This class of affections depends upon constitutional infection, direct extension of disease by contiguity, by contiguity from disease in neighboring organs, or by abnormal conditions excited by disease of remote origin; and are frequently due to changes in the nervous and vascular supply.
True primary syphilitic chancre of the rectum must be an extremely rare lesion, and could have been acquired only by unnatural intercourse. There are syphilographers who deny that the hard chancre has ever been found within the sphincter muscles; but it certainly is not uncommonly found in the anal region, and oftener among women than men. The table of Jullien gives 12 instances of this lesion in males, and 1 instance of chancre of the buttock, out of 77 cases, while among 82 cases occurring in the opposite sex, 21 were of the anus and perineum and 4 of the buttocks. The French authorities give the frequency of this condition in men as 1 case in every 119; in women, 1 case in every 12.
Anal chancres are easily overlooked, as they occupy the puckered folds of the anus, which when not opened out to the fullest extent afford perfect concealment: they may be either in the form of cracks or slight fissures, elongated ulcerations, or firm papules. It has been claimed that the initial lesion has provoked stricture of the rectum, but this is not probable.
The secondary manifestations of this disease which show themselves in the anal region are some of the syphilodermata, moist papules, mucous patches, and moist papillomatous excrescences or condylomata. The statistical tables of Davasse and Deville16 in regard to the occurrence of moist papules and mucous patches in women show that out of 186 cases they appeared about the anus in 59 and on the perineum in 40. Bassereau's17 statistics show that in men these lesions occurred in the anal region 110 times out of 130 cases. These are, of course, very contagious. Besides true syphilitic warts, which sometimes occur in this region, it is quite usual to see the anus surrounded and the entire gluteal cleft filled up with moist, offensive, papillomatous excrescences, which remain obstinately so long as these surfaces are permitted to rest in moist contact. Syphilitic stricture of the rectum is one of the results of a later stage of infection, and occurs oftener among women than men. It is stated by Jullien that of 60 cases only 7 were men, the remaining 53 women. They are invariably formed as follows: A gummatous deposit in the submucosa undergoes ulceration, and the subsequent cicatricial contraction gives rise to the stricture. Whether the stricture will be valvular or annular depends upon the extent of rectal mucous membrane involved in the ulcerative process. The diffuse gummatous infiltration of the ano-rectal tissues and the subsequent deposition of contractile tissue are the most usual causes of these specific strictures. The lower portion of the rectum is commonly the situation of specific ulcerations, usually of the secondary or tertiary stage, which lead to the formation of stricture: this occurs more frequently among women than men, and between the ages of seventeen and thirty years. Gosselin and Mason regard strictures as the result of chancres, and not as the result of constitutional infection; but it is known that ulcerations of secondary syphilis may extend upward from affections about the anus, and also that gummata do commonly give origin to this condition. Gummata, and strictures following them, may be distinguished from other affections on account of the greater distance from the anus at which they occur, chancres or chancroid ulcers being usually within four or five centimeters of the anal orifice. Strictures due to gummata are more apt to occur late in life, but may therefore be easily confounded with cancer. Condylomata at the anus are often associated with syphilitic disease of the rectum.
16 Internat. Encyclop. of Surgery, vol. ii. p. 508.
17 Loc. cit.
There are cases which yield abundant evidence of struma in the form of enlarged glands, chronic abscess in the neck, swelling and abscess in the vicinity of the articulations, and the like, in which ulceration of the mucous membrane of the rectum has been found: this condition may result in fistula in ano by erosion, permitting escape of flatus and excrementitious products into the cellular tissue. A similar result may follow by erosion of the bowel from a strumous abscess in the connective tissue around the rectum; both these forms tend to the production of that class of fistula which has no outlet at the surface, but which has one or more openings upon the mucous membrane of the rectum. Thus concealed (for often there is no marked surface indication of either abscess or fistula), they may remain for a long time unsuspected and acting as a serious drain upon the already impaired constitution. The pus in these cases is watery, curdy, and offensive. These chronic conditions are subject to intercurrent attacks of acute inflammation, due to the lodgment in the abscess cavity or the fistulous tract of fecal matter or indigestible solid substances. Any or all of the abnormalities of this region may be complicated by the existence of tubercular or scrofulous conditions of the system. Tubercular ulceration of the rectum is now a well-recognized condition. Rectal ulceration and tubercular disease of the lungs have not been found to coexist in any marked preponderating number of tabulated cases. The frequent association of fistula in ano and tubercular disease of the lungs has long been recognized, Allingham having found 172 such cases among 1208 cases of fistula in ano.
The pathology of tubercular ulceration of the rectum is graphically described in Ziemssen's Encyclopædia as follows: "These [ulcerations] begin in the follicular apparatus with swelling of the individual follicles and their vicinity from tuberculous deposit. The newly-formed cells become caseous, the superficial layer of the tubercle breaks down, and thus ulcerations arise of a round funnel shape. The enlargement of these ulcerations is probably produced by the constant formation in the base and edges of the ulcers of new nodules, which themselves caseate and ulcerate. This process of extension, to which these tuberculous ulcerations of the intestines exhibit a marked tendency, takes place chiefly in a transverse direction (girdle-shape), following the direction of the blood-vessels. The infiltration and necrosis may advance longitudinally, and, finally, the individual ulcerations coalesce with each other: in this way may be explained in part the dentate appearance of the edges of these ulcerations. The ulceration extends also in depth, although usually the muscular coat appears to be covered by a thick layer of connective tissue: the destruction advances slowly in the muscularis, but in the lymphatic vessels which pierce the muscularis less opposition is presented to the progress of the tuberculosis; and thus it is not uncommon to find tubercles ranged one after the other, like links in a chain, from the base of the ulcer directly down to the serosa. Healing is extremely rare. The most frequent situation is the lower end of the ileum, but the process may extend upward to the stomach, or downward, involving the rectum. There is almost invariably unmistakable signs of tuberculosis in other organs. It is possibly never primary, but this is a still-disputed point. It usually occurs with tuberculosis of the lungs, and when so occurring it is always secondary. The clinical symptoms of this state are by no means characteristic."
Dwelling upon the subject of intestinal tubercle, it has been suggested by Klebs18 that the intestinal disease is produced by swallowing morbid products derived from phthisical lungs—an hypothesis supported also by the fact that tubercle in the intestines tends so strongly to spread downward. "The seat of the deposit is the submucous tissue or the corium of the mucous membrane: it is certainly subjacent to the basement membrane, and not contained in the follicles, as Creswell taught."
18 Jones and Sieveking, London, pp. 593-595.
Woodward, in his article upon diarrhoea,19 says: "The lesions, whether mild or severe, are most generally seated in the cæcum and colon, but more or less extensive tracts of the small intestine, especially of the ileum, are often involved also." He continues: "Tubercular disease of the lung was noted in nearly one-sixth of the autopsies of fatal cases of forms of flux heretofore described. Possibly the frequency in chronic cases may be explained by the fact that protracted intestinal flux forms the development of lung phthisis in the predisposed."
19 Med. and Surg. History of the War of the Rebellion, p. 266.
The rectal fissure or painful ulcer may be connected with diathetic causes, as struma or scrofula: it is doubtful if syphilis should be included among its causes.
The forms of cancer met with in these regions are epitheliomatous, scirrhous, encephaloid, and colloid. Considerable diversity of opinion has existed as to which variety occurs most frequently; but it is now probably a matter of absolute knowledge that the epithelial form is the one most commonly observed, and next to that in frequency the scirrhous form. Encephaloid and colloid are of quite infrequent occurrence. Again, as to the sex in which this affection appears the most often, there is much disparity existing between surgical writers: it is usually thought to be much more prevalent among women than among men. This is not the experience of many of the authorities upon this subject, yet the statistics of the Hôtel Dieu, Paris, furnish overwhelming evidence in favor of its preponderance in women. Carcinoma of the rectum, occurring as a primary infiltration in the rectum, probably occurs oftener in men, but there are among females so many contiguous structures prone to cancerous degenerations, as the uterus, the vagina, the ovaries, the Fallopian tubes, tumors and cancerous masses occupying Douglas's cul-de-sac, that it would seem likely that they would be more frequently the victims of secondary cancerous deposit in the bowel or of erosion and extension of disease by contiguity or continuity. Epithelioma in other situations attacks men much more frequently than women. This form of disease usually occurs in middle life and in old age, but to this general rule there have been many exceptions; it has been seen in children. Allingham quotes its occurrence in a lad of seventeen, and Gowland in one of thirteen. It very rarely occurs as a secondary deposit of cancer in a remote region or organ. In the table of 4000 cases of rectal and anal disease, before referred to, cancer existed in 105. This disease is usually within easy reach of the finger, except when the growth is in the sigmoid flexure, being within an inch or two of the anus or from two and a half to three inches above it. The epithelial form, when it commences at the anus, is closely analogous to epithelioma of the lip: from the anal outlet it spreads upward into the bowel, or it may be primarily seated there. When occupying the junction of skin with mucous membrane it is sometimes sluggish, and a long time may elapse before it takes on aggressive action: induration, nodulation, obstinate fissure, or fungous growth marks its inception; as the condition proceeds, infiltration of surrounding structures takes place and large, hard, irregular masses form, which ulcerate, split, and form cauliflower excrescences. The rectum becomes blocked with fungoid growths: both these and the cancer proper are very vascular, and frequent hemorrhages occur, and an offensive muco-purulent discharge constantly oozes from the bowel.
Scirrhus of the rectum commences as an infiltration of the submucosa, which rapidly involves the other elements of the bowel, pushing hard nodules upward into the lumen of the intestinal tube: these break down and form ragged ulcers with indurated margins, and bleed profusely. Its situation is usually not higher than three inches above the anus. It has a tendency to invade all the neighboring organs and soft structures, to bind them to itself in a firm, dense mass, and to form communications with the vagina, bladder, uterus, perineum, and penis. Abscesses and fistulæ are common complications.
These neoplasms are insidious in their onset, and when seated at some little distance from the anus do not excite much pain at first. In the epithelial form the anus presents an abnormal appearance: it is inflamed and is covered with irritated, hypertrophied tags of integument bathed in a sanious, offensive fluid. Difficult defecation, of which the natural form is absent, with inordinate tenesmus, a sense of weight and fulness in the bowel, and an irritable condition of the bladder, are among the symptoms. The feces are passed in little, irregular lumps or broken fragments, or this state is accompanied by or alternates with small, liquid, offensive stools. As the diseased action proceeds, very severe local and general pain is endured: this is of a dull, lancinating character, and affects not only the diseased bowel, but involves the entire contents of the pelvis, shoots down the thighs, up the back, and into the penis: frequent and exhausting hemorrhages take place; the patient exhales a peculiar sickening odor; his complexion becomes cachectic; his strength fails; and death ensues, after a variable period of intense suffering, from a few months to two or three years after the first symptoms appeared. The modes of termination of life in these cases are—exhaustion, secondary deposition, septicæmia, peritonitis, and hemorrhage. Stricture of the bowel and very extensive ulceration attend all of these advanced cases of malignant rectal disease.
The encephaloid variety is prone to very sudden and rapid breaking down, and may destroy life within a few months. If the finger be passed into the bowel in a case of encephaloid degeneration, it will encounter a large soft tumor occluding the gut: this is a very different sensation from that imparted to the finger in a case of epithelioma or scirrhus. In the former there will be felt a crepitating, as though due to the giving way of a moist, friable substance; in the latter the touch will perceive dense, irregular nodulations and ragged ulcerations having very firm margins.
The rectum may also be involved and destroyed by any of these neoplasms in neighboring organs. A middle-aged woman who was admitted to the Pennsylvania Hospital in a very advanced stage of epithelioma of the cervix uteri died from hemorrhage from the rectum and uterus in eight minutes. At the autopsy it was found that the disease had almost separated the cervix from the body of the uterus, had involved the cul-de-sac of Douglas, and had eroded a large opening into the rectum. Numerous ends of large vessels were observed which had undergone erosion.
Carcinoma of distant organs does not seem to frequently involve the rectum by secondary deposition. "In 160 cases of gastric cancer examined at the Pathological Institution in Prague, Dittrich found secondary cancer of the rectum only twice."20
20 Leube, Ziemssen's Cyclopæd., vol. vii. p. 235.
In these cases of carcinomatous disease originating in the bowel the neighboring lymphatic glands are indurated and enlarged, and secondary deposition in neighboring and distant organs is the rule.
The lower portion of the intestinal tract may become involved in disease by direct extension from the colon, as in dysentery following enteritis or entero-colitis. Habersham says that diarrhoea arises generally from an irritated condition of the large intestine, catarrhal and mucous diarrhoea from slight inflammatory disease closely allied to ordinary coryza affecting the mucous membrane of the large intestine. "In the diarrhoea of soldiers the lesions of the large intestine have been either those of congestion with varying degree of extravasation or of ulceration more or less extensive. The colon in the former cases has invariably presented patches of intense congestion, and in numerous instances extravasation, the amount and intensity varying in different subjects, in a few the whole mucous surface of the intestine having a livid red color; in others tracts of more or less intense congestion at irregular intervals, as in the small intestines, would be noticed. The ileo-cæcal valve almost invariably presented intense congestion. The rectum has uniformly presented intense congestion, with more or less fibrinous exudation. Frequently the presence of fibrinous exudation was a question of doubt."21 The entero-colitis or ordinary summer complaint of infants not infrequently causes a very troublesome form of proctitis. Besides the ordinary causes of dysentery, Feyrer22 states that it is caused by irritation of the solar plexus of nerves, also by the inhalation of sewer emanations and by the ingestion of impure water.
21 Med. and Surg. History of the War of the Rebellion, vol. ii. p. 102.
22 Times and Gazette, 1881, p. 87.
"In dysentery the anus becomes bluish-red, and is even marked with cracks and rents; it is painful to the touch and tightly contracted. In the later stages of severe cases it becomes large and gaping; then the stools are generally discharged unconsciously, and the pain is slight, paralysis of the sphincter ani having occurred. These symptoms indicate generally that death is to be expected. In some of these cases the pathological lesions are limited to the rectum. Dysentery may succeed typhoid fever."23
23 Heubner, Ziemssen, vol. i. p. 552.
"Pigmentation is common after dysentery, and also after typhoid fever when dysentery has existed. Pigment-deposits are encountered in the large intestine in those who have suffered from repeated attacks of acute diarrhoea or from protracted flux. They may be seated as diffuse patches on the general surface of the mucous membrane or may be more especially localized in the closed glands. The diffuse form of these deposits is more frequently encountered in the large than in the small intestine, and is apt to be more intense in the former, producing darker and more extensive discoloration; hence the ash- and slate-colored, greenish, and blackish tracts which are so frequently observed in the cæcum, colon, and rectum."24 Follicular ulceration of the rectum sometimes follows chronic dysentery and typhoid fever. Woodward has observed that a catarrhal condition of the rectum commonly occurs in typhoid fever cases. Referring to typhoid fever lesions of the large intestine, Rokitansky25 says: "The ulcerative process is by no means confined to the small intestine; we have seen the mucous membrane of the large intestine riddled with ulcers. They were many of them of large size, and had clean-cut, non-thickened margins. This condition, indicating the absence of reparative action, is not nearly so frequent as that of thickening and induration, which generally took place to some extent in the edges of the ulcers. The bottoms of the ulcers are commonly formed by the submucous tissue. Sometimes the muscular fibres are completely exposed: this, however, is generally the result of secondary advance subsequent to the reception of the morbid action."
24 Med. and Surg. History of War of Rebellion, vol. ii. p. 308.
25 Jones and Sieveking, p. 590.
John Harley26 calls attention to the intestinal lesions of scarlatina as follows: "I know of no disease in which the morbid effects are more uniform. Scarlatina is essentially a disease of the lymphatic system. It is attended with inflammatory action of this system of glands, in which are included the agminated glands of the intestine. In 28 cases examined, 8 had the solitary glands of the large intestine enlarged and inflamed; in 1 there was acute desquamation of the mucous membrane of nearly the whole of the large intestine. In about half the cases the large intestine was found healthy."
26 Med.-Chir. Trans., vol. iv. p. 102.
The rectum and anus are frequently subject to attacks, by contiguity, from diseases in neighboring organs. The most frequent of these is doubtless that form of ischio-rectal abscess which invades the bowel, causing fistula in ano. Various neoplasms having their seat in the tissues or organs near the bowel may obstruct it by simple mechanical pressure, or may cause inflammation, infiltration, and ulcerative erosion. Mechanical encroachment by the pressure of a foreign body in the vagina may cause grave interference with the normal functions of the lower bowel. At the out-patient department of the Pennsylvania Hospital in 1880, Arthur V. Meigs, assisted by Wetherill, removed a large, hollow, glass ball-pessary from the upper end of the vagina of an aged woman, who declared the pessary had been so placed by a physician sixteen years before, and had remained ever since, despite her repeated efforts to remove it with an ordinary table-fork. Upon its extraction, which was accomplished with difficulty, a small portion of its surface was found covered with scratches. Its presence had caused constipation, impaction of feces, and atony of the rectum.
Interference with the rectal functions often follows tedious cases of labor where the child's head remains long in the perineum.
"In diseases of the spinal cord and its envelopes there is a great tendency to constipation, owing to impairment of the secretion of the intestinal juices. The intestinal movements are usually much affected, either in the way of increase or diminution, in the former of which the symptom is a frequent, watery, slimy diarrhoea; as a less common condition it is even capable of being produced reflexly. Thus in a patient with chronic myelitis I observed the regular evacuation of a mucous fluid mass from the intestine as often as his bed-sores were cleansed; and the like has been seen in dogs after division of the lumbar cord. Much more commonly there is habitual, even excessively obstinate, constipation, of which almost all chronic spinal patients complain. The stool is slowly discharged, dry and hard, and the evacuation occurs only at considerable intervals and after the application of energetic remedies. Several causes doubtless contribute to this: diminution of intestinal secretion and peristaltic contraction, and probably also weakness of the abdominal muscles of compression, which is often present. If there is an extreme degree of weakness, meteorism and accumulation of feces are other consequences. We do not know exactly from what portions of the cord these disturbances proceed."27
27 Erb, Ziemssen's Encyc., xiii. p. 138.
"There are also in many diseases of the cord disturbances of evacuation caused by paresis or paralysis of the sphincter ani. In mild cases simple difficulty in retaining stool for any length of time exists. There may be also great disturbance of sensibility, so that the patient does not feel the call, and even if he possess some voluntary control, he is surprised by the discharge, of which he feels nothing."28
28 Erb, loc. cit., p. 139.
The sphincter ani is affected in cases of myelitis, the usual symptoms being those of paralysis; the same is true in softening of the cord or myelo-malacia, and there is also diminished reflex excitability of the anus.
Paralysis of the bladder and rectum is often delayed in cases of slow compression of the cord; but if the compression exists to any considerable extent, involuntary discharges of urine and feces will be sure to occur. A pressure-myelitis of the lumbar portion of the cord causes paralysis of the bowel, and in the later stage of some cases of bulbar paralysis it also occurs.
Early in the course of spinal meningitis there exists a spasmodic condition of the sphincters: these muscles are also paralyzed in spinal and in meningeal hemorrhage, and from the pressure of tumors upon the cord giving rise to paraplegia. "In acute ascending paralysis the bladder and rectum are generally quite undisturbed in their functions. In hemiplegia and in hemi-paraplegia specialis disturbances in the evacuation of the bladder and bowels are almost always present, and in the acute traumatic cases it is especially common to find severe paralytic symptoms at the beginning of the attack (complete retention or complete incontinence, involuntary stools, etc.), which, however, generally soon recede and give place to lighter, more permanent trouble, as weakness of the sphincters. Sometimes these disturbances are very significant."29
29 Ibid., loc. cit., p. 740.
The following is an extract from Gower's Diagnosis and Diseases of the Spinal Cord:30 "The spinal cord possesses centres, situated in the lumbar enlargement, which preside over the action of the bladder and rectum. They are probably complex reflex centres: that for the sphincter ani is the more simple.... But if the volitional path in the cord is damaged above the lumbar centres, the will can no longer influence the reflex processes: as soon as the feces irritate the rectum they are expelled by the reflex mechanism.... If the damage to the cord involves also the sensory tract, the patient is unconscious of this process; if the sensory tract is unaffected, the patient is aware of the action of the bladder or bowel, but cannot control it. It is often said that there is permanent relaxation of the sphincters, but this is true only when the lumbar centres are inactive or destroyed. In this condition evacuation occurs as soon as feces or urine enter; the urine escapes continuously instead of being expelled at intervals.... We may, however, distinguish between the two states of the rectum by the introduction of the finger: if the lumbar centre is inactive, there is a momentary contraction due to local stimulation of the sphincter, and then permanent relaxation. If, however, the reflex centre and motor nerves from it are intact, the introduction of the finger is followed first by relaxation, and then by gentle, firm, tonic contraction."
30 London, 1880, p. 37.
Morton has at this time in his wards at the Pennsylvania Hospital two cases of rectal paresis following fracture of the vertebræ. The first, a lad aged nineteen years, while crossing the Atlantic was struck during a gale by a spar upon the back about the region of the lower dorsal vertebræ. From the deformity and from other symptoms there was undoubtedly a fracture destructive to the normal functions of the cord. Upon the arrival of the steamer, some ten days after the accident, the lad was brought to the hospital, where he has remained for the past eighteen months. Total palsy of sensation and motion has continued from the time of the accident to the present day, and extends from the navel downward: the sphincter ani is constantly but feebly contracted; the finger, when pressed into the anus, encounters slight resistance, which continues during and after the simple passage of the finger; very slight pressure, however, against the sphincter causes a very marked relaxation, which continues so long as this is kept up. With the removal of the finger the sphincter slowly and fairly contracts. The second case is also one of vertebral fracture which has been in the hospital about ten months. In this instance the sphincter is always found contracted, but it readily yields under finger pressure, and contracts quickly and regularly in the absence of this pressure. Constipation and rectal impaction readily occur, and the bowel requires to be regularly emptied. In another case, at the Episcopal Hospital, under the care of W. B. Hopkins, there is fracture of the spine, with total palsy below the seat of injury. The margins of the anus were found in apposition, but in no firm contraction: mere contact of the finger appeared to have little or no effect, but slight pressure upon the sphincter caused a contraction, and very moderate pressure upon the anus after the introduction of the finger produced excessive dilatation. The action of the sphincter was in all respects very tardy.
Two recent cases (August, 1883) of fracture of the dorsal vertebræ have been admitted into the Pennsylvania Hospital. One, a lad aged ten years, was struck by a bale of cotton which fell upon him; the other, a man aged thirty years, fell from a second-story window. In both cases total palsy occurred at once upon the receipt of injury, and in each the same conditions of the anus have obtained as before described.
In the convulsive attacks incident to epilepsy the sphincters of the bowel and urinary bladder are relaxed and the discharges are involuntary; probably, also, one of the first symptoms indicative of tumor of the base of the brain is recognized in involuntary rectal evacuations. Rectal incontinence may be also due to tabes, while atony and constipation are sometimes noticed as a result of excessive intellectual exertion (DaCosta). The same may be said of chronic lesions of the brain and spinal cord. Paresis of the rectum has been noticed as a result of chronic congestions of the heart and in hepatic disease. Allingham has observed failing nerve-power as a cause of rectal atony: the latter, with constipation, is one of the commonest troubles attendant upon melancholia and the chronic forms of insanity. Seeley of Ovid, New York, related to Morton a case of paraplegia with rectal paresis and dysenteric symptoms from malarial poisoning in a married lady aged thirty years. An examination revealed an immense rectal impaction. A free administration of quinia was followed by complete recovery in a few weeks.
Apart from those cases in which spasm is induced by the irritating stools of diarrhoea and dysentery, or by local ulcerations, fissures of the anus, and intestinal worms, there are those in which painful spasm occurs, due to the presence of a vesical calculus: it is also caused by urethral stricture, impaction of feces, irritations and inflammations involving the bladder or the adjacent organs. Spasm is also seen in nervous females, without constipation; also in the varied irritations of the female genito-urinary apparatus. In cases where spasm is due to rectal impaction retraction of the anus is frequently seen.
This most painful, distressing, and obstinate affection belongs to the class of neuroses, and is simply functional in character, without the least structural change in the skin or mucous membrane of the anus or rectum: the itching may be confined to the former or it may extend into the latter. It may be brought about by a constipated state of the bowels, but it is more often due to derangements of the digestive apparatus.
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 Portal31 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.
31 Cours d'Anatomie médicale, tome iv. p. 276.
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 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. Anstie33 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.
32 Erb, Ziemssen's Cyclop., vol. xiii. p. 139.
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 reported35 of a curious pain in the sole of a foot caused by rectal disease; and another36 in which irritation of the eyes was caused by hemorrhoids.
34 Ziemssen's Cyclop., vol. xiii. p. 138.
35 Med. Times and Gazette, 1868, vol. ii. p. 175.
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.
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 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. Wilkes37 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.
37 Soc. Trans., vol. ii.
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.