Observations on injuries and diseases of the rectum

Front matter

V s

LEEDS INFIRMARY

MEDICAL LIBRARY.

Chap. VI. Of Constipation And The Use Of Instruments

Of the Causes of Constipation in the Lower Bowels. Nature and Treatment of different Cases. Of Accumulations in the large Intestines. Caution, requisite in the Use of the Bougie; of the Flexible Tube; of the Syringe 123

CONTENTS. Vll

Chap. VII. Of Stricture Of The Rectum

Of Spasmodic Stricture. Of Permanent Stricture. Of the Irritable atid Contracted Sphincter 152

Chap. VIII. Of Cancer Of The Rectum

Two forms of Cancer in the Rectum. The Treatment adapted to them. Operations occasionally available 188

ON

INJURIES AND DISEASES

OF

THE RECTUM.

Chapter I. Of Laceration Of The Rectum

The simplest affection of the rectum is its partial or complete rupture. The bowel may be torn through by violence applied either from within or from without. Partial laceration of the bowel is the consequence of force applied to its inner surface. When the slightness of the materials is considered, of which the intestine is framed, its coats consisting but of three slender membranes, the combined thickness of which does not exceed a tenth part of an inch, it appears

B

2 Of partial Laceration

surprising that this accident is not more frequent. In the dead body, the intestine is found to be torn by very trifling pressure ; and the tone of its fibres when living cannot be supposed to add materially to its strength.

I. I attended a lady under the following circumstances. She had been confined three months before. During her recovery the action of the bowels had been irregular. Without medicine the bowels seldom acted at all ; and the relief which she obtained through medicine was attended with great pain. It had therefore become her practice, in order to obtain intervals of ease, to allow the bowels to remain two or three days without acting, and then to take some purgative. The effect of the medicine used to be distressing. What first came away was solid and of large size, and passed only after repeated efforts ; and this was attended with great local pain, and a sense of dragging or Fissure of the Mucous Membrane. 3

at the loins, followed by languor and exhaustion.

On one of these occasions something appeared to give way, or to be torn, and her sufferings were now increased by a sense of exquisite soreness at one part in the rectum. It was upon this that she consulted me. Upon examining the bowel 1 found a small transverse fissure in the lining membrane, at the back part of the bowel immediately within the sphincter, which is the point where fissure is most common. There was a little hardness round it, and it was acutely sensible. The bowel above was large and relaxed, and contained at the time a considerable volume of fecal matter.

I recommended that the bowel should be immediately washed out with warm water, by which means its contents were brought away : that every morning the injection of warm water should be repeated, with the

b 2

4 Of the ordinary Causes and Treatment

object of completely unloading and relieving the rectum daily : and that at night a mild mercurial ointment should be applied to the fissure of the mucous membrane. By steadily pursuing this plan, the lady in a short time recovered. Occasionally, since her recovery, when the action of the bowels has become irregular, she has been threatened with a return of the complaint ; but upon resuming the use of the remedies by which the part was before restored, she has in each instance found the uneasy sensations cease.

II. A young gentleman, who had been accustomed to an active country life, fell into sedentary habits upon engaging in the study of the law. He experienced frequent headaches, and the bowels were generally constipated. The effort used in evacuating the bowels was now attended with slight eversion of the rectum ; and at last, in addition to this source of inconvenience, of Fissure of the Mucous Membrane. 5

he became sensible of acute pain at a point just within the sphincter, which was brought on whenever the bowels acted, and continued for some time afterwards.

After trying several remedies ineffectually, among which was the daily use of an enema, I advised this patient to take every night a grain of blue pill with three grains of compound extract of colocynth, and to apply to the surface, upon which a fissure existed, as in the preceding case, a mercurial ointment. Under this plan the part healed.

The preceding cases may serve to explain the nature of the affection which I would describe, and the principle upon which it is to be treated. It is required . to find some remedy by which the action of the bowels may be rendered and kept regular, and to apply to the fissured surface an ointment which may dispose it to heaJ. Ointments containing the milder

6 Treatment of more serious Cases.

preparations of mercury generally best answer the latter purpose.

As it is evident, that when a laceration of the mucous membrane has existed for a few days, it has become an ulcer, so is it probable that fissure of the rectum often has this character from its commencement. At all events it is as an ulcer, that when neglected the complaint becomes more serious and difficult to manage. The patient then experiences greater pain ; mucus, purulent matter, and occasionally blood are discharged with the faeces, and some extent of ulcerated surface is felt upon examination.

The remedies, however, which have been already recommended, are still available in the more aggravated form of the complaint. If the pain be severe, blood may be taken with advantage from the hemorrhoidal vessels by leeches applied to the mucous membrane at the anus, and sup-

Of the Operation sometimes necessary. 7

positories containing opium or belladonna should be used. The application of lunar caustic to the ulcer, either undiluted or in an ointment containing ten grains to a drachm of lard, will occasionally lessen the irritability of the part, and produce a favourable change. When these means prove ineffectual, and the disease threatens to assume a more formidable character, a remedy may be resorted to with advantage, which, although too severe for common occasions, is exceedingly useful in the present. By an operation resembling that for fistula, the sphincter muscle is to be completely divided on one side, and to be temporarily prevented reuniting by the introduction of a strip of lint into the wound. The sphincter is to be divided in a line leading to the ulcer; the incision is to divide the ulcer itself. The operation may be performed either with a bistoury or with a scalpel.

8 Case of Fissure

The advantages which result from the di - vision of the sphincter in this case are the following. The resistance of the sphincter . being temporarily removed, there is much less strain and effort upon the ulcerated membrane in the evacuation of the faeces than before. The abstraction of blood from the vessels of the part, which commonly bleed freely, contributes in addition to lessen the sensibility of the ulcer. The application likewise of the mercurial ointment to the sore is. rendered more easy, and may be more complete after this operation than before. The following case may serve as an example of the relief afforded by the remedy which I have here recommended, and of the obstinate nature of the affection, as well as of its liability to be overlooked from the sympathetic disorder of adjacent organs which it occasionally produces.

III. James Farrant, retat. 45, was adcured by the Operation. 9

mitted into the Middlesex Hospital on the 9th of October. Fifteen months previously he began to experience a sensation of heat and pain at the anus, which would last a few hours and then subside, leaving a feeling of numbness. While the pain lasted, the anus was strongly drawn inwards. The pain extended to the hips and to the sacrum. These symptoms recurred daily : they were always brought on when the bowels acted. About a month after the commencement of the complaint, something appeared to him to give way in the bowel, and a slight discharge of mucus took place, which continued afterwards. Other symptoms were present, which led to a suspicion that the prostate gland was the seat of the disorder. The patient made water more frequently than common; and after the water had passed, some pain or uneasiness was commonly felt deep in the perineum, and of the same description

10 Case of Fissure

with that which ensued upon evacuating the bowels : mucus was likewise often discharged from the urethra after the urine had passed.

Upon examining the rectum the prostate gland was felt to be large and full and tender on pressure ; and to this organ the treatment first employed was directed. Leeches were applied to the perineum, and the hip bath was used. Blood was taken by cupping from the sacrum : an opiate suppository was used at night, an enema of tepid water in the morning. The bowels acted regularly, but the patient did not improve in other respects ; the pain remained.

Upon re-examining the rectum, the case presented another character. The seat of pain, at least of soreness, was discovered not to be the prostate, but the posterior surface of the rectum within the sphincter. The bowel at this part was extremely loose and flaccid ; but there could be discured by the Operation. 11

tinguished upon it an oblong ulcer with a hardened edge.

After trying several remedies ineffectually in this case, I divided the sphincter, delaying afterwards the healing of the wound by the introduction of a few threads of lint into it.

The subjoined figure, which is an imaginary section of the rectum, may convey an idea of the place and character of the ulcer in this case, and of the direction of the incision made.

The patient was sensible of great relief, soon as the smarting occasioned by the

12 Case of complete Laceration

operation had ceased. The pain which he experienced for several days afterwards he felt to be the soreness of the wound, not the original pain of the ulcer. He resumed the use of the mercurial ointment. Upon examining the bowel a fortnight after the operation, the ulcer was found to have much improved, although it was still to be felt ; it had lost much of its sensibility together with its hardened edge. By continuing the use of the mercurial ointment, the patient entirely recovered. It was satisfactory to observe, that as the ulcer healed the pain in making water, with the discharge of mucus from the urethra, and the swollen state of the prostate, equally subsided.

The causes which have been described as sufficient to occasion a partial rupture of the coats of the rectum, will sometimes produce complete laceration of the gut. This accident occurred to an unmarried of the Rectum from within. 13

lady, whom I subsequently attended with Mr. Langmore, of King Street, Finsbury Square.

IV. ******, getat. 40, naturally of a very constipated habit of body, and at the time being on a journey, on striving to relieve the bowels, which had not acted for many hours, felt something give way, to use her own expression, and on the following morning some faeces passed per vaginam. On examination by the vagina and rectum, a transverse rent was found two inches within the parts, sufficiently large to admit the end of the finger. The only treatment adopted in this case consisted in frequently and carefully cleansing the part by injections of water, and regulating the state of the bowels by proper medicines. The patient entirely recovered. In five weeks the fasces had ceased to pass per vaginam.

As long as such an opening shows a disposition to contract, it is unnecessary and

14 Other Methods of Treatment.

may be prejudicial to employ any other means than the most scrupulous cleansing. But if the part becomes indolent, and its progress towards restoration stops, various remedies may be resorted to with advantage. The simplest of these is the application of the nitrate of silver to the edge of the opening; or a combination of this, or of some other escharotic, with the use of an elastic gum pessary*.

If the communication of the rectum with the vagina does not contract under the means which have been recommended, there

* The use of nitrate of silver, or of other strong escharotics in parallel cases, is most striking in ulcers through the soft palate. I remember in one instance by this means having caused such a perforation to contract and close, which was an inch in length and half an inch in breadth: it had been produced by syphilitic ulceration, but the edges had put on a healthy appearance, when the use of the escharotic was commenced.

Cose. 15

remain others which are available. The edges of the opening having become cicatrized, and the use of escharotic or stimulating applications having been discontinued, the following operation may be resorted to. The edges of the opening may be pared off with curved scissars, and one or two stitches may be passed through the vaginal side of the opening, so as to bring the edges of the rent into close and uninterrupted contact. It is conceivable, that in certain cases of this description it may be necessary to lay the vagina completely into the rectum by dividing the sphincter from the perforation. I have not however met with an instance which required this treatment.

The origin of the following case, I am disposed to think, may have been a small opening suddenly taking place through the rectum into the adjacent cellular tissue.

16 Communication of the Rectum

V. A young man was admitted into the Middlesex Hospital with swelling of the perineum, scrotum, and penis. The skin of the scrotum and penis was greatly distended, and of a dark red colour, with here and there patches of gangrene. The parts therefore presented the appearances which follow rupture of the urethra. But the patient stated that he had never experienced any difficulty in making water ; and the symptomatic fever which had supervened had not that low character which commonly attends sloughing from the escape of urine. The tongue was white, the countenance flushed, the pulse frequent and full.

The patient stated, that for six weeks antecedently to the attack his bowels had been remarkably costive, after which he had had a looseness for a few days, when he seemed to feel that an inward with the adjacent Cellular Tissue. 17

lump had formed in the perineum. This lump or uneasiness between the urethra and rectum had existed two days when the swelling of the scrotum and penis began, which had increased with alarming rapidity.

A deep incision was made in the perineum towards the prostate gland, and superficial incisions were made through the distended skin of the scrotum and penis. A fluid like brownish serum oozed freely from these wounds, but it had at no part an urinous smell. On the contrary, that which flowed from the incision into the perinaeum had a distinctly fecal odour. The patient experienced great relief: the gangrene ceased to spread : the redness and tumefaction gradually diminished, the sloughs separated, the symptomatic fever subsided. But in a few days fecal matter began to escape through the wound in the perineum ; and the nature of the case was

18 Cases attended with similar features.

cleared up by the discovery of an opening from the rectum into the cellular tissue of the perineum, which was finally cured by the common operation for fistula ani.

I entertain no doubt, that in the case which has been narrated the sudden swelling and effusion resulted from the escape of fecal matter into the cellular membrane ; but it is possible that the cause in which the opening originated may have been the formation of an abscess on the outside of the bowel, and that the communication may thus have been effected by ulceration from without. Still I have thought that case admissible into the present chapter, in connection with cases of giving way of the bowel from within ; as it is not very unlikely, that the symptoms which have been described may have proceeded from the latter cause*.

* The most frequent cause of sudden tumefaction of the scrotum, is rupture of the urethra. The

Laceration of the Rectum by Instruments. 1 9

The rectum may be torn through from within, by violence done in the improper use of instruments. I removed a stone from the bladder of a boy fourteen years of age by the lateral operation. The stone, which was of a favourable shape, was extracted quickly. Every thing went on satisfactorily till the eighth day, when

escape of fecal matter into the cellular membrane, as in the case above described, is probably the rarest. I have seen two instances in which sudden swelling of the scrotum, which came and gradually subsided, was not attributable to either of these causes, or to any local cause that was detected. In one instance I have seen the scrotum enormously distended with blood from violence done to the part. In another, the perineum and scrotum were distended and discoloured with blood and serum that had escaped at the lower outlet of the pelvis, after fracture of the ilium, which had lacerated the internal iliac vein. In another instance a child of five years of age was brought into the hospital with extensive swelling and sloughing of the scrotum and integuments of the penis, which had originated in phymosis and ulcers round the glans.

c 2

20 Laceration of the Rectum by Instruments.

the bowels being confined an injection was ordered, which was administered by the nurse of the ward. I believe that she forced the pipe of the instrument through the rectum into the wound ; for the following day fecal matter appeared in the wound, through which it thenceforth for a short time passed as freely as through the anus. The incision, however, in the perineum gradually contracted to a very small sinus, through which a little moisture only escaped, and this finally closed. Still there remained a communication between the bladder and rectum, which was evinced by the urine depositing a sediment of fecal matter. After three months this deposit was no longer seen.

The closing of the communication between the rectum and urinary canal was in this case entirely spontaneous. It was evident, after a few days, that the discharge of fecal matter through it would not

Case and Recovery. 21

prevent the contraction of the wound, and T determined, as long as the case should go on favourably, not to risk any thing by interfering with the natural process of reparation. I cannot state at what part the communication between the rectum and urinary canal in this instance was situated : I abstained from making an examination which would have satisfied my curiosity on this head, as no further object was to be attained by it.

Some caution is requisite in administering enemas ; and many of the ordinary instruments are particularly dangerous. There is a preparation in the museum of Bartholomew's Hospital, from the body of a patient, whose death had been occasioned by the injection of a pint of water gruel into the abdominal cavity through the torn rectum. A similar accident has happened in private practice.

But the most frequent instances of lace-

22 Laceration of the Rectum in Labour.

ration of the. rectum into the vagina result from other causes than those already de^ scribed, and are produced by violence acting from the vagina towards the bowel. This violence is the pressure of the head of the child in labour. The degrees of injury which it occasions are very various.

Occasionally the injury is the same in its degree as in Case IV, being a laceration within the sphincter of trifling extent, which heals as readily when ensuing upon this cause as where it follows any other.

Frequently the laceration is limited to the perineum, is quite external, and involves at the utmost the marginal fibres of the sphincter muscle. In this instance again, the recovery is certain and spontaneous : but it is necessary in both instances to employ cleanliness and rest to promote the reparation of the part.

There are however severer cases, in which the sphincter being completely rup-

Incomplete Rupture of the Sphincter. 23

tured, the extremity of the bowel communicates with the vagina by a longitudinal fissure from three-fourths of an inch to an inch in length. It is known in such a case that all the fibres of the sphincter are torn through, by the total want of tonic contraction of the bowel at the part where it begins to be entire.

In many instances in which this accident happens, spontaneous reparation of the part does not take place. The force of the sphincter muscle is employed in keeping the rent wide open; and the faeces continually passing through it contribute to prevent its uniting.

In a conversation with Mr. Copeland, I learnt, that in a case of this description he had successfully employed the following method. It occurred to him, that if the sphincter were divided at a second part, its strain upon the rent into the vagina would be greatly lessened, and that the chance of

24 Entire Laceration of the Sphincter.

reparation would be proportionately increased. I understood from him, that he had divided with this object the sphincter laterally, and that the case had turned out completely to his wish.

Soon after this conversation, a similar case came under my own care.

VI. I was requested by a medical practitioner to see, in consultation with him, Mrs. Quye, who had been confined of her fifth child eight days before, Mar. SI, 1830. The labour had been rapid, and the pressure of the head of the child had ruptured the perineum and the sphincter. The faeces passed freely through the vagina by a gaping fissure nearly an inch in length. As the edges of the fissure were not cicatrized, I thought the present a very favourable opportunity for repeating Mr. Copeland's operation. To give the parts every chance, I divided the sphincter muscle upon both sides, performing therefore on either side

Complete Rupture of the Sphincter. 35

the operation for fistula ani. A small strip of lint was introduced into each wound. The edges of the original rent were afterwards washed daily with a solution of nitrate of silver, and fresh lint was replaced in the incisions as often as it was removed by the passage of fasces. The original rent healed very speedily : when it was nearly closed, the lateral wounds were allowed to unite. In five weeks from the operation the incisions had healed, and the patient had recovered the use of the sphincter. She has continued perfectly well to the present time, and was safely confined of another child in November 1832.

The remarkable success which has attended this practice in recent cases, has induced me to determine to employ it, after the manner recommended by Dieffenbach, in cases in which laceration of the sphincter has occurred, and has not been remedied at the time.

26 Complete Rupture of the Sphincter.

In cases of long standing it is however obvious, that the lateral division of the sphincter is a part only of the operation requisite for the restoration of the parts. It is necessary besides, at the least, to produce a granulating surface upon the edges of the fissure.

And as the parts in this class of cases have lost, from time, the tendency which exists in the freshly-torn parts to come together, I conclude that it is absolutely necessary to use ligatures to bring them and to hold them in contact. In other words, I recommend the performance of the following operation. The first step of the operation consists in paring the edges of the fissure : the second is the introduction of sutures, to be tied afterwards in the vagina : the third is the division of the sphincter on either side : the operation is completed by tying the ligatures in the vagina, and by introducing a strip of lint into each of

Operation practised by Dieffenbach. 27

the two lateral sections of the sphincter. I am the more sanguine as to the general result of this operation, since I had the good fortune to apply ligatures successfully to an old laceration of the rectum into the vagina, without the assistance of the method which I have now described, and therefore under circumstances considerably less favourable. Much, after all, in such an operation depends upon causes over which the surgeon has a very imperfect control. Inflammation of the parts supervening, or diarrhoea, would still be liable to render the operation ineffectual. But the surgeon of course defers attempting it, till the patient is in her best state of health, and the bowels have been thoroughly unloaded by repeated doses of opening medicine. The bowels should not be moved for several days after the operation.

CHAP. II.

OF PROTRUSION OF THE RECTUM.

Another affection of the rectum, which like the preceding has a mechanical origin, is its eversion and protrusion at the anus. This disorder is called prolapsus or procidentia ani.

Several writers upon this subject, among whom is M. Dupuytren, have described prolapsus ani as consisting in an extrusion of the mucous and submucous coats alone through the action of the muscular coat of the bowel. To correct this misapprehension, I have given a figure from a preparation in the museum of King's College, in which a protrusion of inverted bowel through the sphincter ani is represented,

Nature of Protrusion of the Rectum. 29

and the muscular layer is shown to be equally inverted with the lining membranes.

It is natural to suppose that the bowel derives sufficient support from its adhesions to neighbouring organs, to have little disposition to protrude in the healthy state. But a remarkable case, which I shall take another opportunity of relating, served to convince me of the contrary. I had occasion to extirpate the lowest part of the rectum, together with the sphinc-

30 Use of the Sphincter Aid.

ter ani. The part healed favourably, and a firm hollow cylinder of cicatrix led up to the commencement of the bowel. In this instance it is to be supposed that the inflammation attending the process of healinggave additional strength to the natural adhesions of the rectum. Nevertheless, in a short time after the recovery of the patient the bowel began to protrude. The weight and pressure of the bowels and abdominal muscles appeared to occasion this occurrence. The most important use therefore of the sphincter ani is probably to prevent protrusion and eversion of the bowel, against which the adhesions of the intestine to neighbouring parts are not sufficient to guard it.

Now at the time the bowels act, the sphincter is necessarily relaxed. The bowel for the time is unsupported, and the strain is allowed to tell upon its lateral adhesions. Under unfavourable circumstances, it is therefore easy to understand that protrusion

Protrusion of the Rectum. 31

may take place even when the sphincter is entire, and when the bowel has not lost the support which it affords.

If the contents of the bowel are habitually too firm and solid, in passing through the extensible canal they temporarily drag it with them, and elongate its adhesions to the adjacent surfaces. Nature indeed has aimed at providing against this occurrence, by throwing round those portions of the alimentary canal, which are intended to hold solid contents, a strong coat of longitudinal fibres. The rectum, the oesophagus, and the colon even although in a less extent, are thus provided with the means of resisting the traction and extension, which the passage of solid contents tends to produce. But the provision has its limits; and where the bowels are habitually costive, it is often found to be inadequate. The adhesions of the bowel to neighbouring parts are lengthened, and the passage of

32 Protrusion of the Rectum.

a mass of solid feces will carry through the rectum an everted fold : this, it is true, at first spontaneously returns ; but the cause continuing, the eversion becomes more certain and considerable at each recurrence of action of the bowels.

A gentleman, whose case I have described (Case II), in addition to the fissure in the inner membrane of the rectum, laboured under prolapsus. Both affections had proceeded from the same cause, and were relieved at the same time by the same means. His brother, whom I happened to attend for the effects of a severe accident, mentioned to me, that whenever it happened to himself that the bowels were confined, more or less protrusion of the rectum invariably took place. Thus, in its slightest form, this complaint admits of being remedied, and its recurrence prevented, by obviating the costiveness which has produced it.

Protrusion caused by Stone. 38

Habitual straining of the abdominal muscles, without costiveness, is liable to produce prolapsus. Among the children whom I have operated on, or have seen cut for stone, I hardly recollect an instance in which this symptom has been absent. The reason is very evident. The expulsion of the water in persons afflicted with stone is commonly attended with involuntary bearing down and forcing of the diaphragm and abdominal muscles. The repetition of the violent pressure upon the bowels forces their lowest portion in a state of eversion out of the anus. When the stone has been removed, the cause of irritation which led to the violent action of the abdominal muscles is at an end ; the straining does not recur ; the bowel is no longer habitually forced down; it gradually recovers its tone : in a short time the protrusion ceases to take place.