Chapter II: Front Matter (2)

All hemorrhoids of any appreciable size, or other tumorous growths in the same vicinity, will show at defecation and can be treated while the parts are extruded. All abrasions, ulcerations, indurations, etc, are discoverable by the sense of touch. Hence, it will be seen that the uses of the speculum are narrowed down to a few in number. Namely: in that of bringing to view for observation and treatment diseased surfaces previously located; small, soft hemorrhoids and other minor affections which may have escaped detection by a careful digital examination.

Then, in view of the foregoing facts, and in consideration of the anatomical formation of the parts, being a collapsable tube, highly sensitive and extremely difficult of accessibility, quite unlike the vaginal canal, which is closed at one end, more capacious and dilatable, and designed by nature to be approached from the exterior, a speculum should be so constructed as to not only be easy of introduction and withdrawal, but to exclude all the surface except a limited portion, and permit the greatest amount of available light possible to fall on the exposed part shown _in situ_.

The greatest barrier to the successful use of a speculum is the unruly external sphincter and the excessive mobility of the mucous and muco-cutaneous surfaces. The upper margin of the external sphincter terminates beneath the junction or the skin with the mucous membrane, which place also marks the beginning of the internal sphincter and its junction with the external muscle by a more dense connective tissue, sometimes appearing as a white line at the muco-cutaneous junction called the white line of Hilton.

According to Dr. Andrews, Hilton has demonstrated that the locality where the two muscles join by the intervention of this fibrous ring forming the anal verge, the junction of the skin and mucous membrane, and the exit of the branches of the pudic nerve, is identical.

The internal sphincter is a collection of the circular fibres of the muscular coat of the bowel, about five-eighths of an inch in width, and constitutes in reality the terminus of the gut. For the external sphincter is a thin band of distinct and separate muscular fibres, elliptical in shape, between three and four inches from its anterior to its posterior extremity, and expands out around the margin of the anus like the flaring end of a trumpet; with its superficial layer in close relation to the skin which it draws down in radiating folds.

With this understanding of the anatomical relations, it will be seen that the external muscle contributes so slightly to the length of the canal, that it might be considered wholly on the outside, where it guards closely the entrance, and is nowise concerned in an examination with a speculum except as a feature of incumbrance.

To correct an erroneous idea that there is any considerable depression or space intervening between the muscles, we mean, when we say between the sphincters, the distance bounded by the fibrous ring uniting the two muscles below, and the upper portion of the internal muscle above. More simplified, we mean all the surface included between the upper margin of the internal sphincter and its junction with the external muscle at the anal verge.

All examinations with a speculum should be preceded by an enema of warm water to wash away the mucous and retained feces in and about the sphincters. Let the patient lie on either side, turning partially on the chest, with knees drawn up, the one uppermost more firmly flexed on the abdomen, and hips so elevated that the speculum, when introduced points or inclines downward, and admits of strong natural light to fall in parallel rays to its axis.

Warm the speculum by _dry heat_ over a single blast kerosene stove, where gas is not convenient. A suitable kerosene stove is an indispensible adjunct to an office for heating instruments, water, etc., causing no smell and leaving no deposit of sut on the bottom of vessels as done by gas or alcohol. Use _white_ vaseline as a lubricant; everything that tends to whiteness helps the sight. The vaseline may be squeezed from a tin-foil tube, and the finger not soiled in preparing the speculum for insertion.

To prevent the loose tissue from rolling up and being pushed in with the speculum, the patient may assist by holding the upper buttock away, while the physician introduces the instrument with one hand and retracts the opposite buttock with the other.

Introduce slowly, giving time for the muscles to relax, bearing in mind that all movements about the rectum and anus must be extremely easy and gentle. The proximal end of the slot must be carried and kept above the external sphincter during the entire course of the examination. It matters not what kind of a speculum is being used, the value of the instrument will greatly depend upon its power to hold this muscle out of the way.

A closed end speculum, with a proportionate slot and smooth corners, can be slowly rotated without any difficulty where the mucous membrane is not very loose and baggy and no prominences in the route. But if a hemorrhoid be in the way it will immediately drop in the slot and further progress is thus impeded.

When examining above the internal sphincter, especially posteriorly, where the bottom or floor of the rectum forms a cul-de-sac, direct the patient to strain down a little; this effort will throw the mucous membrane out into the speculum, at the same time spreads out and smooths its surface. In looking through a speculum this cul-de-sac of the rectum sometimes appears as a vacancy behind the internal sphincter, and has been mistaken and treated as an ulcer cavity. It often contains a liberal supply of mucous.

FISTULA.

Fistula in the recto anal region so far exceeds that in any other locality, that its overwhelming predominence here almost entitles it to the exclusive right of the term; while, to those who have given this part of the physical organism special study, the word itself, calls to mind a local condition of disease that is anything but an easy one to manage.

In point of frequency fistula is next akin to hemorrhoids, but a much less desirable complaint to treat. Allingham states that the number of cases occurring in hospital practice is greater. That two-thirds of all the cases operated upon of the in patients at St. Mark’s Hospital, London, were fistula. The most frequent cause assigned being abscess. A failure of the abscess to heal, leaving a sinus or sinuses, is explained by the presence of loose areolar tissue and fat, excessive mobility of the parts by the action of the sphincters, respiration, coughing and sneezing, and a strumous diathesis.

In consequence of an occasional failure of the muscles to regain their power after division by the knife, elastic ligature or galvano-cautery wire in the treatment of fistula, leaving the subject in a pitiable state of incontinence of feces, which has resulted in several well authenticated cases in suicide, new and rational methods have been devised for the relief of this very troublesome and unpleasant affection.

Kelsey says: “A permanent incontinence of feces is _always_ considered by the patient a very poor exchange for fistula, which was causing comparatively little suffering and annoyance.”

The fact that such a deplorable condition does sometimes follow complete section of the sphincters, and that we have no means of knowing previously when it may or may not occur, I submit the question to all thinking, conscientious and painstaking physicians: Should we not seek the adoption of any efficient means of treatment, whereby such risk is wholly avoided?

About the first of March, 1890, Daniel Mc., aged 35, who a few months before had been operated upon by a reputable surgeon for a simple, uncomplicated fistula, sought my acquaintance, exhibited his condition and related his experiences.

The fistula originated from a small abscess, with its internal opening between the sphincters, the external scarcely an inch outside the anus, and was not of long standing. The operation consisted in a division of the external muscle with the greater portion of the internal; he was put on a liquid diet, bowels confined for fifteen days and kept in a recumbent posture.

The incision was slow in healing, between three and four months; his health, which was formerly good, has been greatly impaired ever since the operation. The external sphincter has lost its power altogether and the internal muscle greatly weakened, which necessitate the wearing of a clout whenever the bowels become a trifle loose, and he lives in constant fear of soiling himself by allowing the escapement of the least quantity of flatus. The time lost, the money expended, and the unfortunate condition in which he finds himself eight months after the operation, have so thoroughly embittered him against the cutting process, that he spares no pains and loses no opportunity to influence every one with whom he comes in contact, against all such heroic and uncertain measures.

For the purpose of obviating these very unsatisfactory and highly objectionable results, we have a choice of any one, or all of three different methods, viz: treatment by injection, treatment with the fistulatome, and treatment by the galvano-cautery as practiced by Dr. Shotwell; who, fully appreciating the dangers of muscular section, has hit upon a plan both new and commendable.

The sub-cutaneous, or sub-mucous fistula can be cocainized and slit up with a pair of scissors, and the tract cleansed and cauterized with a solution of carbolic acid, a comparatively trivial affair; but the external blind, the internal blind, the complete, the complete with diverticula etc., are varieties which call forth a decidedly greater amount of ingenuity and thought in bringing them to a successful issue.

The treatment by injection, sometimes classified as a “non-operative method,” has been so successful in the hands of many, that it is stoutly affirmed that any case curable by the usual heroic methods is equally curable by this method. Different preparations have been used, chief of all being carbolic acid, ranging in strength from 50 per cent. up.

In adopting the carbolic acid treatment, probably the better way after preparing the sinus, will be to use a 95 per cent. the first time and subsequently a 50 per cent. solution; protecting the parts from excoriation by any suitable unguent and absorbent cotton. Hot water compresses to relieve pain and reduce swelling. Iodoform, Eucalyptol, etc., in the _interim_. Judgment will be required in not making too many irritant applications and granulation thus hindered for want of rest.

The object is to destroy the pyogenic membrane by the cauterizing effects of the acid and get up a granulating carbolic acid sore. It may be necessary to evacuate the bowels and constipate for several days to give the muscles rest, or resort in extreme cases to divulsion. The sinus must have constant, free external drainage until the healing process is complete. Allingham recommends the introduction of the small end of a bone collar button to keep the orifice open, with a hole drilled through its centre for drainage.

As a preliminary step the external orifice should be dilated with a laminaria tent or other appropriate means. The fistulous tract explored with a common probe and thoroughly cleansed with hot water introduced through a flexible silver canula; which is also used for the injection of a 5 or 10 per cent. solution of cocaine to obtund the sensibility.

Concerning the carbolic acid treatment Allingham says: “Since the publication of my last edition I have cured many patients by dilitation of the sphincters and the use of the bone stud and carbolic acid. One practical point I would mention. The further the external aperture is from the sphincter the more likelihood is there that the sinus will heal. This is shown as well in the cases of spontaneous cure as in my own successes. You must always enjoin rest after a strong application, and watch that not too much inflammation be set up.”

The fistulatome shown in fig. 16, is a contrivance which is perhaps destined to take the lead in the treatment of fistula generally. It is so constructed that the fine cutting blades close on themselves, while the instrument, which is probe pointed, is being introduced, but immediately open on withdrawal, and thus catch up and cut through the fistulous membrane.

Who the inventor of this clever device is, I have been unable to ascertain, having seen it claimed by three different physicians, one of whom speaks of curing 76 per cent. of all cases treated by one operation. That is by drawing the fistulatome through the tract once. Cases of long standing require that the instrument should be turned at right angles and drawn through the second time and possibly repeated later on, or a tenotome employed to scarify any remaining indolent sinus.

It will be readily seen, however, that a fistula with a side pocket, branch or diverticulum, would hardly be reached by this method; although the blades are so formed that they draw the membrane of a dilatable pouch to them from the sides. In such cases a little ingenuity would be required in finding these diverticula, for the purpose of scarifying them with a tenotome.

The preparation of the sinus and the after-treatment are the same as already mentioned. Also evacuation of the bowels and constipation by the use of an opium suppository, even to the dilitation of the sphincters, if thought necessary to bring about a cure. In rare instances, where divulsion has been practiced and while yet under the influence of anæsthesia, it might be advisable to lay open the cavity by cutting _from_ the sphincters, pockets traced, scarified and partitions divided.

In relation to treatment, Andrews says: “The truth is, that anal fistulæ have a natural tendency to recovery, and are held back from it mainly by two things.

1. “The unfavorable effect of the undrained septic fluids within the sac.

2. “The tightness of the external opening, which prevents free drainage, and keeps the sac distended with this putrid pus.

“It is demonstrated by Dr. Mathews on the one hand and by the experiments of quacks on the other, that by controlling these two conditions, many cases will heal spontaneously. It follows that among the thousands of patients subjected to cutting operations by surgeons for this disease, there are many who might be cured by much milder means.”

Shotwell’s operation consists in straitening out of the fistulous tract with a steel probe, having an eye at its distal end, which is carried entirely within the bowel whether the fistula is complete or not. He next pierces the solid structure about three-eighths of an inch farther from the anus with a lance-pointed probe also having an eye near its end, parallel with the first probe, until its end is seen penetrating the bowel a little beyond.

The eyes of the probes are then threaded with the opposite ends of a No. 24 platinum wire about ten inches in length, and both probes withdrawn, leaving the wire _in situ_ forming a loop; both ends are now secured to an electrode, the current turned on and the loop drawn through the partition. Little, if any, dressing is required, but the bowels must be kept locked up for at least a week. This of course involves the use of general anæsthesia.

A word to the beginner, in the prevention and detection of fistula. Since abscess is the most prolific source, proper attention to the abscess by poulticing, early lancing, the sinus washed with hot, heavily carbolized water, allowed free drainage, the bowels evacuated, constipated and the muscles put at rest for a few days, will doubtless be successful in forestalling its almost certain fistulous sequence.

Dr. Hoyt strongly recommends divulsion of the sphincters, immediately after opening the abscess, as an unfailing remedy in preventing fistula.

Annoyance by itching, a slight discharge and soreness at times in a circumscribed spot, with previous history of abscess, might be considered a sure sign of fistula. But the patient may give the same symptoms with no knowledge of previous abscess, or other cause pointing to the formation of a fistula. Yet, on inspection, a small opening with pouty lips, or a closed cicatricial depression not much larger than a pin-head, will be found. This is the external ring or opening of a fistula, and if closed, may resist the introduction of a probe sufficiently to create the belief that no sinus exists.

ULCER, STRICTURE, ETC.

A solution of continuity, varying from a slight abrasion of the mucous membrane to a marked degree of destruction of tissue, comes within the scope and meaning of rectal ulcer.

A deep-seated, non malignant type of rectal ulceration, complicated with stricture, fistula, etc., is not so very common, and seldom met with outside of hospital practice.

The less serious and more simple varieties, such as may be productive of considerable systematic disturbance through reflex excitability, without attracting much, if any attention locally, are the forms most frequently seen by the general practitioner.

With few exceptions, rectal ulcer is insidious in its nature; in some instances passing on to the stage of stricture, which alone may be the first symptom to cause alarm, as the following recent case will illustrate.

Mr. C⸺, aged thirty-three, married, applied for the treatment of hemorrhoids. He stated that the only inconvenience suffered was from constipation. That the piles did not come out and were never very sore but he had seen a little bloody mucous at times and had a constant desire to go to stool. A free evacuation and relief being obtained only after the feces were made liquid by the injection of warm water.

On the introduction of the finger I found about one-inch and a half from the anus, an annular stricture which almost entirely occluded the bowel, with ulceration and gummata below. More close inquiry elicited the fact that the stools were not much larger in circumference than a lead pencil. He had noticed the trouble not more than two months before. There was a previous history of chancroid at the age of 19, with no constitutional symptoms.

It is claimed that organic stricture does occur without previous ulceration by interstitial deposit and thickening, and ulceration follow. But this must be considered exceptional. The ulcerative process usually precedes, and through efforts at repair, cicatricial bands are thrown out, producing a narrowing and contraction of the canal, either in places or throughout the circumference of the bowel.

Electrolysis may be tried for the relief of stricture before resorting to the usual methods of breaking up by forced dilitation. If divulsion be decided upon it should be complete at one operation. Should the fibrous bands be strong and unyielding, nicking the edges with a probe pointed bistoury is advantageous.

On account of severe hemorrhage and other untoward symptoms likely to follow a complete division of the stricture, the galvano-cautery is decidedly preferable to the common proctotomy knife. A duplicature of the peritoneum coming down to within about three and a half inches of the anus anteriorly, should not be lost sight of in operations on the rectum. The persistent use of bougies will be necessary for a long time after divulsion.

Stricture is mostly of syphilitic origin. Of the seventy cases, tabulated by Allingham, ten of the number were found in men and sixty in women, showing a great predominence in the latter; and none were more than three and a half inches above the rectal orifice.

It is not an easy matter to diagnose between the advanced stages of non-malignant rectal ulcer and cancer. Both may be accompanied by tender, condylomatous growths or flaps of skin outside the anus, bathed with an ichorous fluid. The characteristic, unremitting pain of cancer may be absent in its formative stage, and in this respect insidious in its approach, the same as the non-malignant ulcer.

Allingham speaks of a very rare species of rectal ulcer, which he terms rodent or lupoid, that is superficial, does not implicate the surrounding parts, devoid of hard edges or surface, very painful and only cured by complete extirpation.

I have intentionally omitted the early symptoms and course of rectal ulcer for the purpose of giving audience to Dr. A. C. Hall, who, in a communication to a medical journal, writes the following lucid description:

“Rectal ulcer is a more common disease than is generally supposed. Unfortunately the symptoms are generally obscure, and the patient suffers but very little, if any pain, and consequently consults his physician for some of the reflex symptoms, rather than for the initial disease itself; and very often these reflex symptoms are vainly treated till the patient and physician are both thoroughly disgusted and disheartened. There is one maxim which every physician should always bear in mind, and that is, _always suspect rectal ulcer in every case of protracted or chronic diarrhœa_. I have reports from eighty-six pension surgeons, in which they estimate that they have examined two thousand cases, where chronic diarrhœa was the alleged cause of disability in applicants for pensions. Of these two thousand cases of chronic diarrhœa, eighty-seven per cent. had rectal ulcers, and fully ninety per cent. of those who claimed chronic diarrhœa as their disability and who had no ulceration were rejected, because their proofs of the disease, aside from the ulceration were too meagre. Thus the strongest and most prominent symptom of rectal ulcer is _chronic diarrhœa_.

“The diarrhœa is generally more troublesome in the morning. The patient often on arising feels an urgent desire to go to stool. This act is often very unsatisfactory, for he passes very little feces and a great deal of wind. Occasionally these small stools are covered with a jelly-like, or white of an egg substance, or the motion may be only a jelly-like mucous, with no feces. There is generally more or less tenesmus, or a disagreeable feeling, as if the rectum was imperfectly evacuated. Sometimes the patient will be compelled to go out two or three times before breakfast, and he may in the later attempts to have a stool, pass lumpy or scybalous feces, covered with mucous, and often streaked with blood. There sometimes exists, as a symptom of rectal ulcer, a desire to go to stool when cold drinks are taken. But generally the diarrhœa and tenesmus subside soon after breakfast, and the patient has no more trouble until the next morning. A great many, or I might say a majority of those suffering from rectal ulcer consult the physician for some symptom or other that suggests anything else but the rectum, but by close questioning, and following up the symptoms, one can soon tell whether they are reflex or otherwise.

“In cases of rectal ulcer of long standing, there is always more or less cachexia, or peculiar waxy, sallow, unhealthy complexion, which sometimes alone points significantly towards the disease.

“There is often more or less enlargement of the liver and spleen, especially the spleen.

“In advanced cases, the diarrhœa comes on at night as well as morning, and defecation is accompanied with pain and griping. Another almost characteristic sign of rectal ulceration, is alternating diarrhœa and constipation. The bowels remain constipated for a considerable while, then diarrhœa supervenes, and is accompanied by severe and excruciating colicky pains, and often nausea. Persons subject to chronic diarrhœa always dread to take a physic to relieve a temporarily constipated state, for it will almost invariably put them to bed.

“In extreme cases, infiltration and thickening of the sub-mucous and muscular coats supervene, as a result of nature’s effort to repair the lost tissue. This thickening may be so extensive as to threaten and actually produce stricture. It will often convert the rectum into a passive tube, through which feces and fluids trickle, the patient having little or no control over the sphincters.

“The passage of hardened feces and the pressure of internal hemorrhoids and polypi are the most common causes of rectal ulceration. The lodgment of foreign bodies, such as fish bones, cherry stones and plum seeds that have been swallowed, and which act as irritants and produce ulceration.

“In women the pressure of the fœtal head on the rectum during childbirth is a frequent cause of ulceration, likewise the pressure of a misplaced uterus.

“On examination, by means of a speculum, the ulceration will be found about an inch or an inch and a half from the anus, generally on the posterior wall, but often on the anterior wall.

“When the ulcer is on the anterior wall, there is more or less irritability of the bladder, and seminal emissions or impotency. The ulcer itself may be round, oval or elongated, radiating or following the columns of Morgagni. The ulcer may present ragged, interrupted elevated edges, or they may be sharp cut and regular, as though cut with a sharp punch. The edges are sometimes hard and gristly, or may be soft and with no elevation above the surrounding tissues. The surface of the ulcer is often clean, and healthy looking granulations may be seen, or the ulcerated surface may be loosely covered with a greyish, grumous scum, that is offensive, and decidedly unhealthy for the patient. Underneath this scum there is often found an ulcerated spot, that is apparently lifeless, and will require much attention, locally and constitutionally, to prevent its rapid extension. In this form of rectal ulcer there is always more or less marked cachexia. It is the indolent ulcer, occasioned by the gradual breaking down of the tissues, that produces the grave constitutional disturbances and death. It is the small, round, or oval ulcer, with elevated, hardened edges, that produces the many and various reflex nervous symptoms, which are misleading and troublesome.”

In all cases of rectal ulcer of any considerable gravity, absolute rest, both of the parts and the body, is to be maintained. Hot water irrigations and a complete destruction of the diseased surface by carbolic acid, are the first things to be thought of, together with a liquid diet.

Convert the ulcer into a carbolic acid sore and use an iodoform suppository. In fact the treatment is very similar to that recommended as an after treatment in a bad case of hemorrhoids, with such variations as the ingenuity will suggest. Bismuth, oxide of zinc, eucalyptus, mercury, resin cerates, etc.

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

FISSURE, OR IRRITABLE ULCER.

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

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

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

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

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

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

℞ Acidi Salicyl. ʒ ss
Vaselini ℥ ss