CHAPTER XVII.

INJURIES OF THE RECTUM.

THE rectum is wounded intentionally in some surgical operations, as in puncturing the bladder through the trigone vesicale for the relief of retention of urine, when an instrument cannot be passed per urethram; also in the treatment of some forms of stricture, a subject on which Mr. Cock has made some valuable observations in a paper published in the thirty-fifth volume of the 'Medico-Chirurgical Transactions.' * It is wounded in operating for fistula in ano, but not so extensively as was formerly the custom: and it may be necessary to incise it for the extraction of foreign bodies: the surgeon sometimes accidentally wounds the rectum in performing the operation of lithotomy, but this is seldom the case if the operator depresses the intestine with the fore finger of the lefthand whilst he is making the deeper incisions; he should also introduce the finger into the rectum before

*See also Mr. Henry Thompson's Essay on the Pathology and Treatment of Stricture of the Urethra,' pp. 303-309.

he commences, as, by so doing, he will cause the bowel to contract, or should it be loaded with fæces he will be made aware of the fact, and will not proceed till he has procured their evacuation. Some years

since I saw the rectum of a child cut freely into by an hospital surgeon in consequence of the neglect of these precautionary measures: the fæces were forcibly ejected through the incision in the perineum, and greatly embarrassed the operator.

The rectum is lacerated in various degrees and directions by external injuries, and from causes acting from within the body, as in parturition, or during the expulsion of bulky and indurated fæces. The laceration may involve the whole of the structures or the mucous membrane only, and thus two forms of injury are met with the complete and the incomplete.

The incomplete form of laceration generally occurs in those who are of constipated habit, and is more frequently produced by the expulsion of a hardened stool than from any other cause. If the rent is the consequence of defecation, it may be either vertical or transverse: when vertical it results from undue distension of the anus during the violent efforts of the expulsive muscles, or from the sphincters, by irritation, being in a preternatural state of contraction, and usually terminates at the line of junction of the skin and mucous membrane: when the laceration is trans

verse, its situation is above the margin of the internal sphincter, and is the effect of a fold of mucous membrane of the pouch of the rectum falling under a mass of indurated fæces at the time of their forcible extrusion, and being dragged down with them is torn from side to side. Those who are liable to this accident are the subjects of constipation, and have the upper part of the rectum relaxed. Complete laceration sometimes ensues from the same cause, though it must be a very rare occurrence. Mr. Mayo* relates a case in which he was consulted, the patient, a lady of forty, of constipated habit, was on a journey, and the bowels had not acted for many hours: during a violent effort to relieve them she felt something give way, and on the following morning some fæces passed per vaginam. An examination revealed a rent two inches from the anus sufficiently large to admit the end of the finger.

The symptoms of laceration, the consequence of defecation, are a sense of tearing and giving way of the part, attended with pain, which is lessened after a time, but does not entirely subside, and recurs with greater or less severity whenever the patient goes to stool: at the period of the occurrence, the fæces are streaked with blood, and with pus as soon as suppuration is established. After the accident the same phenomena occur as in wounds of other parts, inflammation is set up, * Op. cit., p. 13.

lymph is effused, the margins of the rent become swollen, granulation and cicatrization follow, or the lacerated surface failing the reparative process degenerates into an ulcer.

In the treatment of this injury, it is essential to diminish as much as possible the irritation consequent on the action of the bowels, and the exhibition of emollient enemata will best effect this object; but mild aperients may be exhibited if they be thought advisable; active cathartics must not be had recourse to, or they will be productive of harm by exciting determination of blood to the rectum, and rendering the evacuations acrid and irritating. The wound must be cleansed after each evacuation, or the lodgment of particles of fæcal matter will possibly give rise to agonizing pain and spasm of the sphincter. When the laceration does not readily heal, but remains irritable and painful, nitrate of silver in solution should be applied, or the solid pencil may be passed lightly over the surface. In spite of these means the wound sometimes will not heal, but passes into the condition of an ulcer, in which case it will be necessary to make an incision through it in the manner directed in the Chapter on Fissure of the Rectum.

In the greater number of cases, the treatment described, conjoined with the recumbent position and moderate unstimulating diet, will be all that is neces

sary.

However, instances occur in which slight injuries are productive of excessive local inflammation or great constitutional excitement: under these circumstances, in plethoric individuals, it may be necessary to take blood from the system generally, to apply leeches around the anus, or to cup over the sacrum. When the wound is inflamed and painful, a cataplasm of linseed, or bread impregnated with a solution of acetate of lead and infusion of tobacco or laudanum, must be applied to the anus.

M. K

consulted me under the following circumstances: the day previously, while passing an indurated motion, she suddenly felt great pain and a sensation of tearing of the anus; she also noticed signs of blood: the pain decreased, and she remained tolerably easy till she went to stool the following morning, when it returned with great severity, which induced her to seek medical assistance. On examination, I perceived a slight fissure at the margin of the anus, and found it involved the mucous membrane for about an inch. I ordered her to have an ounce of castor oil, and to wash out the rectum with an enema of warm water: there being tenderness on pressure around the external portion of the laceration, a poultice was directed: these means afforded relief; however, the laceration did not heal, it became irritable, and defecation was followed by considerable pain: after eight days I applied the nitrate of silver, and repeated it two or three times at intervals of two days, and a cure was shortly effected.