — These terms are applied
to various operations in which access to the rectum is obtained by re-
moving the coccyx or cutting off certain portions of the lower end ot
the sacrum. They are all modifications of Kraske's original method.
^^n some the coccyx and parts of the sacrum are removed altogether, in

822 THE ANUS, RECTUM, AND PELVIC COLON

others they are left in the flap, and restored to their normal positio
after the operation is completed.

Kraske removed the coccyx and left lower angle of the sacrum (Fi
270); Ilochenegg the lower end of the l)one by an oblique section extem
ing from llie third sacral foramen on the left to the notch below tl
fourth foramen on the right (Fig. 271); Bardenheuer cut the bone squar
ly across just below the third sacral foramina, and removed all that po
tion ])eh)w tliis level (Fig. 272); Kose went higher and removed all bclc
the second foramina (Fig. 273). Kraske, recognizing that suflSciei
spice was not always furnished by his original method, revised it (Be
lin. klin. Woch., 1888, No. 48), and laid down the guiding principles
all these operations by stating that only so much of the sacrum shou
be removed as is necessary to reach all the disease, and in many c^
excision of the coccyx alone will accomplish this. Senn (Surgical Tecl
ni([ue, Fsmarch and Kowalzig, Amer. edit., 1901, p. 821) limits him!>e
to this excision.

Ileinecke, recognizing the disadvantages of removing any of the bou
floor of the j)elvis, flrst proposed osteoplastic resection of the ooccj
and sacrum (Miinch. med. Woch., 1888, Bd. xxxvii). He made a media
incision from the posterior border of the anus to the fourth sacral fon
m(»n, divitled the coccyx and sacrum longitudinally with a saw, and the
chiseled the sacrum off transversely below the foramina in order to pn
serve the fourth sacral nerv'cs; he then turned the flaps of bone an
soft tissues aside and thus exposed the rectum (Fig. 274); Gusser
bauer followed the same plan, but made the transverse cut just belo^
the second sacral foramina. Levy (Centralbl. f. Chir., 1889, No. 13
made a rectangular flap, including the bone and soft tissues below th
level of the fourth sacnil foramen, and dragged the flap do\*Tiwar<
(Fig. 275). Finally, Rehn (Deutsch. Cong. f. Chir., 1890) and Rydygio
(Centralbl. f. Chir., 1893, No. 1) proposed the following method: \]
oblique incision is made through the soft parts on the left side of thi
sacrum from the posterior superior spine of the ilium to the tip of ih
coccyx, and thence in a median line to the margin of the anus: i
transverse incision is then made at the level of the third sacral foramen
and the bone chiseled off transversely at this point; the bone and tissm
flap thus formed is now drawn aside, exposing the posterior surface oi
the rectum (Fig. 27(1), and extirpation is then carried out.

The author adopts a modification of this plan in preference to all
other sacral methods for the following reasons: It furnishes a rapi'l
and adequate approacli to the rectum; it facilitates the control of luTni-
orrhage; it restores the bony floor of the pelvis and attachment of the
anal muscles; it involves injury of the sacral nerves and lateral sacral
arteries on one side only.

BXTIEPATION OP THE RECTUM

The technique whicii he employs is as follows: The patient is
previously prepared as heretofore described, and an artificial anus
established or not as the conditions indicate; before the final scrub-

Fif[. S7B.— Brdjffrior's.
FiM. S70-aTT.— MrfHoDB ot S*fi

bing. the sphincter should be dilated and the rectum irrigated with
bichloride solution (1 to 2,000) or peroxide of hydrogen; it should then
be packed with absorbent gauze so that the finger can not be intro-

THE ANUS, BBCTUH, AND PELTIC COLON

duciKi into it; the patient is then placed in the prone poeition c
left siile, with the hips elevated on a hard pillow or sand-bag: after fl
operative fiehl haa been thoroughly cleansed an oblique incision is inadc
from the Icvfl of the third foramen on the ri^ht side of the mcmin
down to the tip of the coccyx, and extcndeil Iialf-wa}- between this point
and the posterior margin of the anii^. This incieioii should be made
boldly with one stroke through thi; skin muscles and ligiiments into
the cellular tissue pfjsterior to the rectum; the latter is rapidly scparalf>d
by the fingers from tiie sacrum, and the space thn? foriucd, together
with the wound, sliould be firmly packi^d with sterilized gauze (Fi^^

a transverse incision down to the bone is then made at the level o£B

fotirtii sacral foramina, the bone is rapidly chiseled off in this line, bd^
the triangular flap is pulled down to the left side, where it is held bj
the weight of a heavy retractor attached to it. At this point it is usually
necessary to catch and tie the right lateral and middle sacral arlerii'S-
Frequently these are the only vesecla that need be tied during the
entire operation of resection, although, if one cuts too far away from
the sacrum, the right sciatic artery may be severed. The relatione of ihe
parts thus exposed are well shown in the cut (Fig. 27B), made from a
very old picture lent to the author by Dr. A. T. Cabot, of BostOD-

^^^^^■' 'wVxTv^'' 'MT^SjtfjJiJI'fe^l ' 1

s, 370.— 8»oiiiT« RKHovF.n TO KSFtiBE Bk.tib *kd otiikb Fii.tic Ohoanh (pHrtly Bohematio).

A, superior hiBmoirboiilal ari«r>- ; B. vus ilcftrons ; C urolnr; 0, lutcrul BBcml uMury ;
£, neniuial v«jii>lL-» : f, rL'ttiLia ; O". bWder. (t'libot,)

fi2(> TBE ANUS, RECTITM. AND PELVIC COLON ^H

The first step in the actual estirpation of the rectum cnn^
isolating the organ below the level of the resected sacrum so that a
ture caa be thrown around it, or a long clamp applied to cooLrol
bleeding from its walls (Fig. 280). If the neoplasm extends above

level and it is necessary to open the peritoneal cavity to extifj
should do this at once, as it will be found much easier to dissect tfw
turn out by following the course of the peritoneal folds. By opening
perttnmeuni and incising its lateral folds dose to the rectum (Fig. '
the danger of wounding the ureters is greatly decreased and the g
much more easily dragged down. When the posterior peritoneal foji
mesoreetum is reached, the incision should be carried as far away i
the rectum, or rather as close to the sacrum, as possible in order lo a
wounding the superior hfemorrhoidal artery, and to remove all the a
glands. The gut should be loosened and dragged down until its hea
portion easily reaches the anus or the healthy segment below the gn
(Fig. 288). A rubber ligature or strong clamp should then be placed t
the intestine about 1 inch above the neoplasm, hut should never be pli
in the area involved by it, for in so doing the friable walls may rop
and the contents of the intestine be poured out into the wound.

EXTIRPATION OP THE RECTUM 827

soon as the gut has been sufficiently liberated and dragged down, tbe
peritoneal cavity ehould be cleansed by wiping with dry sterilized gauze,
and then closed by sutures which attach the membrane to the gut (Fig.
282, P). By this procedure the entire intraperitoneal part of the opera-
tion is completed and this cavity closed before the intestine is incised.
Aiter this is done the gut should be cut across between two clamps or lig-
atures above the tumor, the ends being cauterized with carbolic acid, and
covered with rubber protective tissue. The lower segment containing
the neoplasm may then be dissected from above downward in an alnioot
[ bloodless manner until tbe lowest portion is reached. It is much mote
isily removed in this direction than from below upward, and there is
5 danger of wounding the other pelvic organs. If the neoplasm e\-
( within 1 inch of the anus it will be necessary to remove the
mtire lower portion of the rectum. If, however, more than 1 inch
E perfectly healthy tissue remains below, this should always be pre-

served. Having removed all of the neoplasm, if 1 inch or more of
healthy gut remains above the anus, one should unite the proximal
and distal ends of the gut either by the Murpby button or end-to-end
suture (Fig. 283). The author has applied both methods about an equal

THE ANUS, RECTUM, AND PELVIC COLON

number of times. He is of the opinion that through-aDii-through suture
of the intefitino irf quite as Batisfactory as any other method. Posterior

I
I

Fi8. asa.— KouitTB Step in Bii(iE-rL*p Omkatiob.
B, reGtum: ShrigmDid; £, siu orrvcto-veKico! cnl-iU-Htc; P, piiritoiiuil caritj eloMiL

fietula follows in almost every case, but it generally heals spontanvousl,*,
anil need give no Bfrious concern.

^\Tiere there is less than 1 inch of the rectum left below, and th*
giit can be easily brought down to the anus, it ia well to dissoct off
the mucous membrane from the latter organ, invaginatc the upper end
of the intestine through this, and suture it to the skin outside. The
gnt is not sutured to the margin of the anus, hut entirely ouside of
it, in order that the fa?cal passages will not come in cuutact with the
line of union between the freshened portion of the anns and th«
peritoneal surface of the gut which has been dragged dowD. N*
tension should be employed in bringing the gut down to [losilion. After
it has been fixed in place, a large silk anchoring suture is pUced
in the mesorectum about 3 inches above the anus and attached to the
skin outside the lower angle of the wound, in order to prevent retraction
of the gut and tension on the sutures. In some instanct>B in which, cnn-
trary to expectations before the operation, we are unable to reunite the
ends of the intestine or to bring the proximal end down to the anae. it
is neeessary to attach the latter at a higher level in the wound, thus

EXTIRPATION OF THE KECTUM

829

forming what U known as a sacral anus (Fig. 284). All oozing is checked
by hot compresses, and the concavity of the sacrum is packed with a large
mass of sterilized gauze, the end of which protrudes from the lower
angle of the wound; this serves to check any oozing and also furnishes
a support to the bone-flap after it has been restored to position. Finally,
the flap is fastened back in its original position by ailkworni-gut sutures,
which pass deeply through the skin aud periosteum on each aide of the
transverse incision. Suturing the bone itself is not necessary. The
lateral portion of the wound is closed by similar sutures down to the level
of the sacro-eoecygeal articulation; below this it is left open for drainage
(Fig. 385). A large drainage-tube is carried up through the gut beyond
the line of intestinal sutures, and the whole is dressed with sterilized
absorlx-nt gauze held in position by adhesive straps and a firm T-bandage.
The patient is placed in bed, lying upon the back or right side, and the
head of the bed is slightly elevated in order to prevent any concealed
hsemorrhage escaping upward into the peritoneal cavity. It is important

The growth boa iuxa rtnKutud nnd tbe euda of the intuatlau linve been nuturtJ logethor.

that the surgeon should know exactly how much oozing is taking place
from the wound; the decrease in oozing accomplished by raising tha foot
of the bed does not compensate for the dangers of concealed bleeding.

830

THE ANUS. RECTUM, AND PELVIC COLO:

Usually there is considerable oozing for the first twe
following the operatioD, during which time the outside d
be replaced by fresh ones several times, the inner dresi
in situ for seventy-two hours. After this they are remo
drainage-tubes or small gauze strips introduced into the
sacrum. The patient is encouraged to get upon his f
possible in order that the parts may drain more easily
weight of the abdominal contents will press the pelvic
in contact with the sacrum, and thus hasten the filling ie

The patient is kept upon concentrated liquid diet, ai
nary artificial anus has not been employed his bowels sboi
by opium for the first ten days, after which they are mo\
of oil and glycerin.

This technique has now been employed for six years;
that of Rehn and Hydjgier in the following points: First,

Fio. !64.— Eaciul Aki«.
Made in boneHap operaUon when it waa impowlblc to establish aperture 1:

made upon the right side of the sacrum because it is m
venient to operate from this side, the bone-fiap falls o
through gravitation, and because the rectum is slightly n
side of the sacrum at its lower end; second, the peritoi

;he operation is completed and the cavity closed before the gut is J

)pened at all; third, the extirpation of the rectum itself is made from (

ibove downward, in which line the elearage of tlie parts ia much more I

"ly determined tliaii from below upward; fourth, the haemorrhage

EXTIRPATION OF THE IlECTUM

S31

)ractioalIy controlled by tying off the middle and lateral sacral arteries
□ the beginning, and clamping the superior biemorrhoiiial artery before
he lower dissection is made. The author does not mean to claim any
iriginality by pointing out these distinctions, but simply to impress
tpon the reader tlie points in which he has found it advisable to modify
he original Rehn-ltydygier technique.

The objections urged against this operation are that the boue does
lot reunite, and necrosis ia likely to occur. The author has not seen
, single ease of necrosis follow the bone-flap operation, and in every
■ase in which he has employed it the bone has reunited in fairly accurate
losition. In two or three cases suppurating sinuses through tiie trans-
erse incision have developed, but they have invariably healed without
econdary operation. Some operators do not suture the flap back in
losition, and claim that to leave the entire wound open furnishes better
Irainage and affonls a safeguard against sepsis. It appears, however,
hat the long, oblique opening below is sufficient for this, and that

833 THE ANUS, BECTUM, AND PELVIC OOIiON

suturing the bones in position accomplishea a more accurate reslomtion
of tho parts and quicker healing.

The other modifications of Kraske's operation consist simply in dif-
ferent incisions of the soft parts and treatments of the bones a* is
seen in the illuBtra-

tioDB (Fig8. sea to

276), The technique
of removing the rec-
tum after it is exposd
io the same in all
They possi'ss no nd-
vantages over the
Ixme-flup method dur-
ing the operation, and
leave a gap in the pel-
vic floor which is. lo
Ally the least, uniitwiT-
able. The author nn
longer eniploj's ill'"*
inethoile, and will not
describe them in de-
tail.

The V a o I s a I
JIethod. — Eslirpi-
tion of cancer of th''
rectum through the
vagina was first donelij
Dcsguins (AnnalM tie
!a Bocifet^ de roW.,d'An-
vere, 1890) in a ca»e in
which the recto-vagin»l
sfeptuiii was invohtd-
The steps of this original operation are not very clearly describt^i.
but it appears to have been a perinseo- vaginal procedure, with i*n-
eervation of the sphincters. The patient died, hut the cause of deatli
was not stated. Norton (Trans. Clin. Soc. Ixindon, 1890) performe'l
the operation in the same year, excising the entire lower segment of
the gut, including the sphincter, and suturing the bowe) to the skiiu
This patient made a good recovery, and had fa?cal control within i
short time after the operation. Oampenon (Union mMical, October,
1894), Rehn (C'enlrallil. f. Chir., Berlin, 1895, S. 241). Vautrin (G«.
hebdom. de mM. et de chir., 1896, p. art:!). Price (Med. and Siirg. !!■•■
porter, 1896, p. 66), Bristow (Med. News, 189G, p. 40), Byford (Annil*

FlO. S86.— EbCTU. CiHOIK'

a Vaoikal Wall.

EXTIRPATION OF THE RECTUM

of Surgery, 1896, p. 631), and Earic (Proc. Am. Proctologic Soc, 1899)
have adopted this method with various degrees of success. Gersuny
employed it in 14 eases with only 2 operative deaths (Sternberg, Cen-
tralbl. f. Chir., 189T, S. 305).

More recently Murphy, of Chicago, has reviewed this subject in detail,
and reported 5 successful cases. Up to 1897 most operators confined
this method to tumors in the middle and lower portions of the rectum,
but with the development of the vagina! method in gynecological opera-
tions, it became more and more apparent that even the uppermost portion
of the sigmoid flexure could he reached and extirpated by this route.
The method is therefore no longer lintited to the rectum, but is even
advocated in carcino-
ma of the lower loops
of the sigmoid. The
technique of the oper-
ation, as laid down by
Murphy, is as follows:

The patient is
placed in the lithot-
omy position, with the
hips slightly elevated.
The site of the tumor
determines whether the
peritoneum should be
opened or not {Fig.
286). The vagina is
dilated with broad
retractors, the cervix
drawn down, and Doug-
las's cul-desar opened
by a transverse inci-
sion just below the
cervical juncture. The
small intestines are
then pushed upward
out of the way, and
the peritoneal cavity
is packed with large
laparotomy sponges or
pads, a careful count being kept of the number used. The recto-vaginal
sfeptum is then divided by a vertical incision in the median line, extend-
ing from the Rmt incision down to the margin of the anus, and including
the external sphincter (Fig. 287). The vaginal wall is then dissected

834

THE ANUS, RECTUM, AND PELVIC t'OLON

from its attaL'lmn.-iita to the rectum, thus esijosing this organ in iU en-
tire length and enabling one to examine it and drag down the sigmoid
flexure ahnost at will (Fig. 288). At this point Murphy divides the
anterior rectal wall up
to the lower border of
the tumor, and incises
the gut transversely 1
inch below the lower
limits of tht' growth.
carrying the incision
into the retro-rectal
tifisue (Fig. 289). The
proxiinal end of the gut
is then grasped with
forceps, which close il,
and by the use of curbed
^eifisors it is sepamtM)
from its posterior at-
tachiiicuts us far as th«
promoutory of the sa-
crum, or at least suffi-
di>nt!y far for the
hi)wcl (o he drawn down
until its healthy por-
tion reaches the lower
segment without undue
tension. The gui is
then amputated abort-
the growth (Kig. 290),
aud the upper and low-
er segments arc niiiti-d
end to end by eilkworm
sutures. These sutures should be passed from within outward, the knots
being tied upon the inside, and the ends left long to facilitate their
removal. The wound in the anterior wall of the rectum is closed in the
same manner, ami the ends of the sphincter brought together hy buried
catgut sutures (Fig, 291). After the la[jHrotomy pads are removed, the
peritoneal wound is closed with a continuous catgut suture, and the
vaginal wound is brought together with silkworm-gut sutures (Fig, 29?)-
A large drainage-tube is introduced through the anus above the point
of anastomosis and sutured in position, the vagina and external parti
being dressed with sterilized gauze. Murphy does not advise prelirainiry
colostomy, and it is difficult to understand how he can avoid a ceriain

(Murpliy>.

S~6r infection in t
id in the operative fie
KCt that a large space
Wount of the removal
S, renders it very imp
Id be furnished. Tlie
ommencing the open
iDus and coceyx, aud
Ingers or a dull inet
'ati-d from the autei
up as the growth e
round and eacral
ivitj are packed

iodoform gauze
tntrol the oozing,
the vaginal por-
of Ihe operation
len conducted ac-
Dg to Murphy's
lique, with the ex-
on that the giit is
nit across until ii
been freed frorii
its attachments.
jed down as fur ;
necessary, and Ihi
oneal cavity closi^il
tures or firm pack-

The post-anal
id and loosening
le retro-rectal tis-
not only furnishes
late drainage in
of leakage, but it
tates the digsoet-
nit of the rectum
saves time in the
Ition. The use of
omi-gut sutures in
ntestinal wall ne-
ates their removal, u
ay chromicized eatgi

to be removed. W

'ATIUN OF THE RECTUM 835

his operation, as the gut is cut across and
Id before the peritonipum is closed. This and
is necessarily left in the hollow of the sacrum

of the ccUular mass in which the glands are
■ortant that adequate drainage for this cavity

author therefore varies Murphy's technique
ation with a semicircular incision between
extending into the retro-rectal space. With
rument the cellular tissues and rectum are
rior surface of the sacrum and coccyx as
xtends. After this has been accomplished,

Fio. 2S9.— RicTi-M LAin "IT.n am. tit achch-s dkluw

Bually under an^psthcsia; on the other hand,
It serves every purpose, and does not re-

ith these few modifications, the author be-

^^^^^1
^^^^^1

^^^^^^^1

336 THE ANUS, RECTUM, AND PEI

ievi's this technique of Murphy to h<! a uioat

urgery.

On the whole, howCTCr, except in cases v

he uterus is involved, there is no great advan
over the perineal and bone-Hap operations dee
more time, there is greater loas of blood, an«
infection through uterine discharges and drib
sacral operation. Surgical shock is aomew!

han it is in the perineal or vaginal operatio
compensated hv iho diuiiiii-^lu'd tuss of bloo

VIC COLON

useful addition to rectal

here the vaginal wall or

tage in the vaginal route

cribed above. It requirei

there is more danger of

jling of urine than in the

at greater in the sacral

us, but this is more than

d. The results thus fa

reported are en tire) J

favorable to the vgj!-

inal route, hut thv

number of operations

is not sufficiently larp;

as yet to justify itt

universal adoption.

AnnoMisAL Meth-
od.—Operations on ihe
pelvic organs with the
patient in the Tr«-
delenburg position
early demonstrati-d ihfl
feasibility of reuiuvinK
neoplasms of the up-
per rectum and sig-
moid flexure Uirongh
the abdominal ronlft
ttTiere the tumc.r n
limited to that portinn
of the intestinal tm-I
entirely surroundfd Ijj
peritonaeum, especia"?
where it is in the nw'-
able sigmoid and f^"
be drawn out of the

Fio. 290.-K«iirfio!t or Isn'oivin Abea, iv \■^o<s^u
ExTiui'ATiuN or Tii» Ke.iti-v |Murphyl.

t involves no great mutilation of tissues,
uickly executed by the aid of a Murphy h
Vhere the tumor is well below tlie promont
ver, in Ihat portion of the gut only part

alKlominal wonnd, thit
method is undoubtedlj
superior to gll othef-
md the excision can t*
ulton or O'Hdra clamp^
ory of the sacrum, ho"-
iully covered by p<ml*

EXTIRPATION OP THE RECTUM

837

iia-um, complete removal by this route alone is attended with many
difiitulties.

Mann, of Buffalo (Jour, of the Amer. Med. Ass'n, vol. ii, p. 23),
has recently advocated the method even in these latter cuses. He states
that by the aid of the
Murphy button eiid-to-
end union can be ob-
tained even in that por-
tion of the intestine
well below the perito-
neal cul-de-sac. His ex-
perience (3 casL'S with
1 death) is too limited
to warrant any conclu-
sions with regard to
the operation. Murphy
himself, Marcy, and
the author have applied
the button in cases
where there was no
peritoneal covering on
one segment of the gut,
and almost invariably
leakage and a fisliihi
have followed. In the
sacral operation, where
there is wide drainage
below, this has not re-
sulted in any serious
consequences. In an
abdominal operation,
however, in which there
is no dependent drain-
age, such an accident as this will almost certainly prove fatal. End-to-
end suturing of the gut deep down in the pelvic cavity is one of the
most difficult procedures, as the author can testify from three attempts,
in two of which he was compelled to abandon it and employ another
method. In his opinion, therefore, the abdominal method should be
limited to those cases in which the neoplasm is entirely within the
peritoneal portion of the intestine:

As early as 1895 Kelly resected the upper portion of the rectum
and a part of the sigmoid, and invaginated the proximal end of the latter
through a longitudinal slit in the anterior wall of the rectum in Doug-

irphy).

838 TEE ANUS, RECTUM, ASD PELVIC COLON

las's cul-de-sac; tliiis the peritoneal i^urfaci- of the sigmoid was hold in
contact with a coniparativi-ly wiile surface of the peritonstuni covering
the rectum. The up-
per end of the resi-clcd
rectum waa invaginat-
cd and closed by Letu-

>^|w\. ^V ^^»//!l^v ^^^1 Following hie ^ug-

gcstioD, the author has

».\XM\ \''~-MMW ■ ^^^^B employed this method
^?V \ V^Iekj B ^^^^I three times, twice in
^K\^jlCr ^Km. I ^^^1 resection of tlie sig-
i^^ jCi^jP'^^W ^l ^^Hl moid and upper rec-
tum for carcinoma and
once in entcro-anasto-
ninsifi for irremovable
i-ancer of the sigmoiiJ.
The first of these op-
iTations was done in
March, 18a6. The pa-
tient was sulTerinj!
from curciTioina of Ihe
lugt loop of the eigmoid
9 inches above llie
anus. An oblique ab-
dominal incifiion i
inches in length was
made aliout 1 inch in-
side of the ordinary in-
cision for col ostomy -
After tlic peritonei
cavity had been opened, the patient was placed in the Trendelen-
burg postiire, and the small intestines and omentum were forcrd
upward toward the diaphragm and held there hy large alidominal
puds. The tumor was isolated by incising the inesosigmoid down to ■
point about opposite the second sacral vertebra, where the gut ap-
peared to be healthy. Two Hgaturos were thrown about the intostine
at this point, and it was cut transversely between them, gauKC being
packed all around the parts in order to prevent soiling the pcritaQsam
with intestinal contents. The upper aegmont was drawn out of the
abdominal wound, cauterized with carbolic acid, and covered with pro-
tective tissue. Without removing the gauze packing, the lower wgrnrni
was similarly cauterized, its edges invaginatod, and closeil Iiy l^nibert

1 (Murphy).

EXTIRPATION OP THE RECTUM

839

sutures; after this the gauze packing was removed and the cut edges
of peritona-um composing the mesentery were draH-n together with fine
silk sutures. The segment of the gut containing the carcinoma was then
excised, a stout ligature having been placed around the intestine about
1 inch above the transverse section. The mucous membrane of the
upper segment was then cauterized with pure carbolic acid and dried
with ganze. After this four long sutures were placed equidistant in
its circumference, the ends of each being tied together so as to form
a loop. An incision of about IJ inch was then maile in the anterior
wall of the rectum through the peritoneal cul-df-sai: after the sphincter
had been stretched and the anus thoroughly irrigated. A long for-
ceps was then introduced
through the anus and
through this incision, by
which the loops in the
proximal end of the
gut were grasped and
brought out below.
These loops were thor-
oughly twisted together
80 as to narrow the
aperture of the gut be-
fore any traction was
made upon it. After
this the sigmoid was
dragged downward and
invaginated through the
incision in the anterior
wall of the rectum (Fig.
293). When the end of
the upper segment had
passed through the in-
cision the ligature sur-
rounding the intestine
was cut off. The long
eutures attached to the
intestine were wrapped
around a hemostatic
forceps, which was twist-
ed until they held the bowel comparatively taut, and this was al-
lowed to lie across the anus as a sort of windlass. A gauze drain
was carried down to the point of invagination and out through the
lower angle of the abdominal wound, which was then closed except

840

THE ANUS. RECTUM. AND PELVIC COLON

at this point. The liealing of llie parta was uneventful, but at the end
of one month it wag apparent that the caliber of the gut at the point
of invagination was entirely too narrow. In order to overcome thift.
the patient was placed in the Trendelenburg posture and a hystercftomy
clamp was passed upward through the anus, one blade of it being cur-
ried through the narrowed orifice into the sigmoid and iho other into
the upper segment of the close<l rectum (Fig. Wi). The clamp, I»eing
closed and tightened daily, cut its way through in five days, thus iiiaie-
rially widening the caliber of the gut. From that time forward the
patient's symptoms continued to improve. He gained in flesli and

strength, ami up
to April, 19i)!i,hiid
presi'iited no eigna
of recurrence. Tlie
(•ul'iU-mu- ffirnied
liy the closing of
tlic upper end uf
till- reetuu) gradu-
illy atrophied imil
.i|Jl)aronlly disap-
i-ared (Fig. 895).
A I Ihc last I'lam-
:ii^ition a sigmoid"
■ wopc of 25 milli-
iirtiTs in diaiDflifr
v.L- paBswi imo the
I unnoid tlexiire
■.. ithout any diffi-
ilty. In the other
. ,ims of rosi-ction
ill which this meth-
od was employe
no drainag".' was
used, and the 8^
dominul carity wa*
closed cm complet-
ing the operation.
A longer iaeisiov
was made in th»
rectum in one instance, and it was not necessary to afterward enhirpe the
opening in the gut at the point of ]'uncture. This patient was nViserv*^
for two years, and remained well during that periw). He disappeared^
however, and has not been heard from in the past eighteen munthi*.

Fio. 294.— MiTlluU

EXTIRPATION OF THE RECTUM

841

Where the tumor is low down in the sigmoid and yet can be removud,
at the same time preserving the anterior wall of the rectum, it appears
to the author that this method is superior to attempts at end-to-end
union, inasmuch as there is a wide apposition of the peritonea! surfaces
and the proximal end of the sig-
moid is carried well within the
rectum, thus avoiding any great
danger from leakage and peri-
tonitis.

Where the tumor is confined
to the sigmoid proper and can
be brought outside of the ab-
dominal wound, resection should
be made according to the accept-
ed methods of intestinal surgery.
The author has resected the sig-
moid flexure nine times, in five
of which the operation was done
for malignant growths, with one
fatal result. He has invariably
employed a Murphy button which
fitted loosely in the caliber of
the gut, and reenforced it with
Lembert sulurea. While he is
aware that this is contrary to
the teachings of Murphy him-
self, nevertheless it appears
safer to have a supplementarj'
guard against leakage, and from
his experience he sees no reason to alter this course. End-to-end
suturing, with or without the aid of an O'Hara clamp, may be em-
ployed in these cases, but it consumes more time than the application
of the Murphy button, and does not give any better results.

The thought has suggested itself that in carcinoma of the sigmoid,
in which the tumor can be brought entirely outside of the abdominal
wall, it might be safer to fix it in this position until the peritoneal
cavity is closed off by adhesions, and then excise it extra-abdominally.
This would involve an artificial anus, to close which finally it would be
necessary to employ end-to-end union of the segmenta, and this might
be quite as dangerous as performing the entire operation at one sitting.
The case which suggested this thought was the fatal one in this series.
The stricture in this instance was so tight that it was impossible to
thoroughly empty the bowel before the operation; as a consequence of

Fio. 29B.

FifE Ykah

I Phootu

842 THE ANUS, RECTUM, AND PELVIC COLON

this there was a large mass of hard faecal balls in the colon above the
site of the tumor. The gut was dragged outside of the abdominal
wound after it was cut across above the tumor, and as many of these
as possible were removed, but unfortunately one of those high up in
the transverse colon came down and obstructed the aperture in the Mur-
phy button, thus causing obstruction and tearing of the gut, which
was followed by peritonitis and death. In such cases, therefore, where
the upper bowel can not be emptied before the operation, the author
would advise either making a temporary colotomy until the bowel could
be cleaned out, and then removing the neoplasm at another sitting, or
the employment of the extra-abdominal method suggested above. It is
unnecessary to go into the details of intestinal resection as applied to
the sigmoid flexure. This operation is described in all modem works
on general surgery. The author prefers the use of the Murphy button
supplemented by Lembert sutures, but excellent results may be obtained
by other methods. That the button may be retained there is no doubt.
We have failed to recover them in 6 cases, but in none of these has it
seemed to do any harm. The other complications which are said to
follow its use have not been met with, and are certainly no more fre-
quent than those which occur in end-to-end union or lateral anastomosis
by sutures. To conclude this subject, the abdominal operation alone
should be reserved for neoplasms of the pelvic colon as defined in the
chapter on Anatomy.

Combined Methods: Abdomino-atial, Abdomino-perineal, Abdomino-
sacral. — A combination of the abdominal with the other methods for ex-
tirpation of the rectum has been suggested from time to time during
the past two decades. In carcinomas of the extreme upper end of the
rectum and lower portion of the sigmoid it has been found easier to
loosen the gut from its higher attachments through an abdominal in-
cision than through the perineal, vaginal, or sacral routes. These com-
binations are termed the abdomino-analy the abdomino-perineal, and the
abdomi no-sacral methods.

Abdomino-anal Method, — Maunsell (London Lancet, August 27, 1892,
p. 473) first suggested this operation. He opened the abdomen by me-
dian incision above the pubis, incised the peritoneal attachments of the
bowel, and loosened it well above and below the growth. He then passed
a loop of tape by a long mattress needle from the abdomen through the
rectum and out of the dilated anus. With this loop he pulled the
neoplasm down through the anus, thus everting the lower part of the
rectum. He suggested that, if the tumor were large, it might be neces-
sary to incise the anus back to the coccyx in order to bring the growth
outside of the body. The tumor thus exposed was then resecteil, and
the healthy ends of the intestine united by sutures. The everted and

EXTIRPATION OP THE RECTUM

84:i

prolapsed rectum was then restored to its position, the peritoneal wound
sutured from tlie abdominal side, and the abdominal wound closed in
tiie ordinary way.

Weir (Jour. Amer. Med. Ass'n, 1901, vol. ii, p. 801) states that in
a trial of this method he was unable to bring the tumor through the
divided anus, and that forcible traetion upon the tape enlarged the
opening through which it passed into the bowfl, so that the contents
of the latter es-
caped into the
peritonieum. fie
therefore modified
the operation as
follows:

After making
an abdominal in-
cision with the pa-
tient in the Tren-
delenburg posture
and forcing the
small intestine up
into the abdom-
inal cavity with
an artificia! dia-
phrajrni, he ties
the inferior mes-
enteric artery as
it passes over the
promontory of the
sacrum. He then
loosens the sig-
moid and rectum
by incision of the
peritonteum and
blunt dissection
down to the tip
of the coccyx and

lower border of the prostate. At this point, below the tumor, two
iodoform tapes are tied around the gut about an inch apart, and the
latter is cut through between them (Fig. 296). The upper portion of
the bowel is then dragged out through the superior angle of the abdom-
inal wound and the neoplasm is excised. The lower end of the rectum
is then seized liy forceps in the hands of an assistant, who everts it
through the anus. A long forceps is then carried through this everted

844

THE AKUS, RECTUM, AND PELVIC COLON

rectum into the pelvis, and with it thu upper bowel is grasped and
dragged down through the everted lower end. Two needles are then
passed through the invaginated ends in order to maintain the parts in
position, and the upper and lower
ends of the gut are sutured together
(Fig. 297). The fixation needles are
then removed and the invaginated
gut is restored to its position (Fig.
298). The pcritonseum is then sewed
together and to the bowel so that tk>
general abdominal cavity and tht
pelvis are separated from each other,
and the abdominal wound is clo!>td.
The operation is completed bv an in-
cision posterior to the anus and jusl
in front of the coccyx, extending into
Ihe pelvic space from which the tu-
mor has been removed, and through
this a tube is introduced to secure
drainage; a second smaller tube,
wrapped with iodoform gauze, is
carried into the rectum and througli
the sutured area to facilitate the
escape of gas and prevent the intes-
tinal contents from coming in con-
tact with the wound.

At the time of Weir's report the
operation had been employed three
times, with two recoveries and one
death. There was some tendency to stricture at the point of suture,
but this was overcome by the passage of Wales bougies. The strictest
rules of asepsis arc insisted upon, the ends of the liowel at each point
of section being cauterized by carbolic acid, and the pelvis is repeatedl;
washed with sterilized salt solution after the rectum has been everti-d.
Weir advises that the eversion of the lower bowel, the suturing of
the ends together, their replacement, and the introduction of drainage-
tubes should be trusted to a competent assistant, and that the surgeon
should restrict himself to the interior abdominal work in order that
the strictest asepsis may be maintained. This modification of Maunaell's
method is a fine conception, and appears to be well worthy of further
trial. The chief difficulty in its performance will be found in loosening
the gut sufficiently to invaginate it through the anus without impairing
its circulation. Where the superior hfcmorrhoidal artery is tied off, the

EXTIRPATION OF THE RECTUM

845

chief supply to the lower segment of the gut is obliterated with the
exception of that slight portion furnished by the middle htemorrhoidal
artery. It sometimes happens, therefore, that the anastomotic circula-
tion is too feeble to maintain the vitality of the intestine, and gangrene
occurs. It is important, therefore, when the end of the gut is cut across,
to observe whether the circulation in it is sufficient to supply its needs.
Where there are no pumping arteries upon transverse section it is better
to cut the gut off at a higher level until such are found. This sug-
gestion applies with equal force to the sacral, perineal, and abdominal
methods. The author has seen gangrene occur three times from this
default, and in future, whenever he fails to observe a satisfactory blood
supply in the superior segment of the gut, he will undoubtedly carry
'the latter out through the abdominal opening and convert it into an
artificial anus rather than take the chances of this accident.

AMnmino-perineal and Abdomitiosacral Melhods.^ln 1884, Czemy,
in attempting to remove a high cancer of the rectum by the perineal
method, found himself unable to
complete the extirpation from be-
low. Rather"than leave the patient
in a hopeless condition, he boldly
resorted to abdominal incision and
completed the operation through
this route. This was the first appli-
cation of the combined method, hut
it was not a preconceived procedure.
Maunsell, as we have stated else-
where, was the first to conceive the
idea of premeditatedly opening the
abdominal cavity for the extirpa-
tion of a cancerous rectum. Cha-
put (Finet, op. cit., p. 338), on
August 27, 1894, deliberately per-
formed a median laparotomy to
loosen the cancerous rectum from
its higher attachments before ex-
tirpating it by the sacral method.
To him, perhaps, should be ac-
corded priority in the combined
sacro-abdominal procedure, fiau-

dier. to whom this priority is sometimes attributed, premeditatedly
performed the ahdomJno-perineal operation in November, 1895, more
than a year after Chaput's operation. He made a median laparotomy,
cut the gut transversely above the tumor, loosened its lower end as

'erituDeal cavily oloBcd. InlcKliunl tnc
Btnred, iiDil dminoge-tube flxcU in r
rixTtul Bpnce,

846 THE ANUS, RECTUM, AND PELVIC COLON

far down as the mesorectum, then fixed the upper end in the abdom-
inal wound for an artificial anus, and finally dissected the rectum
out by the perineal route from below. Challot performed this same
operation with some modifications only a month later. The chief
point in his technique, however, consists in preliminary ligature of
the superior ha^morrhoidal artery just before it passes into the pelvic
cavity. He therefore appears to have preceded Weir in this pre-
caution.

Boeckel (Societe de chir., October 28, 1896), in removing a high
cancer by the Kraske method, found himself in the same position as
Czemy, and was forced to do a laparotomy in order to complete the
extirpation. The steps which he advises after describing his case are
as follows:

Isolate the rectum as far as possible through the sacral route, create
an artificial anus in the descending colon or the sigmoid flexure by
cutting the gut squarely across and dragging its superior end out of
the abdominal woimd, then loosen all the intestine below this point
and extirpate it by the sacral way.

The writer can see no advantage in this latter suggestion. If the
gut has been liberated entirely from below before the laparotomy is
made, what possible good can come from turning the patient upon his
side again simply to draw the gut out from below instead of removing
it at once through the abdominal wound? In such cases the abdominal
wound should be made wide enough to thoroughly manipulate the parts,
and this turning of the patient backward and forward not only disturbs
the relationship of the abdominal organs, but it also predisposes to
accidents of infection.

All the combined operations described above leave the patient with
an artificial anus. Giordano (Clin. Chir., Milano, 1896, p. 463) devised
and carried out a combined abdomino-perineal operation for extirpation
of cancer high up, which he completed by dragging the superior seg-
ment of tlie resected gut down through a slit in tlie gluteal muscles and
suturing it to the skin. Before attempting to remove the rectum, Gior-
dano tied both internal iliac arteries. It is not stated whether this was
done with a simple view of controlling haemorrhage or with the intent
of starving out the cancerous process by cutting off its blood supply,
as has been suggested by Pryor and others in cancer of the utenis.
Shortly after this Quenu (Societe de chir., November 4, 1896) performed
a similar operation, but advised approaching the organ through the
sacral or perineal way first, and then completing the abdominal part of
the operation afterward. Reverdin reversed this procedure (Quenu and
ITartmann, op. ri7., ii, p. 292) in a remarkable manner. After opening
the abdomen and incising the gut transversely above the neoplasm, he

EXTIRPATION OP THE RECTUM 847

loosened the upper segment for 12 or 15 centimeters, dragged it out
through the upper angle of the abdominal wound, and tied into it a
glass cylinder with a depressed groove around one end, into which a
ligature drawn around the gut fitted, thus holding the tube in position.
The gut was thus sutured with 12 centimeters entirely outside of the
bowel. To the end of the glass tube which was thus fitted in the intes-
tinal caliber a rubber drainage-tube was attached, which was carried
into a basin beneath the bed. All these precautions were taken to pre-
vent the possible soiling of the wound by the discharges from the intes-
tinal canal. The lower segment of the gut containing the neoplasm was
then excised, the peritoneal toilet completed, and the wound dressed
in the usual way. He states that his patient died three days later from
exhaustion from feebleness (" par I'epuisement, par faiblesse ^'). To
those familiar with this class of surgery, Keverdin's description will
carry the conviction that the cause of death in this instance was nothing
more nor less than septic peritonitis of a subacute type, notwithstanding
all the precautions which he took to avoid ftecal extravasation.

On July 30, 1896, the author removed by abdominal section a large
carcinoma of the sigmoid and upper rectum as follows: The abdomen
was opened in an oblique line, beginning just above the pubis and
extending upward to a point 1 inch inside of the left anterior superior
spine of the ilium. The sigmoid flexure was dragged upward and out
of the wound, its mesentery incised about midway between the gut and
sacrum, beginning at a point 2 inches above the tumor; the vessels
were caught with pressure forceps as the dissection proceeded. The
superior hjrmorrhoidal artery was cut during this process and tied off.
After the section of gut containing the tumor was loosened down to a
point about opposite the third sacral vertebra, the gut was surrounded
with two ligatures below the growth, and, being thoroughly protected by
gauze pads, was cut through transversely. The upper segment, contain-
ing the neoplasm, was drawn outside the wound, a ligature was placed
around it above the growth, and it was again cut off below this ligature,
thus extirpating the neoplasm. The cut ends of the two segments were
cauterized with pure carbolic acid and covered with iodoform gauze.
The patient was then turned upon his side, a lateral sacral incision was
made, and the upper end of tlie lower segment was dissected out and
dragged through this wound; with a long forceps the upper segment
was then seized, brought out through the sacral wound, and an end-to-
end union of the two parts was accomplished by Czerny-Lembert su-
tures. The gut was then replaced in the pelvis, gauze drainage was
placed around the point of union, and the sacral wound left open.
The patient was then turned upon his back again, the peritoneal floor
of the pelvis was sutured, and the abdominal wound closed without any

848 THE ANUS, RECTUM. AND PELVIC COLON

drainage. The patient died upon the fourth day, supposedly from sup-
pression of urine, but later observations lead us to conclude that the
true cause was sepsis.

Following in the footsteps of Giordano, Quenu has formulated a
technique for the combined operation, as follows:

First, open the abdomen in a median line and ligate both hypo-
gastric arteries.

Second, free the sigmoid loop, cut it across between two ligatures
with a thermo-cautery, and establish an artificial anus in the left in-
guinal region by means of the upper segment.

Third, liberate the lower segment by incision of the lateral and
posterior peritoneal bands and dull dissection below this point down
to the tip of the coccyx and lower border of the prostate. In this
dissection the superior hemorrhoidal artery will have to be tied. The
intestine thus loosened is dropped down into the pelvis, covered over
with sterilized gauze, and the abdominal wound is rapidly closed.

The patient is then placed in the lithotomy position, the perianal
region recleansed, and the lower portion of the rectum is extirpated by
the perineal method heretofore described. In establishing the artificial
anus Quenu drags the gut out through an incision in the abdominal
wall in the inguinal region and sutures it to the different layers. He
leaves the ligature around the protruding end for several hours in
order that adhesion between the peritoneal surfaces and the wound may
take place before any danger of infection from the escape of faeces can
occur. Finally, the abdominal wound is sealed off by " adhesol."

The author has modified this technique in his operations by the
combined method, as follows: The abdomen is opened by a long colos-
tomy incision on the left side. The sigmoid is dragged out of the abdo-
men and cut transversely between two ligatures at a point 1 inch above
the growth, the ends being cauterized with carbolic acid and covered
witli rubber protective. The lower segment is then dissected out without
tying the hypogastric arteries. The superior ha3morrhoidal is either
ligatured beforehand (Fig. 299) or caught and tied if cut. After dis-
section has gone below the tumor, the latter is excised between two liga-
tures and removed from the abdominal cavity. If end-to-end union
between the remaining segments is feasible it is employed; if it is not,
the lower segment is invaginated and closed by sutures. The peritoneal
breach below is then sutured, and an artificial anus is made after the
manner of Bailey, and the abdomen closed.

Where the anus needs to be extirpated no abdominal operation \^
necessary; the perineal or sacral methods will accomplish all that is
justifiable in these cases, and laparotomy only adds to the shock and
exposes the patient to greater danger of sepsis. The mortality from

EXTIRPATION OF THE RECTUM

849

these combined methods has been very high, and they should not be
employed save in exceptional cases.

Disposition of the Jnlestinal Ends. — Operations by the sacral and
abdominal methods largely resolve themselves into resections of the
intestine. Under such circumstances one has always to deal with two
intestinal cmls, and the disposition of these is a question of much im-
portance. Kraske (Centralblatt f. Chirur., 1891, S. 942) in his earlier
operations only sutured the anterior circumference of the rectum in

ElTIHFtTlOM or T11E RkCTLH.

order to prevent retraction of the two ends, and left the posterior por-
tion open so that the f.-ecal materials could be thus discharged without
any obstruction. Ijater, however, he advisod suturing the entire cir-
cumference, although admitting that leakage and fistula would likely
occur.

Hochenegg dissected off the mucoua membrane from the lower end
of the rectum and invaginated the upper segment of the gut through
this freshened canal, suturing it to the skin about the margin of the
anus. This is a most excellent method where the upper segment is euffi-
ciently long to be brought down through the anus without undue ten-

850 THE ANUS, RECTUM, AND PELVIC COLON

sion or interference with its circulation. In cases where the length is
not sufficient, the gut may be sutured in the upper angle of the sacral
wound, thus establishing an artificial sacral anus, for the control of
which Hochenegg has devised an ingenious and quite satisfactory truss.
Perron (Gaz. hebdom. de Bordeaux, 1890) described a method similar to
that of Maunsell. He everted the lower end of the rectum, dragged the
upper segment down through this, and sutured the two ends of the
gut together by circular suture. He then allowed the parts to slip back
into position, and introduced a drainage-tube through the anus up
beyond the sutured area. The author has performed this method twice
with very satisfactory results.

In cases in which a preliminary artificial anus has been made, the ♦
treatment of the intestinal ends will depend largely upon whether it
has been determined to maintain this anus permanently or only as a
temporary measure. When it is seen upon abdominal exploration that
there is no probability of reestablishing the normal faecal channel, then
a permanent artificial anus should be made, either by the Bailey method
or by cutting the gut transversely across, closing the lower end and
dropping it back into the abdomen, and establishing the new anus in
the upper segment, after the manner of Witzel. The extirpation is
undertaken some days later, and the treatment of the section below the
artificial anus will depend largely upon the type of inguinal anus em-
ployed. If the gut has been cut across and the segment dropp)ed back
into the abdominal cavity, it may be removed in its entirety along with
the tumor, it may be closed after the tumor has been resected and the
closed segment left to atrophy, or its lower end may be sutured in the
upper angle of the sacral wound. If the artificial anus has been made
after the ordinary spur method, with a double-barreled aperture, the
lower leg of this spur, after the tumor has been resected from below,
may be everted through the inferior aperture of the artificial anus and
clamped or tied off with a ligature (Qu6nu). It may also be fixed in
the upper angle of the sacral wound, where it will form a sort of mucous
fistula, which eventually atrophies and closes spontaneously. Some sur-
geons simply tie a ligature around it and leave the gut loose in the
wound. This is a dangerous experiment, for sepsis is likely to follow,
however thorough the drainage. The invagination and excision of the
segment through the lower opening of the artificial anus is more satis-
factory when it can be accomplished, but sometimes the attachment
of the mesosigmoid, adhesions, or other complications render this al-
most impossible, and one must resort to the other methods.

Where the two ends of the bowel can be brought together after re-
section of the tumor they may be united either by suturing or by the
aid of a ^lurphy button. The author has employed the latter method

EXTIRPATION OP THE RECTUM 851

a number of times^ and^ while it does not prevent the formation of a
fistula, it facilitates the bringing of the ends together and enables one
to introduce a supplementary row of Lembert sutures around it much
more rapidly. Mayo, Meyer (Annals of Surgery, 1896, p. 687), and
Marcy (Boston Med. and Surg. Jour., 1893, p. 561) have all employed
the Murphy button in these cases, but in almost every instance posterior
fistula has followed its use.

Where the upper segment is sufficiently long to accomplish it, the
author prefers the Perron or Hochenegg methods of treating the intes-
tinal ends; but in cancers high up in the rectum these are not feasible,
and one will find the Murphy button of great assistance in such cases.

Whatever method is employed in the treatment of the intestinal
ends, it is necessary to thoroughly dilate the sphincter or incise it pos-
teriorly in order to obviate any obstruction to the passage of fa?cal
material and gases from the bowel. WTien end-to-end suturing has been
employed, one should also pass a firm rubber drainage-tube through the
anus and above the line of anastomosis in order to prevent any tension
upon these parts from the accumulations of gases or faecal material.

Complications in Extirpation. — The accidents and complications
connected with extirpation of the rectum for malignant disease may be
described as immediate and remote.

Immediate Complications. — Haemorrhage is ordinarily spoken of as
one of the chief complications and contraindications in extirpation of
the rectum. It can not be denied that operation by the perineal method
is attended by considerable bleeding, and on this account it is inadvisable
in cases already weakened by hgemorrhages from the growth itself. The
operation by the sacral route, if conducted according to the technique
already laid down, is not accompanied by any excessive loss of blood.
The application of the ligature or clamp to the intestine before at-
tempting to dissect out the lower portion of the rectum absolutely
precludes the loss of much blood during this part of the operation.
The author has succeeded in extirpating the rectum more than ten
times without tying over four vessels. The secret of this lies in the
fact that the same artery is cut many times in the course of extirpa-
tion, and if the operator stops to catch and tie it each time, the opera-
tion will be unduly prolonged and an unnecessary amount of blood lost.
If the superior dissection and dragging down of the gut is all accom-
plished first and the peritonaeum closed before the gut is cut across,
the lower segment may be rapidly excised, gauze compresses being
crowded into the wound as the dissection proceeds, and a very small
amount of blood will be lost. As soon as the excision is completed
these gauze compresses can be removed and the two or three vessels
which bleed can be caught and tied. Practically the middle sacral.

852 THE ANUS, RECTUM, AND PELVIC COLON

the right lateral sacral, and two middle hgemorrhoidal arteries are all
that are necessary to ligate. In only one case operated by this method
has there been any excessive haemorrhage, and this was due to the fact
that undue traction upon the gut tore the superior haemorrhoidal arten'
off at the promontory of the sacrum, and the presence of the gut in
the wound rendered the catching and tying of this exceedingly difficult.
This accident can be entirely avoided, as the gut should be brought
down by clean dissection without dragging and tearing.

Escape of Intestinal Contents into Wound. — Another accident, and
one of the most serious complications in extirpation, is the rupture of
the intestinal wall and escape of its contents into the wound. This is
also occasioned in the majority of instances by imdue traction in at-
tempting to loosen the gut by dull dissection. It may also occur from
attempts to separate adhesions of the peritoneal cuUde-saCy or between
the rectum and other organs, by blunt dissection. The best method
of avoiding this consists in isolating the gut aroimd its right side by
clean dissection with scissors until the peritonaeum is opened. As soon
as this is accomplished the lateral peritoneal folds should be cut off
close to the rectal wall. This will allow the gut to be brought down a
considerable distance so that its healthy portion can be grasped. Upon
this a clamp should be placed, and then the mesorectum can be cut
loose close to the sacrum, thus enabling one to rotate the neoplasm
and complete the dissection upon the left side without any undue drag-
ging upon the diseased portion. The adhesions should be handled very
gently, and those between the rectimi and uterus or prostate should be
shaved off rather than torn loose. WTierever it is possible, the entire
intraperitoneal dissection should be completed and the gut drawn down
to the extent desired before it is cut across; the section should always
be accomplished well outside of the wound, and with the latter com-
pletely protected by gauze packing.

Injury to other Organs. — Injury to the ureters and bladder have
frequently occurred during the course of rectal extirpation by the sacral
method. A thorough knowledge of the anatomical relations alone will
enable one to avoid these accidents. They are often occasioned by drag-
ging upon the gut before it has been loosened from its lateral and an-
terior peritoneal attachments. These accidents also emphasize the im-
portance of opening the peritoneal cavity early in the operation in order
to establish one's landmarks. Twice in cases where the cul-de-sac has
been obliterated by inflammatory adhesion the author has accidentally
cut into the bladder, but the wounds were immediately sutured, and
apparently the accidents did not interfere with the subsequent course
of the operation. In one case the ureter was torn across, and an attempt
was made to restore its caliber. This patient died forty-eight hours

EXTIRPATION OF THE RECTUM 853

later, and therefore the results of this effort could not be determined.
The author knows of one case in which both ureters were torn off by
attempting too much blunt dissection in this operation; great care is
necessary to avoid these accidents, and it is much safer to separate the
parts by clean incision than by dragging and tearing.

Post-operative Complications. — The chief complication which follows
these operations is sepsis. As has been stated, over 75 per cent of the
deaths occurring from extirpation of cancer of the rectum are caused
by infection. Whether this is due to faulty technique, to the escape
of faecal material during the operation, to rupture of the sutures after
the operation, or to the presence of bacilli in the perirectal tissues at
the time of operation, it is impossible to say. To the present time no
technique has been devised which will positively secure asepsis in opera-
tions of this type. The precautions which were suggested for the pre-
vention of the escape of faecal matter into the wound, the closure of
the peritoneal cavity before the gut was incised, the avoidance of intro-
ducing the finger into the rectum and then into the wound, are all im-
portant in the prevention of this complication. While it seems im-
possible to avoid a certain amount of suppuration after extirpation, if
the peritonaeum can be protected this complication will not often prove
serious. Some cases have succumbed to prolonged suppuration, but these
compose a very small percentage of the fatalities.

Gangrene is the next most serious post-operative complication. This
may be due to three causes: First, deficient blood supply of the superior
segment, which has been referred to. Second, too great tension upon
the superior segment. WTiile the blood supply may be adequate, if
the gut is sutured in a taut condition this may result in the acute
flexure and occlusion of its arterial supply, which will result in gangrene
of its lower end, with retraction or systemic infection, which brings
about a fatal end. Third, it may occur from infection. In the first
two instances the condition develops within the first twenty-four hours;
in the last, the gut may appear perfectly healthy for two or three days,
and then entirely slough away. There is no way to avoid this except
through the most rigid asepsis. This complication more than any other
inclines the author to the systematic employment of a preliminary colos-
tomy, as he has seen gangrene occur in but one case where this has
been done.

Abnormal Anus. — In certain cases after the tumor has been resected
it will be found impossible to bring the gut do^\^l to the anus or the
lower end of the resected rectum. Under such circumstances it be-
comes necessary to establish the anus in some abnormal position. This
may be done in the inguinal region, after the method of Bailey, or, if
the superior segment is long enough, it may be brought down and

854 THE ANUS, RECTUM, AND PELVIC COLON

stitched to the skin at the lower end of the coccyx; or, finally, the gut
may be sutured in the upper angle of the sacral wound. The latter
position is that advised by Hochenegg. The author is in favor of this
procedure when the sphincters have been preserved; for, thanks to the
prolapse which often occurs, it is occasionally possible at a later period
to dissect the gut loose from this position and reestablish the anus in
its normal position. When the sphincters are removed, however, better
faecal control can be obtained through the modem inguinal anus.

Prolapse of the Gut. — Following extirpation of the rectum, especially
where the anus is established in the sacral region, prolapse of the gut
is very likely to occur. Sometimes when the anus is established in
its normal position, an excessive mucous prolapse takes place. In
the first instance, where the prolapse is complete and of sufficient
length, the gut may be dissected out from its attachments, brought
down and sutured at the normal site of the anus after the patient has
regained his strength. Where the prolapse consists of mucous mem-
brane alone, this may be excised after the manner of Whitehead, or it
may be clamped off and cauterized, as has been described in the sec-
tion on incomplete prolapse.

Incontinence. — Incontinence of faeces is a very frequent complication
following extirpation of the rectum. To avoid this, Gersuny (Cen-
tralbl. f. Chirurg., 1893, S. 553) has proposed twisting the gut two or
three times around before it is sutured in position. This procedure
has been adopted by numerous surgeons, notably by Gerster, and seems
for the time being to be quite effectual. It does not remain permanent,
however, for in the large majority of cases the incontinence returns
after a longer or shorter period. In order to overcome this, Willems
(Centralbl. f. Chir., 1893, S. 401) proposed carrying the superior segment
through the fibers of the glutaeus maximus muscle, thus constituting a
sphincter ani. Witzel (ibid., 1894, pp. 937 and 1262) first carried out
this procedure, and with considerable success. Rydygier (op. ciL) car-
ried the gut through the glutaeus maximus and pyramidal muscles, and
combined with this the torsion of Gersuny. Where the sphincter mus-
cles are involved in the neoplasm and it is necessary to remove them, one
should always establish a permanent inguinal anus before attempting
to extirpate the new growth.

Stricture. — Stricture of the rectum of greater or less degree has
occurred in many of the cases of resection, and even in a larger percent-
age of the cases of amputation. This complication is unavoidable. It can
be limited, however, by the assiduous passage of bougies, which should be
bogim about ten days after the operation. If the patient is taught to use
the bougie himself, the caliber of the gut may be practically maintained,
and the stricture will not constitute a serious complication.

EXTIRPATION OP THE RECTUM 855

Functional Complications, — Diarrhoea and constipation are among
the post-operative complications of this operation. They occur about
equally in a given number of operations, and sometimes alternate with
each other from day to day. The cause of the diarrhoea may be reflex
irritation or infection. The treatment consists in thoroughly cleaning
out the intestinal canal, irrigating the colon with astringent solutions,
and regulating the diet in such a manner that the smallest amount of
detritus possible will be produced. The constipation should be treated
according to the principles laid down in the chapter upon that subject.

Injury to the nerves during the operation of extirpation has been
frequently mentioned as the cause of incontinence. The author has not
had the misfortune to observe any accidents of this kind. It is irrational
to suppose that such operations as those of Bardenheuer and Rose
could do otherwise than result in some alteration of the nerve supply
to the lower end of the intestinal canal. In operations, however, re-
stricted to that part of the sacrum below the third sacral foramina, no
grave injury of this character is likely to occur.

Conclusions. — After this somewhat prolonged discussion of the vari-
ous methods employed in extirpation of the rectum, it is incumbent
to express an opinion as to when such operations should be undertaken
and the preference in the selection of methods. It was stated that all
cancers should be extirpated which are confined to the intestinal wall,
are movable, and are not complicated by ganglionic or metastatic ex-
tension; adhesion to the bladder, uterus, or the prostate does not con-
stitute a positive contraindication to the removal of the neoplasm;
neither does enlargement of the inguinal glands, as this may be en-
tirely inflammatory. The same may be said with regard to ganglionic
enlargements in the sacral cavity.

The elevation of the tumor in the intestinal tract does not in any
way limit the indications for extirpation. Operations upon carcinoma
of the rectum, involving the uterine or genito-urinary organs, are only
justifiable upon the demand of the invalid. The patient has the right
to take a desperate chance for his life, but it is not right for the sur-
geon to induce him to undertake this chance against his will, for the
probability in such cases is a fatal termination.

The Choice of Method, — No one method of procedure is applicable
to all cases of carcinoma of the rectum and sigmoid. The method
to be pursued in any individual case will depend upon the location
and extent of the tumor, the patient^s physical condition, and, finally,
upon the average results from the different operations. It is customary
in discussing the choice of operations to divide the rectum into four
or five sections, indefinitely described as anal, subampullary, ampullary,
recto-sigmoidal, and sigmoidal. Practically there are but three divisions

856 THE ANUS, RECTUM, AND PELVIC COLON

— the inf raperitoneal, the supraperitoneal, and the sigmoidal. All oper-
able carcinomas below the peritoneal cul-de-sac demand a practical am-
putation of the lower end of the gut, with or without removal of the
sphincters. WTiere the growth is limited to this lower portion, there
is no longer any question as to choice of operation. The perineal
method should be invariably adopted on account of its low mortality
and the comparative absence of shock which follows it. Unquestionably
there is more haemorrhage by this method, and it is more frequently
followed by an ulcerative area at the lower end of the rectum; but inas-
much as free drainage is afforded through the anus, fatalities from
sepsis are comparatively rare. The modified method of Quenu is a
large step in advance of any other technique for perineal extirpation,
and if it is carefully conducted the immediate mortality ought not
to be above 10 per cent. This operation, as Quenu has pointed out,
is applicable to tumors much higher up, but it is not so satisfactory
as the sacro-coccygeal route in tumors located above the peritoneal re-
flection— that is, more than 3 inches from the anus.

In tumors confined to the rectum proper — that is, below the third
sacral vertebra and removed more than 1 inch from the upper border
of the internal sphincter — the sacral method of approach, especially
the Rehn-Rydygier bone-flap operation, is preferable. In an experience
of over 20 cases by this method, the author has not seen one in which
survival after the operation was not followed by comparatively good
restoration of the bony floor of the pelvis. He is decidedly in favor
of suturing the bone back in position, leaving the horizontal portion
of the wound open for drainage. In many cases excision of the coccyx
gives all the room necessary for extirpation, but one can never tell
beforehand whether it will or not; therefore it is better to adopt the
bone-flap operation in the first place. It is rapid, effectual, and by it
any growth of the rectum or lower sigmoid can be removed.

For tumors situated above the recto-sigmoidal juncture, the abdom-
inal method, first suggested by Kelly, seems to give excellent results.
Wherever the superior limits of the growth can not be reached by the
finger through the anus, abdominal exploration should always be em-
ployed; and under these circumstances it is wise to complete the opera-
tion by this route at the time, if feasible, or at least to establish an
artificial anus preliminary to subsequent extirpation by the perineal or
sacral route. If during such an exploration the growth is determined
to be of a recto-sigmoidal nature, and the patient's condition justifies
the same, one may proceed by the combined method, adopting Weirs
modification of ^launseirs operation or the modified technique of Quenu.
If the patient is feeble, and there is an accimiulation of hard faBcal masses
above the neoplasm at the time of such an exploration, one should not

BXnitPATION OF THE RECTUM

857

attempt to extirpate the tumor until this accumulation has been relieved
through the establishment of an artificial inguinal anus. The preference
of the French, and some American surgeons, for a permanent inguinal
anus in all carcinomas of the rectum is not shared by the writer. Just
as good and permanent results can be obtained through the reestablish-
ment of the normal exit to the intestinal canal where the limits of the
growth admit of the resected ends being brought in apposition. The
mental effect of the artificial anus upon these patients is distinctly
unfortunate. It is true that by the modem methods one can establish
a comparatively continent inguinal anus; at the same time this abnor-
mality in sensitive patients is always a great source of annoyance and
depression. Where, however, upon abdominal exploration it is clear
that restoration of the intestinal canal can not be safely made, one should
not hesitate to establish a permanent inguinal anus at once. The estab-
lishment of an artificial anus as a preliminary to extirpation of the
rectum is undoubtedly a safeguard to the procedure; it enables one to
obtain by irrigation through the lower end of the inguinal anus a more
healthy and less septic condition of the intestinal canal below; it obviates
the danger of soiling the operative field during the operation, and also
that of fsBcal extravasation should the sutures give way subsequent to the
union of the ends of the intestine. At the same time, where the growth
is low down and it is possible to bring the superior segment well below
the peritoneal reflection or out through the anus, one may avoid the
necessity of colotomy and subsequent closure with comparative safety.
However, in patients who are already septic and feeble, one should take
no chances in attempting extirpation without the preliminary anus.

Finally, the choice of method in such cases should be influenced
very largely by the probable results of each as derived from the observa-
tion of a large number of cases. The following table, gathered from
a collection of 1,578 cases of extirpation of the rectum and sigmoid,
indicates in a very positive manner the probable results which may be
expected from each procedure:

Table

Method.

Number of cases.

I>eath8.

Mortality.'

Sacral

913

569

211

23.1 per cent.

Perineal

13.5 "

Abdominal

36.7 "

Combined

40.9 "

Vairinal

14.8 "

Anal

100

Total

1,578

319

20 . 2 per cent.

From these statistics one is forced to the conclusion that, where the
location and extent of the neoplasm warrant it, the perineal operation

858 THE ANUS, RECTUM. AND PELVIC COLON

should be the method of choice. In women the vaginal method i
seem to have many advantages, but in a closer examination o
statistics the curious fact appears that in them the abdominal and
bined operations have given almost as low a mortality as the va^
In 18 cases of the abdominal and combined operations in women
were 3 deaths. For some unknown reason they appear to stand
toneal invasion better than men. In Qu^nu's collection of 16
operated upon by the combined method, there were 8 women and 8
Of the 8 women, 7 recovered and 1 died; of the men, 7 died a
recovered, notwithstanding the fact that there appeared to be no
disparity in the gravity of the cases before operation. From the«
periences one must be discouraged from the application of the al
inal or combined methods in men, whereas the results in wome;
comparatively satisfactory.

In small isolated epitheliomas or villous tumors in the lower e
the anus, one of two methods may be employed. The anus may be
posteriorly and the growth excised, if it be low enough down
reached by this method. The edges of the wound from which the t
is removed should be carefully sutured together, but the posterior
incision should be left open in order to secure perfect drainage
i the parts. Where the growth is too high up to be reached and ma

lated in this way, one may approach it by the sacro-coccygeal i
open the intestine posteriorly, excise the tumor, and close the w<
in the gut. The superficial portion of the wound through the
and cellular tissue, however, should be left open for drainage in
infection and sepsis should occur. The author has little sjrmpathy
either of these operations. In his experience limited excision oi
cinomatous growths has always been followed by a rapid recur
> ' either necessitating secondary operation or ending fatally before

relief could be rendered. Wide extirpation of all malignant grow
advisable when feasible; otherwise palliative treatment, as has bee
scribed above, must be employed.

The author's experience with colotomy in these cases has been s
larly unfortunate. In only one instance of 20 operations done by
self, and many others seen after operation by others, has the life c
patient been prolonged more than twelve months. In a number of
in which no operative interference has been employed, he has see
patient survive from one to three years in comparative comfort thi
the persistent application of palliative methods. He therefore be
that in the large majority of inoperable eases just as much eomfor
prolongation of life can be obtained by these methods as by the i
lishment of an artificial anus.

CHAPTER XXI
COLOSTOMY— COLOTOMY-'ARTIFICIAL ANUS

The old term colotomy has in recent years been superseded by the
term colostomy y which more properly describes an artificial anus or open-
ing in the colon, being derived from the two Greek words icuAov, colon,
and arofjuiy a mouth or aperture. When the artificial opening is made
in the small intestine it is spoken of as enterostomy. Petit, to whom
we are indebted for the term colostomy, suggested (Union medical, 1886,
p. 577) that its application be limited to permanent artificial anus, and
the word colotomy should be employed to describe the temporary variety.
Aside from the fact that there is no warrant in etymology for such a
distinction, it would be very confusing, for the term colotomy has been
employed in medical literature for the past two centuries to describe
artificial ani both temporary and permanent. In this work, therefore,
the two terms are used as synonyms, and the qualifying adjectives tem-
porary and permanent are employed as the occasion may require.

Fortunately there are very few conditions in which a permanent arti-
ficial anus is required. Temporary colostomy, however, is employed
more and more frequently in the treatment of inflammatory conditions
of the rectiun, sigmoid, and colon, as a preliminary operation to extir-
pations and resections of the lower end of the intestinal canal, in im-
perforate ani, in complicated fistulas between the intestine and urinary
organs, in certain types of prolapse, and in strictures of the sigmoid
flexure. The permanent artificial anus is employed in inoperable stric-
tures and neoplasms of the intestinal tract, in cases in which it is
impossible to reestablish the intestinal canal after resection of the dis-
eased portions, and where the sphincters and entire anus have been
removed in amputating the rectum for malignant disease. Some sur-
geons prefer to establish a permanent artificial anus in all cases of
malignant disease of the sigmoid and rectum whether extirpation is
done or not. The author has expressed his disapproval of this course.
As a temporary measure, however, to divert the faecal current during
extensive operations upon the intestine below, or in the treatment of
conditions heretofore mentioned, there is no more beneficent or useful

859

860 THE ANUS, RECTUM, AND PELvIc COLON

procedure. This side-tracking of the faecal current was first sugge
by Pollosson (Lyon mM., 1884, t. xlvi, pp. 67-75), and put into p
tical application by Schede in 1887 (Deutsche med. Wochenschr., L(
u. Berl., 1887, Bd. xiii, S. 1048); it marks the dividing line bet^
temporary and permanent colostomy. Up to this time all artificial
had been made with the view to establish a permanent exit for
intestinal contents, and every surgical effort was exerted to make
outlet effectual so as to prevent the escape of faecal matter into
gut below, and at the same time to obtain, if possible, a certain amc
of sphincteric control.

Since then, however, surgeons have realized the fact that when
artificial anus has served its purpose and the condition for whic]
was made has disappeared, it is desirable to close the aperture, an^
do so with as little danger to the patient as possible. The trenc
surgical experiments in this line, therefore, has been to establis
method for temporary colostomy which will be effectual as long a
is necessary, and in which the aperture can be closed when advis
without any particular danger to the patient.

In the older operations the closure of t^^*^ artificial anus nec<
tated enterotomy or resection of that portion of the colon or sign
involved in making the colostomy. This procedure, as is well knc
proved to be more fatal than the original operation; therefore b
surgeons hesitated to recommend colostomy except in incurable coi
tions. Happily it has been demonstrated recently that a tempoi
colostomy may be made in such a manner that the artificial anus
be closed when it has survived its usefulness without opening the p
toneal cavity or resecting any portion of the gut. This fact has wide
the field of usefulness of the operation, induced surgeons to emplo]
and made patients willing to submit to its inconveniences for a t
through the assurance that the normal channel could be restored wl
ever the condition of the parts below warranted it.

In works on general surgery two types of colostomy are describe
the lumbar and the inguinal. The term abdominal is preferable
inguinal because the artificial anus is frequently made elsewhere t
in the inguinal region, as, for example, in the operations of Finet
Witzel, and in colostomy in the ascending colon.

Lumbar colostomy is almost an obsolete operation. It was origin;
advocated upon the ground that the colon could be reached from beh
without invasion of the peritoneal cavity. Before the days of ase]
surgery this was a great desideratum, and in the cases in which it
possible no doubt contributed largely to the low mortality in this op<
tion. It has been proved by Allingham (op, cit., p. 421) that in
majority of cases it is impossible to open the colon through this re

COLOSTOMY— COLOTOMY— ARTIFICIAL ANUS 861

without wounding the peritoneum. In certain instances in which
there is no mesentery it can be done; in others in which the mesentery
is short its folds may be separated and the gut reached without ac-
tually penetrating the peritoneal cavity, but this is a very difficult pro-
cedure; while in those with long mesenteries it is quite as impossible to
reach the colon through the lumbar incision as through the abdominal
without invading the peritoneal cavity. The difficulties of the operation,
the fact that the anus was inconveniently placed for the exercise of
proper care without assistance, the peculiar complications which one was
accustomed to meet with on account of displacements of the colon, and
abnormalities in the kidney or ureter, and the almost insuperable obsta-
cles to closure of the artificial anus made by this operation, were recog-
nized by surgeons in general, but these were thought to be compensated
for by avoidance of injury to the peritonaeum. This dread of entering
the peritoneal cavity, sometimes described as " false" was only too well
founded in the days of Amussat, Callisen, and their followers. With
the advent of aseptic surgery, however, it has disappeared, and with
it the operation of lumbar colostomy has almost been discarded from
surgical practice. It is an operation still useful, however, in certain
conditions, such as incurable diseases of the sigmoid and descending
colon, in which the ordinary inguinal anus would be below the site of
the disease, and also in cases of great distention of the intestines, for
in such cases it is sometimes easier to find the colon by this route than
by abdominal incision. It is an operation which will always have a cer-
tain field of usefulness, and therefore merits description.

It has been claimed that the mortality from this operation is less
than that from inguinal colotomy. Before describing the methods,
therefore, let us look into this phase of the subject and determine
somewhat definitely what are the chances of death in these two opera-
tions.

Mortality from Colostomy. — In discussing this question one must not
confound the mortality from operation with that from the disease for
which the operation is done. Many patients in whom colostomy has
been performed have been in extremis at the time of operation, and have
died from the disease and not from the surgical procedure. Bryant,
therefore, in discussing the mortality in lumbar colotomy, divides his
cases into urgent and non-urgent ones. Of the former he tabulates 100
cases, of which 45 died within one month. He does not give the cause
of death, nor does he state in how many it could be attributed to the
operation. But when it is recalled that 45 per cent died within one
month, it is fair to presume that the immediate mortality was not in-
considerable. Of the 70 non-urgent cases which he reports, none died
within the first month. There can be no more forcible argument in

862

THB ANUS, RECTUM, AND PELVIC COLON

favor of early colostomy in malignant disease than these figures of the
great English surgeon. This record is the more remarkable from the
fact that many of the operations were done with the crudest aseptic
precautions.

Croley (Transactions of the Academy of Medicine, Ireland, 1896,
p. 147) has reported 18 cases of lumbar colotomy with no deaths, the
patients all living from a few months to over two years after operation.
On the other hand, Wheeler {ibid., p. 133) estimated the mortality from
this operation in urgent and non-urgent cases at 25 per cent. His sta-
tistics, however, were drawn from the compilations of Batt and others
made before the days of aseptic surgery. The lumbar operation is so
seldom performed at the present day that it is almost impossible to give
any definite figures with regard to its mortality under modem surgical
precautions; but from the figures which the author has been able to ob-
tain, it is estimated that the death-rate in a consecutive number of
cases, as they come, will not fall short of 12 per cent.

In inguinal colostomy it is much easier to arrive at some conclusion
with regard to the mortality. Kelsey says: " Given 100 cases seen early
and in good condition, it would be easy to escape any mortality from
the operation whatever. On the other hand, taking the same number
of cases as they present themselves from time to time, there would
probably be a considerable death-rate." The statistics of Batt (Amer.
Jour. Med. Science, October, 1884, p. 423), in which a mortality of
31.8 per cent for lumbar and 53.1 per cent for inguinal colostomy is
given, must be ignored at the present day. These figures were drawn
from operations done before the advent of aseptic surgery, and at times
when the procedure was so unfavorably considered by surgeons that it
was put off until the patients were practically moribund. They do not
represent in any way the results from either of these operations at the
present time. Under modern aseptic precautions, and in the hands of
competent operators, inguinal colotomy is followed by a comparatively
low mortality. The following table illustrates this fact most forcibly:

Table

Operator.

Allin^hain

Reeves

Cripps

Wheeler

Edwards

Goodsall

Author

Miscellaneous

Total

OOLOSTOMY-COLOTOMY— ARTIFICIAL ANUS 863

In this list we have 255 cases with 8 deaths^ a mortality of 3.1 per
cent.

It is rea^nable to suppose that the average run of cases subjected
to the abdominal operation are equally as grave as those in which the
lumbar method is. employed, and, assuming such to be the case, it ap-
pears very clear that the figures are greatly in favor of inguinal colos«
tomy. Nevertheless the operation is not without its hazard, and it
should not be undertaken without a due appreciation thereof and a
frank statement of the possibilities in the case to the patient and his
friends. It is an operation that requires good judgment to determine
its necessity, an accurate knowledge of the parts involved, and a most
delicate manipulative skill in its performance. As Mathews says, too
many men attempt it who are inexperienced in surgical technique, and
without mature judgment in the selection of cases.

In emergency cases, such as complete obstruction, delay in obtaining
the services of an expert surgeon will often jeopardize the patient's
life. It is necessary, therefore, that every practitioner should be pre-
pared to perform this operation upon a moment's notice. A certain
number of fatalities will, of course, result from inexperience or lack of
aseptic surroundings, but this number will be more than counterbalanced
by the lives saved which would otherwise be lost through delay or
transporting the patient to a hospital.

In operations of election, however, especially where temporary colot-
omy is proposed, there is little excuse for any fatalities. Accidents have
occurred in this operation resulting in death several days afterward,
but it would appear that these were all avoidable. Were this not the
case one would hesitate to advise the operation in such conditions as.
mucous colitis, rectal ulceration, and complicated fistula, for these con-
ditions, while annoying, are not usually fatal.

The conclusions in regard to the mortality from abdominal colostomy
are deduced from the statistics of expert operators. The figures da
not represent accurately the results of all colostomies done everywhere,
but they do represent what can be accomplished by those perfectly
familiar with the method.

Lumbar Colostomy. — This procedure, generally knoA\Ti as Amussat's
operation, was first proposed by Callisen in 1796, who employed a per-
pendicular incision just in front of the left quadratus lumborum mus-
cle. Amussat modified the operation by making a transverse incision
in the loin, and extended its application to the colon on the right side.
Sir Thomas Bryant further modified the operation by employing an
oblique incision just below the border of the floating ribs, thus reaching
the colon at a higher level than was attempted by Callisen or Amussat.
In all these operations the lumbar muscles were incised, but recently

THE ASUa. BECTUM. AND PELVIC COLON

opiTstors liave beeu accustomeil to separate them by blunt dus«
instead of cutting, after tlie manner advised by Howse. The me:
of liryant, who has had the tartest experience in this operation, :
follows:

The patient is laid upon the opposite side from which the coloet

is to be done, and a firm pillow or sand-bag is placed under the loi

order to make the flank prominent, and being turned somewhat i

his face, the ant

border of the qiudi

lumborum can be

tinctly felt. An

siou 16 made just b

the border of the

rib (Fig. 300), b.

ning an inch and a

back of the anterio

pcrior spine, aD<l

lendiuf downward

forward parallel

the crest of the i

for about 5 iw

Having incised the

and cellular tissue,

should sej^arate

fibirs of the Mil

iililiijue and latissi

ilin>i muscles, hoi

tliem ai>arl with b

retraclors; below t

one comes upon thi

ternal oblique mu

which should be e

rated in like mannc

dull dissection, thuf

])osing the lumbar

cia. the fibers of *l

run transversely and may be separated or cut. The estcrnal bo;

of the quadratus lumborum will thus be exposed, together i

the transversalis fascia. At this |tniut one should stop and ligate

bleeding vessels in order to pet rid of any hieniostatic forceps in

wound. With broad retractors holding the tissues apart (Fig. 301).

transversalis fascia is freely incised, and beneath it one enters the bei

subserous fat in which the kidney is embedded and in front of wb

COLOSTOMY— COLOTOMY-ARTIFICIAL ANUS

865

lies the colon. This fat should be cautiously torn apart by the fingers
or a blunt instrument in order to avoid wounding the kidney or ureter,
which are sometimes abnormally placed. The kidney should be located
during this blunt dissection, as, according to Bryant, the colon always
lies just in front of its lower border. In some cases in which there is
a small amount of fat, or when the colon is greatly distended, the latter
will come into view upon incising the transversalis fascia. In other
cases, where the fat is abundant and the gut collapsed, it is quite diffi-
cult to find the colon. It is usually searched for too far away from the
spine. It is sometimes said that the longitudinal fibers of the gut and
appendices epiploica? can be seen at this point, thus distinguishing the
colon from the small intestine; but AUingham has shown this to be
impossible unless the peritoneal cavity is opened. All that one needs
to guide him is the fact that if any gut at all is reached without enter-
ing the peritoneal cav-
ity, it must be the colon.
Whether the latter can
be reached without en-
tering the peritoneal
cavity or not depends
upon the length of the
mesentery.

Assuming that the
latter is short, the next
step in the operation
consists in rolling the
gut slightly forward and
then passing a silk liga-
ture through the skin, then through the gut, embracing about ^ of
its circumference, and then through the skin on the opposite side of
the wound. The gut is now incised longitudinally, and the hoops of the
sutures passed through it are caught, drawn out through the wound,
and cut in the middle; the ends are then tied to those passed through
the skin on their respective sides. In order to avoid soiling the
wound with escaping faeces, the gut should be caught with forceps
and dragged outside, if possible, gauze being packed on each side of it
before the intestinal incision is made. The packing should be kept in
place until the first gush of faeces and gas has subsided; then the canal
should be packed with gauze to prevent any further escape, the parts
washed with sterilized solution, the gauze packing around the gut re-
moved, and the edges of the skin and intestinal wounds should be sutured
together by close interrupted silk sutures. Sometimes there is no faecal
discharge at all for days after the operation.
55

Fio. 802. — Lumbar CoLOfixoiiY Completed.

!.
t

III

1 I.
■»l
t.

■■ *

866 THE ANUS, RECTUM, AND PELVIC COLON

In cases of distention, failure of gas to escape would indicate that
the opening had been made below the point of obstruction, and that
the operation would be of no avail.

After the gut has been fixed in position (Fig. 302), the gauze is re-
moved from the canal and the parts are smeared with sterilized vaseline
or cerate in order to prevent the faeces irritating the skin and the dress-
ings sticking to the edges of the wound. The latter is then dressed with
dry, fluffy gauze covered by rubber protective held in position by a firm
abdominal binder or adhesive plaster. The patient is placed on his back
in bed, and a sufficient amount of morphine is administered hypoder-
mically to overcome nausea; otherwise no opiate should be administered,
as it retards the peristaltic action of the intestine and prevents the
restoration of tone in the bowels which have been overdistended and
partially paralyzed. The stitches should be removed about the sixth
day and the patient allowed to sit up at the end of ten days or two weeks.

As will be seen, no effort is made at first to establish a spur which
will prevent the escape of faecal matter into the lower segment of the

■

bowel. Several methods have been devised to accomplish this. One
of these consists in drawing the deep wall of the gut out through the
opening in the exposed portion, dissecting off the mucous membrane
around the lower opening thus formed, and suturing the freshened sur-
faces together, thus absolutely occluding the inferior segment of the
gut. A simpler method consists in pulling the posterior wall forward
and passing a wire suture through the skin, underneath the gut and out
through the skin on the opposite side; the wire being drawn taut and
fastened by shields on either end thus holds the gut well out of the
wound and produces a very effectual spur.

In cases where on account of a long mesentery the colon can not
be reached without entering the peritoneal cavity, it should be drawn
out of the lumbar wound and fixed by sutures or a supporting rod passed
from one side of the wound to the other. In these cases some hours
should elapse before the intestine is opened, if the condition of the pa-
tient will allow. Where there is very great distention, however, the gut
may be packed around with absorbent gauze, and a trocar introduced
to allow the escape of gases. After this has been accomplished, the
wound made by the trocar should be closed with Lembert sutures, the
gut fixed in position, and opened at a later period.

Inguinal or Abdominal Colostomy, — It is now nearly two hundred
years since Littre (Memoire de Tacademie des sciences, Paris, vol. x,
p. 36) first proposed to make an artificial anus by an incision in the
abdomen (" an ventre '0. His advice was to open the sigmoid flexure
for the relief of obstruction below. He laid no particular stress upon
the point of incision, and does not appear to have done the operation

COLOSTOMY— COLOTOMY— ARTIFICIAL ANUS 867

upon a living subject. Pillore, of Eouen, first made an inguinal anus
for complete obstruction due to cancer of the rectum in 1776 (Brit, and
For. Med. Review, xviii, p. 452). In this case the opening was made
in the ca?cum upon the right side, and the patient lived twenty-eight
days, finally dying from causes not due to the operation. Following him,
Duboise performed the operation in 1783 for imperforate anus, the child
dying in ten days; ten years later Dinet (Med. op^r. sabatier, ii, p. 336)
attempted the procedure for a like cause in a child two days old. This
patient lived many years. In 1794 Desault operated in a similar case,
but without success. Thus in the first four operations by the abdominal
method, three were done for imperforate ani and one for intestinal
obstruction, with a mortality of 50 per cent.

Shortly after this Fine, of Geneva (Manuel de med. pratique de
Louis Adier de Geneve, second edit., 1811), made an artificial anus in the
transverse colon by an incision through the rectus muscle just above
the umbilicus. Following these, Martland, in 1814 (Edinburgh Medical
and Surgical Jour., 1825, p. 271), Freer in 1817, and Pring in 1820
(London Med. and Physical Jour., 1821) performed the operation, mak-
ing the anus in the sigmoid fiexure. Up to this time no effort or sug-
gestion had been made to avoid wounding the peritonamm. Callisen
does not even seem to have thought of this when he proposed the left
lumbar operation, " because," as he says, " the intestine may be reached
more easily in this place than above in the iliac region." Nevertheless,
the fear of wounding the peritonaeum grew, and when Amussat demon-
strated that he could open the colon from behind without entering the
peritoneal cavity, and substantiated his claim by reporting G cases with
1 death (Gaz. med. de Paris, 1839, No. 1), the results were so remarkable
that the Littre operation immediately fell into disuse and became prac-
tically obsolete for the next half century.

Since it has been demonstrated, however, that the peritoneal cavity
can be opened with comparatively little danger under aseptic precau-
tions, the tables have been turned, and the inguinal or abdominal opera-
tion is now almost universally employed. The advantages which it
offers are: First, it is more easily and quickly performed; second, there
is less danger of infection and inflammation in tlie wound because it is
shallower; third, it furnishes an opportunity for abdominal exploration
which is of the greatest importance in all cases in which an artificial anus
is necessary; fourth, the site at which the anus is placed makes it more
convenient and comfortable to the patient; fifth, the difficulties of
closure are much less than when the artificial anus is in the lumbar
region; sixth, the mortality is lower in this method than in lumbar
colostomy. For these reasons this method' should be employed except
in the rare instances mentioned above.

868 THE ANUS, RECTUM, AND PELVIC COLON

Until within a few years, inguinal colostomy was employed only to
overcome or prevent intestinal obstruction. Recently it has been
I adopted generally as a means of treatment in various conditions, and

as a preliminary measure to extensive operations upon the lower portions
of the intestinal canal. It is also being done much earlier and more
frequently in inoperable cases of malignant disease of the rectum and
sigmoid, since it has been shown by Witzel, Bailey, Weir, and others that
the artificial anus can be so fashioned that the patient is comparatively
safe from involuntary faecal discharges. There are therefore two distinct
classes in which it is employed: First, cases in which the disease is curable
hy treatment or surgical procedure, and in which it is possible to reestablish
the normal f cecal canal; second, cases in which the disease is incurable, or
in which, the diseased portion being removed, it is impossible to reestablish
the normal canal.

In the first class, when an artificial anus is determined upon, it is
important that it should be made in such a manner that it can be
eventually closed with the least possible disturbance and danger to the
patient. In the second class the anus should be so fashioned that it can
be easily attended to and will possess the greatest amount of fa?cal con-
trol. In the early application of this operation, when it was only per-
formed for incurable conditions, the chief effort of surgeons was to pro-
duce an artificial anus which would be an effectual exit for faecal material
and prevent its escape into the lower or diseased segment of the gut.
All devices and improvements in the operation during this period were
directed toward the formation of an acute, elevated spur between the two
legs of the loop in whicli the anus was made, and toward the prevention
of prolapse. The methods of Allingham, Cripps, Kelsey, Bodine, Maydl,
and Reclus were all directed toward these ends. On the other hand,
the methods of Witzel, Bailey, Paul, and Weir are all directed toward
the formation of a permanent artificial anus that will possess the greatest
amount of continence, and in the most convenient position for the
patient. The former are adapted to temporary, the latter to permanent,
colostomy. The discussion of this subject, therefore, naturally divides
itself into that of the temporary and permanent methods.

Temporary Colostomy, — The temporary artificial anus consists in an
opening made in the intestine at some point above the seat of disease
for the purpose of turning aside the faecal current while local treatment
or some operative procedure is being carried out upon the parts below.
The site at which this opening is made depends upon the location of the
disease and the treatment which is to be adopted. If the latter is to be
local medication, the artificial anus should be placed as close to the
diseased area as is consistent with its establishment in healthv tissue; if
operative procedures are to follow, it should be placed sufficiently far

COLOSTOMY— COLOTOMY— ARTIFICIAL ANUS 869

away to allow the greatest freedom to the surgeon in dealing with the
healthy segment of the gut between it and the diseased portion. In
other words, if there is a tumor or strictiye to be removed, the artificial
anus should be so placed that it will not interfere with tlie manual
performance of the operation, and that there will remain sufficient
healthy intestine below it through which to reestablish the normal faecal
canal if such is possible. Thus, in some cases, it is advisable to make
the artificial anus in the lower portion of the sigmoid, in some in the
upper portion, and in still others in the transverse or ascending colon.

The essentials of a temporary artificial anus are, a free exit for faecal
matter, absolute prevention of its escape into the gut below, and facility
of closure after its purposes have been served. The latter is of the
utmost importance, for if the closure of the temporar}' anus is more
dangerous than the operation of making it, or even than that for which
it is made a preliminary procedure, it could hardly be recommended
to patients with much confidence. It is necessar}% therefore, in making
such an anus to have clearly in view its ultimate closure, and so make
it that this may be comparatively sure, and as far as possible free from
danger to life.

The Operation. — There are several different techniques employed in
the performance of this operation. Some were devised especially to
form an effectual spur, others to prevent prolapse, and still others with
a view to ultimate closure.

The preparation of the patient, the incision and the opening of the
abdomen are practically the same in all, and need be described but once.
The patient should be prepared as for laparotomy; the pubes should be
shaved, the abdomen scrubbed with green soap and dressed with bichlor-
ide gauze the night before the operation. The bowels should be moved
by a laxative the day previous, and by an enema on the day of the
procedure. These preparations will be impossible in emergency cases,
and in such one must content himself with the best immediate aseptic
preparations possible. After the patient is amesthetized, the abdomen
should be thoroughly scrubbed with tincture of green soap, then with
a solution of bichloride (1 to 2,000), and finally with alcohol 95 per cent.
This simple aseptic preparation, if thoroughly carried out, is as effectual
as the most complicated methods. In 350 aseptic cases in which it was
employed in the Almshouse and Workhouse hospitals in the years
1898 and 1899, only 3 cases of infection occurred — one due to escape
of urine into the wound, one to the use of old catgut by mistake, and
the third to the patient's having got out of bod and disarranged the
dressings a few hours after the operation. With such an experience,
the author is convinced that no more elaborate preparation of the
patient is necessary.

870

THE ANUS, RECTUM, AND PELVIC COLON

T]ie abdomen having been thus prepared, is covered with sterilized
towela or sheets except at the immediate operative field. If the artiliciil
anus is to be made in the left inguinal region, an incision should be
made through the skin in a line with the fibers of the external obliquB
muscle; it should Ins
^^^^ f,in 1 inch above and
E ^^^1 1^ inch inside of lliv

n ^^^H anterior superior spioe;

T I^H its length should be ^

V ^^H to 3 inches or longer

I ^ ^^H in fat people, and it

( ^f '^H should be earned

p mKL ^^I through the skin and

I ^^'9^^ ^^1 superficial fama to Ihe

^ ^""-^"^ ^^* fillers of the external
oblique muscle (Fig.
303). Some operatun
divide tlic entire fill
of the abdomen I7
^^^^^m ili'an incision. It i

I , .^^^KK^r I preferable, however, t»

^^^^^^^^^^E separate the fiWrs of

^^^IPI^^^^^B the muscles eadi

^^^■^ ^^^^^ft instnh

^^^^K , ^^^^^^L dragging theni

^^^^C^^^^^B - apart retmctoni

and thus prescrvifl
their functional actioil
By this method the
ternal ol)li({ue is Gnl
separated in one line, the internal oblique in another, and the fascii
transversalis then comes into view (Fig. 304). At this jioint (
should tie all bleeding vessels, and thoroughly dry the wound in ord«f
to prevent any oozing of blood into the peritoneal cavity. The fmcift
tranaversalis is then incisotl in a line with Pouparfg ligament to tlif
extent of about 2 inches; this brings the peritonH?um into view, tad
it should be incised in the same line, its edges being caught by artcij
clamps and drawn up through the wound to prevent its being stripped
off from the abdominal wall during the exsniination. The patieU
should then be placed in the Trendelenburg posture in order to fra
the pelvis, if possible, from the loops of small intestine and omeatniQ.
The incision should be made large enough to permit the inlroduA
tion of the hand, so that it will be possible to explore carefully till

— IdOiaiON IN 1 NO cm At. CnLOSTflWY

uidu, exposing fi]

COLOSTOMY— CO LOTOMT— ARTIFICIAL ANUS

871

pelvic and abdominal cavities before attempting to find the sigmoid.
One can never say exactly at what point the artilicial anua should be
made until such an exploration has been carried out. Evt^n in ca^cs
with great distention this examination is of the utmost importance,
becauee it enables one sometimes to find the collapsed portion of the
gut below the obstruction, and thus determine the exact site of the
latter. After this exploration has been made, with the hand well down
in the pelvis, one may trace the rectum upward, and thus without any
difficulty secure the lower loop of the sigmoid flexure and drag it out
of the wound, being absolutely certain as to which is the superior and
which is the inferior segment. The sigmoid and colon are recognized
by the longitudinal muscular bands and by the attachment of the
appendices epiploicie. \\Tiile such extensive exploration adds to the
possibility of peritonitis, this danger is more than compensated for by
the exact knowledge which is acquired of the parts tJiat are to be dealt
with. Most operators advise introducing the forefinger through the
abdominal wound, and search-
ing for the sigmoid in the iliac
fossa before exploring the ab-
domen, but this is not so sat-
isfactory as exploration with
the whole hand.

Fimlion of Ike Gut.— Alter
the sigmoid is found and it has
been determined which part of
it is to be fixed in the abdom-
inal wotmd, the operation mnv
proceed in several different
ways.

Some surgeons suture the
parietal peritoneum to tlu'
edges of the skin wound, hulil-
ing that union between tiiis
and the peritoneal layer of tlie
gut will be more rapid than
that between the intestine and
freshly cut surfaces. Reclus,

however, has shown that this is a useless waste of time, as it does not
hasten union in the least, and produces a weaker adhesion of the gut
to the abdominal walls. The author has verified this claim, and in his
last 15 cases has not sutured these tissues together. The fixation of
the gut in the wound and the method of opening it are the points on
which operators essentially differ.

Kxpojinre and tepsralion of tlic iuleiaal obllqiM

8T3

THE ANUS, RECTUM, AND PELVIC COIX)X

: ft ft, Mir

Y (Crippn's muthixl).
ir^ rH^HtniiiPiiiii and skin.

Cripps's Afethod.—AiteT the sigmoid has been found, it is dragged ont
of the wound until the upper Hcgniont is taut, the lower being pmlni!
back in the abdomen; this is done in order to prevent subsequent prola|»?.
In the loop thus brought out of the wound two provisional ligatun*
are passed tlirough the longitudinal muscular band opposite the mesen-
tery. The ends of these ligatures are left long, and are used to steidy
the bowel during its subsequent stitching to the abdominal wall; they
also act as guides in opening the intestine. The loop is now dropped

back in the •)>-
doraen while the
parietal perilo-
iia-uni is sutured
to the skin; it ic
then drawn v^
into the wound
again, and, wliitt
nuassiiitantholdt
the long liga-
tures taut, it t
fi^^ed in position
by T or 8 fine si "
.-iitures, whivh
|inss tlirough its
ixriloneal and
muscular wolli^
!ind thenlhrou^
ihe edges of tbt
peritona-um ai
^kin (Fig. 303
The sutures .
the angles »f tbil
wound pass firel
through thv skin
and peritonvnni,
then through the
peritoneal and muscular layers of the gut, and out througli
peritoDEBum and skin uiwn the opposite side. The sutures in th«
gut are introduced in the longitudinal band on one side and alon)
the border of the mesentery on Ihe other; about two-thirds of tM
circumference of the gut is thus secured outside of the wound (Fig.
30G). Unless the case is very urgent, the gut is not opened until several
hours, or even two days, after the operation. The wound is dresswl hf
being smeared with sterilized vaseline and covered with thin oiled sJlk

L Cuuwnjjiv (Crippa'n
Final sulurw In pWia.

lelbod).

COLOSTOMY— COLOTOMY— ARTIFICIAL ANUS 873

or rubber protective tissue, over which is placed a thick mass of gauze
or cotton held in position by adhesive plaster or an abdominal bandage.
The vaseline and rubber tissue prevent adhesion of the gut to the
gauze dressings, so that they may be easily removed whenever it
is thought wise to open the gut. When this period arrives, the gut
is incised longitudinally between the two long ligatures which have
been left in position, and its edges above the level of the skin are
trimmed away.

Allingham^s Method, — After the abdomen is opened the parietal peri-
tonaeum is sutured at once to the skin around the edges of the wound;
the sigmoid is then found and dragged out of the abdomen until both
the upper and lower legs of the loop are drawn taut. A suture of
carbolized silk is then passed through the skin and peritonaeum on the
outer side of the wound, then through the mesentery, back again
through the latter, and then tied to the end left outside of the skin.
The mesentery is thus held in apposition with the parietal peritonaeum,
and all of the sigmoid which can be drawn through the abdominal
woimd is held outside of the abdomen. The edges of the wound are
then sutured to the gut; the greater the distention the more sutures
will be required to prevent hernia of the small intestines through the
wound. The gut is not opened for some hours, or even three days if
the sjonptoms are not urgent. It is then incised longitudinally, and
after the bowels are once thoroughly emptied through this opening a
specially devised clamp is applied which, being tightened daily, cuts off
the entire loop left outside of the abdomen.

The special features of this operation consist in the production of
a good spur and the removal of all that portion of the sigmoid which
is likely to prolapse through the artificial anus. The sacrifice of this
intestine seems altogether unnecessary. The pain produced by the slow
cutting of the clamp is very trying to the patient, and, finally, the opera-
tion is not satisfactory in temporary colostomy on account of the amount
of gut destroyed, and because it necessitates either enterotomy or in-
testinal resection to close it.

Kelsey fixes the sigmoid in the wound as follows: One end of a
silver wire is prepared with a metal shield held on by a perforated shot,
the other end, threaded to a strong, sharp needle, is passed through the
entire abdominal wall about 1 inch to the right of the abdominal in-
cision, then through the mesentery, and back through the abdominal
wall on the opposite side from within outward. The wire is drawn taut,
thus bringing the edges of the wound in close apposition with the
mesentery, and the free end is fastened with a shield and shot as on
the opposite side. He does not suture the peritonaeum and skin to-
gether at first, but brings them together with interrupted silk sutures.

874

THE ANUS. RECTUM, AND PELVIC COLON

each passing throuffh the skin, tlu-u through the parietal pemonipnni,

and then through the peritoneal and muscular coats of thp intestine.

As will be obBerved from the cross-sections (Figs. 3U7, 308)

the preceding operations, the posterior wall of the gut is below the

level of the skin, and it is impossible without sacrificing a consideraMe

portion of the gut to pre-

[ ' ^~' ~~ ' vent the escape of a cep-

tiiin amount of fa'cnl

terial into tiie dependent

Begmont.

Boditif's Meihod.—\
very effectual method
producing a spur is t!
]iraposi»d by J. A. Bodini^
of New York. It eoQEifitoiii
ilnnving a loop of the sig*
iiuiid well out of the wound
and uniting its afferent and!
efferent legs to thp extrnt
of about 2 ineheB with fine
silk BUlures placed oi
either side of the mesen-
tery alwut i an inch apart.
The acutely flexed knuckle
is then sutured iu the ab-
dominal wound «o that it
stands well above the levd
<>( the skin (Fig. M9).
After the gut has thor*
tui^'Iily united with the ab-
ihimtnal wound and thiis
sealed off the peritoneal
cavity, this protruding
knuckle iii aniputaiMt,
leaving a double-liorreled
aperture with a perpen-
dicular division which *f
fectually prevents the passage of fa'cal material into the intertini
below.

The originator claims that an artificial anus formed in this tnfttmiv
can be safely and surely closed by cutting away this spur through ths
aid of Grant's enterotome (Fig. 310), or even by incising it witli
straight scissors, inasmuch as the union between the two legs pre-

COLOSTOMY— COLOTOMY— ARTIFICIAL ANUS

876

Tents any danger of such an incision penetrating the peritoneal cavity.
The proposition aounda practical, and it has been highly indorsed by
many of our best surgeons. The author has never employed it, however,
because it is believed that in the Maydi-Reclus method there is a simpler
and surer means to accomplish the desired ends without the sacrifico of
any portion of the gut.

Mathews employs long harelip pins passed through the abdominal
walls and mesentery to support the gut (Fig, 311). Jeannel has advo-
cated making an irregular incision in the skin, passing the trans-
verse part of the flap through the mesentery, and suturing it back in
its normal position, thus
using it as a means of sup-
port for the gut. These
methods, however, possess
no advantages over those
previously described, and
the difficulty of thor-
oughly sterilizing the skin
forms an insuperable ob-
jection to the method of
Jeannel.

The Maydl-Reclus
Method.— yUyAl {Cen-
tralb. f. Chir., No. 24,
1888) suggested support-
ing the loop of intestine
drawn out of the inguinal
wound by an inflexible
rod mnde of vulcanized
rubber with flanges upon
either end. The tech-
nique, as he first proposed
it, consisted in drawing
the loop out through the wound, making a small incision in the mesen-
tery, care being exercised to avoid the blood-vessels, then passing the rod
through this incision; two or throe sutures were placed so as to
hold the intestine together below the rod, and then, with the latter
resting upon cither side of the wound, the protruding portion of the
gut was sutured to the skin and peritoneum. A cross-section after this
operation shows that the posterior wall of the gut is above the level of
the abdominal wall (Fig. 312), and thllB forms a spur beyond which the
f feces rarely pass.

With some modifications, tliM i* *^* '" ' ' «t, simplest, and most

Fm. BOP. — IbouiN:

876

THE ANUS, EECTUM, AND PELVIC COLON

satisfactory method of col-
ostomy. It is not only suit-
able for a. temporary in-
guinal anus, but an artificial
anus made by this method
can be easily converted into
the permanent type if it is
found inadvisable to cloae
the aperture.

Kfaydl and Beclus opened
the gut by transverse inci-
sion in a line with the sup-
porting rod and extending
two-thirds around the cir-
cumference of the gut. This
incision v&s made with a
Paquclin cauterj- immedi-
ately after the gut was fixed
in position or, if the case
was not urgent, two or three
days later. After two or
three weeks the remainder
of the circumference of the
gut was cut through upon the rod in a like manner, and the protruding
ends were sutured to the skin around the wound. This treatment of

y (Aludiuwit's methodi.

COLOSTOMY— CO LOTOMY— ARTIFICIAL ANUS

877

the gnt neceesitatea a resection of the bowel in ease it is deemed wise
to close the artificial anus at a later date, and therefore it is to be
rejected.

Tke Author's Technique
for Temporary Inguinal
Colostomy. — An incision
through the skin and su-
perficial fascia is made in
a line with the fibers of
the external oblique mus-
cle, beginning at a point
1 inch above and IJ inch
inside of the anterior su-
perior spine of the ilium.
It should be at least 3
inches in length. The
fibers of the external and
internal oblique are sepa-
rated with a dull instru-
ment and drawn apart with broad retractors. The fascia transversalia
is tben divided by incision in the line of Poupart's ligament. At this
point all bletidiug veesele are ligatured and the wound thoroughly dried
with sterilized gauze.
The peritonteum is
then openetl by a
small nick, the finger
being introduced
through this as a
j;iii(!t', and the mem-
linine ineiaed the
«1ink' length of the
"I'lUid in the trans-
viTi^alis fascia; its
(■ili.'1'fi are caught with
li;i'niostntic forceps
:iii(l drawn up into the
w.iund. The hand of
I he Operator is then
iiilrnduocd and a thor-
KcU„:inEi»'.>.iti,n>uBhm«seni«n-. •'"fe''! exploration of

the abdominal and
pelvic cavities is made. After this has been done, if it is found
advisable to proceed with the temporary artificial anus, the sigmoid

THE ANtrS, RECTUM, AND PELVIC COLON

is caught, dragged out of the wound, and the proper point to tie
utilized is determined upon. A small incision is then made throu^'h
the mesentery, car-
being taken to avuid
the blotxl-reafifld, ami
a glass rod about {
of an ineh in diauietiT
and 4 inches in lengili
is passed through tliis,
its ends resting upon
either side oi the
wound (Fig. 31:J).
The lower angle ot
tht> wound is tli^Q
closed by silkwomi-
gut sutures passeil
through all its coats
to sueh an extent that
OuD-iupiKirt«donrodaH.Uuiun«mi««iiiou. >* Compresses the in-

ferior leg of the in-
testinal loop against (he glass roil. Fine chromicizeil eatgiit sutures
arc tlu'n passed at the two angles of the wound through the skin an<l
peritonajuni, then through the muscular wall of the gut, and butk

tJirongh the pcritonanim

and skin upon the opposite
side (Fig. 314). Suiall pads
of iodoform gauze are in-
trixtucod under the pro-
truding ends of the glass
rod ami along tlie edges of
the wimnd close to the in-
testine after the latter has
been smeared with steril-
iKed vaseline. The whole
is ili-essed with in-oledivc
tissue covered \>y a thick
jmd 111' gauze or cotton,
which is held in position
bv adiiesive straps and a
linn ahdoitiinal hiindiige.
Tlie giiL is never o].encd
at thi< tim('. If there is
grcai disieulimi hy giLs a

COLOSTOMY— COLOTOMY— ARTIFICIAL ANUS

trocar is inserted to allow ita escape. After this has taken place, the
opening made by the trocar is closed by two Lembert sutures and
sealed with iodoformized coUodiun. The patient is placed in bed with
his hips well elevated, and is given sufticicnt morphine hypo-
dermically to control vomiting and intestinal peristalsis for
the succeeding ten or twelve hours. The gut may be opened
with perfect safety at any time after the first six hours, al-
though it is better to wait two or three days in cases which
will admit of such delay. This opening should be made by

an incigion through the longitudinal muscular band opposite the mesen-
tery, extending from the superior angle of the wound to ^ an inch below
the supporting rod. A transverse incision ia then made at the lower end

of this wound involving two-thirds of the circuiuference of the gut {Fig.
315). By this means the triangular flaps in the upper segment roll back-
ward and curl up like dried leaves. The straight flap in the lower seg-

ments falls downward and inward, practically closing the lower aperture.
The faecal discharges are thus carried outside of the abdominal cavity,
and there is scarcely any possibility of their escaping into the lower

880 THE ANUS, RECTUM. AND PELVIC COLON

segment. In addition to this, no portion of the intestinal wall is sacri-
ficed, and when it becomes advisable the artificial anus can be closed by

simply suturing the edges of the T-shaped wound together without
opening the peritoneal cavity. At the same time the lower segment
may be opened by simply lifting up the transverse flap, thus furnishing

an opportunity for irriga-
tion and treatment of the

parts below so long as is

necessary.

In this operation the

author adheres to the

principle laid down in

the foregoing pages witli

regard to the portion of

the sigmoid in which the

artificial anus ought to be

made. If tlie disease is

to be treated by resection

of a portion of the gut

below, the artificial anus
ciriiu liuHK-pLATK. j^ made high up in the

tiroxiiiwiion Kuturw; Sigmoid in order tliat as

e, niwiiiiiBB in pluto much as possible of this
organ itiny he left below
to be utilized in the reestablishment of the natural intestinal canal.
The longer the loop tlius left below the artificial anus, the easier will

Fio. 330.— Sehk'b

COLOSTOMY— COLOTOMY—ARTIFiaAL ANUS

be the subsequent operation of extirpation or resection. The glass roA
is retained in position for two weeks, or even longer. It occasions the

patient no inconvenience, and it is prevented from slipping out of place
by a narrow strip of adhesive plaster around each end and fastened
to the abdominal wall above the wound.

If unexpectedly it becomes necessary to convert this temporary arti-
ficial anns into a permanent one, this can be accomplished by cutting
through the posterior wall of the gut, which is supported upon the

882 THE ANUS, RECTUM. AND PELVIC COLON

rod, and trimming off the protruding edges to within about 1 centi-
meter (f of an inch) of the 8kin. The opening of the inteetine requires
no anseBthesia whatever. Unless the cutting involves the mesentery.

■s (O'lli

there is no pain connected with this part of the operation, and the
hsemorrhage is always bo alight that it need not give any anxiety. When
the mesentery is incised, however, local or light general aiuesthesia
ought to be employed, as the
sensitive nerves of the gut
seem to be located in this
portion, and any cutting here
occasions considerable pain.
There is also likely to be con-
siderable bleeding from this
incision, which should be con-
trolled by twisting or ligating
the arteries.

Closure of a Temporarf

Artificial Anus. — The methoil

of closing an artificial anus

will depend altogether upon

the manner in which it has

been made. In operations such

as Allingham's and Bodine's one may follow one of two plans: First,

the spur may be cut away with an ontcrotome (Figs. 31G, 317). A

straight hysterectomy or long clamp forceps (Fig. 318) serves verj- well

COLOSTOMY— COLOTOMY— ARTIFICIAL ANUS

for this purpose. The blades o£ the instrument are introduced one
into the upper and the other into the lower aperture of the gut, and
they are gradually tightened day by day until they cut their way through
by necrosis of the tissues. This process is exceedingly painful to the
patient, and it requires two to six days to accomplish it. After tliia
the fiecal current will generally pass downward through the rectum,
and the artificial anus may heal spontaneously. If this does not occur,
the edges of the gut around the abdominal opening may be dissected
up from the skin and closed by Czerny-Lembert sutures, the sltin
being brought together above the freshened surfaces. It is perfectly
evident that this method will result in a very abnormal condition

of the intestine, neverthe-

less quite satisfactory re-
sults may be obtained
through it.

The second method con-
sists in dissecting the ends
of the gut loose from their
attachments to the abdom-
inal wall, freshening their
edges, and uniting thera by
end-to-end or lateral anas-
tomosis. This may be done
by the aid of the Murphy
button {Fig. 319), Senn's
bone-plates (Fig. 3301. or
by suturing with or wilhout
the use of the Laplace or
O'Haiti clamps (Figs. 321,
322). The latter instru-
ment is a most ingenious
and practical one. It not

only facilitates the suturing, but it at the same time controls hsemor-
rhage and prevents the escape of intestinal contents into the wound.
The method of employing it has been graphically described by the
inventor (Amer. Jour, of Obstetrics, vol. xlii, p. 82), and is easily
understood from the accompanying illustrations (Figs. 323, 334, 325,
Safi, 327, 328). This operation involves opening the peritoneal cav-
ity, and i^, in fact, more dangerous than an ordinary resection of
the gut, because it is difficult, without considerable sacrifice of the
organ, to obtain portions which are completely covered with peri-
toneum. The various methods of resecting and reuniting the ends
of the intestine are described in works on general surgery. An excel-

B (second step

884 THE ANUS, RECTUM, AND PELVIC COLON

lent resume of the technique will be found in Bryant's Operative Sur-
gery, vol. ii, to which wo are indebted for numerous illustrations.

After operations by the Cripps, Kelsey, or other methods, in which
only a part of the intestinal circumference has been destroyed, the
artificial anus may sometimes be successfully closed by a plastic opera-
tion, after the manner of Szymanowski's procedure for closure of ure-
thro-perineal fistula. A curved incision, ABC (Fig. 330), is made
through the skin internal to the artificial anus. This is dissected up
for about 1 inch from the opening to the dotted line ADC. A second
curved incision, AEC, is made on the opposite side, about IJ inch from
J. .. ^ _ _. _ the artificial anus. The

^ ^W ' \\ f f superficial layer of the skin

v.* ■ -Sf i^ dissected off from this

flap with the exception of
a small portion immedi-
ately surrounding the arti-
ficial anus Euflficiently large
to cover the latter aper-
ture. The flap is then
raised over the entire area,
AFCE, leaving it well at-
tached around the artificial
anus. It is then folded
over on this hinge-like at-
tachment and sutured to
the freshene<l surface from
which the fiap ABCD has
been raised. To prevent
their cutting into the
skin, these sutures should
nS"""" ^''"'■""" be tied over pledgets of
gauze. The flap ABC is
then dragged across and sutured to the margins of the incision AEC
(Fig. 331). In this manner the artificial anus is closed by a double
layer of skin without opening the peritoneal cavity. Parker Syms and
others have succeeded in closing artificial ani after this manner.

When the colostomy has been done after the author's method, it may
be closed as follows: The little triangular flaps in the upper s^ment,
which curl up and become adherent in their peritoneal layers, are un-
rolled by carefully breaking up these adhesions with dull instruments
or with the finger nail. Their edges are then freshened, together with
that of the lower transverse flap. The T-shaped wound in the gut is
then brought together by silk sutures passed through the mucous mem-

COLOSTOMY— COLOTOMY— ARTIFICIAL ANUS 885

brane, after the mannor of Czem}-, and a row of Leinbert sutures out-
t-ide of these. Aftt-r this has bfen accomplishetl, the gut is dissected
loose from its attachment to the abdominal wall down to the peritoneal
layer. This layer is carefully stripped from the abdominal wall to the
extent of aliout 1 inch all around the artificial anus. This loosening
provides a loop of peritoniEum which allows the closed giit to drop down
below the level of the abdoiiunal uiill (Fiy. 3.32). The opening in
the latter, already freshcm'ii
by dissecting loose the iuti.-,-^-
tine, is then brought together
by silkworm-gut sutures passed
through all its layers. By
this method the gut is effec-
tually closed with very slight,
if any, diminution in its cali-
ber, without opening the peri-
toneal cavity, and the abdom-
inal wall is restored in all its
thickness, which is a matter
of considerable importance in
the prevention of hernia.

Permanent Cohstomy. —
The chief requisites of a per-
manent artificial anus consistf;
in an effectual outlet for tln'
fipcal discharges, eonvenieiU"
in its management by the |i;!-
tient, the absence of prolapM'.
and the greatest possible fsetul
control. It is generally coil-
ceded that an artificial ami-
in the inguinal region can be
better attended to by the pa-
tient himself than in the lum-
bar, gluteal, or sacral posi-
tions. It will also be admitted ,,, miui,,,, i-.m.i!]]!.
that prolapse is no more like-
ly to occur in this position than elsewhere. It may therefore be as-
sumed that the inguinal site, when practicable, is the most satisfactory
one. An effectual outlet for the fffical material can be easily obtained
in any one of the positions mentioneil. Control of fteca! discharges is,
therefore, the most important subject in connection with permanent
colostomy. The constant escape of gas and fieces from artificial ani

886 THE ANUS, RECTUM, AND PELVIC COLON

has brought the operation into disrepute with both patients and sur*

geona. The former are usually well eatisfied for a time by the relie

from pnin nnrl imprnvempnt in their g'eneral condition due to the reg»

lar action of their bov(>l«

through the newly formed
exit; but when they lei
that the opening i
permanent; that they hari
no control over their pu
pages; that they are il»
barred from society, biiai
nei^s, and travel, and i
addition to all this thi
the operation has not b
curative, a dissatisfactio
arises which ends in mo:
tal depression and somfl
times in deep melanebolj
The mental condition of such patients is pitiable indeed. Therefor^
when it is known beforehand that an artificial anus is to be a j
nent affair, it should certainly be fashioned so as to give the patiea
the greatest possible control of the fsecal discliargca.

The greatest improvements in permanent colostomy have been aloiij
this line. Numerous ingenious mechanical appliances have been devise
in the form of bags to catch the escaping fieees, and pads or plugs to "b
struct the fa?ca! exit. One of the best of these is the double inflatabl
bulb of 'Weir, a modification of Jacobson's intestinal plug. The
bulbs are connected by a hollow, hard-rubber tube for ease of intnxlDB
tion, and furnished with a stop-coek to prevent the escape of ai
The lower bulb is passed into the proximal opening of the arti6ini
anus and inflated. The upper bulb, covered with a perforated. Hard*
rubber disk, rests upon the externa! surface and holds the lower againi
the inner sui'face of the abdominal wall, thus occluding the opening
The whole is held in position by adhesive straps passed across the niblM
disk and attached to the abdominal wall. Various modifications of the<
])lugs have been devised, but apparatuses of this type, while they conln
the faeces and are satisfactory for a time, usually produce so much loc
and reflex irritation that it is impossible for patients to employ thei
for any great length of time.

Many surgical devices have also been employed to establish ttect
control in artificial ani. Among these may be mentioned twisting a
the gut after the manner of Gersuny, rotating the intestinal loop in tlu
abdominal wound so that the proximal opening will be below the distal

COLOSTOMY— CO LOTOMY— ARTIFICIAL ANUS

and suturing tlie abdoniina! wound so closely as to constrict the external
aperture in thi> gut. Xone of these, however, has proved successful.
JIany elforts liave been made to establish an involuntary sphincter from
the circular fibera of the gut. In one case the author apparently accom-
plished this by making tucks in the gut just above its point of exit
from the abdominal wound by introducing several fine silk sutures
longitudinally through the muscular layers for about 1 inch, the ends
of which, being tied together, jjrodueed an aggregation of circular fibers
at this point. The patient lived ten years after the operation, and always
had comparatively -good control. Subsequent trials of this method, how-
ever, were not so successful. One of the most ingenious of these at-
tempts is that of Bemays, and was termed by him " spkinderopwsis."
After fixing the gut and allowing it to adhere in position, he cut it
across; he then dissected the mucous membrane and submucosa loose
from the proximal opening in the gut for the distance of 1 inch, thus
exposing the circular muscular fibers. The latter were then caught by
catgut sutures running longitudinally and matted together. The mu-
cous membrane was then trimmed off to the proper length and sutured
back in its original position. The results of this operation, however,
were not satisfactory.

Another attempt in this line consisted in tying a strong silk ligature
around the intestine, just above its exit, sufficiently tight to narrow the
caliber to about the size of the index finger. The ligature was buried
by suturing the perito-
neal coats of the gut
over it (Fig. .333). This
operation has nothing
to commend it. Howse
{Holmes's System of
Surgery, vol. i, p. 801)
first suggested bringing
the loop of sigmoid out
through the fibers of
the rectus abdominis,
thus hoping to obtain
some sphincter ic con-
trol from the contrac-
tions of this muscle.
Von Hacker (Beitriige

zur klin. Chirur., 1899, S. 628) advised splitting the rectus muscle
both vertically and laterally, and then dragging the loop of sigmoid
through this split: this operation is very difficult, and the amount
of control obtained is not at all satisfactory. In fact, none of these

888 THE ANUS, RECTUM, AND PELVIC COLON

methods was any improvement upon the Maydl-Reelus procednre car-
ried out by separating instead of cutting the muscular layers of the
abdominal wall.

The first real advance toward the establishment of the modern per-
manent inguinal anus was that of Witzol (Centralblatt fiir Chir.,
1894, No. 40), who,
instead of bringing the
loop of intestine out
through the first ab-
dominal wound, made
a canal for it by sepa-
rating the external and
internal oblique mus-
cles over the brim of
the pelvis, and su tared
it to the opening in the
ekin 1 inch below (Fig.
334). Bailey modified
this operation of Wit-
zel by carrj'ing the in-
testine down between
the skin and the exter-
nal oblique muscle, and
bringing it out through
an opening in the ekin
just above Pou part's
ligament, 8 inches below the abdominal incision (Fig. 335). Braun (Bry-
ant's Operative Surgery, vol. ii, p. 99G) proposed closing the lower Fog-
ment ot the gut after the manner of Schinzinger, dropping it back in the
abdomen, and then carrying the upper segment underneath the skin
to an openinj,' on the anterior surface of the thigh (Fig. 336). Witzel,
and Lenkinheld and Borchardt, who have applied his method, state
that their patients all possessed excellent sphincteric control of both
gas and ficees without the aid of any bandage or compress whatever.
The fact, however, that it is often impossible to obtain a loop of sig-
moid sulTiciently long to be brought out over the brim of the pelvis,
renders this operation a very uncertain procedure. In Bailey's method,
as well as that of Paul, a truss or compress placed upon the intestine
as it passes from its exit from the abdominal cavity underneath the
skin will eiTeclually control both ftrcal and gaseous passages, but with-
out such a compress this control is not so perfect as that claimed for
the Witzel method.

Weir (iled. Record, 1900, p. fifiC) has combined the Schinzinger and

FlQ. 334.— WlTlEI

The loop of

ne held by liKBture Id dra)[Ketl through
'cea cxtvrnsl and Inunial oblique niuKles
through opemng Id skin Indicated byline

COLOSTOMY-COLOTOMY— ARTIFICIAL AMDS

Witzel methods as follows; The ordinary incision for inguinal colotomy
ia made through the abdominal wall, and the loop of sigmoid in which
the artificial anus is to be made is dragged out of the abdomen. It is
then cut in two, the lower end being invaginated, closed with T^mbert
sutures, and dropped back into the abdominal cavity. A canal is then
formed by separating the external from the internal oblique muscles
out to the crest of the ilium, at which point the fascia is divided and
the canal continued underneath the skin to a point about 2 inches out-
side of and below the crest. The upper end of the gut having been
disinfected and tied with a ligature, the ends of which are left long,
is then dragged through this canal and attached to the skin around the
opening in the gluteal region (Pig. 33T). The abdominal opening is
then closed, the gut being sutured to the pariftal periton.Tiuii at the
point of its exit from

the peritoneal cavity-
Great care must be ex-
ercised in incising the
mesocolon to loosen the
intestinal loop lest its
circulation be inter-
fered with and gan-
grene result, as hap-
pened in one case of
"W'eir's. Theoretically
there are two objec-
tions to this opera-
tion: First, the sit\ia-
tion of the artitifiiil
anus would appear xo
be very inconveniiTit;
second, the closiin' ^iml
dropping back of ihr
distal end of the jiui
destroys all opportu-
nity of disinfection and
treatment of the loii-er
segment through the
artificial opening. The

latter objection may be overcome by suturing the lower end in the
inguinal wound and opening it at a later period after it has thoroughly
adhered. Witzel, Borchardt, and Weir report that their patients suf-
fered no inconvenience from the situation of the anus, and we may
therefore assume that the first objection is without any particular force.

(1 METnoD or Pebm^nbit C

THE ANUS, EECTUM, AND PELVIC COLON

On account of its ease in execution and most satisfactory results ob-
tained from it, the author employs the following modification of Bailej-'s
method in permanent colostomj.

Author's Method. — The operation Is begun by the ordinary incision
for inguinal colotomy. The fibers of the external and internal oblique
muscles are separated by a blunt in-
strument instead of being cut. The
__ /■ transversalis fascia and peritonaeum
f^jf^j' ^i'<^ incised in a lino parallel to Pou-

^K_.E^^ part's ligament. After abdominal ex-

' I ploration has been carried out with the

J t I if hand and a permanent inguinal colos-

j"| iM ' i'HP*" tomy has been finally determined upon,

VWM ^ '*^"I' "^ sigmoid sufficiently long to

P be drawn at least 2 inches outride of

W ' the abdominal cavity is selected, and a

I tape or loop of large silk is passed

around it through a small slit in the
Fig. 33«.— BRAts'H Mkthop ur Pkb , ^. .,.,,. ,

HANENi c'oLosToMr (BryBni 1 mesentery, the ends being left long and

held by an artery forceps. The lower
fibers of the external oblique are then pulled downward, and the internal
oblique is split laterally to the distance of about 2 centimeters (J inch).
A canal is then made between the skin and the external oblique down-
ward to the extent of

about 2 inches, open-
ing through an inci-
sion in the skin just
above Poupart's liga-
ment (Fig. 338). This
canal and incision
should be large enough
to admit of the loop of
sigmoid being drawn
through them without
much compression.
With the aid of the
dressing forceps the
knuckle of gut is then
dragged through the
lateral slit in the in-
ternal oblique and

downward through the canal outside of the externa! oblique muscle
until it emerges at the inferior opening in the skin. It is held

COLOSTOMY-COLOTO MY— ARTIFICIAL ANUS

891

in this position eitlier by the paasap^e of a glass rod through the
opening in the mesentery, or by suturing it to the edges of the
skin wound. The abdominal wound is then closed by chromicized cat-
gut sutures in the muscular layers and a subcutaneous silk suture in
the skin; it is then sealed by iodoforinized collodion and dressed with
sterilized gauze, over which a layer of rubber protective tissue is placed
and sealed to the skin with chloroform. This latter precaution ie taken
to avoid infection of the primary wound through the escape of ficces
when the gnt is opened.
If necessary, the loop
of intestine may be
opened immediately,
but ordinarily it is bet-
ter to wait twenty-four
to forty-eight hours be-
fore doing so. This is
accomplished by a sim-
ple slit in the line of
the longitudinal fibers
of the gut. After ten
days or more, the pro-
truding portions of the
gut should be trimmed
down ilush with the
skin and the artificial
anus will present itself
as a double-barreled
aperture, one opening
of which eonneclfi wilh
the proximal and the
other with the distal
end of the sigmoid
(Pig. 339). The gut
is brought outside of
the external oblique

mnscle in order that it will rest upon a resisting plane, and a truss
or compress can be placed upon it, thus absolutely occluding its caliber.
Being passed through the slit in the external oblique, it is summnded
by muscular fibers, and thus obtains a certain amount of voluntary
control. In the majority of cases no compressing apparatus is neces-
sary, as the patient usually possesses almost complete continence with-
out it. When it is necessary, an ordinary single spring hernia! truss
with an elongated pad placed somewhat outside of the usual position

^^^^^^1 892 THB ANUS. BBCTUM. AND PELVIC COLON

^^^^^^^H serves every purpose. The author has practised this method in 7 case*,
^^^^^^^H and in only 2 of them has a truss been necessary. With the latttf
^^^^^^^^^1 in position, the continence was so perfect that it was neeessary foC
^^^^^^^1 the to rain
^^^^^^^^^1 ^^^H the order
^^^^^^^H ^^1 the q
^^^^^^^^^1 ^^H intestinal gaaee. Xo
^^^^H -^H only the

^^^^^^^H V tlie the anus

^^^^^^H V tiK' a
^^^H 1 sit .„,on an

^^^^^^^H ^Hp^^ J undernea
^^^^^^^H ^^^ f the artificial anus aa

^^^^^^1 1 iDconvenieM

^^^^^^BbI i^^^^^V normikl positid
^^^^■n ^^^Hr parts can be

^^^^^^^Hll ^^^^^f J the eases thus far
^^^^■U ^^m i served there has nev

^^^^^^^HM tlQ. 33!'.— I'KliUA-iENT t.PLrpsTOliV BT AuTMORV METai>tl f

^^^^^^^H ten<lency toward pi
^^^^^^^H The

^^^^^^^H segment of the sigmoid can also he washed out and irrigated thrmi)
^^^^^^^^^B this type of permanent artificial anus, ihus obviating the danger of ec
^^^^^^^H lections of pus and putrefying substances in this portion of the guU
^^^^^^^^^H Colostiimy on the Right Shle. — Inguinal ealotoniy upon the right mi
^^^^^^^H differs from that upon the left on account of the anatomical variatioa
^^^^^^^H ill the parts. The ascending colon is not situated as low down in tl
^^^^^^^^^H pelvis as the descending colon; it is not continuous with a gut of 13
^^^^^^^H caliber, hut united at an angle with the ileum: it ends in a blind pow
^^^^^^^H to which is attached the appendix vermiformis, which may jirove a SM
^^^^^^^H ous complication in colotomy on the right side; and finally, the meeei
^^^^^^^H tcry of the ascending colon Is usually so short that it is very diflica
^^^^^^^H to bring a loop outside of the abdominal wall and thus form an effieia
^^^^^^^H spur for Ihe prevention of fa'ces passing into the portion of the gi
^^^^^^^H the

COLOSTOMY— COLOTOMY— ARTIFICIAL ANUS 893

Another point of importance with regard to colotomy upon the right
side is the fact that the faeces are almost always fluid in this portion of
the intestine, and under such circumstances it is almost impossible to
form a permanent artificial anus which will possess any degree of fa?cal
continence on this side. Happily it is very rarely necessary to make a
permanent artificial anus at this site. Temporary colostomy in this posi-
tion, however, is sometimes called for in the treatment of chronic, in-
tractable inflammations of the colon. In malignant diseases of the
latter, those which are operable can be removed by resection almost as
safely without preliminary colotomy as with it. In the inoperable cases,
anastomosis of the healthy gut above the growth, with a similar por-
tion below it, offers a better solution of the problem with almost as little
danger to the patient's life as colotomy. When the operation is called
for on account of inflammatory conditions, it should be made as high
up in the ascending colon as possible in order to avoid the constant
escape of fluid faeces through it. When the mesocolon is long enough
for a loop to be brought outside and supported by a glass rod, the
Maydl-Reclus method should be employed here as upon the left side.
When this is not the case, one can only bring as much of the gut as
possible up into the wound and suture it to the skin. This, of course,
will not produce a spur sufficient to prevent the escape of faecal matter
into the intestine below the artificial anus, but inasmuch as such escape
would necessarily be against the force of gravity, it will not be very
great. As colostomy upon this side is nearly always of the temporary
variety, no portion of the gut should be destroyed in opening it, for this
will increase the difficulties of closure.

CHAPTER XXII
FOREIGN BODIES IN THE RECTUM AND SIGMOID FLEXURE

The conformations of the rectum and sigmoid flexure render them
peculiarly liable to the arrest and retention of foreign bodies.

There are three methods by which they enter these cavities: First,
by being swallowed and passed through the intestinal canal; second,
by their development in some portion of this tract and passage through
it to the sigmoid or rectum; third, by introduction through the anus.
Medical literature abounds with instances of foreign bodies of the most
varied and marvelous character found in these cavities. Ale-jugs, cham-
pagne-bottles, segments of ball-bats, needles, pins, spools of thread,
pipes, chain-saws, screws, nails, coins, bones, door-knobs, cows' horns,
pocket-books, medicine glasses, and hundreds of other articles have been
found in the rectum and sigmoid.

Physiological Causes predisposing to the Formation of Foreign Bodies
in the Intestinal Canal. — These depend upon altered or deficient secre-
tions from the intestinal glands, the liver, or the pancreas. Patients
differ in regard to the habitual condition of the contents of the intes-
tine; in some they are always more or less hard and dry, while in others
they are always soft or fluid. These conditions depend largely upon the
habits of the individual, upon his diet, and sometimes upon his tem-
perament. Those who live in limestone regions and drink the hanl
alkaline water are liable to the formation of calcareous masses in the
intestine. Where the intestinal contents are habitually dry and hard,
it is very easy for a small foreign substance to form a nucleus aroimd
which the lime salts incrustate, and thus form fa?cal calculi which may
be arrested in any of the saccules of the sigmoid or in the ampulla of
the rectum; the small, hard masses seen in certain individuals who are
the subjects of chronic constipation may also form the nucleus of such
enteroliths. Rheumatism and gouty diatheses are said to have some in-
fluence in their production. Old age and prolonged constipation are
the chief predisposing causes.

Pathological predisposing Causes. — Under this heading may be enu-
merated all the pathological conditions wliich tend to form concretions
894

FOREIGN BODIES IN THE RECTUM AND SIGMOID FLEXURE 895

or to narrow the rectum or sigmoid. Vitiated appetites, such as the eat-
ing of clay, slate-pencils, chalk, magnesia, etc., the formation and passage
of gall-stones, and multiple adenoids or fibromata of the intestine are
instances of these predisposing causes. Paraplegia and spinal paralysis
at any level may be predisposing causes of the arrest of foreign bodies
in the rectum and sigmoid, owing to the atony of the muscular fibers,
of the gut and consequent inability to pass these bodies out of the
intestinal canal. Poulet says that " paresis " of the intestine plays an
important role in the production of constipation and consequent arrest
of foreign bodies. Stricture of the gut at any level may also be such
a cause, but the arrest of stercoral masses above a stricture of the rec-
tum or sigmoid could scarcely be considered under the head of foreign
bodies. Hernias may also act in the same way, and such a condition
should always be looked upon as a serious complication when bodies
of unusual size are known to have been swallowed. Abdominal tu-
mors also may be said to increase the probability of arrest of foreign
bodies while passing through the intestinal canal, but there is no re-
corded instance in which they have actually done so.

Anatomical predisposing Causes. — In addition to the coarctations at
the anus and at the junction of the rectum and sigmoid, unusual devel-
opment of the folds of Houston, the crypts of Morgagni, and the diver-
ticuli sometimes found in the large intestine are predisposing causes
to the arrest of foreign bodies; displacements and adhesions of the
sigmoid or transverse colon, hypertrophy and spasm of the external
sphincter, may also be classed in this category.

Bodies which have been Swallowed. — Generally there is some knowl-
edge upon the part of the patient of having swallowed such objects,
yet sometimes, especially in children, the fact may have escaped their
memories, or they may have been entirely unconscious of such an acci-
dent. The first intimation they have of the condition arises from the
irritation and suffering due to the presence of the body. The author
has recently seen 2 cases of the most marked suffering due to the arrest
of foreign bodies at the anus, where the patients were entirely ignorant
of having swallowed any such substances. One of these cases was in a
gentleman from Boston, who was seized on a Friday with sharp, cutting
pains in his rectum. His medical attendant, without examination, im-
mediately surmised that he was suffering from fissure or ulcerating haem-
orrhoids, inasmuch as some blood had appeared, and prescribed a sooth-
ing ointment for his relief. After having visited two other physicians
in the mean time, neither of whom made a careful examination, he
consulted the author on the following Tuesday; he was under the influ-
ence of opiates, and yet suffered intensely with pain in his rectum.
An ocular examination showed congestion about the anus and slight

896 THE ANUS, RECTUM, AND PELVIC COLON

protrusion of small hajmorrhoids. These, however, did not account for
his pain. An effort to separate the margins of the anus greatly increased
his pain; upon attempting to introduce the finger into the anus it
came in contact with a hard, angular body, pressure upon which gave
the patient such agony that it was necessary to desist until he had been
anaesthetized. After chloroform was administered, the finger was intro-
duced alongside of the foreign body, the sphincter was stretched, and
there was removed from the rectum the breast-bone of a snipe, kite-
shaped, with three sharp points, which had been grasped by the sphinc-
ter so that they all punctured the mucous membrane. Infection and
suppuration had set in, but no burrowing had taken place, and under
antiseptic treatment the parts healed rapidly. The patient had no
recollection of having eaten a bird of any kind except a snipe, some eight
weeks previous to the time of his accident.

In the second case the outer hull of an apple-seed was arrested in
one of the crypts of Morgagni, and grasped tightly by the sphincter.
He also had consulted a physician, who told him he had fissure. It is
not intended to relate a number of such cases in this connection; a
brief outline of these two histories has been given to impress upon the
reader the importance of local examination in such cases, and to illus-
trate how much suffering can be produced by the arrest of insignificant
foreign bodies at this point.

When large bodies are swallowed accidentally the patient is always
aware of the fact, and generally seeks for assistance or advice imme-
diately. If the bodies are comparatively smooth and of a size which
allows them to be swallowed without great difficulty, we may trust
with fairly good confidence that they will pass through the intestinal
canal, at least as far as the sigmoid or rectum. Arrest at the caecum
may occur, but this is rare. What passes the pylorus will usually pass
through this aperture.

The length of time which a foreign body takes to pass from the
stomach to the rectum is most variable. A case has been reported in
which a plate of teeth, swallowed at night, was found in the anus
the next morning. Another was treated in which the tin tag off a piece
of tobacco was swallowed, and did not appear until found in the rectum
almost three months later; in this case, the fact of the tin tag^s having
been swallowed at all was doubted, and yet the child was watched care-
fully during the whole period, and her rectum was examined regularly
for the first t^'o weeks without discovering any evidence whatever of
the foreign body. Eighty-four days after the accident the author was
called to her on account of griping pains in her abdomen and inability
to move her bowels. Introduction of the finger into the rectum showetl
the tin tag squarely across the anus and forming a complete metallic

FOREIGN BODIES IN THE RECTUM AND SIGMOID FLEXURE 897

occlusion, with its five points sticking into the mucous membrane and
the sphincter grasping it. The parents claimed the recovered tag as a
family relic, and still retain it.

Another illustration of how long these bodies may remain in the
rectum and continue to produce irritation, and yet not be discovered,
is that related by Ackers (London Lancet, 1898, vol. ii, p. 690). The
patient consulted him, complaining of the frequent desire to go to
stool, but inability to accomplish it on account of a sharp, pricking
pain immediately following any effort to relieve hi^ bowels. He said
that he had suffered from this pain for thirty years; sometimes it was
more severe and sometimes less; when the faecal mass was hard, it was
almost impossible for him to bear it; when the passages were fluid, the
pain was not so severe, but that it had always been present, and that
he felt it whenever he sat in certain positions. He had consulted physi-
cians with regard to the trouble, and had been told that it was simply a
fissure or haemorrhoids, and soothing ointments had been prescribed.
Upon examination. Ackers found a long bent pin which was stuck into
the tissues just above the internal sphincter, and extended downward
and backward almost to the skin, while the head, like a crank, extended
quite across the anal aperture; thus, whenever the faecal mass passed over
this, it carried the point downward and backward, producing a scratch-
ing, as well as a pricking pain. Without any anaesthetic, Ackers re-
moved the pin, and the patient was immediately relieved. This case
is quoted because it is reported by a man entirely worthy of belief, and
yet it is almost incomprehensible that a pin should remain in the in-
testinal canal for thirty years without rusting and being dissolved
by the secretions of that canal. Admitting this as a possibility, it is
just as incomprehensible that any body should penetrate the mucous
membrane and remain in this position for any considerable period of
time without causing infection, abscess, fistula, or some perirectal in-
flammation. There seem never to have been any such complications
in this case. The length of time intervening between swallowing a
foreign body and finding it in the rectum or sigmoid does not indicate
how long it has been arrested at this point, for it may have been lodged
in some fold or diverticulum of the intestine, dislodged and arrested
again and again in its passage through the canal; but such cases as
Morton's (Penn. Hosp. Eepts., 1880, p. 335), in which the foreign body
was known to have been in the rectum for four years, and Ogle's (Proe.
Roy. Mjed. and Chir. Soc, London, 1861-'r)4, p. 267), in which a stick
remained in the rectum four months, gives one some idea of the possi-
bilities in these cases.

The cases which interest us most, and which will give the practitioner
more trouble, are those in which the foreign bodies have been swallowed
57

898 THE ANUS, RECTUM, AND PELVIC COLON

unconsciously or thoughtlessly, and in which the sjrmptoms of arrest
come on later. Fruit-seeds, coins, false teeth, pins, buttons, etc., fre-
quently pass through the alimentary tract and become arrested in the
sigmoid or rectum. The author once removed from the rectum of a lady
a mass of grape-seeds almost as large as a foetal head, that weighed
22 ounces. Examination with the speculum showed that the rectal
mucous membrane was studded all over with little ulcerated spots, evi-
dently the result of punctures from the points of the seeds. The pa-
tient had suffered from a watery diarrhoea that might easily have misled
one who was not in the habit of making local examinations in all cases
of diarrhoea and constipation. Poulet {op. cit,, p. 304) relates a case in
which 60 snails were found in the patient's rectum, and the author has
seen 2 cases in which plates of false teeth were swallowed and lodged,
1 in the sigmoid and 1 in the rectum.

Enteroliths; Colproliths; Fsoal Stones. — Faecal concretions develop
in those portions of the intestine where the movement of the faecal
current is not active, at the hepatic and splenic flexures, the caecum, the
sigmoid, and in the ampulla of the rectum. The vermiform appendix
is also a frequent site for their formation, but they rarely pass out from
this organ. They are of a firm consistence, and sometimes form real
enteroliths.

Leichtenstem describes three varieties: First, concretions of a stony
consistence, brown in color, and composed of phosphates of magnesium
and calcium. They are formed by concentric layers around foreign
bodies, such as inspissated masses of faeces, ascarides, small pieces of
bone, fruit-seeds, etc. Second, concretions of light specific gravity com-
posed largely of imdigested vegetable matter. Third, chemical stones,
or those resulting from the protracted use of calcium and magnesium
carbonates, bicarbonate of soda, salol, and other drugs. This last variety
is not frequent, but they may acquire enormous size, and even cause
obstruction of the intestine. They become dislodged from the points
at which they form, pass downward, and are arrested in the sigmoid or
rectum. A very interesting specimen of this kind was shown me by a
member of my class during the winter of 1898. He was called to see
an old lady suffering with intense pain in the right inguinal region.
Upon examination he felt a mass about the size of a cricket ball or larger.
There was no fluctuation and no rise in temperature. The woman said
the lump had been there a long time, and thought it had nothing to
do with her pain. He administered a mild laxative and ordered large
rectal enemata, and called to see the patient three days later. Not-
withstanding the fact that no unusual mass or solid faecal matter had
passed, the lump which he felt before had absolutely disappeared, and
the patient complained of a weight in her back and pressure at the

FOREIGN BODIES IN THE RECTUM AND SIGMOID FLEXURE 899

lower end of the rectum. An examination with the finger in the rectum
elicited a mass hard as a rock and so large that it was impossible
to remove it without divulsing the sphincter. The body when shown
had every appearance of stone formation; it was 4 inches long by 2}
wide, rounded at both ends and sides, and formed an elliptical, smoothly
polished body. The woman gave no history of ever having swallowed
any foreign body, and there was no possibility of its having passed from
the bladder into the rectum, as that viscus was absolutely healthy.
Evidently it had been formed in the ca?cum or appendix, and being set
free it was carried along the canal until it lodged in the rectum. Gant
has also reported an interesting case of this kind (Proceed. Amer.
Proctologic. Society, 1900).

Foreign Bodies introduced into the Kectnin. — ^\Vhen foreign bodies
have been introduced into the rectum through the anus, there is nearly
always a knowledge of such condition when the patient seeks advice.
Unfortunately, the purposes for which tliese bodies are introduced are
of such a nature that the patient will not admit the accident until he
is forced to do so by great pain and dire distress. Such introduction
may be intentional or accidental. Ball, quoting Hamilton, says that
the inhabitants of Balason, on the Bay of Bengal, were in the habit
of introducing into the rectum after defecation small bodies of clay,
and removing them at the next stool. This was done with a view of
preventing further movements during the day, or it may have been
done for hygienic purposes, but there is no history given of any of
these bodies having been retained (A New Account of the West Indies,
London, 1708).

In some countries foreign bodies are introduced into the rectum as
a means of punishment, but usually they are introduced for tlie relief
of certain S3rmptoms, for excitation of passion, for the purposes of
concealment, or by accident.

Foreign Bodies introduced for the Belief of Certain Symptoms, — A
large number of foreign bodies have been found in the rectum, intro-
duced by ignorant people for the purpose of relieving some pathological
condition. Some have used these bodies to provoke a movement of tlie
bowel and thus remedy an obstinate constipation; others have intro-
duced them with a view of controlling a diarrhoeal discharge.

One theoretical individual, who evolved the idea that the less matter
he discharged from his bowel the less food he would need in order to
live, introduced a stone jar into his rectum to avoid faecal movements.
It was with great difficulty and pain that the body was removed. Moran
reports the case of a pious monk^ who suffered with a severe colic, and
thought to relieve the same by ponring a bottle of Hungarian water
into the rectum, and so arranged hiB ^'^ ^<^ter would flow

900 THB ANUS, RECTUM, AND PELVIC COLON

little by little into the intestine. The bottle slipped from his grasp,
escaped into the rectum, and resulted, not in his relief but in the in-
crease of his colic, and an inflammation which threatened his life. After
many attempts by forceps and other instruments to remove the bottle,
it was finally dragged out by the hand of a small boy who was induced
to thus relieve the good monk.

Where these bodies are introduced for legitimate purposes, such as
those mentioned, and escape from the grasp of the patient, there is gen-
erally no delay in consulting a physician, and little irritation, inflam-
mation, or swelling complicates their removal, but the large majority of
these bodies are introduced into the rectum for other purposes or by
accident.

Foreign Bodies introduced for Purposes of Concealment. — The rectum
has long been known as a means made use of by thieves and criminals for
the concealment of stolen articles or instruments for crime; jewelr}%
coins, money, gems, false keys, etc., have been concealed in the rectum,
and found there, sometimes after death and sometimes during life.

The well-known report of Closmadeuc (Society of Surgery, May 15,
18G1) describes a case of a criminal from whose transverse colon there
was removed a sort of box or necessairey covered with the omentum of
a lamb, and containing coins, several small saws, and numerous instni-
ments for effecting his escape from prison. This article had been intro-
duced into his rectum for the purpose of concealment, and had grad-
ually worked its way upward into the position in which it was found,
where it produced peritonitis and the subsequent death of the patient.
There are a large number of cases on record of this kind, and a knowl-
edge of such facts is important to prison physicians as well as to the
police.

Foreign Bodies introduced into the Rectum by Accident. — It is a
rare thing that foreign bodies are introduced by simple accidents, such
as a fall on pointed sticks or on the palings of fences, which penetrate
the anus and are broken off and left there. An interesting case of this
kind is reported by Hawkins (Indian Lancet, 1898, vol. i, p. 417), in
which an Italian, dancing an obscene dance around a tumbler set on
the floor, slipped and fell upon this object. The tumbler broke, and
about I of its bowl penetrated the man's anus and lodged in the rec-
tum. The patient reported having had a great haemorrhage, but at
the time that he entered the hospital this had ceased. Two points of
the broken tumbler had penetrated deeply into the perirectal tissues,
and it was impossible to withdraw the object until the doctor had
excised the coccyx and split the rectum upward for about 2 inches,
thus affording room to remove it backward and disengage the points
penetrating the tissues in front.

FOREIGN BODIES IN THE RECTUM AND SIGMOID FLEXURE 901

Delbet (Gaz. hebdom., Paris, 1877, p. 1069) was the first to make
use of Amussat's suggestion to cut out the coccyx in order to gain
space for the removal of foreign bodies from the rectum. Buffet (Nor-
mandie med., April, 1894) has also employed this method. It indicates
a very practical procedure, which may be adopted in cases of large
bodies, the lower ends of which penetrate the tissues about the mar-
gin of the anus.

Camper (Prix de Pacad. de chirurg., t. xii, p. 165) reports the case
of a man who fell from a considerable height upon the sharp point of
a piece of wood which penetrated his anus and entered the bladder,
resulting in a urinary fistula. The pieces were removed from the rectum
about one year afterward, coated with a calcareous deposit from the
urine, and the patient made a good recovery.

The history of the brutal murder of Edward II, by the introduction
of a red-hot iron into his rectum, is quoted in many books as an in-
stance of foreign body in this organ. Its bearing in this connection
is not apparent, but a number of cases have been reported in which
individuals have had foreign bodies introduced into their recta, either
as a practical joke or in revenge for some offense.

An instance of this kind is reported by Matienzo (New York Med.
Record, 1898, vol. liii, p. 533), in which a man, during a drunken de-
bauch, had shoved into his rectum a piece of smooth wood, spherical
at the top, but rough and serrated at the bottom, 26 centimeters (10|
inches) long and 6 centimeters (2f inches) in diameter. The patient
began to suffer from pain in his abdomen immediately after recovering
from his debauch, but never realized that any foreign body was present
until he consulted a physician sixteen days afterward, when tlie body
was found, the upper end being felt through the abdominal wall to the
left of the umbilicus. It was removed by traction on the lower end,
and pressure from above.

Under this head may also be mentioned those distressing and de-
testable cases in which foreign bodies have been used for the purposes
of exciting passion in degraded and depraved individuals, and which
have accidentally slipped into the rectum. Perhaps the majority of the
large foreign bodies, such as bottles, sticks, lamp chimneys, pipe-stems,
etc., found in the rectum have occurred in this way. It is usually
in old men whose desires have survived their virile powers, and any
explanation which they may give of these accidents will ordinarily be
utterly unreliable and unworthy of belief. In such cases the infundib-
ular shape of the anus, the evidences of traumatism, and the irritation
of the parts will generally give a good idea of the moral character of
the patient, and point to the real cause of suffering. Under such cir-
cumstances, and with guilty consciences, patients trust to the illusory

902 THE ANUS, RECTUM. AND PELVIC COLON

hope that the bodies will be passed spontaneously. They do not, there-
fore, consult a physician until their sufferings have become unbearable
and their condition often desperate, if not absolutely beyond relief.

Some remarkable cases have occurred in which large bodies have
remained in the intestine for considerable periods of time without per-
foration, and have worked their way upward until they were beyond
the reach of the hand or of instruments for their removal through the
rectum.

Poulet, quoted by Kelsey, reports a case of a farmer who introduced
a piece of wood, over 13 centimeters (+5 inches) long and nearly 3
centimeters (+1 inch) in diameter, roughened and serrated at its broken
end, into the rectum. All attempts to remove it failed, and it passed
up into the sigmoid, and could be made out apparently as high as the
floating ribs. After thirty-one days, during which eneraata and cathar-
tics were given with greater or less regularity, the object was passed
by the rectum, and proved to be the end of a bean-pole. The patient
recovered without any serious difficulty.

Pierra (Indian Med. Record, 1896, p. 131) reported the case of a
man who passed a roughened stick 9^ inches long by 1 J inch in diameter
into his rectum. This was extracted without any permanent damage
having been done.

The results are not always so favorable. Several instances have been
reported in which the body penetrated the bladder, leaving recto-vesical
fistula; others in which the peritonaeum was perforated, causing death;
and very many in which rectitis, ulceration, periproctitis, fistula, and
sepsis have followed the introduction of foreign bodies into the rectum.

Symptoms. — The symptoms in these cases are subjective and objec-
tive.

Subjective Symptoms, — Ordinarily the patient will consult a physi-
cian for symptoms which may be referred to simple intestinal or rectal
complaints, such as constipation, diarrhoea, haemorrhage at stool, tenei*-
mus, the passage of mucus, slight passages of blood, etc. If the foreign
body has entered the rectum through the mouth, or through having
been formed in the intestine unkno\^Ti to the patient, or if it has been
introduced into the anus for legitimate purposes, the patient will gen-
erally give a true account of his condition, not biased by any embar-
rassment or shame, and the correct diagnosis may be easily made. Where
the body is small and arrested in one of the folds of Houston or the
crypts of IVforgagni, the pain may be more or less constant, or it may
only appear when straining at stool. This will depend largely upon the
shape of the body; if it is a round, smooth body, it will cause little suffer-
ing. If it is an irregular body, with sharp edges or points, it will give pain
upon motion and efforts at defecation; if the mucous membrane or the

FOREIGN BODIES IN THE RECTUM AND SIGMOID FLEXURE 903

walls of the rectum have been penetrated, this pain will be more or less
constant; especially will this be so if the foreign body be grasped by the
sphincter muscle, as in cases where a sharp body, such as a fish-bone or
pin, has lodged at the anus. A case with all these symptoms has been
reported by Billingslea (Southern Med. and Surg. Jour., August, 1856,
p. 148), in which there was an arrest at the juncture of the rectum and
sigmoid of a piece of bone which the patient had no recollection what-
ever of having swallowed. In other cases the foreign body may present
symptoms of fissure in ano, with nervous and constitutional disturbances.
A small piece of egg-shell arrested within the grasp of the sphincter
has given rise to such symptoms in a case reported by Whitehead (Trans-
actions of the Colorado Med. Soc, Denver, 1874, p. 42).

If the body be large and its edges smooth or round, the pain will not
be acute, but a dull, heavy, aching pain, increased upon movement or
jarring, bending down, efforts at stool, and sometimes the sitting posture,
through pressure upward upon the perinajum and downward upon the
abdomen, will give great discomfort. The fact that these patients have
numerous stools during the day of thin, watery fluid may lead the physi-
cian to suppose it is a case of diarrhoea.

Spasm of the sphincter and levator ani muscles are often present
with foreign bodies in the rectum. These spasms are increased by
whatever act or motion causes the foreign body to press upon the mus-
cles. Sometimes the spasm occurs upon bending over or sitting down
upon the commode; at other times, where the muscles and membranes
are penetrated by sharp points, the spasm is continuous.

Constipation is frequently observed, but this is a relative term and
not much can be gathered from it as a symptom. When sjrmptoms of
obstruction appear, such as swelling of the abdomen, nausea, vomiting,
hiccough, high temperature, rapid pulse, etc., the case becomes very
grave. Genito-urinary symptoms are a very frequent complication of
foreign bodies in the rectum. Sometimes these symptoms so predom-
inate that the physician is led in the beginning to consider those organs
as the main cause of offense, and to search them in vain for some con-
dition to account for the suffering. Dysuria, anuria, cystitis, neuralgia
of the testicles, pain in the scrotum and along the tract of the crural
nerves, are frequent complications. These are due, first, to mechanical
pressure upon the parts by the foreign body and, second, to reflex action.

When the body has remained for some time in the intestine and
produced much irritation, grave constitutional symptoms, such as cold
sweats, fainting, convulsions, and high temperature, may supervene.
Hawkins (The Indian Lancet, 1898, p. 417) reported an interesting
case of this kind in which a glass tumbler was introduced into the
rectum with a view of overcoming diarrhoea, and was broken in the

904 THE ANUS, RECTUM, AND PELVIC COLON

efforts of the patient to extract it. The doctor was consulted after the
patient had suffered for some days, the symptoms being those of intes-
tinal obstruction; he succeeded in removing the glass and relieving the
patient.

Objective Symptoms. — The physical symptoms which are produced
by a foreign body in the rectum are very vague and indefinite, espe-
cially if the body is formed in the intestinal canal, or has entered
through the mouth, and thus approaches the rectum from above. Ordi-
narily ocular observation will reveal nothing to indicate the nature of
the patient's disorder. There may be a protrusion of haemorrhoidal
tumors, a slight discharge of pus, a moist condition about the anus, or
sometimes a prolapse of the mucous membrane of the rectum, but all
of these conditions are compatible with simple inflammatory diseases
of the rectum, and are not necessarily connected with foreign bodies.

If the latter are introduced through the anus, there may be some
wound, crack, or fissure of the parts indicating the cause of the trouble,
but it is remarkable what large bodies can be passed through the anus
without producing any apparent lesions. Poulet says haemorrhage of
moment rarely if ever occurs except when leeches have been introduced
into the anus.

If the foreign body is introduced by accident, such as falls upon
sharp objects, the wound of a bayonet, or impaling upon a stake, con-
siderable haemorrhage may follow immediately, and yet at the time of
the examination by the surgeon no bleeding may be present. In certain
cases, where the foreign body is very large, a bulging of the perinieum
may be felt and seen; when such is the case the anus generally protrudes
to a certain extent, and the haemorrhoidal vessels are congested and
swollen, forming a sort of a nipple upon the distended perinaeum.

Diagnosis, — The only reliable means of diagnosis in these cases are
the educated touch and the rectal tube. Where the body is low enough
down to be felt, the finger is all that is necessary; but when, as fre-
quently occurs, the body has slipped beyond the reach of the finger,
or has lodged at a point so high up that it can not.be touched by
digital examination, recourse must be had to a rectal speculum of some
sort.

The pneumatic proctoscope and the simple rectal tube are the most
useful instruments for this purpose, and they serve also as a means
through which to grasp the foreign body and drag it down. With these
instruments it is possible to see and clearly diagnose the presence and
nature of the body up to the lower end of the descending colon. In
those cases in which it is arrested in one of the crypts of Morgagni, the
fenestrated speculum used in connection with a laryngeal mirror is of
great value.

FOREIGN BODIES IN THE RECTUM AND SIGMOID FLEXURE 005

When the body is arrested above a stricture or hypertrophied valve
of Houston, a bent probe or searcher may be necessary to make this
search.

Complications, — The complications or accidents associated with for-
eign bodies are very numerous, and depend largely upon the character
of the body, the method of its introduction, and the amount of manipu-
lation and traumatism in efforts to expel or withdraw it.

In spontaneous expulsion of small foreign bodies, such as bones, pins,
seeds, needles, etc., there may be wounding or tearing of the mucous
membrane at any point of the sigmoid or rectal tract. Frequently these
bodies produce only a slight scratch of the parts, cause some little pain,
and the sjTnptoms rapidly disappear. Sometimes, however, the injury
may be more extensive. The patient may have considerable haemor-
rhage, as from a hemorrhoid, and there may result an acute fissure,
and an ulcerated or inflammatory condition about the margin of the
anus.

This spontaneous expulsion of foreign bodies from the rectum may
take place after the body has remained there for comparatively long
periods. Schmidt (Annals de Schmidt, 1862, vol. cxiii, p. 95) reports
the case of a man who passed a piece of wood 5^ inches long, after it
was embedded in the rectum for thirty-one days. The length of time
which foreign bodies may rest in the cavity without serious inconve-
nience has already been discussed, but the longer they remain the more
likely are they to produce serious complications. \Vhen large they cause
congestion, inflammation, thickening of the walls of the gut, ulcera-
tion, and sometimes stricture. Invagination or prolapsus is also said
to have been produced by their presence in the rectum, exciting con-
stant peristaltic action and straining at stool. Where the object is of
an irregular nature, with sharp edges or points, the walls of the gut
may be perforated and produce perirectal inflammation, abscess, and
fistula. After the removal of such bodies from the rectum, one should
always carefully examine the parts to be sure that no blind fistula has
been left behind.

Punctures by these bodies may cause localized suppurative peritonitis,
and yet not prove fatal on account of the tendency of Nature to shut
oflf such septic products and enclose them in separate cavities, thus to
protect herself from general infection. The cases, however, in which
the peritoneal cavity is opened through gangrene due to pressure upon
the parts are sure to prove rapidly fatal.

One other complication should be noticed, and that is the fact that
foreign bodies that remain in the rectum for considerable periods of
time may become coated with calcareous substances, generally phosphate
of magnesium or lime. Sometimes this coating may be due to a recto-

906 THE ANUS, RECTUM, AND PELVIC COLON

vesical fistula, and the leakage of urine into the rectum (Cnimmer, Kel-
sey), and at others it is due to incrustations from the intestinal salts.
Dahlenkampf (Poulet, p. 313) has reported a case in which a piece of
wood introduced into the rectum was thoroughly incrusted with a silvery,
crystallized phosphate of lime. The incrusting material will aid in de-
ciding the nature of the injury.

The symptoms and history of foreign bodies in the rectum may exist,
and yet one may find it impossible to determine their presence either
by digital or ocular examination. This may be due to the fact that the
foreign body has dropped into a diverticulum of the rectum or has pene-
trated the mucous membrane and passed into the surrounding tissues.

Cunningham (Southern Med. and Surg. Jour., Augusta, 1887, p. 764)
gives an account of a foreign body found in the nates 6 inches or more
from the anus, but which had evidently penetrated the wall of the gut
above the internal sphincter, and thus burrowed down in the direction
in which it was found. This was a case in which there was no particular
history of a foreign body^s having been in the rectum; but the following
case (Phil. Tr., London, 1720-'35, p. 521) is one in which a distinct
history of the foreign body was given. The patient had introduced a
fork, with its tines downward, into the rectum a short time previous.
Shame and embarrassment prevented his seeking relief until his agonies
were so great that he could no longer bear them. Upon consulting a
physician, the latter found a sharp protrusion in the man's buttock some
distance from the anus, with one of the tines of the fork almost pene-
trating the skin. An incision was made, and the fork dragged through
this, leaving a complete fistula, which afterward healed. Tumey (Nash-
ville Med. and Surg. Jour., 1883, p. 261) and Hood (Australasian Med.
Gaz., 1888, vol. viii, p. 285) have reported similar cases. In Hood's, the
foreign body penetrated the rectal wall, burrowed through the peri-
naBum, entered the scrotum, and there caused a scrotal fistula.

All such cases give a certain number of rectal symptoms, or at least
a history of having suffered from rectal irritation, although at the time
at which they consult the surgeon these may have disappeared and other
symptoms predominate. Careful exploration of the rectum will fre-
quently make plain obscure conditions by the discovery of small foreign
bodies or internal blind fistulas through which the foreign body has
passed into the surrounding tissues.

Prognosis. — In general, one may say that the large majority of cases
of foreign bodies in the rectum end favorably. From reading the most
popular works upon diseases of the rectum, one would judge that thesie
accidents never ended in any other way except when they penetrate<l
the peritoneal cavity. As a matter of fact, however, there have been
a number of fatal cases in which this cavity was not penetrated.

FOREIGN BODIES IN THE RECTUM AND SIGMOID FLEXURE 907

Canton (Lancet, 1849, p. 620) reports the case of an old man who
died from haemorrhage brought about by fish-bones in the rectum. The
post mortem showed a number of fish-bones throughout the large in-
testine; the lower half of the rectum was three times as thick as normal,
and the mucous membrane was gangrenous and deeply perforated pos-
teriorly. Half a dozen of these bones were entangled in the deeper area,
some of which entered the haemorrhoidal vessels and caused the haemor-
rhage. C. S. Briggs (Nashville Jour, of Med. and Surg., 1880, p. 149)
records the case of a man who had introduced a wine-glass into his rec-
tum, measuring 5 inches in circumference and 2^ inches in length, in
order to control diarrhoea. The foreign body was removed under anaes-
thesia. The posterior wall of the rectum was lacerated, and the man lost
a large amount of blood. The diarrhcea continued, and the patient died
at the end of one week. A question here arises whether the patient
died from the diarrhoea, which did not seem to be dangerous at the time
of the operation, or whether it was due to injury of the rectum, loss
of blood, and subsequent infection. The latter theory seems the most
probable. Laroyenne (Gaz. med. de Lyon, 1867, p. 49) has reported a
similar case to this.

M. Tillaux (Bull, et m6moires de chirur., Paris, 1877, p. 532) gives
an interesting account of a man who had introduced a bougie into the
rectum, and it slipped from his grasp. By examination of the abdomen
one could feel the upper end of the bougie in the left iliac fossa. The
patient developed an abscess in the fossa before the bougie was re-
moved, and died the second day after it. The post mortem showed
localized peritonitis around the sigmoid, but no perforation. The rec-
tum was healthy, but in the sigmoid flexure there was a large ulcera-
tion about the size of a 50-cent piece, which was no doubt the point
where the extremity of the bougie was arrested for the five days dur-
ing which it was retained. Stone, quoted by Gibbs (Western Lan-
cet, 1856, p. 7), reports the case of a man who passed a tin cup into
his rectum for prolapse. All efforts to remove it were unsuccessful,
and the patient died from peritonitis without puncture, so far as I can
learn.

Weist (Indiana Med. Jour., 1873, p. 17) has recorded a very inter-
esting case of a man who had been accustomed to treat his haemor-
rhoids by passing into his rectum a corn-cob, 2^ inches long and f of
an inch in diameter. To this he had attached a sort of a handle; one
day, upon its introduction, the handle broke off and the corn-cob slipped
into the rectum. He consulted Weist sixty hours later, at which time
his abdomen was found swollen and tympanitic, his pulse quick, and
he was suffering from nausea and hiccough. The foreign body could
be felt in the sigmoid, but it was impossible to remove it through the

908 THE ANUS, RECTUM, AND PELVIC COLON

rectum, owing to its lying at an angle and the handle being eaugl
one of the folds. The patient died eighty-four hours after the i
duct ion of the foreign body. The post mortem showed a general
tonitis. The corn-cob projected IJ inch through the sigmoidal \
Its total length, with the broken handle, was 4 inches. This cas<
been quoted somewhat at length in order to bring out the fact
perforation of the rectum and sigmoid is not always due to the
used in the introduction of the foreign body, nor to rough manipul
in efforts to extract it. They may be brought about by perisi
movement, tenesnms, and straining of the patient himself. In this
the body was too short to have been pushed through the gut h^
patient, and no efforts had been made to extract it. Where such a
is left in the intestinal canal for any undue length of time it will <
inflammation and ulceration by pressure, thus weakening the intes
wall and inviting perforation; it may then, during a spasm or p
of tenesmus, be thrust through into the peritoneal cavity and <
death.

The prognosis in these cases will therefore depend upon the m
and shape of the body, upon its size, the force with which it is i
duced, the roughness of manipulation in the efforts to withdraw it,
finally, upon its location, whether above or below the peritoneal ci
sac. Perforation of the bladder through the rectum is likely to
fatally through infection of the bladder and its progression to
kidneys.

If none of these complications occur, and the bodies are pron
removed and properly treated, the prognosis in these cases is gene
good. Their dangers, however, should never be underrated, and
tive opinions should not be given until all risk of secondary comp
tions has passed, especially in cases in which the foreign body is i
above the sigmoid flexure. [Velpeau (Elements of Surg. Path., 1
p. 42), Dor (Gaz. med. de Paris, 1833, p. 199), Lane (Brit. Med. J
1874), and Tillaux (Gaz. hop., 1877, p. 695).]

Treatment. — The ingenuity exercised in the introduction of foi
bodies into the rectum is only exceeded by that necessary for thei
moval. They are generally introduced with the conical end upward,
thus the sphincter is gradually dilated until the object slips from
grasp and the muscle contracts behind it. Their removal mus
obversely, with the large end first, and is consequently more diflR
The spasm of the sphincter consequent upon the traumatism incr<
the difficulty of withdrawal.

Wliere the body is of a soft substance, such as wood, it ma;
grasped by a forceps, or a gimlet or screw may be introduced
it to assist in its removal. When, however, it is composed of g

FOREIGN BODIES IN THE RECTUM AND SIGMOID FLEXURE 909

porcelain, steel, or stone, it will be much more difficult to grasp it, and,
moreover, the breaking of the object into fragments will greatly com-
plicate affairs. Too great pressure or too much manipulation of the
body in order to grasp it may cause it to slip beyond reach and enter
the sigmoid flexure. If the upper end of the object be pointed, such
manipulation may cause it to perforate the intestine and bring on fatal
peritonitis. Thus one must avoid pressing too firmly upon the abdomen
from above or upon the object below in these manipulations.

In general, it will be necessary to anaesthetize the patient and dilate
the sphincter before any attempt at removal is made. Tlie parts should
first be irrigated thoroughly with antiseptic solutions to remove, as far
as possible, causes of infection. After this a large injection of oil will
facilitate the operation by lubricating the parts and causing the body
to slip more easily through the constricted points. If the caliber of the
anus is found insufficient for the removal of the foreign body, it will
be advisable to split the rectum backward to the coccyx and upward
through the internal sphincter. By this procedure abundant room will
generally be afforded for the removal of any body whicli has originally
been introduced through the anus. Sometimes it may be necessary to
excise the coccyx before the body can be removed. Buffet has reported
a case of this kind (Normandie med., 1894).

The necessity of such operations is brought about by the congestion,
oedema, and swelling following the introduction of the objects; other-
wise a body which passed through the anus going in could be forced
through it on withdrawal. When the lower ends of these bodies are
rough and serrated, their withdrawal is made difficult or impossible,
owing to the fact that these points and rough ends catch in the mu-
cous membrane or the folds of the rectum and arrest tlieir passage in
the outward direction. In such cases the operator will have to exercise
his ingenuity to cover such points by gauze or other substance in order
to facilitate their withdrawal.

The classical case of Marchettis (Poulet, loc. cit., p. 260) illustrates
this. A boar's tail, with the bristles cut short and pointing toward the
end, was introduced into the rectum, leaving a small portion of the end
extending through the anus. Any effort to pass it, or at withdrawal,
only sunk the bristles more deeply into the mucous membrane and held
it in position. Marchettis ingeniously selected a hollow reed, and, after
having first tied a string to the end of the tail and passed it through
the reed, he slipped the latter upward upon the boar's tail, thus reversing
the direction of the bristles and loosening them from their punctures
in the mucous membrane. He thus removed the body with great suc-
cess, and gave immediate relief to the patient.

When the body is composed of soft metal, such as hairpins, wire.

910 THE ANUS, RECTUM, AND PELVIC COLON

safety-pins, nails, etc., they may be cut in two with forceps and re-
moved piecemeal.

Lefort has suggested that when the body is hollow it might be filled
with plaster of Paris, allowing this to harden, with a handle of some
kind in its center, thus affording a grip by which it can be removed.
This is an ingenious method, but unfortunately in most cases the open-
ing into such bodies is upward, and the filling it with plaster from this
direction would be impossible and at the same time useless.

The application of an obstetric forceps has been advised by some
writers, but one can understand how difficult it would be to apply them
to a large body in the rectum. A very small placental forceps might
be useful in removing smooth, round bodies which it is difficult to
grasp.

WTiere the object is of glass, china, or any fragile material, great
care must be exercised not to break the same if it can possibly be
avoided, lest the fragments should cut the blood-vessels and cause severe
haemorrhage or puncture the peritonaeum. Occasionally it must be done;
it is well under such circumstances to pack a layer of gauze around the
foreign body between it and the rectal wall before shattering it, in order
to collect as many of the small pieces as possible, and to protect the
rectal wall from injury by the fragments. This is not a difficult pro-
ceeding; if the body is low enough down to be grasped and broken, it
can be steadied while the gauze is being packed around it. If the ob-
stetric or placental forceps is used, it should be covered with gauze
or flannel for this purpose.

A complication has arisen in some cases, in which a body with an open
aperture at the upper end has been introduced into the rectum, from
the fact that straining and tenesmus have caused the upper segments
of the bowel to prolapse into this aperture, and, becoming congested
and swollen, thus absolutely obstructed the intestine.

The difficulty here is not only in the removal of the body, but in
doing so without injuring the prolapsed gut. If the bottom can be
perforated and cocaine or extract of suprarenal capsule applied, the
congestion may be so reduced that the prolapse will be released, and
then the body can be removed without much injury to the parts; other-
wise the object will have to be broken and the injuries repaired.

Another danger with regard to such bodies in the rectum is that by
too vigorous and unwise manipulation they may be pushed upward into
the sigmoid flexure, where they can no longer be felt by the finger or
grasped by any instrument to withdraw them from below. It is said
tliat these bodies are carried up in this direction and beyond reach
by the retroperistaltic action of the intestine described by O^Beirne.
I have never seen anything that convinced me of this action. Bodies

FOREIGN BODIES IN THE RECTUM AND SIGMOID FLEXURE 911

which have traveled upward in this way have always been those which
had sharp edges or points below, so that when the motion of the body
or intestine took place, they were lifted up little by little, exactly in
the same way that a head of bearded rye, when introduced upside down
into the lower end of a boy's trousers, will crawl up to his shirt-collar
as he walks along. The retroperistaltic action is not necessary to ac-
count for the movement of these bodies; it is simply a question of
mechanical action, which is found in numerous instances in nature.

Sometimes where the foreign body has come from above and has
lodged in the sigmoid flexure, the introduction of a long sigmoidoscope
to establish its presence and to determine its nature may straighten
out the convolutions, excite an active peristalsis, and cause the body to
be expelled shortly thereafter. This occurred in the case of a friend
of the author's, who swallowed his false teeth. The plate was not
found in the rectum or seen in the sigmoid at the time of examination,
but within an hour afterward it was protruded at the anus during stool.
If the body can be seen through such a tube it may be located at the
end of the instrument, grasped with an alligator forceps, and gently
drawn out through the intestine. If the pneumatic proctoscope is used,
the dilatation of the gut will allow of the body's being passed along with-
out any mutilation of the parts.

Always after the removal of a foreign body from the rectum the
organ should be thoroughly irrigated and washed out with antiseptic
solutions, such as boric acid or l-to-8,000 bichloride of mercury. If
the bowels have not been moved regularly, a cathartic should be given
at once to relieve them of any accumulation that may be present. But
as soon as this has been accomplished, some opiate or sedative should
be given to quiet the peristaltic action, and thus give an opportunity
for rest and the subsidence of all congestive and inflammatory compli-
cations.

The application of styptics to control haemorrhage in the rectum
has been productive of more harm than good. Irrigation with cold or
very hot water and pressure by packing are the best means to accom-
plish this.

Removal hy Cceliotomy. — When large bodies have escaped, or have
been arrested in the sigmoid flexure, much manipulation to remove them
through the rectum should be avoided. The dangers of rupturing the
gut above the juncture of the sigmoid and rectum are always present,
and if the foreign body has produced inflammation of the parts, these
will be increased. Under such circumstances the proper and rational
proceeding is to open the abdominal cavity at once, make a longitudinal
incision in the gut, and remove the foreign body through this aperture.
If the gut la healthy and not gangrenous, it should be closed and dropped

912 THE ANUS, RECTUM, AND PELVIC COLON

back into the abdominal cavity; otherwise it should be drawn through
the abdominal wound until all the diseased area is outside, and then
sutured to the edges. It may be cut off, or if it resumes its nonnal
condition it can be closed and restored to the abdominal cavity at a later
period. The incision for such an operation should always be made at
the left side and in line with the rectus muscle, inasmuch as the
sigmoid and descending colon can be most easily reached from this
point.

When the foreign body has been located in the intestine it should
be drawn out of the abdomen, if possible, and the cavity thoroughly
packed off with sterilized gauze before the gut is opened. Sometimes,
on account of its length, it is impossible to draw the entire body out
of the wound. In such cases, for instance, as that of Pierra, in which
the piece of wood was 9^ inches long, only a part of it could be brought
out before the intestine was opened.

Thorndike (Boston City Hospital, 1882) reports the case of a man,
forty-one years of age, who had been in the habit of introducing for-
eign bodies, such as bottles and jars, into his rectum for the relief of
the retention of urine. At one time, not having any of the objects
which he was in the habit of using, and finding a comparatively round,
smooth stone (weighing about 2 pounds, elliptical in shape, and smaller
at one end than at the other), greased it, and, introducing the smaller
end into his anus, sat down upon it. While he was thus seated the
sphincter gave way, and the stone suddenly shot up into the rec-
tum. Efforts were made by surgeons and others to remove it, but
the more it was manipulated the farther it receded from the anus.
A small boy was induced to pass his hand and arm up into the pa-
tient's rectum, but, passing it the whole length, could not reach the
stone.

Thorndike found the patient forty-eight hours later suffering from
tympanites, pain, high temperature, rapid pulse, and, in fact, with all
the symptoms of septic peritonitis. With his hand in the rectum he
could feel the foreign body in the abdominal cavity, but could not
reacli it. By an incision at the outer border of the left rectus muscle
the peritoneal cavity was opened, and the stone found loose among the
intestines. The aperture through which the stone escaped from the in-
testine was about 8 inches above the anus, and was not gangrenous. It
was closed and the patient recovered. Now it is perfectly clear that
this stone was thrust through the intestinal wall by the efforts to re-
move it. Xature would never exercise retroperistaltic force enough to
rupture hor own organs in any such way as this.'

While there is no other recourse for the removal of foreign bodies
which have escaped beyond the reacli of instruments and the hand than

FOREIGN BODIES IN THE RECTUM AND SIGMOID FLEXURE 913

laparo-enterotomy, one should not be misled by the literature upon this
subject as to the favorable prognosis in these cases.

Poulet quotes three cases in which the operation has been done, and
all of them successfully. Kelsey quotes the same three cases. Stuts-
gaard, Thorndike, and Realli have successfully removed large foreign
bodies by laparo-enterotomy, but all the cases in which this has been
tried have not ended so favorably. Thus Stanton (Brit. Med. Jour.,
1881, vol. i, p. 848) removed a wine-bottle by this method, and the opera-
tion was promptly followed by death. Hunter (Trans, and Phys. Soc,
Bombay, 1860, p. 24) attempted to remove tlie horn of a bullock, which
had been passed into the rectum, by abdominal section. The patient
died shortly afterward.

In another case, in which a glass telegraph insulator was introduced
into the rectum and passed up into the sigmoid, laparo-enterotomy was
performed with a fatal result (Review Medical Quir., Buenos Ayres,
1883, p. 125).

Bryant (Med. Press and Circ, London, 1825, p. 228) reports a case
of laparo-enterotomy for a foreign body, after which the patient died.

Gentilhomme removed a foreign body from the rectum by inguinal
enterotomy, sutured the intestine, and dropped it back into the ab-
dominal cavitv with a successful result.

Trull (Boston Med. and Surg. Jour., 1870, p. 3) operated upon a
patient who had introduced a stone into his rectum, which soon per-
forated the rectal wall and escaped into the abdominal cavity; the
foreign body was removed by an abdominal incision, the rent in the
intestinal wall through which it had escaped was sewed up, and the
patient made a good recovery. (This appears to be the same case re-
ported by Thorndike.) The facts are practically the same in all: either
the foreign body has escaped upward into the colon or sigmoid, and,
being beyond the reach of the surgeon, it has been necessary to remove
it by abdominal section, or the wall of the intestine has been ruptured
and the body has escaped into the abdominal cavity. Happily the peri-
tonaeum seems wonderfully tolerant of faecal matter for a brief length
of time, and if it is promptly wiped out and extravasation and suppura-
tive products prevented from reentering, peritonitis may be very fre-
quently avoided.

One interesting case of spontaneous exit of a foreign body through
the abdominal wall is worthy of mention. Yergely (Jour, de med. de
Bordeaux, 1884-'85, p. 575) reported the case of a young man who had
introduced into his rectum a penholder 19 centimeters long. He suf-
fered no inconvenience in the rectum particularly, and consulted no
physician, but finally began to have pain in the abdominal wall at the
juncture of the hypochondriac and right inguinal region. After a time
58

914 THE ANUS, RECTUM, AND PELVIC COLON

a small, hard object was felt in this region. It soon penetrated the
abdominal wall, and proved to be the penholder which had thus bevn
spontaneously expelled. Whether it had followed the course of the
intestine all around the descending, transverse, and ascending portions
of the colon, or whether it had perforated the rectum or sigmoid flexure
over toward the right side, and penetrated the abdominal wall through
this route, is not definitely known.

CHAPTER XXIII
WOUNDS, INJURIES, AND RUPTURE OF THE RECTUM

Wounds and Injuries. — The anus and rectum, owing to their pro-
tected position between the folds of the buttocks and within the bones
of the pelvis, are not frequently injured through external agencies. A
sufficient number of accidents, however, has occurred to make the
subject worthy of consideration. Injuries to these organs may result
in contused, lacerated, punctured, or incised wounds. The contusions
result chiefly from pressure of the foetal head during prolonged labor,
pressure from ill-fitting pessaries, the prolonged retention of foreign
bodies in the rectum, too forcible manipulation in stretching the sphinc-
ter, falls upon the buttocks, and pressure from pelvic tumors.

Lacerated wounds occur from the introduction of foreign bodies,
divulsion of the sphincter, the passage of coproliths or sharp foreign
bodies in the stools, such as fish-bones, pins, pieces of metal, etc., the
sitting down or falling upon rough, sharp objects. Chamber-pots have
broken while the patients were sitting upon them, resulting in laceration
and severe haemorrhage, even in severing the external sphincter, and
resulting in partial incontinence. Punctured wounds of the rectum and
anus occur chiefly through gunshot and bayonet injuries, but occasion-
ally through other accidents. The records of the late civil war in the
United States show that in 103 gunshot injuries of the rectum, 44, or
42.7 per cent, of them resulted fatally. In the Franco-Prussian War
there occurred 31 wounds of the rectum, with 15 deaths. In one man
the rectum was penetrated by the sharp stump of a weed, over which he
squatted down for the purpose of stool; the point entered about 1 inch
from the margin of the anus, and penetrated the rectum \ an inch above
the internal sphincter. Such wounds may also occur through accidents
in passing a urethral sound; a false passage is made and, owing to the
unhealthy condition of the saeptum, the instrument penetrates the
rectum.

Numerous cases of perforating wounds of the rectum have been re-
ported through patients falling upon sharp bodies which passed through
the anus without injury to it, and punctured the wall of the rectum

915

916 THE ANUS, RECTUM, AND PELVIC COLON

higher up. A strange coincidence lies in the fact that nearly all the
cases in which the perforating body has passed through the anus with-
out injury at that point and perforated the rectal wall above the in-
ternal sphincter, have proved fatal. Among the most frequent sources
of this kind of injury is the improper use of syringes and rectal bougies.
Nordmann (Kelsey, p. 463) has recorded 25 separate injuries to the
rectum due to the improper use of syringe-tips in the administration
of enemata; Edwards records a case in which a full quart of soap and
water was injected into the perianal tissues in an attempt to administer
a clyster. In this case the tissue sloughed, the rectum was practically
dissected out from its attachments to the muco-cutaneous border, and
retracted upward, thus leaving a large cavity for the accumulation of
faecal material.

Injuries from the use of rectal bougies are not so frequent at the
present day owing to the fact that stiff instruments are very seldom
used for this purpose. Formerly, when the old conical, hard, stiff
bougie was used, such wounds were not at all infrequent. Numerous
instances have been reported in which the wall was perforated and the
instrument passed either into the cellular tissue around the rectum or
into the peritoneal cavity, thus causing death. Three instances are
known by the author in which the use of the Kelly tube resulted in
the perforation of the rectal wall, fa)cal extravasation, peritonitis, and
death.

Instruments penetrating the rectum may occasion more than one
wound. Bumier (Revue niM. de la Suisse Xormandie, 1885, vol. v, p.
171) reports the case of a boy who fell upon a flat bar of iron, which
penetrated the anus, perforating the peritonieum at 6 centimeters (2?
inches), and entered the rectum again at 8 centimeters (3-^ inches)
above.

Wounds of the rectum in operations for stone by perineal section
have frequently occurred, and they may be inflicted during the operation
of prostatectomy. Wounds of the rectum and sigmoid during opt»ra-
tions for pelvic tumors or vaginal hysterectomy are not at all rare; it
is very easy to catch a fold of the gut in the clamps or angeiotribo,
and thus wound it.

Enptnre of the Eectum. — Fowler, Nicaise, and Hatche have each
reported instances in which the rectum has been ruptured by the use
of the colpeurynter in suprapubic cystotomy. AMiite and Martin state
(op. cit., p. 707) that this accident has occurred so frequently that the
large majority of surgeons no longer make use of this apparatus. Drag-
ging upon the organ in efforts to break up attachments between it an»l
pelvic neoplasms have frequently resulted in this injur}'. Tlie autlior
has reported one case in which the accident occurred through the pas-

WOUNDS, INJURIES, AND RUPTURE OF THE RECTUM 917

sage of an extra-uterine foetus into the rectal cavity. Several cases have
occurred during efforts for the reduction of rectal procidentia.

In the chapter upon examinations the fatalities supposed to have re-
sulted from the introduction of the hand into the rectum have been
reviewed at some length; while in none of these cases was tliere any abso-
lute rupture of the entire rectal wall, yet one can not doubt but that this
injury may occur from such a procedure where the hand is large and
the rectal cavity small and non-distensible.

Prognosis. — The gravity of wounds and injuries to these organs will
depend largely upon their site and the tissues and organs involved.
Where the injury is confined to the anus and rectal walls, the wounds
usually heal under proper antiseptic precautions, and no serious results
follow.

Sims (British Med. Jour., February 18, 1882) claims that gunshot
wounds of the rectum, although involving the pelvis, bladder, and peri-
naeum, are not very fatal. Out of 7 cases occurring at Sedan, all recov-
ered. The records, however, of our civil war and those of the Franco-
Prussian War do not bear out this statement. The statistics in both
of these cases record a mortality of over 40 per cent. " Pelvic cellulitis
and septica?mia from infiltration, diffuse suppurations, and other con-
sequences, obstructions, lesions, and secondary bleeding were the com-
plications which most frequently preceded a fatal termination in this
group of cases " (Medical and Surgical History of the War of the Re-
bellion, Surg. Vol.).

Where the bladder is involved in the injury and the wound is suffi-
ciently large to admit of faecal extravasation into that organ, the acci-
dent should be considered very grave. Fourteen out of 34 such cases
resulted fatally.

The seriousness of any injury to the rectum depends, first, upon
its height and extent; second, upon the form of the body causing it,
its direction, and the force by which it is made to penetrate; and,
finally, upon the length of time elapsing between the injury and the
observation of the surgeon. The principal factor in all these injuries
is the wounding of the peritonaeum. Septic peritonitis ordinarily de-
velops within twelve to fourteen hours. It may be possible, therefore,
in injuries in which this cavity has been penetrated, to open the abdo-
men, clean it out thoroughly, close the wound in the gut, and thus
prevent the development of septic inflammation. In all such cases
there is a certain amount of localized traumatic peritonitis, but this
condition is not necessarily fatal. Van Hook has collected 58 cases of
injury to the rectum, of which 28 were complicated by wounds of the
peritonaeum (Monthly Jour, of Med. ind Surgery, June, 1896). Of the
26 cases in which there was perfr tonsBum, death fol-

dlS THE ANUS, RECTUM, AND PELVIC COLON

*> lowed in 20, and recovery in 6, cases. In the large majority of these

no operation was done until long after the period for the development
of septic peritonitis had passed.

In 30 cases in which the peritonaeum was not injured, all recovered.
The point at which the peritonaeum had been penetrated varied from 5
to 25 centimeters (from 2 to 9J inches). In the case of Lambotte, the
foreign body penetrated the wall of the rectum, and afterward entered
the sigmoid flexure. Instances of injury to the omentum (Kurella), the
jejunum and liver (Poulton), the psoas muscle (Heath), the mesentery
and ileum (Watson), the diaphragm and mediastinum (Chattergee), have
been reported, and one even in which the puncturing body passed up-
ward to the flexure of the neck (Woodbury). Haemorrhage from such
wounds is usually checked by pressure of the woimding object, if the
latter is not withdrawn, or, owing to the lacerated character of the

i wound, ceases itself before the surgeon reaches the case. There is no

record of a case of serious or fatal haemorrhage from such accidents.
Infection of the wound is, of course, likely to occur at all times; this,
however, can be prevented, or at least controlled, by free drainage and
proper antiseptic treatment. Abscesses, flstulas, and ulcerations may
result from such wounds, but they can not be considered as serious
results.

Symptoms. — It requires no detailed sjrmptomatology to recognize an
injury or wound of the rectum, as the history, the appearance of the
parts, the loss of blood, pain, and shock will clearly indicate what has
happened. Symptoms which indicate the involvement of other parts,
however, especially the peritonaeum, are of the greatest importance. In
the latter case they are those of immediate traumatism, shock, haemor-
rhage, and pain. All of these differ greatly in individuals. In several
of the cases reported by Van Hook, in which the peritonaeum was pene-
trated, pain was almost entirely absent. In some the haemorrhage was
exhausting, while in others there seemed to be none at all. Shock is
a very variable quantity; some patients completely collapse and become
unconscious, while others do not show any symptoms of it. In the
case reported by Heath, a boy of eighteen walked over a mile to the
doctor's office after a penetrating wound of the rectimi involving the
peritonaeum; he died of peritonitis a few hours afterward. The absence
of external evidences of haemorrhage may be very deceiving. While
there may be no blood discharged, the peritonaeum and the upper cavity
of the rectum may be filled with blood. Tympanites and abdominal
pain may occur immediately after the accident or they may be delayed
for twenty-four hours, being preceded by a chill, and followed by all
the symptoms of septic peritonitis; meteorism will develop, and an anx-
ious expression of the face, vomiting, hiccough, and collapse compose

WOUNDS, INJURIES, AND RUPTURE OF THE RECTUM 919

the final picture in the case. Death is generally quite rapid, occurring
within the first seventy-two hours. In two cases reported by Qu6nu it
was delayed until the eighth day, and in one (Neal) it did not occur
until the second month.

Quenu and Watson distinguish between the deaths due to peritoneal
septicaemia and peritonitis, and claim that the former is more frequently
the cause of death than the latter. Watson has shown that a wound
may penetrate the mucous wall of the intestine without involving the
peritoneal cavity, and yet at the same time peritonitis may follow. Pain
in the region of the pubis, dysuria, the presence of urine in the rectum
or of blood and faeces in the urine, will indicate the involvement of the
bladder in these injuries. Sometimes there is complete retention of the
urine, and the patient must be catheterized. In such cases one may find
faecal material and blood in the urine, or he may find no urine in the
bladder at all, it having escaped through the bladder into the rectum
or into the peritoneal cavity.

Aside from the subjective 83nmptoms, examination of the organ by
the finger and instruments will indicate more clearly than anything else
the size and extent of the injury. Where the bladder is perforated, one
may usually reach the wound with the finger, or see it at least through
the proctoscope. We should not be deceived, however, by the fact that
there is no leakage of urine or faeces immediately after a puncture or
gunshot wound involving the bladder and rectum. The congestion and
oedema following an injury of this kind may entirely close the tract of
the missile for the time being, but in the course of a few days this
reopens through subsidence of the oedema or through sloughing of the
tissue around the wound. In gunshot wounds especially there is a trau-
matism which radiates in all directions and frequently causes gangrene
around the tracts some days after the injury; thus, while there may
apparently be no communication between the two organs at the first
examination, it is altogether possible that a very wide one may develop
at a later date. A guarded prognosis is therefore necessary in such
cases. Sometimes in perforation of the peritoneal cavity one may also
be able to determine the condition with the finger; as a rule, however,
such perforations are too high to be so reached. The rectal tube or
speculum should always be employed to examine these wounds. By the
pneumatic endoscope or the ordinary Kelly tube (with the patient in
the knee-chest posture) one may be able in the majority of cases to
see the whole field, and sometimes pack the wound so as to avoid further
faecal extravasation; in a case of rupture of the rectum through the
passage of an extra-uterine foetus, it was possible to control the haemor-
rhage and pack the foetal sac in this way. In a case of a perforating
wound of the bladder the urine could be seen to trickle into the rectum.

920 THE ANUS, RECTUM, AND PELVIC COLON

The rapid escape of air from the rectum, and inability to inflate this
organ after a suspected perforation of the peritonaeum, would be indica-
tive that such had taken place, even if the point of injury could not
be seen.

Treatment, — The treatment of the rectal wounds and injuries may be
summed up in the brief words drainage and disinfection. Where these
are properly carried out little trouble is to be anticipated from minor
wounds or injuries confined to the anus and rectum. Haemorrhage
should be controlled according to the surgical principles described in the
chapter upon foreign bodies. The rectum, however, should always be
thoroughly irrigated with hot antiseptic solution before it is packed,
except when the peritoneal cavity is penetrated.

If fistulas, abscesses, or ulceration occur, they should be treated
according to the methods heretofore laid down. Perforations of the
bladder through rectal wounds often heal spontaneously, and therefore
in those cases in w^hich there is no peritoneal involvement early opera-
tive interference is not advisable. The bladder may be drained by a
soft-rubber catheter and the rectum kept as free from faecal material
as possible by daily cold-water enemata, and if after due time the
condition develops into a recto-vesical or recto-urethral fistula, it should
be treated after the methods heretofore described.

The treatment of rectal injuries involving the peritonaeum is of the
greatest importance. Wherever there is any reason to believe that the
peritoneal cavity has been opened through a wound in the rectum an
exploratory laparotomy should be done at once, and the site, course, and
extent of the injuries determined. In doing this one should not waste
any time in the removal of the patient, but should operate immediately
without any undue movement, so as to disturb the parts as little as pos-
sible. If there should be much extravasation of blood and faecal material
into the peritoneal cavity it should be waslied out thoroughly with large
douches of normal saline solution. If, however, there is only a very
slight escape, it is better to wipe the parts off gently with pledgets soaked
in mild bichloride solution. It is better to clean out Douglas's cul'de-sac
by this method than by general irrigation, for by the latter one may
distribute throughout the cavity septic germs which were originally con-
fined to the pelvic space. If septic peritonitis has begun, Qu6nu ad-
vises prolonged lavage with artificial serum at 40 degrees centigrade,
but normal saline solution is quite as effectual.

Wliere the wound in the intestine is within reach, it may be sutured
and dropped back into the abdominal cavity, or it may be brought up
and attached to the edges of the abdominal incision, thus fonning an
artificial anus. If the wound, however, is low down in the pouch of
Douglas, one may find great difficulty in carrying out either of these

WOUNDS, INJURIES, AND RUPTURE OP THE RECTUM 921

methods. A colpeurjmter introduced into the rectum will lift the parts
up in the pelvis to a certain extent, and bring them within easier reach.
One need not mention the advantages of the Trendelenburg posture in
performing such operations; the patient should not be thrown into this
position, however, until after the pelvic cavity and Douglases cul'de-sac
have been thoroughly cleaned out.

Where the opening into the gut can not be closed by sutures, and
even in all cases where it has been closed, it is advisable to pass a gauze
wick down to the site and bring it out through the lower end of the ab-
dominal wound; it is not safe to close this up without drainage in any
case in which there has been a communication between the intestine and
peritoneal cavity.

The results of laparotomy in these cases are very encouraging. In
6 cases in which the operation was done, 4 recovered and 2 died, giving
a mortality of 33i per cent. Of 29 cases not operated upon, 5 recovered
and 24 died — a mortality of 82 per cent. It is altogether probable
that the mortality in the 6 cases would have been still less had the
patients been operated upon before the time for the development of
septic peritonitis. In the fatal cases, one was done sixteen, and the
other more than twenty, hours after the injury.

The treatment of rupture of the rectum should be immediate lapa-
rotomy and suture of the wound. If it has occurred during the manipu-
lation of a prolapsed gut, amputation above the point of the rupture
may be done, and laparotomy thus be avoided. It is not safe, however,
to attempt to close these wounds by suture from the mucous side. In
such cases, moreover, laparotomy and dragging upon the gut from
above will facilitate the reduction of the prolapse, and in all probability
one will be able to close the wound without any escape of fajcal material
into the peritoneal cavity. Under such circumstances it wuU be per-
fectly proper, after having sutured the intestinal wound, to close up
the abdominal cavity without drainage.

CHAPTER XXIV

NERVOUS OR HYSTERICAL RECTUM^INSANE RECTUM— NEU-
RALGIA OF THE RECTUM— OBSCURE DISEASES OF THE
RECTUM

Under one or the other of the above titles a large variety of affec-
tions of the rectum have been described. Curling first took up this
subject and divided these cases into three classes — the " irritable rectum,^'
*^ neuralgia/' and " morbid sensibility of the rectum.''

In the first class he included all those cases in which the rectum is
more sensitive to nerve influences, and reacts abnormally to reflex irri-
tations. In the second class he placed all those cases in which neuralgic
pains occur about the lower end of the bowel without any discoverable
organic lesion in the rectum itself. In the third class he included those
cases in which there is a true hypersesthesia associated with hypertrophy
and spasm of the voluntary muscles. He stated that in the majority of
such cases a pathological condition exists to account for the symptoms,
imder which circumstances one can not properly class them under the
neuroses.

Hysteria and neuralgia are two very vague terms. They are ordi-
narily understood by practitioners to mean a condition of the nerves
or the nervous system to account for which there is no pathological
lesion discoverable. They are both used as mantles to cover up our
ignorance in many instances, and when hysterical women and neuralgic
Tectums are mentioned, it is generally in connection with cases in which
there has been a failure to make a diagnosis.

Neuralgias arc always the expression of nerve irritation, either
mechanical or pathological. Whether that irritation is central or
peripheral it is sometimes impossible to state, but it is not likely that
any peripheral nerve persistently or periodically produces pain unless
there is some excitation of the sensory fibers. That patients sometimes
overestimate their pain, and complain more of sensitive areas at different
portions of the body than the pains justify, may be conceded; but in
these cases there is always a disease of the mind or of the general nerv-
ous system wliich renders the patient incapable of bearing pain. In other
words, all pains have a mechanical, chemical, or pathological cause.
922

NERVOUS OR HYSTERICAL RECTUM 923

The condition ordinarily described as hysteria has of late years ob-
tained much greater respect among physicians. Formerly a woman
who fainted or cried without any commensurate provocation was con-
sidered hysterical, and little patience was had with her. The large
majority of these patients have been found, after making the rounds
of different specialists, to have some disease of the ovaries, uterus, or
other organs which accounted for their symptoms; in most of the cases
termed nervous or hysterical rectum, if one searches long and carefully
enough, he will find some local or reflex cause for the symptoms exhibited.

In a discussion of this subject before the American Medical Asso-
ciation in 1888, William Goodell stated that few muscles of the body
are exempt from attacks of hysteria, and that the circular ones are
the most liable of all to be so attacked. He stated that " in many
cases the mind is sane, the organic body is sound, the individual as a
whole is above reproach, and yet these muscles will behave as if bereft
of reason.** In most of the cases so affected, according to this author,
one will find symptoms of nervous prostration, backaches, and ner-
vousness, but the chief sjrmptom is referred to the rectum. So intense
is this symptom that it masks all the other phenomena, and leads one
to believe that he is dealing with some marked patliological lesion of
the organ.

In some the symptoms closely resemble those of anal fissure, as there
is great pain during or after defecation; in others, tlie pain is higher
up than the sphincter muscles, and there is a periodicity in its character
which is probably due to the accumulation of faeces in the rectum; and
in others still there is a throbbing, pulsating pain that occurs before
and during defecation, but disappears after the bowels have been emp-
tied; this may be more intense at one portion of the rectimi than at
another, as in those cases simulating coccygodynia. Aside from these
cases associated with actual pain, there are others described by Goodell
in which the sphincter muscle is persistently and powerfully contracted
without any cause to account for it.

The movement of the bowels is not associated with any pain, but
requires either artificial assistance or an enema before it can be accom-
plished. In these cases defecation is sometimes followed by great ex-
haustion, whether the stool is fiuid or solid. In other cases the rectum
is so sensitive and irritable that the least pressure either from the faeces
low down within it or the introduction of the syringe will bring on
spasm and actual agony.

The least excitement from social, business, or other causes will some-
times bring on either a relaxation of the sphincters and inability to
control the movements of the bowels or a spasm of those muscles which
unfits the patient for society or affairs.

924 THE ANUS, RECTUM, AND PELVIC COLON

Mathews practically denies the existence of any such symptoms
without a commensurate pathological cause. When Goodell wrote the
article referred to, his methods and means of rectal examination were
crude and unsatisfactory; nevertheless, they were as good as any others
at that time, and it is improbable that he overlooked or failed to ob-
serve the gross pathological lesions which are claimed by Mathews
to account for all these conditions. At that time these were recognized
as well as the reflex influences produced by diseases of the bladder,
uterus, ovaries, and other organs, just as they are to-day; but after all
these conditions have been accounted for, there still exist a certain
number in which it is impossible to find a pathological cause for the
irregular behavior of the muscles. The author knows a surgeon, and
has examined him carefully and in vain to find any abnormal condition
in his rectum, who before he enters the operating-room must invariably
retire to the toilet to have a movement of the bowels, notwithstanding
he has already had his regular passage for the day.

Goodell quoted an interesting case of a woman whose bowels never
gave her any trouble whatever so long as she remained at home and in
indoor dress, but as soon as she put on her hat to go out, a painful tenes-
mus with repeated stools began, and did not cease until she took off
her hat and resumed her household duties. Many such eccentric in-
stances can be mentioned, and are only explicable through some ab-
normal condition of the nervous system.

In those cases in which there is actual pain in or about the rectum
associated with or following the stool, it is possible ordinarily to find
some pathological change to account for the symptoms. A fissure,
whether active or healed, a small ulcer just within the sphincter, a
hypertrophied papilla which prolapses and is caught in the grasp of the
sphincter, a small polypus, or an inflamed haemorrhoid, may any of them
produce the symptoms described as obscure diseases or hysteria of the
rectum.

A small fffical concretion or foreign body lodged in one of the crypts
and out of sight may keep up an irritation or neuralgia for an indefinite
period; in a case of this kind in the author's experience the patient
suffered for from eighteen to twenty-four hours after stool, and yet
many examinations by a noted specialist in rectal diseases revealed
nothing whatever to account for the s3nmptoms; the rectum and crypts
were searched carefully, but nothing was found except a small indurated
ridge, apparently the seat of an old fissure which had healed. It was
a case in which the nerve-ends had become caught in the cicatrix, and
this caused a neuritis. In another case a similar conclusion was about
reached when, upon withdrawing the speculum, a minute drop of pus
coming from just above the muco-cutaneous margin was observed. At

NERVOUS OR HYSTERICAL RECTUM 925

a second examination a very fine probe was introduced into one of the
crypts of Morgagni, and a small burrowing tract extending down about
i an inch was found. The moment the probe entered into this tract
the patient shrieked with pain, and stated that it was the same kind of
suffering she had every time she went to stool. The little crypt was
slit up and the sphincter muscle incised under the influence of cocaine,
and within ten days' time she was entirely well of a condition which
had lasted for months.

Many of these cases occur in young women who have not been taught
the importance of regularity in the action of their bowels, and conse-
quently they have allowed themselves to become constipated at times,
and then, by the use of cathari;ics and enemas, have brought on drastic
movements, forcing large faecal masses through the sphincter and set-
ting up an irritation in the rectal mucous membrane. The pressure of
the fa?cal mass during the periods of constipation produces irritability
of the lower end of the rectum, h}T)ertrophy and spasm of the sphincter,
and congestion of the blood-vessels of this region. Along with these
changes there is an increase in the fibrous elements, and this constricts
the nerve-ends, thus producing neuralgias. Allingham believes that
this congestion accounts for a large number of the cases of so-called
nervous rectum. It is not necessary to describe here the influence of
ulcers of the rectum and neoplasms, such as polypi, adenomata, and
papilloma, in producing rectal pain, but attention should be directed
to a condition described by Ball, Allingham, and Mathews, in which
a small congested or irritated spot well above the sphincteric region
causes a tenesmus and bearing-down sensation in the organ. The slight-
est abrasion of the epithelium, the lodgment of small foreign bodies or
hard faecal masses in diverticuli of the rectum, or a follicular inflaili-
mation, may bring on symptoms which are referred to the anus, owing
to the fact that while the afferent nerves supply the upper portion of
the rectum and sigmoid flexure very freely, the efferent are largely dis-
tributed to the lower end and the voluntary muscles of the organ. Thus
the pains may be far removed from the site of causative lesion.

Eeflex Irritations, — The intimate association between the rectum and
the genito-urinary organs, both in the male and in the female, will ac-
count for many reflex symptoms between the two. It is well known to
all surgeons how diseases of the rectum, such as fissure, fistula, and
ulceration, may simulate uterine or urethral diseases, and how a stricture
in the deep urethra may find its most prominent expression in neuralgia
and bearing-down pains in the rectum. Prolapsed ovaries, subinvoluted
uteri, stone in the bladder, inflammations of the seminal vesicles, all
frequently cause rectal symptoms when there is no disease of this organ
at all. It is quite necessar}% therefore, that the rectal surgeon shall be

926 THE ANUS, RECTUM, AND PELVIC COLON

thoroughly posted in regard to diseases of this kind, and capable of
diagnosing any such disorders. Where no organic lesion can be found
to account for the symptoms in the rectum a systematic examination
of the other organs of the pelvis should always be made.

Nerve Affections. — Frequently, however, nothing will be found in
any of these organs to account for the neuralgic pains or irregular symp-
toms that occur in the rectum. In such cases one must have recourse
to the study of the nervous system, especially the spinal cord. Spasm
and pain about the rectum are not infrequent sjrmptoms in the begin-
ning of locomotor ataxia; in many of these cases the pains occur in the
rectum before they do in the legs and sciatic regions.

AUingham states that in the beginning of mania one often observes
the patient has severe pains in the rectum without any pathological con-
dition to account for the same. Reference has been made to the fact
that accumulation of faeces in the rectum or sigmoid flexure may, by
its irritation or the auto-intoxication produced thereby, bring about
symptoms of insanity with delusions, which are relieved when the im-
paction has been removed. One must therefore be careful to distinguish
between the cause and effect in such cases.

Bheumatism and Oout, — In the chapter upon pruritus attention was
called to the influence of gout or rheumatism in producing rectal sjrmp-
toms; not infrequently the muscles and perirectal tissues are the seat
of gouty or rheumatic inflammations. The writer has quite frequently
operated for haemorrhoids upon patients who suffered with severe aching
pain around the anus, expecting the operation and stretching of the
sphincter would bring radical relief; but after a few days all the old
pains returned. In such patients the administration of large doses of
salicylates with alkaline diuretics have invariably given relief, whereas
the operation had done no good in this direction. In a number of such
cases operation has been deferred until the effect of therapeusis was
tested, and it has been gratifying at times to find that the medication
entirely relieved the sjrmptoms without a resort to operative interfer-
ence. The fact that full doses of colchicum sometimes relieves these
symptoms lends color to the theory that gout may occasionally cau^
them.

Insensitive Eectum, — This consists in a decrease of the normal sensi-
bility of the rectum. The patient's bowels will be perfectly regular for
weeks at a time, then, after a period of nervous strain or excitement,
cither from social or business affairs, there will come on a diarrhcea
with involuntary passages of faeces lasting for several days. The patient
will have no warning or sensation of such an impending crisis until the
actual escape of the faecal material. Under such circumstances they
become hypochondriacal and depressed, unfit for society, and at times

NERVOUS OR HYSTERICAL RECTUM 927

utterly unable to keep themselves clean. In one patient this condition
continued for three years; it first developed after a combined operation
for haemorrhoids and appendicitis, the haemorrhoidal operation having
been done one week later than the appendectomy; for a time it was
thought it was due to overstretching or to some inflammatory condition
around the anus, but prolonged observation and many examinations have
failed to find any lesion or lack of sphinctcric power to account for the
symptoms; sensation in the mucous membrane, however, is below par.
Had a Whitehead operation been done in this ease, one would have said
that the tactile or sensitive area of the rectum had been removed; inas-
much as a simple clamp-and-cautery operation involving only a very
small portion of the circumference of the rectum was done, no such
explanation can be given. This patient is of a very excitable tempera-
ment, suffers greatly from insomnia, and has a small abdominal aneu-
rism. The faecal passages occur when she is just dropping off to sleep
or when she is busily engaged in her social or household duties. It
would appear, therefore, that the cause lies in some disturbance of the
inhibitory centers governing the sphincter muscles. A similar condition
has also been observed in a case of syphilitic disease of the cord.

While, therefore, the large majority of this type of cases may be
accounted for by local or reflex diseases, there is still a certain number
in which these do not exist. They are due to diseases of the nerves
or nerve centers, and this must be recognized in order to avoid opera-
tions which will do more harm than good.

Treatment. — The treatment of these conditions will, of course, depend
upon their cause. Wherever there is hypertrophy with spasm of the
sphincter, together with tenderness and pain, one should not hesitate
to follow Mathews's advice and dilate or incise this muscle, and thus
put it at rest. At the same time, if there are hypertrophied papillae
or haemorrhoids, they should be removed. Ulceration should be treated
by appropriate measures, such as are indicated in the chapter upon
this subject. In those cases in which there is a localized area of in-
flammation with an abrasion in the mucous membrane, Mathews and
Allingham have both obtained excellent results by the application of
nitric acid or nitrate of silver to the spot; tincture of iodine serves the
same purpose without producing an actual ulceration, such as always
follows the application of the severer cauterizing agents.

When the condition is due to a general congestion of the rectum,
cold-water irrigation is ordinarily effectual. Better results will be ob-
tained in these cases from the irrigation than from the simple injection
of cold water into the rectum. In those cases in which the cold appli-
cation does not produce as much relief as expected, alternating hot and
cold irrigations will often succeed. In order to do this properly, one

928 THE ANUS, RECTUM, AND PELVIC COLON

should have a Y-shaped tip connecting the irrigator with two bags.
The hot water should be run through first at a temperature of llC to
120°. This should be continued for about ten minutes, when the cold
current should be turned on, and this continued for about the same
period. By this means excellent results have been obtained in those
cases in which there was dull continuous aching, and heaviness about
the lower end of the rectum.

Where there is a prolapsed ovary, much benefit may be derived from
placing the patient in the knee-chest posture, and placing a tube in the
vagina so as to allow this canal to become inflated with air, which will
thus carry the ovary upward and lift it out of the cul'de-sac, provided
there is no adhesion. If in this position the physician can feel the pro-
lapsed organ by means of the finger in the rectum, it will indicate an
adhesion, and this should be treated by proper surgical intervention.

Some of these cases are due to retroversion and prolapse of the
uterus, often associated with adhesions between this organ and the
rectum. Where the uterus can be lifted up and replaced, it may be
held in position by a properly adjusted pessary, and the rectal symptoms
will immediately disappear. If, however, there are adhesions, these must
be broken up and the uterus drawn up into its position by shortening
the round ligaments, or by some fixation method.

Where there is a large hypertrophied cervix, with laceration and
inflammation, the symptoms are frequently expressed in rectal uneasi-
ness, pain upon movement of the bowels and upon walking, and some-
times intense neuralgia around the lower end of the rectum; often
all these symptoms disappear entirely after the amputation of the cer-
vix, or even after a properly performed trachelorrhaphy.

It is a good practice always to dilate the sphincter whenever an
operation for lacerated cervix or ruptured perinapum is done. Much of
the discomfort following these operations is due to spasm of this muscle.
If, therefore, it is well dilated, this source of irritation will be radically
removed, and at the same time obscure fissures which may be present
will be cured.

The author has reported elsewhere a number of cases of uretliral
and bladder affections causing rectal symptoms (X. Y. Polyclinic, No-
vember, 1894, and ibid,, September 15, 1896). \Miere such conditions
are found to exist, they should be treated before resorting to any opera-
tions on the rectum. The influence of disease or small foreign bodies
in the crypts of ^lorgagni should not be forgotten in the treatment
of these ol)scure diseases. The writer is well aware that these little
pockets have been nuich maligned bv charlatans, who have ascril)ed to
them many disorders of the rectum of which they are not guilty. Xever-
theless, they do occasionally become irritated, and when such is the

NEEVOUS OR HYSTERICAL RECTUM 929

case they will account for a great deal of pain and rectal uneasiness.
In patients who suffer with symptoms such as have been described, the
rectum should never be exonerated until a careful search of every one
of these little pockets has been made. If in such an examination any
one of them is found to be the seat of either inflammation or arrest of
a foreign body, it should be slit open, the body removed, and the in-
flamed condition treated.

Occasionally in these cases one finds a type of stricture which is
not ordinarily described in books. It consists in a fine, thread-like
band that extends sometimes half-way or more around the rectum, and
which is not easily made out by touch unless the rectum is distended
more or less. The author has seen this condition four times — thrice in
women and once in a man. In two of the cases there was no history
of any operation having been performed, nor of any inflammation of
the rectum, so far as the patient knew. In one a small tumor had been
removed from the posterior wall of the rectum some four years previ-
ously, and in the last an operation had been done by the writer five years
previously for a submucous fistula. In neither of these cases, however,
were the bands confined to the lines of the previous incisions, nor did
they obstruct the caliber materially. They appeared when the part
was put upon the stretch like a small thread over which the mucous
membrane could be moved. Stretching gave some relief, but it was
only temporary. In all of them permanent relief was obtained by
dissecting out the fibrous cords completely, and suturing the wound
together. Microscopic examination showed one of these bands to be
of a purely fibrous nature, and not a nerve as was suspected. The
treatment of those cases due to diseases of the nerves or central nervous
system can not be entered into in a work of this kind. The reader is
referred to books on neurology for this.

There still remains a certain number of cases in which no organic
disease can be found in the rectum, pelvic organs, spinal cord, or brain
to account for the pain. Most of these cases are the victims of anaemia
and nervous exhaustion. The treatment of such cases consists in rest,
forced feeding, tonics, and change of environment. The so-called " rest
cure '' of Weir Mitchell will generally give good results.

Xerve sedatives, such as hyoscyamus, asafcetida, bromides, and sum-
bul, are useful. Excellent results sometimes follow the use of the com-
poimd sumbul pill advised by Goodell. At other times the admin-
istration of viburnum gives the most relief. Opium is contraindicated
in these cases, and, so far as iron is concerned, its tendency to produce
constipation overbalances the good which it sometimes serves in the
anaemic. Some of the modem preparations which do not so act may
be of benefit, but, as a rule, this remedy is detrimental in rectal diseases.
59

CHAPTER XXV
RECTO-COLONIC ALIMENTATION OR RECTAL FEEDING

Rectal alimentation is seldom applicable in the treatment of dis-
eases of the rectum, but the teacher in this line is so often consulted
with regard to the formula? and means of carrying out this method of
feeding in the various forms of chronic and acute diseases that it
seems justifiable to give a short resume of this subject. It is by no
means a new method, for nutrient clysters are mentioned in the works
of Galen and many of the earlier writers. Not until 1872, however,
when Leube first employed pancreatic extract in nutrient enemas, was
the method placed upon a scientific basis. From this time forward it
was recogniz^ed that the colon secreted no digestive ferments, that its
function was purely an absorptive one, and that nutrient injections,
in order to be of the greatest benefit, must necessarily be predigested
and fluid in character.

The more knowledge of stomachic and intestinal diseases, especially
of the functional ix^a, that has been gained, the wider and wiser has
the application of rectal feeding been. Eichhorst, Huber, Boas, Plan-
tenga. Van Valzah, Einhorn, Ewald, and Nothnagel have paid much
attention to this subject, and the following directions are based largely
upon their experiments, with the results of personal experience. WTien-
ever it is necessary to give functional rest to the upper portion of the
alimentary canal, whether it be the throat, oesophagus, or stomach, the
temporary abstinence from food given by the mouth is absolutely neces-
sary. Happily in such cases, a sufficient amount of nourishment may
be absorbed through the rectum and colon with which to prolong life
for weeks or even months.

M. Tournier (Province medicale, 1895, Nos. 29, 30) and Professor
Lepine (Semaine medicale, 1895, pp. 317, 389) have made interesting
experiments in this line. The former fed a patient by this means alone
for seventeen days, and observed no wasting, but, on the contrary, an
increase of weight. A. P. Gross (Th., Paris, 1898) has collected 66
cases, in which exclusive rectal feeding was carried out in the treat-
930

RECTO-COLONIC ALIMENTATION OR RECTAL FEEDING 931

ment of patients suffering from various forms of stomachic disease;
many of these cases gained in weight while undergoing this treatment;
only a very few of them lost at all, and those very slightly. He states
that the result as to nourishment seems comparable to that obtained
from the milk diet; the diseases in w^hich he found it most useful were
ulcers of the stomach; hypersecretion, or excessive sensibility of the
gastric mucosa, Reichmann's disease, hyperchlorhydria, stenosis of the
pylorus, vomiting of pregnancy, neoplasms of the stomach, and peri-
gastritis. He states that the method should be used exclusively in
ulcerations of the stomach, in cases of stenosis of the pylorus, hyper-
chlorhydria, and hypersecretion, and in cases of dilatation of the stom-
ach with inadequate power from various causes. It is only a comple-
mentary method in cases of carcinoma and incoercible neuropathic vom-
iting. In these a certain amoimt of predigested food of a bland, non-
irritating quality may be administered by the stomach, but the quantity
is insufficient to maintain strength, and therefore it should be supple-
mented by the use of nutrient enemata. At the same time he concludes
that in the majority of cases exclusive colonic alimentation is preferable,
because the mixed feeding often seems to prevent the absorption of the
nutrient enemata. The length of time which such treatment should
continue in these stomachic cases is about twenty days.

In surgical operations about the throat, mouth, larynx, stomach, and
intestines, this method of feeding is of the utmost importance, and the
patient's strength may be very equably maintained if it is properly
carried out.

There are two explanations of the methods by which nutrient ene-
mata are absorbed. The first is that the absorptive power of the rectum
and colon is adequate to take up the food in sufficient quantities to
support life and strength. The other is that these nutrient injections
are carried by reverse peristalsis through the Bauhinian valve and into
the small intestine, where they are further digested by the pancreatic
and biliary secretions, and absorbed by the villi of this region. This
latter theory would very easily explain all these cases, but unfortunately
this retroperistalsis is the exception rather than the rule. Tournier
gives an interesting account of a woman to whom ho administered ene-
mata of cod-liver oil in the morning, and who vomited distinct globules
of oil during the afternoon. Lepine, Grutzner, and Swiezinsky have all
conducted interesting experiments to prove that substances injected in
the rectum find their way into the small intestine and stomach in animals.
Those upon men, however, are absolutely unsatisfactory. Voit and
Bauer recognize the possibility of fluid substances passing from the
large intestine through the Bauhinian valve into the stomach; never-
theless, they aver that it is an indisputable fact that the large pro-

932 THE ANUS, RECTUM, AND PELVIC COLON

portion of the albiuninoid material so injected is absorbed in the c(
itself. As further evidence of this fact, the author may state from
experience, that in two patients in which right inguinal colotomies v
done for carcinoma of the transverse and splenic colon, the pati<
were nourished for considerable periods of time by the use of nutr
enemata on account of secondary and reflex involvement of the stomj
In these cases it was absolutely impossible for the alimentary substa
to pass beyond the artificial anus, and consequently the nutrition
tained was beyond question due to the absorption from the colon its
The ex{)eriments of Grutzner and Xencki have been made upon rabl
guinea-pigs, and dogs, whose intestinal conformation is different fi
that of a man, aside from the fact that the erect posture has m
to do with tlie movement of the fluid in tlie intestinal canal. T]
conclusions, therefore, can not be relied upon to explain the sub
of nourisliment bv rectal feedin*::.

In the chapter upon constipation, the possibility of an occasic
passage of fluid from the rectum into the stomacli was admitted,
such an action is very far from being tlie normal course of eve
Numerous experiments upon patients with artificial ani convinces
that the large proportion of the fluid material injected in the reci
or colon is either absorbed by that organ or passed out through
anal canal. These experiments seem to do away, then, with the p(
bility of the digestion of the nutrient enemas after they have l
injected into the intestinal canal. It is of tlie utmost importance, th
fore, that the substances used for this purpose should be either ;
digested or ready for direct absorption.

It has been demonstrated by Leube, Huber, and Ewald that prot
are fairly well absorbed by the large intestine. The results of their
periments show: First, milk proteids are not very well absorbed; sec<
eggs given alone are not well absorbed, but if 20 grains of salt be adde
each (}f:g the results will be as satisfactory as if they had been peptoni
third, raw beef-juice is well absorbed; fourth, peptones are well absorl
fifth, glucose is well absorbed if it is not in concentrated solutions
which case it irritates the mucous membrane, and is likely to be expe
before absorption takes place, so that Leube advises that it should no
used in stronger than 15-per-cent solution, nor in greater quantity t
300 cubic centimeters; sixth, starch is very well absorbed, even in
raw state, and is not irritating. Fats are not well absorbed, this dept
ing upon the quantity administered, the time that they remain in
bowel, the presence or absence of salt, and the temperature; under
most favorable circumstances not more than 10 grammes of fat can
absorbed in one day; seventh, alcohol in the form of wine, whiskv,
brandy, well diluted, is quickly and completely absorbed. From ti

RECTO-COLONIC ALIMENTATION OR RECTAL FEEDING 933

experiments it may be concluded that the most satisfactory substances
for rectal alimentation are, first, alcohol; second, albuminose or pep-
tones, eggs with salt; third, beef -juice, unboiled starch, and diluted
solutions of grape-sugar. Milk, while not freely absorbed in its raw
state, when peptonized forms the best basis or menstruum for all ene-
mata. Somatose may be substituted for peptone, as may also Valentine's
beef-juice and beef peptonoids.

Red wine has been recommended by a large number of European
writers as a satisfactory method of administering alcohol by enemas
owing to its astringency as well as its acidity, thus contributing to their
retention in the intestine. Fresh blood has been advocated by a num-
ber of writers, especially by Eicketts, of Cincinnati, who uses from.
5 to 10 ounces daily of defibrinated beef blood, which must be obtained
fresh every morning. He reports having kept a patient alive for six
weeks upon this treatment, and having finally obtained a very satisfac-
tory result. Andrew Smith (Bull, of Academy of Med., New York, 1879^
p. 123), as chairman of a committee appointed to investigate this sub-
ject, reported a number of observations in which enemata of defibrinated
beef blood had been used in different pathological conditions; many of
these were tubercular, others carcinomatous, and others in advanced
stages of chronic disease; the results in the majority of instances were
exceedingly good; in a few cases, however, the patients not only did not
improve, but were rendered worse by the treatment. This form of rectal
alimentation does not seem to have established any great superiority
over the other forms, and at the same time it is very inconvenient, and
often impossible to obtain.

Recently French therapeutists have obtained some very excellent
results by the use of organo-serum for nutrient enemata, especially in
cases of nervous exhaustion and inability to retain food from one cause
or another; this substance possesses excellent tonic effects, and in cases
where it is impossible to administer sufficient nourishment by the mouth,
one may supplement this by injections of organo-serum, with permanent
and decided benefit.

In deciding upon rectal alimentation, one should always consider
what elements are most necessary in the individual case. In acute ex-
haustion from ha?morrhage, overwork, or nausea, w^here stimulation and
filling of the blood-vessels are indicated rather than actual nourish-
ment, one should have recourse to enemas of hot normal saline solu-
tion, with small quantities of red wine, whisky, or coffee. In shock
and collapse, whether from surgical operations, injuries, or other causes,
great benefit may be obtained from an injection of 1 pint of hot black
coffee.

Where the case is one of chronic disease, in which the enema is not

934 THE ANUS, RECTUM, AND PELVIC COLON

intended for temporary purposes but as a means of permanent feeding,
the stimulating portion of the enema should be left out, inasmuch as
it is likely to irritate the mucous membrane of the intestine and render
it intolerant of the injection. A good formula for rectal feeding is a
mixture of 3 eggs, ^ a*teaspoonful of salt, 6 ounces of peptonized milk,
with or without a tablespoonful of beef-juice or beef peptonoids, 1
tablespoonful of good rye whisky.

Gross recommends the formulas of Ewald and Boas in the majority
of cases.

Ewald's formula is: Two to 3 eggs, 1 glass of red wine, 1 cup of
20-per-cent solution of grape-sugar, 2 or 3 grains of salt.

Boas's formula is as follows:

Milk 250 c.c;

Yolk of egg 2;

Salt 1 pinch;

Red wine 15 c.c.

A- little starch may be added to this.

The methods of administering nutrient enemata vary considerably.
It is important in all cases that the bowels should be cleaned out at
least once in twenty-four hours when rectal alimentation is being car-
ried on, and this is best accomplished by large saline enemas, which act
more effectually if administered cold, though Ewald, Toumier, and
Gross prefer to use them hot. The cold, however, acts more promptly,
and the bowel seems to be more tolerant of the nutrient enema after
them than after the hot ones. The amount of the nutrient enemas can
not be laid down by any hard-and-fast rule; some patients will retain
6, 8, and 10 ounces, while others can not retain more than 3 or 4
ounces. Where the patient will retain as much as 8 ounces at one time,
the enema should be administered not oftener than four times in twen-
ty-four hours. AMien, however, only 3 ounces can be retained, they
should be administered more frequently. Occasionally it will be neces-
sary to add a little opium to the enema in order to quiet the sensibility
of the mucous membrane of the intestine. The quantity necessairy,
however, is generally quite small, 4 to 5 drops of laudanum being onli-
narily sufficient. This use of opium becomes more necessary after the
process has been carried on for some days, and it may be necessary
to increase the quantity from day to day.

As to how long rectal alimentation may be continued can not be
stated. Hutchinson claims that it is impossible to develop more than
500 calorics of energy daily by this means, whereas at least 1,500 are
required by patients to maintain the equilibrium of health. The experi-
ences of Tournier, Gross, Ewald, and others do not bear him out in this

RECTO-COLONIC ALIMENTATION OR RECTAL FEEDING 935

statement. A patient has been kept alive by this method twenty-six days,
so that an extensive gastric ulcer has been cured because of the func-
tional rest to the stomach; she lost flesh, but was no more emaciated
than one often finds after attacks of typhoid or other acute diseases.
In the last five or six days of her treatment she was able to take about
2 ounces of peptonized milk daily by the stomach.

In another instance of gastroptosis with ulceration and severe hsBm-
orrhages, the patient was fed by nutrient enemata for eighteen days
exclusively. When the treatment was begun the patient was practically
pulseless, emaciated, and collapsed, following a severe haemorrhage. At
the end of eighteen days his pulse was full and round, 70 beats per
minute, his respiration normal, his body had filled out, and he was able
to walk several blocks. He finally resumed taking food in the normal
manner and lived one year comparatively comfortably, when suddenly
the old condition redeveloped with, at the same time, an abnormal irrita-
bility of the rectum, which rendered the organ intolerant of the nutrient
enemata, and it could not be made so, even by the use of opiates in
large quantities. The patient being unable to take nourishment, either
normally or artificially, succumbed. As a rule, however, one may say
that twenty days will probably cover the average period in w^hich ex-
clusive rectal alimentation may be carried out.

The method of administering these clysters is as follows: The pa-
tient is laid in the Sims's position, with the hips elevated upon one or
two pillows. A Xo. 5 Wales bougie is then introduced into the rectum,
and whatever gas is contained in this organ is allowed to escape through
its opening. The bougie should be introduced to the distance of 3J
inches, or just high enough to be entirely above the sphincteric con-
traction.

Some writers advise injecting the nutrient fluid into the sigmoid
flexure; but this method is much more likely to excite peristaltic action
and ejection of the fluid than if it is poured into the ampulla of the
rectum and allowed to find its way upward.

The fluid should also be injected very slowly; if given from a foun-
tain syringe, the bag should not be raised more than 2 feet above the
level of the patient's hips. The small soft tube is important in order
to avoid injury to the parts about the anus, and also because it does not
stretch the parts and produce a tenderness which might militate against
prolonged treatment by this method. The fluid should be heated to
100° Fahrenheit. Cold or very hot solutions always excite peristaltic
action, and are not suitable for this method of treatment.

The following formula?, given by the most noted writers upon this
subject, may be of interest to our readers, as many of them differ from
those heretofore given, and may be applicable to special cases:

936 THE ANUS, RECTUM, AND PELVIC COLON

Eiegl's formula:

Milk 250 c.c;

Eggs 2 to 3;

Salt 2 to 3 pinches;

Red wine 30 grammes.

Catillou's formula:

Beef peptone (saturated solution) 50 grammes;

Water 125 grammes;

Bicarbonate of soda 30 centigr.;

Laudanum 4 drops.

Tournier:

Salted bouillon 140 to 150 grammes;

Yolk of egg 2;

Wine 20 to 40 grammes;

Sydenham's laudanum 4 to 8 drops.

Tournier:

Milk 140 grammes;

Yolk of egg 2;

Sugar 10 grammes;

Laudanum 4 to 8 drops.

Tournier:

Bouillon 140 grammes;

Yolk of egg 6;

Wine 20 grammes;

Salt 2 teaspoonf uls.

Tournier:

Water 150 grammes;

i Dry peptone 10 grammes;

Yolk of egg 1;

Glucose 20 grammes;

Sydenham's laudanum 4 drops.

Professor Jaccoud's formula:

Bouillon 250 grammes;

Wine 150 grammes;

^ Yolk of egg 2;

I Dry peptone 4 to 20 grammes.

RECTO-COLONIC AUMENTATION OR RECTAL FEEDING 937

Lathier employs:

Dry peptone 3 teaspoonfuls;

Yolk of egg 1;

Milk 125 grammes;

Tincture of opium 5 drops;

Starch-powder 5 grammes.

Adamkiewicz recommends:

Dry peptone 100 grammes;

Flour 300 grammes;

Oil 90 grammes;

Salt 30 grammes;

Bouillon 1,000 grammes.

In several injections.

Fleiner:

Bouillon 200 grammes;

White wine 50 grammes.

Singer uses:

Milk 125 granmies;

Wine 125 grammes;

Yolk of egg 1;

Salt 2 granmies;

Witt's dry peptone 1 teaspoonful;

Glucose . . . .* 2 grammes.

Sclilesinger employs:

^Milk 200 grammes;

Eggs 2;

Wine 15 grammes;

Rice flour 6 grammes;

Salt 2 pinches.

Ratjen uses:

Milk 250 grammes;

Yolk of egg 2;

Salt 1 pinch;

Red wine 15 grammes;

Starch 15 granmies.

INDEX

Abbott, ocular examination of rectum, 126.
Abdominal extirpation of rectum, 886.
Abdomino-auul extirpation of rectum, 842.
Abdomino-perineal extirpation of rectum, 847.
Abdomino-sacral extirpation of rectum, 845.
Abnormalitien of anus, 50.
AbHcess, 319.

afler operation for haemorrhoids, 664.

as cause of fistula, 356.

aspiration of, 886, 847.

bacteria, 330.

circumscribed, 324.

dilatation of sphincter, 888.

dysuria, 335.

escape of )f ases, 335.

etiology, 333.

feecal odor, 335.

fre<|uency of, 331.

gauze drains, 347.

Ilartmann's operation, 887.

interstitial, 339.

intramural, S29.

isclno-rectal, 324, 831.

marginal, 322, 323.

multilocular, 331.

perianal, 319.

perianal, course of infection, 824.

perianal, etiology of, 819.

perirectal, 319.

perirectal, course of infection, 321.

IK'rirectal, diffuse, 324.

perirectal, dilatation of sphincter, 338.

perirectal, sui)erticial, 324.

perirectal, throml>osis of lymphatics, 323.

phlegmonous, 329.

posterior communication, 332.

profound, 324, 839.

profound interstitial, 324.

profound retro-rectal, 339.

profound superior pelvi-rectal, 342.

remote results, 345.

repair of, 359.

rctro-roetal, 339, 840.

source of infection, 382.

subtegumentary, 824, 327.

Abscess, superficial, 825.

symptoms, 834.

tegumentary, 825.

treatment, 886.
Accelerator urinse muscle, 6.
Aohaxd, perirectal abscesses, 821.
Aoklanil, colitis, 180.

trophic ulceration, 288.
Actinomycosis of anus, 757.
Adamkiewioi'B formula, 937.
Adeno-cystoma, 755.
Adenoma of rectum, 722.

malignant, 768.

multiple, 725.
etiology, 726.

multiple, pathology, 738.

multiple, symptoms, 780.

multiple, treatment, 734.

simple, 723.

simple, histology. 724.

himple, symptoms, 725.

simple, treatment, 725.
Adler, pruritus ani, 578.
A£bioii, lipoma of rectum, 718.
Agnew, injection of haMuorrhoids, 624.
Agnew, 1). II., haemorrhoids, 635.
Ainfworth, malformations, 01.
Alimentary canal, 1.

development of, 1.
AUingham, atmospheric ballooning of rectum,
118.

colostomy for stricture, 512.

colostomy in carcinoma, 796.

colostomy, inguinal, 873.

colostomy, lumbar, 860.

extirpation of rectum, 815.

forceps, 647.

ha*morrhoidal crusher, 646.

hiemorrhoids, 635.

ligation of haemorrhoids, 633.

lupoid ulceration. 201.

operation for prolapse of rectum, 686.

procidentia, 667.

pruritus ani, 569, 579.

rodent ulcer, 263.

939

940

THE ANUS, RECTUM, AND PELVIC COLON

AlHTigham, dysenteric stricture, 481.

tuberculosis, 199, 360.

venereal diseases, 213.

villous tumors, 788.
American operation for haemorrhoids, 658.
Amputation of rectum, 700.

for prolapse, 698.

Fowler's method, 700.

Mikulicz's method, 699
AmoBiat, malformations of rectum, 59, 70, 76.

lumbar colostomy, 863.
Anaesthesia :

complications, 410.

in examinations, 130.

in rectal operations, 631.
Anal canal, 7.

description, 7.

dimensions, 8.

position, 7.

relations, 13.
Anal cul-^e-saCy 79.

rhaphe, 8.
Anden, malformations, 83.
Anderson, nerves of anus and rectum, 83.
AndiewB. anatomy of rectum, 9.

bougie, 180.

injection of haemorrhoids, 622.

speculum, 117.
Angeioma of rectum, 755.
A no-rectal syphiloma, 248.
Anus, 1, 7.

abnormalities, 49, etc.

actinomycosis of, 757.

artificial, 859.
closure, 882
control of, 886.
inguinal, 865.
lumbar, 863.
permanent, 886.
temporary, 877.

blcnnorrhagia, 213.

chancre, 230.

chancroid, 219.

complete occlusion, 85.

definition, 1.

dermoid cyst, 752.

dimensions, 8.

eczema, 261.

entire absence, 49.

fissure, 291.

functions, 44.

herpes, 260.

imperforate, 54.

imperforate, colotomy, 80.

intolerable ulcers, 291.

irritable ulcers, 201.

luj)oid ulceration, 199.

lymphatics, 34.

Anus, nerve supply, 33.

obstruction of, by diaphragm, 54.

partial occlusion, 53.

partial occlusion, treatment, 85.

physiology, 43.

position, 7.

spinal nerves, 34.

treatment of anal cul-de-tae, 79.

tuberculosis, 192.

ulcerations, 264.

vaginal, 90.

verrucous ulcerations, 204.
Applicators, 127.
Archocele, 676.
Arteries of anus and rectum, 29.

inferior haemorrhoidal, 80.

middle haemorrhoidal, 80.

sacral, 80.

sigmoidal, 42.

superior hsemorrhoidal, 29.
Artificial anus. See Anus.
Asohoff, colitis, 188.
Ashhnnt, haemorrhoids, 685.
Ashby, tuberculosis, 209.
Atresia ani, 62.

ani urethralis, 68.

utenniP, 62, 67.

vaginalis, 64-67.

vesicalis, 62, 63.
ATeling, malformations, 91.

Bacillus, 136.

aerogenes capsulatus, 186.

cholera, 136.

coli commune, 186.

diphtheritic, 186.

Klebs-Loeffler, 166.

lactis aerogenes, 186.

of tetanus, 186.

of tuberculosis, 186.

of typhoid, 186.

pyocyaneus, 136.

staphylococcus, 186.

streptococcus, 186.
Baoon, lateral entero-anastomoeis, 510.
Bacteria, 185.
Bacterium ooli, 820.
Bailej, malformations, 87.

permanent inguinal colectomy, 888.
Ball, ano-rectal syphiloma, 248.

cause of stricture, 478.

congenital syphilis, 255.

follicular ulceration, 281.

foreign bodies, 899.

gummata of rectum, 244.

haemorrhoids, 605.

lipoma of rectum, 719.

lupoid ulceration, 201.

INDEX

941

Ball, lymph adenoma, 721.

malformations, 24, 58, 61, 66, 91.

sarcoma, 808.

spasmodic stricture, 462.

theory of fissure, 295.

treatment of stricture, 499.

white haemorrhoids, 609.
Ballanoe, recto- vesical fistula, 439.
Bftmboiger, follicular ulceration, 282.
Bangs, hydatids, 758.
BaidenlMoer's operation, 822.
Barker, angeiomo, 755.

dermoid cysts, 748.
Barlow, colitis, 182.
Barnet, chronic constipation, 547.

fibroma of rectum, 716.
Bartela, recto-vcsical fistula, 438.
Baanrean, chancre, 228.
Batt, inguinal colostomy, 862.
Bauhinian valve, 536.
Baiel, dermoid cysts, 748.
Beach's sigmoidoscope, 121.
Beard, stricture, 501.
Beaninets, chronic constipation, 547.
Bender, lupoid ulceration, 201, 204.
Benham's hsgmorrhoidal crusher, 645.
Bennett, malformations, 60.
Berg, myoma of rectum, 720.
Bernard, recto-urethral fistula, 429.

venereal diseases, 213.
Bemays's operation, 887.

case of sarcoma, 808.
Besnier, lupoid ulceration, 202, 203.
Bidder, cntero-uterine fistula, 447.
BiUingalea, foreign bodies, 903.
Billroth, hyjKirplastic tuberculosis, 211.

venereal diseases, 213.
Bladder, the, 88.

essential gas in, 441.

rectum communicating with, 89.
Blake, venereal diseases, 217.
Blot, hydatids, 758.
Blunt- hooks, 127.
Boas's formula for rccto-colonic alimentation,

l»34.
Bodenhamer, congenital syphilis, 255.

niul formations, 58 et seq.
Bodine, inguinal colostomy, 874.
Boeokel, extirpation of the rectum, 846.
Bolton, colitis, 192.
Bone-tiap o[)eratiou, 831.
Bose, lipoma of rectum, 718.
Bonchard, relations of the sigmoid, 43.
Bougies, 128.

bouifie u boule, 129.

Crede's, 41»6.

in stricture, 490, 496.

retention of, 498.

Bougies, Wales's, 128.

Wyeth's, 129.
BonisKm, malformations, 47.
Bowlby, fibroma of the rectum, 716.
Bqyer, fissure :

incision, 310.

theory, 295.

treatment, 306.
Branca, adenoma, 723.

lymphadenoma, 721.
Brann, permanent colostomy, 888.
Breschat, malformations, 69.
Briggs, foreign bodies, 907.
Biinckerhoff's speculum, 115.
Biistow, colitis, 180.

extirpation of rectum, 832.
Broca, lipoma of rectum, 718.

perirectal stricture, 466.
Brodie, fissure, 292.

grooved director, 387.

haemorrhoids, 635.
Brown, Tilden, case of rectal ulceration, 162.
Bninn, rectal hernia, 706.
Bryant, foreign bodies, 913.

lumbar colostomy, 863.

mortality from colostomy, 861.

prolapse of rectum, 695.
Bnchanan, catarrhal diseases, 164.
Bndkmaster, malformations, 65, 91.
Bnfbt, foreign bodies, 901.
Bnnun, venereal diseases, 214.
Bnmstead, gummata of rectum, 244.

venereal diseases, 213.
Bnmier, wounds of rectum, 916.
Bnms's tenaculum, 127.
Bnshe. malformationa of rectum, 59.
By&rd, vaginal extirpation of rectum, 832.

Oabot. chronic constipation, 547.
Oalbet, extra-rectal dennoids, 750.

suero-coccygeal tumors, 754.
Galliaen. lumbar colostomy, 863.
Gaaipbell, colitis, 180, 181.
Campbell, John, on malformations, 69.
Gampenon, vaginal extirpation of the rectum,

802.
Cancer. See also Carcinoma.
Cancer, 760.

acinous. 770.

juice, 769.

pearls, 767.

scirrhous, 770.

skin, 767.

Hotl, 770.
Oanton, forei^^n bodies, 907.
Garadec, malformations, 66.
Carcinoma, 760.

abscess, 777.

942

THE ANUS, RECTUM, AND PELVIC COLON

Carcinoma, adenoid, 768.
adenoid, metastasis, 769.
age, 764.
anuria, 776.
cauterization, 795.
changes in types, 766.
colostomy, 796.
colloid, 772.

compatibility with good health, 772.
constitutional symptoms, 775.
curettage, 795.
degenerative stage, 776.
diagnosis, 779.
drugs, 795.
dysuria, 776.
enccphaloid, 770.
entero-anastomosis, 796.
epithelial, 767.
etiology, 763.

excision of rectum, prostate, and part of blad-
der, 792.
fibrous, 770.
fistula, 777.

general symptoms, 772.
hard, 770.
hemorrhages, 774.
heredity, 763.
histological types, 766.
importance of early examination, 772.
indications for palliative treatment, 793.
indications in treatment, 790.
intestinal obstruction, 776.
involvement of other organs, 777.
involvement of small intestine, 779.
laparotomy in diagnosis, 788.
latent period, 772.
ligation of iliac arteries, 846.
lines of extension, 777.
malignancy of different varieties, 766.
manual exploration, 783.
medullary, 770.
metastasis, 779.
morning diarrhoea, 774.
mortality, 785.
mucoid degeneration, 772.
obliteration of peritoneal cul-de-sac, 778.
ocular appearance, 776.
occupation, 765.
odor, 776.
pain, 775.

palliative treatment, 794.
patient's rights, 792.
perforation, 777.
permanent cure, 785.
phototherap> , 779.
prevalence of, 760.
previous disease, 765.
procidentia, 774.

Carcinoma, proliferative stage, 773.

results of treatment, 789.

seat, 761.

sepsis, 777.

sources of error in diagnosis, 780.

syphilis, 766.

treatment, 784.

villous, 788.

X-ray, 779.
Oanuiok's peptonoids, 145.
Oaipenter, atmospheric ballooning of rectum,

125.
Oanon, pruritus ani, 578.
Garr6, excision of stricture, 506.
Oairieie, chancre, 228.

perirectal abscesses, 820.
Oaitellane, lipoma of the rectum, 718.
Gastez, stricture due to dysentery, 481.
Casts of rectum, 16.
Catarrh of rectum and sigmoid, 189.

acute, 141.

atrophic, 152.

hypertrophic, 146.
OathcHUt's ointment, 615.
OfttUloa's formula for recto-colonic alimenta-
tion, 936.
Cautery, Paquelin, 689.
Ghadwiok, circular fibers, 20.
Olutlmflr, prolonged constipation, 518.
Ghfllot, extirpation of the rectum, 846.
Chancre, 228.

anal, 230.

anal, complicating hemorrlioids, 231.

anal, condylomata, 282.

anal, course of, 282.

anal, excision, 235.

anal, phagedenic, 231.

anal, treatment, 284.
Chancre of the rectum, 282.

cases of, 288.

symptoms, 234.

treatment, 23.
Chancroid, 219.

anal, 221.

complications, 227.

distinguished from fissure, 221.

etiology, 219.

frequency of, 219.

multiple, 220.

perianal, 220.

phagedenic, 224.

rectal, 223.

septicemia, 222.

symptoms, 223.

treatment, 222, 224.
Obapat, extirpation of the rectum, 845.
OhassaignafO, excision of fistula, 891.

hiemorrhoids, 645.

INDEX

943

Ohanaignao, 8ubtegumentar>' abscess, S27.

throinbobiB of the lymphatic trunks, 324.
Qieieldeii, excision of fistula, 391.
Ghetwood's operation for incontinence, 417.
Ohiui, tuberculosis, 192.
Clamps, 639.

Earless hiemorrhoidal, 654.

Gant*s haemorrhoidal, 639.

Kelsey's hemorrhoidal, 639.
Olerk, chancre, 228.
Cloaca, the, 2.

fllmmadwio, foreign bodies, 900.
Closure of artificial anus, 882.

author's method, 884.

end-to-end union, 883.

plastic method, 884.
Glorer's crutch, 641.
Oluttom, dermoid cysts, 748.
Coactor, 500.
Coelum, the, 2.
OolemAn, colitis, 180.
Ooley, case of malformations, 64.
Colitis, 167.

chronic, 167.

"colitis cystica," 188.

etiology, 167.

floating kidney, 170.

follicular, 186.

inflammation of appendix, 169.

membranous, 167, 168-192.

mucous, 167-192, 522.

pathology, 171.

pelvic adhesions, 169.

reflex causes, 168.

secondary membranous, 178-180.

symptoms, 173.

treatment, 175.

ulcerative, 180.

valvular colostomy, 191.
OoUm'b fascia, 5.
OoUiiii, malformations, 47.
Colon, 39.

congenital hyperplasia, 536.

dilatation, 536.

pelvic, 39.
Colopexy, 696.

in constipation, 554.
Colorectostomy, 839.

widening of the gut caliber, 840.
Colostomy, 859.

abdominal, 860.

inguinal, 866.

inguinal, Allinghanrs method, 873.

inguinal, author's method, 890.

inguinal, Bailey's method, 889.

inguinal, Bodine's method, 874.

inguinal, Braun's method, 890.

inguinal, flxation of gut, 871.

Colostomy, inguinal, indications for, 868.

inguinal, Jeannel's method, 875.

inguinal, Maydl-Reclus method, 875.

inguinal, on right side, 892.

inguinal, permanent, 885.

inguinal, sphincteropocsis, 887.

inguinal, temporary, 868.

inguinal, valvular, 191.

inguinal, Witzel's method, 888.

in stricture, 512.

lumbar, 860.

lumbar, Amussat's operation, 863.

lumbar, Bryant's method, 863, 864.

mortality, 861.

preliminary, 812.

preparation of patient, 869.

technique of o(>eration, 870.
Colotomy, 859.

in imperforate ani, 80.
Condylomata :

gonorrhceal, 216.

lata, 236.
Gomiar, manual exploration, 112.
Constipation, 517.

acute, 543.

acute flexure of pelvic colon, 537.

age, 526.

as cause of cancer, 766.

a symptom, 519.

bladder and urethral afl'ections, 514.

changes of mucosa, 535.

changes of subnmcosa, 535.

chronic, 545.

chronic, colopexy, 554.

chronic, constitutional effects, 546.

chronic, diet, 552.

chronic, electricity, 555.

chronic, haemorrhoids, 557.

chronic, Houston's valves, 557.

chronic, massage, 555.

chronic, nervous nymptoms, 547.

chronic, pneumatic distention, 555.

chronic, spasm of sphincter, 556.

chronic, symptoms, 546.

chronic, treatment, 548.

chronic, valvotomy, 557.

deflnition, 525.

diagnosis, 542.

due to circulatory disease, 531.

due to digestive disorders, 530.

due to diseases of the nervous system, 531.

due to drugs, 529.

due to enterospasm, 582.

due to liver disease, 531.

enlarged prostate, 541.

entcroptosis, 586.

etiology, 526.

exciting causes, 528.

THE ANUS, RECTUM, AND PELVIC COLON

ConAtipatioQf extra-intestinal obstructions, 540.

fissure, b'6\i.

foreign bodies, 539.

heredity, 526.

influence of food, 52S.

intra-intestinal tumors, 541.

intussusception and prolapse, 541.

umiforuiatious, 535.

luedicinul treatment, 502.

mental symptoms, 547.

occupation, 527.

prolonged, 518.

sex, 527.

spasm of the circular fibers, 539.

spasm of sphincter, 53b.

spastic, 532.

valvotomy, 534, 55b.
Con us medulluris, 44.
Oooper, lueinorrhoids, G35.
Oook's s|>cculum, 117.
OqpeUnd, constipation, 535.

iia'inorrhoids, G35.

incision of fissure, 310.
Coproliths, bi»b.

Ooquet, hyperj^lastic tuberculosis, 211.
*' Core ^ in abscess, 325.
Ooniil, stricture, 472.
OoaBoilouui, catarrhal diseases, 159.
Ooaty, malformations, 47, 84.
Oowan, trophic ulceration, 288.

colitis, 180.
Cowpcr's glands, 5, 6.
Crcde's bougie, 49S.
Orippi, absorptive action of rectum, 45.

adenoma of the rectum, 723.

benign stricture?*, 455.

connective-tissue hn?morrhoid8, 603.

extirpation of the rectum, 814.

inguinal colostomy, 872.

lupoid ulceration of anus, 203.

nialformutions, 75, 83.

papilloma. 7J^0.

prolapse, M7.

recto-vesioal fistula, 440.

simple cysts, 747.

spasmodic stricture, 462.

strict ural ulceration, 282.

stricture due to dvsenterv, 481.

varicose ulceration, 276.

V('ins of rectum. 31.
Oroley. lumbar colotoniy, 862.
GrtdkflhankB, catarrlinl diseases, 159, 164.
Ousher, Allinirliam's, 646.

Benhani's hannorrhoidal, 6.45.

hrt?morrhoidal, 645.

Smith's, 647.
Cmveilhier, fistula, 356.
Culs-de-nac^ 38.

Culs-de-sae, Douglases, 41.

peritoneal, 38.

prostato- vesical, 38.
Ominingham, foreign bodies, 906.
Onrling, acute catarrhal proctitis, 143.

colotoniy for stricture, 512.

htemorrhoids, 635.

incision of fissure, 310.

malformations, 47, 83.

obscure diseases of the rectum, 922.
Onaaok, clamp-and-cauter>' operation, 637.

haemorrhoids, 621.
Cystoma, 747.
CysU, 747.

dermoid, 747.

dermoid, anal, 752.

dermoid, extra-rectal, 750.

dermoid, rectal, 749.

simple, 747.
Gwmj, extirpation of the rectum, 845.

recto- vaginal fistula, 454,

treatment of multiple adenoma, 734.

Ba OofU. colitis, 174, 178, 186.

Dshlenkampf^ foreign bodies, 906.

Dandiidge, manual exploration of rectum, 111,

112.
Deayar, lymphatics of the rectum, 36.
De OarUar, myoma, 720.
Dsfeoation, 519.

colon, 522.

infiuence of food, 520.

infiuence of gases, 520.

O'Beime's theory, 523.

physiology, 520.

remission of inclination, 525.

reverse peristalsis, 523.

stimulants, 521.
Degonj, malformations, 84.
Delftfield, colitis, 180, 182, 186.
Delbet, hyperplastic tuberculosis, 211.

foreign bodies, 901.
Delonne, operation for prola j>se of rectum, 688.
Demuquaj, incision of fissure, 314.
Dennii, rodent ulcers, 263.
Denta. recto-urethral fistula, 432.
Depage, extirpation of the rectum, 814.
Dermoids. See Cvsts.
Desanlt, excision of stricture, 506,

inguinal anus, 867.

treatment of stricture, 497.
Desgnhifl, vaginal extirpation of the rectum, 83i
Demos, stricture from prostatic disease, 467.
Desprey, marginal absces.<ies, 322.
Derillier, prolonged constipation, 518.
Diagnosis, 94-138.
Diarrhoea in faecal impaction, 542.
DiokiiiBOiL, nephritic ulceration, 285.

INDEX

945

Didaj, phagedenic chancroid, 224.
Diefibnbftohf extirpation of the rectum, 814.

imperforate anu8, 69.
Dietfenbach- Roberts operation for prolapse of

rectum, 689.
Dilators, 120.

Kelly's sphincter (conical), 120.

rectal, 500.
Dimples, postanal, 752.
Dinet, inguinal anus, 867.
BioniB, malformations, 69.
Diphtheria of rectum, 166.
Dlttel, recto-vesical lihtula, 439.
Dolbean, enehondroma of rectum, 717.
Dolore, actinomycosis of anus, 757.
Douglas's cul-Je-mCy 22.
Dojon, phagedenic chancroid, 224.
Dressing-forceps, 127.
DnboiM, inguinal anus, 867.
Dncrey, venereal diseases, 220.
Dohring. chancre, 229.
Dumazqnaj, recto-vaginal fistula, 451.
Dnnoan, tuberculosis, 20l.
DnBglJHOTi, prootooace, 351.
DapUix, verrucous ulceration of anus, 205.
Dnplay, etiology of stricture, 490.
Dnprdfl, phagedenic chancroid, 225.
Dapnytren. incision of fissure, 310.
Dnran-Bordii, fistula, 3r)9.
Dnrand, Marius, malformations, 69.
Dnret, dermoid cysts, 752.

liwmorrhoidal plexus, 31.

operation for prolapse of rectum, 688.
Dvsenterv, 158.
Dysuria in ischio-rectal abscess, 335.

Earle, constipation, 560.

hiemorrhoidal forceps, 654.

vaginal cxtir])ation of the rectum, 833.
"Ectropion recti," 142.
Eczema of anus, 261.

erythematous, 261.

moist, 261.

treatment, 261.

vi'sioulosum, 261.
Edebohls, extirpation of the rectum, 811.
Edwards, hypertrophied valves, 535.
Egineta, malformations, 69.
Einhom. colitis, 176, 178.
Eldridge, catarrhal disoa-^es of rectum, 164.
Electrolysis in lupoid ulceration of anus, 204.

in stricture, 5ul.
Embryology, 1.
Enehondroma of rectum, 717.
Endarteritis in syphilitic stricture, 474.
Endoscope, 121.

Engle, relations of the sigmoid, 43.
Entero- anastomosis, 796.
60

Enteroliths, 898.
Enteroptosis, 536.
Episeiocleisis, 454.
Epithelial pegs. 767.
Epithelioma, 767.

appearance, 768.

columnar, 768.

cylindrical, 768.

discharge, 768.

distinguished from rodent ulcer, 768.

limits, 768.

seat, 768.

squamous, 767.

superficial, vegetating, 738.

symptoms, 768.
EBmazch, cicatricial stricture, 465.

li^>oma of rectum, 718.

perirectal abscesses, 319.

sarcoma, 808.
Esthiomene, 200.
Eniioh, colitis, 180.

trophic ulceration, 2b8.
Evans, William A., rectal valves, 26, 28.
Ewald, formula for recto-colonic alimentation,

934.
Examination in rectal diseases, 94-138.

anesthesia, 120, 130.

apparatus, 105.

bougies, 128.

digital, 107, 488.

enemata, 99.

external appearances, 106.

historical, 95.

instrumental, 113-130.

light, 113.

local, 96.

manual, 110.

methods, 95.

ocular, 125.

oeular, limits of, 126.

of caput coli. 111.

of la-ofs, 131-138.

of fieces, bacteriological, 135-138.

of fieces, chemical, 136-138.

of fa'ces, methotis, 131-138.

of faeces, microscopical, 133-135.

of fieces. Von Jaksch, 133.

pain. '.C

|K>sturcs, lol.

preparation of patient, 98.

l>rotrusion, 97.

state of bowels at, 97.

symptoms suggesting, 96.

vagi no- rectal, 489.
Excision of fistula, 391.
Excision of rectum :

probtate and part of bladder, 792.
Extirpation of the rectum, 810.

946

THE ANUS, RECTUM, AND PELVIC COLON

Extirpation of the rectum, abdominal method,

836.
abdomino-anal method, 842.
abdomino- perineal method, 845.
abdomino-sacral method, 845.
after-treatment of patient, 829.
Allingham^s method, 815.
anchoring sutures, 828.
aitificial anus, 858.
Bardenheuer^s method, 822.
bone-flap operation, 824.
cases, 839, 840.
causes of death, 788.
choice of method, 855.
colorectostomy, 839.
combined methods, 942.
complications following, 951.
concealed haemorrhage, 829.
control of hsemorrhage, 826.
Cripps's method, 814.
diarrhcea after, 855.
disposition of intestinal ends, 849.
evolution, 810.
fistula from, 828.

functional complications following, 855.
gangrene, 853.
Gersuny's method to prevent incontinence

ailer, 854.
Hegar's method, 822.
llochenegg^s method, 822.
incontinence following, 786, 854.
indications for, 790.
infection, 852.
influence of age, 788.
injury to other organs, 852.
Kraske^s method, 821.
length of life after, 786.
Levy's method, 822.
Maunscirs method, 842.
Murphy button, 827, 850.
Murphy's method, 835.
perineal method, 813.
preliminary colostomy, 812.
preliminary curettage, 818.
preparation of patient, 811.
preparation of surgeon, 798.
prolapse following, 854.
Qudnu's abdomino-perineal method, 848.
Quenu's perineal method, 817.
Rehn-Kydygier method, 824.
relation of the parts involved, 825.
results of, 786, 841.
Rose's method, 822.
Rydygicr's method to prevent incontinence

after, 854.
sacral method, 821.
HcpsiH, 788, 7^9.
statistics, 857.

Extirpation of the rectum, stricture following,

854.
treatment of intestinal ends, 849.
treatment of the bone-flap, 829.
treatment of the peritonaeum, 826.
vaginal method, 832.
Van Buren's rule, 791.
Von Heinecke's method, 822.
WeirV method, 843.
Willems's method to prevent incontiDenee

after, 854.

Fffical impaction, 517, 564.
Faecal stones, 898.
Faeces, 185.

examination, 181.

incontinence, 412.
Faget, extirpation of the rectum, 810.
Fayazd, extension of carcinoma, 778.
Fehling^s sugar teat, 138.
Feliwt, lymphadeuoma of rectum, 721.
Fergmon, speculum, 116.
Feolaid, chancre, 229.
Fibroma of anus and rectum. 716.

pathology, 716.
Fine, artiticial anus, 867.
Finet, carcinoma, 765.
Ffaik, multiple adenoma, 727.
Finkler, spirillum, 136.
Fissure in ano, 291.

as cause of abscess, 832.

author's method of incision, 311.

complications, 817.

etiology, 298.

excision, 814.

extent of incision, 811.

ichthyol, 305.

incision, 310.

incontinence from incision, 817.

laxatives, 303.

location, 298.

multiple, 291.

non-operative treatment, 308.

operative treatment, 306.

pain, 298.

pathology, 296.

Pennington's tube, 809.

polypus, 294.

reflex symptoms, 299.

results of dilatation, 309.

sex, 298.

shape, 292.

stretching of sphincter, 807.

stricture from, 317.

submucous, 316.

symptoms, 298.

treatment, 302.
Fistula, 353.

INDEX

947

Fistula, age, 358.
after operation for hcemorrhoida, 664.
anatomical character, 867.
blind external, 362.
blind external, diagnosis, 362.
blind external, treatment, 389.
blind internal, 362.
blind internal, diagnosis, 363.
blind internal, symptoms, 363.
blind internal, treatment, 398.
chronieity, 357.
classification, 353.
complete, 354, 363.
complex, 854, 367.
complex, diagnosis, 867.
complex, treatment, 400.
complicated, 354, 421.
complications in operations for immediate,

408.
complications in operations for late, 412.
connecting rectum with other organs, 423.
constitutional conditions, 359.
course of burrowing, 401.
danger of force in examination, 400.
definition, 353.
diagnosis, 364.
due to carcinoma, 370.
entero-vesical, 438, 443.
etiology, 356.
examination, 364.
excision, 391.

excision with immediate suture, 391.
external opening, 364.
fistulotomy, 383.
frecjueuoy of, 355.
from bone disease, 421.
from osteosarcoma, 422.
from stricture, 370.
from wounds, 356.
ha'morrhage, 409.
liorseshoc, 404.
importance of finding pathological internal

opening, 367.
incomplete, 353.
incontinence following, 412.
influence of tuberculosis, 359.
injection of colored fluids in diagnosis, 366.
instruments for operation, 387.
internal opening, 365.

in voluntary defecation after oj>erationfor,41 1.
ligature, 381.
line of incision, 389.
lymphatic tlirombosis, 857.
movement of the bowels after excision, 896.
uon-oi)erative treatment, 378.
non-specific, 855.
operative treatment, 384.
origin, 368.

Fistula, osmosis of gases, 357.

packing of, 390.

patliological nature, 371.

perineal, 424.

position for operation, 386.

premature healing, 420.

preparation of patient for operation, 884.

prognosis, 872.

prolapse following, 418.

protracted suppuration, 58.

recto-genital, 446.

recto-ureteral, 446.

recto-urethral, 425.

recto- urethral, author^s operation, 435.

recto-urethral, diagnosis, 428.

recto-urethral, etiology, 426.

recto-urethral, symptoms, 428.

recto-urethral, treatment, 430.

recto- uterine, 446.

recto- vaginal, 449.

recto- vesical, 438.

recto- vesical, diagnosis, 440.

rccto-vesical, etiology, 438.

recto- vesical, symptoms, 441.

recto-ve&ical, treatment, 444.

recto-vulvar, 447.

repair of, 858.

resulting from false passage in urethra, 870.

retention of urine, 410.

sepsis, 412.

sex, 358.

shock following operations, 411.

specific, 355.

spontaneous cure, 878.

subaponeurotic, 354.

subnnicous, 854.

submuco-cutancous, 854.

submuscular, 854.

subtegumentary, 354.

sutures and ligatures, 888, 398.

symptoms, 361.

syphilis, 861.

tract, 365.

treatment, 378.

tubercular, 371.

tubercular, operation, 878.

tubercular, pathology, 875.

tubercular, statistics, 360.

urethral, resembling ano-rectal, 869.

urinary, 424.

use of probe, 366.

watering-pot, 403.

with multiple internal openings, 404.
Fistulas, wljy they do not heal, 357.
Fistulotomy, 383.

FldnaHB formula for recto-colonic alimenta-
tion, 937.
Bazner, catarrhal diseases, 158, 159.

958

THE ANUS, RECTUM, AND PELVIC COLON

■I

■

J
I

Sigmoldopexy, 695.

MacCleod'a method, 697.

MathewsV case of, 697.
Sigmoidoscope, author's curved, 121.

author's pucuniatic, 124.

Kelly's, 121.

Laws's, 123.
Simnioiui, perianal abscesses, 320.

perirectal abscesses, 320.
Sinmui, wounds and injuries of the rectum, 917.

atmospheric ballooning of the rectum, 167.
Siinoii, manual exploration, 110.

recto-vaginal fistula, 454.
Singer, formula for recto-colonic alimentation,

937.
Sinus, sacro-coccygeal, 751.
Skene, entero-vesical fistula, 446.
SUifiuKnnki, multiple adenoma, 732.
Smith, haemorrhoids, 637.

hsemorrhoidal crusher, 647.

perirectal stricture, 468.
Smith, Henry, extirpation of rectum, 812.

prolapse of rectum, 687.
Smith, Stephen, excision of fistula, 391.
Sodth, Thomas, treatment of multiple adenoma.

736.

Snare, Ladinski's rectal, 715.
Sormanftni, perianal abscesses, 819.

perirectal abscesses, 319.
Sounds, 128.
SoDidille, hyperplastic tuberculo.«(is, 211.

stricture, 472.
Space, ischio-rectal, 6.

prevesical, of Retzius, 36.

retro-rectal, 36.

superior pelvi-rectal, 86.
Specula, 114-118.

AUinghani's, 118.

Andrews's tubular, 116.

Bodenhamer's tubular, 116.

BrinckerhotTs, 115.

Cook's tubular, 117.

Ferguson's tubular, 116.

Ilelmuth's, 116. ^

Kelly's, 117.

Kelsev's, 115.

Mathews's self-retaining, 116.

CNeiU's, 115.

Sims's vaginal, 116.

Van Buren's, 116.
Sphincteropa»sis, 887.
Spina bifida, anterior, 755.
Si>oniro-holder, 127.
Stafliird, j)r()ototomy for stricture, 502.
Starr, malformations, 47.
Stengel, inyxonia. 722.
Stierlin, hereditv in carcinoma, 763.
Still6, Alfred, catarrhal diseases, 163.

Stolti, adenoma of the rectum, 728.
Stone, foreign bodies, 907.
Stone in bladder, 541.
Stricture of rectum, 455.

after operation for haemorrhoids, 664.

annular, 455.

cauterization, 501.

cicatricial, 464.

classification, 455.

colostomy, 512.

congenital, 458.

danger of dilating, 500.

diagnosis, 486.

diagnosis by laparotomy, 491.

diarrhoea, 495.

diet, 494.

digital examination, 488.

diffuse inflammatory, 463.

discharge, 485.

divulsion, 500.

due to constipation, 481.

due to gunshot wounds, 481.

due to injections, 481.

due to pederasty, 481.

dysuria, 482.

electrolysis, 501.

etiology, 479.

examination, 487.

excision, 506.

following fissure, 317.

from prostatic disease, 467.

gradual dilatation. 496.

gummata, 475.

inflammatory, 463.

inflammatory stage, 482.

of large caliber, 456.

latent period, 481.

lateral entero-anastomosis, 510.

local treatment, 496.

location, 463.

malignant, 492.

medical treatment, 494.

method of development, 251.

neoplastic, 459.

non-malignant, 492.

obstruction in, 495.

obstructive period, 488.

odor of discharges, 487.

operative treatment^ 496.

pathology, 472, 478.

perineal excision, 507.

perirectal, 465.

phantom, 468.

proctoplasty, 503, 509.

proctotomy, 502.

raclage, 501.

rapid dilatation, 500.

recurrence, 505, 516.

INDEX

949

QosaeliiL, glandular papilloma, 738.

stricture, 470.

tliird sphincter, 20.
Oowen, physiology, 44.
GbyiBiid, malformations, 71.
Careen, tubercular ulcerations of rectum and

sigmoid, 209.
Qieffirath, fistula, 359.

tuberculosis of the rectum, 360.
Oienet, sarcoma, 805.
Qron, hasmorrhoids, 635.

malformations, 91.

recto-col onic alimentation, 930.
Omtiner, recto-colonic alimentation, 932.
Gumma, 244.

anal, 244.

distinguished from enlarged glands, 246.

in congenital syphilis, 254.

in recto-genital sseptum, 244.

in stricture, 475.

obstruction of rectum from, 246.

photomicrograph, 245.

rectal, 244.
QnyoiL, treatment of multiple adenoma, 735.

lIuErmorrhage, rectal, 336.

concealed, resembling abscess, 336.

following operations under cocaine, 410.

from foreign bodies in rectum, 904.

in fistula, 409.
Hemorrhoids, 582.

abscess after operation, 664.

accidental, 592.

accidents after injection, 628.

accidents and complications following opera-
tion, 650, 660.

after-treatment in clamp-and-cautery opera-
tion, 644.

age, 5S3.

Allinghum's operation, 633.

American operation, 658.

ana'sthetics, 631.

anatomical causes, 586.

arterial, 593.

bleeding, 592.

blind, 592.

capillary, 593, 610.

cauterization, 621.

clamp and cautery, 637.

columnar, 605.

compound, 592.

connective- tissue, 593, 603.

constipation, 587.

constitutional, 593.

crushing oj>eration, 645.

cutaneous, 593.

definition, 582.

diet, 588.

llffimorrhoids, dilatation of sphincter, 618.

drugs as cause of, 588.

dysuria following operation, 661.

Earless operation, 654.

electrolysis, 622.

etiology, 563.

excision, 648.

exciting causes, 587.

external, 594.

fistula atler operation, 664.

fieshy, 693.

from constitutional disease, 589.

habits, 584.

" haemorrhoids cteca,*' 592.

" hcemorrhoidcs fiucntes sue coruenta," 592.

heredity, 585.

in catarrhal diseases, 591.

inflammatory, 593.

internal, 592, 604.

interno-external, 592.

itching, 593.

ligature in, 631.

limited excision, 655.

Mathews's method of ligation, 632.

mixed, 592, 611.

naevoid, 610.

nomenclature, 592.

occult, 592.

open, 592.

operation for, in connection with fistula, 419.

operative treatment, 618.

pain following o(>eration, 661.

palliative treatment, 613.

period of confinement after operation, 662.

pile- pipe, 616.

predisposing causes, 583.

preparation of patient for operation, 630.

preventive treatment, 612.

recapitulation, 666.

recurrences after injection, 629.

secondary hcemorrhage after operation, 662.

sex, 5S4.

solution for injection, 627.

strain as a cause, 589.

strangulated, 658.

strangulated, operation, 659.

stricture after operation, 664.

submucous ligature, 636.

temperament, 585.

the emotions. 591.

thrombotic, 594.

treatment by injection, 622.

ulceration after operation, 665.

varicose, external, 697.

varicose, internal, 605.

venous, 593.

wliite, 593, 609.

Whitehead's operation, 648.

960

THE ANUS, RECTUM, AND PELVIC COLON

Ulcer, 2G3.

intolerablOf 291.

irritable, 291.

Jacob's, 263.

rodent, 268.
Ulcerationj*, 258.

eczeraatous, 261.

gonorrhoeal, 216.

herpetic, 261.

of anal canal, 264.

of anal canal, distinguished from fissure,
265.

of pelvic colon, 207, 266.

of rectum, 207.

of rectum, anatomical causes, 269.

of rectum, bacteria, 268.

of rectum, carcinomatous, 285.

of rectum, catarrhal, 275.

of rectum, crypts of Morgagni in, 271.

of rectum, diabetic, 287.

of rectum, dysenteric, 284.

of rectum, etiology, 267.

of rectum, exciting causes, 271.

of rectum, follicular, 280.

of rectum, from Bright's disease, 285.

of rectum, general symptoms, 271.

of rectum, hepatic, 288.

of rectum, hoBuiorrhoidal, 279.

of rectum, incontinence of fteces, 273.

of rectum, marasmic, 289.

of rectum, morning diarrhoea, 272.

of rectum, non-specific, 258.

of rectum, pain, 272.

of rectum, predispasing causes, 268.

of rectum, simple, 266.

of rectum, specific, 267.

of rectum, strictural, 282.

of rectum, syphilitic, 247.

of rectum, systemic, 266.

of rectum, tertiary, 247.

of rectum, traumatic, 273.

of rectum, treatment, 280.

of rectum, trophic, 288.

of rectum, tul>ercular, 207.

of rectum, varicose, 275.

of rectum, verrucous, 204.

perianal, 2r>8.
Ureter, 92.

communicating with rectum, 92.

transplantation into the rectum, 446.
Urethra, conmiunicating with rectum, 89.

diseases of, in relation to rectum, 541.
Urine, retention of, in rectum, 441.
Uterus, communication with rectum, 92.

Vairina, opcninjj into rectum, 92.

rretuui opcnintr into, 89.
Valentine, pn>longed constipation, 518.

Vtltot, stricture, 472.
Valves, Bauhinian, 536.

rectal, 24.*

rectal, function, 28.

rectal, Houston's, 24.

rectal, hypertrophied, 535.
Valvotomy, in constipation, 534.

the operation, 558.
Valvular colostomy, 192.
Van Boren, chancroids, 213, 223.

enchondroma of rectum, 717.

extirpation of rectum, 791.

haemorrhoids, 635.

operation for prolapse, 686.

spasmodic stricture, 460.

speculum, 116.
Van BoyM, dermoid cysts, 749.
Van Harlingon, ano-rectal syphiloma, 24S.
Van Hook, wounds of rectum, 917.
Vanolain, malformations, 84.
Vangfaaa, bacilli in perirec&l abecessea^ 320.
Vantrin, vaginal extirpation of rectum, 832.
Veins of rectum, 80.

external hsemorrhoidal, 33.

internal hemorrhoidal, 83.

middle hemorrhoidal, 33.
Veins of sigmoid, 42.
Velpean, third sphincter, 20.

extirpation of rectum, 814.

recto- vesical fistula, 438.
Vermiform appendix, 2.
Vemenil, extirpation of rectum, 810, 814.

gumma of anus, 244.

lisemorrhoids, 587.

malformations, 70.

operation for prolapse, 690.

theory of rectal veins, 82.
Verruca, 756.
Veilin, chancre, 229.
Vidal de GmiIi, chancre of rectum, 233.
^gne. fistula, 359.
Villaid, hydatids of rectum, 758.
Villous tumor, 738.
Vinoent, malformations, 74, 77.
Viola tricolor in eczema, 262.
Virchow, colitis, 179.

follicular ulceration, 282.

lipoma of rectum, 718.

multiple adenoma, 726.

papilloma, 738.
Voillemier, malformations, 59, 86.
Voit, recto-colonic alimentation, 931.
Von Haoker. colostomy, 887.

forci^rii iHxlies in the rectum, 897.
Von Heinecke, operation for extirpation of rco

turn, ^<22.
Von Jakaoh, parasites, 133.

jK-'ri rectal abscesses, 320.

INDEX

951

Jesiett, carcinoma, 761.
Johniton, intu.s»uM;option, 541.
JonneBOOf retro-rectal Bpaccs, 36.

Higmoid, 39.

superior pelvi-rectal spaces, 36.
Jordan, idiopathic gaugrenouB periproctitis, 350.
Jnllien, chancre, 228.

venereal diseases, 218.

XauBrnm, adenoma of rectum, 723.
Kammerer, colostomy for stricture, 513.
Kartnlis, catarrhal diseases, 159.
Xelly, Howard, abdominal extirpation of the
rectum, 838.

apparatus for knee-chest posture, 104, 114.

scoop, 126.

tubes, 117, 121.
Xelsey, catarrhal diseases, 142.

dysenteric stricture, 481.

dysenteric ulceration, 284.

idiopathic gangrenous periproctitis, 351.

inguinal colostomy, 862.

injection of htemorrhoids, 629.

lupoid ulceration of anus, 203.

proliferating proctitis, 249.

rectal hernia, 705.

speculum, 115.

subtegumentary abscess, 327.

treatment of incontinence, 418.

treatment of umltiple adenoma, 737.

tuberculosis, 200.
£eu8ter, gummata of rectum, 244.
Keyei, treatment of stricture, 498.
dmiflioii, stricture from prostatic disease, 467.
Xlebe-Loeflkr bacillus, 166.
Xlflin, catarrhal diseases, 166.
Xooh, initial tuberculosis of the rectum, 360.

l>erianal and perirectal abscess, 319.
Koenig. tubercular fistula, 356.
Xohliaxuoh, constipation, 535.

muscularis mucosa, 18.

plica transversalis recti, 25.

tensor fascioe pelvis, 13.
Xonig, extra-rectal dennoids, 751.
Kraske's operation, 821.
Krefting, venereal diseases, 220.
KnmleiiL, malformations, 79.

Htatistics on carcinoma, 761.
Xroiue, cicatricial stricture, 465.

proctoplasty, 510.
Sjnae, catarrhal diseases, 159.
Kiuimaiil, diabetic ulceration, 287.

Ladhowaki, excision of stricture, 508.
TiftdlnBki, case of prolapse, 679.

rectal snare, 715.
Lafleor, catarrhal diseases, 159.
Liinbotte, prolapse of rectum, 704.

Liinbotte, wounds of the rectum, 918.

Lamier, longitudinal muscular libers, 22, 28.

Landel, papilloma, 738.

Lane, phagedenic ulceration, 247.

Lange, operation for prolapse of rectum, 690.

Langley, nerve supply of anus and rectum, 33.

Lannelongne, malformations, 84.

perianal and perirectal abscesses, 321.
Laparotomy in diagnosis of cancer, 491.

in diagnosis of stricture, 491.

for foreign bodies, 912.
Laplaoe, forceps, 880.
Lapointe, excision of stricture, 509.
Laioyenne, foreign bodies, 907.
Lartigaa, hyperplastic tuberculosis, 211.
Lateral entcro-anastomosis, 883.
Lanenstein, operation for recto- vaginal fistula,

451.
LanarB, ent«ro- uterine fistula, 447.
Langier, rcctomcter, 491.
LawB, proctoscope, 125.
Layers of rectal walls, 39.
Le Bentn, recto-vaginal fistula, 452.
Ledzn, extirpation of rectum, 814.
Lee. haemorrhoids, 637.
Le Fort, electrolysis in stricture, 501.

suggestion in foreign bodies, 910.
Leiohtenfltem, carcinoma, 761.

foreign bodies in the rectum, 898.

rectal malformations, 61.
Lenbe, extension of carcinoma, 778.

recto-colonic alimentation, 930.
Levator ani muscle, 11.
Levy, operation, 822.
Lieberkttlm, follicles, 18, 45.
Llefiing, perianal and perirectal abscesses, 821.
Ligament, Poupart^s, 36.

sacro-ischiatic, 7.
Ligature, elastic, in fistula, 381.

in haemorrhoids, 631.
T.<Himt.lia1 multiple adenoma, 732, 736.
Lii)oma, perineal, 718.

rectal, 718.

treatment, 719.
Liifrano, excision of stricture, 506.

extirpation of rectum, 810, 814.
Little, lounge, 105.
Littre, inguinal colostomy, 866.
Lowaon, colostomy in stricture, 513.
Lndlow, rectal hernia, 705.
Lumbar center, 44.

colostomy, 864.
Lupoid ulcer, 200.
Lupus exedens, 200, 263.
LuBohka's gland, 2, 4, SO, 88.
Lymphadenoma, 721.
Lymphatics, 34.
Lymph-paths, 18.

INDEX

953

Hargagni, columns of, 22.

crypU of, 23.

imperforate ani, 48.

malformations, 66.

Hemilunur valves, 14, 18.
Morning diarrhoea, 272.
Morphine in shock, 412.
Moxrifl, recto-urethral fistula, 403.
Moaohet, hyperplastic tuberculosis, 211.
Jloxon, colitis, 179.

Mucous colitis. See Membranous Colitis.
Mucous membrane, 2.

appearance of, in gonorrhoea, 214.

susceptibility to gonorrhojul virus, 213.
Mucous patches, 235.
Mttller, catarrhal diseases, 151.
Multiple adenoma, 725.

age, 726.

color, 729.

conformation, 728.

consistence, 729.

diagnosis, 731.

distribution, 727.

iieredity, 727.

microscopic appearance, 732.

mucous membrane, 730.

pathology, 732.

sex, 726.

symptoms, 730.

transformation, 733.

treatment, 734.
Mand6, recto-vaginal fistula, 449.
Murphy, J. H., button, 880.

failure to recover, 842.

recto-vaginal extirpation of rectum, 833.
Murray, catarrhal diseases, IGO, 165.
MoBoatello, perirectal abscesses, 321.
Muscles of anus and rectum, 6.

accelerator urinse, 6.

circulatory fibers, 19.

external sphincter, 10.

internal sphincter, 19.

isfhio-coccygeus, 13.

levator ani, 11.

longitudinal fibers, 21.

recto-coccygeus, 13.

transversus perinrei, 6.

third spliincter, 20.
Muscularis muco.sa, 18.
Miuilier, recto-uterine fistula, 447.
Myoma of rectum, 720, 722.

Xffivus of rectum, 755.
HedhaoL, case of prolapse, 709.
Needle-holder, 887.
Heisser, venereal diseases, 213, 214.
Hdlaton, third sphincter, 20.
Neoplastic stricture, 459.
61

Nerve, sphincterian, 84.

centers of rectum, 44.
Nerves of anus and rectum, 84.

of sigmoid, 42.
Nervous rectum, 924.

ftecal concretions, 924.

inflammation of crypts, 924.

insensitiveness, 926.

rheumatism and gout, 926.

treatment, 927.
Henmann, chancre, 229.

electrolysis in stricture, 501.
Hewaholme, carcinoma, 760.
Hivet, chancre, 228.
Hordmaim, wounds of rectum, 916.
Narton, extirpation of rectum, 832.
Hothnagel, hyperplasia of colon, 536.
Nutrient enemata. See Kecto-colonic Alimcn<
tation, 930.

(VBeinie, defecation, 45.

rectal valves, 25.

third sphincter, 20.
Ohr«, hydatids, 758.
Obscure diseases of the rectum, 922.

Curling on, 022.
Obstipation, 517.

definition, 525.

malformations, 533.
Obturator, MartinV, 12.
Occlusion of anus, 85.
(VHara, intestinal clamp, 8S1.

metliod of entero-anastomosis, 883.
Ohmaxm-DnmeBidl, cliancre of rectum, 233.
Ombredanne, (K'lvi-rectal spaces of rectum, 36.

retro-rectal spaces of rectum, 36.
Omega loop, 39.
Omerod, colitis, 182.
O'Neill, speculum, 115.
( ).steosarcoma, 422.

fistula from, 422.
Otia, rectal veins, 25, 30.
Otis, F. N., venereal diseases, 213.

Pago, extra-rectal dermoids, 752.

Fa^ cutaneous growths about the anus, 239.

Failhes, abnormal narrowing of anus, 21.

Fanaa, stricture, 472.

Papillae, anal, 9.

hypertrophied anal, 758.

hypertrophied anal, symptoms, 759.

liypertrophicd anal, treatment, 759.
Papilloma, 738.

complications, 739.

constipation, 742.

constitutional symptoms, 743.

development, 741.

diagnosis, 744.

r'l

THE DISEASES OF THE

STOMACH.

By Dr. C. A. EWALD,

EXTRAORDINARY PROFESSOR OF ICEDICIKE AT THE UXIVERSITT OF BERLIN.

Second American Edition, translated and edited, with numerous Additions^

from the Third German Edition,

By MORRIS MANGES, A. M., M. D.,

ASSISTANT VISITING PHYSICIAN TO MOUNT SINAI HOSPITAL; LECTURER ON
GENERAL MEDICINE, NEW YORK POLYCLINIC, ETC.

This work has been thoroughly revised, rearranged, largely rewritten, and
brought up to date from the most recent literature on the subject.

8vo, 602 pages. Sold by subscription. Cloth, $5.00 ; sheep, $6.00.

"In giving the medical profession this second revised translation of Prof.
Ewald's treatise on the Diseases of the Stomach, Dr. Manges has placed the profes-
sion under even greater obligations than we owed for the first. The first transla-
tion was then an almost exhaustive treatise, and now, with so much new and
valuable data added, the work is a sine qua non" — Atlanta Medical and SurgictU

(i Journal,

.1 "This work as it now stands is the best on the subject of stomach diseases in

the English language. No physician's library is complete without it. It is in
every way well adapted to the requirements of the general practitioner, although
complete enough to meet also the requirements of the specialist." — American
3Iedic0' Surgical Bulletin.

"The present American edition is a peculiarly valuable one, as the editor.
Dr. Manges, has done his work in a thoroughly creditable manner. His numer-
ous notes, additions, and new illustrations have made the book a classic one.
Under these circumstances it should find a place in the library of every Amer-
ican physician, as their clientele is composed of such a large proportion of patients
suffering from gastric complaints and more or less improper medication which
most often ends in failure. There is no doubt that more properly directed efforts
in the proper direction, as outlhied in Ewald's book, would soon remove from
Americans the reputation of being a nation of dyspeptics.** — St, Louis Medical
and Surgical Journal.

" Dr. Ewald*s book has met with a very cordial reception by the medical pro-
fession. Within a short period three editions have appeared, and translations
published in England, Spain, France, Italy, and the United States. To the
present edition the author has not only added considerable new matter, but he
has also entirely rewritten the work. The arrangement of the chapters has been

j somewhat changed, and many new personal observations and therapeutic experi-

"1 ences added. The desirability of surgical interference is carefully considered, and

the pros and cofis given so far as would be necessary to enable a physician to
determine whether the aid of the surgeon might be required. The translator has
done his work well, and has incorporated much new matter into the text and
footnotes." — North American Journal of Homoeopathy.

D, APPLETON AND COMPANY, NEW YORK.

\ •

\ .

INDEX

955

Procidentia intestini recti, 6C7, 672.
Proctodfieum, 3.
Proctitis, 139-166.

acute catarrhal, 141.

cautjies of, 139.

chronic, 146.

diphtheritic, 166.

dysenteric, 168.

gonorrhceal, 213.

proliferating;, 249.
Proctoplasty for stricture, 509.

versus colotomy, 82-84.
Proctoscopes, 122, 125.

Laws\ 122.

pneumatic, 123, 490.

Tuttle's pneumatic, 123.
Proctotomy, 502.

complete, 503.

internal, 502.

partial, 502.
Prolapse of rectum, 667.

age, 703.

Allingham on, 686.

amputation, 698.

colopexy, 696.

complete, 672.

complete, degrees of, 678.

complete, etiology, 678.

complete, pathology, 679.

complete, symptoms, 675-677.

complete, treatment, 680.

complications, 701.

Delorme's operation, 688.

Dieffenbach-Roberts*8 operation, 689.

Duret's ojHjration, 688.

excision, 703.

haemorrhages, 702.

hernia, 705.

incomplete, 667.

incomplete, etiology, 668.

incomplete, symptoms, 669.

incomplete, treatment, 670.

inflammation, 702.

Lange's operation, 690.

partial, 667.

Peters's operation, 690.

rectoj>exy, 691.

reduction, 683.

rupture of hernial sac, 708.

sitrmoidopexy, 695.

sloughing in, 683.

strangulation, 702.

strangury, 683.

treatment, 670, 685.

Van Buren's operation, 686.

Vemeuil's operation, 690.
Prolapsus recti, 667.
Pruritus aui, 568.

Pruritus ani, characteristics, 570.

constitutional causes, 574.

eczema, 572.

csscntialis, 568.

etiology, 571.

external causes, 571.

gout, 574.

herpes, 572.

idiosyncrasies, 573.

local causes, 572.

parasites, 571.

pressure, 580.

reflex causes, 575.

rheumatism, 574.

symptoms, 570.

treatment, 575.

treatment, constitutional, 577.

treatment, local, 577.

treatment, o}K»rative, 580.

urictcmia, 574.

venereal diseases, 573.
Pnlitier, chronic constipation, 547.
Pye-Smyth, colitis, 180.

Qnain, villous tumors, 738.
Qntou and Hartnuum, abdomino^pcrincal extir-
pation of the rectum, 848.

adenoma, 723.

anatomy, 15.

ano-rectnl sypliiloma, 249.

catarrhal diseases, 149, 158.

chancre, 228.

constipation, 535.

etiological factors in perirectal abscesses, 824.

excision of stricture, 506, 509.

extension of carcinoma, 778.

fissure, 294.

horseshoe fistula, 407.

lupoid ulceration of anus, 203.

lymphadenoma of rectum, 721.

lymphatics, 34.

papilloma, 738.

perineal extirj>ation of rectum, 817.

repair of abscess, 358.

treatment of stricture, 499.

tuberculosis, 198.

veins of the rectum, 81.

verrucous ulcerations of anus, 206.

Babe, carcinoma, 778.

Baljen, formula for recto-colonic alimcntatioD,

937.
Ray fungus, 757.
BMamier, fissure, 306.
Kectitis proliferante, 478.

»yphilitique^ 249.
Rectometer, 491.
Rectophobia, 610.

INDEX

957

Binoli, malfonnations, 91.
Boberto, lipoma of rectum, 713.
BobinBOii, dermoid cysUf 750.

rodeut ulcer, 264.
Kodcnt ulcers, 263.
Boeoke, sarcoma, 800.
Roentgen rays, 198.
Rokitansky, villous cancer, 738.
EoUeston, tubercular stricture, 480.
Bollet, phagedenic chancroid, 213, 224.
Bow, extirpation of rectum, 822.

recto- vaginal fistula, 454.
BoMnheinu enteroptosis, 536.
Boeer, catarrhal diseases, 142.

intersigmoid fossa, 41.
Botter, multi])le adenoma, 732.
Bontier, extirpation of rectum, 814.

verrucous ulceration of anus, 205.
BoDZ, hydatids, 758.

malformations, 70.
Bydygier, incontinence after extirpation of rec-
tum, 850.

Sabine, manual exploration. 111.

Soliotto, chancre, 228.

Bandfl, ha^morrlioids, 635.

Sands, II. B., manual exploration, 111.

Sappey, anatomy, 15, 20.

Sarcoma, 800.

age, 805.

alveolar, 802.

blood-vessels, 803.

capsule, 803.

color, 801.

consistence, 801.

course of, 801.

diagnosis, 807.

etiology, 804.

extension, 803.

form, 800.

general symptoms, 807.

histology, 802.

melanosis, 804.

metastasis, 802.

mixed, 802.

number, 800.

odor, 806.

pain, 807.

polypoid, 802.

prognosis, 808.

protrusion, 806.

round-cell, 802.

sacro-coccygeal, 764.

sex, 805.

site, 801.

Bpindle-cell, 802.

state of bowels, 807.

symptoms, 805.

Sarcoma, treatment, 808.

types, 802.

wide distribution, 807.
Schilffer, embryology, 2, 18.
Sohanta, recto- vaginal fistula, 452.
Sohede, colostomy, 812, 860.
Sohelky, extirpation of rectum, 814.
Sohonok, malformations, 58.
Sohiflbxdeoker, the sigmoid, 39.
Sohleiinger, formula for recto-colonic alimenta-
tion, 937.
Schmey, prolapse of rectum, 679.
Sohoening, extension of carcinoma, 778.
Sohnohardt, lupoid ulceration of anus, 202.
Sohnh, metastasis in carcinoma, 779.
Scirrhus, atrophic, 771.
Scissors, rectal specimen, 781.
Scoop, rectal, 126.

Kelly^s, 119, 127.

Tuttle's, 126.
S^dillot, malformations, 47.
Benn, bone-plates, 880.

extirpation of rectum, 822.

myoma of rectum, 720.
Sepsis from fistula, 412.

in extirpation of rectum, 788.
Berrenume, congenital narrowing of anus, 52.
Shnfind's solution, 627.
Shnldham, venereal diseases, 217.
Sick, chancre, 228.

venereal diseases, 219.
Sigmoid fiexure, 1.

absorptive action of, 45.

acute flexures, 537.

anatomy, 39.

blooil supply, 42.

catarrhal diseases, 189-166.

course, 14.

development, 1.

direction, 39.

divisions, 39.

extent, 1.

functions, 45.

mesentery, 40. ^

mucous layer, 39.

muscular layer, 40.

nerves, 42.

physiology, 43.

relations, 42.

serous layer, 40.

submucous layer, 39.

tuberculosis, 206.

ulcerations, 266.

walls, 39.
Sigmoiditis, 139, 166.

causes, 139.

chronic, 146.

dysenteric, 158.

•T96 Treatise on diseases ■■
1908 of the anus, rectum 4H

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