Diseases of the rectum and anus

Preface

Ix preparing the following pages for publication, I have endeavored to condense into convenient form, for both student and practitioner, as great an amount as possible of practical information concerning diseases of the rectum and anus.

The advances which have been made during the past few years in this special branch of surgery have been very great. The whole patholog}" of malignant disease has been rewritten ; and the close relationship of the so-called benign polypoid growths to epithelial cancer has been worked out after careful study with the microscope. The operation of excision of cancerous growths in the lower part of the rectum has again become a legitimate surgical procedure, and what is better, its range of applicability has been definitely determined. The advances in abdominal surgery, for which the present century will always be famous, have also had a bearing on diseases of the rectum, and the operation of excision of cancer of the upper part of the rectum and the sigmoid flexTire, through an incision made in the abdominal wall, has brouglit within treatment a class of cases formerly beyond the reach of art.

New methods of treatment of benign stricture have been devised as a substitute for colotomy. New methods of palliation in benign and malignant stricture have been devised as substitutes for the repulsive operation of colotomy, and that operation bids fair in the immediate future to assume deservedly a place of less prominence than it has occupied in the past. New and effectual methods of curing haem-

IV PREFACE.

orrlioids and prolapse mthout cutting operations have been added to the surgeon's resources.

The advances have been due to the efforts of no one man or nation. The records of them are scattered through English, Continental, and American periodical literature, and many of them are practically beyond the reach of the busy practitioner.

I have tried, therefore, as far as possible to condense what was positively known within the following pages, and to reduce it to a form suitable for ready reference by student and practitioner, giving not only the results which have been reached by experiment and clinical experience, and wliich may be relied upon as the basis of practice, but in many questions marking out by foot-notes and references the way for any who may desire to go over for himself the ground which I have followed with no little difficulty.

In addition, I have endeavored, whenever possible, to illustrate the subject under consideration by the reports of cases either from my own practice or that of others, knowing that a lesson is often conveyed to the student in this way better than by any other.

My thanks are especially due to the librarians of the Kew York Hospital for their unvarying kindness and assistance, which has rendered my work a far from unpleasant one.

Chakles B. Kelsey.

"The Madison," No. 25 Madison Ave., Corner of 25th Street, New York, September, 1882.

CHAPTER I. PRACnCAL POINTS IX ANATOMY AND PHYSIOLOOY

f

Rectum. — Position and Measurements. — Curves. — Divisions. — Relations.— Arms. — Parts in Detail. — Peritoneum. — Relations to Three Portions of the Rectum. — Distance of Peritoneal Cul-de-Sac from Anus. — Muscular Layer.— Arrangement of Fibres. — Submucous Layer. — Mucous Membrane. — Sustentator Tunica? Mucosae. — Columnae Recti. — Glands of Mucous Membrane. — Muscles of the Rectum and Anus. — External Sphincter. — Internal Sphincter. — Recto-Coccygeus. — Levator Ani. — Transversus Perinei, — Arteries.— Superior Hemorrhoidal. — Middle Hsemorrhoidal. — Inferior Hiemorrhoidal. — Veins. — Superior Haemorrhoidal. — Middle Heemorrhoidal. — Inforior Haemorrhoidal. — Minute Anatomy of Veins. — General and Visceral Venous Systems. — Nerves. — Cerebro-Spinal and Sympathetic Nerve Supply. — Tonic Contraction of Sphincter. — Explanation of Wandering Pains in Rectal Disease. — Lymphatics.— External and Internal Lymphatic Vessels. — Physiology. — Aftatomy of the Third Sphincter.— Valves of Mucous Membrane. — Plica Transversalis Recti of Kohlrausch. — Lack of Uniformity in Dififerent Subjects. — Physiology of Defecation. — Explanation of Retention of Faeces after Destruction of the Sphincter. — Conclusions Resulting from Study of Third Sphincter ....

Chapter II. Congenital Malformations Of The Rectum And Anus

Se[»arate Development of Rectum and Anus. — Narrowing of the Anus or Rectum without Complete Occlusion. — Congenital Stricture. — Closure of the Anus by a Membranous Diaphragm. —Entire Absenceof the Anus, the Rectum Ending in a Blind Pouch at a Point more or Less Distant from the Perineum — Ile(^tuiu Same as in Last Variety and the Anus Normal. — Anus Absent and Rectum Oiiening by an Abnormal Anus at Some Point in the Perineal or Sacral Regions. — Ca.ses. — Anus Absent and Rectum F-nding in the Bladder, Urethra, or Vagina. — Cases. — Rectum and Anus Normal, but Ureters, Uterus, or Vagina Empty into Rectum. — Total Absence of Rectum. — Alwence of Large Intestine. — Obliteration from Intrauterine Disease. — Treatment. — Operation Should Always be Performe*! and Without Delay. — Attempt Should First Ikj Made to Establish an Anus

VI CONTENTS.

PAGB

in the Anal Region. — Measurements of Pelvis at Birth. — Use of Trocar not Justifiable. — Useful Anus Seldom Obtained by Means of Incision Alone. — Objections to Cutting Operation Without Plastic Operation. — Proctoplasty. — If Attempt to Establish New Anus in Anal Region Fail, Colotomy at Once to be Performed. — Inguinal Preferable to Lumbar Colotomy. — History of Colotomy.— Callisen. — Amussat. — Description of Operation of Colotomy. — Dangers of Operation. — The Inguinal Operation.— Description. — Attempts at Establishing Anus in Anal Region after Colotomy Generally Unsuccessful. — Cases. — Closure of Artificial Anus. — Operation of Dupuytren. — Modifications of Dupuytren's Operation . . 30

Chapter III. < General Rules Regarding Examination, Diagnosis, And Operation

Necessity for Physical Examination. — Questions which may lead to Diagnosis.— How to make Examination. — Table. — Lamp. —Instrument Case. — Position of Patient. — Necessity for Enema before Examination. — What may be learned by simple Inspection. — Rectal Touch. — What may be discovered by it. — ^Bougies; Varieties; Author's Bougies. — Rectal Specula: Van Buren's; Fenestrated; Bivalve; Objections. — Colonoscope. —Stretching the Sphincter; Proper Method of Performing the Operation; Resiilts. — Difficulties of Diagnosis of Disease high up in the Rectum. — Manual Examination. — What may be Learned by this Method. — Preparation of Patient for Operation. — Assistants. — Primary AnsBsthesia. — Thermo-Cautery. — Hcemorrhage. — Rules for Controlling Haemorrhage. — Cold. — Styj)- tics. — Packing the Rectum. — Treatment after Operation.— Dressings. — Necessity for Rest. — Retention of Urine. — Case of Fatal Retention . . 48

Chapter IV. Inflammation Of The Rectum

Cases of Proctitis. — Varieties : Acute, Chronic, Primary, Secondary, Localized, General. — Symptoms and Course of each Variety. — Causes of Proctitis : Direct Propagation, Foreign Bodies, Drastic Cathartics, Gout, Pederasty, Gonorrhoea. — Treatment 66

Chapter V. Abscess And Fistula

Abscess divided into Superficial and Deep. — Superficial Abscesses. — Simple Furuncles; Causes; Characters; Results; Treatment. — Suppuration of External Haemorrhoid. — Suppuration of Internal Hsemorrhoid. — Diffuse Inflammation of Subcutaneous Tissue, Causes; Symptoms; Treatment. — Form of Incision. — Deep Abscesses. — Divided into Abscess of the Ischio- Rectal Fossa and of the Superior Pelvi-Rectal Space. — Cai ses; Symptoms; Diagnosis. — Dangers of Deep Abscess. — Formation of Deep and Extensive Fistulae. — Horse-shoe Abscess. — Idiopathic Gangrenous Cellulitis.— Reasons why Abscesses do not Heal Spontaneously. — Prognosis. — Treatment. — Incisions and Subsequent Treatment of Deep Abscesses. —

CONTENTS. VU

Incontinence of Faeces. — Relief of Incontinence resulting from Operation. — Fistula. — Generally due to Abscess. — Divided into Superficial and Deep. — Complete Fistula. — External Fistula. — Internal Fistula. — Description of Superficial Fistulae. — How to Detect an Internal Opening. — Location of Internal Opening. — Description of Track of Fistula. — Symptoms of Superficial Fistula. — Deep Fistula. — Fistula with Numerous External Ojjenings. — Blind Internal Fistula. — Ulceration of Rectum Causing Internal Fistula. — Treatment. — Spontaneous Cure. — Advisability of Operation.— Fistula in Relation to Phthisis. — Contra-indications to Operation. —Treatment by Cauterization. — The Ligature. — The Elastic Ligature. — Galvano-Cautery. — How to Pass Ligature. — Incision. — Description of Operation. — Author's Knife for Fistula. — Division of Deep Tracks. — Treatment of Track running up the Bowel. — Treatment of Blind External Variety; of Horse-shoe Variety; of Fistula with Numerous External Openings. — Dressing after Incision. — Packing the Incision. — Hajmorrhage in Operation. — Treatment of Blind Internal Variety. — Incurable Fistulse. — Treatment of Deep and Extensive Tracks. — Fistula with Stricture . 71

CHAPTER VL

HiCMORRHOIDS.

Definition. — Division into External and Internal. — Differences between the two Varieties. — External Haemorrhoids. — Pathology. — Inflamed Haemorrhoids.— Treatment. — Means of Prevention. — Palliative Treatment. — Excision. — Internal Haemorrhoids. — Division into Capillary, Arterial, and Venous. — Description of Capillary Variety, of Venous Variety, of Arterial Variety. — Symptoms of Internal Haemorrhoids. — Strangulation. — Diagnosis.— Treatment of Internal Haemorhoids. — Palliative Treatment. — Constitutional and Local Means of Palliation. — Treatment of Strangulation. — Curative Treatment. — Haemorrhoids Associated with Uterine Disease. — Symptomatic Haemorrhoids. — Radical Cure. — Caustics. — Dangers of Nitric Acid. — Vienna Paste. — Treatment by Carbolic Acid Injections; Cases and Cures. — Advantages of this Treatment. — Treatment by Ligature.— Description of Operation. — Operation with Clamp and Cautery . i)!

Chapter VI L Prolapse

Four Varieties. — First Variety: Prolapse of the Mucous Membrane Alone. — Second Variety: Prolapse of all the Coats of the Rectum. — Third Variety: Prolapse of the Upper Part of the Rectum into the Lower, or Invagination.— Fourtli Variety: Invagination in the Continuity of the Bowel. — Prolapse of the Mucous Membrane alone. — Causes. — Symptoms. — Treatment: Palliative and Curative. — Prolapse with Haemorrhoids. — Treatment by Injections. — Cauterization.— Description of Operation. — Smitli's Clamp. — Dupuytren's Operation. — Prolapse of the Second Degret^. — Pathological Changes. — Presence of Peritoneum.— Strangulation. — Dangers in Forcible Re<iuction. — Fatal Case of R«Hlu(;tion. -Advisability of Reducing Infiameil or Gangrenous Prolapse. — Excision of Prolapse after the Formation of a Slough. — Dangers of Oi>eration of Excision in Extensive

Vlll CJOKTENTS.

PAQE

Prolapse. — Operation by Elastic Ligature. — Third and Fourth Varieties. — Differences between Tliird and Fourth. — Degrees of Invagination. — Anatomical Appearances. — Pathology. — Relative Frequency. — Symptoms.— ^Physical Signs. — Acute and Chronic Forms. — Diagnosis. — Differential Diagnosis from Volvulus; from Stricture; from Internal Hernia; from Obstruction by Pressure from without the Bowel; from Foreign Bodies; from Peritonitis with Perforation. — Treatment. — Replacement by Manipulation; by Injections. — Treatment by Puncture. — Laparotomy. - Description of Operation 110

Chapter VII L Non-malignant Growths Of The Rectum And Anus

Polypus. — Definition. — Hypertrophy of Villi. — Characteristics. — Villous Tumor.— Adenomatous Polypus. — Fibrous Polypus. — Structure; Characteristics.— Symptoms of Polypus. — Diagnosis. — Diagnosis from Malignant Disease. — Treatment. — Vegetations. — Definition. — Description. — Microscopic Appearances. — Relation to Syphilis. — Symptoms of Vegetations. — Diagnosis. — Treatment. — Condylomata. — Distinction between Condylomata and Vegetations. — Description. — Syphilitic and Non-syphilitic Condylomata.— Benign Fungus. — Gummata. — Rarity and Literatui'e. — Ano-rectal Syphiloma. — Definition of Fournier. — Fibromata. — Lipomata. — Characteristics. — Enchondromata. — Cysts. — Dermoid Growths. — Characters.— Pilo-Nidal Sinus. — Hydatids. — Foetal Inclusions. — Spina Bifida. — Congenital Cysts ...-.., 135

Chapter IX. Non-malignant Ulceration

Varieties. — Simple Ulcers. — Generally due to Traumatism. — Various Forms of Injury to which Rectum is Subject. — Sodomy. — Injury of Rectum in Labor. — Ulcers due to Surgical Interference. — Fissure or Irritable Ulcer. — Nothing Distinctive in the Ulcerative Process. — Characteristics of Irritable Ulcer. — Theories concerning this Form of Ulcer. — Description. — Herpes. — Tubercular Ulceration. — Distinction between True Tubercular Ulcer and a Simple Ulcer in a Tuberculous Person. — Description of Each. — Scrofulous Ulceration. — Esthiomene. — Rodent Ulcer. — Dysentery. — A Cause of Stricture. — Venereal Ulceration. — Gonorrhoea. — Chancroids. — Chancroidal Stricture. — Discussion. — True Chancre. — Secondary and Tertiary Syphilitic Ulcerations. — Diagnosis of Syphilitic Ulcers. — Ano-rectal Syphiloma as a Cause of Ulceration. — Ulceration Secondary to Stricture. — Gangrene. — Symptoms of Ulceration. — Gravity of the Disease. — Diagnosis.— Treatment. — General and Local Measures. — Treatment of Fissure. — Fissure Complicated with Polypus. — Treatment by Rest, Fluid Diet and Incision of the Sphincter. — Local Applications 158

Chapter X. Non-malignant Stricture Of The Rectum

Stricture due to Changes in the Rectal "Wall and to Pressure from Without. — Spasmodic Stricture. — General Division into Venereal and Non-Venereal

CONTKNT8. IX

PXGE

Strictures and into Fibrous and CicatriciaL — Frequence of Syphilis in (>>nnection with Stricture. — Non- Venereal Strictures. — Congenital, Dysenteric, Traumatic, Varieties. — Stricture from Hj'pertrophy of Valves. — Pathological Anatomy. — Changes in Rectal Wall above and below the Stricture. — Changes in Parts around the Stricture. — Symptoms. — Value of Flattened Passages as Symptom. — Signs of Obstruction. — Obstruction with Stricture of Considerable Calibre. — Diagnosis. — Dangers to be Avoided in Examination. — Difficulty when Disease is Situated high up in the Bowel. — Use of Bougie for Diagnosis. — ^Treatment. — Advisability of Anti-Syphilitic Medication.— Palliative Treatment. — Medicinal Treatment of Threatened Obstruction. — Surgical Measures. — Dilatation, Gradual or Sudden — Rules for Gradual Dilatation. — Divulsion, Dangers of, and Methods of Performing. — Treatment by Free Division. — Description of Operation. — Collection of Cases.— Results of this Treatment. — Com- I)arison with Colotomy. — Cases from Author's Practice. — Knife for Operation.— Excision of Non-Malignant Stricture. — Colotomy. — Restrictions to the Operation. — General Considerations Regarding it. — ^Treatment of Stricture High Up 181

CHAPTER XL

CANCER.

t]-neral Ciiaracters of Malignant as Distinguished from Benign Growths. — Malignant, Semi-Malignant, and Benign Adenoma. — Encephaloid.— Colloid.— Melanotic Cancer. — Osteoid Cancer. — Age at which Cancer occurs. — Symptoms. — Diagnosis. — Treatment. — Excision: History and Results of Operation.— Conclusions Regarding Excision. — Modes of Performing the Operation. — Excision of Cancer of the Sigmoid Flexure. — Palliative Treatment .218

Chapter XII. Impacted Faeces And Foreign Bodies

Impacted Faeces. — Intestinal Concretions. Diagnosis and Treatment of Impaction.— Foreign Bodies Swallowed. — Results which may Follow the Swallowing of a Foreign Body. — Ulceration and Abscess. — Foreign Bodies introduced per Anum. — Cases. — Prognosis. — Treatment. — Dangers of Attempts at Removal. — Laparotomy for Removal. — Cases Successful . 252

Chapter XIII. Pruritus Anl

Pruritus Generally a Symptom of some other Disease.— Description.— Causes. — Relations of Internal Haemorrlioids, Fistula, Worms, Parasites, and Eczema to Pruritus. — Treatment of Eczema. — HerjH's and Erythema. — Constitutional Conditions causing Pruritus. Dependence ujxm Constipation.— Treatment of Constipation. — General Treatment of Pruritus . 269

X CONTENTS.

Chapter XIV. Spasm Of The Sphincter, Neuralgia, Wounds, Rectal Alimentation

PAGE

Spasm without other Disease. — Cases. — Authorities. — Symptoms. — Treatment.— Neuralgia. — Cases. - Diagnosis. — Treatment. — Wounds. — Complications.— Spontaneous Rupture. — Treatment of "Wounds. — Alimentation. — Physiology of Absorption. — Nutritive Enemata. — Nutritive Suppositories 277

LIST OF ILLUSTRATIONS.

PAOB

FiauRB 1. Antero-posterior curve of tlie rectum, 2

" 2. Section of normal rect.al wall, 8

" * 3. Section of rectal mucous membrane, 9

** 4. Rectal veins seen from without . 14

" 5. Rectal veins seen from within, 15

*' 6. Nerves of the anus, 18

" 7. Third variety of congepital malformation, . . . . ' . 32

" 8. Fourth variety of congenital malformation 33

" 9. Fifth variety of congenital malformation, 34

10. Sixth variety of congenital malformation, 35

11. Condition of bowel after colotomy, 46

13. Enterotome of Dupuytren in jiosition, 47

14. Examining table, closed, 50

15. Examining table, opened, 50

" 16. Lamp for rectal examinations, 51

*' 17. Case for rectal instruments, 52

" 18. Blunt-pointed bougie, 55

*' 19. Sharp-pointed bougie, 56

" 20. Bougie a boule, 56

" 21. Van Buren's rectal speculum, 58

22. Fenestrated rectal speculum, .'>9

*• 28. Bivalve rectal speculum 59

24. Rectal depressor, 59

•• 25. Endoscope, 60

" 26. Thermo-cautery, 63

27. Varieties of fistula, 78

*' 28. Fistula with double track, 79

" 80. AUingham's ligature holder, 84

31. Helmuth's ligature holder, 84

82. Author's fistula knife, 86

33. Gorget 86

34. Spring scissors, 87

35. Forceps for haemorrhoids, 107

36. Smith's clamp, 109

37. First variety of prolapse, Ill

" 38. Second variety of prolapse, Ill

" 39. Third variety of prolapse, 112

Xll LIST OF ILLUSTRATIONS-

PAGE

Figure 40. Rectal supporter, 115

41. Rectal polypus, 13G

42. Villous polypus, 137

43. Microscopic section of villous polypus, 137

44. Glandular polypus, . . . . . . . . . 138

45. Vertical section of glandular polypus, 139

46. Vegetations around anus, 142

47. Condylomata, 147

48. Stricture of the rectum, 184

49. Rectal dilator 200

50. Wales's dilator, 201

51. Knife for proctotomy 205

52. Cancer of the rectum — Malignant adenoma (Stimson) . . 219

Chapter I. Practical Points In Anatomy An"d Physiology

Bectuin.^Position and Measurements. — Curves. — Divisions. — Relations. — Anus. — Parts in Detail. — Peritoneum. — Relations to Three Portions of the Rectum. — Distance of Peritoneal Cul-de-Sac from Anus. — Muscular Layer. — Arrangement of Fibres. — Submucous Layer. — Mucous Membrane. — Sustentator Tunicse Mucosae. — ColumnaB Recti. — Glands of Mucous Membrane. — Muscles of the Rectum and Anus. — External Sphincter. — Internal Sphincter. — Recto-Ckx;cygeus. — Levator Ani. — Transversus Perinei. — Arteries. — Superior Haemorrhoidal. — Middle Haemorrhoidal. — Inferior Haemorrhoidal. — Veins. — Superior Haemorrhoidal. — Middle Haemorrhoidal. — Inferior Haemorrhoidal.— Minute Anatomy of Veins. — General and Visceral Venous Systems.— Nerves. — Cerebro-Spinal and Sympathetic Nerve Supply. — Tonic Contraction of Sphincter. — Explanation of Wandering Pains in Rectal Disease.— Lymphatics.— Elxternal and Internal Lymphatic Vessels. — Physiology, — Anatomy of the Third Sphincter.— Valves of Mucous Membrane. — Plica Transversalis Recti of Kohlrausch. — Lack of Uniformity in DiflFerent Subjects. — Physiology of Defecation. — Explanation of Retention of Faeces after Destruction of the Sphincter. — Conclusions Resulting from Study of Third Sphincter.

The rectum is the terminal portion of the large intestine extending from the sigmoid flexure to the anus. In its natural position its length varies in different persons from six to eight inches. When dissected out of the body and straightened, it will be found to measure about two inches more. Its position in the true pelvis is comparatively fixed; and its fixity renders it the more liable to those displacements, such as invagination and prolapse, which are due to straining at stool; and accounts also for the fact that, when denuded by the destruction of the surrounding cellular tissue, it remains separated from the walls of the pelvis, and cannot come in contact with the adjacent soft parts and thus undergo healing.

2 DISEASES OP THE KECTUM AND ANUS.

The upper limit of the rectum is difficult to determine with accuracy, except from the fact that it is separated from the sigmoid flexure by a slight constriction which becomes more apparent when attempts are made at dilatation. From this tipper point it gradually expands into a pouch, the ampulla, and then again suddenly contracts under the grasp of the muscles which close its lower end.

Curves. — The curves of the rectum are exceedingly important in a practical point of view. There are two, one antero-posterior, the other lateral. The former is double. From above downwards it follows the curve of the sacrum and coccyx, being concave in front, and convex behind. When it reaches a point opposite the tip of the coccyx it suddenly reverses its direction, turns sharply backwards, and ends at the anus about one inch in front of the tip of that bone.

By this backward curve of its lower end, which is represented in an exaggerated form in Fig. 1, it is separated from the vagina in the female.

Fig. 1. — Exaggerated antero-posterior curve of rectum.

and from the urethra in the male, by a triangular space having its base at the perineum, its upper wall at the vagina or urethra, and its lower at the upper wall of the rectum. The angle of junction of these two curves is well marked, measuring from twenty to thirty degrees; and the curve is not without influence in the function of defecation, since, by it, an. obstruction is formed to the downward course of the faeces.

The lateral curve is generally a single one from left to right, starting at the left sacro-iliac synchondrosis and ending at the median line at a point opposite the third sacral vertebra, from which point it generally passes straight on to the anus. This curve may, however, pass beyond the

PEACTICAL POINTS IN ANATOMY AND PHYSIOLOGY. 3

median line to the right in its lower portion, and again return to the median line at the anus. It is subject to many variations, and the upper portion may be more or less twisted on itself like the sigmoid flexure.

The sigmoid flexure may occupy an unnatural position, and the rectum* instead of commencing at the left sacro-iliac junction and curving towards the right, may commence at the right and curve toward the left. In one case, reported by Cruveilhier,' where the sigmoid flexure was in the natural position, the rectum passed almost transversely to the right side as far as the right sacro-iliac junction, and then returned again very obliquely in the left side.

Divisions. — For convenience the rectum is usually divided into three portions, named first, second, and third, from below upward. The first extends from the anus to the tip of the prostate; is about an inch and a half long; is firmly closed by the sphincters; and gives attachment to a portion of the levator ani muscle. On account of the direction of this portion, which is the reverse of that next above, the finger should never be passed toward the sacrum, or even directly inward in making an examination; but rather toward the pubes. Bearing this simple anatomical point in mind will often save the patient much unnecessary suffering. The second portion is often described as reaching from the apex of the prostate to the recto- vesical fold of peritoneum; but, as the point of duplicature of the peritoneum is not only variable in different individuals, but at different times in the same individual, it is better to adopt a fixed bony point, as the third piece of the sacrum; in which case the middle portion will measure about three inches in length. This portion, it will be remembered, is convex backward, following the curve of the sacrum. The third portion extends from the third sacral vertebra to the left sacro-iliac synchondrosis; its lower part is partially, and its upper, completely, surrounded by peritoneum; which, in the upper part, forms the meso-rectum attaching it to the sacrum.

Relations. — The most important surgical relations of the rectum are on the anterior surfjvce. The first portion is surrounded laterally and posteriorly by a bed of connective tissue, rich in ^it and blood-vessels, and may, therefore, be incised on either side, or backward, with comparative safety. In front, however, it is directly in relation with the membranous urethra in the male, and with the vagina in the female; though at the anus it is separated from them both by its backward and downward course. This intimate relationship with the urethra is often taken advantage of in catheterism, when by passing the finger into the rectum the tip of the instrument may easily be felt; and it also explains why in all operations on the urethra or vagina the rectum should first be emptied to save it from being wounded.

In the second portion also, the lateral and posterior surfaces have no

'Anat. Path.. Amer. Edition. 1844, p. 377.

4 DISEASES OF THE KECTIJM AND ANUS.

special surgical relations; while the anterior is in direct contact with the prostate, the base of the bladder, the seminal vesicles, and sometimes, at its tipper limit, with the peritoneal fold of Douglas. This portion is closely connected with the bladder in the male, and Avith the vagina in the female, by connective and muscular, tissue; and the two cavities may easily be made to communicate by any morbid process or by a surgical procedure. It was at this point that the trocar was plunged from the rectum into the bladder in the old operation of puncturing the bladder through the rectum; and Hyrtl' speaks of a man who was only able to pass his water after first introducing his finger into the rectum and raising a calculus out of the trigone of the bladder. A somewhat analogous case is reported in which a long slender calculus perforated the bladder and projected into the rectum, from which it was easily removed." The prostate, when large, may project over the sides of the rectum, or the latter may receive the prostate in a kind of gi'oove on its upper surface.

The third, or upper portion, unlike the other two, has important surgical relations on every side. Posteriorly it is in whole or part covered with peritoneum; and is separated from the sacrum by the pyriformis muscle, the sacral plexus of nerves, and the branches of the internal iliac artery. On its sides it is in contact with the adjacent convolutions of small intestine, and lower down, with the levator ani muscle and the connective tissue of the ischio-rectal fossa. In the male it is in relation, in front, with the posterior surface of the bladder, from which it is separated by coils of small intestine. In cases of retention either of urine or fseces the two may be brought into actual contact. In the iemale, it is in relation, anteriorly, with the broad ligament, the left ovary and Fallopian tube, the uterus and vagina. When the rectum and uterus are empty, the coils of small intestine pass down between them to the bottom of the fold of Douglas, and they may even escape through the posterior wall of the vagina in case of injury.

From these relations it is apparent that enlargements and malpositions of the uterus may act directly upon the rectum. The vessels may be so obstructed as to cause hemorrhoidal troubles, or interfere with operations for their relief. The rectum may be entirely occluded by the pressure of a uterine tumor; and a hasty examination of the rectum may lead to the diagnosis of a cancerous tumor when in reality the normal uterus alone is felt. The advantage of a rectal examination in all doubtful cases of pelvic disease is also manifest.

Tlie Anus. — The rectum terminates below in the anus which is tightly closed by the external sphincter muscle. The skin around its border is thin and pigmented, covered with fine hair in the male, and contains a great number of sebaceous follicles and muciparous glands. The skin

^Topog. Anat., ii., p. 103.

•G<xx5h: Chirurg. Works, London, 1792, vol. iii., p. 216.

PBACnOAL POENT8 IN ANATOMY AND PHYSIOLOGY. 5

passes deeply into the anal orifice, and its point of junction with the mucous membrane is in some persons indicated by an indistinct white line. ' This white line of junction also corresponds to the division between the external and internal sphincter muscles; and also to the point at which many of the terminal filaments of the internal pudic nerve perforate the gut. Both skin and mucous membrane at the anus are remarkable for the development of erectile tissue; the arteries coming from the inferior haemorrhoidal, and the veins being very numerous, winding, and twisted. The presence of this erectile tissue accounts for the habit of pederasty which will occasionally be referred to as a cause of rectal disease. It is a habit to which few are addicted in this country, but which is not uncommon in some other parts of the world. In America it is chiefly seen amongst the negro race and on shipboard amongst sailors who are on a long voyage. Among the latter it was a vice whose existence was well known and which was occasionally punished by the officers during the late war. The nerves are derived both from the cerebro-spinal and sympathetic systems, as will be shown later.

After these general considerations of the position and relations of the rectum as a whole, the individual parts may be taken up more in detail. The rectal wall is composed, as are the other parts of the intestine, of four layers: an external or peritoneal; a muscular, divided into longitudinal and circular; a sub-mucous connective tissue layer; and most internally, the mucous membrane. The total thickness of these coats collectively varies greatly in different subjects, the variation being chiefly in the muscular coat, the others remaining pretty constantly of the same thickness.

Peritoneum. — The upper portion of the rectum is entirely surrounded by peritoneum, and has, beside, a fold of attachment to the anterior surface of the sacrum, known as the meso-rectum. The meso-rectum is about four inches long, blends with the meso-colon above, and extends down as low as the third or fourth sacral vertebra, from which point its two layers are reflected over the sides and anterior surface of the rectum on to the posterior wall of the uterus and upper limit of the vagina in the female; and on to the bladder in the male, forming the cul-de-sac of Douglas. The meso-rectum may be so short as to disappear when the rectum is distended, or it may be entirely absent; in which case the peritoneum pjisses directly from the sides of the rectum to the sacrum. Between its two layers may be found some loose connective tissue, the haemorrhoidal vessels and nerves, and the lymphatics.

In passing from the limit of the meso-rectum behind, to form the cul-de-sac in front, the peritoneum covers more or less of the lateral and anterior surfaces of the middle portion of the rectum. As before men-

' Hilton: Rest and Pain. Wood's Library of Standard Medical Authors, p. 166.

tioned, the point at which the peritoneum leaves the anterior surface a the middle portion of the rectum to be reflected upon the posterior surface of the bladder in the male, or of the vagina or uterus in the female, varies in different subjects, and at different times in the same subject; and hence the differences in its distance from the anus as given in different works on anatomy. In new-born children the bottom of the cul-desac touches the upper edge of the prostate and approaches to within about an inch of the anus. At five years it rises in the pelvis with the development of the seminal vesicles and internal organs of generation; and in old people with enlargeihent of the prostate, it is carried still higher. In women it generally extends to the uj)per border of the posterior vaginal wall; so that the latter is separated from the rectum by peritoneum for about one-third of an inch. By every expansion of the bladder or rectum as well as by tumors of the pelvis the fold is carried further away from the anus, as may easily be demonstrated on the cadaver by forcible injections of the bl&dder.