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When an affliction is seemingly universal it is reasonable to conclude that it springs from universal conditions. Proctitis, the most widespread disease of civilized man, originates very early in life, and develops in after years numerous painful symptoms—such as piles or hemorrhoids, con­sti­pa­tion, etc.

Now, what is the most common exciter of proctitis, which, as has been said, is an inflammation of the mucous membrane of the anus and rectum? In my earlier work, Intestinal Ills, I have shown that inattention to the soiled diaper is generally the original cause of this most grievous of ills, with its train of malign consequences continuing throughout the victim’s life on earth. Unnoticed by nurse or mother, the inflammation of the anus and rectum makes headway with each subsequent soiling; and thereafter, when the use of the diaper is dispensed with, inattention to the normal action of the bowels, improper food, the resort to purgatives, stimulants, and opiates, play no small part in aggravating the existing malady.

Fig. 1.

A portion of the wall of the rectum has been removed exposing various layers: 1, serous layer; 2, muscular layers; 3, 3, submucous layers; 4, 4, mucous membrane; 5, internal sphincter muscle; 6, external sphincter muscle; 7, circular muscular bands forming the rectum; 8, rectum; 9, sigmoid flexure. (See Fig. 7, showing the longitudinal muscular bands.)

The first care-taker of the infant is therefore responsible for the initial process, which progresses to a chronic condition by subsequent inattention. She is indeed solicitous over the inflamed buttocks of her charge, but overlooks the far more dangerous inflammation of the mucous membrane of the anus and rectum, or she does not realize its insidious and subtly progressive character. Candidates for motherhood should be instructed on this momentous subject.

Fig. 2.

a, Ulcer on sphincter ani. b, Filaments of two nerves are exposed on the ulcer, the one a nerve of sensation, the other of motion, both attached to the spinal marrow, thus constituting an excito-motory apparatus. c, Levator ani. d, Transversus perinei. (Hilton.)

There are other exciting causes of proctitis, but, since they are exceptional when compared with the neglected diaper, we need not concern ourselves with them at present.

The muscular coat of the rectum consists of two layers: an inner circular and an outer longitudinal band. The inner circular layer of muscular tissue of the rectum forms the internal sphincter muscle; and the outer longitudinal bands merge with those of the external sphincter. The anal orifice is closed or guarded by two strong sphincter muscles, as shown in Figs. 1, 2, and 3. These muscles are abundantly supplied with nerves, of which branches are distributed to the bladder and other adjacent organs, which accounts for the sympathy of these organs and their grave disturbance when disease inheres in the anus and rectum.

Fig. 3.

a, Sacrum. b, Coccyx. c, Tuberosity of ischium. d, Posterior or larger sacro-sciatic ligament. e, Anterior or small sacro-sciatic ligament, with the pudic nerve passing over its posterior aspect, and proceeding to the rectum and penis. f, Sphincter ani receiving its nervous supply from the pudic nerve. Portions of the muscles have been cut away, in order to show nerve filaments going to the mucous membrane, through the muscular fibers. g, Levator ani. h, Fat and areolar tissue occupying the ischiorectal fossa and covering the levator ani. i, Transverse muscles of perineum. k, Erector penis. l, Accelerator urinæ. 1, Pudic nerve. 2, Posterior sacral nerves proceeding to posterior part of the coccyx and to the sphincter ani. 3, Anterior sacral nerve (4th) supplying the sphincter ani. (Hilton.)

The orifice used for the elimination of undigested food and waste matter plays quite as important a part in the organic economy as the orifice that is employed for receiving food. Normal elimination, physiological and psychological, is the correlative process to prehension (seizure or appropriation), and the concord of the two forms the key-note of the organism.

The muscles and tissues constituting the anal vent should be as flexible and responsive to the will or desire of the rectum for relief of its contents as the lips are in permitting the saliva to escape. In like manner the upper portion of the rectum (Figs. 6 and 8) should respond with instant readiness to the effort of the sigmoid flexure to expel its contents. But an abnormal condition like inflammation rooted in the anus and lower part of the rectum (Fig. 1, 4–4) will inhibit the passage of the pressing burden above them, which inhibition will cause the inflammation to extend to the sigmoid flexure, and thence on to the colon proper; and sooner or later the inflammation will penetrate the submucous coat (Fig. 1, 3–3), which is composed of fatty or areolar connective tissue in which trunks of nerves and blood-vessels are imbedded.

The first symptom of inflammation is undue redness, followed by slight puffiness of the anal and rectal mucous membrane (Fig. 1, 4–4), with more or less sensitiveness of the tissues involved; and as its irritability increases there is more or less contraction of the muscular tissue forming the anus and rectum, which lessens the diameter of their bore. And the consequence of this contraction is of physiological concern to the victim, for in proportion to the contraction the normal demand of the victim for relief of the impending feces and gas is modified and lessened.

In health, the anal canal is from two to three inches in length, and it will distend about two inches—an elasticity quite equal to that of any other orifice of the body. As the anal tissues are usually the first to be invaded by disease, it is but natural that the ob­sti­pa­tion or con­sti­pa­tion should occur right above it—namely, in the rectum. The average length of the rectum is about six inches, and when the disease invades its whole length the con­sti­pa­tion occurs in the sigmoid flexure and may thence extend to the colon.

The filling of the intestine with feces and gases usually occurs just above the diseased portion of the gut; but at the same time the walls of the affected part of the canal are more or less coated with feces, and its abnormal pouches here and there contain more or less liquefied or dried feces. A diseased canal cannot expel all of its contents, since its normal expulsive power is gone. Some of the feces somehow or other gets down and out, but a larger portion inevitably remains. It is for this reason that a diseased intestine always reminds one of the Augean stable. It is simply marvelous that the human body continues as a living organism with so much filth and bacterial poison stored in its alimentary canal, and the vaults that result from abnormal pressure during periods of fecal impaction (Fig. 4).

When the inflammatory process extends up the rectum and at the same time into the spongy, fatty, or areolar tissue under the mucous membrane (Fig. 1, 3–3), thence to the muscular and serous layers (Fig. 1, 2–1), or through the four layers of tissue comprising its wall, we have a more marked and serious occlusion (closing) of the organ than when only the mucous membrane was affected. When muscular tissue is inflamed, its tendency is to contract and become solidified by an adhesive inflammatory product secreted between the circular and longitudinal muscular fibres (Fig. 1, 7, and Fig. 7). Often the circular or sphincter muscles forming the anal canal have to be distended to bring about a more normal vent. The same pathological conditions that occasion contraction of the anal bore or caliber occur, more or less, as far up the gut as the disease has advanced.

In a normal state of the lower bowel the sigmoid flexure passes its contents into the rectum, and the desire to defecate is reported—that is, the impulse to stool becomes more or less urgent until it is performed. But when all four coats of the anus and rectum are diseased, with perhaps a portion of the sigmoid flexure also, it is very difficult for the healthy portion of the sigmoid flexure and the colon to discharge their contents into the rectum; consequently no call, impulse, or desire reaches the mind. Constipation will then ensue, for the stool, not being called for, is not performed. Every demand of a healthy portion of the intestine is answered by increased contraction of the muscles of the diseased portion of the rectum. While the war between the healthy and the diseased sections of the bowels goes on, the victim naturally concludes that there is no occasion or demand for defecation, and he attends to other affairs, ignorant of the fact that he is thus making a fatal mistake.

The first condition that ensues is the tendency of the rectum to fill unduly with feces and gases, impelling the victim to “strain” in order to force the feces through the constricted anal canal. After a while the sigmoid flexure and colon will fill unduly, and then the victim will form the habit of waiting for the feces to descend, and of straining to expel what little manages to escape through the diseased gut.

A portion of the imprisoned feces in the healthy section of the intestine sometimes, at an unguarded moment, manages to distribute itself along the length of the diseased and constricted canal, where it is retained indefinitely, increasing the local irritation. And when the fecal mass accumulates sufficiently in both the healthy and the diseased portions of the intestines to set up a vigorous excitement, the victim may, by the aid of his waiting and straining habit (which habit, by the way, only torments and bruises the chronically diseased organs), bring on some sort of evacuation. In the early history of the disease this habit may serve for a time; but, as the disease progresses, the “laxative” habit is formed, which, in turn, settles into a chronic “drug” habit for all sorts and conditions of gastro-intestinal and other ills, which inevitably ensue. As the ravages of chronic inflammation of the anus and rectum increase, the symptoms rapidly multiply, till finally the victim, in desperation, feels that he must find additional sources of relief—and, among other habits, he forms the “diet” habit.

The order of abnormal habits brought into existence by ulcerative inflammation of the anus, rectum, and colon is about as follows: (1) the habit of unduly retaining the feces in the rectum; (2) the habit of straining at stool; (3) the habit of unduly retaining the feces in the sigmoid flexure; (4) the habit of resorting to the use of purgatives, pepsin, and other drugs; (5) the chronic “physic” habit; (6) the foolish “diet” habit; (7) the gastro-intestinal neurasthenic habit; (8) the health-resort habit; (9) the habit of trying desperately to appear agreeable while feeling really ill; (10) the habit of blaming the liver for all direful feelings, physical and mental.

It is but natural that the lower portion of the rectal and anal structures should be affected more severely than any other portion of the intestines by the ulcerative, inflammatory process. The sphincter muscles are very strong, as a rule, and fill their office only too well when the anal and rectal canals are in a diseased state, for they effectually prevent the contents from escaping. Often their contraction or stricture is so great that their expansion is limited to from one-fourth to one-half an inch. This virtually permanent closure of the anal vent naturally results in an accumu­la­tion of feces just above it, or in the lower portion of the rectum, which accounts for the dilatation, stretching, or ballooning of the anal and rectal tissues immediately above these muscles, as shown in Fig. 4.

Fig. 4.

1, The dotted lines indicate the normal direction of the anus and rectum; 2, 4, the cavities or pouch formed by dilatation or ballooning from the storage of impacted feces; 3, a probe bent at right angles, and introduced through a speculum, to ascertain the depth of the pouch, which is frequently found to be two and a half inches.

In not a few cases where dilatation of the rectum exists, the upper half or more of the anal canal is also dilated, leaving an anal canal only an eighth of an inch in length in some cases; in other cases, perhaps half an inch to an inch.

Similar dilatation of the sigmoid flexure occurs as the result of the severe contraction of the upper half of the rectum, and especially at the bend shown by Fig. 6 and Fig. 12. This bend forms quite a sphincter for the normal receptacle—the sigmoid flexure. Here also prolapse, distention, and dislocation of the sigmoid flexure may occur, somewhat similar to the anal prolapse from disease and abuse.

Piles and itching of the anus are symptoms of proctitis, or inflammation of the anus and rectum. Why should we find such dissimilar symptoms proceeding from the same cause? The reason is plain when we consider the results following chronic inflammation of the mucous membrane of the anus and rectum and the deeper tissues. Those who suffer from catarrh of this membrane are familiar with the discharge of mucus that appears from time to time during the progress of the inflammation. But, as the inflammation penetrates the mucous membrane and the underlying tissues of the anus and rectum, the escape of the inflammatory product is prevented; and this imprisoned fluid must either be absorbed by the system or retained in reservoirs or in channels wherever the least resistance is offered to its invasion.

The mucous membrane of the anus and rectum is loosely attached to the subjacent parts by areolar tissue (Fig. 1, 3–3), which is sufficiently lax to allow an expansion of two inches; and in a puckered or contracted state the membrane is thrown into folds, or into shallow or deep wrinkles. The loose areolar attachment and folds of various depths afford space for lodgment of the inflammatory discharge, which channels its way down along the folds through the areolar tissue under the mucous membrane to that of the integument, and so on for a distance of a foot or more from the anus in some cases.