Vol. II.

Original Articles.

*DIAGNOSIS OF DISEASES OF THE RECTUM AND ANUS.

By C. M. Ferro, M. D., Minneapolis.

I desire to call your attention to certain rules and methods that should be employed in the examination of rectal and anal affections, with a view to a correct diagnosis. Nearly all these affections are inclined to be chronic in their nature, but fortunately they tend to a satisfactory recovery if treated in an intelligent manner. For often these diseased conditions are regarded with indifference, at least very often no pains-taking methods are followed to ascertain their true character.

Nearly all rectal and anal troubles are regarded by the laity as piles. The patient presents himself to the practitioner, asking relief for "piles." The doctor accepts the diagnosis and prescribes an ointment or suppository, but should the patient apply for relief of some disordered condition of the nose, throat, ear, or eye, the case will, undoubtedly, receive careful consideration. before any line of treatment is advised. I have been called to operate on piles, which, upon examination, proved to be cancer. Patients, frePatients, frequently from feelings of modesty, are reluctant in having these parts examined, but they will usually consent to this procedure when they are told that no satisfactory treatment can be employed until the true nature of their malady is definitely established.

There are a great many symptoms and conditions to be considered in arriving at a correct diagnosis. A great deal of information can be gained from the patient if intelligent and observant. Corroborative proof and further knowledge of the complaint can only be elicited by careful investigation of the parts. The data obtained from the patient will refer to pain, discharges, character of stools and protrusion, if any, whether there is incontinence of urine or feces, constipation or diarrhoea, shape and form of stools.

Pain may be of all degrees, from a slight uneasiness to that of an intolerant character, and may occur in hemorrhoids, fissure, fistula, ab

*Read before the Minnesota Valley Medical Society, December 5, 1899, at Mankato, Minn.

No. 1

scess, stricture, ulceration and cancer. Internal hemorrhoids, as a rule, are not accompanied by much pain,unless inflamed or strangulated. Sometimes the contraction of the sphincter muscle will occasion sharp, stabbing, pricking pains. External hemorrhoids are always painful. The pain in fissure of the anus is paroxysmal in its character, occurring at stool or soon after, or possibly not for some hours after. It is frequently excited by some sudden movement of the body, as in the act of coughing or sneezing. It may also occur when the body is in a completely passive state, awakening one from a sound sleep. The pain of ulceration, when situated low down, is inclined to be more constant, as well as that of cancer, which is of an intense burning character. In abscess and in fistulæ that have become temporarily occluded at their outlets, Pruritis Ani, which is, in fact, a modified form of pain, is generally caused by some diseased condition within the bowel, or irritation of cutaneous tags and

eczema.

Protrusion will indicate hemorrhoids, polypus prolapsus or procidentia. The discharge may consist of blood, pus, mucous or a modification of any of these. A discharge of blood may be associated with all rectal complaints and does not, therefore, aid in arriving at a definite diagnosis. Pus may be found in abscess, fistula, suppurating hemorrhoids, it is sero purulent in fistula, cancer, stricture with ulceration, sero-saguineous in cancer, mixed with coffee-ground material. The odor from the discharge of cancer of the rectum is frequently of an intolerant character, so much so, that prominent writers have considered this an important element in differential diagnosis. Discharge of mucous may signify proctitis or polypi, but it is more likely to be associated with stricture and hemorrhoids.

The countenance of the individual should be noted. Anemia, if there is any rectal ailment, will likely be the result of hemorrhage from hemorrhoids, or it may be associated with tubercular or syphilitic ulceration of these parts. Cancer produces the cachexia peculiar to that malady. Heredity plays no part in the development of rectal ailments.

Frequency, consistency and form of stools, constipation and diarrhea may be associated with all rectal ailments, but they are of special importance when considering the existence of fibrous stricture and cancer. In the early stages

Having gained any of the preceding information, the practitioner should proceed to confirm it by making an ocular and manual inspection of these parts. Of all means the surgeon can summon to assist him in the diagnosis of these complaints, the sense of touch by the use of the index finger is the most valuable. If possible, the contents of the lower bowel should always be evacuated before making any digital or instrumental examination. The patient should be directed to lie down on the side, assuming the Sims position. This is usually the most advantageous position for examination, though when the ailment is located in the upper part of the rectum it may be required in some cases to have the patient on his feet in a slightly stooping posture. The surgeon introduces the finger into the bowel, the patient is requested to bear down, while at the same time an assistant presses upward against the elbow. This will enable the finger to come in contact with the tissues higher in the bowel than could otherwise be effected. The patient having assumed the desired position, lying on the side the surgeon seeks for any evidence of disease about the anus or adjacent parts. It goes without saying that a good light, either artificial or natural, is necessary. Old scars, discolored spots, orifices of sinuses, external hemorrhoids, cutaneous tags, condylomata, a nipple-shaped anus indicative of cancer at the outlet of the bowel, may be

seen.

The nates are separated by placing the hands with the fingers firmly pressed against the sides of the anus, at the same time requesting the patient to bear down. This brings into view a half inch or more of the mucous membrane of the bowel for inspection. In women who have born children, the finger may be introduced into the vagina, pressing downwards and upwards everting the anterior rectal wall. The finger should be lubricated with vaseline or some unctuous fatty material. Never use soap as a lubricant, as it is excessively irritating in some cases, and does not protect the finger from possible infection or from the presence of an unnoticed hangnail; besides it is difficult to remove the fecal odor that clings to the finger when soap is used.

The finger, with practice, can be made competent to detect nearly every diseased condition. to which these parts are liable, the hardened ridges beneath external tegument indicating the tracks of sinuses, their external and internal orifices, external piles and cutaneous tags, condylomata, a rigid, irritable and hypertrophied sphincter, indicating an anal fissure or ulcer, en

larged papilla, ulceration, polypi stricture, malignant and non-malignant ulceration and firmly organized piles.

There is one condition, the commonest of all rectal ailments, which the finger is incompetent to define, viz: internal hemorrhoids that are soft, compressible and varicose in their nature. It may be necessary to explore the bowel in its highest parts. The metallic sound was formerly used a great deal for this purpose. It is an unsafe instrument and even in the hands of experienced men it has been forced through the rectal walls, producing fatal peritonitis. In the place of this instrument the flexible, soft, rubber bougies are to be employed, and even then must be used with great caution and gentleness. The rectal walls are often extremely fragile in stricture with ulceration. In case of fistula, the rectum should be carefully examined, for it is often associated with stricture. The rectal speculum is an instrument that should be used with great gentleness. At this day it is quite the proper caper to conduct examinations with a view to the moral effect they may have on the patient. This is one of the instruments that cannot be used for this purpose, for the patient must indeed be unusually pious who does not say, or at least think, "damn" when one of these instruments of torture is thrust into a painful and excessively sore anus or rectum. There are many speculums, the majority of them only fit to be used when the patient is placed under an anesthetic. For ordinary use the duck-bill and Cook's three bladed, are the best.

My friend, Dr. A. W. Abbott, has devised a speculum that possesses a great deal of merit. With the patient lying on the side, with the hips well elevated, and the aid of reflected light and a retractor, the rectal walls may be inspected quite up to the sigmoid flexure.

Having very briefly alluded to the methods that should be observed in arriving at a diagnosis of an ailment situated in these parts, permit me to still occupy a little more of your time in referring to the most salient points that may be considered important elements in differential diagnosis. I am sure that what I have said or will say may be considered commonplace by men of years of experience. To the young practitioner I hope it may prove helpful when called to examine these affections.

Now, as regards hemorrhoids: Briefly, there are three forms, external, internal and a kind that may be termed extero-internal.

External hemorrhoids are situated on the margin of the anus entirely without the bowel. They have no mucous membrane covering them. They are bluish-purple in color, as they are composed of a clot of blood occasioned by dilation and partial or complete rupture of a vein. Hence they are frequently termed thrombotic hemorrhoids.

The internal are situated within the bowel, unless prolapsed, and are covered with mucous

membrane.

The third mentioned form are partially covered with true skin and partly with mucous membrane. To determine whether hemorrhoids are external or internal, the parts may be lubricated while an attempt is made to push them into the bowel, requesting the patient to bear down. If they can be replaced they are internal. The third variety should always be dealt with as though they were internal.

There is a condition which consists of hypertrophied integument about the margin of the anus, which is termed incorrectly cutaneous hemorrhoids. These tags or flaps sometimes become inflamed and are then a source of annoyance and distress. They are, if multiple, inclined to excite no little itching and constitute one of the conditions called by the laity itching piles. There is still another cutaneous affection located at margin of the anus and adjacent to it, known as condylomata, consisting of patches raised above the level of the skin. They have a pink granular surface that emits a thin, fetid secretion that once it greets the olfactory sense is never forgotten. They develope slowly and ought not to be confounded with external piles, which come on very quickly while the former are very slow in their development.

Prolapse of the bowel may be mistaken for rectal polypus. Prolapse of the bowel is strictly a protrusion of the mucous membrane outside of the anus, having no hemorrhoids attached to its surface. It may be only a side of the bowel or it may include the entire circumference. It may be distinguished from polypus as the latter is pedunculated and the finger pushing up the mass can easily detect the pedicle.

Fissure of the anus can hardly be mistaken for anything else, though it has been confounded with fistula. It is a fact that it may be overlooked in certain cases when it is concealed beneath folds or rugae of the anus and will require close scrutiny to reveal its existence. A rigid, painful, irritable sphincter that manifests great intolerance to the finger, will at once suggest the likelihood of its presence. Some cases are so excessively painful that the victims of this condition will not permit any digital examination without an anesthetic. It should not be forgotten that retention of urine, painful micturition and other reflex symptoms may be concomitant.

Fistula is not likely to be mistaken for any other condition save the one just considered, but it is sometimes difficult to determine whether a given sinus which has an external orifice opens into the bowel or at least where the internal orifice is situated. A complete fistula will, of course, allow gas to escape from the bowel. It should be remembered that the majority of fistulæ open into the bowel in the first half inch. It is usually necessary to bend the probe in order to get it to follow the course of the sinus. The finger ought not to be introduced into the bowel until the probe has found its way through the sinus. The introduction of the finger will excite contraction of the sphincter and alters the course of the fistu

la. The trained finger can usually detect the orifice without the aid of the probe. It need scarcely be mentioned that the probe must be manipulated with a delicate hand, as it causes no little distress.

Cancer of the rectum and non-malignant stricture are liable to be mistaken one for the other. Pages might be written with reference to the differential diagnosis of these maladies. will very briefly allude to the most important factors that may guide one in establishing a correct opinion.

Cancer rarely affects the young. It is usually within reach of the finger, which is able to detect a nodular roughened infiltration on one side of the bowel, or it may be uniform encircling the rectum. Evacuation of the bowels becomes painful and difficult quite early in its history. The pain is of a burning, boring character and persists long after the act of defecation. The general health speedily gives evidence of its baleful influence. Diarrhea and constipation may alternate. There is a discharge of mucous which soon becomes tinged with blood, later on purulent and finally a dark, grumous fluid, the socalled "coffee-ground discharge." Many victoms at first apprehend they are suffering from dysentery and are treated for that disease, especially when the trouble is situated high up out of reach of the finger. This may be considered an important element of diagnosis. Enlargement of the inguinal glands will take place if the trouble is situated at or near the anus. If it is beyond the first inch and a half they are not involved. It is then the deeper glands that are affected. Hemorrhage is likely to occur early, especially after examination, and may be for some time persistent. Hemorrhage wthout the presence of piles should always excite suspicion.

Non-malignant stricture may affect any age. It is almost always situated in the lower two inches of the bowel, is usually anular and smooth to the touch. Defecation is not painful in the early stages. It is of slow development and does not early affect the general health. Hemorrhage is not likely to occur until ulceration takes place. Diarrhea then becomes troublesome. A discharge of mucous is a persistent symptom.

Ribbon-shaped feces, of which so much is written, are not assumed unless the stricture is near the anus. Abscess and fistula are frequently associated with this form of stricture. There is very often a history of syphilis. The anus is likely to be patulous and almost resistless in cancer and stricture. This is an important symptom in stricture or cancer. Non-malignant and cancerous stricture may be mistaken for intussception of the rectum. There is a condition of excessive discharge of mucous. The finger can detect the cul de sac by keeping it close to the sides of the rectum and pushing upwards, while the patient is standing in a slightly stooping posture and makes an effort to force the parts downward.

In conclusion, it should not be forgotten that

The obstruction is usually, though not always due to actual blocking of the intestinal lumen by the stone. A localized peritonitis in the region of the gall bladder may paralyze the bowel in that vicinity, causing obstruction for a short time, but usually ending in recovery. Twisting of the small intestine may result from biliary colic and occlusion may be produced from the vigorous contortions of the bowel incident to its containing a gall stone. Again, after the stone has passed, peritonitic adhesions may result in complete occlusion. The healing of a large cystico-duodenal fistula may cause such narrowing of the bowel that nothing can pass it.

Large calculi nearly always reach the intestine by the formation of a fistula between the gall bladder and the duodenum. This opening, of necessity, is often of great size-even large enough to admit the insertion of four fingers. and its constancy as shown by autopsies and laparotomies for intestinal obstruction from gall stones argue very strongly for this pathological process; Rokitansky and Abercrombie, however, believe the largest stones found in the intestine can pass through the bile duct. These stones ulcerate also into the peritoneal cavity, the colon, the stomach, the urachus and thence to the bladder, being expelled par urethram,

*Original abstract of paper read before Mississippi Valley Medical Association in Chicago, Ill., October 4th, 1899.

through the abdominal wall, and it is supposed, even through the kidney and the lung. The fistula between the bowel and gall bladder usually connects with the duodenum above the outlet of the ductus communis choledochous.

LOCATION.

Leichtenstern collected thirty-two cases in which the site of obstruction was seventeen times in the lower part of the ileum, ten times in the jejunum and in the middle of the ileum five times. A few times the stone has been found wedged tightly in the ileocecal valve. The gradual lessening of the bowel diameter from above downward to the valve together with the relative fixation of the lower part of the ileum by its short mesentery, would seem to explain the comparative frequency near the valve. Two stones obstructing the bowel at different places have been found at autopsies even in cases operated. At other times the obstruction has been relieved and the trouble been later repeated at nearly the same site by another stone. The rectum has been obstructed by gall stones, probably from pre-existing pathological conditions of the bowel, by deposits on the stone in the bowel or by the direct passage of stones from gall bladder to colon.

CAUSES.

The question of aetiology of gall stones and why they are expelled into the bowel is purposely avoided in this paper. Consideration will be given only to the reasons for occlusions resulting from their presence in the bowel. Gall-stones of diameters less than one inch no doubt can be passed through the whole length of the bowel without serious annoyance to the individual, but as the small intestine is usually entered at its largest part by the stone which is urged along through a canal having a decreasing caliber (the ileum is 14 inches wide, the jejunum 11⁄2 and the duodenum is larger) it finally reaches a point. beyond which it cannot be forced. Then, too. in late life the muscular tonicity of the bowel is lessened, hence the propulsive power of it is lessened. Adhesions and from former peritonitis and other conditions, formerly mentioned in speaking of the varieties, also properly belong under the head of causes. No satisfactory explanation has been given for the successful passage of large gall stones and fatal obstructions from others of about one-fifth the size. Disproportion in the size of the intestinal canal or difference in the general scale of individuals may in a measure account for it where other conditions are absent. Women seem to be afflicted with this trouble four times as often as men.

I have had the good fortune to see one case -fortunate in experience and result, as the patient recovered without operation. The history of it is as follows:

Mrs. D, white, aged 44 years, multipara. was seen August 9, 1897, in answer to an urgent summons. Previous health had been good, al