Joseph McDowell Mathews.

A treatise on diseases of the rectum, anus, and sigmoid flexure online

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that is given for its effect. I am in the habit of prescribing,
as a beginning, ten drops of the saturated solution in a half-
glass of water three times a day, and increasing from two to
five drops each day until, if the case seems to demand it, I
reach as much as fifty drops at a dose, or one hundred and
fifty grains i)er day, to be taken indefinitely and its effects
carefully watched. It should always be seen that it is fully
diluted with water. Sometimes you will see a patient who
has an idiosyncrasy to the drug, and its effect may be mani-
fested by the taking of a few grains. Of course, in these
cases, the physician is to determine what is best to be
done. I am satisfied that I have seen quite a number of ul-
cerations of the rectum get well under this kind of treat-
ment. It should not be forgotten that, along with the mer-
curial and iodide treatment, these patients need a good
tonic course as well. Some one of the good tonics should
be given. One of the best is the elixir of iron, quinine, and
strychnine.



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830 DISEASES OP THE RECTUM, ANUS, AND SIGMOID FLEXURE.

For the ansemia which frequently follows antisyphilitio
treatment or the disease itself, or for the same condition
produced by struma, tuberculosis, etc., a most admirable
preparation will be found in the Elixir of the Three Chlo-
rides with Calisaya prepared by Renz & Henry, of this city.
Each fluidrachm contains an eighth of a grain of protochlo-
ride of iron, yj^ grain of bichloride of mercury, and ^h
grain of chloride of arsenic. I have derived much benefit
from treating this class of patients with this preparation.
Indeed, it is wonderful to see the rapid improvement in aU
enfeebled natures, especially the syphilitic, after taking the
three chlorides.

Under this classification of ulcers of the rectum, but more
esi)ecially of the anus, I wish to speak of chancroids. They
are said by Pean and Malassez to have constituted nearly one
half of all the ulcerations in this region examined at the
Lourcine in 1868. I can not understand how it is that, if
this statement is correct, we in America have seen so few
cases.

I am sure that I never saw a stricture of the rectum pro-
duced by chancroidal pus, and I can not remember to have
ever seen an ulcer on the mucous membrane of the rectum
caused in this manner. We do tolerably often see condylom-
ata around the anus, and such a condition is very ugly, and
may be so extensive as to often lead the physician to susx>ect
that he is dealing with a more serious condition than exists.
But we must remember that all condylomata are not syphi-
litic. This condition is recognized by the elevation above
the cuticle, in a well-defined grouping, of what appear to be
small, nodular tumors, with an ulcerated surface, discharg-
ing pus. But of all forms of ulceration around the anus, or
in the rectum, this is the most amenable to treatment. Abso-
lute cleanliness of the parts should be brought about by hot
water and Castile soap, then drying off and applying the fol-
lowing:

9 Bismuth, subnitratis 5 ss. ;

Hydrarg. chlor. mit 3 iij.

M. Sig. : Dust on the parts.



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ULCERATION OF THE RECTUM. 331

Under tWs treatment this condyloma tons mass frequently
disappears as if by magic. If the ulcerations appear to be at
all indolent, I have found it best to irrigate them with a solu-
tion of bichloride of mercury (1 to 3,000).

Dysentery.— I have taken the position, in the chapter on
stricture, that I did not believe that dysentery was a com-
mon cause of stricture, as is stated by some. In giving my
reasons I stated that an ideal case for a pension would be
where a soldier should show a stricture of the rectum re-
sulting from dysentery contracted during a war, and inci-
dentally remarked that the Pension Office was singularly
quiet on that point. I have just noticed that in the Medical
History of the War of the Rebellion Dr. Woodward remarks
that stricture resulting from dysenteric ulceration seems to
have been much rarer than might have been supposed, and
that no case has been reported at the Surgeon-General's Office,
either during the war or since ; that the Army Medical Mu-
seum does not contain a single si)ecimen ; nor has he found
in the American medical journals any case substantiated by
post-mortem examination in which this condition is reported
to have followed a flux contracted during the civil war. It
is only since taking up this chapter that I have seen this state-
ment from Dr. Woodward, and I am glad to see that it sub-
stantiates so fully the opinion that I have expressed. Dysen-
teric ulceration of the rectum, however, is sometimes seen,
although not as often as one would suppose. We more fre-
quently have colitis existing as the result of dysentery than
proctitis, and I believe the sigmoid flexure is affected oftener
in this manner than the rectum. These ulcers appear isolated
and are very seldom grouped. I believe that their origin oc-
curs by the i)eeling off of the epithelium, and the friction
to which they are afterward subjected by the faeces or strain-
ing, or both, tends also to implicate the mucous membrane.
If the dysenteric patient could be watched and have his rec-
tum irrigated after his attack, I dare say that the number of
cases of dysenteric ulceration, although already few, would
be diminished. '



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833 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE.

Treatment— If it is supposed that the ulceration is the re-
sult of dysentery, the same treatment would obtain as pre-
scribed for simple ulceration from other causes — viz., an abso-
lute rest given the bowel by first causing a free evacuation in
order to clear out the intestinal tract, rest in bed, and sooth-
ing applications locally applied. In such a case I would use
frequent injections of very hot water, not only for the pur-
pose of cleansing the mucous membrane, but for its stimu-
lating proi)erty as well. If an ulcer is defined and evinces
an indolent disposition, one of the best local applications
is pure carbolic acid. In makiTig this application it is well
to guard the surrounding mucous membrane by seeing that
the cotton on the probe is not over-supplied with acid, and
also to use an application of vaseline around the contigu-
ous parts after the application. As a subsequent local appli-
cation, I am in the habit of using iodoform for ulcers of the
rectum by distending the sphincter muscles with a specu-
lum and blowing the powder by means of an insufllator
upon the diseased membrane. As an injection, a prex>aia-
tion of iodoform or aristol, one drachm to eight ounces of
olive oil, one ounce to be injected each night at bed-time
by the patient. By absolute rest, and under this treatment,
such ulcers would be very likely to heal. I very seldom in-
ject opium for ulceration of the boweL It is very true that,
of all agents, It is the quickest to quiet pain and distress, but
it establishes a habit which is hard to overcome. In ulcerar
tions of the rectum which have existed for any length of time
and show a well-defined, hardened base with indurated bor-
ders, it is a good plan to scarify them, and especiaUy to see
that the knife goes through the edges of the ulcers. This
should be done before any si)ecial treatment is begun.

mceration from Foreign Bodies. — Of course it is an admitted
fact that traumatism, the result of the introduction of for-
eign bodies into the rectum, may be followed by ulceration,
and yet this should be classed under the head of simple
ulceration and treated as such. It is remarkable the number
of foreign bodies and the character of some that are some-



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ULCEBATION OF THE RECTUM. 833

times found in the rectnm. In many cases the patient will
absolutely deny that any effort has been made to introduce
the foreign body into the rectum, and yet, upon investigation,
such may be found, and, unless removed, might result fatally ;
to the contrary, the surgeon might be led into error by the
statement of patients as to the swallowing of foreign bodies
or substances.

Case. — A short time ago a young gentleman came to my
office in very great distress of mind. In giving me a history
of his disturbed condition, he said that he had the day before
swallowed his upper set of teeth, including the plate. I
asked him to tell me how this was done, and he replied that
while eating raw oysters at a restaurant it must have oc-
curred, from the fact that, as he was leaving the place, he
detected that the plate containing his teeth was not in his
mouth. Upon further questioning, I ascertained the fact that
before going to the restaurant he had placed postage stamps
upon a number of letters, and that to moisten the stamps he
would insert a number that were attached into his mouth
against this upper plate. I suggested to him that possibly
the suction and the gum arable upon the stamps had been
the means of drawing the plate from his mouth without
his knowledge. In questioning him for symptoms of any
foreign body in the intestinal tract or stomach, he placed
his hand over the region of the sigmoid flexure and said he
felt pain there. It was a question in my mind whether so
large a body could pass the ilio-ccBcal valve. It was my
own opinion that if he had swallowed the body it was still
in the stomach, and possibly gastrotomy would have to be
done. I asked him, however, to dismiss the subject from his
mind by trying to persuade himself that he had not swal-
lowed the plate, and come to see me the next day. He failed
to rei)ort, and, as there were no further developments, I sup-
I)ose that it was a fact that the source of his trouble was in
his mind and not in his stomach.

As I have intimated, foreign bodies are often introduced
into the rectum with malice or by intention, and, if of such a



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834 DISEASES OP THE RECTUM, ANUS, AND SIGMOID FLEXURR

size as would admit of it, will find their way upward into the
colon. Such bodies may include pieces of wood, lead or slate
pencils, stones, pieces of coin, sticks, pieces of bottles, or
whole bottles. Velpeau reported the detection of the bottom
of a long Cologne- water bottle felt beneath the false ribs on
the right side, where he was enabled to touch the open end
of the bottle, which was a little over eleven inches long, with
the finger in the rectum. It was safely extracted, and left
no bad consequences. The late Valentine Mott reported a
case where a paving stone had been thrust through the anus
by malice on the part of a sober companion on his drunken
friend. In another case, under similar circumstances, a tum-
bler had been inserted into the rectum. A late writer in one
of the foreign journals reports the extraction of a large goblet
which had been thrust into the rectum, and a laparotomy was
done for its removal. It can be easily understood what the
danger to life is under such circumstances. M. Gerard made
a report of thirty-four cases, the fourth of which terminated
fatally. If the patient escapes peritonitis, we may have — ex-
cited by the presence of the foreign body— inflammation of
the rectum, gangrene, abscess, fistula, false passages, etc. It
must be understood that the removal of large foreign bodies,
esi)ecially those of glass, is attended with much danger.
In one of Velpeau's cases, in trying to remove a beer glass, it
was broken, and serious laceration of the gut took place.
The man died in eight days from abscess of the pelvis. As
far as a diagnosis is concerned, it is generally made plain by
introducing the finger into the rectum, when the foreign
body can be found, unless it has been small enough to pass
up into the colon.

The method to be practiced for the removal of these for-
eign bodies must be made to suit the case. Generally it
will be sufficient to anaesthetize the patient and divulse the
sphincter muscle freely, and then, by the aid of the fingers
or forceps, to extract it. It is very well after the sphincters
are dilated to pour into the rectum an ounce or two of oil,
which lubricates the parts and aids us materially in the efforts



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ULCERATION OF THE RECTUM. 335

If it is found after the divulsion of the sphincters that the
space is not large enough to admit the removal of the body,
Esmarch has advised that a free division be made in the me-
dian line, back to the coccyx. K it is found that the foreign
body is held higher up, and yet can be detected by the fin-
ger, the whole hand should be introduced into the rectum in
order to obtain a good hold upon the foreign body. It has
already been stated in a former chapter that the size of the
hand should be considered, and, if necessary, to procure the
aid of some person having a small hand, and yet it requires
that the mancBuvre thould be executed slowly and vnth gen-
tleness. If all these efforts fail, a laparotomy should be done.
A number of such cases are reported.

The ulceration that results from foreign bodies remaining
in the rectum should, as I have already said, be treated in the
same manner as simple ulcerations arising from other causes.



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CHAPTER XV.

KON-MALIGNANT STMOTUBE OF THE BECTUM.

In discussing the subject of non-malignant stricture of the
rectum, I shall take some positions which are contrary to the
accepted teachings of the day, but I do so after weighing the
matter carefully and taking my experience as my teacher.

JBtiology. — ^The following classification of the varieties of
stricture of the rectum is given by Kelsey, It is the usual
one given by most authors :

Congenital. — ^1. Complete. 2. Partial.

Acquired. — 1. Spasm, (a) Dysenteric. 2. Pressure from
without. (6) Tubercular. 3. Non-venereal, (c) Inflamma-
tory, {d) Traumatic. 4. Venereal, {a) Ulceration (either
chancroidal, secondary, or tertiary). 6. Cancer. (J) Due to
unnatural vice, (c) Neoplastic (gummata, anorectal syphi-
loma).

The first great division, it will be noticed, is congenital and
acquired stricture. In writing of or dealing with stricture,
the idea intended to be conveyed is that of a pathological
change in tissues, etc., a deviation from the natural, brought
about by disease. Hence I object to the consideration of con-
genital malformations of the rectum, or to define them under
the head of strictures of the gut, for the reason that it is mis-
leading to do so. It will be more to the point to deal with
such as atresias. Exception could also be made to the second
division of this grand classification — viz., the acquired. I am
aware of the fact that the term is often used in the sense
herein applied, but to my mind a better classification should
be employed. It is very easy to understand how one could
acquire a stricture the result of venery, but it is difficult to



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NON-MALIGNANT STRICTURE OF THE RECTUM. 337

understand how one could acquire a spasmodic or cancerous
stricture. But I will adopt, for the sake of discussion, the
above classification, leaving out the congenital variety.

1. Spasm.— To this form of stricture I shall prefer two
objections. First, if it be true that such condition ever
exists, which I doubt, it should not be classed as stricture at
all, for the reason that no patholol^ical change is manifest to
constitute a stricture, and no treatment could be given it^^
se. In other words, it would be a symptom of some lesion
or trouble outside of the so-called stricture. Second, I be-
lieve that, from the anatomical construction of the rectum, it
would be utterly impossible for its lumen to be so constricted
as to be perceptible as an obstruction by spasmodic contrac-
tion of its muscular fibers. I might add as a third reason
that in all my examinations of this part of the gut I have
never seen a spasmodic contraction that could be called a
stricture.

2. Dysenteric, — Although it is frequently stated that dys-
entery is a common cause of stricture of the rectum, I have
never seen a case of suflScient worth to convince me of the
truth of the statement, or indeed that it was a cause at all. I
have many times seen patients who gave a history of having
had dysentery, and were treated for a long time for the affec-
tion, but a close scrutiny of the case revealed the fact that the
so-called dysentery was caused by an already existing stricture
and ulceration, the rule here being reversed — that dysentery
was the result, not the cause. If dysentery really be a cause
of stricture of the rectum, how very often we would expect
to meet with it in our practice, considering the great number
of people who have dysentery, especially in the warmer cli-
mates ! Again, practitioners of medicine know that ulcera-
tion proper very seldom exists in the rectum during or after
attacks of dysentery. The sloughing in these cases occurs
from the gut above the rectum. I do not deny, but my expe-
rience has not taught me, nor am I convinced, that ulceration
of the rectum is caused by repeated dysenteries or diarrhoeas.

I am sure, at least, that the cases are infrequent. If a long-
22



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338 DISEASES OP THE RECTUM, ANUS, AND SIGMOID FLEXURE.

continued irritation is kept up in the rectum from any cause,
the result would be, of course, an inflammatory exudate,
resulting, perhaps, in ulceration and stricture; but I must
confess that, in searching for this as a cause, the road to a
cenclusion has not been plain enough for me to put dysentery
in the list as a cause at all for stricture of the rectum. If
this disease is a common cause of stricture, as asserted by so
many, it occurs to me that the trouble would be often found
in the veterans of war. Indeed, I could not imagine a more
ideal case for a pension than the existence of stricture of the
rectum the result of a dysentery contracted while in the
service, yet the pension records are singularly silent on this
point. At a meeting of the Louisville Clinical Society, Pro-
fessor John A. Ouchterlony, a distinguished pathologist and
teacher, in discussing the subject of stricture of the rectum,
said: ''I call to mind a dead-house experience extending
over many years. During the war I made post-mortem ex-
aminations upon hundreds of cases who died of dysentery—
the most malignant forms of the disease, as all will attest
whose observations extend back to war times— and I can not
remember to have ever seen a stricture of the rectum as the
result of dysentery. In the two hospitals to which I was
pathologist there were eleven hundred and fifty beds, and we
sometimes made as many as five or six post-mortems a day.
After the close of the war I was for many years pathologist
to the City Hospital, but in all my dead-house experience I
never saw a stricture of the rectum caused by dysentery."

These are the remarks of a very close observer, and my
experience certainly coincides with his.

3. Tubercular. — It is evident that a tubercular condition
is often met with in the mucous membrane and the structures
of the rectum, and the lymph follicles of the ileum and large
intestines are the organs usually infected when the disease
has its origin in the intestinal tract. If stricture and ulcera-
tion were the terms used, I could make no objection to the
classification of tuberculosis as the cause of ulceration. That
ulceration frequently results from this diathesis or dyscrasia



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NON-MALIGNANT STRICTURE OP TOE RECTUM. 339

no one can doubt, but that the coincident stricture follows,
as from other well-known causes, notably syphilis, I can not
agree. The disposition of tuberculous tissue everywhere is
to break down. Before the capacious rectum is tilled with
tubercular deposit sufficient to stricture it, it will have broken
down from ulceration, etc., and it must be by deposition
only that we can conceive of stricture from this cause, be-
cause cicatrization is so seldom and so feeble in these parts
that it would be the rarest accident to find it. In no instance
have I ever seen a stricture of the bronchi as the result of
tuberculosis. There would be just as much reason to expect
it there, or indeed more, as in the rectum.

4. Inflammatory. — This term is so broad and comprehen-
sive that we must perforce of reason admit it as the cause of
stricture of the gut — indeed, as the one grand and common
cause — for if stricture exists from trauma, pressure, venery,
dysentery, cancer, syphilis, tubercle, ulceration, or w hat not,
it is inevitably due to the processes and products of inflam-
mation. In no other way can a stricture be formed.

It might be argued that a lesion or wound existing in the
bowel by the reparative process heals and leaves cicatricial
tissue, and that stricture is the result of the cicatrix, and not
of plastic infiltration of the tissue proper. In answ er, I would
say that there could have been no cicatrization if there had
been no inflammatory process ; hence, inflammation, being
the cause of the cicatrix, was in truth the cause of the strict-
ure. It is said that any severe form of proctitis resulting in
ulceration may be a cause of stricture. To this proposition I
freely assent ; but the most difficult part of the whole matter
is to tell the cause of the proctitis, which is inflammation. It
is not therefore to the proposition that I object, but to the
proposed or suggested causes. For instance, in naming sev-
eral, the following is given by some author as the cause of
stricture : '* Erosion and ulceration of ha^morrhoidal tumors."
Now, in the nature of things, how can this be true? We
might understand how the hsemorrhoidal tumor could by
friction excite some ulceration of the bowel, or the hsemor-



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340 DISEASES OP THE RECTUM, ANUS, AND SIGMOID FliEXURE.

rhoid itself, being a tumor, could have its own mucous mem-
brane injured and ulcerated. Suppose it does, how can that
ulceration produce a stricture of the rectum ? As we have
intimated, strictures may result from two pathological con-
ditions — first, from a deposition of plasma causing an ob-
struction ; second, by cicatrization causing a stricture. Can
either of these conditions result from haemorrhoidal tumors
being ulcerated ? I think not. The inflammatory deposit
would only involve the tumor, and a cicatrix on top of a pile
would not amount to a stricture.

Traumatism. — Under this head the authors include ulcer-
ation following operations or the cicatrizing of wounds made
around the rectum, and cite the surgical operation done for
haemorrhoids and fistula in ano. In all my practice I have
never seen such result follow either operation. I can under-
stand how a cicatrix resulting from the removal of too much
skin from this region might cause a stricture of the anus.
Dr. W. O. Roberts, of Louisville, has told me recently of
operating on a patient of this kind, the original operation
having been done by an inexperienced hand. I can not un-
derstand how a surgeon used to operating in this region
would do an operation that would result in a stricture of the
rectum. These constrictions that might result at the anus
can not properly be called a stricture of the gut ; but, as far
as the classification goes, traumatic strictures are in fact in-
flammatory strictures. Inflammation is the result of trauma ;
so one class might be made to include both. For brevity this
would be the best.

Venereal.—'' Without admitting too much," says one au-
thor, "it may be safely said that, beyond dispute, there are
three forms of well-recognized venereal disease in the rectum
which may result in stricture. These are chancroidal, sec-
ondary, and tertiary ulcerations, either simple, traumatic, or
the result of direct inoculation, and an unusual form of ter-
tiary disease, of the general nature of gummatous dejx^sit,
variously described by different authors, and by Foumier as
ano-rectal syphiloma." This author leads us to infer that



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NOX-MALIGNANT STRICTURE OF TUE RECTUM. 34I

these three venereal causes — viz., chancroidal, secondary,
and tertiary ulceration — are the most infrequent way that
stricture of the rectum can be produced, and he classifies the
form of tertiary disease of the general nature of gummatous
deposit as an unusual form of stricture. To the proposition
that chancroids are responsible for stricture of the rectum I
certainly must dissent, and that the gummatous deposit of
syphilis is an unusual form of stricture of the rectum I
can not admit. Allingham reports that out of seventy pa-



Online LibraryJoseph McDowell MathewsA treatise on diseases of the rectum, anus, and sigmoid flexure → online text (page 29 of 49)