THE RECTUM
To treat the rectum intelligently and thoroughly, requires special knowledge on the part of the osteopath. A speculum should be used in many cases when making an examination, and all abnormal conditions carefully inspected with the eye; although much can usually be noted by the examination with the finger alone. The best position in which to give an examination and treatment is to have the patient on the side, with thighs flexed upon the abdomen. In a few cases the patient may lean over an operating table.
The objects of rectal treatment are many—to relieve hemorrhoids, etc., of the mucous membrane; to correct a dislocated coccyx; to treat an enlarged prostate gland; to replace a prolapsed rectum; to tone the lower bowel in cases of constipation; to give reflex stimuli to the heart and lungs, in cases of fainting, paroxysms, etc.; to relieve severe pains in the rectum at the time of the menstrual period, and to relieve congestion, inflammation, contracted tissues, etc., of local sources; to relax spasms in croup, and to remove tension to the nervous system in some forms of insomnia. In fact, so many diseases are affected by reflex irritations from the rectum that its examination is a necessity in many cases. The phrase “when in doubt treat the rectum” was coined by a progressive student and there is an element of truth in it. Surgical assistance to treatment will be considered under hemorrhoids.
The principal need of osteopathic internal rectal treatment, is: (1) To relax all contracted and constricted fibres about the walls of the rectum and between the sacrum and coccyx. (2) To correct a dislocated coccyx. (3) To dilate the sphincters thoroughly, in order to relieve irritations about the sphincters, and to stimulate the sympathetic nerves.
Work through the rectum to treat an enlarged prostate gland, to correct a displaced uterus, and to make a more thorough examination of the uterine tissues, the Fallopian tubes and the ovaries, is a frequent occurrence.
In giving local treatment, cleanse the fingers and oil the index finger; then, after introducing it into the rectum relax the contracted tissues by an upward sweeping motion on all sides. This treatment relieves all obstructions to vessels and nerves caused by contracted fibres, and tones the rectal walls. In prolapsed sigmoid, causing obstructive constipation, the finger can be used to separate the folds of mucous membrane and open the lumen of the bowel. Frequently there will be enough tone to the muscular coat so that the irritation will set up slight peristalsis and cause the bowel to draw up to a considerable degree. In children where there is much straining at the stool, the sigmoid will often be found down and by using the little finger the same results can be accomplished and much relief given.
To dilate and stretch the sphincters thoroughly a speculum or dilator should be used under anesthesia; still, considerable can be done by one or two fingers. The sphincter should be thoroughly stretched in all directions, care being taken when an instrument is used that too much force is not applied. Secure as much voluntary relaxation of the sphincter as possible. Inhibition at 2d and 3d sacral will aid. This treatment is of aid in cases of hemorrhoids and prolapse of the rectum, in constipation due to the loss of tonicity of the lower bowels, in tightness of the sphincters, in pain of the rectum, and in stimulating the heart and lungs. In cases of a prolapsed rectum, due to irritation about the sphincters, causing tenesmus, this treatment is of special value, as it gives the sphincter a physiological rest. Frequency of treatment per rectum must depend entirely on the patient and disease. It can be given daily in many cases and is frequently so indicated in acute hemorrhoids, prostatic troubles, etc.
According to Quain, the sensory nerves to the rectum are from the second, third and fourth sacrals. Some of the motor fibres of the circular muscles of the rectum are from the lower dorsal and upper two lumbar nerves; these pass by the aortic plexus to the inferior mesenteric ganglion. Associated with these fibres, are the inhibitory fibres of the longitudinal muscles of the rectum. The sacral nerves contain motor fibres to the longitudinal muscles, and inhibitory fibres to the circular muscles of the rectum. In all cases of rectal trouble, the lower dorsal and upper lumbar vertebræ may be found deranged, and thus interfere with the rectal nerves. Relaxation of the sacral muscles over the sacral foramina has a marked effect in relieving tenesmus. In dysentery, where there is a constant desire to defecate, a thorough upward relaxation of the sacral muscles will give great relief.
Proctitis or inflammation of the rectum is not an uncommon disorder. The disease has been divided into acute, chronic, gonorrheal, dysenteric, and diphtheritic. Foreign bodies, impacted feces, cold, purgatives, prolapse of the sigmoid, and lumbar, coccygeal and innominate lesions are the most important causative factors. The acute form is more frequently found in older people. The symptoms are tenesmus, frequent evacuations of blood and mucus (possibly pus), prolapse of the mucous membrane, feeling of fullness, and radiating pains. The gonorrheal, diphtheritic and dysenteric forms are of rare occurrence, with the exception that the dysenteric may be somewhat frequent. The treatment is to remove all local irritations, cleanse the bowels, and put the patient in bed. All irritating foods are to be prohibited. Use milk, soups, beef juice, soft boiled eggs and similar foods. Correct all osteopathic lesions; especially will inhibition over the sacral foramina relieve the tenesmus. Cold water in the rectum and applied to the anus will be beneficial. If abscesses occur, employ surgical measures.
Prolapse of the rectum is another common rectal disorder. Acute cases are especially found in children, due to straining at stool. The sacrum is more straight, and thus violent straining, coughing, etc., the more readily produces prolapse. Prolapse of the mucous membrane is the most common, although all of the rectal coats may be involved. Prolapse of the upper part of the rectum into the lower or invagination is frequently met with by osteopaths. The sigmoid may prolapse and also affect the rectum. The treatment is to return the mass, using an anesthetic if necessary. If it is not retained, place straps across the buttocks. Then with attention to lesions that may be disturbing and weakening the rectal walls, and thorough local toning treatment, the prognosis should be favorable. In high rectal prolapse local attention is necessary as well as deep treatment through the abdominal walls to the sigmoid and upper rectum. The use of Cole’s irrigator for high enema will replace and elevate both the upper rectum and sigmoid and greatly aid in a cure. Regularity of habits and proper food are essentials.
Hemorrhoids
Definition.—A dilated or varicose condition of the plexus of veins lying in the submucous tissue of the lower part of the rectum. The dilatation of these hemorrhoidal veins may extend into the adjoining subcutaneous tissues and mucous membrane, and the perirectal plexus and adjoining venous plexuses of the bladder, uterus, vagina and sacral canal may become involved.
Osteopathic Etiology and Pathology.—The chief predisposing cause of piles is man’s erect position and the absence of valves in the hemorrhoidal veins. Thus a retardation or stagnation of the portal vein would cause a backward movement of the entire column. It is evident that such a downward pressure of the blood in the portal system would dilate and extend the blood vessels, to the very capillaries in the rectal region.
This retardation may arise from several causes: obstruction of the portal vein, from diseases of the liver; diseases of the heart; obstruction or destruction of the capillaries of the lungs; pressure from a gravid uterus, tumor, etc.; a general loss of tonicity of the abdominal walls, as in persons who take but little exercise; the excessive use of wine, tea and coffee; injuries to the spinal column, especially in the lumbar, sacral and coccygeal regions; a dislocation of an innominate bone; lifting; constipation; straining at stool; carelessness of the calls of nature, etc. Catarrh of the bowels may cause a congestion of the mucous membrane and consequently piles. Hereditary influence may be a factor in a few cases.
Hemorrhoids are divided into two classes, external and internal. An external pile is one that arises from the margin of the anus outside of the external sphincter muscle. It differs from the internal pile from the fact that it is always composed either of skin or hypertrophied connective tissue, forming a mere cutaneous tag, or else it is composed of a small cutaneous vein enlarged by a clot of blood. The internal hemorrhoids are composed mostly of enlarged veins and are connected by hypertrophied connective tissue. They have a free arterial supply and are covered by the mucous membrane of the rectum. They are due, usually, to an affection of the middle hemorrhoidal blood supply, thereby being a part of the visceral vascular system. Internal hemorrhoids, when protruding, can be returned within the rectum, while the external ones cannot. The venous turgescence varies in size from a pea to a walnut. They may be single or may surround the entire anal opening like a bunch of grapes.
Repeated attacks of engorgement of the veins involved, will in time change the mucous membrane or the submucous tissue, and cause catarrhal swelling of the mucous membrane, or hyperplasia of the connective tissue. At first the hemorrhoid is usually a blood tumor, but in chronic cases it is oftentimes made up largely of connective tissue. Owing to pressure of the varicose veins, atrophy of the mucous and submucous tissue may occur. The white or slimy hemorrhoids occur when these roughened parts of the mucous membrane become inflamed and thickened, resulting in suppuration.
Symptoms.—The symptoms are quite diagnostic and need not be mistaken. Besides the appearance of tumors, there may be constipation, pain during stools, indigestion, headache and pain in the back. Hemorrhages frequently occur, and if suddenly checked, as by cold, other disturbances may occur, as congestion of the head, lungs, stomach, liver, kidneys, etc., which may result in hemorrhages from these organs. Fissures of the anus, contraction of the rectal sphincters and prolapse of the rectum may occur. Occasionally in old people there is a varicose state of the veins of the neck of the bladder, and in females, of the uterus and vagina, which causes hemorrhages of these organs. The communicating plexus of the spinal canal may be affected, causing weight, numbness and pain, so as to simulate a lesion of the cord. The patient may have a hypochondriacal disposition and be disinclined to work, especially at mental labor.
Prognosis.—Depends upon the predisposing and immediate causes, but a large majority of cases can be cured.
Treatment.—A thorough examination of the patient should be made, not only to ascertain the extent of the local trouble, but to understand thoroughly the general health of the sufferer, especially the state of the heart, lungs and liver.
Many cases of hemorrhoids are caused by lesions in the lumbar and sacral regions, and especially dislocations of the coccyx (usually anterior) and the innominata. Correcting these lesions will oftentimes cure the hemorrhoidal disorder. Simple dilatation of the rectum once a week, in addition to other treatment, is of great aid in curing hemorrhoids, not a few of the cases being cured by dilatation alone. It relaxes the tissues about the tumefied vessels. Treatment is rarely necessary above the second lumbar, (unless there is more or less of a constitutional disorder) as the superior hemorrhoidal blood vessel of the inferior mesenteric is given off about opposite the second lumbar.
In cases where the abdominal walls have become relaxed, a treatment should be given to strengthen the abdominal muscles and viscera. Particular attention should be given the liver. Treatment should be given over the abdominal muscles directly, and also to the spinal nerves of the same region. The diet should be strictly regulated and the bowels kept loose, and stimulants, indigestible food, full meals and too much meat should be avoided. Injection of cold water before stools is a good prophylactic, and applications of cold water to the protruding pile will be of some help in relieving the congestion. A squatting position during defecation will relieve considerable strain.
Hemorrhoids in the acute state, within twelve or twenty-four hours from the engorgement, yield quickly to treatment. The local technique is to relax the tissues about the tumor, especially above and along the line of the vein, then with pressure at its base carefully force out the engorged blood. Follow this up by another treatment the next day and continue until normal. The vein wall, not being permanently stretched, will contract and if the irritating cause is found, there is little danger of return. Remember, in a case like this, the danger of embolism and be sure a clot has not formed. Cases of hemorrhage at stool, during or immediately following evacuation, when not from a bleeding pile, may be of considerable quantity and the source difficult to locate. It may be due to ulcerations or easily ruptured capillaries of the mucosa, but the cause will in many cases be found in the innominata and a reduction of the lesion give relief.
Rectal conditions, associated with piles, and requiring surgery after treatment has failed, are: hemorrhoids, which are of such long standing as to become organized tissue, (these will keep up continual irritation and cannot be absorbed); saccules or pocket, formed by folds of mucous membrane catching and holding particles of feces, gradually enlarging and ending with considerable reflex symptoms; fistulae, complete or incomplete, may frequently be healed by adjusting coccygeal or innominate lesions, but are apt to recur from the tract not being clean in the center or bottom; abscesses in or about the anus or rectum are usually traced to coccygeal, innominate, or local interference to circulation; fissure, complete dilatation under anesthesia to insure physiological rest of parts, is probably the best treatment. It is suggested that a fissure may be healed by making surgically clean, touching with iodine and coating with collodium. Papillae are small, hard black-capped papules in the lower rectum, each one involving a nerve terminal and causing much distress. All these conditions give rise to much discomfort and with surgical assistance can be cured without much trouble. It is not necessary to make them a major operation and do uncalled-for things. The less surgery about the rectal sphincter the better.
Care of the anus and rectum after operation or successful treatment is a factor in preventing return. First, there should be soluble, non-irritating stools, which do not tend to bring about prolapse from straining. Diet and regularity contribute to this. Second, absolute cleanliness. This can only be obtained by following the stool with an enema of four or five ounces of cool water and immediately passing it. It will bring forth a considerable quantity of feces which would otherwise have been retained for another twenty-four hours. This procedure following, as it does, the stool does not in any way interfere with the normal function or create a habit. The anus should then be thoroughly washed in cool water and as thoroughly dried. Dusting with borated talcum powder, starch, etc., will prevent chafing.