Joseph McDowell Mathews.

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

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For a number of years I have been trying, in my lectures
to students and in the medical periodicals, to refute this false
anatomical doctrine, and it affords me pleasure to subjoin
such testimony as that of these distinguished authorities.
No one knows so well of the great damage that is being done
by these ignorant itinerants in cutting away the normal struct-
ures of the rectum as the surgeons who see the results of this
foolish practice. Haemorrhage, ulceration, fissures, strictures,
and inflammation of the rectum frequently follow in the
wake, and it may be that the surgeon profits in pocket, but
the patient suffers in health. I have now under treatment a
most excellent woman from the central part of the State, who
submitted to the "treatment." She is really in a deplorable
condition in consequence, and it will take a long time to re-
duce the extensive proctitis from which she is now suffering.

External Sphincter Huaole. — This muscle is one of the most
important in the whole body, for the reason that it oj)ens
and closes the anus ; and, if by disease or trauma its office
is destroyed, the person is rendered miserable for life. In-
continence of faeces results, and no greater calamity could
befall the sensitive person.

Although a little out of place in this chapter, I feel like
taking the opportunity of warning those doing rectal surgery
against injury to this muscle. In women, especially, who re-
quire surgical treatment of the anus or rectum, be careful,
very careful in your divulsions and cuttings of the muscle.
In patients, either male or female, who are disposed to a
weakened condition of the muscle, you must tax your sur-



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

gical ingenuity to prevent any harm being done to it. This
muscle is more developed and better defined than the internal
sphincter. It has both voluntary and involuntary power. It
is made up of a flat plane of fibers, and is closely adherent
to the integument. It is elliptical in shape, and completely
surrounds the anus. It is likely to become greatly hyper-
trophied by the inflammatory process, and, from the fact
that it controls, more or less, the peristaltic action of the
bowel, it is a great factor in producing constipation. The
nerve-supply is from the hemorrhoidal branch of the inter-
nal pudic and the haemorrhoidal branch of the fourth sacral.
It arises from the tip of the coccyx and is inserted into the
perineal center. In making a cut for fissure or stricture, if
the median line is closely hugged, the muscle will not be
divided.

Internal Sphincter. — ^This muscle is diflScult to define. It is
situated immediately above the external sphincter, but is
only two lines in thickness. It has not nearly the surgical
importance of its neighbor. As an anatomical guide, in lo-
cating the openings of internal fistulse, it subserves a good
purpose, for they are usually between the two.

Is there a third sphincter muscle ? Kelsey, in his work
on Diseases of the Rectum and Anus, in discussing this sub-
ject, says : "From a study of the literature of this question,
and from the results of dissections and experiments which
we have i)ersonaUy been able to make, we are led to the fol-
lowing conclusions : 1. What has been so often and so differ-
ently described as a third or superior sphincter-ani muscle
is, in reality, nothing more than a band of the areolar mus-
cular fibers of the rectum. 2. This band is not constant in
its situation or size, and may be found anywhere over an
area of three inches in the upper part of the rectum. 3. The
folds of mucous membrane (Houston's valves), which have
been associated with these bands of muscular tissue, stand in
no necessary relation to them, being also inconstant and vary-
ing much in size and position in different persons. 4. There
is nothing in the physiology of the act of defecation, as at



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ANATOMY OF THE RECTUM. 41

present understood, or in the fact of a certain amount of con-
tinence of faeces after extirpation of the anus, which necessi-
tates the idea of the existence of a superior sphincter. 5.
When a fold of mucous membrane is found which contains
muscular tissue, and is firm enough to act as a barrier to the
descent of the faeces, the arrangement may fairly be consid-
ered an abnormity, and is very apt to produce the usual
signs of stricture."

The only exception that I would make to any of these
conclusions is to No. 2, which says, ** This band is not con-
stant in its situation or size." I would beg to amend by say-
ing that the band in many instances is entirely absent. I
quite agree with all these conclusions of Kelsey, and would
relegate the third or superior sphincter-ani muscle to the
company of "Houston's valves" and of the "pockets and
papillae."

Levator Ani. — ^This is a very important muscle, from a sur-
gical standpoint. It takes its origin in front from the pos-
terior surface of the body and ramus of the pubes, on the
outer side of the symphysis ; posteriorly, from the inner sur-
face of the spine of the ischium ; between these points from
an angle of division between the obdurator and the recto-
vesical layers of the pelvic fascia on their under surface. The
general origin is from the under side of the true pelvis. Its
insertion posteriorly is to the tip and sides of the coccyx.
More anteriorly, they unite with each other to form the pos-
terior rhaphe. In the middle : The largest portion is inserted
into the sides of the rectum, blending with the fibers of the
sphincter muscle. Anterior : The largest fibers descend on
the sides of the prostate gland and unite with the fibers from
the opposite side, blending with the fibers of the external
sphincter and transversus perinei at the tendinous center.
Inferiorly it is related by its convex surface to the sacro-
sciatic ligaments and the gluteus maximus. Posteriorly it is
in contact with the lower border of the pyriformis. Its action
is to draw the coccyx up, or, when both muscles act together,
to fix that bone and prevent its being pushed backward in



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42 DISEASES OP THE BECTUM, ANUS, AND SIGMOID FI.EXUBE.

defecation. Its fibers unite with those of the opposite side
beneath the neck of the bladder, the prostate, and the nre-
thra. This muscle acts as a support to the pelvic organs. It
prevents the rectum from being protruded. It also acts upon
the neck of the bladder, because it incloses it, and in the act
of defecation the bladder is pressed upon and the urethra
closed. It is easy to be seen, then, that any abnormal condi-
tion of this muscle would reflect upon the bladder and the
prostate, especially, and that many affections of them can
be traced to this spasmodic action of the muscle, which is
caused, of course, by some diseased condition. It can be
also understood that these organs, being diseased, will reflect
to these muscles, causing much of the distress which has
been described in a preceding chapter. The muscle receives
its nerve-supply from the fourth sacral and internal pudic.

Beoto-Coocygeiu. — This muscle is located directly under the
levator ani, as it goes to make up the floor of the i)elvis, be-
tween the tip of the coccyx and the anus. Its office is to
hold the end of the rectum to a given point in defecation.
If it is injured, either by disease or by trauma, it is with the
greatest difficulty that the act of defecation is accomplished.

Transversos Perinei — The main function of this muscle is to
aid the act of defecation. The two muscles are sometimes
continuous and form a half ring, and brace the anterior i)art
of the rectum.

Blood-sapply of the Bectnm. — ^The rectum receives blood from
three different sources. The upper part is supplied only by
the sui)erior haemorrhoidal, a branch from the inferior mes-
enteric, which also supplies the lower part of the colon.
The terminal branches of the sui>erior hsemorrhoidal pass
to the lower part of the rectum, but the principal blood-
supply to this part comes from the middle and inferior
haemorrhoidal, which are primary and secondary branches
from the internal iliac, which artery affords the principal
blood-supply to all the i)elvic viscera. The middle hsemor-
rhoidal is distributed to the pouch of the rectum, while
the inferior, a branch from the internal pudic, passes across



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ANATOMY OP THE RECTUM. 43

the iscMo-rectal fossa and reaches the rectum at its lower
part. The internal pudic, besides giving a large supply
of blood to the rectum, supplies blood to the bladder, pros-
tate, vagina, perinseum, and external organs of generation.
The veins which return the blood from the rectum are numer-
ous. The hffimorrhoidal plexus communicates in front with
the vesico-prostatic in the male, and the vaginal plexus in the
female. While the inferior and middle hsemorrhoidal arte-
ries supply the principal part of the blood to the lower part
of the rectum, the corresponding veins return but a small
portion of this blood ; almost all the blood from the rectum
passes through the superior hsemorrhoidal veins and into the
I)ortal system.

In the chapter upon the anatomy of the rectum in relation
to the reflexes, we have given the nerve-supply of these
parts.



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CHAPTER III.
CONSTIPATION.

Perhaps there is no subject of as mucli importance to the
rectal surgeon as that of constipation. Patients suffering
from this trouble drift to him after having gone the rounds
with the general practitioner. It is a well-recognized fact
that patients are allowed to make their own diagnosis in
this affection, and that the physician drops into error by
prescribing accordingly. We must also recognize that con-
stipation is a relative term. Whatever we may teach and
believe in regard to its effects, the history of patients wiU
frequently unsettle any such doctrine. To properly under-
stand the subject, it is necessary to consider both the anato-
my and the physiology of defecation. O'Beime, of Dublin,
believed that the rectum in its natural state was very like
the oesophagus when it was not distended with food — in
other words, that its walls were in apposition. He claimed
that the rectum, in its normal state, would show the folds
lying closely together, and that they were only distended,
or effaced, during the time that the pouch was filled with
fsecal matter. According to his views, when a peristal-
tic action of the bowel proper occurred, the faeces would pass
from the caecum, through the colon, and thence fall into the
rectum. If this call of Nature is heeded, a natural evac-
uation takes place ; if it is not, an anti-peristaltic motion
occurs, which lifts the mass back into the sigmoid flexure.
Now, we must remember that the evacuation is composed
partly of solid material but mostly of water. If the dis-
charge is according to health rules, it passes as Nature in-
tends ; but if there is a refusal of the same on the part of the



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CONSTIPATION. 45

person, or from some physiological reason, then the water is
reabsorbed and passes into the circulation, while the solid
material is lifted back and remains in the sigmoid flexure.
Therefore, in considering the accumulations in which the
faecal mass plays part, we are to look to two points specially,
namely, the ccecum and sigmoid jlexure. The ascending,
descending, and transverse colon are free from such obstruc-
tion. The muscular coat of the rectum is composed of cir-
cular and longitudinal fibers. The circular are internal, the
longitudinal are external It is an aggregation of the circu-
lar fibers which go to make up the sphincter muscles, and
also that which stands guard between the sigmoid flexure
and the rectum. These fibers are separated from the mucous
membrane by loose areolar tissue. The longitudinal fibers
j)ass down the external aspect of the rectum to its lower bor
der, and thence curve under the internal sphincter muscle.
They then ascend and are attached to the substance of the
areolar tissue. This will explain the eversion of mucous mem-
brane which takes place in the act of defecation. The longi-
tudinal fibers draw down the sphincter in this act, and the
levator muscles retract it. It has been stated before, in the
anatomy of the rectum proper, that the mucous membrane is
movable. It can be now understood how it is that eversion
of the mucous membrane takes place during the act of defe-
cation. It being a truth that the membrane is everted during
this act, it can be seen that any rough substance — as a matter
of fact, if printed pax)er be used as a detergent — it could
produce such a condition of the blood-vessels as would
ultimately terminate in hsemorrhoids, etc. It becomes the
province of the surgeon who gives attention to these diseases
to lay down rules of health to his patients in regard to this
very common subject of constipation. It can be very well
understood how non-attention to the calls of Nature would
produce faecal accumulation in the rectum, or sigmoid flex-
ure, or possibly the caecum. It is very natural to infer that
the anti-peristaltic motion of the bowel could lift, for a cer-
tain time, the mass, or portion of the mass, from the rectum



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

and would land it back into the flexure ; but if constipation
becomes a disease, or the bowels are not unloaded for a num-
ber of days, yet this effort would be made by Nature, a por-
tion of the mass would be left in the rectum, even grant-
ing that a i)ortion of it was lifted up and landed back
whence it came. Therefore, the watery element being ab-
sorbed, and constipation progressing, we are likely to have an
accumulation, as has been intimated, first in the sigmoid flex-
ure, next in the rectum, and, lastly, in the caecum. Now, it
is a well-known fact that such accumulation has ended in
the death of the patient. Obstruction, caused by fsecal mat-
ter in the caecum, has been confounded, time and again, with
appendicitis, and operations have been done looking to the
removal of the appendix, which were unwarrantable; and
right here begins the discussion of that much-discussed sub-
ject, whether these cases belong to the surgeon or physician.
If the accumulation of faecal matter be in the caecum, it is
evidently a case for the physician. If, as the abdominal
surgeon says to-day, these cases are, nearly without excep-
tion, an inflammatory condition of the appendix termiform-
is^ then such cases belong to the surgeon, and an operation
for the removal of the appendix is justifiable. We believe
that accumulations of faeces do take place, in the locality and
order named. I must differ from some surgeons who believe
that the favorite site of obstruction by faecal accumulation
is the rectum proper. Therefore, I shall take occasion, in
writing the chapter on impacted faeces, to state that, in my
opinion, the most important part to be looked after is the
sigmoid flexure^ and not the rectum, for such trouble. I also
quite agree that the caecum may be so loaded as to be ob-
structed, and that the symptoms are both confusing and mis-
leading ; and, recognizing the physiology of defecation to be
as we have given it, we believe that a fair trial with medi-
cine, to the border-line at least, should be given before sur-
gery is thought of. Now, while I agree with O'Beime in the
main, I must disagree with him, in an everyday observation
of the normal bowel, as to the condition of the same. In the



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CONSTIPATION. 47

majority of instances, I believe that there is some accumula-
tion in the rectum, of faeces, after the daily evacuation has
taken place. Therefore I am to conclude, if he is correct
about the anti-peristaltic motion of the bowel, that there is
also an accumulation in the sigmoid flexure. In other words,
I believe that if the rectum is examined, some hours after
the natural evacuation of the day has taken place, faeces may
be found within its folds. This, at least, has been my ob-
servation. That they are of a dry character, devoid of the
watery constituents, which have been absorbed, is the truth,
and I am very much inclined to his view that, if the daily
evacuation is not observed, the main portion of the mass
is lifted back into the sigmoid flexure. This I believe to be
one of the chief reasons for the disorders and disease found
in the flexure, of which but little account is given in the
books. Now, if we are to take for granted the statements of
O'Beime, which are corroborated by many who have written
upon the subject, we can understand how these accumula-
tions in the rectum and the sigmoid flexure would derange
the whole pelvic circulation. Outside of doing damage to
the mucous membrane of the parts, causing congestion, in-
flammation, and ulceration of the same, such accumulation
is liable to produce external piles, to make internal growths
bleed, and to cause a general atony of the gut, by pressure
ui)on its muscular coat and an interference with its fibers.
It is very natural, then, to suppose that a person in this con-
dition should suffer from a so-called constipation, and seek
the advice of a physician. It is needless to say that the pre-
scription usually given is a purgative. It also goes without
saying that such a prescription never relieves the patient.
Indeed, if we would stop for a moment to consider the effect
of a purge under such circumstances, we would be deterred
from giving it. When we remember that the veins of the
rectum have no valves, that the erect position of the human
being, etc., renders these parts liable to a congested state of
the vessels, it is no wonder that many diseases incident to
the rectum follow in consequence of a neglected condition



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48 DISEASES OP THE RECTUM, ANUS, AND SiaMOID FLEXURE.

which terminates in constipation. The natural pressure ex-
erted by the mass in the sigmoid flexure or the rectum pre-
vents the return of the venous blood, and hence causes a vari-
cose condition of the veins. This, if kept up, ends in haem-
orrhoids. The passage of such a mass is the most frequent
cause of fissure of the anus. Internal fistula may result from
direct pressure, causing inflammation, and then ulceration or
abscess, and then fistula. By the temporary paralysis of the
bowel, caused by the accumulated mass, its tonicity is lost,
and hence prolapsus may result. If impacted faeces remain
as the result of constipation for any length of time, this self-
constituted irritant may not only result in ulceration of the
bowel, but, in its eflfort to cicatrize, a stricture may be estab-
lished. So it can be seen that many diseases of the rectum
are caused by constipation and its results. But these local
diseases are not all. The natural refusal to abide by the
calls of Nature ends in constipation, and from this state many
diseases result. It is a well- recognized fact, as intimated,
that the faeces are at first soft, made so by the water that
they contain. It is also true that, if the caUs of Nature are
not heeded, the watery constituent is absorbed, and, being
absorbed, passes into the blood.

It is very easy to understand what the effect of all this is.
Faecal matter can be no more nor less to the natural blood
than a poison. The red corpuscles are diseased by it ; they
are altered in color and have less power ; their health-pro-
ducing and life-giving property is destroyed. Instead of
the red cheeks and bright complexion, the rapid circulation
and energy that are supplied and caused by these corpuscles,
we have, after the absorption of the faecal mass into the cir-
culation, the sallow complexion, dark rings under the eyes,
cold extremities, a less supply of oxygen, and a lethargy
which is due to a vitiated condition of the blood and en-
feebled corpuscles. The system is not nourished as it was
intended that it should be, and in consequence there is a loss
of flesh. The diseased blood resulting from this condition
now circulates to the nervous system, hence we have nervous



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CONSTIPATION. 49

depression. If we examine a patient nnder these circnm-
stances, we will find that the pulse is slow and easily com-
pressed, and the organs of digestion and assimilation are
very much interfered with. These patients will tell you that
they suffer from a loss of memory, and especially that they
are unable to concentrate their thoughts on any single sub-
ject for any length of time, and that in their daily voca-
tions they are overcome by drowsiness, which interferes with
their business as well as their happiness. Although they
are frequently drowsy and go to sleep even when trying to
pursue their business vocations, they are not relieved by
sleep, either by day or by night. If this condition con-
tinues, all the functions of the body may be deranged, and,
if not relieved, actual disease and suffering are the result.
There are many factors concerned in the production of con-
stipation which vary in different cases: First, it must be
agreed that where food is not properly digested or assimi-
lated, the intestinal tract must suffer, and eventually end
either in a diarrhoea or constipation. Second, it is too much
the habit, in treating a functional stomach indigestion, to
forget that an intestinal indigestion may also exist. Third,
there may be deficiency of fiuid in the intestinal canal, caused
by want of a proper supply of food, excessive waste, or
deficient secretion from the intestinal mucous membrane.
Fourth, there may be a deficient peristalsis, especially in the
large intestine, from defects of diet or from atony due to
over-stimulation by purgatives, or to degeneration of the
muscular coat from the effects of pressure by the faecal mass,
as the result of the accumulation of the fseces. Fifth, inhibi-
tory influences of the nerve-centers of the bram and cord,
probably affecting both peristalsis and secretion of fluid.
Sixth, deficient bodily exercise and movement. Seventh,
dilatation of the intestines, especially the colon, due to de-
bility of the intestinal wall, or to actual dilatation by accu-
mulated ffieces, gaseous distention, repeated enemata, or lax-
ness of the abdominal wall, etc. Sach are the chief causes,
ordinarily considered, which give rise to constipation. Any-



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

thing that weakens the muscular fiber of the intestine, such
as deterioration by age, mental depression, deficient bodily-
exercise, astringent food, direct pressure, etc., is a well -recog-
nized cause. In children, putting aside malformation, such
as atresia, more or less complete, peritonitis, intussusception,
etc., as causes, we have : First, food which leaves little resi-
due — ^very completely digestible food, e. g., milk — ^fsecal mat-
ter too small to duly excite peristalsis. Second, deficiency
of liquid food, not enough to drink, causing dry faeces.
Third, deficient biliary secretion. Fourth, deficient secretion
of glands of the mucous tract, and dry faeces. Fifth, over-
stimulation, and consequent atony of the intestines ; loss of
excitability and loss of power, caused (a) by coarse food ; (6)
by frequent purgatives ; and (c) by too frequent use of ene-
mata. To these may be added, both in the adult and in chil-
dren, the dread of evacuation because of pain excited by
hard stools. The resistance to the passage of faeces, partly
voluntary and partly reflex, is caused by the pain that is
brought on by the act, from the sensitive condition of the
anus, especially by the existence of a fissure. The symptoms
produced by the retention of faecal waste in the intestines are
very remarkable. In some cases there may be absolutely no
derangement of the general health. This holds good, whether
the patient be a child or an adult. They may eat and sleep
well, be hearty and robust, and look the picture of health.
Although the physiology of defecation tells us that the ab-
sorption of this watery constituent of the faecal mass continu-
ally takes place and is a poison to the blood, in many of
these patients there appears to be no faecal absorption of the
foul matter from the intestines. Indeed, the chi^ difficulty
is the pain caused by the passage of the hardened, dry fae-
ces. If it be a child, it screams and cries, and dreads the ac-
tion, and will not assist by its own efforts. If an adult, they
will tell you that the torture is so great when the bowels



Online LibraryJoseph McDowell MathewsA treatise on diseases of the rectum, anus, and sigmoid flexure → online text (page 4 of 49)