Inflammation and suppuration in the lower part of the rectum are even more common than the corresponding affections of the cæcum, and their causes are quite as various. In many cases, no doubt, this affection is traceable to ulceration (perforative or otherwise) of the mucous membrane; in others it probably originates in the connective tissue which surrounds the rectum (periproctitis). The rectum, still more frequently than the cæcum, becomes involved in inflammation and suppuration originating in the various pelvic, and even in distant, organs. Abscesses arising in the abdominal cavity or its parietes are peculiarly apt to gravitate into the pelvis and to communicate with the rectum.
Proctitis in its acute form has some symptoms in common with dysentery, but it differs from it by the absence of abdominal pain, tenderness, and severe constitutional symptoms. The pain in proctitis is usually referred to the sacrum and perineum, and there is frequently dysuria from sympathetic affection of the bladder. This disease may be acute or chronic; the latter form occurs in those advanced in life. Frequent attempts to evacuate the bowels, with great tenesmus, heat, weight, and fulness in the bowel, and a mucous and bloody discharge in the absence of impaction of the rectum, characterize the attack. Should it be protracted and severe, the discharge will become purulent. A digital exploration should always be made to ascertain if any foreign or irritating substance is exciting the inflammation.
The presence in large numbers of Oxyuris vermicularis may excite irritation and inflammation of the rectal mucous membrane, which is sometimes very intense.3
3 Curschmann, Ziem. Encyclop., Am. ed., vol. viii. p. 848.
Inflammation of the anus and buttocks, caused by the application of the leaves of Rhus toxicodendron after defecation, has extended into the rectum and produced proctitis and peritonitis.4 "In some cases of dysentery the pathological lesions are limited to the rectum, which would produce an apparently local inflammation very similar to proctitis. The irritation of unnatural sexual intercourse and the contact of gonorrhoeal poison have been known to excite intense inflammation of the mucous membrane of the rectum, with a copious discharge of pure pus, and accompanied by intense burning pain and great heat of the parts involved."5
4 Case of Dunmire, Philada. Med. Times, vol. xii.
5 Heubner, Ziemssen's Cyclopæd., vol. i. p. 552.
The painful ulcer of Allingham is quite a common affection, attacking women more frequently than men, and no age is exempt from it. Of 4000 consecutive cases of rectal and anal disease observed by Allingham, 446 presented fissure of the rectum. They are rarely multiple. Their usual position is dorsal, although they may be found at any part of the circumference of the anus, and just within the verge of the anus at the junction of the skin and mucous membrane, extending upward toward the rectum usually not more than half an inch, and appearing as a crack or fissure, often very trifling in appearance, or a club-shaped ulceration, the floor of which will be very red and inflamed if it is recent, but if chronic the floor will be grayish, with hard, well-defined margins. Sometimes there will be found at the external extremity of the fissure a small club-shaped papilla or muco-cutaneous polypoid growth; but this is not to be confounded with the ordinary polypus, nor is it the cause of the fissure, but the result of irritation caused by the latter. In other cases the external site of the fissure is indicated by a very tender and swollen flap of integument, which often becomes the seat of a small but very painful fistula. The club-shaped papilla is said to indicate invariably the existence of fissure.
Fissure of the rectum is often associated with anteversion and retroflexion of the womb. In many of these cases the fissure will heal spontaneously when the malposition is rectified. However treated, the result will not be satisfactory while the uterine trouble remains uncorrected.
Fissure is not infrequently caused by and accompanied with polypi: it may be caused by any accident whereby the verge of the anus is torn or superficially lacerated—by chronic diarrhoea, by violent expulsive, straining efforts, as in labor, by the passage of very hard, dry stools—and very frequently it is syphilitic in origin. The most prominent symptom of this disease is pain, and this is very severe and peculiar in character, coming on in most cases not during the act of defecation, but twenty minutes to half an hour afterward, and is preceded by a hot, burning, throbbing sensation at the anus: then comes on spasmodic contraction of the sphincters, and the patient endures agonizing pain, often for several hours, when relief is gradually experienced, and no pain is felt until defecation again becomes necessary. Now, it has been observed that in some cases where the local lesion is very trifling the pain and spasm are intense and long-continued; in other cases, where spasm and agonizing pain followed every act of defecation, no lesion of the anus or rectum could be found. This led Dolbeau to consider the essence of fissure of the anus neuralgic, and to define it as "a spasmodic neuralgia of the anus with or without fissure." The mental depression is so much out of proportion to the local disease that this may come within Curling's observation, that "mental causes may produce local disease in the rectum."
This is, fortunately, a rare disease, and is peculiar and distinct from any other form of ulceration in this region. It is not cancerous, although bearing some resemblance to epithelioma. As it first appears it is very like a syphilitic sore, and its situation and the character of the pain might lead to the supposition that fissure existed. Rodent ulcer is usually situated upon the mucous membrane, although it occasionally invades the integument about the anus; its shape is irregular, its edges sharp and well defined, and it does not undermine the neighboring tissues. There is no induration about this sore, as nature does not seem to attempt to limit it or to set up any reparative action, and its surface is red and dry. The surrounding tissues seem quite normal. It is very destructive, and seems to prefer mucous membrane, although sometimes it destroys deeply. It does not cause infiltration; it does not spread by the lymphatic system, forms no secondary deposits, nor does it produce stricture. It may remain in a quiescent state for some time, and a certain amount of cicatricial tissue may form; but it never heals spontaneously, and an exacerbation comes on which destroys in a very few hours the repair which may have been the work of many days. This form of ulceration of the rectum is usually considered incurable; the pain is intense, being compared to that produced by hot iron, and of course being much aggravated by the acts of defecation. Patients so affected die from exhaustion and pain, although recovery may take place, I have known one case entirely cured by complete excision. Spasm of the sphincters is a usual accompaniment, and greatly augments the suffering of the patient. Of the four thousand consecutive cases of rectal disease tabulated by Allingham, only two were cases of rodent ulcer.
This condition may be caused by foreign bodies introduced into the anus, by indigestible substances swallowed, by impaction of feces, by pressure of tumors external to the rectum, and by intestinal concretions. Any condition which causes loss of muscular and nervous tone in the large intestine favors its obstruction; thus, it is not uncommon in the aged of both sexes, but especially is this the case in women, and in them it often follows parturition. Hysterical, nervous, and debilitated persons are particularly prone to it. The insane, if not carefully watched and regulated, will become the subjects of it. Impaction of feces is a very common cause of obstruction of the rectum, and atony of this organ is usually the primary cause, the feces in these cases being either very hard and dry or clayey and tenacious. These masses are of a more or less globular shape, and, as they irritate the bowel and produce diarrhoea, the practitioner sometimes falls into the error of prescribing doses of opium and the astringents, misled by the appearance of feculent fluid which oozes around the impacting mass. The impaction occurs just above the internal sphincter. Habitual constipation soon stretches the rectum and robs it of expulsive force, and an accumulation of months of fecal matter is sometimes found. The appearance of persons so affected suggests malignant disease: they are cachectic, sallow, dyspeptic, irritable, and nervous. Vomiting, anorexia, thirst, cough, hectic, irregular and profuse sweating, are also among its symptoms. Cases of melancholia and of hypochondriasis have been cured simply by the discovery and removal of rectal impactions. This condition has been mistaken for cancer, phthisis, intermittent fever, and enlarged mesenteric glands. Accompanying impaction, and as a result, is spasmodic contraction of the sphincter ani, which causes the anus to protrude in a nipple shape and to firmly resist the introduction of the finger. Usually, there is no discharge from the anus in these cases. Tenesmus, a sense of weight and of a body present in the bowel, are experienced. Young people are not often subjects of impaction.
Concretions also cause obstruction of the rectum: these are more frequently cylindroid in shape, and sometimes have a nucleus consisting of some firm foreign body. Wetherill reports a case of a young adult, who had been accustomed to the daily ingestion of a substance known as hygienic bread (this substance is made from the husks of grain, and is very coarse: it is used to excite peristaltic action), from whose rectum he removed a very hard ball of this substance which was covered with mucus, but which contained no nucleus. He reports another case in which the offending substance was a globular mass of casein, stained with bile and covered with mucus, and which had for a nucleus a small mass of hardened fecal matter.
Guéneau de Mussy6 reports a case in which there was an occlusion of the rectum by a mass of magnesia, which was so firmly impacted that it had to be removed by a mallet and chisel. A similar case occurred in the practice of Dunlap of Norristown. Fendick7 relates an instance of impaction by a fish-bone near the anus, causing obstruction requiring surgical interference; which illustrates the importance of examining carefully all cases of acute piles and threatened abscess.
6 Medical Times and Gazette, 1879, vol. ii. p. 214.
7 Lancet, 1880, vol. ii. p. 239.
These concretions often consist of animal and vegetable fibres matted together about a nucleus, the latter consisting of the seeds of fruit, fragments of bone or gristle, hair, small coins, or pins. "Enteroliths may lodge in the rectal ampullæ" and cause obstruction. Indigestible substances swallowed with the food may be arrested in the rectum, such as grape-skins, fruit-pits, husks, and fibres, and where there already exists stenosis of the bowel a dangerous form of obstruction may be produced. Jones8 reports a case of chronic impaction of the rectum by plum-stones, which gave rise to trouble in defecation, and at the end of eighteen months produced symptoms of piles; at the end of two years impaction occurred, and the mass was removed by the surgeon. Hazelhurst relates a case of impaction in a negro where two hundred and eighty plum-stones were removed from the rectum after having been there for a week. The records of the Pennsylvania Hospital furnish the following interesting case of obstruction:9 "The patient (a male) stated that twenty years before he swallowed a peach-stone. Two years afterward he had symptoms of rectal irritation, tenesmus, constipation alternating with diarrhoea, and liquid stools, etc. These symptoms had continued ever since. His health had been markedly impaired. A digital examination revealed a hard, stony mass two and a half inches above the anus. Under ether Morton divided the external sphincter, and with a pair of bone-forceps removed, with considerable difficulty, a good-sized peach-stone which was lodged in the rectal tissues. The stone was very sharp at the ends, and had evidently lodged crosswise and become imbedded. The patient was discharged quite well and free from all symptoms."
8 Lancet, 1856, vol. ii. p. 278.
9 Surgery in the Pennsylvania Hospital, Phila., 1880, p. 335.
Gall-stones may cause impaction or they may form the nuclei of concretions. A case of impaction is related by Walker,10 who removed a gall-stone from the rectum which measured three and a half inches in its longest and one and a quarter inches in its shortest diameter; also one by Roberts,11 in which he removed a gall-stone measuring five inches in circumference from the rectum of a woman two weeks after confinement. Mischievous, revengeful, insane, or intoxicated persons sometimes force very curious foreign bodies into the rectum, among which may be mentioned hot iron, bottles, cups, bougies, pieces of wood, stones, a champagne flask, a goblet, slate-pencils, and the tail of a pig with the bristles cut short. Some foreign bodies introduced from below find their way through the sigmoid flexure and lodge in the colon, or they may remain for a long time in the rectum. The cæcum is the favorite resting-place of foreign bodies. Turgis12 removed by linear rectotomy a cup which had been forced into the bowel. These foreign substances, if not promptly removed, set up violent inflammation. Obstruction of the rectum may be caused by vast numbers of round- or thread-worms twining themselves together in a mass; and when this happens in children or in adults of very nervous organization a curious train of reflex symptoms may be developed, among which may be mentioned choreic movements, convulsions, pruritus ani, insomnia, irritability, melancholia, and hypochondriasis. Finally, the rectum may be obstructed mechanically by pressure exerted from without. Such an effect might be produced by morbid growths from the sacrum or ileum; by deposits in Douglas' cul-de-sac; by ovarian disease; by pelvic cellulitis causing stricture of the rectum; by vesical trouble; by ascites with hepatic disease; and by various abnormalities of the uterus, such as inflammation, morbid growths within or upon, simple retroversion or retroflexion, or retroflexion of this organ in a gravid state.
10 Flint, Prac. Phys., 460.
11 Bost. Med. Journ., 1879, vol. ii. p. 116.
12 Société de Chirug., 1878.
Impaction of feces under some circumstances may give rise to extensive sphacelus of the rectum and the contiguous parts from pressure. This is well illustrated in the following case of a woman aged sixty-five, who was found to have an immense distension of the abdomen from ascites, incident to a large omental scirrhus. The patient suffered greatly from the pressure caused by the accumulation of water, and she was tapped. Soon after this an impaction of feces was observed, which probably had been forming for some time prior to her coming under observation. A week or ten days after the tapping the impaction was detected, but not soon enough to prevent the formation of a large slough of the posterior and inferior part of the rectum immediately above the anus. The submucous tissues and the skin, owing to the greatly enfeebled condition of the patient, soon gave way, leaving a large opening which communicated with the bowel. The tissues adjacent were oedematous, red, and painful. The finger carried into the bowel through the anus discovered the slough to have involved a region of at least two and a half inches in diameter.
These are quite numerous, and they almost invariably produce much distress and excite painful pruritus, which is augmented rather than relieved by scratching or friction of any sort. The application of the leaves of Rhus toxicodendron after defecation is capable of exciting considerable inflammation upon and around the anus, accompanied by small pearly vesicles, which, when ruptured by scratching, seem to spread the disease wherever the contained serum flows. Eczema, when found in the anal region, is usually due to parasitic growth. Erythema intertrigo is caused by the friction of moist opposing surfaces, as between the nates of stout persons, who perspire freely, and infants. The abraded derma exudes a sero-purulent fluid which excites troublesome pruritus. When this condition exists about the anus it causes painful defecation and spasm of the sphincters. Erythema chronicum occurring in this locality is frequently a sequel to chronic eczema and chronic lichen: the skin cracks, is moist, thickens, and the epidermis exfoliates. The proximate cause in both of these conditions is congestion of the vascular rete of the derma. In prurigo podicis papules appear which itch intensely, and when scratched bleed, the summit of each papule bearing a small black scab. If not cured, in time a true psoriasis may develop. Herpes of the anus occurs similar to herpes at the other mucous outlets of the body, and is usually symptomatic of slight disorder of digestion. Wetherill has seen a case of herpes zoster, (var. proserpens,) in which the vesicles extended from the side of the scrotum along the perineum to the verge of the anus. This condition was accompanied with neuralgia of the rectum, painful defecation, and spasm of the sphincters. Furunculi sometimes form at the verge of the anus, causing spasm, pain at stool, and occasionally marginal fistulæ. Various syphilodermata also appear in this region. Gross was the first to describe a condition of trichiasis of the anus—a very irritating complication to fissure—due to a perverted recurvation of the hairs usually found in the anal region. Villermé states that hairs have been found growing from the mucous membrane of the rectum. The colonization of pediculus pubis about the anus occasions a certain amount of irritation. Sarcoptes hominis is sometimes found in this region, having been carried there by hands infested with this parasite. The result is very distressing. The peculiar tracks or burrows made by this little animal, and the use of the microscope, make the diagnosis certain. The Acarus autumnalis, or mower's mite, has been found in the skin of this part, and it is capable of causing great distress. These do not furrow the integument longitudinally, but burrow vertically, and may be picked out of the summits of the wheals, where they appear as small red points.
This is a condition very different from fissure or the painful ulcer of Allingham—much more grave, difficult to treat, and, in chronic cases, much less hopeful of cure. It is not an uncommon affection, Allingham's table of 4000 consecutive cases of diseases of the rectum and anus furnishing 190 of the disease under consideration. An ulcer of the rectum may be partly within, partly without, the internal sphincter, but in most instances is found above that muscle, from an inch and a half to two inches from the anus, situated dorsally.
The symptoms are unfortunately obscure and insidious, misleading not only the patient, but also too frequently his medical adviser, and gaining grave headway before a correct diagnosis is reached. Often the very first symptom is a slight diarrhoea every morning as soon as the patient rises, accompanied with a little discharge resembling coffee-grounds; or, again, the discharge is like the white of an egg; in some rare instances pus is formed. At this stage there is little or no pain, but the patient suffers from tenesmus—which is not followed by relief—and a sense of uneasiness in the part. Several stools of this nature or streaked with blood may be passed during the earlier part of the day, after which the patient feels partly relieved, and no more evacuations occur until the following morning, when he again experiences the same train of symptoms; and this repeats itself daily for a long time. Finally, these discharges occur in the evening as well as in the morning, then at various times during the day: his general health begins to give way; the discharge becomes augmented in amount and contains more blood and pus; and he suffers occasional pain from flatulent distension. Local pain in the rectum is now felt, which is not acute, but is very wearying, is augmented by much walking or by long standing, and which has been described as similar to a dull toothache. These ulcers may be multiple, and not infrequently lead to stricture of the rectum, which condition is indicated by the alternation of attacks of diarrhoea and constipation. As the ulcerative process proceeds, nature makes efforts to limit the process, which causes infiltration and thickening of the submucous and muscular tissues, and produces narrowing of the lumen of the intestine, which in time loses its tone and contractile power and becomes a passive tube, utterly unfit to perform its normal duties. The sphincters give way and the patient loses control over his evacuations. Finally, abscesses form, which, burrowing toward the surface, form fistulæ, and may perforate the bladder, the vagina, or the peritoneal cavity. If one of these ulcers be examined while yet in the acute stage, it will be found to be oval in shape, with well-defined edges: the base will be either grayish or very red and inflamed, the surrounding mucous membrane appearing normal. The rectal glands will be found to be enlarged. Should the ulcer be examined at a later stage, it will be found to be much deeper and more extensive, with great thickening and nodulation of the mucous membrane, and looking in places as though the latter had been torn off. At this stage the ulceration may be partial or may involve the entire lower portion of the rectum. The suffering is now intense, and a constant discharge of fetid pus and mucus takes place. The appearance of the anus at this time suggests malignant disease: it is covered with swollen, shiny, tender, club-shaped flaps of integument constantly bathed in an ichorous discharge. The entire rectum and sigmoid flexure have been involved in some cases, while in others necrosis of the sacrum has occurred. Patients suffering from ulceration and stricture are very liable to a low form of peritonitis, attended by intense abdominal pain.
The causation of these ulcers of the rectum is frequently very obscure: some are of syphilitic, others of strumous, origin. Some are of traumatic origin, but more often the patient was in apparent health up to the time of the appearance of the disease. The experience of Allingham would indicate that neither chronic constipation nor dysentery is a frequent forerunner of this malady. T. Claye Shaw,13 in an article entitled "On Some Intestinal Lesions of the Insane," says: "After death are found patches of ulceration sometimes so extensive as to resemble a honeycomb network. The edges are usually slightly raised, and perhaps hardened; but the ulcers are at other times mere local punchings out of the mucous membrane, and there is often a little loose gelatinous material." It is claimed that such disorders are not infrequent among the insane.
13 St. Bartholomew's Hospital Reports, 1880.
It is also claimed that the chronic mechanical irritation from foreign bodies, impacted feces, and the like exert a causative influence in the formation of ulcer of the rectum. Like typhlitis, this affection leads to chronic inflammatory changes in the immediate neighborhood (periproctitis), with the formation of fistulæ and crater-shaped ulcerations, and to the extensive destruction of the mucous membrane, followed by wasting and contraction of the rectum. The healing of these ulcers is much delayed by the fact that the ulcerated and undermined mucous membrane is irritated by the fecal masses which are especially apt to accumulate in the lower part of the bowel and around the anus. We find also hemorrhoidal swelling and ulcerations, which may be regarded as partly a cause, partly a result, of the ulcerative proctitis.
In this condition the most extensive ravages are found in the rectum and sigmoid flexure. The causes are identical with those of catarrh of the large intestine, if we except the follicular disease produced by dysenteric infection. In this form of the disease, at least in its earlier stage, the form of these ulcers is always round and funnel-shaped, with distinct thickening of the edges of the mucous membrane around the ulcers. These appearances may be explained by the mode in which the follicular ulcerations originate: "The solitary follicles become swollen, a result of catarrhal irritation, and the cellular elements accumulate in the reticulum, giving rise at first to nodules which project above the level of the mucous membrane: then the newly-formed tissue-elements become necrosed in consequence of the mutual pressure of the cells upon each other; finally, the apices of the follicular nodules give way and the ulcers are formed. The surrounding mucous membrane bends over downward toward the base of the ulcer, so that the orifices of the crypts look down into the same."14 As the suppurative process extends, particularly in the submucosa, and the tissue surrounding the follicles becomes destroyed, these small ulcers coalesce to form larger ones, and the undermined edges of the mucous membrane project over the base of the ulcers, bleed, and become necrosed. Healing is possible by cicatrization, the borders of mucous membrane becoming applied to the base of the ulcer and gradually drawn together by the cicatricial tissue. Still, this result is extremely rare if the ulcerative process has gained much headway. When, however, a follicular ulcer of some size does heal, cicatricial stenosis may result, followed by chronic constipation, just as in the case of simple catarrhal ulceration. The situation of follicular ulcerations is almost always in the large intestine, and they vary considerably in number: sometimes only a few follicles are thus affected, while in other cases the bowel is crowded with them.
14 Rokitansky, Path. Anat., iii. 1861, S. 226.
The anus and rectum may become the seat of chancroidal invasion. An ulcer of this character fairly within the rectum is very rarely met with, especially in this country, and could scarcely be produced except by unnatural intercourse. They are of not uncommon occurrence in the anal region, and are met with in this situation more frequently among females than among males. Occurring among the former, they no doubt often arise from accidental contact during normal sexual intercourse. When this condition is found in males, it rather indicates at least an attempt at unnatural intercourse. Of 1271 males affected with chancroids, only 3 were found with the disease in the anal region. Out of 388 females similarly affected, 33 were found with chancroid of the verge of the anus. The table of Debauge gives 23 cases among 206 females having chancroid in various other situations. The destruction of tissue in these cases may be very serious should the nature of the ulcer not be recognized, and stricture of the rectum or cicatricial stenosis of the anus might result. Ulceration of the rectum may occur during chronic proctitis; it may accompany advanced states of prolapse and procidentia of the bowel; it may attack a stricture of the rectum and cause peritonitis by erosion. Ulceration may accompany hemorrhoids, or it may attack them and cause dangerous hemorrhage. Finally, a very intractable form of ulceration may follow the clamp-and-cautery operation upon piles. When this untoward result is seen, it is usually due to the fact that the patient has been allowed to move about too soon. Allingham claims to have seen these ulcerated stumps of piles even ten days after operation.
The ischio-rectal fossa is peculiarly liable to attacks of inflammation resulting in abscess, as it is filled with much loose connective tissue which supports a considerable amount of fat, and is situated in a region which is constantly exposed to injury both from within and without. It is a very vascular part, being freely supplied by branches of the inferior hemorrhoidal arteries and veins; the latter, being large and destitute of valves, empty into the portal circulation. Abscess in this region is of very common occurrence, and may attack any one at any period of life. It occurs more frequently among men than among women, and usually during middle life.
Abscesses in this situation may be acute or chronic. The former variety may be caused by injury to the anus or to the surrounding parts; by exposure to cold and wet, and particularly by sitting upon damp seats while the body is overheated; by impaction of feces, constipation, and straining at stool. Irritating substances swallowed with the food, such as small pieces of bone, oyster-shell, or the stones of fruit, may excite abscess by their presence in the rectum. Among other causes are general debility, an impoverished state of the blood, the scrofulous and tuberculous diatheses. The disease sometimes occurs in quite young infants. Wetherill reports the case of an infant attacked by an enormous ischio-rectal abscess while nursing from the mother, who was at the time suffering from a succession of boils. Many cases have been traced to sitting upon the outside of damp omnibuses. Hepatic disorders, causing engorgement and stasis of the blood in the hemorrhoidal plexus, have frequently occasioned this condition. These abscesses are not always situated in the ischio-rectal fossa; frequently they are subcutaneous and just outside the anus: in other cases the starting-point may be ulceration of the mucous membrane of the rectum, with escape of fecal matter into the areolar tissue; they also originate in the submucous connective tissue of the rectum. The acute abscess is sudden and very severe in its onset; the pain is continuous, throbbing, and augmented during defecation; dysuria is almost always present, and in some cases there is total inability to pass water. There is local tenderness, dusky redness, and fluctuating prominence, and, if not interfered with, a rupture of the integument will take place and the pus will escape externally. Sometimes their formation is accompanied with a chill or with a succession of rigors: there is always considerable constitutional disturbance, febrile movement, loss of appetite, and malaise. This form of abscess is usually circumscribed and does not burrow irregularly, and sudden relief of pain and distress is coincident with their evacuation.
Chronic rectal abscess corresponds to the cold or chronic abscess in other situations: it is apt to occur among those who are much debilitated or among those of the scrofulous diathesis. These abscesses have little disposition to open spontaneously upon the surface, but they burrow extensively in all other directions—high up along the outside of the rectum, laterally into the tissues of the buttock, or downward and forward into the perineum. The process of formation may occupy many months, and sad havoc may be occasioned before their existence is suspected. They occasion no pain nor distress nor acute febrile movement, but may be accompanied with a hectic condition, erratic sweatings, and rapid loss of strength. Upon examination of the anal region in these cases a painless flat, boggy, crepitating enlargement is the only surface-indication of the probably extensive damage sustained by the deeper structures.
This form of abscess may be of traumatic origin, but more frequently the inflammatory process arises in the cellular tissue of the ischio-rectal fossa; in some cases the morbid action is due to ulceration of the rectum. In either case peri-rectal or peri-anal cellulitis will be induced. When these abscesses are of strumous origin the pus is thin, curdy, and offensive.
Both the acute and the chronic abscesses of this region are often difficult to heal, the external opening remaining permanently patulous, communication with the bowel resulting from internal burrowing and erosion, with the formation of extensive sinuses in all directions, resulting in fistulæ in ano.
This condition occurs more frequently than any other of the abnormalities of this region, Mr. Allingham finding 1208 out of his table of 4000 consecutive cases of diseases of the rectum and anus. He found also that fistulæ followed rectal abscess in 151 out of 196 cases, the abscesses which healed kindly and gave no further trouble being only 45 in number. A fistula in ano is a linear ulceration with a patulous orifice which discharges pus: it may or may not communicate with the bowel, and it may have more than one external opening. The great majority of fistulæ in this region are caused by abscess, either arising in the submucous areolar tissue of the bowel, or in the subcutaneous connective tissue in the immediate neighborhood of the anus, or in the ischio-rectal fossa, or in an ulcerated state of the mucous membrane of the rectum: in other cases it is congenital, or it may result from the presence of foreign bodies or worms in the bowel, or from puncture of the rectum by pins, scales of shell, fragments of bone, or other sharp substances swallowed with the food. Abscesses leading to fistulæ have followed kicks, blows, or wounds of the anal region: in short, anything which induces an abscess here may result in a fistula, and as in the former more cases occur in males than females, and more during middle age than at any other period, the same is true as to the latter. Fistula is quite common among the phthisical as a result of malnutrition and septicæmia, aided by the constant succussion of the perineum produced by efforts at coughing. Of the 4000 cases previously referred to, 1208 were cases of fistula; "of these, 172 presented more or less marked symptoms of lung trouble, hæmoptysis, cough, or impaired resonance in some portion of the chest."
A fistula may be complete or incomplete. To be complete, it must have two openings (it may have more)—one in the anus or rectum, and one upon the surface. There are two forms of the incomplete or blind fistula—one in which there exists an internal but no external opening, and the other in which there is an external but no internal opening. In complete fistula there may be more than one external opening, and this is in the majority of cases not far from the anus, but it may open in the perineum or upon any part of the gluteal region. When the openings are multiple they usually converge to form a common tract or sinus. The external opening presents nothing to the untutored eye to lead to the suspicion of grave internal trouble: frequently the vent is so minute and valvular or shielded by a thin pellicle as to be entirely overlooked; in other cases a little teat formed of superabundant granulations guards the entrance: there may or may not be discoloration, elevation, or depression of the surrounding integument, and erythema resulting from the irritating nature of the discharge. Inflamed and suppurating follicles in the integument about the anus are not to be mistaken for the orifices of fistulous tracts.
The internal opening in anal fistula is situated between the sphincter muscles, sometimes just within the anus, but oftener about half an inch above; in rectal fistula the internal opening or openings may be at any point above the internal sphincter. These sinuses may be very tortuous, with pockets, blind passages, or diverticulæ, and are known as horseshoe fistulæ when they commence at one side of the bowel and ulcerate around it to a point opposite before making an opening.
Of the two varieties of incomplete fistulæ, by far the least frequent is that where no internal opening exists, but where there are one or more external orifices: these do not invariably even run toward the bowel, but may extend off through the tissues in any direction. In the other variety, where there exists no external evidence of disease, considerable damage may be done before its recognition. Fistula may coexist with hemorrhoids, stricture, ulcer, or malignant growth: it may be a very trivial affair, with the internal but a fraction of an inch from the external opening, or it may be long, deep, and tortuous, with sinuses running in all directions through the buttock.
Usually, fistulæ become worse when not operated upon, but there are cases which have healed without surgical interference—others in which this condition has gone on for many years without getting any worse or without the discharge increasing in amount. The fluid discharged from a chronic fistula loses after a time much of its purulent character and becomes serous and watery; but fresh abscess and inflammation is apt to take place in these cases from feculent matter lodging in the sinus. Those which burrow most readily are the internal fistulæ with large openings, into which the feces are pushed, with the sinus running toward the anus, because of their funnel-shape.
The presence of fistula may be suspected if there are in the anal region abscesses which have not completely healed, or which, having apparently done so, break out from time to time and discharge pus; or from the existence of a circumscribed hardness or swelling unaccompanied by an opening which varies in size and is at times painful; or if there exist any ulcerated moist openings. To make a positive diagnosis the tract must be explored by a probe: enter the oiled, blunt-pointed probe gently into the external opening and let it find its way along without force, bending the probe if necessary, until it has traversed the sinus as far as it will go; then pass the finger into the rectum and feel about for an internal opening or for the point of the probe. If the finger be introduced first, the relations of the parts are interfered with and the internal opening, should one exist, might not readily be found. Sometimes the bottom of the tract does not correspond in situation to the internal opening, but extends beyond it. In those cases where no external opening exists, the rectal speculum, aided by judicious pressure, will discover an issue of pus from a sinus upon the mucous membrane of the rectum.
In order to illustrate the amount of damage which a small foreign body may cause when lodged in the rectum, Wetherill relates the following case, which occurred in his practice at the Pennsylvania Hospital for the Insane: The patient was a middle-aged man, intelligent, and an employé of the hospital. "Upon examination of the anal region I found a small, tender, firm swelling, which did not fluctuate, about an inch to the left of the anus: this had been forming for about a week, and there was no history of painful defecation, of exposure to damp and cold, nor of a blow or injury of the part. Without waiting for the development of fluctuation, I made a free and deep incision into the ischio-rectal space, and a large quantity of very fetid pus escaped: upon introducing a large probe I found that it passed up into the fossa to a depth of four and a quarter inches and turned but slightly toward the bowel. Remembering the experience of Allingham, that when the pus in these cases was very offensive there existed an opening in the bowel, I questioned the patient again as to pain in the bowel or painful defecation, which was answered in the negative. No communication could be found with the finger in the bowel and a probe in the wound, and poultices were applied, liquid diet ordered, and the man kept in bed. The cavity was loosely filled with absorbent cotton and the entire wound (apparently) healed slowly, but kindly, and in about ten days after operation the patient left the house to all appearance sound. About a week after the patient returned with the report that he felt uneasy throbbing in the part, and that there was a very slight discharge. Upon inspection I found in the surface-line of the cicatrix a pinhole opening which yielded upon pressure a drop or two of pus; upon entering a very fine probe it passed into a narrow sinus to a depth of three and a quarter inches, but no communication could be made with it with the finger in the bowel. Upon withdrawing the probe it grated over something which felt like dead bone, about two inches from the surface. I enlarged the opening, introduced a pair of fine dressing-forceps, and withdrew a piece of the rib of a chicken about half an inch in length and sharpened at one extremity to a fine point. Upon making inquiry I found that he had not eaten any chicken since the development of the abscess. He then suddenly remembered that while he was at stool a few days prior to the formation of the abscess he experienced a sudden pang of very acute pain in the rectum, which, however, soon passed off. This was no doubt the moment when the piece of chicken-bone pierced the rectum."
Hemorrhage from the rectum may be accidental, primary, or secondary—accidental when it follows the ulceration of internal piles or the erosion of large arterial or venous trunks during the progress of malignant disease, or when it occurs from the rupture of a rectum during defecation—a very rare and curious occurrence reported by M. E. Quénu;15 primary when it occurs during, and secondary when it occurs after, a surgical operation upon these parts.
15 Révue de Chirurg.; Practitioner, p. 29, Oct., 1882.
Hemorrhage from the rectum without any structural lesions is quite unusual, but occasionally copious losses of blood are seen in vicarious menstruation, and several instances have been reported.
When ligatures separate after operations upon those of broken-down constitution very copious and dangerous bleeding may occur without any symptoms save a "sensation of something trickling in the bowel," a feeling of weight and fulness in the part, with increasing weakness and syncope of the patient, until he expresses a desire to go to stool, when suddenly a large quantity of blood escapes.