of Rhodes. Spurious works Andronicus.

The American journal of obstetrics and diseases of women and children online

. (page 81 of 109)
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ment of their functions and sympathetic pains. As instances
we may cite the inability to urinate after an operation on the
rectum; menstrual irregularities in ulcerations of the rectum;
or amenorrhea in cases of periodic hemorrhage from hemor-
rhoids. On the other hand, diseases of the female pelvic organs
have their reflexes just the same way on the rectum and sigmoid
flexure. For example, hemorrhoidal congestion in dysmenor-
rhea; constipation in prolapse of the ovaries; proctitis in para-
metritis; spasmodic sphincter in cystitis, etc. ,

The chief symptoms to which I wish to call your attention are
pelvic and sacral pains; irregularity of functions; inguinal or
iliac tenderness; pains shooting down the legs; reflex pains;
digestive disturbances; mental and nervous affections.

Pelvic and Sacral Pains. — These symptoms are so commonly
associated with both sets of organs that one must determine
their cause by elimination, or even sometimes by exploratory
operation. We were first taught by Emmet and his followers
that lacerations of the cervix were the cause of every pain in the
back and pelvis; later it was taught that laceration of the peri-
neum, weakness of the floor of the pelvis, and dragging of the
womb upon its supports was the fons et origo of such pains. As
surgery progressed and the invasion of the peritoneum become
less dangerous, the theory was advanced that ovarian or tubal
diseases were the cause of all pelvic and sacral pains; and finally
when these failed to cure it was advocated from a gynecological
point of view that a large or adherent uterus was the cause, and
hysterectomy was offered as the one panacea. Many women



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786 TRANSACTIONS OP THE

were cured, but in many the backaches went on and the func-
tional and reflex disturbances persisted, and the poor patients
were in despair until the rise of the proctologist who began to
find that the backaches and pelvic pains lay in a mass of con-
gested hemorrhoids, a concealed fissure, an ulceration of the
rectum, fecal impaction, or fecal stasis in the sigmoid.

In fact, either or neither of these classes of disease may be
the cause of the pelvic or rectal pains. It has been pointed out
by.Goldthwaite and Taylor that in many cases such pains are
due to strain, inflammation, or rheumatism of the iliosacral
, joints, and their relief may be readily accomplished by fixation
and the proper medical or surgical treatment of these joints.
Sometimes it is a combination of conditions; especially is this
true in injuries following childbirth, where the perineum has not
been completely repaired and rectocele exists; and where as
the result of straining to empty the bowels fissure or hemorrhoids
are produced; or again where the supports of the uterus are
weakened and some involution exists, and where an overweighted
organ sags down against the rectum — producing congestion,
hemorrhoids, and irritability from pressure.

Under such conditions an operation for hemorrhoids will not
cure the backache, nor will an operation upon the rectocele,
or shortening of the round ligaments, do it either. One should
be prepared to remedy both conditions if the patient's phjrsical
status will allow it at one operation, and not subject the in-
dividual to two or three operations. I perfectly agree with the
celebrated dictum, "Worse things can happen a patient than
to live to undergo a second operation." At the same time,
nothing much worse can happen to the surgeon's reputation than
to do an operation, with the assurance that it is going to relieve,
and to have the patient recover without any relief, consult
another surgeon* and be cured by some minor operation that
might easily have been done at the first stance. The question
is one of complete diagnosis — the determination of what con-
ditions are causing the symptoms and, whether there be one or
two, doing radical and effective work at once.

Reflex Pains, — Medical literature is full of instances of remote
neuralgic pains relieved by operation on the uterine organs,
especially lacerated cervices and prolapsed ovaries, and by
operations upon the rectum especially for fissure. I have re-
lieved pain in the eye, constant headache, and facial neuralgia
by the removal of hemorrhoids or the incision or stretching
of a fissure. I do not care to go into this subject to-night, but
to call your attention to the reflexes of rectal diseases upon the
female pelvic organs, and vice versa. The conditions which
I have found to cause these pains are d)rsuria, vaginismus,
dysmenorrhea; or ulcerations of the rectum, stricture, fissure,
cryptitis, or inflammation of the cr)rpts of Morgagni.

Many a neurasthenic, care-worn woman suffering with pelvic
pains referred to her uterus and ovaries, tired out with vaginal



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tamponing and daily douching of the vagina, has been relieved
of all these symptoms by the cure of a rectal ulceration, fissure,
or some other of the diseases mentioned. These conditions act
not only in a reflex manner, but by causing spasms of the levator
ani muscles, which surround the vagina and the neck of the
bladder and consequently restrict these parts when in a state
of spasm, they act also in causing constipation and its local or
ph)rsiological sequences. On the other hand, the rectum is very
often irritated and kept in a state of pain by such conditions as.
displacement and adhesions of the uterus, cystitis, and vulvo-
vaginal diseases. Old inflammations around the uterus often
cause perirectal strictures, in which the symptoms are referred
to the rectum, and yet the original cause and pathological con-
ditions lie in and around the uterus. It is useless to attempt
to treat the latter condition through the rectum; it is relieved
only through medical and surgicaJ attention to the organ in
which the condition arises; and, on the other hand, it is just as
useless to attempt to treat those vague and indefinite pains of
the pelvic organs due to rectal anomalies or pathological con-
ditions by operation and treatment through the vagina. The
differentiation between actual and reflex pain, the determina-
tion of the seat of the pathological condition is the one desidera-
tum to learn the cause of our patient's complaint, and then
usually our course of action is clear.

Pains Shooting down the Legs, — One type of reflex pains to
which reference has been often made in medical literature is
pain shooting down the legs. It is common to diseases both
of the rectum and female pelvic organs. Hilton has said that
such pains in the left leg are almost pathognomonic of rectal
ulcers or fissures. It seems to me that his experience must have
been coincidences, for in my own, I believe, I have seen just as
many pains in the right leg as in the left; and as a large majority
of fissures are in the anterior or posterior commissure, I can see
no reason why these pains should shoot down the left leg any
more than the right. I have paid more attention to this in
recent years and I am convinced that one should not eliminate
the rectum because the pains are in the right leg; nor do I be-
lieve that we should conclude that a pain shooting down the
left leg is conclusive evidence of disease of the rectum. A tumor
of the uterus or uterine organs pressing upon the nerves as they
extend down from the spinal canal to their exit from the pelvis
may cause just such pains in the legs, either right or left, as are
attributed to diseases of the rectum. We should never, there-
fore, give opinion as to the cause or origin of such pains until both
sets of organs have been carefully examined.

IrregtUarity of Functions. — The functions of either the rectum
or the female pelvic organs may be disturbed by various causes,
especially by disease in one or the other. The functions of the
rectum are absorption of the fluid contents of the feces, the
furnishing of a reservoir for the detritus of the alimentary canal,



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788 TRANSACTIONS OF THE

and to extrude this from the system at more or less regular
periods. All of these functions may be influenced, interfered
with, or suppressed entirely by diseases of the female pelvic
organs. The diseases which chiefly act in this way are hyper-
trophied or displaced uteri, tumors, and cysts of the uterus and
ovaries, which in a mechanical way may retard or prevent the
passing of fecal matter by causing pressure upon the intestines;
(rare) by producing inflammation or irritation, and arrest of
.peristalsis; by pushing the gut to one side — upward or down-
ward — and causing a flexure or angulation; and adhesions — all
of which interfere with the functions of the gut and at times
prevent them altogether. Prolapsed and inflamed ovaries and
tubes by reflex action often arrest the peristalsis of the gut.
Nature is self-protecting, and where the passage of the fecal
matter through the gut presses upon the inflamed or tender
organs she resists, and often the collection of feces in the descend-
ing colon is nothing more than the evidence of Nature preventing
pressure upon the inflamed organs of the pelvis.

Adhesions of the gut through inflammation of the uterus and
its appendages are common causes of interference with the
intestinal functions. One chief cause of purely rectal disturb-
ances in women is rectocele, a condition which from its name
would be more properly relegated to rectal surgery than to
the field of the gynecologists; a condition which it seems to me
is not well understood by the average operating surgeon. When
I state that within one month I have seen six cases of severe
rectal disturbance due solely to rectocele, and all in women who
had been operated upon for lacerated perineum, one of them as
many as three times, you will understand the import of this
remark. The restoration of the perineum only will not cure
rectocele, and, until the gynecologists and obstetricians recognize
the fact that the lesion is as much in the rectal as in the vaginal
wall they will find their patients drifting to the proctologist's
ofiice for relief of rectal disturbances which never should have
occurred.

The functions of the female genital organs are micturition,
menstruation, procreation, and parturition. Micturition is
affected by traumatism, acute inflammation, fissures, ulcera-
tions, and large tumors of the rectum. Menstruation is in-
fluenced by constipation, which delays it; diarrhea, which
hastens it; by bleeding hemorrhoids, which may prevent it
or act in a vicarious manner; and by all the other rectal condi-
tions which cause discharge, hemorrhage, or profound impres-
sion on the nervous system. Procreation may be prevented by
fecal stasis or impaction pressing upon the uterus from above
and causing an acute flexure in the cervix; by endometritis or
vaginitis due to colon bacillus infection passing by osmosis
from one organ to the other; or it may be intercepted or aborted
by diarrhea or dysentery; straining at stool due to stricture,
inflammation, ulceration, fissure, or obstruction of the rectum.



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NEW YORK OBSTETRICAL SOCIETY. 789

Parturition may be influenced by constipation, by proctoliths
or other foreign bodies in the rectum, by inflammation of the
rectum causing distress and arrest of the labor pains when the
head presses down upon this organ; and by hypertrophy of the
levator and muscles which prevents the relaxation of the peri-
neum, arrests the head, and is often the direct cause of lacera-
tion. It may be absolutely prevented by a large polypoid,
fibroid, or other tumor of the rectum.

Inguinal or Iliac Tenderness or Pain, — It is a common assump-
tion that tenderness or pains in the iliac regions made worse by
walking, deep pressure, or palpation through the vagina are due
to tubal, uterine, or ovarian diseases. I have seen operations
done for the removal of these organs when there was practically
no organic disease to account for the pain. In recent years we
have come to know that such pain and tenderness are frequently
associated with inflammation of the sigmoid, such as sigmoiditis,
mesosigmoiditis, diverticulitis, or tumors of the gut — these
conditions are often overlooked in operating on the uterine
organs. It is not even always necessary that there should be
inflammation, for the symptoms may be produced by angulations
of the bowel, with a fecal accumulation above, and pressure upon
the female pelvic organs. These same conditions I have found
to account for the dragging pains associated with, and often
falsely attributed to, ** falling of the womb.'*

Accumulation of feces in the sigmoid or descending colon has
often been mistaken for pelvic, ovarian, or uterine tumors.
Operation should never be done for such pains and such tumors
until such a possibility has been eliminated. The inflammations
of the sigmoid may spread to the uterus and ovaries, causing
adhesions to, and involvement of, these organs. On the other
hand, diseases of the reproductive organs may be the original seat
of disease and the bowel be secondarily involved, causing arrest
of its function, and acting in a circle as it were, keeping up the
pain. The right procedure in such cases is to determine before-
hand, if possible, by rectal and vaginal exploration which set of
organs is at fault, and, if exploratory operation is necessary
to consider the condition of both the intestines and the pelvic
organs well before operating upon either. In other words, let
the gynecologists be posted as to the abnormalities and diseases
of the intestines, and the proctologists be well informed as to
the pathological condition of the uterine organs, in order that
the patient may be justified in her resort to surgery, that she
may not recover from one operation only to be subjected to
another when all may have been done for her at once.

Nervous and Mental Disturbances, — There is no doubt that
many of the nervous and mental disturbances in women are due
to affections of the uterine organs. A few years since a wave of
gynecological enthusiasm passed through all the insane hospitals
of this country and Europe. Operating surgeons were appointed
as consultants and attendants to these institutions, and thousands



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790 TRANSACTIONS OF THE

of women were ovariotomized or otherwise operated upon with
the hope of quieting their disturbed minds and restoring them
to reason. The results of this procedure have not been all
that could be hoped for: some have been benefited and some
cured, but many more have failed. More recently the theory
of autotoxemia has become prominent, and to-day we are of
the impression that more can be done by better attention to the
lower end of the intestinal canal than by ovariotomy, hyster-
ectomy, etc. I do not mean to depreciate the effects of proper
gynecology in nervous and mental diseases, but I do wish to
emphasize the importance of first obtaining what benefit is
possible from nonsurgical methods or less radical methods if
surgery is necessary in the treatment of this class of cases.

The influence of the absorption of putrid matter from the
intestinal canal upon the nervous and mental system has long
ago been pointed out, and it is becoming more and more acknowl-
edged by neurologists at the present time. Hypochondria and
melancholia are in many cases nothing more than the result of
such absorption, and as this proceeds the resistive power of the
patient decreases, the pelvic pains are magnified, the interference
of the functions appear, and the whole category of nervous ex-
haustion and true melancholy develops. Many of these patients,
no doubt, have uterine disorders and ovarian pathological con-
ditions, but these are secondary and not the cause of the mental
condition. It is not necessary to go to the asylums to find such
cases; our cities are full of tired, depressed, melancholic women,
who are being treated by tampons and douches, for backaches
and pelvic pains which are due to fecal stasis — ^imperfect empty-
ing of the bowel and other rectal conditions. The problem
which presents itself to us is the differentiation between the
conditions, the seeding out and determining whether the rectal,
sigmoidal, or pelvic organs are at fault, and to do this there must
be a passing of the specialties. In other words, the proctologist
must be a gynecologist, in diagnosis at least, and the gynecolo-
gist must be a proctologist.

DISCUSSION.

Dr. Dickinson. — The Society is greatly indebted to our
guest for his clear and interesting paper. The matter is before
you for discussion.

Dr. Krug. — I came here to listen, not to speak. The ground
has been covered thoroughly and I think it would be quite difficult
for me to try and bring out any new points. I consider it a
compliment that there is so very Uttle to be gainsaid.

Dr. Hiram N. Vineberg. — Dr. Tuttle brought out the point
that the true function of the rectum consists in its being a recep-
tacle for the feces. Now, how are we to tell in a given case that
the feces sojourn for too long a time in the receptacle? We all
recognize that in marked rectocele the feces are not easily expelled



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NEW YORK OBSTETMCAL SOCIETY. 791

from the rectum and are abnormally arrested in that part of the
alimentary canal, but in the absence of that condition it may be
a nice point to determine, in an obscure case, whether the symp-
toms be due to too long a delay of the feces in the rectum. On
the other hand, I think too much importance is attached to the
lodgment of the feces in the lower rectum as a cause of various
disturbances. In women continuous impaction of hardened
feces in the rectum will in time bring about uterine displacement
with its train of symptoms. Still one frequently sees women
who for years may not have a movement of the bowels of tener
than once every two or three days without any apparent ill eflfects.
The cases one sometimes sees in the puerperium in which the
temperature shoots up to io6° and as suddenly drops to normal
on emptying of the bowels we know is not due to the accumu-
lation of the feces in the rectum per se, but to mechanical inter-
ference with the lochial discharges from the uterus.

I would like, also, to ask Dr. Tuttle how he would determine
stricture of the upper rectum caused by inflammatory bands
in the pelvic cavity, for it seems to me as one views the upper
part of rectum with the proctoscope, the patient being in the
knee-chest position, there is abundance of room in that part of
the rectum and that it would require more than an ordinary
inflammatory strand in the Douglas sac to so constrict the
rectum as to cause a hindrance to the passage of the feces and
be the cause of painful defecation. When the latter symptom
is present in such conditions is it not more likely that the
passage of the fecal mass over the inflammatory mass on the
peritoneal surface of the rectum to be the cause of the pain than
to a narrowing of the lumen of the gut? I have been using the
proctoscope for a number of years, using the Kelly instruments,
and with the patient in the knee-chest position I can usually
obtain a satisfactory view of the entire rectal canal.

It seems it would be difficult to distinguish, without opening
the abdomen in a given case, that a mass in the right inguinal
region is not a perimetritic exudate with pus, but is a pus collec-
tion due to a localized sigmoiditis with a probable inflamed
diverticulum.

Dr. West. — Dr. Tuttle has brought out a point which I think
to be an extremely important one, and that is the failure often-
times to repair the levator ani muscle in repair of the perineum.
It is my good fortune to have an enormous amount of material
pass under my hands at the Post-Graduate Hospital where I have
charge of operative gynecology upon the living subject. I find
a good many cases often operated upon by different men come
back with a rectocele and with separation of the levator ani
which is never apparently in that way united. The work has
been done superficially and the levator ani muscle has remained
untouched. I think it behooves us to look into the methods
which we use because a good many of these cases come from very
good men — gynecologists well known. I have had two cases



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792 TRANSACTIONS OF THE

only recently who were operated upon by well-known men where
the operation was an absolute failure because they did not get
the levator ani muscle. I only wish to emphasize in this way a
point which I believe to be extremely important.

Dr. Wylie. — I read, in 1882, a paper on the dynamics of the
pelvic organs. I brought out the fact that with complete
laceration there was no displacement of the generative organs
at all, but if the perineum was torn internally, and the
sphincter ani was stretched, even if you sew up the perineum,
you still have a rectocele form, because the fecal matter
was not deflected backward out to the anus. I tried to
make a distinction between what I called the anus portion
of the gut between the external sphincter ani proper and
the levator ani. If this inner portion is torn away from the
perineum the rectum does not act normally. Therefore it
descends and pushes out through the vaginal outlet. The
effect of that is to pull on the posterior wall of the vagina;
that throws the fundus backward and the straining at stool
forces the uterus out. Then, if the patient becomes constipated, '
this pouch receives all the force of that strain and it stretches
more and more, so we have rectocele, prolapse of the uterus, etc.,
all pending. This mechanical fact has never been recognized
and considered in the operation on the perineum. If I ever
failed to cure a rectocele in perineal operations I do not know
it. It is simply because I make it a point in sewing up the
retracted edges of the levator ani, especially those fibers between
the rectum and the vagina. If you secure these tissues and the
tissues are fastened there, we cure the rectocele, and sew up th^
perineum properly, but if I was asked what organ was most
important, I would say that the perineum is. We know it is
of more importance in the defecation. In fact, if this mechanical
fact was recognized and properly treated we almost alwa3rs could
get a good result from the perineum, but not very many of us
have studied good mechanics enough to do this.

Dr. Tuttle. — I thank you very much for your kind reception.
I will just answer two questions which have been put here.
First, I was a little afraid to go over the subject of rectocele in
this congregation for fear I would be stepping on somebody's
toes. I simply referred to it as a proctologist. They do not
come to me imtil after they are through with this Society
(laughter), and I have to keep it very quiet when I do one.

With regard to rectal injections, my attention has been called
to the same article. I think the gentleman there had very
poor tubes, or had a very poor conception of what position to
get the patient in, or he would have succeeded. I quite agree,
however, that most of the rectal tubes run up into the rectum
and fold up. The average rectal tube is useless. I use what
is known as the Murray (?) rectal tube. It is not pointed on
the end, rather stiff, and will come back upon itself whenever it
begins to fold. If it is folding, it will throw itself right out of the



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NEW YORK OBSTETRICAL SOCIETY. 793

rectum. No man can persuade me that I can get three quarts
into the rectum, and I have to-day put in more than three
quarts.

A Member. — Did your tube go through the sigmoid?

Dr. Tuttle. — I know it did. I put the patient in the knee-
chest posture and introduced a sigmoidoscope about ten inches.
Then I take my rectal tube and pass it; I have no trouble in get-
ting these tubes in; they are twenty-four inches long. Whether
they go up into the descending colon or not, I cannot say.

As to the injections, if the patient is put in the knee-chest
posture, you certainly can wash out the entire colon. One
of the latest methods is that of Hayne (?) which I saw demon-
strated last March, in which they take the patient and they let
him lie gradually across a table until, in fact, he is on his hands;
they then introduce the ordinary funnel into the rectum and pour
the water in. So it is a question if the patient is put in the
right position whether a tube is necessary at all. We can get
just as large injections without the tube as with it.

Dr. Wylie. — I have tried myself to pass the tube in the



Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 81 of 109)