CHAPTER IT. (Part 9)

years and a half after. The third patieflt, a female, aged forty-five, was cured in fifteen days by six injec- tions of twenty or twenty-five drops each. The solution used consisted of fifteen grains of Bonjean's ergotine dissolved in seventy-five minims of cherry-laurel water. The injections were made at the distance of one- fifth of an inch from the anus. Acute pain always followed, and con- traction of the sphincter lasting several hours. Several times an injec- tion of twenty-five drops of the solution caused spasm of the neck of the bladder and retention of urine. In no case did the injections produce any local inflammation or abscess. Dr. Vidal has more recently expressed himself* as preferring Yvon's solution of ergot to Bonjean's ergotine, as causing less pain. The danger to be avoided in this method of treatment is the use of too irritating solutions, or solutions in too great quantity which shall excite a suppurative action and produce constitutional poisonous effects. Cauterization. — In children in whom milder measures have failed, a very effectual means of cure is the application of fuming nitric acid to the mucous membrane of the prolapsed part. The bowel should first be carefully wiped off with a towel or sponge, and the acid then applied by means of a small stick all over the mucous membrane, but not at all to the skin adjacent. After such an application the bowel should be replaced, a pad of lint firmly applied over the anus by means of broad strips of adhesive plaster, and the bowels confined by means of opium. Allingham speaks of stuffing the rectum with wool in addition, but I have always found the pad and straps sufficient when thoroughly applied, and the child kept on its bed. After three or four days the straps may be removed, and the bowels moved with castor oil. In a large proportion of cases, the cure will be found complete, though, in a few cases, I have seen a return of the disease after a few months. In any case^ however, the benefit will be found to be very great, and should the disease return, a very careful search shorrld be instituted for some existing source of irritation, such as polypus, phymosis, or calculus. In case of a recur- rence, a second application will be effectual in causing a cure. This treatment, though successful in children, is by no means so in 1 Paris Medical, Augast 28th, 187a 'Gaz. Hebdom., Jan. 2d, 188a PB0LAP8B. 117 adults. Allingham calls attention to the occurrence of deep sloughs in old persons with debilitated constitutions ; and, as a result of such a slough, he has seen an almost fatal haemorrhage. Stricture of the rectum may, without doubt, be caused by too free use of this remedy, but since it follows its abuse and not its proper use in appropriately selected cases, it can hardly be considered an objection. Linear Cauterization. — In adults this is undoubtedly the best means at our command for dealing with this affection, and the best means of ap- plying it is that recommended by Van Buren, with Paquelin's cautery. The patient is at first etherized and placed in Sims's po8itio^. Van Buren reduces the prolapse, and applies the iron with the aid of a spe- culum. Allingham first applies the iron and then reduces the prolapse. In: either case, from three to six vertical stripes should be made upon the mucous membrane, with the iron heated to a dull-red heat. The caute- rization should begin about three inches up the rectum, and end at the junction of the skin and mucous membrane. They should also be deeper at the end, where there is no danger, than at the beginning, where the bowel may be perforated. Van Buren recommends that the iron be bent at a right angle a short distance from the end, so that it may be the more thoroughly applied to the concavity of the rectum, and that, in mild cases, a small iron should be used, '^ no thicker than an ordinary probe." Allingham, in bad cases, bums through the sphincter muscle at two opposite points, after reducing the bowel, and inserts a small pledget of oiled wool.' By this burning through the sphincter, the patulous condition of the anus is overcome. The result of the operation is to decrease the circumference of the anal orifice, and, in this way, to effect a cure. The patient should be confined absolutely to bed till the wounds are entirely healed, so that a recurrence of the descent may be effectually avoided. For some time after the healing, and after the patient is allowed to be up and about, in fact, until the full effect of the operation has been ob- tained, a bed-pan should be used. The first operation, if thoroughly performed, will probably result in permanent cure. Should it not, it may be repeated. The only danger in connection with it is the occur- rence of secondary hasmorrhage when the sloughs separate, and of primary haemorrhage from large veins at the time of the application of the iron. To avoid this, Allingham recommends the choosing of points for cauterization which are free from large venous pouches, such as may be visible on the surface of the tumor. In old cases of extensive disease, the operation as thus described may not be effectual, and it may be necessary actually to produce a stricture at the anus to prevent recurrence of the trouble. There is, perhaps, no better means of accomplishing this than to apply the iron to the whole circumference of the anus, circularly, instead of in longitudinal stripes; but such an operation will seldom be called for. 118 DiBEASES OF THE RECTUM AND ANIJS. There is one other method of dealing with this afiEection^ which, though not as simple as the cautery-iron alone, is well worthy of trial, and that is Smith's operation with the clamp and cautery. We have already given a figure and description of the clamp and the operation in speaking of haemorrhoids, but the operation is even better adapted to cases of prolapse than to haemorrhoids, the mass being larger and more readily seized, cut off, and cauterized. Having thus described the most effectual means of dealing with this troublesome affection, it is scarce worth while to describe the various cutting operations by which pieces are removed either from the mucous membrane alone, or from the sphincter muscle, with the object of ac- complishing the same result that is more readily attained with the cautery iron. Dupuytren's operation consisted in removing three ellip- tical folds of skin and mucous membrane from the verge of the anus. The same idea has been more recently applied in Germany.* Bobert and Diefifenbach cut out wedge-shaped pieces, and approximated the edges with deep sutures ; and the latter even went so far as to cut off the whole tumor — an operation now seldom practised, except in slight cases, such as those accompanying internal haemorrhoids. Prolapse of the Second Degree. — As already said, the second variety of prolapse differs from the first in the fact that it is composed of the whole thickness of the bowel, and, therefore, when of sufficient length, of peri- toneum also. It is probable that every prolapse of more than two inches in length may contain peritoneum; and it follows from the anatomy of the parts that the peritoneum will extend lower on the front than behind. In the peritoneal pouch thus formed in fi*ont there may be located coils of intestine, an ovary, or a part of the bladder. In this form of prolapse there is no groove or sulcus, as is shown by the figare, and the absence of such a groove is, therefore, no proof of the non-existence of a fold of peritoneum in the tumor. It is a mistake to suppose that this second variety is not met with in children, for it is only an exaggerated form of the first, being the next step in the descent after the submucous connective tissue has yielded its utmost; and exaggerated cases of prolapse are often seen in children. It is distinguished from the first variety — first of all, by its size. The first is never very large; while the second, from the nature of the case, must be of considerable dimensions. Again, a prolapse of the first variety is seldom of long standing; while one of the second is generally so. The second generally follows the first, but a prolapse may be of this variety from the beginning; resulting, in such a case, generally from violent straining, and coming on suddenly. The first variety is not firm and thick to the feel; the folds of mucous membrane radiate from the orifice * ** Elne neue Methode der operativen Behandlung des MastdarmvoTfall&'' Deutsche Med. Woch., No. 83, 1880. PBOLAP8E. 119 t to the circumference, and the opening is circular and patulous. In the second, the orifice is slit-like and is drawn backwards by the attachment of the meso-rectum, or in females forward by the closer attachment to the vagina. The form of the tumor is conical, its walls are thick and firm, and when pressed between the fingers, the gurgling of gas in a con- tained loop of intestine may sometimes be detected, and a resonance may be obtained on percussion. If such a tumor be carefully dissected, the coats of the protruded bowel will be found enlarged; the mucous membrane will be seen to be thickened and dense in structure, especially at the free extremity; and it will also sometimes be found eroded and granular. The submucous are- olar tissue will be seen to be infiltrated with albuminous deposit, and the muscular layers will be hypertrophied. Owing to these changes, the bowel is actually increased in size, and becomes too large to be retained in its proper place; which explains the difficulty often experienced in reduc- ing it and in keeping it reduced, in spite of the constant straining and desire for defecation which it produces. These changes in the mucous membrane may in rare cases result in the production of a foul, hard, bleeding, eroded mass, which may at the first glance strongly suggest malignant growth. The bleeding from a prolapsed rectum is commonly in the form of a general oozing, and applications of astringents may be necessary for its control. Strangulation is rare in infants and in feeble old people, but in a 3trong person the sphincter may be sufficiently powerful to produce such a result. A strangulation may be only temporary when met by the proper means, or it may continue long enough to cause ulceration and partial gangrene; the latter, however, is rare. When it occurs, it is pos- sible for it to end fatally from the contiguity of the peritoneum; but it more often results in a spontaneous cure of the prolapse, and in a cica- tricial stricture, the location of which will depend upon the length of the prolapsed portion and the point at which the sphacelus occurs. The causes of the second variety are the same as of the first, and need not again be enumerated. The symptoms also are the same, with the ad- dition of more or less incontinence of faeces in old cases; but the treat- ment is not the same in all respects; for certain measures which may be safe when a prolapse contains no peritoneum may be fatal under the op- posite condition. In cases in which curative measures are out of the question, the haem- orrhages and the erosions may be relieved by suitable applications, rest in bed, defecation in the recumbent posture, etc. Persulphate of iron is perhaps as good an application to the bleeding surface as any other; and weak solutions of nitrate of silver often have a good effect upon the ero- sions. The reduction of a prolapse of the second degree is by no means as simple a matter as that of the first. When the sphincter is tight and the tumor oedematous, it nLay be nearly impossible; and in aid cases 120 DI8SA8B8 OF THB RECTUM AND AKUS. where the opposite condition of the sphincter obtains, it may be equallj difficult to keep the parts within the body after placing them there. The latter may, however, generally be accomplished by the means already enumerated, and the reduction in obstinate cases may generally be ob- tained through the influence of ansdsthesia. The dangers which may attend an attempt at reduction by taxis are well illustrated in the follow- ing case. Case X. — Complete prolapse of the rectum; rupture of the bowel during reduction. ' The case was that of a woman, aged forty-six years, who about twelve years before, a short time after a difficult labor, had begun to suffer from prolapse which came down daily at the time of de- fecation, and was easily reducible. She was seen by the doctor at a time when the tumor had been down nearly twenty-four hours and had resisted all the efforts of herself and female friends at replacement. She had passed a restless night and was much fatigued by her journey in an old cart, but had experienced no bad symptoms referable to the stomach or bowels. The doctor found at the anus a tumor larger than the fist^ round, red, and covered with bloody mucous. The prolapse was directly continuous with the margin of the anus in such a manner as to render the introduction of a sound between them impossible. At the extremity of the tumor there was a rounded aperture which admitted the finger without obstacle. To accomplish the reduc- tion the woman was placed on the bed with the thighs separated; the tumor was seized in the palms of the two hands and the ends of the fin- gers, and a gentle circular compression was exercised in order to diminish its volume and cause it to go up by an operation similar to the taxis. The resistance being great, a few moments were allowed for rest, and after a quarter of an hour the same manoeuvre was repeated after having en- veloped the tumor in a cold cloth. ** After a few moments I felt," says the narrator, * Muring a violent effort of the patient, the tumor distend under my fingers, and at the same time I heard a noise similar to that made by tearing parchment. At the same time the tumor suddenly dis- appeared of itself, and syncope, nausea, and a marked change in the ex- pression of the face supervened. When the pafcient came to herself she complained of severe colic. I then found outside of the anus a loop of intestine which I easily replaced, and on introducing the finger into the rectum I recognized at a consider- able height an irregular longitudinal rent the extent of which I was un- able to determine. I placed a tampon of lint over the anus and kept it in place with a T bandage and compress. I sent the patient to her home, ordering that nothing be disarranged. As the case was very serious, I requested a neighboring confrere to come and aid mo with his advice. At our arrival, six hours after the accident, I found the patient sitting by ' Condensed from report by Dr. Roch6, Revue Med.-Chirurg., 1858. PBOLAP8B. 121 the comer of the fire, without the dressings. Between the separated thighs were exposed^ in the midst of the ashes, the large and a consider- able part of the small intestines, distended with gas, cold, and in several spots livid. The face was Hippocrafcic, the pulse thready and much accelerated, the voice feeble; and to this was joined colic and continual vomiting. After having placed the woman in bed and raised the intes- tines, the mass was replaced within the body, the former dressing was applied, and the woman died in a few hours. ' Two questions may arise in this connection. Should reduction be tried when the tumor is inflamed; and should it be tried in case of a circular slough? In answering the first question, the distinction must be made between a prolapse which is merely strangulated and one which is inflamed. The appearances may be much the same, but an old pro- lapse in an old person when found in this condition is much more apt to be inflamed than strangulated, for the sphincter muscle in such cases has generally lost the power of forcible constriction. The danger in re- turning an inflamed prolapse into the bodj^ is that the inflammation may extend and cause general and fatal peritonitis; and as a rule it is safer not to employ the taxis in such a case, but to put the patient in bed and treat it by local applications and rest till the acute symptoms have disappeared. In answer to the second question, Molli^re recommends extirpation of the prolapsed portion rather than its reduction when there is a circular slough, on the ground that no matter how radical such a step may appear at first sight, it is better than leaving the case to nature. For a circular slough moans inevitably a cicatricial stricture; and if the prolapse be ex- tensive, a stricture situated high up m the rectum or sigmoid fluxure be- yond the reach of art. As preferable to this he recommends the complete ablation of the tumor with all the dangers which attend such a step. These dangers are easily understood to be hasmorrhage, hernia of the intestines through the incision, and peritonitis. Each may be avoided where the surgeon is prepared beforehand for their occurrence, and Molli^re relates one case where the operation was performed by himself vrith the hot iron, but the patient " died on the eighth day from the effects of the chloroform " so that he was unable to decide on the value of the operation.