CHAPTER IX

THE DIGESTIVE SYSTEM-Continued

PROCTOLOGICAL MEMORANDA (RECTAL AILMENTS) SYNOPSIS: Preliminary Remarks. Catarrh of the Rectum (Simple, Syphilitic, Atrophic Follicular).-Periproctitis and Abscess.-Impacted Fæces.-Foreign Bodies.-Condylomata (Syphilitic; non-Syphilitic).-Hæmorrhoids (Internal, External). — Rectal Polyps.-Rigid Sphincter.-Pruritus Ani.-Prolapse of the Rectum.-Simple Fissure and Painful Ulcer.-Ulceration and Stricture of the Rectum.-Neuralgia of the Rectum. Coccygodynia.-Remarks on the Upper Rectum and Sigmoid Flexure.

PRELIMINARY REMARKS

Examination. An examination of the rectum is made by the finger and by means of a speculum in direct or reflected light. The upper rectum and sigmoid flexure may be inspected with the "Kelly tube." Constriction of the calibre of the intestine from organic disease or by pressure from without, and extreme tortuosity of the sigmoid flexure with adhesions, may prevent the use of instruments. A long flexible silver probe is useful for exploring fistulous tracts. The most comfortable and delicate position in which the patient may be examined is on the left side; the left arm brought behind the body, the right shoulder turned away from the examiner, the right thigh well flexed upon the abdomen.

In interrogating the patient we inquire as to pain, protrusion of parts, discharge, gonorrhoea, bowel action, hæmorrhage, syphilis, menstruation, and pregnancy.

Before examining the patient the bowels must be moved, and in some instances local or general anesthesia is necessary to a thorough examination. A knowledge of the state of the heart, kidneys, lungs, liver, central nervous system, and genital organs is essential to correctly interpret some of the conditions found in the rectum.

In the management of rectal disease, as in the treatment of nasal disease, local treatment is of prime importance in conditions requiring operative interference, but in the various catarrhal conditions too much local treatment often prolongs the trouble, and therefore general hygienic management steps to the foreground. The interdependence of rectal and genitourinary disturbances must not be overlooked.

CATARRH OF THE RECTUM; PROCTITIS

On careful local examination we can distinguish four forms: Simple acute catarrh, hypertrophic catarrh, atrophic catarrh, and follicular inflammation.

PROCTITIS AND IMPACTION OF FÆCES

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Proctitis is a catarrhal inflammation of the mucosa from many causes. There is a sense of heat and weight in the perinæum, with a constant desire to defæcate. The anus is hot and tender, and there is a mucous discharge. This form of inflammation may terminate in speedy resolution or develop into periproctitis, abscess, fistula, or ulcer.

General Treatment.-Remove the cause if possible. Order a dose of castor oil or a saline cathartic, a cold compress to the parts, or a suppository of opium and belladonna, āā, gr. §.

In periproctitis with ischiorectal abscess the treatment is the same as in proctitis, and as soon as an abscess is evident, open it freely and pack the wound to allow it to heal from the bottom. A dressing of balsam of Peru or ichthyol ointment, 10 per cent, is advisable.

Chronic atrophic catarrh is a common ailment. A dry, brittle condition at the margin of the anus is characteristic of this affection and gives rise to intractable pruritus. In addition, there is constipation with dry stools and some mucous discharge.

TREATMENT.-Cleansing the intestinal tract with salt solution and injecting half an ounce of a 5 or 10 per cent solution of argonin is appropriate treatment. Where there is distinct ulceration the insufflation of aristol or iodoform is excellent. Hydrochloric acid may be required to aid digestion.

Hypertrophic catarrh is found in plethoric individuals. There is a persistent moisture at the anus, the stools are soft, liquid, or mucous, and there is marked flatulence with poor digestion.

TREATMENT.-Phosphate of sodium before breakfast, a general tonic, hygienic measures, and hydrochloric acid to aid digestion. Locally, we inject into the rectum from one to six ounces of a 25 per cent solution of aqueous extract of krameria.

Follicular inflammation, or catarrh, of the rectum shows a hyperæmic mucous membrane with small nodular, elevated swellings. Patients afflicted with this form of catarrh do not have a satisfactory stool, but go to the closet several times a day and pass small round masses coated with this mucus, and complain of flatulence.

TREATMENT. The treatment is local and constitutional, as in the other

forms.

IMPACTION OF FECES

The term impaction is used when the accumulation of fæces takes place in the pouch of the rectum. It may occur at any age and is due to inertia of the intestine or spasm of the sphincter, and it should be noted that a fluid discharge from the bowels (diarrhoea) is not incompatible with great retention of solid fæces.

Diagnosis and Treatment. The diagnosis is made by digital examination, and the impacted mass is removed by breaking it up with the fingers or by means of a spoon handle. After the patient is relieved, general hygienic and tonic management, including massage, are indicated.

A rigid sphincter is often associated with fissure and is the cause of many cases of constipation in children and adults. It requires digital divulsion under narcosis by means of the thumb and index finger. This effort must be continued until the muscle has lost its power.

Foreign bodies in the rectum are detected by digital examination and are removed under narcosis if necessary.

Condylomata, warts, excrescences, vegetations, and mucous tubercles occur at the anus and vulva. There are two varieties: Condylomata lata and condylomata acuminata. Condylomata may be of syphilitic origin or may be due to irritation and filth. Those of syphilitic origin disappear after specific treatment and cauterization with nitrate of silver or chromic acid. The others may be snipped off with sharp scissors, and the bleeding spots should be cauterized.

FISTULA IN ANO

Definition. A sinus left by an abscess in the neighborhood of the anus. A blind fistula has no communication with the intestine. A complete fistula communicates with the lumen of the intestine. The external orifice may be of the size of a pin or lie in the centre of a mass of granulations. The fistula secretes a thin purulent fluid. Now and then the orifice becomes obstructed, the discharge collects, a small abscess forms, and the skin becomes hot and tender. When this breaks, the symptoms subside. A certain proportion of anal fistulas are of tuberculous origin. In making a bacteriological diagnosis the Smegma bacillus should not be mistaken for the tubercle. bacillus.

Treatment. The parts are made anæsthetic by means of cocaine or, according to Gant, by injections of sterile water under the skin. A grooved director is passed into the fistula and out through the anus and the tissues are divided until the director is free. Peroxide of hydrogen is now sprayed on the wound and the latter packed with iodoform gauze. The patient can go about on the following day, wearing a diaper or bandage. An incomplete. fistula is made complete by forcing the grooved director through into the gut.

HÆMORRHOIDS (PILES)

Definition. A varicose condition of the vessels around the anus, fre quently associated with eversion of the rectal mucous membrane. External hæmorrhoids are of two kinds:

a. A tag of skin somewhat inflamed.

b. A thrombotic or blood clot hæmorrhoid.

The symptoms of both varieties are very much the same, heavy, weighty feeling and an aching pain. Some piles have an ulcerated surface.

Treatment.—a. PALLIATIVE. A laxative medicine, heat or cold to the part, and subsequently the following ointment:

An ointment of tannin, opium, and belladonna, or of cocaine, gr. x, carbolic acid, gr. xx, and vaseline, 3j, is also effective.

FISTULA AND HÆMORRHOIDS

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b. OPERATIVE. The skin hæmorrhoid may be cut off at its base with a pair of scissors. The thrombotic pile should be slit open with a sharp knife and the blood clot released. The wound may be dressed with carbolated vaseline.

Internal Hæmorrhoids

These are troublesome on account of hæmorrhage, protrusion, and pain. They can readily be distinguished from a polypus, which has a pedicle, and from prolapse of the rectum by its velvety appearance and uniformity of circumference. Cancer and ulceration of the rectum cannot be mistaken for hæmorrhoids by a careful examiner. Among the local causes of hæmorrhoids may be mentioned as of importance any condition which interferes with the return flow of blood from the rectum, tumors, the gravid uterus, constipation, and circulatory obstruction of hepatic, renal or cardiac origin.

Treatment.-a. PALLIATIVE. The first indication is to prevent fæcal accumulation and establish soft stools. With that object in view, we not only resort to certain medicines, but we must put the patient on appropriate diet and under good hygienic surroundings. Absolute cleanliness of the anus and irrigation with tannic acid and alum are among the latter. Of medicines, rhubarb and its preparations, and pulv. liquirit. comp., are useful, but all drastic purgatives are to be avoided. When bleeding is copious, injections of fl. ext. of hamamel. virg., a teaspoonful to a wineglassful of water, used once daily, are sufficient. In the event of an "attack" of inflammation the patient is put to bed, the bowels are kept open, and heat or cold is applied. An ointment of opium and belladonna or cocaine is serviceable. After the "attack," daily cold water enemata may be continued for a long time.

b. BY INJECTION. A solution of carbolic acid may be injected into the protruding hæmorrhoidal tissue once a week:

R Acid. carbolic, pur.,

Glycerini,
Aquæ,.

equal parts.

M. S.: Inject five drops into the centre of the pile.

This process takes several weeks to effect a cure. required to give the injections are:

The instruments

1. A hypodermic syringe of glass and a platinum needle two inches long. The needle can be readily sterilized by making it red hot in the flame of an alcohol lamp. 2. A rectal speculum with a section of its wall cut out and replaced by a sliding piece. This permits of the inspection and treatment of isolated portions of the bowel. 3. Aluminum or silver cotton carriers with cotton for mopping and cleansing the parts.

The patient is to have an enema a few hours before treatment. The small tumors are injected first, and the trifling pain from the needle can be overcome by applying a 5 per cent cocaine solution to the parts on a cotton swab. Two or three piles are injected at each sitting. Piles that do not protrude can be reached by means of the speculum. Two sittings a week. can be safely carried out.

C. OPERATIVE TREATMENT. Whitehead's Method.-Resection of the entire hæmorrhoidal area is an operation of some magnitude, and its success depends upon aseptic and primary healing in a region where asepsis is difficult to obtain.

Allingham's operation.-Excision of each hæmorrhoidal tumor, with ligation of the vessel at its base, is free from risks and an excellent operation. The clamp and cautery operation can be rapidly performed and gives very satisfactory results.

RECTAL POLYPI

They are found in children and adults. They are pedunculated growths attached to the mucous membrane, and may be soft or fibrous, and are sometimes multiple. By thoroughly searching the bowel they can be felt and seen. They give rise to the following symptoms: Tenesmus, desire to go to stool, bleeding, and the passage of mucus. They may protrude

from the anus on straining.

Treatment. They should be removed by means of a torsion forceps or by ligature.

PRURITUS ANI

Painful itching of the anus is a very distressing minor ailment, often very intractable, but eventually curable if the patient will persist in carrying out well directed treatment. The itching and irritation are worse at night, when the patient is in bed, and they interfere with sleep. Pruritus is possibly a pure neurosis, but usually there is some underlying local or constitutional cause, such as gout, diabetes, or hepatic disease, hæmorrhoids, uterine disease, vaginal discharges, constipation, ascarides, or pediculi.

The treatment must be directed to any underlying constitutional dyscrasia and the removal of local irritation. The parts should be thoroughly washed several times a day with soda water followed by a 2 per cent carbolic acid solution. If an examination with a magnifying glass reveals fissures or breaks in the mucous membrane of the parts, cauterization with a 5 per cent nitrate of silver solution is indicated, three times a week. The following dusting powders and protecting ointments are useful: Stearate of zinc with acetanilide.

In intractable cases of pruritus a division of the nerves leading to the

parts has been practised with apparent success.