CHAPTER XIV. SPASM OF THE SPHINCTER, NEURALGIA, WOUNDS, RECTAL ALIMENTATION. (Part 1)

CHAPTER XIV. SPASM OF THE SPHINCTER, NEURALGIA, WOUNDS, RECTAL ALIMENTATION. PAGE Spasm without other Disease. — Cases. — Authorities. — Symptoms. — Treat- ment. — Neuralgia. — Cases. — Diagnosis. — Treatment. — Wounds. — Com- plications.— Spontaneous Rupture. — Treatment of Wounds. — Alimenta- tion. — Physiology of Absorption. — Nutritive Enemata. — Nutritive Suppositories 2T7 nis look w the pt^pcrty of COOPER m::3Icam coixeg^:. SAN r.AtlCi-^-'. •^•^»-* 1 • . / /,. .iv'.'4;-. '/ fi'OiU the Libra''' ' ' ' ' /.^,^.^ LIST OF ILLUSTRinONS. PAOB Figure 1. Antero-posterior curve of the rectum, 2 2. Section of normal rectal 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, IS 7. Third variety of congenital malformation, 32 8. Fourth variety of congenital malformation, .... 33 9. Fifth variety of congenital malformation, 34 10. Sixth varied of congenital malformation, 35 11. Condition of bowel after colotomy, 46 12. Idem, 46 13. Enterotome of Dupuytren in position, 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 d boule, 56 21. Van Buren's rectal speculum, 58 22. Fenestrated rectal speculum, 59 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 29. Idem, 79 30. Ailingham's ligature holder, 84 31. Helmuth's ligature holder, 84 32. Author's fistula knife, 86 33. Gorget, 86 34. Spring scissors, 87 85. Forceps for haemorrhoids, 107 36. Smith's clamp, 109 37. First variety of prolapse, •. , . Ill 38. Second variety of prolapse, Ill 89. Third variety of pidapBe, 112 it tt n n i( it it <( ( < (( i i (< it tl tt tt tt (( It tt it tt (( it tt t t t t * t it .t (t tt t t tt Xll LIST OF ILLUSTRATIONS. PAGE Figure 40. Rectal supporter, . .• 115 41. Rectal polypus, 136 42. Villous polypus, 137 43. Microscopicsection of villous i)olypu8, 137 44. Glandular polypus, . . 138 45. Vertical section of glandular polypus, 139 46. Vegetations around anus, 143 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 This look is the propcrfij of COOPER MEDICAL COLLEGE, SAN FRANCISOO. CAL. 0)((I is "fiot f(» hi' r^'tn^^rr/l fraiii the J/ilvuni /^" ' ' I'll <' .'' p^'^'^Oii or I' .L r nr;f i>r DISEASES OF THE RECTUM AND ANUS OHAPTEE I. PRACTICAL POINTS IN ANATOMY AND PHYSIOLOGY. Bectum. — ^Position and Measurements. — Curves. — ^Divisions.— Belations.— Anus. — Parts in Detail. —Peritoneum. — Relations to Three Portions of the Bectum. — Distance of Pentoneal CtU-de-Sac from Anus. — Muscular Layer. — ^Ar- rangement of Fibres. — Submucous Layer. — Mucous Membrane. — Susten- tator Tunicad Mucossb.— Oolumnaa Recti — Glands of Mucous Membrane. — Muscles of the Rectum and Anus. — ^£xtemal Sphincter. — Internal Sphincter. — Recto-Coccygeus. — Levator Am. — ^Transversus Perinei. — ^Arteries. — Supe- rior Hsemorrhoidal. — Middle Hsemorrhoidal. — ^Inferior HsBmorrhoidal. — Veins. — Superior HsBmorrhoidal. — ^Middle HaBmorrhoidaL — Inferior Hsb- morrhoidaL — ^Minute Anatomy of Veins. — General and Visceral Venous Sys- tems. — Nerves. — Cerebro-Spinal and Sympathetic Nerve Supply. — ^Tonic Contraction of Sphincter. — Explanation of Wandering Pains in Rectal Dis- ease. — ^Lymphatics.— External and Internal Lymphatic Vessels. — ^Physiology. — ^Anatomy of tiie Third Sphincter.— Valves of Mucous Membrane. — Plica Transversalis Recti of Kohlrausch. — Lack of Uniformity in Different Subjects. — ^Physiology of Defecation. — ^Explanation of Retention of FsBces after De- struction 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 inva- gination and prolapse^ which are due to straining at stool; and accounts also for the fact that^ when denuded by the destruction of the surround- ing cellular tissue, it remains separated from the walls of the pelvis, and cannot come in contact with the adjacent soft parts and thus undergo heahng. 3 DISEASEB OF THB BEOTHU AND ANTS. 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 constrictioa which becomes more apparent when attempts are made at dilatation. From this upper point it gradually expands into a pouch, the ampalla, 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 Tiew. There are two, one antero-postetior, 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 be- hind. When it reaches a point opposite the tip of the coccyx it suddenly reverses its direction, turns sharply backwards, and ends at the anas 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. FiQ. 1,— Exae:genl«d ontero-posteiior curve ol rectum. and from the nrethra in the male, by a triangular space having its baae at the perineum, its upper wall at the vagina or nrethra, and its lower at the upper wall of the rectnm. The angle of junction of these two curves is well marked, measuring from twenty to thirty degreesj 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 fEeoes. 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 PSAOnOAL POINTS IN ANATOICY AND FHTBIOLOGT. 8 median line to the right in its lower portion^ and again return to the median line at the anns. It is subject to many variations^ and the npper 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 rights 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 rigbt 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 ex- amination; but rather toward the pubes. Bearing this simple anatomi- cal 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 du- plicature 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 remem- bered, is convex backward, following the curve of the sacrum. The third portion extends from the third sacral vertebra to the left sacro-iliac syn- chondrosis; its lower part is partially, and its upper, completely, sur- rounded 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 surface. The first portion is surrounded laterally and posteriorly by a bed of connective tissue, rich in fat 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 ad- vantage 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 BEOTITM 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 upper limit, with the peritoneal fold of Douglas. This portion is closely connected with the bladder in the male, and with 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 pro- cedure. 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 Hyrtr speaks of a man who was only aljle 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 groove 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 pyri- f ormis muscle, the sacral plexus of nerves, and the branches of the in- ternal iliac artery. On its sides it is in contact with the adjacent convo- lutions 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 f SBces the two may be brought into actual contact. In the female, 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 malposi- tions of the uterus may act directly upon the rectum. The vessels may be so obstructed as to cause hsemorrhoidal 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 normd uterus alone is felt. The advantage of a rectal examination in all doubtful cases of pelvic disease is also manifest. The Anus, — ^The rectum terminates below in the anus which is tightly closed % 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 1 Topog. Anat., iL, p. 108. *Gooch: Ghirurg. Works, London, 1792, voL ilL, p. 216. FSAOnOAX POINTS 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 per- forate the gut. Both skin and mucous membrane at the anus are re- markable for the development of erectile tissue; the arteries coming from the inferior hsemorrhoidal, 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 intes- tine, 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 ^eatly 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, b.eside, a fold of attachment to the anterior sur- face 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 peri- toneum passes directly from the sides of the rectum to the sacrum. Be- tween its two layers may be found some loose connective tissue, the haBmorrhoidal 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 suifaces of the middle portion of the rectum. As before men- 1 Hilton: Best and Pain. Wood's Library of Standard Medical Authors, p. 166. 6 DISEASES OF THE BEOTUM AND ANUB. tioned^ the point at which the peritoneum leaves the anterior surface o the middle portion of the rectum to be reflected upon the posterior sur^ face of the bladder in the male^ or of the yagina 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 differ- ent works on anatomy. In new-born children the bottom of the cul'de- sac 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 enlargement of the prostate^ it is carried still higher. In women it generally extends to the upper border of the poste- rior vaginal wall; so that the latter is separated from the rectum by peri- toneum for about one-third of an inch. By every expansion of the blad- der 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 bladder. The average distance from the anus of the point at which the serous coat leaves the anterior wall of the rectum is, therefore, very difficult to determine; and yet it is of the greatest importance in all surgical opera- tions on the part; since the fact of opening or not opening the peritoneal cavity may make all the difference between life and death in the result of an operation. Dupuytren gives the distance as seventy mm., and less when the organs are empty; Lisfranc gives six inches in the female, and four in the male, but does not state in what