CHAPTER XLII (Part 2)

or less redness and swelling of the skin ; this is a thrombosis of a hsemorrhoidal vein, known as an inflamed ex- ternal h'cemorrhoid, or more commonly as a throm- bosed pile." The SAvelling, however, may take the form of an indolent infiltrating swelling without marked pro- jection of the surface, and more apparent- to touch than to sight. If it is an ill-defined thickening of the skin and subcutaneous tissues, painless, with slight livid-red discoloration of the skin, or the skm is ulcerated, with a firm yellowish-white slough form- ing the floor of the ulcer ; or if there is independent ulceration of the bowel, gumma of the anus, or ano-rectal syphiloma, is to be diagnosed ; a positive VVassermann reaction and other evidence of syphibs confirm the diagnosis. If, however, the induration is more nodular, or assumes the form of an ulcer having thick everted edges and firm uneven base XLii] PROLAPSE OF RECTUM 609 with small warty excrescences, and the inguinal glands are enlarged, it is epithelioma of the anus. Lastly, the surgeon may find that there is a pro- trusion from the anus. He must examine any such protrusion carefully to notice whether it consists of the everted mucous membrane of the bowel, and whether there is or is not a groove or sulcus be- tween the protrusion and the anus, and whether there is an orifice at the end of the protrusion. If the mucous membrane covering the protrusion is directly continuous with the skin of the anus, it is either a simple prolapsus or prolapsed internal hfemorrhoids, and this must be decided by detect- ing low, soft, sessile, deep-red or livid projections from the surface of the membrane, which prove the case to be one of prolapsed inleryial hcemorrhoids ; if no such vascular outgrowths are seen it is a case of simple or partial prolapsus. If, however, the finger or a probe can be intro- duced into a sulcus around the base of the protrusion, it is a case either of complete prolapse or of polypus' and this can be decided by noticing whether or not there is an orifice at the extremity of the projection. If the projection has an orifice at its extremity, and is covered by normal mucous membrane, it is a. complete prolapse, or procidentia recti. This will he distinguished from the partial prolapse, or prolapse of mucous membrane only, by the sulcus round its base, by the fact that it is marked by circular folds in the mucous membrane, by its greater size, and often by its greater length ; when it is of old standing and one that has been habitually down, the mucoils membrane becomes drier than normal, approachin.. the condition of skin. ^ If the finger passed into the sulcus round its base can feel the refiection of the wall of the rectum on u 610 SURGICAL DIAGNOSIS [chap. to the prolapse, it is usually called prolafsus or fro- cidentia ; but if the finger cannot reach the bottom of the sulcus, or feel this reflection, it is spoken of as an intiissuscepion. When the projection is large the surgeon may be able to feel the gurgling of coils of small intestine within its anterior part. In rare instances a stricture of the rectum may be forced down through the anus ; the character of the orifice, its induration or ulceration, may indicate the nature of the case, but after reduction the diagnosis will be readily made. If the patient complains of severe pam and of inabihty to replace a projecting mass, and if it la oedematous and swollen, livid in colour, or perhaps even black and gangrenous in places, it is a strangu- lated frolapsus, in which strangulated internal files can usually be recognized. Where the projecting mass is sohd, without any terminal orifice, it will be identified as a folypus. The most common variety of polyp is a bright-red, soft, pedunculated growth about the size of a cherr)^ found in children and yoimg persons, consisting of adenoid tissue, and called the glandular folyp ; it causes hfemorrhage, and is the great cause of hsmor- rhac^e in children ; if strangled by the sphmcter or associated with a fissure, there is acute pam. These polyps grow from the mucous membrane of the rectum proper. Firm fibrous polypi are found only m adults, in the form of smooth rounded growths with a slender and often a long stalk. They vary much in size, spring from the ano-rectai ]uiichon, and are also known as anal fibromata, fdlous polypi, recognized from their velvety surface, rarely pro- trude from the anus. Small polyps may be foimd thickly scattered over the surface as far as tlii finder" can reach. Cancerous masses arc recog- XLii] RECTAL EXAMINATION 611 nized by tlieir hardness, tlieir association with ulceration, and the fact that they infiltrate the wall of the rectum. Polyps are to be distinguished from internal hsemorrhoids by their being distinctly pedunculated, while piles are sessile, and also by the fact that their pedicle is attached well above the sphmcter ani ; piles are swellings of the anal canal. The verge of the anus should be carefully exam- ined for ftstulcB ; minute fistulse in this situation are said to be not infrequent in syphilitic disease of the rectum. 3. Examine the rectum.— For this, the right fore- finger, protected by a rubber finger-stall or glove and well greased, is gently introduced into the bowel, while the patient " strains down " to relax the sphincter muscle ; in this way the tone of this muscle can be determined. The finger should be passed in to Its full length, and gently swept round the bowel, feeling especially for any narrowing of its calibre, any induration of its walls, and any breach in the smooth mucous surface; by sweeping the finger round, a mucous or soft gelatinous polypus may be caught, or even have its pedicle torn across. It is necessary to use the utmo.st gentleness in this ex- amination, where there is any ulceration of the surface, or stricture, as forcible pressure has been known to rupture the thinned and infiltrated bowel In the male, the prostate, the base of the bladder when full, and the vesiculse seminales can be felt in front of the rectum ; in the female, the cervix uteri projects back towards the sacrum and is plainlv felt through the rectal walk; in both sexes the sacrum and coccyx are felt behind, and the ischial spines and tuberosities at the sides. These parts either in their natural condition or enlarged must not be mistaken for disease of the rectum G12 SURGICAL DIAGNOSIS [chap. By meaus of a suitable speculum the interior of the bowel can be examined with the eye, and the characters of any ulceration or new growth, or pro- jection from the surface, as well as the condition of the vessels of the mucous membrane, can be deter- mined. It must be passed with care, and only after the finger has demonstrated the safety of passing it. It will be most convenient to discuss iirst of all the diagnosis of those lesions which are revealed by the speculum, but which are not detected by the finger. Immediately within the anus the submucous veins may be found congested, tortuous, and en- larged, and visible as a venous plexus beneath the ' mucous membrane ; this is best described as limnor- rhoidal varix ; it is a common condition, and gives rise to itching about the anus, sometimes to hasmor- rhage, and it may run on to the formation of piles. A ncevus of the rectum may be met with as a livid, raised, soft, compressible, circumscribed swelling of the lining of the bowel ; the only symptom it occa- sions is severe haemorrhage from time to time ; being a congenital disease, it will usually be found in chil- dren and young persons. These two affections will be distinguished by the position of the dilated vessels, : and by the ncems forming a distinct soft bulgmg of the surface in which individual vessels are not per- j ceived, while the varix does not form a tumour j and individual veins are seen with clear spaces between them. A very different condition is that m which the mucous membrane is found of a uniform deep-red colour without its normal gUstening look, is hot to the touch, and occasions an aching or burn- ing pain to the patient, and an increased secretion of rectal mucus ; this is chronic catarrhal proctitis. Sessile deep-red projections from the mucous mem- XLii] RECTAL EXAMINATION 613 brane of the anal canal are to be recognized as internal hcetnorrJioids ; these vary somewhat in appearance, some being very livid, others being of a bright-red colour and bleeding very readily ; they are usually too soft to be detected by the finger, but if of long standing, and occasionally prolapsed and strangled, they may become firmer and distinctly palpable. The various forms of polypi already mentioned may be seen by the speculum. The villous polypus, forming a sessile warty or papillated tumour, or consisting of numerous detached villi, and then called polyadenoma, may only be detected by this means of examination ; it will be distinguished from cancer by the absence of induration of the rectal wall. The inner orifice of a fistula may be seen, and a probe can be introduced to detect the course of the sinus ; the orifice can generally be felt. The surgeon will recognize two forms of blind or in- complete internal fistula, in one of which the sinus passes outwards under the skin, causing induration and lividity by the side of the anus ; while in the other the probe passes up along the gut, either in the submucous tissue, or outside the bowel in the superior pelvi-rectal space. By the thickness or thin- ness of the tissues overlying the probe in the sinus the surgeon will distinguish between the latter two. In some cases of simple stricture of large calibre the finger fails to detect the narrowing, owing to the absence of induration, but the contraction is ren- dered visible by the speculum ; the size and shape of the opening, as well as its lack of dilatability, will at once enable the surgeon to diagnose it. The speculum will, of course, expose to view the anal fissures and irritable ulcers already mentioned. 614 SURGICAL DIAGNOSIS [chap. The afiections of the rectum which the frnger detects may be grouped into ulcers, fishdce, com- pression of the bowel from without, stricture, and neiv cjrowths of the rectum. Ulcers of the Eectum An ulcer is detected by the absence of the per- fect smoothness of the mucous lining of the bowel. The features to be specially recognized in reference to any rectal ulcer are — (a) whether it is the inter- nal orifice of a fistula (this can only be determined by making an effort to pass a probe along it) ; (5) whether single or multiple ; (c) whether attended with other changes in the coats of the bowel. The ulcer may be foimd on an internal jjiie or polypus as a result of injury in the act of defsecation. Chronic ulceration of the rectum is very often the result of infection, and the surgeon must try to identify the particular organism concerned. An ulcer found in a person known to be suffer- ing from tuberculosis is probably a tuberculous ulcer ; and if the ulcers are multiple and there is slight thickening of the edge of the sore, or yellow tuber- cles are seen in the mucous membrane, or the tubercle bacillus is found in the pus, the diagnosis is established. Tuberculous fistulse are often associ- ated with tuberculous ulcers. In other cases the amoeba of dysentery, the goa- ococcus, or the Sj^iironema pallidum will be isolated from the discharge, and the ulcer thus shown to be in the one case due to dysentery, in another to gonorrhoea, and in a third to syphilis. Where only staphylococci, streptococci, and the Bacillus coli are found in the discharge, one or other of them may be found to be more abundant or more vigorous than the others, and to be the probable cause of the ulceration. XLii] KECTAL STRICTURE 615 If the ulcer has a thickened base, and an everted raised edge, with an uneven warty surface, it is a cancerous ulcer. Strictures of the Rectum Lastly, we must speak of the diagnosis of the conditions leading to narrowing of the calibre and induration of the walls of the rectum ; these are often met with together, and are recognized by the finger. If the bowel is found to be narrowed, notice par- ticvdarly the position and extent of the narrowing, the character of the mucous membrane at the seat of stricture, and whether there is idceration or a nodular thickening of the mucous membrane. The rectum may be displaced or compressed by swell- ings or other pathological changes outside it ; the commonest instance of this is hypertrophy of the prostate, which is recognized as a firm rounded mass bidging into the front of the bowel and causing troublesome tenesmus. Abscess in or around the prostate forms a very tender fluctuating tumour in the same position, and malignant tumours may develop in this situation, eventually infiltrating the walls of both the bladder and the rectum. Tuber- culous vesicidte seminales bulge "into the bowel higher up, and tumours springing from the pelvis may com- press the bowel. In the female a retroverted uterus, or a tumour of the uterus or ovary, may have a similar effect. In both sexes, but more often in women on account of the greater frequency of pelvic inflammation in that sex, the bowel may be bound down by firm fibrous bands. The surgeon will recognize these conditions by the position of the compressing masses, and by the other signs and symptoms occasioned by them, and particularly by noticing that the rectal walls are not infiltrated or 616 SURGICAL DIAGNOSIS [chap. lixed, but glide more or less freely over llie eoiu- pressing structures. If about IJ in. from the anus a narrow circular crescentic fold is felt, with healthy mucous membrane covering it, and there is no history of previous in- jury or disease, it is a congenital fibrous stricture due to imperfect fusion of the hindgut with the anus. It is more common in women than in men, and is usually noticed early in life. The lower end of the rectum may be narrowed as the result of cicatrization of wounds, accidental or operative — traumatic stricture. If the bowel is fomrd narrowed and the wall a little hardened by irregular bands of imyi elding tissue, the stricture is due to the cicatrization of ulcers, some of which may be found still present both above and below the healed ones. There may be a history of gonorrhoea, or of syphilis, or of dys- entery, which will throw light upon the cause of the original ulcer. If the surgeon discovers a nodular mass infil- trating and inseparable from the wall of the rectum, diagnosis of cancer of the rectum is to be made. The surface is usually ulcerated and uneven and bleeds more or less readily, so that there is a history of muco-sanious discharge. The growth may be annular and narrowing the bowel, or limited to one side and slightly polypoid. An annular growth is sometimes prolapsed into the bowel below and is felt as an intussusception with firm ulcerated or nodular sur- face ; it may thus strikingly resemble to the touch some cases of cancer of the cervix uteri. The sur- geon should carefully notice the situation of the growth, its vertical and transverse extent, the mobil- ity of the rectum over the sacrum, bladder, prostate, vagina, and uterus, tlie degree to which tlie lumen XLii] DISEASES OP RECTUiAI 617 of the bowel is narrowed, the presence or absence of secondary nodules in the bowel above or below the primary growth or in the cellular tissue behind the rectum, any enlargement of the inguinal or ■pelvic glands or of the liver, and especially any sign of obstruction, such as distension or tenderness of the colon and caecum. The relative proportion of growth and ulceration differs much : in some cases the bowel becomes completely blocked by the nodular masses of growth, while in other cases the neoplasm quickly ulcerates, and the rectum may be converted into a cancerous chasm with firm irregular walls, often extending into the bladder or uterus or vagina. Cancer in its late stages is not infrequently complicated with com- plete external fistula;, which may open into the bowel above or below the constriction ; recto-vesical fistula will be recognized by the escape of flatus and feeces with the urine, usually associated with great pain during and after the act of micturition. Recto- vaginal fistula is recognized by the passage of fseces through the vagina. Cancer of the rectum is columnar carcinoma ; it may extend into the anal canal and even project from the anus. It is common after the age of 45, but may be met with in quite young adults. Cancer originating in the anal mucous membrane is squamous carcinoma ; it may extend a short distance up the bowel, but is more prone to extend towards the buttocks. Much less common than cancer of the rectum, it occurs only in elderly people. Sarcoma of the rectum is occasionally met with. It is recognized by the large size of the tumour; ulceration is late, and haemorrhage, when it occurs, is' profuse. This condition can only be diagnosed with certainty by microscopical examination of a piece u* 618 SUKGICAL DIAGNOSIS of the tumour. Simple tumours of the rectum also occur — -adenoma, lipoma, myoma, and fibroma. They are recognized by their smooth outline, by their cover- ing