Chapter LVI: Front Matter (56)

Sufferers from pruritus ani are generally dyspeptics, although the malady is observed in persons who are otherwise in most robust health. Overwork, mental and physical exhaustion, have been charged with producing pruritus, and in some instances spinal irritation seems to have been unquestionably the exciting cause: now and again, pruritus ani has been produced by the pregnant condition, and in some cases this malady has persisted during the entire period of utero-gestation. Intestinal worms, uterine maladies, rheumatism, and especially gout, have unquestionably been exciting causes. Some years since a gentleman having the most intense pruritus, which defied all treatment, was suddenly relieved of all former distressing symptoms by the passage of a small vesical calculus, the presence of which had never been suspected, as no vesical symptoms had at any time existed. Some of the most aggravated instances of anal pruritus are found in those far advanced in diabetes mellitus. The nerves of the lumbar plexus in rare instances have suffered from compression, more or less severe, from fecal accumulations; in one case of spinal curvature detailed by Portal[31] the rectum at its upper part was so narrowed by the encroachment of the false ribs that excessive fecal accumulation occurred which gave rise to remote pain in the great toe.

[Footnote 31: _Cours d'Anatomie médicale_, tome iv. p. 276.]

Neuralgia of the Rectum.

It seems to be unquestionable that there are instances of pure neuralgia of the rectum, for in such cases the most carefully conducted explorations have failed in demonstrating any evidences of disease. The pain is doubtless reflex, due to depressing causes, to atmospheric conditions, or to exposure to cold and wet. Neuralgia of the rectum has also been noticed in malarial {910} poisoning, and especially in those who have long been victims of intermittent fever. Neuralgia in this region of the body is also due to general causes, as witnessed in cases of rheumatism and of the gouty diathesis. Patients now and again complain of "violent and painful pressure in the rectum, conjoined with active pains in the perineum and anus and in the sexual parts: these symptoms probably have a neuralgic character."[32] In many nervous disorders, but especially in spinal irritations or inflammation, the rectum is invaded by pains of a neuralgic nature more or less severe, which are undoubtedly only functional in character. But 12 cases of neuralgia were observed out of 4000 cases of rectal disease. Anstie[33] says: "It needs some very powerful irritant to set up neuralgia in any portion of the alimentary canal: ... this condition has been described by Ashton.... In one case the patient complained of acute, paroxysmal, cutting pain extending about an inch within the rectum.... The cause of this attack was his getting chilled from sitting in his wet clothes." Curling says that constantly directing the mind to this part of the body will excite congestion and disease, possibly by producing abnormal sensations, itching, and superficial inflammation.

[Footnote 32: Erb, _Ziemssen's Cyclop._, vol. xiii. p. 139.]

[Footnote 33: _Neuralgia and its Counterfeits_, p. 130.]

"In patients with piles hyperæmia of the spinal cord may become habitual, returning regularly and frequently, and this may lead by degrees to severer disturbance by the development of chronic inflammation and proliferation."[34] Among some of the reflex troubles arising from rectal disease are--sterility in women, simulation of uterine disease, pruritus ani, pseudo-sciatica, pains in the legs and feet, and impairment of co-ordination in the muscles of defecation. There is a case reported[35] of a curious pain in the sole of a foot caused by rectal disease; and another[36] in which irritation of the eyes was caused by hemorrhoids.

[Footnote 34: _Ziemssen's Cyclop._, vol. xiii. p. 138.]

[Footnote 35: _Med. Times and Gazette_, 1868, vol. ii. p. 175.]

[Footnote 36: Cooper, _Lancet_, 1862, i. p. 625.]

There are some cases occasionally met with of so-called irritable rectum. Now, a rectum may be irritable because irritated, but in some of these instances there is no apparent cause. There occur frequent, small stools expelled with force, but without pain: there must be abnormal peristaltic action to cause this condition.

The Effects of Cholera and of Certain Poisons and Remedies upon the Rectum.

After death from cholera there is found congestion and a swollen state of the mucous membrane of the rectum: in some cases the epithelium of the entire alimentary canal is almost absent. In slow poisoning by arsenic the bowels show ulceration, but more particularly the rectum. After phosphorus-poisoning the large intestine has been found inflamed and contracted to the calibre of a quill. Among the effects of copper have been seen ulceration and a peculiar green staining of the rectum; of lead, no marked change of the mucous membrane except, in some instances, hardening, but the muscularis was in an advanced state of hardening and contraction. The action of croton oil is to render the mucosa very soft and friable. Extensive destruction of the mucous membrane of the rectum has resulted {911} from poisoning by bichromate of potassium. The mineral acids and the caustic alkalies, when not immediately fatal, cause corrosive ulceration of the rectum; the soluble salts of zinc, tin, bismuth, and antimony produce a like effect. Corrosive sublimate in its action upon the large intestine produces a dysenteric condition; similar in their effects are colocynth, jalap, elaterium, and cantharides. Strychnia causes a deep violet congestion; alcohol, congestion and thickening; and tobacco, redness of the mucous membrane with great engorgement of the vessels of the rectum. One of the results of the long-continued abuse of morphia is a catarrhal condition of the large intestine, accompanied with exfoliation of the intestinal epithelium. Some persons are very susceptible to the action of jaborandi, and in such its exhibition is followed by hyperæsthesia and dull pain in the rectum and the urethra.

It is interesting to note that an abnormal condition in the rectum may cause extensive disease in a remote organ; thus, a stricture of the rectum may cause abscess in the liver. Wilkes[37] exhibited at the Pathological Society a specimen in which an abscess, a diffuse, purulent infiltration of the liver, and a gall-bladder filled with purulent bile were distinctly traceable to the suppuration arising from an ulcerating stricture of the rectum consisting of dense fibrous tissue situated about four inches from the anus of a man aged thirty-seven years. "Any form of suppurative intestinal disease seems capable of producing hepatic abscesses of a metastatic or pyæmic character."[38] It has not been found, however, that tubercular ulceration of the intestines has ever given rise to hepatic abscess.

[Footnote 37: _Soc. Trans._, vol. ii.]

[Footnote 38: Darley, _On the Liver_, 1883, p. 536.]

Examinations and explorations of the abdominal viscera by the hand introduced into the rectum, having for their object the detection of tumors or morbid growths, are procedures which have fallen into merited disrepute, and are mentioned here in condemnation. However, some years since, Morton, in consultation with (J. Forsythe) Meigs, satisfactorily demonstrated the absence of a suspected renal calculus by this method.

The distension of the rectum with water, either free or contained in a rubber bag, in order to facilitate operations upon the pelvic viscera, has been lately brought into notice by Garson at a meeting of the British Medical Association. The most significant point brought out at the meeting was that the water-distended rectum displaced the distended urinary bladder upward and forward until it occupied a position quite outside of the pelvic cavity, carrying along with it the peritoneum both in front and behind. By this method of distension it was found possible so to raise the peritoneum in front of the bladder as to leave a clear working space of four centimeters between the upper border of the symphysis pubis and the edge of the peritoneum: this may prove useful in suprapubic lithotomy, as well as in operations upon the uterus and its appendages during laparotomy.

RÉSUMÉ OF THE THERAPEUTICAL AND SURGICAL TREATMENT.

FISSURE OF THE ANUS, in its true sense, is not to be confounded with ulcerations either slight and superficial in extent, or with more grave ulcerations involving not only the anus, but the mucous membrane of the {912} rectum also. The true fissure is a mere linear crack or abrasion or superficial ulceration. The pain accompanying this condition is out of proportion to the length and depth of the fissure, varying from slight uneasiness to as severe suffering as that caused by a deep and extensive ulceration.

The treatment to be adopted in such cases is first to regulate the bowels and to insist upon a scrupulous cleansing of the part after each evacuation. Much sitting is to be avoided and a sedentary mode of life is to be discouraged. Sometimes a few light topical applications of the solid nitrate of silver will bring about a cure, or a lotion of the same of the strength of from two to ten grains to the ounce of water should be applied with a camel's-hair brush every other morning. The ointment of the oxide of zinc, combined with any of the local anæsthetics, will be found useful. As a dernier ressort in obstinate cases an incision should be made through the fissure, together with a thorough dilatation of the anal sphincter.

ULCER OF THE RECTUM, OR THE GRAVER FORM OF FISSURE OF THE ANUS.--In the milder forms of this very common and painful affection the treatment consists in thorough cleanliness of the part; the ulcerated surface may be cauterized with nitrate of silver, and subsequently the application of the red precipitate ointment or the lotio nigra. Should a vaginal discharge exist, treatment should be instituted with a view to its arrest, as the irritating fluid coming in contact with the ulcer would prevent its healing. The treatment of that variety of ulceration where the disease is situated partly without the anus and partly within the rectum, besides the use of the means enumerated above, embraces the daily introduction of a full-sized bougie made of wax or of yellow soap. Henry Hartshorne says: "Experience leads me to have especial confidence in collodion, to which one-fiftieth of glycerin has been added to lessen its constricting effect." Glycerite of tannin and tinct. benzoin. comp. have been useful. J. C. Peters[39] recommends the use of iodoform suppositories. Tarnier[40] dusts the part with the same drug in fine powder. Créquy[41] has had success with a dressing of charpie saturated in a solution of hydrate of chloral. For the more extensive and obstinate forms of ulceration the three methods of treatment mainly relied on are--by cauterization, by dilatation, and by incision. The caustics usually relied upon are the fuming nitric acid and the acid nitrate of mercury, one application of either of these often exciting healthy granulation. This application is to be followed by the use of an ointment consisting of thirty grains of calomel and three grains of morphia to one ounce of lard. If there is much spasm of the sphincters, extract of belladonna may be added.[42] During this treatment the bowels should be kept rather loose by the use of compound licorice powder, and if much pain is experienced an opium suppository should be used. Dilatation, first practised by Récamier, consists of the introduction of the thumbs of the operator into the rectum, placing them back to back, and then forcibly separating them from each other until the sides of the bowel can be stretched out as far as the tuberosities of the ischia. On account of the fact that both cauterization and dilatation are not infrequently followed by relapse, the method of operation which includes both incision and dilatation can usually be relied {913} upon. The bowels should be thoroughly emptied by a laxative, and an enema should be given three hours before the operation.

[Footnote 39: _Philada. Med. Times_, Nov. 8, 1879.]

[Footnote 40: _Bull. gén. de Thérap._, Sept. 30, 1875.]

[Footnote 41: Ashton, _On the Rectum_, p. 157.]

[Footnote 42: Agnew's _Surgery_, vol. i. p. 418.]

After full anæsthesia the ulcer may be readily exposed. The left index finger of the operator is then carried into the rectum, and a sharp-pointed curved bistoury is entered, three-quarters of an inch or more from the side of the anus, to the depth of an inch or less, and carried on toward the bowel until the point is felt by the finger within, when it is made to puncture the mucous membrane, and then to cut out to the surface. In some cases of deep fissure, before dividing the sphincter the ulcer may be scraped freely or the entire ulcer may be removed. The anus should now be well dilated with the fingers, after which an opium suppository should be introduced and a fragment of lint or linen well oiled be placed in the wound. The subsequent treatment consists in keeping the patient in a recumbent position and confining the bowels with opium. After three or four days a laxative may be given. No dressing is necessary save attention to cleanliness.

The subcutaneous division of the sphincter has been proposed, but is objected to on account of the liability of the extravasated blood retained in the very loose cellular tissue of the part to form abscess. In one case which Morton operated upon in this manner many years ago a large abscess formed very rapidly, with serious constitutional symptoms, which were relieved only after the freest opening and division of the sphincter.

Should any polypi be found, their removal by ligation or by the knife is an essential element of success in the operation; retention of urine is not infrequent after operations upon fissure. When fissure or ulceration makes its appearance in a syphilitic subject, it will usually disappear under appropriate constitutional treatment.

TUBERCULOUS ULCER OF THE ANUS is best treated by the topical use of a weak solution of chloral hydrate.

CHRONIC ULCER OF THE RECTUM.--In this condition the treatment should include the use of anodyne and astringent lotions, suppositories or enemata, and the internal administration of Ward's paste--_i.e._ confection of black pepper.

RODENT ULCER OF RECTUM.--In this rather rare, exceeding painful, and generally incurable malady the patient sometimes dies merely from the exhaustion of pain. Another mode of death is by diarrhoea; another by hemorrhage. To quote Allingham:[43] "I have really nothing to offer as regards treatment; all the various sedatives will be required in their turn, and in the earlier stage I should recommend excision--not that I have much hope that you will eradicate the malady, but you will remove the pain, and for some time the sufferer will be comparatively comfortable. I think also the application of fuming nitric acid should be tried with the same object; one of my patients was fairly easy for three months after I had destroyed the ulcer with the acid." Morton accomplished the permanent healing of an undoubted rodent ulcer of the rectum by the complete divulsion of all the involved tissues.

[Footnote 43: Page 30.]

CANCER OF THE RECTUM.--The medical treatment of this affection is necessarily restricted to efforts to alleviate suffering and to obtain sleep--anodynes in the form of suppositories of pil. saponis comp. or of morphine mixed with ext. hyoscyamus in the proportion of a half grain of the {914} salt to ten grains of the extract. Enemata of warm water are useful. D'Arpene of Elba has suggested enemata of gastric juice. The profuse discharge of sanious pus must be met by weak injection of sulphate of copper and opium or a very dilute solution of chloride of zinc. Now, as to the use of bougies in these cases, it may be laid down as a general rule that their employment may be mischievous, yet in certain cases justifiable--indeed, absolutely necessary. When the disease is met with in its early stage, has not ulcerated, is within reach of the finger, and is producing much contraction of the calibre of the gut, a gum-elastic bougie, thoroughly lubricated, may be introduced through the contraction. In case this produces much suffering, the attempt must be abandoned; if not, once or twice a week is often enough. Where no extensive ulceration exists the patient can be much helped by this procedure. F. N. Otis[44] has reported a case of malignant stricture in which he completely divided the recto-vaginal septum, sphincter ani, and perineum with great temporary relief to his patient. When large portions of a malignant mass protrude from the anus, they may be removed by the application of a paste of arsenite of copper or by the elastic ligature, the destruction being safe and rapid. The injection of acetic acid into these growths has been practised, but is useless and harmful.

[Footnote 44: _Arch. Clin. Surg._, 1877.]

As to operative procedure, when the morbid growth is an epithelioma situated within a short distance of the anal opening an excision is not only justifiable, but may be recommended. The results show that its removal from this situation is as frequently successful as is its removal from the lip. When a cancer completely fills the lumen of the gut and plugs it so that the act of defecation becomes impossible, excision of the rectum and the establishment of an artificial anus are the two operative procedures open to the choice of the surgeon. A decided reaction of opinion has lately taken place among members of the profession relative to the latter of these; the few surgeons who did practise excision of the rectum in cases of cancer were looked upon as being rather unscientific and unsurgical. Billroth has excised the rectum 16 times, with 4 fatal cases; Dieffenbach performed it 30 times; Lisfranc had recourse to this operation as early as 1826; while the operation has been performed very frequently in this country, and with success.

Morton says: "In the spring of 1882, I was consulted in the case of a lady aged fifty-six who had suffered for two years from what were supposed to be internal hemorrhoids. An examination revealed the existence of a large scirrhous mass encircling about two-thirds of the gut, on the anterior part especially, and extending upward three inches. The patient was worn down by long suffering, but was otherwise in fair condition of health. With the assistance of Gross and Agnew, I excised the mass, which included the entire lower part of the rectum. The wound healed kindly, without an untoward symptom, and the patient was very soon enabled to leave her home for the seaside, where she passed the summer. The disease, however, resumed, but without any of the severe pains which she had had prior to the operation. Death occurred from gradual exhaustion seven months afterward."

He also relates the following case of excision of the rectum: The patient, a female aged thirty-five years, first noticed some rectal {915} irritation about four years ago. This was followed by distressing pain during defecation and by hemorrhages; finally a tumor, which was described by her medical attendant as being like an opened umbrella, protruded, partly at first, then fully, through the anus. The growth seemed to be spongy in character, and was very vascular. It was removed by carrying a double-threaded needle through the mass, and thus ligating it. Upon the seventh day after the operation a hemorrhage occurred, which was controlled by plugging the rectum. Although the growth was removed, the patient did not make a good recovery; symptoms of rectal irritation continued. In September, 1884, the patient presented herself in a wretched condition, with bearing-down pains and frequent hemorrhages. Upon digital examination an elevated mass was readily detected upon the sacral aspect of the bowel. By carrying the fingers beyond this mass and making traction, it was brought down within working distance, and was excised along with the entire lower portion of the rectum. The freshly-cut edges of the gut were then drawn down and stitched to the mucous membrane just above the anus. The patient made a good recovery and has a serviceable anus.

R. J. Levis[45] has operated upon two cases of cancerous growth in the rectum, removing the lower part of the bowel. The first case was that of a man aged sixty, who made a very good recovery from the successful operation, although three inches of the gut were removed. The second case was that of a man aged fifty-two, who had a carcinomatous tumor the size of a hen's egg at the right side of the rectum. The section of gut excised was about one and a half inches in length. The patient died of peritonitis upon the fourth day after operation. At the autopsy there was no wound found in the peritoneum, the lowest point of which was one inch above the end of the excised bowel.

[Footnote 45: _Surgery in the Pennsylvania Hospital_, pp. 81-83.]

The etherized patient, his bladder having been emptied, should be placed in the lithotomy position. If a male, a sound should be passed into the bladder. An incision is then carried from the centre of the perineum along the raphé to the anterior margin of the anus, encircling the latter by two semicircular cuts and continuing the division directly back to the coccyx. In the female the incision should begin just posterior to the vagina. If the anus is not included in the diseased mass, the external sphincter may be spared by raising the skin and the muscle together and turning them on each side. When the lower end of the rectum is reached the dissection should be made entirely by the fingers or by the handle of the knife, tying vessels as they spring. Double ligatures should be introduced through the gut from its mucous surface outward, and, when possible, then stitched to the skin at the margins of the wound. The bowels should be controlled by opium for the following eight or ten days.

The other operative procedure is lumbar colotomy. This was first advocated by Amussat in 1839, when he appeared in a treatise upon the subject entitled _On the Possibility of Establishing an Artificial Anus in the Lumbar Region_. It is denied that he ever performed this operation. It has happened to sound surgeons and skilful operators, when the patient has been very muscular or very fat or when the colon has been collapsed, that they have been at length compelled to abandon the search for the gut {916} and to stitch up the external wound. Allingham states that the cause of failure often is that the colon is searched for too far from the spine, resulting, in the opening of the peritoneum, in the starting up into the wound of a mass of small intestine which baffles the operator very seriously. He, having made more than fifty dissections, has come to this conclusion: "that the descending colon is always normally situated half an inch posterior to the centre of the crest of the ileum (the centre being the point midway between the anterior, superior, and posterior-superior spinous processes)." An incision four inches in length should be made midway between the last rib and the crest of the ileum. The incision may be made transverse, or, better, obliquely downward and forward, as suggested by Bryant. Allingham says that care should be taken to preserve the original length of the incision down through all structures, lest when the operator approaches the gut he finds himself working in the apex of a triangle the base of which is the line of the wound. If the surgeon has reason to expect the gut to be collapsed, an attempt should be made to distend it with some fluid. The intestine should be drawn well out through the wound, and a longitudinal opening an inch in length made in it. The edges of this are to be stitched to the edges of the skin. Fecal matter is much less likely to flow into the wound if the sutures are passed through the intestine previous to opening it. A weak carbolated wash is all that is required as a dressing. In one case of stricture of the rectum from a scirrhous mass, in which Morton performed colotomy, an immense cyst of the kidney, which was somewhat puzzling for a moment, protruded in the wound. After emptying the cyst the gut was readily discovered and opened.

DILATATION AND INFLAMMATION OF THE RECTAL POUCHES.--This is a comparatively rare condition of the rectum, called by Physick encysted rectum, which is treated by bending the end of a probe into a hook, passing it up into the bowel, and then withdrawing it with its extremity resting against the surface, so as to engage and draw down the pouches, the straining or bearing down of the patient assisting in their extrusion; they may then be incised or cut off with a pair of curved scissors.

LOSS OF CO-ORDINATION IN THE MUSCLES OF DEFECATION.--In those cases where it can be ascertained that this curious trouble is not symptomatic, sympathetic, nor reflex, the treatment must be directed to the building up of the general health, such as electricity, baths, asafoetida, and iron. Regular outdoor exercise should be enforced.

SPHINCTERISMUS.--This condition, though frequently attendant upon, may exist in the absence of, any fissure, crack, or ulcer of the anus. It is usually associated with constipation. In its treatment magnesia and rhubarb are to be used, and the diet must be simple, unstimulating, and taken at regular intervals. A hot hip-bath at night, with the use of a belladonna suppository, often proves effective. In more obstinate cases a bougie covered with ointment of belladonna should be used daily. In still more intractable cases the muscle must be forcibly stretched with the fingers. In the more obstinate cases which now and then occur it becomes necessary to completely divide the fibres of the sphincter muscle, followed by a thorough stretching of the parts.

{917} PRURITUS ANI.--This distressing and vexatious complaint proceeds frequently from hemorrhoids. When caused by the presence of seat-worms, they must be dislodged by purgatives and enemata of quassia or of one composed of one part of carbolic acid to six parts of sweet oil, or of turpentine and flaxseed tea. An enema of milk of asafoetida answers a good purpose. If the pruritus is a result of the burrowing of the itch insect, any wash, ointment, or dressing that evolves sulphuretted hydrogen will rapidly bring relief. If caused by other parasites, an application of ung. hydrarg. or red precipitate ointment, followed by a warm bath, will be all that is necessary. In some it is a symptom of dyspepsia, in others of a disordered state of the nerves of the anus independent of local cause: in this case iron, quinia, and arsenic should be given, and the patient should live an outdoor life as much as possible. The remedies that have in turn been extolled and abandoned during the treatment of this distressing condition it would require too much space to even mention. The following are among the best: Sulphate of zinc and alum, equal parts, are to be placed in an earthen vessel and heated until a glassy mass is left, which is to be dissolved in a little water and thrown into the bowel; palm soap pressed into the anus, ointments of carbolic acid and morphia or of bromide of potassium and cosmoline, citrine and other mercurial ointments, and suppositories containing iodoform. Allingham uses a bone or a metallic plug of peculiar construction, so as to keep the anus upon the stretch at night without slipping into the bowel. The pressure which this exerts upon the nerves and vessels prevents the itching. Hot (not warm) water pressed against the anus with a sponge, or ten-drop doses internally of tincture of gelsemium, or washes of dilute hydrocyanic acid or of chloroform, or ointments of balsam of Peru or of veratria and aconitia, or the corrosive chloride of mercury in solution applied locally, are a few of the more reliable among this host.

STRICTURE OF THE RECTUM (NON-MALIGNANT).--The main modes of treatment of non-malignant stricture of the rectum are two--by dilatation or by linear incision (rectotomy). Dilatation may be practised by the finger alone or by the finger covered with hollow rubber covers of various sizes. These are open at the end, so that the guiding and recognizing sense of touch may be left to the end of the finger. When the stricture is out of reach of this method, either gum or metallic bougies must be used, beginning with the smaller sizes and deliberately and carefully adding sizes. When the lumen of a stricture is tortuous it is best to use a long rather flexible rubber bougie having an olive-shaped extremity. It is not necessary to leave these bougies standing for hours in a stricture, according to the practice of some; this merely excites inflammation. Should the stricture be irritable, every second or third day would be sufficiently often to attempt dilatation. In constrictions which are firm, but not sensitive, a good plan is to insert a Molesworth elastic tube and gradually distend it by hydrostatic pressure; Barnes's dilators have also been successfully used. When the stricture is elastic and re-forms itself at once after dilatation, incision should be practised. In those strictures which are low down, the constriction may be nicked in several places by a hernia knife, the blade of which is guided along a finger in the bowel; when high up, a long double-bladed knife must be employed. In syphilitic strictures, in addition to dilatation, proper alterative treatment is {918} indispensable. As dilatation has often to be kept up for a long time, the patient may be taught to practise this for himself.

PERI-ANAL AND PERI-RECTAL ABSCESS.--When acute, and when the surgeon is called in time, the prompt application of leeches may abort the abscess, but usually, by the time the surgeon sees it, it is necessary to apply hot flaxseed poultices as fast as they become cool, keeping the patient in bed upon light diet. The rule is to open deeply and freely so soon as the least softening under the poultices indicates that pus is within reach. After lancing, the poultices should be continued for a few days: then the deep wound should be packed with a strip of oiled lint and allowed to granulate from the bottom. As the fetor of these abscesses is horrible, they should be injected with a solution of permanganate of potash or liq. sodii chlorinata. When the chronic variety of this abscess is discovered, it, with all its sinuses, diverticula, and pockets, should be laid freely open upon a director and packed with carbolized lint. It is often very necessary in these chronic cases to use tonic and alterative treatment, such as cod-liver oil and iodide of iron.

GONORRHOEA OF THE RECTUM.--Undoubted cases of gonorrhoea of the rectum in the persons of prostitutes have been observed. Burning heat and great pain are usually felt, with a free discharge of pure pus: the mucous membrane is always intensely inflamed. The treatment is simple; an injection of lead-water and laudanum or of sulphate of zinc answers a good purpose. Primary syphilitic disease of the anus and rectum is rarely seen, but of course the treatment indicated would be similar to that laid down for primary syphilis in its usual localities.

IMPACTION OF FECES.--This condition usually occurs among the aged and in women after parturition and in cases of paralysis. Those persons of sedentary habits who do not pay sufficient attention to the necessity of a daily alvine evacuation sometimes find themselves in this condition. Impaction occurs not infrequently among the insane, and more frequently among women than men. Allingham states that he has never seen a case of impaction in a young person; but Wetherill now has under his care a most obstinate case of this disorder in a young man whose system has been completely broken down by intemperance in drink.

In paralysis of the rectum of traumatic origin impaction is almost certain to take place unless great care is taken to prevent it. Diarrhoea is a very misleading element in these cases, and is a symptom which frequently deceives those who are not on their guard. The clayey mass of feculent matter forms a hard ball in the distended bowel, around which the small loose passages flow. Spasm of the sphincter ani is the usual accompaniment of impaction, and the muscle should be gently but thoroughly dilated before means can be used to free the canal. The finger or the handle of a tablespoon is best to use in the dislodgment of these masses, and should be oiled before introduction, the accumulation broken up, and then washed out by an enema of soap, turpentine, and warm water. Purgatives and hydragogue cathartics usually fail to give relief, and add much to the patient's discomfort. The bowel once freed, care must be taken to prevent a reaccumulation, which very readily takes place, as the bowel in these cases is distended and has lost tone. To this end frequent enemata of cold water should be used, and the patient should {919} take a pill of dried sulphate of iron, sulphate of quinia, extract of nux vomica, extract of aloes, as recommended by Allingham. The diet should be restricted. An excellent adjunct to this treatment is the local use of the faradic galvanic current daily after breakfast. Let the patient lie upon a bed and apply one pole or electrode to the anus, while the other one is passed with pressure along the course of the large intestine. Not infrequently it happens after this has been continued for a few minutes that a very urgent desire is felt to go to stool. In the case mentioned of the young man affected with impaction this treatment answered admirably well, but before its use he had to take a small dose of croton oil daily to cause an action of the bowels, all milder measures having proved ineffectual. It is important in these cases to interdict a sedentary mode of life.

IRRITABLE RECTUM.--A rectum is said to be irritable when it shows an intolerance of the presence of feces or flatus, causing frequent desire to go to stool. From such abnormal activity of the part there arise a burning, uncomfortable impression of fulness and a soreness of the anus. If after examination it is found that there is no local exciting cause, a starch enema containing forty drops of laudanum should be given and retained. This plan of treatment will usually afford relief. Should the irritability prove to be obstinate, examine the rectum, and if a spot of redness or increased vascularity be found, touch the spot with strong nitric acid.

CONCRETIONS IN THE RECTUM.--These occur less frequently than do impactions, and differ from them in being cylindrical and nucleated, the nuclei being such bodies as balls or tangled masses of hair, or coins, buttons, biliary calculi, or the like. Covering these are matted animal or vegetable fibres or hardened fecal matter. They are not so readily dislodged as are impactions, and it is necessary to dilate the sphincter thoroughly and remove them with a scoop. Not infrequently these bodies are bathed in pus and are very fetid.

PROCTITIS, OR INFLAMMATION OF THE RECTUM.--This may be either acute or chronic, the latter being a disease of the aged. Allingham recommends in this variety small doses of Barbadoes aloes to stimulate the bowel, also such drugs as copaiba, turpentine, and black pepper. As an injection in the acute form starch and laudanum, or bismuth suspended in a mucilaginous vehicle, should be used. Probably the use of small, smooth fragments of ice in the rectum would allay the tenesmus and help to subdue the inflammation.

PROLAPSUS ANI AND PROCIDENTIA.--Prolapsus occurs much more frequently in children than in adults, making its appearance at every movement of the bowels. The child thus affected should not be allowed to sit upon the chamber-vessel and strain, but should lie upon the side or stand, while the nurse should be instructed to draw to one side one of the buttocks so as to tighten the anal orifice. After the motion the protruded part should be well washed in cold water, and afterward with some astringent solution of oak-bark, matico, or a weak solution of carbolic acid applied with a soft sponge. The bowel should then be gently returned and the child be allowed to lie at rest for a while. If there exists intestinal irritation, small doses of mercury with chalk, with rhubarb at night, with wine of iron three times daily, would be indicated. {920} The application of an anal pad and a T-bandage will give sufficient support. If this treatment be carried out a cure usually results in a few weeks. Some cases do not yield to this mode, and then the surgeon has to make trial of ergotin given hypodermically, each injection representing a grain of ergot, which is to be thrown into the submucous tissue of the rectum every second day for two weeks. Should relief not follow its use, cauterization is to be tried. The cauterants usually applied are nitrate of silver, acid nitrate of mercury, and nitric acid. Of these, nitric acid is the best. After anæsthesia is complete every portion of the extrusion should be touched with the acid, care being taken not to bring it into contact with the skin; afterward the bowel is to be freely oiled and returned. To prevent its extrusion the bowel should be filled with soft cotton wool, a compress placed over the anus, and the buttocks strapped tightly together with adhesive plaster. For a general quieting effect the child should be given paregoric. About the fourth day the adhesive plaster may be removed and a dose of castor oil administered, which will bring away the cotton plug with the dejection.

Prolapsus and procidentia in the adult are much less manageable; indeed, these conditions are usually very obstinate. There may exist causes extraneous to the bowel, such as urethral stricture or enlarged prostate or an impacted renal calculus or a calculus of the prostate. The bowel should be searched for polypi or hemorrhoids, and the prolapse may be cured by the removal of the irritating cause. Failing to find any such cause, the surgeon has at his command either cauterization or a removal of redundancy. The former may be by nitrate of silver or acid nitrate of mercury or the actual cautery. It is well not to apply these strong acids to the aged or those who are broken down in health, as very destructive sloughing has followed their use in these cases. When these are used, the same plan as that mentioned in case of prolapse in children should be pursued. Strong carbolic acid may be used in these cases with much less risk of sloughing than when the acid is employed, and it may be applied oftener--indeed, daily if desirable. Van Buren has recommended linear cauterization with the hot iron to the mucous membrane, the bowel contracting as a result of cicatrization. In adults generally, and especially in the aged, all the forms of cauterization are less satisfactory as a means of relief than either of the various modifications of Copeland's operation, which consists in removing by ligation elliptical portions of the mucous and submucous tissues of the prolapsed bowel. The most satisfactory of these is either to excise two or three oval portions of the mucous membrane with flat-curved scissors and bring the edges together with interrupted suture, or to pinch up in several places the redundancy in a Smith's clamp and cut off the folds in advance of the instrument, applying to the stumps the hot iron. Allingham prefers ligatures of horsehair in these operations, and mentions the carbolized catgut in preference to silk. He cautions the operator not to carry his knife into the submucous tissue, as free hemorrhage would inevitably occur.

In old cases of prolapsus or of procidentia that are not amenable to operative treatment much can be done to render them comfortable: the air-dilated gum pessary will sometimes afford relief, or a pad and T-bandage will prevent the parts becoming ulcerated by friction. Neither gallic {921} nor tannic acid answers the purpose so well as acorn flour. The frequent use of cold water to the part is always attended with comfort, and sometimes with relief. In these old cases of great relaxation Nélaton has used strychnia by the mouth, and Weber (of New York) hypodermically, with fair result. Vidal has cured three cases by the repeated use of ergotin locally, hypodermically. In order to bring about a radical cure in these very chronic cases, very decided means sometimes are justifiable. The late Mr. Hey of Leeds was the first to propose a plan by which, through cicatricial contraction and inflammatory gluing together of the various tissues composing the bowel, the anus and sphincter muscle might be strengthened and improved in tone; to which end he proposed to cut away the pendulous flaps of skin around the anus. In cases where these flaps are very redundant a cure is sometimes effected by this procedure alone. Other cases will be benefited by the operation proposed by Dupuytren, which consists in the removal of radiating folds of the skin and mucous membrane at the edge of the anus. To quote from Holmes's _System of Surgery_: "This operation is effected by laying hold of the fold of skin on each side of the anus with forceps, then with a sharp curved pair of scissors removing both skin and mucous membrane. In very severe cases four or six applications of the scissors may be necessary."

POLYPUS OF THE RECTUM.--The polypi of the rectum are the gelatinoid and the fibroid, but as a very rare occurrence a villous or warty polypus has been found. Polypoid growths are very different bodies, but they are too frequently confounded with true polypi. The only treatment is their removal, and the safest method is by ligation of the pedicle, and either cutting off the growth in advance of the knot or returning it into the bowel. The patient should remain quiet until the sloughing is complete, and his bowels must be confined, otherwise profuse and very troublesome hemorrhage might ensue. Their removal by the clamp and cautery is equally safe. Their removal by torsion or by the scissors is unsafe.

The peculiar villous polypus causes great and exhausting hemorrhage. A case was successfully treated by the application of fuming nitric acid.

FISTULA IN ANO.--In the palliative treatment of this very common malady no great amount of relief can be afforded. Those who are aged and feeble or those who are much broken down will find comfort to attend the free local use of warm water, and the sinuses should be injected with dilute solutions of one of the mineral astringents, the strength of these not exceeding two grains to the fluidounce of water. Cosmoline, simple cerate, ointment of the oxide of zinc, and even fresh lard, make the patient easier, as they prevent friction of the buttocks. One of the forms of the radical treatment consists in the division of all the structures between the fistulous tract and the surface. This may be accomplished either by the use of the knife or by seton. Stimulating injections or cauterization has been known occasionally to permanently close fistulæ in ano; but such plans of treatment are unreliable, and usually unjustifiable. When the fistula is not so high up in the bowel as to render the use of the knife unsafe, this plan of treatment should be adopted. As an invariable preliminary to all operations upon the rectum the bowels should be thoroughly emptied and the patient should be placed under the influence of {922} an anæsthetic. A flexible grooved director should then be carried through the opening of the tract upon the surface and along the tract to its opening in the bowel, should such exist. The forefinger within the rectum will meet the point of the director as it emerges from the internal opening, and the director should be pushed onward and its extremity guided outward until it rests fairly upon the sound integument outside, and all the included structures should be divided along the groove of the director with a sharp-pointed curved bistoury. Should the fore finger in the rectum not discover an internal opening, one should be forced at the very bottom of the tract by rotating the point of the director while making counter-pressure with the end of the finger. Should several fistulæ be found, they should be treated in like manner. Sometimes it will be found that the incision is overlapped by the dusky-red flaps composing its margins, in which case they should be trimmed off with scissors. When the tract extends deeper than its internal opening, the latter should be ignored and the sinus laid open to its very bottom. When no external opening exists, one should be made, and the guide for this incision will be a point of induration felt by the finger at some point not far from the surface. The director entering at this point will find the tract, and should be pushed forward as described above. These opened sinuses should be packed with lint soaked in carbolized oil and confined by a pad and a T-bandage. It is the practice at the Pennsylvania Hospital to apply after division a stick of caustic potassa, allowing it to remain in contact with the cut surfaces for several seconds, after which the wounds are to be packed. This procedure ensures their healing from the bottom. The bowels should be confined for a few days, after which a dose of oil may be given. Besides attention to cleanliness and a daily renewing of the packing no further treatment will be demanded. The hemorrhage attending these operations is usually trifling. Should a vessel spring, a ligature may be thrown around it. When an abundant general oozing occurs, the rectum must be packed and a compress and bandage firmly applied. Should the surgeon prefer the seton operation, he should carry several threads of stout silk or a piece of rubber cord on an eyed probe into the fistula and out of its internal opening, and by tying their ends firmly down upon the enclosed tissues slowly effect the same result as in the cutting operation. When the seton used is silk, the ends should be carried through holes in a round leaden plate or through those of an ordinary button, and tied. These setons are to be drawn tighter every three or four days until the division of the enclosed tissues is complete. The subsequent treatment is the same as in the other operation.

A difference of opinion exists among surgeons as to the propriety of operating for fistula in ano in persons afflicted with tubercular disease of the lungs. The practice of the present day is decidedly in favor of operating, without reference to the condition of the lungs, provided the patient is not too much reduced in strength.

An operation for fistula in ano has been proposed and practised by Reeves, which is a compromise between cutting and ligation. He says: "It consisted in passing a strong and well-waxed silk ligature along the track of the fistula into the bowel. An ordinary surgical probe with an eye in its end carried this thread into the rectum. My bivalve expanding speculum was previously introduced, and by its use there was no difficulty {923} in seeing and seizing the ligature and bringing it out through the anus. The probe was then withdrawn, and the ends of the silk were wound round two strong pieces of wood which were held between the fingers of each hand. An assistant passed a finger on either side of the track of the fistula to steady the tissues and to resist the traction which was put on the silk thread. The two pieces of wood were then drawn toward me with a rapid sawing motion, and the fistula was quickly divided, with the loss of scarcely any blood. Some oiled lint and a pad and bandage were applied in the usual way; and the wound healed well. No anæsthetic was administered, and although the patient did not relish the operation, still it was quite bearable, and what she felt most was a burning sensation, due, doubtless, to the friction of the silk."

HEMORRHOIDS.--The treatment of this form of rectal and anal disease is either medical or surgical according to the gravity of the case and according to the obstinacy with which it resists local and general therapeutic agents. An ordinary acute attack of external piles, such as is often produced by neglect of the bowels, causing constipation, may be treated in the following manner: The patient should rest and avoid stimulating food and beverages. He should employ cold bathing to the part frequently: indeed, great comfort and relief often follow this treatment alone. An ointment of tannic acid, glycerin, and simple cerate, or one containing calomel and extract of opium, will be found useful. Fresh lard, cosmoline, vaseline, cold cream, ointment of the oxide of zinc (benzoated) or an ointment containing extract of opium, extract of galls, and extract of belladonna or stramonium, are some among many agents that have been extolled for their relief. H. C. Wood[46] recommends enemata of solution of chlorate of potassium and laudanum. Enemata of lime-water and linseed oil are recommended by Agnew: "One of the very best formulas for allaying the irritation incident to hemorrhoidal affections consists of the following combination: Acetate of lead and tannin, of each fifteen grains; carbonate of lead and extract of stramonium, of each thirty grains; creasote, five drops. With a sufficient quantity of cocoa-butter mould this into fifty suppositories."[47] The internal exhibition of the balsam of copaiba, twenty drops in capsules taken four or five times daily, or the use of fifteen drops of liquor potassa rubbed up with half a drachm of the balsam into emulsion, taken three times a day, has been much extolled, as has also the confection of black pepper. Sometimes these various means will cure a chronic or long-standing case of piles, either internal or external. Wetherill has found that the topical application of rectified oil of amber has cured long-standing cases of piles. This oil should not be applied in cases where much inflammation exists, and where the piles are internal the best mode of bringing it in contact with them is to incorporate from three to five minims of the oil with sufficient cocoa-butter to make a suppository. One of these, pushed into the bowel night and morning for a week, will not infrequently cause the piles to shrink up and finally to disappear. The bowels should be kept open with the compound powder of licorice. It should be remembered that magnesia irritates hemorrhoids. Success has followed the internal use of ergotin, of the fluid extract of hamamelis virginica, of the corn blast (ustilago maidis), and of small doses of aloes combined with hyoscyamus. {924} D. Young has had good results follow the internal use of glycerin. Chronic cases of piles have been cured by the application of ointments containing carbonate of lead, creasote, carbolic acid, or iodoform. Ergotin used hypodermically in the vicinity of the anus or injected into the piles has frequently resulted in a complete cure, and the same may be said of the injection of carbolic acid directly into the tumors. In the application of cold water to inflamed piles it should be borne in mind that its forcible impingement upon them in a fine stream acts far more efficiently than the mere bathing them. Some cases do better under the use of warm water or warm sedative and astringent lotions. A warm flaxseed poultice mixed with laudanum is a very comfortable application. In obstinate cases of prolapse Agnew[48] recommends the use of a rectal obturator or the use of a hemorrhoidal truss.

[Footnote 46: _Philada. Med. Times_, Dec. 6, 1879.]

[Footnote 47: _Surgery in the Pennsylvania Hospital_, p. 210.]

[Footnote 48: Agnew's _Surgery_, vol. i. p. 445.]

Those who suffer from prolapse of piles should avoid the habitual use of cushioned seats. They should assume a semi-erect posture during defecation, or, when this is attended with difficulty or inconvenience, they should contrive a portable water-closet seat by boring a hole an inch and a half in diameter through a piece of planed board, bevelling it so as to fit the person. These means will often prevent the extrusion of the tumors. After defecation the patient should rest for a little while in the recumbent attitude.

The careful touching of external piles with strong nitric acid is a mode of treatment that has been quite successful in the hands of some surgeons. The intolerable itching of these bodies can be allayed by touching them with tincture of aconite-root or with a concentrated tincture of prickly-ash bark. Freezing them with the ether spray allays the pain and itching for the time being, but these symptoms return with redoubled energy after the effect has subsided.