OBSERVATIONS 
ON 
INJURIES AND DISEASES 
OF 
THE RECTUM. 
BY HERBERT MAYO, F.R.S. 
SURGEON TO THE MIDDLESEX HOSPITAL. 
WASHINGTON: 
STEREOTYPED AND PUBLISHED BY DUFF GREEN. 
1834. ADVERTISEMENT. 
The following pages contain an account of cases intended to exemplify 
the principal varieties which are observed in diseases of the rectum, with the 
appropriate methods of treatment. I have been led to write upon this sub- 
ject by several considerations. Diseases of the rectum are of frequent oc- 
currence : they are extremely troublesome, and are often attended with severe 
pain. The greater number admit, if judiciously treated, of speedy and com- 
plete relief: while on the other hand, when not understood, they are liable 
through misdirected remedies to be seriously aggravated. Much good may 
be done by one who is well acquainted with these complaints; much harm, 
by one who treats them ignorantly. 
I may add, that diseases of the rectum are more common in the higher 
ranks of society than among the poor; and that the ordinary routine of sur- 
gical education affords comparatively few opportunities for their study. 
19 George Street, Hanover Square, 
July 18 1833. CONTENTS. 
CHAPTER I. 
Of Fissure and Laceration of the Rectum. 
Of Fissure of the Mucous Membrane.-Of Laceration of the Bowel.- 
Of Laceration of the Sphincter in Labor, - - - - 7 
CHAPTER IL 
Of Protrusion of the Bowel. 
Nature of Prolapsus.-Ordinary Cases.-Cases which require an Ope- 
ration -------- ----------- -13 
CHAPTER III. 
Of Hemorrhage and Pain. 
Cases of Hemorrhage from the Rectum.-Cases of Pain without Local 
Disease, ------------------- ]9 
CHAPTER IV. 
Of Piles. 
Of Inward Piles.-Varieties.-Ordinary Treatment.-Operation.-Of 
Outward Piles.-Treatment.-Of Excrescences at the Anus, - - - 21 
CHAPTER V. 
Of Fistula. 
Of Abscess near the Rectum.-Origin of Fistula.-Treatment, - - - 32 
CHAPTER VI. 
Of Constipation and the Use of Instruments. 
Of the Causes of Constipation in the Lower Bowels.-Nature and Treat- 
ment of different Cases.-Of Accumulations in the large Intestines.- 
Caution requisite in the Use of the Bougie; of the Flexible Tube; of 
the Syringe. - 37 
5 6 
CONTENTS. 
CHAPTER VII. 
Of Stricture of the Rectum. 
Of Spasmodic Stricture.-Of Permanent Stricture.-Of the Irritable 
and Contracted Sphincter, 44 
CHAPTER VIII. 
Of Cancer of the Rectum. 
Two forms of Cancer in the Rectum.-The Treatment adapted to 
them.-Operations occasionally available, 52 OBSERVATIONS 
ON 
INJURIES AND DISEASES OF THE RECTUM. 
CHAPTER I. 
Of Laceration of the Rectum. 
The simplest affection of the rectum is its partial or complete rupture. 
The bowel may be tom through by violence applied either from within 
or from without. Partial laceration of the bowel is the consequence of 
force applied to its inner surface. When the slightness of the materials 
is considered, of which the intestine is framed, its coats consisting but of 
three slender membranes, the combined thickness of which does not ex- 
ceed a tenth part of an inch, it appears surprising that this accident is 
not more frequent. In the dead body, the intestine is found to be torn 
by very trifling pressure ; and the tone of its fibres when living cannot be 
supposed to add materially to its strength. 
I.-I attended a lady under the following circumstances. She had been 
confined three months before. During her recovery the action of the 
bowels had been irregular without medicine, the bowels seldom acted at all; 
and the relief which she obtained through medicine was attended with great 
pain. It had therefore become her practice, in order to obtain intervals of 
ease, to allow the bowels to remain two or three days without acting, and then 
to take some purgative. The effect of the medicine used to be distressing. 
What first came away was solid and of large size, and passed only after re- 
peated efforts; and this was attended with great local pain, and a sense of 
dragging at the loins, followed by languor and exhaustion. 
On one of these occasions something appeared to give way, or to be 
torn, and her sufferings were now increased by a sense of exquisite sore- 
ness at one part in the rectum. It was upon this that she consulted mtx 
Upon examining the bowel I found a small transverse fissure in the lining 
membrane, at the back part of the bowel immediately within the sphinc- 
ter, which is the point where fissure is most common. There was a lit- 
tle hardness round it, and it was acutely sensible. The bowel above was 
large and relaxed, and contained at the time a considerable volume of faecal 
matter. 
I recommended that the bowel should be immediately washed out with 
warm water, by which means its contents were brought away: that every 
morning the injection of warm water should be repeated, with the object of 
completely unloading and relieving the rectum daily; and that at night a 
mild mercurial ointment should be applied to the fissure of the mucous mem- 
7 8 
OBSERVATIONS ON 
brane. By steadily pursuing this plan, the lady in a short time recovered. 
Occasionally, since her recovery, when the action of the bowels has become 
irregular, she has been threatened with a return of the complaint; but upon 
resuming the use of the remedies by which the part was before restored, she 
has in each instance found the uneasy sensations cease. 
II.-A young gentleman, who had been accustomed to an active country 
life, fell into sedentary habits upon engaging in the study of the law. He 
experienced frequent headaches, and the bowels were generally constipated. 
The effort used in evacuating the bowels was now attended with slight ever- 
sion of the rectum ; and at last, in addition to this source of inconvenience, 
he became sensible of acute pain at a point just within the sphincter, which 
was brought on whenever the bowels acted, and continued for some time 
afterwards. 
After trying several remedies ineffectually, among which was the daily use 
of an enema, I advised this patient to take every night a grain of blue pill 
with three grains of compound extract of colocynth, and to apply to the sur- 
face, upon which a fissure existed, as in the preceding case, a mercurial oint- 
ment. Under this plan the part healed. 
The preceding cases may serve to explain the nature of the affection which 
I would describe, and the principle upon which it is to be treated. It is re- 
quired to find some remedy by which the action of the bowels may be ren- 
dered and kept regular, and to apply to the fissured surface an ointment which 
may dispose it to heal. Ointments containing the milder preparations of mer- 
cury generally best answer the latter purpose. 
As it is evident, that when a laceration of the mucous membrane has exist- 
ed for a few days, it has become an ulcer, so is it probable that fissure of the 
rectum often has this character from its commencement. At all events it is as 
an ulcer, that when neglected the complaint becomes more serious and difficult 
to manage. The patient then experiences greater pain; mucous, purulent 
matter, and occasionally blood are discharged with the faeces, and some extent 
of ulcerated surface is felt upon examination. 
The remedies, however, which have been already recommended, are still 
available in the more aggravated form of the complaint. If the pain be 
severe, blood may be taken with advantage from the hemorrhoidal vessels by 
leeches applied to the mucous membrane at the anus, and suppositories con- 
taining opium or belladonna should be used. The application of lunar caustic 
to the ulcer, either undiluted or in an ointment containing ten grains to a 
dram of lard, will occasionally lessen the irritability of the part, and produce 
a favorable change. When these means prove ineffectual, and the disease 
threatens to assume a more formidable character, a remedy may be resorted to 
with advantage, which, although too severe for common occasions, is exceed- 
ingly useful in the present. By an operation resembling that for fistula, the 
sphincter muscle is to be completely divided on one side, and to be temporarily 
prevented reuniting by the introduction of a strip of lint into the wound. 
The sphincter is to be divided in a line leading to the ulcer; the incision is 
to divide the ulcer itself. The operation may be performed either with a 
bistoury or with a scalpel. 
The advantages which result from the division of the sphincter in this case 
are the following. The resistance of the sphincter being temporarily removed, 
there is much less strain and effort upon the ulcerated membrane in the 
evacuation of the feces than before. The abstraction of blood from the 
vessels of the part, which commonly bleed freely, contributes in addition to 
lessen the sensibility of the ulcer. The application likewise of the mercurial INJURIES AND DISEASES OF THE RECTUM. 
9 
ointment to the sore is rendered more easy, and may be more complete after 
this operation than before. The following case may serve as an example of 
the relief afforded by the remedy which I have here recommended, and of 
the obstinate nature of the affection, as well as of its liability to be overlooked 
from the sympathetic disorder of adjacent organs which it occasionally 
produces. 
III.-James Farrant, setat. 45, was admitted into the Middlesex Hospital 
on the 9th of October. Fifteen months previously he began to experience a 
sensation of heat and pain at the anus, which would last a few hours and 
then subside, leaving a feeling of numbness. While the pain lasted, the anus 
was strongly drawn inwards. The pain extended to the hips and to the 
sacrum. These symptoms recurred daily : they were always brought on 
when the bowels acted. About a month after the commencement of the 
complaint, something appeared to him to give way in the bowel, and a slight 
discharge of mucus took place, which continued afterwards. Other symptoms 
were present, which led to a suspicion that the prostate gland was the seat 
of the disorder. The patient made water more frequently than common; 
and after the water had passed, some pain or uneasiness was commonly felt 
deep in the perineum, and of the same description with that which ensued 
upon evacuating the bowels: mucus was likewise often discharged from the 
urethra after the urine had passed. 
Upon examining the rectum the prostate gland was felt to be large and full 
and tender on pressure; and to this organ the treatment first employed was 
directed. Leeches were applied to the perineum, and the hip bath was 
used. Blood was taken by cupping from the sacrum: an opiate suppository 
was used at night, an enema of tepid water in the morning. The bowels 
acted regularly, but the patient did not improve in other respects; the pain 
remained. 
Upon re-examining the rectum, the case presented another character. 
The seat of pain, at least of soreness, was discovered not to be the prostate, 
but the posterior surface of the rectum within the sphincter. The bowel at 
this part was extremely loose and flaccid ; but there could be distinguished 
upon it an oblong ulcer with a hardened edge. 
After trying several remedies ineffectually in this case, I divided the 
sphincter, delaying afterwards the healing of the wound by the introduction 
of a few threads of lint into it. 
The subjoined figure, which is an imaginary section of the rectum, may 
convey an idea of the place and character of the ulcer in this case, and of the 
direction of the incision made. 
The patient was sensible of great relief, 
as soon as the smarting occasioned by the 
operation had ceased. The pain which he 
experienced for several days afterwards he 
felt to be the soreness of the wound, not the 
original pain of the ulcer. He resumed 
the use of the mercurial ointment. Upon 
examining the bowel a fortnight after the 
operation, the ulcer was found to have 
much improved, although it was still to be 
felt; it had lost much of its sensibility 
together with its hardened edge. By 
continuing the use of the mercurial oint- 
ment, the patient entirely recovered. It OBSERVATIONS ON- 
10 
was satisfactory to observe, that as the ulcer healed, the pain in making water, 
with the discharge of mucus from the urethra, and the swollen state of the 
prostate, equally subsided. 
The causes which have been described as sufficient to occasion a partial 
rupture of the coats of the rectum, will sometimes produce complete laceration 
of the gut. This accident occurred to an unmarried lady, whom I subsequently 
attended with Mr. Langmore, of King street, Finsbury square. 
IV. -*****, aetat. 40, naturally of a very constipated habit of body, and at 
the time being on a journey, on striving to relieve the bowels, which had not 
acted for many hours, felt something give way, to use her own expression, 
and on the following morning some faeces passed per vaginam. On examina- 
tion by the vagina and rectum, a transverse rent was found two inches within 
the parts, sufficiently large to admit the end of the finger. The only treat- 
ment adopted in this case consisted in frequently and carefully cleansing the 
part by injections of water, and regulating the state of the bowels by proper 
medicines. The patient entirely recovered. In five weeks the faeces had 
ceased to pass per vaginam. 
As long as such an opening shows a disposition to contract, it is unnecessary 
and may be prejudicial to employ any other means than the most scrupulous 
cleansing. But if the part becomes indolent, and its progress towards 
restoration stops, various remedies may be resorted to with advantage. The 
simplest of these is the application of the nitrate of silver to the edge of the 
opening; or a combination of this, or of some other escharotic, with the use 
of an elastic gum pessary.* 
If the communication of the rectum with the vagina does not contract 
under the means which have been recommended, there remain others which 
are available. The edges of the opening having become cicatrized, and the 
use of escharotic or stimulating applications having been discontinued, the 
following operation may be resorted to. The edges of the opening may be 
pared off with curved scissors, and one or two stitches may be passed through 
the vaginal side of the opening, so as to bring the edges of the rent into close 
and uninterrupted contact. It is conceivable, that in certain cases of this 
description it may be necessary to lay the vagina completely into the rectum 
by dividing the sphincter from the perforation. I have not however met 
with an instance which required this treatment. 
The origin of the following case, I am disposed to think, may have been 
a small opening suddenly taking place through the rectum into the adjacent 
cellular tissue. 
V. -A young man was admitted into the Middlesex Hospital with swelling 
of the perineum, scrotum, and penis. The skin of the scrotum and penis 
was greatly distended, and of a dark red color, with here and there patches 
of gangrene. The parts therefore presented the appearances which follow 
rupture of the urethra. But the patient stated that he had never experienced 
any difficulty in making water; and the symptomatic fever which had 
supervened had not that low character which commonly»attends sloughing 
from the escape of urine. The tongue was white, the countenance Hushed, 
the pulse frequent and full. 
The patient stated, that for six weeks antecedently to the attack, his bowels 
* The use of nitrate of silver, or of other strong escharotics in parallel cases, is most striking 
in ulcers through the soft palate. I remember in one instance by this means having caused 
such a perforation to contract and close, which was an inch in length and half an inch in 
breadth : it had been produced by syphilitic ulceration, but the edges had put on a healthy 
appearance, when the use of the escharotic was commenced. INJURIES AND DISEASES OF THE RECTUM. 
11 
had been remarkably costive, after which he had had a looseness for a few 
days, when he seemed to feel that an inward lump had formed in the perineum. 
This lump or uneasiness between the urethra and rectum had existed two 
days when the swelling of the scrotum and penis began, which had increased 
with alarming rapidity. 
A deep incision was made in the perineum towards the prostate gland, 
and superficial incisions were made through the distended skin of the scrotum 
and penis. A fluid like brownish serum oozed freely from these wounds, 
but it had at no part an urinous smell. On the contrary, that which flowed 
from the incision into the perinseum had a distinctly fecal odor. The 
patient experienced great relief: the gangrene ceased to spread : the redness 
and tumefaction gradually diminished, the -sloughs separated, the symptomatic 
fever subsided. But in a few days fecal matter began to escape through the 
wround in the perineum ; and the nature of the case was cleared up by the 
discovery of an opening from the rectum into the cellular tissue of the perineum, 
which was finally cured by the common operation for fistula ani. 
I entertain no doubt, that in the case which has been narrated, the sudden 
swelling and effusion resulted from the escape of fecal matter into the cellular 
membrane; but it is possible that the cause in which the opening originated 
may have been the formation of an abscess on the outside of the bowel, and 
that the communication may thus have been effected by ulceration from 
without. Still I have thought that case admissible into the present chapter, 
in connection with cases of giving way of the bowel from within ; as it is not 
very unlikely, that the symptoms which have been described may have 
proceeded from the latter cause.* 
The rectum may be torn through from within, by violence done in the im- 
proper use of instruments. I removed a stone from the bladder of a boy 
fourteen years of age by the lateral operation. The stone, which was of a 
favorable shape, was extracted quickly. Every thing went on satisfactorily 
till the eighth day, when the bowels being confined an injection was ordered, 
which was administered by the nurse of the ward. I believe that she forced 
the pipe of the instrument through the rectum into the wound; for the fol- 
lowing day fecal matter appeared in the wound, through which it thenceforth, 
for a short time, passed as freely as through the anus. The incision, however, 
in the perineum gradually contracted to a very small sinus, through which a 
little moisture only escaped, and this finally closed. Still there remained a 
communication between the bladder and rectum, which was evinced by the 
urine depositing a sediment of fecal matter. After three months this deposit 
was no longer seen. 
The closing of the communication between the rectum and urinary canal 
was in this case entirely spontaneous. It was evident, after a few days, that 
the discharge of fecal matter through it would not prevent the contraction of 
the wound, and I determined, as long as the case should go on favorably, 
* The most frequent cause of sudden tumefaction of the scrotum, is rupture of the urethra. 
The escape of fecal matter into the cellular membrane, as in the case above described, is 
probably the rarest. I have seen two instances in which sudden swelling of the scrotum, 
which came and gradually subsided, was not attributable to either of these causes, or to any 
local cause that was detected. In one instance I have seen the scrotum enormously distended 
with blood from violence done to the part. In another, the perineum and scrotum were 
distended and discolored with blood and serum that had escaped at the lower outlet of the 
pelvis, after fracture of the ilium, which had lacerated the internal iliac vein. In another 
instance a child of five years of age was brought intorthe hospital with extensive swelling and 
sloughing of the scrotum and integuments of the penis, which had originated in phymosis and 
ulcers round the glans. 12 
OBSERVATIONS ON 
not to risk any thing by interfering with the natural process of reparation 
I cannot state at what part the communication between the rectum and urin- 
ary canal in this instance was situated : I abstained from making an examina- 
tion which would have satisfied my curiosity on this head, as no further 
object was to be attained by it. 
Some caution is requisite in administering enemas; and many of the ordi- 
nary instruments are particularly dangerous. There is a preparation in the 
museum of Bartholomew's Hospital, from the body of a patient, whose death 
had been occasioned by the injection of a pint of water gruel into the abdo- 
minal cavity through the torn rectum. A similar accident has happened in 
private practice. 
But the most frequent instances of laceration of the rectum into the 
vagina result from other causes than those already described, and are pro- 
duced by violence acting from the vagina towards the bowel. This violence 
is the pressure of the head of the child in labor. The degrees of injury 
which it occasions are very various. 
Occasionally the injury is the same in its degree as in Case IV, being a 
laceration within the sphincter of trifling extent, which heals as readily 
when ensuing upon this cause as where it follows any other. 
Frequently the laceration is limited to the perineum, is quite external, and 
involves at the utmost the marginal fibres of the sphincter muscle. In this 
instance again, the recovery is certain and spontaneous : but it is necessary 
in both instances to employ cleanliness and rest to promote the reparation of 
the part. 
There are, however, severer cases, in wrhich the sphincter being completely 
ruptured, the extremity of the bowel communicates with the vagina by a 
longitudinal fissure from three-fourths of an inch to an inch in length. It is 
known in such a case that all the fibres of the sphincter are torn through, by 
the total want of tonic contraction of the bowel at the part where it begins to 
be entire. 
In many instances in which this accident happens, spontaneous reparation 
of the part does not take place. The force of the sphincter muscle is em- 
ployed in keeping the rent wide open; and the faeces continually passing 
through it contribute to prevent its uniting. 
In a conversation with Mr. Copeland, I learnt, that in a case of this des- 
cription he had successfully employed the following method. It occurred to 
him, that if the sphincter were divided at a second part, its strain upon the 
rent into the vagina would be greatly lessened, and that the chance of repa- 
ration would be proportionately increased. I understood from him, that he 
had divided with this object the sphincter laterally, and that the case had 
turned out completely to his wish. 
Soon after this conversation, a similar case came under my own care. 
VI. I was requested by a medical practitioner to see, in consultation with 
him, Mrs. Quye, who had been confined of her fifth child eight days before, 
March 31, 1830. The labor had been rapid, and the pressure of the head 
of the child had ruptured the perineum and the sphincter. The faeces passed 
freely through the vagina by a gaping fissure nearly an inch in length. As 
the edges of the fissure were not cicatrized, I thought the present a very fa- 
vorable opportunity for repeating Mr. Copeland's operation. To give the 
parts every chance, I divided the sphincter muscle upon both sides, perform- 
ing therefore on either side the operation for fistula ani. A small strip of 
lint was introduced into each wound. The edges of the original rent were 
afterwards washed daily with a solution of nitrate of silver, and fresh lint INJURIES AND DISEASES OF THE RECTUM. 
13 
was replaced in the incision as often as it was removed by the passage of 
faeces. The original rent healed very speedily : when it was nearly closed 
the lateral wounds were allowed to unite. In five weeks from the operation 
the incisions had healed, and the patient had recovered the use of the sphinc- 
ter. She has continued perfectly well to the present time, and was safely 
confined of another child in November 1832. 
The remarkable success which has attended this practice in recent cases, 
has induced me to determine to employ it, after the manner recommended by 
Dieffenbach, in cases in which laceration of the sphincter has occurred, and 
has not been remedied at the time. 
In cases of long standing it is however obvious, that the lateral division of 
the sphincter is a part only of the operation requisite for the restoration of the 
parts. It is necessary besides, at the least, to produce a granulating surface 
upon the edges of the fissure. 
And as the parts in this class of cases have lost, from time, the tendency 
which exists in the freshly-torn parts to come together, I conclude that it is 
absolutely necessary to use ligatures to bring them and to hold them in 
contact. In other words, I recommend the performance of the following 
operation. The first step of the operation consists in paring the edges of the 
fissure : the second is the introduction of sutures, to be tied afterwards in the 
vagina : the third is the division of the sphincter on either side : the opera- 
tion is completed by tying the ligatures in the vagina, and by introducing a 
strip of lint into each of the two lateral sections of the sphincter. I am the 
more sanguine as to the general result of this operation, since I had the good 
fortune to apply ligatures successfully to an old laceration of the rectum into 
the vagina, without the assistance of the method which I have now described, 
and therefore under circumstances considerably less favorable. Much, 
after all, in such an operation depends upon causes over which the surgeon 
has a very imperfect control. Inflammation of the parts supervening, or 
diarrhoea, would still be liable to render the operation ineffectual. But the 
surgeon of course defers attempting it, till the patient is in her best state of 
health, and the bowels have been thoroughly unloaded by repeated doses of 
opening medicine. The bowels should not be moved for several days after 
the operation. 
CHAPTER II. 
Of Protrusion of the Rectum. 
Another affection of the rectum, which like the preceding has a mechani- 
cal origin, is its eversion and protrusion at the anus. This disorder is called 
prolapsus or procidentia ani. 
Several writers upon this subject, among whom is M. Dupuytren, have 
described prolapsus ani as consisting in an extrusion of the mucous and sub- 
mucous coats alone through the action of the muscular coat of the bowel. 
To correct this misapprehension, I have given a figure from a preparation in 
the museum of King's College, in which a protrusion of inverted bo.wel 14 
OBSERVATIONS ON 
through the sphincter ani is represented, and the muscular layer is shown to 
be equally inverted with the lining membranes. 
It is natural to suppose that the bowel derives sufficient support from its 
adhesions to neighboring organs, to have little disposition to protrude in the 
healthy state. But a remarkable case, which I shall take another opportunity 
of relating, served to convince me of the contrary. I had occasion to extirpate 
the lowest part of the rectum, together with the sphincter ani. The part 
healed favorably, and a firm hollow cylinder of cicatrix led up to the com- 
mencement of the bowel. In this instance it is to be supposed that the in- 
flammation attending the process of healing gave additional strength to the 
natural adhesions of the rectum. Nevertheless, in a short time after the 
recovery of the patient the bowel began to protrude. The weight and 
pressure of the bowels and abdominal muscles appeared to occasion this 
occurrence. The most important use therefore of the sphincter ani is probably 
to prevent protrusion and eversion of the bowel, against which the adhesions 
of the intestine to neighboring parts are not sufficient to guard it. 
Now at the time the bowels act, the sphincter is necessarily relaxed. The 
bowel for the time is unsupported, and the strain is allowed to tell upon its 
lateral adhesions. Under unfavorable circumstances, it is therefore easy to 
understand that protrusion may take place even when the sphincter is entire, 
and when the bowel has not lost the support which it affords. 
If the contents of the bowel ape habitually too firm and solid, in passing 
through the extensible canal, they temporarily drag it with them, and elongate 
its adhesions to the adjacent surfaces. Nature indeed has aimed at providing 
against this occurrence, by throwing round those portions of the alimentary 
canal, which are intended to hold solid contents, a strong coat of longitudinal 
fibres. The rectum, the cesophagus, and the colon even although in a less 
extent, are thus provided with the means of resisting the traction and exten- 
sion, which the passage of solid contents tends to produce. But the provision 
has its limits; and where the bowels are habitually costive, it is often found 
to be inadequate. The adhesions of the bowel to neighboring parts are 
lengthened, and the passage of a mass of solid feces will carry through the INJURIES AND DISEASES OF THE RECTUM. 
15 
rectum an everted fold: this, it is true, at first spontaneously returns: but 
the cause continuing, the eversion becomes more certain and considerable at 
each recurrence of action of the bowels. 
A gentleman, whose case I have described (Case II,) in addition to the 
fissure in the inner membrane of the rectum, labored under prolapsus. Both 
affections had proceeded from the same cause, and were relieved at the same 
time by the same means. His brother, whom I happened to attend for the 
effects of a severe accident, mentioned to me, that whenever it happened to 
himself that the bowels were confined, more or less protrusion of the rectum 
invariably took place. Thus, in its slightest form, this complaint admits of 
being remedied, and its recurrence prevented, by obviating the costiveness 
which has produced it. 
Habitual straining of the abdominal muscles, without costiveness, is liable 
to produce prolapsus. Among the children whom I have operated on, or 
have seen cut for stone, I hardly recollect an instance in which this symptom 
has been absent. The reason is very evident. The expulsion of the water 
in persons afflicted with stone is commonly attended with involuntary bearing 
down and forcing of the diaphragm and abdominal muscles. The repetition 
of the violent pressure upon the bowels forces their lowest portion in a state 
of eversion out of the anus. When the stone has been removed, the cause 
of irritation which led to the violent action of the abdominal muscles is at an 
end; the straining does not recur ; the bowel is no longer habitually forced 
down ; it gradually recovers its tone: in a short time the protrusion ceases 
to take place. 
In young persons, the peristaltic action of the intestines is peculiarly lively. 
On examining the bodies of infantsan intus-susception or invagination of some 
part of the small intestine is often observed to have taken place. The 
invaginated part being everted bears a close analogy to a prolapsus ani. 
There is little constriction at the point where the intus-susception begins, 
and the invaginated part may be drawn back with ease. It is probable that 
in healthy infants invagination of the small intestine is frequently taking 
place, but producing no symptoms, and being after a short time withdrawn 
and set right upon the renewal of the vermicular action. It is to be presumed 
that some trifling source of irritation in the bowels is the immediate cause of 
such intus-susception ; but its frequent occurrence in children, compared 
with its infrequency in adults, deserves to be taken as a proof of the remark- 
able mobility of the bowels in childhood. 
To this mobility of the bowels in children is to be ascribed the frequency 
with which they suffer from prolapsus. The complaint therefore when 
occurring in children may be viewed as one to which their time of life 
renders them liable, and the disposition to which will spontaneously cease as 
they grow up. Nevertheless, as protrusion of the bowel by no means takes 
place in children indiscriminately, but in those only who either are of a very 
delicate constitution, or who labor under habitual constipation of the bowels, 
the complaint always requires attention. The more so, that although it is to 
be expected that the disposition towards it will cease with childhood, it is 
always possible that the habit of eversion may become in time so established 
in the part, and the part extruded gradually acquire so great a volume, as to 
require for its relief more serious measures than are necessary if the complaint 
be taken in time. 
In the three cases which follow, are described the common cause and 
proper treatment of prolapsus in children. 
I attended a child between three and four years of age, in which prolapsus 16 
OBSERVATIONS ON 
of the bowel occurred with every motion. The child was not particularly 
delicate, but its bowels were habitually costive. A variety of medicines had 
been tried, to render their action regular, but had failed. I recommended, 
therefore, that the use of medicine should be discontinued, and that an enema 
of water and oil should be administered daily. By these means both ail- 
ments were relieved at once. 
I attended two children in another family, the one three, the other four 
years of age. Both labored under eversion and protrusion of the bowel, 
which took place at each motion, and required pressure to replace it. 
These children were of a delicate habit, but with each the bowels acted for 
the most part with regularity. 
The method which I adopted with success in these cases, consisted in 
giving tone to the part by means of astringent injections. For the youngest, 
which was a girl, I prescribed two ounces of the infusion of catechu as an 
enema, to be used daily ; for the elder, a boy, I ordered three ounces of the 
same infusion, with six grains of acetate of zinc. The remedy was adminis- 
tered in the morning before the children rose ; and they were kept in bed 
for half an hour afterwards, in order that the injection might be retained. 
Both the children recovered under this treatment; the protrusion of the 
bowel being at first lessened in quantity, and then in frequency, till the chil- 
dren would pass two or three days without its recurrence. Occasional doses 
of opening medicine were given when necessary during the four or five 
weeks that the plan which I have described was pursued. 
The next case which I shall narrate will illustrate the consequences of 
neglecting this complaint, and the method of treatment applicable to its 
confirmed and aggravated form. 
A young lady, twenty years of age, had suffered for several years with 
headaches, torpid bowels, painful and irregular menstruation, pains in the 
back and legs, irritability of the bladder, hysteria. Dr. Chalmers of Croy- 
don, who was consulted, was led, after a short attendance, to conjecture that 
there must be some disease of the rectum, a knowledge of which had been 
kept back from her family. By closely questioning his patient, he at length 
learned that she labored under prolapsus ani; that a protrusion took place 
every time that the bowels acted; that it was of considerable volume, and 
that it could not be replaced without difficulty. The young lady it appeared 
had suffered from this complaint as long as she could recollect, and as she 
grew up, the infirmity increasing upon her became a source of perpetual 
misery, which a false shame prevented her disclosing. The constant fear 
upon her mind that the complaint would become known, had probably con- 
tributed more than the local disorder to cause the train of symptoms under 
which she suffered. 
I saw this patient in consultation. The mass which protruded when the 
bowels were moved by an enema was of the size of an orange; and as the 
coats of the bowel which formed it were not at all thickened, I have no 
doubt that the voluminous folds which came down, were an eversion of as 
much as six or seven inches of intestine. The sphincter ani was extremely 
lax: the eversion was ascertained to begin about an inch within it. 
The method of treatment which Dr. Chalmers and myself recommended 
should be followed, was the mildest of those which have been practised in 
confirmed prolapsus; although we were not free from apprehension, consi- 
dering the length of time the complaint had existed, the magnitude of the 
protrusion, and the extreme relaxation of the sphincter, that the plan which 
we proposed to adopt would prove partially successful only, and that more INJURIES AND DISEASES OF THE RECTUM. 
17 
would still require to be done. The operation which was performed was 
the following: .• 
A small fold of intestine was pinched up with forceps, and tied with a 
silk ligature: care was taken to include the mucous and submucous coats 
alone in the ligature : the whole surface included was less than that of a six 
pence. Before finally tightening the ligature, the surface of the little fold 
was cut with scissors. Three such folds were tied upon opposite aspects of 
the bowel, and at different distances from the sphincter. The patient hardly 
felt the operation, so small is the sensibility of the internal parts of the body, 
unless when inflamed. The parts were then replaced. During the four 
days which followed the operation, the patient was not allowed to sit up ; 
and the bowels, which had been well unloaded before, were kept confined, 
very light and moderate liquid nourishment alone being allowed, and an 
enema of laudanum having been administered. Upon the fourth day, when 
the bowels were moved with an enema of warm water, the patient was 
greatly disappointed at finding that the protrusion returned : yet she remarked 
that the bowel admitted of being replaced with greater ease than before. 
Some, little soreness in the part, however, was now observed ; some blood 
was pa'Ssed from the bowel; there was irritation in the bladder; and now, 
for the first time, protrusion of the bowel attended the act of micturi- 
tion. 
Upon an examination of the bowel on the sixth day after the operation, 
it was found to be in the following state. The mucous membrane, when 
the bowel was extruded, appeared fuller and more loaded with blood than 
before the operation. The little portions of membrane which had been 
tied had come away ; but the ligatures had not yet separated, but remained 
fixed in the shallow ulcers which they had produced : they were removed. 
From this time the local complaint improved daily : the protrusions became 
less and less, then did not recur each time the bowels acted, and in a fort- 
night had entirely ceased to appear. 
The operation which has been described, if care be taken that no more 
than the mucous and submucous linings of the bowel be included in the 
ligature, is as free from risk as it is unattended by pain; and is therefore in 
my opinion preferable to many others which have been recommended for 
the cure of prolapsus. I was not, indeed, without some apprehensions, that 
in the case detailed something more might be requisite ; and that the dimi- 
nished mobility of the bowel, which would be produced by the ligatures, 
would be insufficient to keep it from protruding, unless the unnatural relaxa- 
tion of the sphincter were likewise corrected. We were prepared to recom- 
mend, if it had proved necessary, that a small fold of the marginal integu- 
ment of the bowel should be removed by excision, in order to restore to the 
sphincter the deficient tone and closeness. 
M. Dupuytren recommends the removal of several marginal folds of integu- 
ment for the cure of prolapsus: but this operation is severe ; and my expe- 
rience of its success leads me to prefer the simpler operation which I have 
described above. 
In the cases which I have described of simple prolapsus ani, no serious 
difficulty was experienced in returning the protruded bowel. In such cases, 
continued pressure with the hand is all that is necessary, and in a short time 
the bowel is drawn up. But it occasionally happens that the part cannot be 
returned by this means; when more pressure, and that successively made 
upon fold after fold of the bowel, is required. If the part again have been 
several hours down, through the patient s inability to replace it, it sometimes 18 
OBSERVATIONS ON 
becomes swollen, inflamed, and exquisitely tender, and will not immediately 
bear the pressure necessary for its replacement. 
I find among my notes the following case illustrating this state of the dis- 
order. 
Edward Kerrison, set. 65, was admitted into the Middlesex Hospital in 
March 1830, under these circumstances. He had been liable during the last 
sixteen years to occasional protrusion of the bowel, which he attributed, with 
reason probably, to his occupation, which was that of a porter. Till the 
present occasion he had found no difficulty in returning the prolapsus ; but 
the part had now been down eighteen hours, and he had been unable to force 
it back: it was of the size of a large walnut, swollen, of a scarlet color, pain- 
ful and extremely tender, so that he could not bear it to be pressed. The 
practice therefore pursued was the following. Leeches were applied to the 
mucous membrane of the bowel, and afterwards an anodyne poultice; and a 
dose of opium and calomel was administered. The following morning the 
tenderness of the bowel was greatly diminished, and I returned it without 
difficulty. 
When prolapsus ani is described as a protrusion and eversion of the bowel, 
the reader is led to suppose that the complaint is easily identified. And so in 
fact it is, when the protrusion is combined with no other disorder. There are 
distinctly to be seen the folds of everted bowel, the red and vascular mucous 
membrane, and the channel of the intestine opening in the middle of the 
protrusion; and by examination around the tumor within the sphincter, the 
circular line is felt, commonly about an inch from the anus, at which the ex- 
ternal fold of the protrusion begins. 
Occasionally, however, prolapsus ani is attended with, as it may have been 
produced, by piles or by thickening of one or more folds of the mucous mem- 
brane of the bowel. In these cases, the removal of the excrescence by the 
ligature is the first operation to be performed; and this will probably be suf- 
ficient to stop the tendency to prolapsus. Mr. Hey particularly pointed out 
this complication of disease ; and the practice of tying small folds of the 
sound bowel for the remedy of simple procidentia, appears to have been sug- 
gested by the success which attended his treatment of more complicated 
cases. 
Prolapsus ani is most liable to be mistaken for piles, when it is attended 
with pain, and when the protrusion is not considerable. Occasionally, when 
the quantity of bowel everted is very trifling, the patient suffers severely 
each time that the bowels act; and, till he knows the nature of his complaint, 
increases his distress by continuing to strain for many minutes after the con- 
tents of the bowrels are expelled. INJURIES AND DISEASES OF THE RECTUM. 
19 
CHAPTER HI. 
Of bleeding from, and pain in, the Rectum. 
Bleeding from the rectum, and pain in it, are not merely symptoms, which 
singly or together are features in a variety of diseases of the bowel, but both 
are occasionally met with as substantive disorders. 
Many persons experience slight discharges of blood with the feces, when- 
ever it happens that the vessels of the abdomen are in a state of congestion. 
Cold will produce this effect, but more commonly it arises from an over-stimu- 
lating diet. The veins of the rectum are the most dependant part of a large 
system, which has its proper discharge through the capillary circulation in 
the liver. Any circumstance therefore which renders the flow of blood 
through the liver slower in proportion to the mass of blood poured into the 
abdominal veins, is sure to tell upon the hemorrhoidal veins. 
An ordinary attack of bleeding from the rectum has the following course. 
There is a sense of weight, heat, fulness, and general uneasiness in the 
bowel: this goes on increasing for twenty-four hours : then the patient ob- 
serves that when the bowels act, part of the discharge is liquid : it consists of 
blood, which seems poured out at the time only that the bowels act; or the 
passage of the feces seems necessary to rupture the small vessels from which 
the hemorrhage proceeds. In another day the uneasy sensations lessen, and 
they quickly cease altogether. 
Hemorrhage from the rectum, such as I have described it, is generally a 
relief to the system. The vessels of the rectum are thus a kind of safety 
valve to the visceral circulation; and the complaint in this form deserves 
to be viewed, not as a disorder to be arrested as injurious (still less as 
a relief to be encouraged and depended upon), but properly as a warning 
that there is something wrong in the habits of life; that the diet is 
too stimulating ; or that sufficient exercise is not taken ; or that the secretions 
from the bowels are not sufficient in quantity. The recurrence of the attack 
may probably be prevented by attending to the precautions suggested by the 
preceding views. The attack itself may be relieved by the use of gentle 
aperient medicine, with cold bathing to the part. 
Bleeding from the bowel sometimes occurs without any pain or sense of 
fulness in the part, and without sensibly weakening the person who is the 
subject of it. A patient consulted me, who was suffering in this manner. 
He said that he had before occasionally experienced a similar attack; and 
that he had always found it relieved by the use of strong cathartic medicine. 
He was about thirty years of age, of a spare but muscular frame. I recom- 
mended him to try again the remedy which had before agreed with him, 
and prescribed for him every other night a smart dose of jalap and calomel: 
in a few days the discharge of blood had entirely ceased. 
Discharge of blood from the rectum seldom continues long without sensi- 
bly weakening the system. Where it has produced this effect, a different 
plan of treatment to that above mentioned is to be recommended. The fol- 
lowing case will serve to exemplify it. 
James Tucker, setat. 24, was admitted into the Middlesex Hospital, Oct. 6, 20 
OBSERVATIONS ON 
1829. During the three preceding months he had habitually passed blood 
by stool: at first he was considerably reduced in strength by this discharge, 
but afterwards it affected him less. The quantity of blood lost was greater 
at first than afterwards: at the period of his admission it amounted to two 
or three table-spoonsful, which came away immediately after each evacua- 
tion. The only pain complained of was occasional numbness and aching 
down the inside of the thighs. This patient was directed to use an astrin- 
gent enema containing ten minims of laudanum after each discharge of 
blood. 
The effect of the injection was to constipate the bowels, and to produce a dull 
pain at the sacrum. The astringency of the injection was therefore lowered, 
and the laudanum omitted, and a few grains of blue pill and extract of rheu- 
barb were ordered to be taken every night. The discharge of blood gradu- 
ally lessened ; and on the 26th the patient left the hospital cured. 
Hemorrhage from the rectum, as the discharge of blood occurs only at the 
time at which the bowels act, often goes on for a length of time unsuspected 
by the patient. In this manner the health may be undermined, great bodily 
weakness brought on, and a variety of nervous symptoms induced, which 
are often of a character to blind or mislead the observation of the medical 
attendant. I cannot better illustrate these remarks than by quoting the fol- 
lowing case from a paper by Mr. Brodie, in the fifth volume of the Medical 
Gazette. 
A lady consulted me concerning symptoms which were ascribed to a stric- 
ture of the oesophagus. She was unable to swallow the smallest morsel of 
solid food, so that she was compelled to subsist entirely on liquids, and even 
these she swallowed with great difficulty. These symptoms had been 
coming on for upwards of three years. I introduced a full-sized oesophagus 
bougie, which entered the stomach without meeting the slightest impedi- 
ment. From this and other circumstances I was led to conclude, that the 
difficulty of deglutition was merely a symptom of some other disease. The 
lady's face was bleached, as if she had suffered from repeated attacks of 
hemorrhage, and her feet were in some degree oedematous. On inquiry, I 
found she had long labored under internal piles, from which had taken place 
repeated discharges of blood. To this last disease, then, I directed my chief 
attention, prescribing two ounces of the infusion of catechu, with fifteen 
grains of alum, to be used cold, as a lavement, every morning; and at the 
same time a solution of the sulphate of iron and sulphate of quinine to be 
taken by the mouth. When this plan had been persevered in for three 
weeks, the piles were much relieved; they no longer protruded externally : 
there had been no recurrence of hemorrhage ; her cheeks were less pale; and 
she swallowed with comparative facility. At the end of six weeks more, 
the piles occasioned very little inconvenience ; she had lost no more blood ; 
her general health was much improved ; and there was so little difficulty of 
deglutition, that I had no hesitation in recommending that after her return to 
the country she should swallow a bolus of Ward's paste three times daily, 
with a view to the complete cure of the hemorrhoidal disease." 
Of pain in the rectum, unattended with local disease that I could discover, 
I have only seen two cases. 
A gentleman, about forty years of age, sent for me during a paroxysm of 
pain in the rectum, but it had subsided before I saw him. He told me, that 
two or three times a year he was liable to this seizure, which was not, that 
he had observed, connected with the state of his bowels or with his habits of 
living. The pain which he used to experience was intense, and would last INJURIES AND DISEASES OF THE RECTUM. 
21 
half an hour. He was not, that he knew of, liable to lose blood by stool, 
nor had he ever suffered from piles. Upon examining the rectum, I could 
discover no disease in it. The pain did not appear to arise from spasm of 
the sphincter. 
I attended a patient with Mr. Stephenson of the Edgeware Road, who 
suffered from pain in the rectum. Something less than two years before this, 
he had a syphilitic ulcer upon the penis, for which he had taken an unusu- 
ally large quantity of mercury, owing to the difficulty of producing sensible 
mercurial action in his system. The ulcer however healed ; but while he 
was recovering, and his system was yet charged with mercury, he began to 
experience aching pains in the incisor teeth and in the rectum. The sense 
of aching in the teeth and in the rectum was not constant, but would come 
on frequently during the day, without any assignable cause. It had lasted a 
year and a half, during which he had remained perfectly free from symp- 
toms of lues. This patient, who was otherwise in good health, suffered his 
mind to be greatly distressed by the continuance of the neuralgia. He was 
anxious to try every plan which held out the least promise of benefiting 
him. But of all the remedies which he tried, he appeared to experience 
relief from one only, which was a course of sarsaparilla. 
CHAPTER IV. 
Of Piles. 
Piles, or hemorrhoids, are soft tumors, which form either within the 
rectum or about the anus. In the first case they are covered with the mucous 
membrane of the intestine, and are termed inward piles. In the second case 
they are covered entirely or in part with the common integument, and are 
termed outward piles. 
Inward piles, and with some exceptions outward piles, arise from conges- 
tion of the hemorrhoidal veins. The same causes therefore lead to the pro- 
duction of both kinds. Local causes of obstruction to the return of blood 
from the rectum ; increased flow of blood upon the bowels; obstruction of 
the biliary circulation ; sedentary habits; exposure to cold and damp; pro- 
duce indifferently inward and outward piles, and in the same person often 
give origin to both alternately or together. 
Although piles commonly originate in a congestion of the hemorrhoidal 
veins, and the little tumors which they form are therefore at first composed 
of dilated elongated and tortuous veins, the bulk of each tumor after a time 
is often found to be made up either of lymph effused into the adjacent tissue, 
or of a clot of extravasated blood. In the former case, the pressure of the 
lymph effused often goes far to diminish or to obliterate the dilated veins in 
which it began, and the tumor appears as a firm, hard lump, closely resembling 
cellular texture thickened by inflammation. 
Piles are met with in three states: either they are tense, irritable, ex- 
quisitely painful; or, without much tension or sensibility, they are inconvenient 
from their place and size only ; or, thirdly, they are shrunken folds of skin, 22 
OBSERVATIONS ON 
or thin slips of the lining of the bowel. To convey an adequate idea of the 
nature of these varieties, and of the methods to be followed in their treatment, 
it is necessary to consider separately the two classes into which they are 
divided. 
SECTION I. OF INWARD PILES. 
Inward piles vary from the size of a pea to that of a large walnut. They 
are sometimes single, at other times they are several. Sometimes they grow 
immediately within the sphincter; at other times at some distance above it. 
They are sometimes attached by a narrow pedicle, at other times they have 
a broad or elongated base. In some cases they do not protrude beyond the 
sphincter; in others they are extruded at every motion. 
A pile protruding at each action of the bowels, and afterwards returned by 
pressure, in what does it differ from a prolapsus? It differs in this respect 
essentially : it is a tumor formed internally to the muscular coat of the bowel, 
and not involving it. The canal of the rectum is therefore in its natural place, 
without elongation or eversion, the pile being an accidental growth of its 
inner surface. The adjoined diagram represents a section 
of the rectum with an inward pile in a state of protrusion. 
It is evident, that if there be a doubt as to the nature of 
the protrusion, an examination will at once remove it. It 
is no less evident, that the two complaints will occasionally 
exist together. The one indeed naturally leads to the 
other. Neglected piles often prove a source of irritation 
sufficient to produce prolapsus, which ceases to recur upon 
the removal of the cause which occasioned it. 
The color of internal piles varies with their condition. 
It is sometimes that of the bowel itself, a shade of reddish 
brown ; at other times a dark purple, approaching to black ; 
at other times a bright red. Internal piles are particularly 
liable to bleed : yet in some instances they exist for several years without 
bleeding. 
The following case will serve to exemplify one form of this disease, as well 
as the efficacy of a very simple remedy, attention to which is in every case 
of the greatest advantage. 
A gentleman, aetat. 57, of a spare frame of body and of temperate habits, 
consulted me for piles. Thirty years before, when in good health, he lost 
by stool a large quantity of blood. In a few hours the anus became tumefied, 
knotty, painful. The following day he was obliged to ride thirty miles on 
horseback. As he proceeded on his journey he became better, and on the 
ensuing day he felt quite well. About four months subsequently he had an 
attack of the following description. The anus, without any assignable cause, 
became tender, tumefied, and painful. This state of things continued three 
days: on the third night he became better; some discharge of mucus with 
blood took place, and in a day or two he was well again. These attacks 
were repeated during the following twenty years, and usually recurred once 
in three months : they were extremely severe and distressing. This gentle- 
man, who is in the medical profession, entertained a strong aversion to medi- 
cal or surgical treatment: he therefore bore the pain, and contented himself 
with bathing the part with cold water. INJURIES AND DISEASES OF THE RECTUM. 
23 
During the last ten years, the character of the complaint had been different* 
The patient had suffered less severely than before, but he had suffered con- 
stantly. The bowels had acted regularly, and that without pain ; but every 
afternoon, about one o'clock, the part had become heated and uneasy, indis- 
posing him to exertion of any kind. Towards evening the uneasy sensations 
had left him. 
Such was the story which this gentleman told me a year ago, when he 
consulted me. Upon examining the part, I found two internal piles, about 
as large as beans, which half protruded upon his straining. As he would 
take no medicine, aad use no medicated application, I recommended him to 
use with scrupulous regularity a lather of soap and water to the part after 
each action of the bowels, and before the piles were returned. This practice 
he has followed ever since, and the piles have for several months ceased to 
give him any inconvenience. 
The best soap that can be employed is common yellow soap. It is ser- 
viceable in two ways: on the one hand it removes completely any remains 
of faecal matter; on the other it acts as an astringent. In the case which I 
have described, the latter object was I have no doubt quite as important as 
the former,-the piles being in that simply uneasy state, not very irritable 
and angry, in which astringent applications are commonly found useful. But 
the first object is likewise one of great consequence. The want of complete 
cleansing of the bowel is one of the causes which most tend to the produc- 
tion of piles, whether external or internal. Water alone is not sufficient to 
cleanse the part: complete ablution with soap as well is necessary for this 
purpose. Those who are thus scrupulously cleanly suffer less from piles than 
other people. 
A remedy very commonly tried for indolent internal piles, and which in 
many cases proves of service, is the confectio piperis composita of the Phar- 
macopoeia. This remedy is to be taken internally, in the dose of a dram, 
two or three times a day : it seems to act as an astringent when applied lo- 
cally, giving a salutary tone to the vessels of the part. The following case 
narrated by Mr. Brodie, in the paper already quoted, will serve at once to 
illustrate the efficacy of this remedy, and to convey an idea of the irregular 
nervous symptoms which are often produced by piles. 
"A lady consulted me," says Mr. Brodie, "concerning a pain to which 
she had been for some time subject, beginning in the left ankle, and extend- 
ing along the instep towards the little toe, and also into the sole of the foot. 
The pain was described as being very severe. It was unattended by swel- 
ling or redness of the skin, but the foot was tender. She labored also under 
internal piles, which protuded externally when she was at the water-closet, 
at the same time that she lost from them sometimes a larger and sometimes a 
smaller quantity of blood. On a more particular inquiry, I learned that she 
was free from pain in the foot in the morning; that the pain attacked her as 
soon as the first evacuation of the bowels had occasioned a protrusion of the 
piles; that it was especially induced by an evacuation of hard faeces; and 
that if she passed a day without any evacuation at all, the pain in the foot 
never troubled her. Having taken all these facts into consideration, I pre- 
scribed for her the daily use of a lavement of cold water; that she should 
take the Ward's paste (confectio piperis composita) three times daily, and 
some lenitive electuary at bed-time. After having persevered in this plan 
for the space of six weeks, she called on me again. The piles had now 
ceased to bleed, and in other respects gave her scarcely any inconvenience. 
The pain in the foot had entirely left her. She observed, that, in proportion 24 
OBSERVATIONS OK 
as the symptoms produced by the piles had abated, the pain in the foot had 
abated also." 
Another popular and excellent remedy for indolent internal piles is pow- 
dered gall-nuts, either mixed in an ointment, or made into a suppository, and 
introduced into the rectum. It frequently happens, that the preceding or 
some other astringent applied directly to the bowel has principally to be re- 
lied on in the treatment of this complaint, in consequence of the confectio 
piperis disagreeing with the stomach. It is necessary, in conjunction with 
the use of astringent applications, to provide for the regular action of the 
bowels. In general for this purpose the lenitive electuary, or sulphur, or the 
two combined, form the most convenient medicines. The bowels are on no 
account to be purged, but one rather loose evacuation should be procured 
daily. The use of a lavement of half to two-thirds of a pint of cold water 
every morning will often be sufficient for this purpose. Or the two last- 
mentioned remedies may be used together with advantage. In some in- 
stances the use of a short rectum bougie is found beneficial in this complaint, 
but this is not commonly the case. 
When it happens that the remedies which have been recommended prove 
ineffectual, and the disease becomes established, the hemorrhoidal tumors 
generally admit of being removed by a very safe operation. 
Mr. set. 49, who, some months before, had had external piles re- 
moved, applied to me for advice for inward piles; which did not cause him 
pain, and rarely bled, but were extremely inconvenient from protruding at 
each motion. He tried during several weeks the remedies which I have 
described; but not becoming better, he discontinued medicine, determining 
to put up with the discomfort of the complaint. About a year afterwards 
this patient consulted me again, and was desirous to have the piles removed 
by an operation. They were four in number, and of no great size: thev 
were of the color of the bowel, not tender on pressure, nor tense: they pro- 
truded at each motion, when he had to wash and to return them. The ope- 
ration which I resorted to, consisted in tying a strong ligature round the 
base of each pile; drawing each in succession fully out of the anus with a 
tenaculum, and applying a ligature to the root of each. This did not cause 
the patient much pain. On examining the parts on the fourth day, two of 
the piles which I had tied, appeared to be dead and separating; but two, 
which were the largest, appeared yet vascular, and bled upon being pricked. 
I therefore tied a fresh ligature around the base of each of these. In a few 
days the ligature separated, leaving superficial ulcers, which healed rapidly; 
and the patient has been perfectly free from piles since. 
Several points are to be thought of in tying inward piles; and when they 
are duly attended to, the operation is unattended with risk. 
The patient must not undergo this trifling operation, when laboring under 
any casual indisposition. 
Before its performance, the bowels should have been several times freely 
moved with aperient medicine. 
If the patient should be unable easily to extrude the tumors, they may be 
brought to protrude upon the patient sitting over hot water, and endeavoring 
to force them down, or after the use of a lavement of warm water. 
The ligature should be drawn round the base of each tumor so tightly, as 
thoroughly to strangulate it. To ensure this object, it is desirable, after the 
ligature is applied before finally tying it, to cut into the pile; after which 
precaution, the ligature may be drawn much closer than it would otherwise 
be possible. It the pile be of large size, it is desirable for the same purpose INJURIES AND DISEASES OF THE RECTUM. 
25 
to pass a double ligature through the tumor with a needle, and then to tie 
either half separately, in the manner shown in the following diagram. 
If there are several internal piles, it is 
necessary that all should be tied. 
After tying a pile, the ligature is to be 
cut short, and the ends are to be/returned 
with the strangulated pile into the rectum. 
If much pain follow the operation, it may 
be allayed by a dose of laudanum. The pain 
generally in a short time subsides entirely ; 
and it is only requisite for the patient to 
remain at rest for the next few days, when 
the ligatures and the piles come away with- 
out his knowledge. But occasionally fresh 
pain supervenes on the second or third night. When this happens, it is 
presumable that the pile has not been entirely strangulated : the parts should 
then be examined, and the ligature should either be removed for the time, 
or drawn closer, according to the state of the parts. If much pain super- 
vene after tying piles, it is always safe and useful to apply leeches to the 
extremity of the bowel. 
The removal of internal piles by the ligature is preferable to their excision. 
It is not more painful. I removed, on two successive occasions, inward piles 
from the same person, the first set by ligature, the second by the scalpel; and 
he told me that the pain in either case was much alike. But the objection 
to excision is the risk of serious hemorrhage. It is true that hemorrhage 
follows in a very small proportion of cases; but when it happens, it is alarm- 
ing in its extent, and may greatly debilitate the patient. The following case, 
although not one in which excision was intended, served to convince me of 
the hazard of that method. 
A little girl, eleven years of age, was brought to the Middlesex Hospital by 
her mother. She had during the preceding half year repeatedly lost blood 
by stool, and at each motion something protruded. Upon examining the part 
after the bowels had acted, a small pile not bigger than a large pea, of a red 
color, and supported upon a long narrow pedicle which had not much ap- 
pearance of vascularity, was seen. The child appeared to be perfectly in good 
health, and no objection presented itself to tying the hemorrhoid at once. 
Accordingly I applied a ligature to the slender pedicle of the hemorrhoid ; 
but being drawn too tightly, the thread cut through the part, and the pile 
came away at once. No disposition to bleed showed itself at the time ; but 
the following night the child lost a profuse quantity of blood, and came to the 
hospital the following day faint and pale and reduced from the bleeding. 
The hemorrhage did not recur. 
To the sources of inconvenience ordinarily attending inward indolent piles, 
another very serious one is occasionally added, when they attain any consi- 
derable size. The patient is not always able to return the part when it has 
protruded ; which being partially strangulated by the sphincter muscle, 
swells and becomes inflamed and acutely painful. 
I attended with Mr. Reid of Charlotte Street, Bedford Square, Mr. , 
set. 68, a hale man, but of a relaxed and nervous temperament. Twenty years 
before, a considerable protrusion from the anus had for the first time taken 
place, which after several hours of suffering was replaced by a surgeon. The 
protrusion shortly after again took place, when the patient contrived to re- 
turn it himself. He soon found the tumor descend whenever the bowels 26 
OBSERVATIONS ON 
acted; and as his profession required him to be many hours absent from home 
during the day, he was obliged to carry about with him what was necessary 
for washing and returning the tumor, in case the bowels should act in the in- 
terval. 
On the occasion of my seeing him first, he had just arrived in London for 
advice. The tumor had descended some hours before, while he was in the 
country ; and the means of reducing it which were usually successful had 
failed. From an accidental congestion of blood, the tumor had become 
larger than usual, and the country surgeon was unable to reduce it. The 
journey to London had caused considerable pain. 
Upon examining the part, I found a dark-colored tumor projecting at the 
anus, of the size of a large French walnut: it was firmly grasped by the 
sphincter, through which the difficulty of returning it had arisen. The 
tumor was extremely sensible, but by very gently compressing it, and forcing 
it upwards, I succeeded after a few minutes in returning it. The tumor 
seemed double, or had a considerable fissure at its middle, which led me at 
first to suppose it a prolapsus; but after returning it, I found it to be one 
large hemorrhoid. 
I recommended this patient to remain at his house in London for a few 
days at rest, taking light nourishment, and having the bowels daily moved. 
Upon the fourth day the increased sensibility of the part having subsided, I 
passed a strong ligature round the base of the tumor, and tied it. The tumor 
separated in ten days; and the patient was completely relieved of the incon- 
venience it had occasioned. 
The observations which have been made in this section apply principally 
to the nature and treatment of indolent internal piles. In the more painful 
and angry state of hemorrhoidal tumors, a different course must be adopted. 
The following case will serve to exemplify this stage of the complaint, and 
the measures which are requisite for its management. 
Carney, setat. 30, was admitted into the Middlesex Hospital, Decem- 
ber 19, 1830. During the last year, he had lost blood by stpol on an average 
more than a table spoonful daily. During the last month, he had suffered 
severely from aching pain in the lower part of the rectum. On the day of 
his admission he was worn with intense pain. The anus was full and promi- 
nent, and when he strained, the inner part of the bowel protruded in highly 
sensible and vascular knots. Twenty leeches were applied to the verge of 
the anus, and afterwards an opiate poultice. The pain subsided: the fol- 
lowing day the bowels were moved by a dose of castor oil, and the patient 
had obtained complete relief. 
I give the preceding as an example of the simplest form of the affection 
which I am describing. Its features are often complicated or disguised by 
the sympathetic derangement of other organs than the rectum. This is a 
point upon which the practitioner should be particularly forewarned. A 
patient, for instance, who is laboring under a sudden and violent attack of 
piles, may describe as his principal complaint, irritation in the bladder, fre- 
quency of micturition, pain in the back, pain and aching down the thighs. 
In twenty-four hours, a profuse discharge of blood from the rectum will 
spontaneously relieve all these symptoms, and explain the true nature of the 
attack. But by the timely application of leeches to the anus, the symptoms 
might have been removed several hours sooner, had the practitioner discov- 
ered their real origin. 
In such cases there are two objects to be thought of: the first, to reduce 
the unusual congestion, and to subdue the increased irritability of the parts, INJURIES AND DISEASES OF THE RECTUM. 
27 
and the inflammatory character of the disorder; the second, to apply in the 
subsequent stage the remedies recommended for internal piles when indolent. 
These remedies, however, often prove not to be necessary. When the 
angry and turgescent state of an hemorrhoid has been promptly relieved by 
appropriate remedies, the tumor frequently either wholly disappears, or 
shrinks through absorption to so small a size, and is so little sensible and 
vascular, as to be productive of no inconvenience. 
When hemorrhoids of long standing have been removed, and the habitual 
discharge of blood or mucus which attends the disorder has been suppressed, 
it is desirable that the patient should attend very carefully to the state of the 
bowels, using suitable means to prevent costiveness and even to render the 
alvine excretions somewhat more large than natural. It is indeed true that 
the previous discharges of blood and mucus may have been a drain upon 
the system, which, having been lowered by their means, may require their 
cessation to enable it to regain its tone. In such a case, the practitioner 
would be on his guard against perpetuating by the use of purgative medi- 
cine the debility of his patient. But as a general rule, the caution given 
above is strictly to be attended to. The principle is sufficiently established 
by experience, that the sudden drying up of any discharge, which from use, 
has become natural to the system, is liable to be followed in a few months by 
inflammation or congestion of other organs. 
Again, although the means which have been recommended, will succeed 
in curing the greater number of cases of inward piles, yet the practitioner 
will meet with others, in which, through one cause or another, he is entirely 
baffled. Either the patient will not alter the habits of life which have led 
to the complaint; or there may be interna) incurable disease, of which the 
piles may be a necessary consequence; or, the case being a suitable one, 
the patient will not consent to have the tumor removed by an operation; or 
his age or constitution may render an operation unsafe. 
In such cases, there is still room for skilful palliative treatment, through 
which the patient's periods of suffering may be rendered less frequent, and 
the suffering less severe. By the judicious use of aperient medicines, of as- 
tringent and narcotic applications, of the rectum bougie, according to the 
circumstances of the case, even by directions as to the shape of the seat of a 
water-closet, very considerable additions may be made to the patient's 
comfort. 
SECTION II. OF OUTWARD PILES AND EXCRESCENCES NEAR THE ANUS. 
Outward piles commonly appear in the following manner, and run the fol- 
lowing course. After twenty-four or forty-eight hours, during which the 
patient has experienced fulness, heat, and itching at the anus, a hard round 
lump from the size of a pea to that of a chestnut, is felt on one side of the 
margin of the gut. It is extremely tender, so that the patient cannot bear 
to sit; and in every posture the pressure of the adjacent parts produces more 
or less aching pain. The patient finds relief sometimes from bathing the 
part with cold water, sometimes from hot fomentations and poultices, but 
more generally from the latter. Upon the use of one or other of these reme- 
dies, and a dose of laxative medicine, and rest and abstinence, the tenseness 
of the swelling and the sense of fulness and pain abate, and in forty-eight 
hours more so much amendment has taken place, that the patient is able to 28 
OBSERVATIONS ON 
sit and move about with comfort. The tumor after a few days shrinks en- 
tirely and disappears. 
The pain attending an attack of this description is of every degree, from 
inconvenience and discomfort to intolerable suffering. The pain depends 
upon the fulness of the vessels of the part, and it is often removed upon the 
occurrence of spontaneous bleeding from the mucous membrane of the bowel: 
it may always be mitigated by abstracting blood from the part by leeches. If 
the tumor is large the pain is generally greater; and at all events the swelling 
and induration are a longer period in subsiding. 
A physician, whom I had formerly attended for inward piles, came from 
the country to consult me for such an attack as that which I have described. 
He had used the remedies which have been recommended, having applied 
leeches several times, and having been cupped upon the sacrum, and each time 
with relief but there remained a tumor of the size of a chestnut on one side 
of the bowel, which was still painful on pressure, and he was in hopes that 
an operation would relieve him. Before he saw me, after he arrived in Lon- 
don, he met, and the part was examined by, a surgeon of considerable expe- 
rience, who told him that he could if he pleased return the tumor within the 
sphincter, but that the pressure necessary would give considerable pain. 
The appearance which the part presented was that of a solid tumor on one 
side of the anus, extremely firm, partly covered with tense and shining in- 
tegument, partly with the mucous membrane of the margin of the bowel. 
On examining the rectum, the swelling and hardness were found to extend 
an inch within it. It was evident that no operation would be of service; 
and that as the tenderness and pain in the part, though still considerable, 
were progressively lessening, no treatment would be necessary beyond the 
use of a poultice and occasional doses of opening medicine, with abstinence 
from wine and heating food. The tumor I concluded to be an outward pile, 
no part of which would on its diminution be drawn or forced within the 
sphincter. The result proved that this opinion was right: the tumor osly 
shrunk. 
The case which has been described appeared to me interesting in three 
points of view. 
In the first place, it was a striking instance of the possibility of mistaking 
an external for an internal pile. This mistake might have been of conse- 
quence : if it had been acted on, the patient would have been put to great 
pain, and the complaint, instead of being benefited would have been mate- 
rially aggravated. 
In the second place, this case established that an hemorrhoidal tumor may 
form in the part of the bowel surrounded by the sphincter. The swelling 
was not merely prominent by the side of the anus, but could be traced some 
way within the sphincter. I mark this circumstance, because I believe that 
it is laid down on no common authority, that the pressure of the sphincter 
precludes the formation of the hemorrhoidal tumor within its circumfer- 
ence. 
Thirdly, the preceding case gave me an opportunity of ascertaining what 
becomes of inward piles, when they cease to give uneasiness and to be felt 
by the patient. This gentleman had consulted me two years before for an in- 
ward pile, which protruded on the action of the bowel, as a round and vas- 
cular and turgid knot. By the use of appropriate remedies he had entirely 
recovered; but I found upon examining the bowel on the present occasion, 
a soft insensible pendulous process within the rectum, nearly cylindrical about 
an inch in length and a third of an inch in diameter. This had been the INJURIES AND DISEASES OF THE RECTUM. 
29 
inward pile, with which he had formerly suffered ; it had shrunk, and little 
remained but the elongated membranes which had formed its covering. 
It happened shortly after this, that another gentleman consulted me for an 
external hemorrhoidal tumor, which in many respects corresponded writh 
that described above. He told me that his stomach had been deranged for 
some time previously, and that having been exposed to cold and wet, he had 
shortly afterwards noticed some uneasiness about the anus, and had discovered 
a small lump on one side, which appeared springy and compressible. Think- 
ing that he might perhaps succeed in returning it, he made continued pres- 
sure upon the tumor, which he seemed by this means to empty, so that it 
almost disappeared. But the next day the swelling returned, became consi- 
derably more painful, throbbed, and was extremely tender. A day or two 
afterwards I saw this patient. The tumor which I examined, was very like 
the last described, but it was more sensible, the skin covering it was more 
tense, and pressure upon it conveyed a sense of elasticity which made me 
think that it contained fluid. I therefore punctured it with a lancet, when 
a quantity of liquid and clotted blood escaped, the part lost its tenseness, and 
became immediately easier. Some little discharge of blood and serum con- 
tinued for a few days, during which the tumor diminished rapidly: it 
speedily subsided entirely. 
I punctured the swelling in the preceding instance, in consequence of the 
tenseness, elasticity, and throbbing pain which characterized it; without, 
however, feeling certain that the swelling was a pile, as it proved to be, and 
thinking it possible that it might have been an abscess. For I remembered 
a case, in some respects the converse of the preceding, in which I had been 
called to treat a small tumor at the side of the anus, attended with pain and 
throbbing, and in many respects looking like an outward pile, and which 
had been pronounced to be so, but which I punctured upon the supposition, 
which proved to be correct, that it contained matter. 
I presume, where an external hemorrhoidal tumor has the characters 
which I have mentioned-namely, elasticity, tenseness, throbbing-that it 
is always right to pursue this practice. Under other circumstances, it is pro- 
bably injudicious to puncture external hemorrhoidal tumors. I have for- 
merly several times punctured the common form of marginal hemorrhoidal 
swellings, when they project as swollen blue tumors, part covered with 
integument, part with mucous membrane, having no great degree of tense- 
ness, although extremely painful. I discontinued this practice, from finding 
it in no instance of material benefit, and having observed it in some instances 
to be followed by an increase of pain and irritation. The proper treatment 
in such cases is to apply fomentation, and if necessary, leeches, as recom- 
mended above in the irritable stage of hemorrhoids. 
There was a patient under my care, in the cancer ward of the Middlesex 
Hospital, ■with enlarged and indurated womb. The pressure of this organ 
upon the rectum produced habitually a difficulty in evacuating the bowels. 
On one occasion, the sufferings of the patient became aggravated by the sud- 
den oedematous swelling of the skin around the anus as a thick and acutely 
sensible fold or collar, the least pressure or contact upon which caused pain. 
In this instance free scarification was practised ; by which the distension wras 
relieved, and the tenderness of the part subsided with the distension. 
In the class of cases of external piles which I have described, the tumor 
is indeed always without the sphincter, and is for a greater or less extent of 
its surface covered with the common integument; but its situation is mar- 
ginal, so that it is in part covered with an extension of the mucous mem- 30 
OBSERVATIONS ON 
brane. But there is another class of cases, .in which the tumor is entirely 
covered with the skin, and is more detached from the sphincter muscle and 
the border of the anus. 
The hemorrhoids in these cases, which are extremely common, but more 
so in women than in men, either originate suddenly in their acutest form- 
as oblong, firm, highly sensible folds of skin-the swelling generally con- 
taining a dilated vein ; or else form very gradually, the skin slowly throwing 
out the tumors, as soft, pendulous folds of integument. The immediate 
cause of these little growths is irritation of the integument occasioned by the 
secretions of the neighboring parts. 
The first variety to which I have adverted, I may exemplify by the fol- 
lowing case. A young woman, a patient in the Middlesex Hospital for 
another disorder, complained that there were small folds of skin near the 
anus, for which she desired relief. They had made their appearance sud- 
denly, with great pain, two years before. For the last year and a half she 
had suffered little from them, but the apprehension that they would again 
prove painful. As this was likely to be the case, I removed each of the little 
excrescences, fixing each by means of a tenaculum, and dividing its root 
with a scalpel. 
Another young woman was admitted about the same time into the Middle- 
sex Hospital with painful external piles. She had for several years suffered 
from this complaint: every two or three weeks considerable pain and ten- 
derness in the tumors would come on. There were two hemorrhoids, one 
situated behind, one to the side of the anus: they were knotty, and pecu- 
liarly hard, but of the common color, that of the integument. The bowels 
were naturally costive. For a few nights some gentle aperient medicine 
was administered, upon which the tumors became less painful. I then 
removed them ; and as it usually happens, after the momentary smart of 
the operation had subsided, the patient expressed herself as being in a state 
of comfort which she had not known for years. 
The gradual origin of these little folds of skin about the anus from any 
irritation upon the integument, may be exemplified by the following cases ; 
which I select, however, as much in reference to the other features which 
they presented, as to their exemplifying one variety of outward piles. 
The cases I mean are of the following description. Some soreness is felt 
of the skin about the anus, which gradually increases. When the part is 
examined, two or three red circular elevations of the skin are seen, from 
three to four lines in diameter. They are attended with heat and soreness. 
If neglected, they sometimes ulcerate. They commonly get well under the 
use of mercurial applications, joined if necessary with mercury administered 
internally. I do not know whether this affection, which I have seen several 
times, and with one exception in women only, is of a venereal origin. I have 
not seen it in connection with other symptoms of lues. But in one instance, 
in a woman forty years of age, it existed at the same time near the anus and 
in the axilla. The complaint had begun in the first situation, and I have no 
doubt it had been transferred to the axilla by contact. 
I saw the same affection in a child two years of age, a boy. In this case 
mercurial applications irritated the part, which got well under the use of the 
zinc ointment. In this case there were originally two blotches, one of which 
became ulcerated, and the skin beside it grew into a pendulous slip, distinctly 
caused by the irritation of the neighboring ulcer. As the original complaint 
got well, the slip of skin shrunk again and disappeared. 
When these little folds of skin originate from a local cause of irritation, INJURIES AND DISEASES OF THE RECTUM, 
31 
they generally go away spontaneously: sometimes they shrink and disap- 
pear; at other times they perish by ulceration. The most common caus'es 
of their production are gonorrhoea, or leucorrhcea, when insufficient attention 
is paid to cleanliness. 
These folds of skin at the side of the anus sometimes enclose a considera- 
ble mass of dense, white, membranous substance, and form large, hard, fleshy 
tumors, or condylomata, which are commonly very painful. 
A woman, aetat. forty-eight, was under Dr. Watson's care in the Middle- 
sex Hospital. She had been suffering for several years with pain and unea- 
siness, extending from the anus to the loins, and round the lower part of the 
belly; aggravated when the bowels acted, which were generally in a dis- 
turbed state, either relaxed or constipated. All these symptoms depended 
upon two large, thick condylomata, one on each side of the anus. I removed 
these tumors with a scalpel; the surface healed very quickly, and the patient 
was free from all the distress she had previously experienced. 
As a general rule, growths external to the anus are to be removed by the 
scalpel, as the tumors which form within are for the most part best removed 
by the ligature. 
The figure which follows represents the surface of a forest of arborescent 
warts, which grew from the anus of a boy twelve years of age. The 
faeces came through the fissure in the centre. As the parts were very sensi- 
ble, it is to be supposed that the faeces were never dislodged entirely from 
this mass, which was two inches in height. The absence of cleanliness con- 
tributed to the growth of the disease. A surgeon had attempted to remove 
the mass piecemeal, by tying three or four of the stems of these warts: but 
this had had little effect but that of increasing the soreness of the part. The 
boy being placed under my care, I removed the whole crop with a scalpel, 
and touched the roots with nitrate of silver, in order to stop the trifling 
bleeding which followed. The part healed very rapidly, and the warts did 
not return. 32 
OBSERVATIONS ON 
CHAPTER V. 
Of Fistula Ani. 
By a fistula is meant a narrow channel or sinus, secreting purulent or se- 
rous discharge, and having an external opening near the anus through which 
the matter has vent. The opening of a fistula is often extremely small, so 
that there may be difficulty in finding it. The channel itself, or fistula, is 
usually a little larger than a common probe: it is sometimes straight, some- 
times crooked: its length may vary from half an inch to several inches. 
Towards its inner extremity a fistula reaches the coats of the rectum : it may 
terminate inwards by a small aperture of communication with the intestine, 
or blindly as a cul de sac. There may be one fistula, or there may be seve- 
ral ; and in the latter case, the fistulae may or may not reciprocally com- 
municate. 
A fistula is a consequence of an abscess, which, when it has been broken 
or been punctured, contracts to such a narrow channel as has been described, 
which continues permanent. The complaint requires to be studied separately 
in its two stages, first as an abscess, secondly as a permanent sinus. 
Abscesses near the rectum again admit of a practical distinction into two 
kinds: either they are small and superficial, which is the character of those 
that lead to fistula; or they are deep-seated, when they often contain large 
accumulations of matter, but rarely produce the secondary complaint. 
The frequent occurrence of abscess near the rectum, results from the de- 
pendent situation of the part, and from the quantity of loose adipose and 
cellular tissue with which it is surrounded. The blood from these causes in 
the hemorrhoidal veins presses heavily on the capillary circulation; and in- 
flammation and abscess in the part ensue, upon the same principle that in- 
flammation and ulceration of the integuments of the leg are produced by 
varix. Whatever tends to diminish the quantity and firmness of the adipose 
tissue at the lower part of the pelvis, lessens in the same degree the lateral 
pressure upon the veins, and encourages congestion in them. Causes which 
produce this effect, lead therefore to abscess near the rectum. I have fre- 
quently seen large abscesses around the rectum in patients, in whom the com- 
plaint has evidently been brought on by hard work and insufficient nourish- 
ment; and it is well known how liable small and superficial abscesses are to 
occur in those who are extenuated through pulmonary disease. 
The formation of deep-seated abscess near the rectum is to be suspected, 
when the patient experiences aching and throbbing pain in the part, often 
not constant, but recurring at intervals, and frequently with a spasmodic cha- 
racter, the pain being aggravated on the passage of the faeces, and the com- 
plaint attended with symptomatic fever. The abscess often does not declare 
itself by any external fulness or prominence ; and its existence can only be as- 
certained through an examination of the rectum ; when, at some part which is 
more tender than the rest of the mucous surface, a fulness and fluctuation, if 
the abscess is matured, are felt. 
The most important practical rule respecting deep-seated abscesses near 
the rectum is, that they should be opened at an early period. The abscess INJURIES AND DISEASES OF THE RECTUM. 
33 
left to itself is slow in making its way to the surface; and, before it spo? t- 
neously breaks, an immense accumulation of matter will have been forilAd. 
While this process is going on, the patient suffers under increasing pain and 
irritative fever; and as the complaint generally afflicts those who are of a 
debilitated constitution, the patient is in danger of sinking before the natural 
relief of the abscess has taken place. It has not indeed happened to me to 
have seen a patient perish of this complaint; but I recollect two cases which 
came under my care within a short period of each other, in the Middlesex 
Hospital, in which I was apprehensive of a fatal termination. In both cases 
the rectum was contained in an enormous bag of matter. There was ex- 
treme prostration, the tongue dry, the pulse frequent and tremulous; but in 
twenty-four hours after opening the abscesses, a decisive amendment took 
place, and recovery followed. 
When there is a considerable collection of pus about the rectum, it is im- 
portant, as in other instances, to allow the matter a free escape. This object 
is not to be attained by large incisions, which however I have seen made, 
and have been struck with the indolent character which the wound has put 
on, and with the slow and protracted closure which has followed. The free 
escape of the matter is to be attained by making a sufficient number of open- 
ings of the breadth of the blade of a lancet at proper points. Two or three 
will generally be found to be sufficient. There is a hospital patient at pre- 
sent under my care, who was admitted with a large abscess on one side 
of the rectum, which had broken in several ulcerated openings. He had 
been extenuated through hard work and inadequate nourishment; and when 
admitted was in an extreme state of weakness and depression. He was al- 
lowed the roast diet of the hospital, and wine ; and a part of the abscess 
which bagged was opened. A few days had made a surprising difference 
with him; when, without any apparent cause, he again fell back, his coun- 
tenance looked haggard and anxious, and his strength declined. Upon ex 
amining the part, I found that the abscess had burrowed towards the thigh 
and that there was an accumulation of matter which had only a circuitous 
vent. I punctured this, making no alteration in his regimen, and in twenty- 
four hours the patient again presented the appearance of improving health 
and vigor. 
When there is reason to believe that matter is forming bv the rectum, the 
inflamed part should be opened with a lancet, even if no fluctuation can be 
felt. The lancet should be pressed home into the part, where, from an ex- 
amination by the rectum, the inflammatory fullness and swelling is ascertained 
to be. A large escape of matter will then frequently take place, where its 
presence could not have been otherwise ascertained. Or, if a few drops of 
matter only escape, the progress of the disease is by this relief arrested, and 
the patient speedily recovers. 
I attended with Mr. Lamb, of York Square, Regent's Park, a young lady 
in whom an abscess threatened to form by the rectum. In addition to the 
pain experienced io the action of the Bowels, and tenderness in the rectum, 
and constant throbbing and aching in the part, and great distress in every 
posture but that of lying with the face downwards, there was general fullness 
of the nates on one side towards the anus. I therefore introduced a lancet 
to some depth, when blood only followed : I then pressed the.instrument still 
deeper, when a little matter escaped. In a short time the distress which this 
patient had experienced was relieved, and she soon entirely recovered. 
Deep-seated abscesses near the rectum in men produce more or less obstruc- 
tion and irritation in the urinary organs, especially if their situation be to the 34 
OBSERVATIONS ON 
front of the rectum. In the latter case, they often indeed threaten to affect 
the urinary organs principally, and breaking into the urethra, to give rise to 
urinary fistula; or opening at once into the urethra and the rectum, to origi- 
nate at once both urinary fistula and fistula ani. 
The following case, in which the abscess was seated within or close to the 
prostate gland, may serve to exemplify the variety of abscess breaking into 
the rectum alone, and terminating favorably. The collection of the matter 
in this instance was slow, and was not attended with the acute symptoms and 
irritative fever belonging to the class of cases which I have before described. 
Wm. Knight, setat. 65, was admitted into the Middlesex Hospital, August 
9, 1832. For five months previously, he had experienced violent aching 
pains about the hips and loins, and down the back of the thighs to the knees, 
slight dysuria, and habitual constipation of the bowels. During the last six 
weeks he had suffered more acute pain within the anus, shooting to the pro- 
jections of the ischia and round the haunch bones. He passed urine with 
great difficulty, and could scarcely void it unless at the same time he strove 
to empty the bowels. Upon examining the rectum, I found a collection of 
fluid in the region of the prostate gland. This patient experienced relief 
from the use of the hip bath, with an opiate suppository at night, and mild 
aperient medicines. But in five days after his admission, the abscess broke 
into the rectum, discharging as he thought, a pint of matter, which was 
followed by the complete removal of all his symptoms, and a very speedy 
recovery. He left the hospital perfectly well on the 28th of September. 
The small abscesses which lead to or threaten the production of fistula ani, 
are commonly situated close to the sphincter, and frequently are formed in 
the substance of that muscle. They are often attended with considerable 
pain. They are liable to be mistaken for outward piles, of which mistake, 
I have already given an example. It is of consequence to distinguish such 
an abscess from a hemorrhoid, as the practice to be pursued in the two cases 
is different. The outward pile is rarely to be punctured; while the abscess 
which threatens fistula cannot be too speedily opened. By this means the 
fistula is prevented : if the abscess be opened early, it speedily dries up. 
In the history which patients give of the origin of fistula, they usually 
state, that after suffering several weeks with occasional pain and throbbing 
and uneasiness about the anus, something appeared to give way, and that 
this was followed by a discharge of matter externally, which has continued 
to the time of their application for advice. Sometimes the pain attending 
the original suppuration has been so slight as to have passed without notice. 
Every case of fistula ani does not require an operation for its relief. The 
complaint occurring in young persons of a sound constitution from an acci- 
dental cause, such as constipation of the bowels, will, when the cause is re- 
moved, spontaneously get well. The employment of gentle aperients in 
such a case, with wholesome and regulated diet, conjoined with the use of 
astringent lotions to the part, or of the confectio piperis composita internally, 
is frequently sufficient for the cure of the disease. 
Every fistula will not admit of relief even through an operation. Fistula 
frequently occurs in persons laboring under pulmonary disease. In these 
cases it is fruitless to attempt to cure the fistula till the pulmonary symptoms 
are alleviated. If the parts are divided, the patient's distress is only aggra- 
vated by the greater soreness and larger discharge of a larger unhealed and 
indolent fistulous surface. 
In ordinary cases, however, a simple operation is necessary and sufficient 
for the cure of this malady. The operation consists in dividing the substance INJURIES AND DISEASES OF THE RECTUM. 
35 
intervening between the fistula and the rectum, or in laying open the fistula 
into the rectum. 
It is customary to argue, that the action of the sphincter externus ani is 
the cause which renders such an operation necessary. The fistula, it is urged, 
is a narrow channel leading from the skin into the bowel above the sphinc- 
ter. But the sphincter is habitually contracted, while the fistula on the other 
hand is a canal always open. The secretions and contents of the bowel 
therefore, which are under the constant pressure of the adjacent parts, have 
at once no escape through the anus, -while they find a ready passage along 
the fistula, which the irritation they occasion prevents from closing. After 
the division of the sphincter, the contents of the rectum are able to pass as 
readily by the anus as through the fistula, which then granulates and heals 
the wound in the rectum itself healing last. 
It is evident, however, that this account of the principle of the operation 
for fistula will not serve in that large class of cases in which there exists no 
communication between the fistula and the bowel, or in which the sinus is 
contained in the sphincter. Yet these cases are often as difficult to manage 
as the others are, and equally require the same operation for their relief. 
The true reason why a fistula ani is so slow of closing, is, that it is a sinus 
in the cellular tissue. In whatever region of the body such a sinus occurs, 
the same tardiness of healing is invariably observed. This is well known 
to surgeons in cases of sinuses in the groin and in the axilla. A principal 
means available in these cases, is pressure applied in the line of the sinus, 
after action has been excited in it by the use of stimulant injections. But 
pressure, it is evident', cannot be made against the sides of a fistula ani. 
A young woman was admitted into the Middlesex Hospital, with a sinus 
which opened an inch behind the anus. Upon examining it with a probe, 
I found that instead of running towards the rectum, it extended upwards for 
a length of five inches between the skin and the os sacrum. This patient 
was of a good constitution, and the bone was not diseased: she attributed the 
complaint to a blow which she had accidentally received. I tried by pres- 
sure to obliterate the sinus, but it was ineffectual. I then laid open the sinus 
for an inch and a half at its lower part, and made a counter opening at the 
upper part, and left for a week a few threads drawn with a probe through 
the undivided part of the sinus. During this period poultices were applied. 
The threads were then withdrawn, pressure was made, and the part healed 
rapidly. 
The part of the sinus which was divided healed like a common fistula: 
it granulated from the bottom/the integument uniting the last. The original 
indisposition to heal and the cure in fistula turn on the same principles as in 
this case. 
The best mode of operating for fistula ani, and the least painful, is the fol- 
lowing. Having ascertained by means of a probe, in which direction the 
sinus extends, withdraw the probe, and introduce in its place a strong curved 
and probe-pointed bistoury. Pass at the same time the fore-finger of the 
left hand into the rectum, and let the point of the bistoury enter the rectum 
and rest upon the finger. If the fistula do not communicate with the rec- 
tum, it is desirable that the bistoury, in addition to a strong rounded end, 
should have a cutting edge to its extremity: by this means it may be made 
to divide the membrane of the bowel and to reach the finger. The opera- 
tion is then completed at once by drawing out together the finger and the 
instrument resting upon it. It is evident that the intervening substance must 
have been divided. 36 
OBSERVATIONS ON 
It sometimes happens, if the sinus extends some length by the side of the 
rectum, that a slight hemorrhage follows the operation. This, however, is 
seldom more than bathing the part with cold water and keeping it exposed, 
will arrest. I have never seen it extend beyond this. Still it is evident, 
that smart arterial hemorrhage may sometimes take place from the rectum, 
either after the operation for fistula or on other occasions. And it is impor- 
tant to consider how such bleeding is to be arrested, for it has little disposi- 
tion to cease, the marmth and moisture of the part contributing to encourage 
it. An instrument necessary in this emergency, is Weiss's improved specu- 
lum ani, which consists of three bars of steel, that, when they meet, form a 
polished cylinder. The instrument is introduced in this form, and then by 
turning the handle the blades are expanded and dilate the rectum, exposing 
its inner surface, upon which the bleeding vessel may be seen. The source 
discovered, the bleeding may be arrested, either by tying the vessel, or by 
touching the surface with the nitrate of silver or the cautery. 
What is most to be apprehended respecting the event of the operation for 
fistula ani in a favorable case, is an immediate union of the coats of the 
divided bowel, leaving the fistula exactly where it was. To prevent this 
occurrence, and to indispose the divided parts to unite, the operations have 
been employed of dividing the intervening substance by the ligature, or 
tearing it with a flexible wire ; but of these operations one is too tedious, 
and the second is unnecessarily painful. The surgeon need only, after the 
simple division which I have described, introduce a few threads of oiled 
lint into the wound : but even this expedient is not necessary, if on the 
following day the surgeon is careful gently to introduce a probe, and separate 
any adhesion which has taken place ; in the greater number of cases the 
wound will then readily granulate from the bottom, and the part be healed. 
But it is not to be denied that cases occur in which the disease, although 
within the reach of art, is not so easily remedied. The following may serve 
as an example. 
, setat. 23, a clerk in a mercantile house in the city, applied 
for advice for fistula. Two little swellings formed near the anus: they were 
attended with pain, and were supposed to be outward piles. In a month 
they broke, when the pain was relieved, but the discharge continued. In 
another month a third lump formed, which, like the preceding, was poul- 
ticed, and broke. It was not till three months after this that the patient had 
leisure for surgical treatment. I found that there were three sinuses, one on 
each side of the rectum, and one nearly in front. These I divided, using 
the precaution the following day of passing a probe along each incision. By 
these means, which I repeated, the edges of the wounds were prevented 
closing, but the sinuses continued indolent, and indisposed to fill up. The 
patient was then directed to bathe the part twice a day with a strong astrin- 
gent lotion, and to take the confectio piperis composita, together with the 
lenitive electuary. Another abscess now formed anteriorly to the anus : this 
was opened into the nearest sinus, the parts were poulticed, and the stimu- 
lating treatment omitted. After a few days it was resumed, and the patient 
then at length got well. 
When a complication of fistula ani with urinary fistula exists, if the 
patient have a good constitution, he may be cured. Of this I have seen 
more than one instance. The plan to be followed, is first to close the com- 
munication with the urethra; which may often be accomplished through 
regulated diet and medicine alone, without the use of instruments, unless 
there is stricture of the urinary canal. When the communication between INJURIES AND DISEASES OF THE RECTUM. 
37 
the urinary canal and the sinuses has closed, which is known by the urine 
ceasing to flow through them, the cure is completed by the common opera- 
tion for fistula ani. • 
CHAPTER VI. 
Of Constipation of the Lower Bowels, and of the Use of Instruments. 
The disorders which have been treated of in the preceding sections- 
fissure of the rectum, laceration, bleeding, hemorrhoids, fistula ani-would 
admit of being loosely classed together as occasional results of one common 
cause, namely, constipation of the lower bowels. The disorders which 
remain to be described-contraction of the sphincter, spasmodic and perma- 
nent stricture of the rectum, and carcinoma-might on the other hand be 
grouped as a variety of causes leading to one common result, namely, 
mechanical obstruction of the lower bowels. 
Between these two classes of disorders a place may be found for the con- 
sideration of the following questions. 
First, What are the causes of constipation of the lower bowels ? 
Secondly, What are the precautions necessary in the use of instruments ? 
The first of these subjects bears an evident relation to the class of disorders 
already treated of; the second is an essential preliminary to the study of 
those which remain. 
I. Constipation of the lower bowels depends immediately upon one or other 
of three different causes. Either the s ecretions are wanting, of which, 
combined with the refuse of the aliment, faeces are formed ; or, faeces being 
formed, there is not liquid secretion enough for their expulsion ; or, the 
faeces being of a proper quantity and consistence, either they are not of a 
quality to stimulate the bowels to action, or the muscular fibres of the bowel 
being enfebled, have not force enough to expel them. 
The two following cases are instances of constipation from want of fasces : 
they exemplify, in different degrees of severity, the consequences which 
result when the blood is not relieved of this excretion. 
A young gentleman, aitat. 25, consulted me, laboring under the following 
symptoms. He complained of being oppressed with languor, and described 
himself as incapable of any effort mental or bodily. Frequently during the 
day he was drowsy and disposed to sleep, and at night he slept long and 
heavily. He considered that these symptoms, under which, with certain 
intermissions and with variations in their degree he had labored for several 
years, depended upon constipation of the bowels. If it happened that the 
bowels were well relieved in the morning, the oppression which he suffered 
seemed for that day lightened of half its weight. In the preceding autumn 
he had been in the country, taking considerable exercise daily. At that 
time the action of the bowels had been regular, and he had felt himself per- 
fectly well. 
For two months before I saw this patient, he had been endeavoring, by 
means of medicine, to make up for the want of bodily exercise. He had 
used injections, but they seldom brought away faeces : he had taken various 
medicines, but they had generally produced wratery motions, which used to 38 
OBSERVATIONS ON 
lower instead of relieving him. His tongue was clean, his appetite good. 
There was no embarrassment in the early stages of digestion ; no sense of 
weight or uneasiness at the stomach ; no acidity, distension, or flatulence, 
after his meals. The only bodily sensation which he complained of, was 
a sense of uneasiness about the middle of the belly. This uneasiness was 
greatest when the bowels were most confined : at such times he could not 
draw himself fully upright without pain about the umbilicus, which was 
increased by pressure. 
This patient recovered his health upon taking a course of medicine which 
produced daily a full action of the bowels. The medicine which most con- 
tributed to this purpose consisted of equal parts of scammony, gamboge, aloes, 
and the compound extract of colocynth. 
I was requested to see a young medical man, who I heard was in a fit. 
I found him lying on the floor, sensible, but exhausted with suffering: the 
flexor muscles of the limbs and the muscles of the abdomen were in strong 
spasmodic action. He had been in this state for several hours. Ammonia, 
and hot brandy and water were given him, and he gradually rallied. This 
I learnt was not the first seizure of the kind which he had experienced. 
Attacks of a similar description, but of less severity, would come on several 
times in the year: they were preceded by obstinate costiveness. 
This patient, now twenty-eight years of age, up to the age of fifteen, 
enjoyed excellent health. At that age his bowels fell into the state of cos- 
tiveness which has continued since. He grew up of a slight and delicate 
frame, physically incapable of much bodily exertion, and indisposed to it by 
a languor and drowsiness which probably arose from the imperfect action of 
the bowels. The bowels now act once in five or six days only ; what is then 
passed is healthy ; it is only extraordinarily deficient in quantity. With 
this he has little appetite ; and even that he is afraid of indulging, lest it 
should lead to one of the attacks which I have described. These attacks, it 
has been mentioned, recur when the bowels have been confined for an 
unusually long period. The belly then becomes hard, and a little swollen : 
there is sickness, but nothing is thrown up but what has been recently taken 
into the stomach: there is a sense of uneasiness and pain above the umbili- 
cus. When at the close of such an attack the bowels are relieved, the 
motions which pass are still extremely scanty. 
When I was asked to see this patient, it was under an impression that he 
possibly labored under stricture of the colon. It is not the only instance in 
which I have seen deficient formation of feces mistaken for their retention. 
But it was needless in this case to look for a cause of obstruction, when there 
was no evidence that an accumulation of feces ever took place. At the close 
of the severest seizures, the hardness and tension of the belly went away upon 
the expulsion of a quantity of feces, not equalling the ordinary daily excre- 
tions of a healthy person. This patient has taken every medicine and every 
combination of medicines, not entirely without advantage, but without find- 
ing that he can calculate upon obtaining relief from the same remedy a 
second time. 
I have selected the two preceding instances, as exemplifying the simplest 
kind of constipation from deficient secretion. In this class of cases, the de- 
ficiency of secretion probably exists in the great bowels, and perhaps in the 
lower part of the small intestine. But its place may be higher in the alimen- 
tary canal. 
There is no commoner cause of constipation than insufficient secretion of 
bile. Indigestion originating in imperfect gastric secretion is again often a INJURIES AND DISEASES OF THE RECTUM. 
39 
cause of the same effect. But these subjects do not properly fall within the 
scope of the present treatise. I shall, therefore, content myself with two 
remarks which bear upon them.. The first is, that constipation may result 
from deficient secretion of bile; yet the color of the small quantity of evac- 
uation may generally be natural. The second, that as indigestion is often a 
cause of constipation of the lower bowels, so on the other hand it is often 
produced by it, and is completely relieved when a proper action of the great 
intestine is produced. 
Instances in which faeces are formed, but are not easily from want of a 
proper liquid secretion eliminated, have been already given. I have men- 
tioned several cases, in which the action of the bowels became healthy upon 
the daily use of an injection of warm water. The remedy found sufficient 
for its relief explains the nature of the disorder in these instances. 
Dr. O'Beirne has ingeniously supposed, that, in the natural condition of the 
bowels, the reservoir of the faeces is the coiled portion of bowel immediately 
above the rectum. Were this established to be the case, the exact seat of 
the deficient secretion in the simple form of constipation now considered, 
would be shown. But although Dr. O'Beirne's Treatise is not wanting in 
practical value, yet I believe his views to be theoretically ivrong in this in- 
stance. In anatomical examinations, as well as in the living body, healthy 
faeces are as often found contained in the rectum, and in the higher parts of 
the colon, as in the sigmoid flexure. And when from deficient watery secre- 
tion, small masses of hardened faeces or scibalae accumulate in the great in- 
testine producing constipation and obstruction, their place is liable to be any 
part of the great intestine. They are sometimes found collected in the 
rectum, sometimes in the caput coli, and sometimes at an intermediate 
point. 
Mr. Lamb, of York Square, Regent's Park, communicated to me the fol- 
lowing instance. He was present at the examination of the body of a mid- 
dle-aged person, who had died of obstruction of the bowels, having pre- 
viously suffered from constipation. There had been an inward swelling, 
which was felt externally above the right groin, and to which the pain and 
distress which the patient suffered was referred. Upon opening the abdo- 
men, this swelling was discovered to be the caecum, enormously distended 
with scibalae. 
The following case was likewise communicated to me by Mr. Lamb, which 
from its striking features I prefer to others, as an exemplification of the kind 
of costiveness now under consideration. 
A publican, aetat. 55, had been bed-ridden for six months. He lay sup- 
ported in his bed in an inclined position. If he lay down, he was oppressed 
and uneasy; if he stood up, he vomited. He was corpulent, and ate vora- 
ciously. The bowels never acted without medicine. It had been ascertained 
that there was no obstruction in the rectum, and the most powerful purga- 
tives had been resorted to without giving relief. The remedy which led to 
the cure of this patient, wras the injection of nine pints of water into the 
great intestine. The injection brought away an immense quantity of sciba- 
lae. The injection was repeated daily, but not in the same quantity, for a 
week; and for that period accumulated scibalae continued to be discharged. 
When the colon had been thoroughly emptied, an alterative course of medi- 
cine and regulated diet entirely restored the health of this patient. 
Dr. O'Beirne dwells upon the advantage, where more than the rectum is 
to be washed out, of introducing into the intestine a long flexible tube through 
which the water is to be thrown. There are cases no doubt in which this 40 
OBSERVATIONS ON 
practice is extremely valuable; but there is no occasion for its adoption, 
when, by the ordinary mode, a large quantity of water can be passed into the 
bowel. The instance last given shows how much may be done in an unfa- 
vorable case by the common method ; and the passage of instruments into the 
colon is not so perfectly free from danger in inexperienced hands, as to warrant 
the general recommendation of this practice. 
When the faeces are of a proper consistence, and are not deficient in quan- 
tity, constipation may yet result from either of two causes. The quality of 
the faeces may not be such as to stimulate the bowel to action: or the muscu- 
lar fibre of the bowel may be weakened and palsied. 
A pure instance of the first kind is a frequent result of deficient biliary 
secretion. The bowels are loaded with a quantity of clayey formation, 
which they are too sluggish to eliminate. Aperient medicine combined 
with mercury relieves this form of costiveness. Instances of the second kind 
occur in that species of constipation which is met with in elderly people, 
especially women. Yet it is probable that even here the fault may origin- 
ally have been an insufficient acridness in the secretions. 
Accumulation of feces in the great intestine in elderly women often has 
its seat in the rectum. Relief is then easily obtained, the bowel being emp- 
tied mechanically. 
I was requested by Mr. Reid, of Charlotte Street, Bedfore Square, to see 
an elderly lady who labored under this disorder. She had generally enjoyed 
excellent health, and had been accustomed to take much exercise. But ten 
weeks previously, she had had an attack of rheumatic gout, which had con- 
fined her to her bed. The bowels during this ailment gradually became in- 
active, and at length she was unable to pass any dejections without medicine. 
The medicine which best agreed with her was castor oil; but even this 
remedy failed to give full relief to the bowels. The quantity of feces passed 
was small, and their expulsion caused severe pain of a spasmodic character, 
which remained for hours afterwards. These pains occasionally came on at 
other times, and were accompanied with throbbing and a sense of stoppage 
in the rectum. To relieve her sufferings, it was necessary to give opium, 
which increased the constipation. Upon examining the rectum, Mr. Reid 
found that it contained a quantity of clayey feces, which he removed with 
a scoop. Water was then injected, and more feces were returned with it. 
This operation gave the patient great ease; but in the course of a few days 
the pain gradually returned, and became more intense than ever; coming on 
in paroxysms, especially when the bowels were moved, a thin fluid however 
being all that was passed. It was at this period that I saw the patient,Ain 
consultation with Mr. Reid. The accumulation of feces in the rectum had 
now returned to a surprising quantity: but there was great tenderness and 
soreness about the sphincter, which indisposed the patient to allow of any 
mechanical relief. However, with care and gentleness, the sphincter admit- 
ted of being greatly dilated, and an immense volume of feces was brought 
away; and the rectum, which was extraordinarily capacious, was completely 
emptied. She expressed great relief. A dose of castor oil was administered 
at night, which brought away the following day more feces, which had 
probably accumulated in the colon. 
This lady did not live many months after this time ; but no return took 
place of the accumulation and obstruction in the rectum. 
If the accumulation be something higher up in the great intestine, it may 
yet admit of mechanical removal by the use of the flexible tube recommended 
by Dr. O'Beirne. This instrument may reach the mass of clayey feces in INJURIES AND DISEASES OF THE RECTUM. 
41 
the sigmoid flexure of the colon ; when the injection of water into the mass 
will separate it into fragments, which will then be brought away. 
But the accumulation may take place at a point beyond the reach of 
instruments. In this case the exhibition of drastic purgatives is the likest 
means of affording relief. 
I attended, with Mr. Drew, an elderly lady, who was laboring under consti- 
pation of this description. The belly was large and full, but not tense or tender 
upon pressure. In conjunction with strong purgative medicines and purga- 
tive enemata-, the hot bath, and venesection to the extent the pulse and her 
age would bear, had been tried, but ineffectually. The complaint gave way 
under the use of oil of croton : and this patient, after passing an immense 
accumulation of feces, was restored to health, Two years afterwards she 
died of a return of this complaint, in which the remedy which had served 
before was found ineffectual. 
Under one attack of disorder or another, the frame must at length sink in 
old age ; out of the many kinds the present certainly may often be averted 
for years, by attention to the regular performance of one function. When 
the accumulation in the bowels has taken place, it is full of uncertainty 
always whether the disorder can be relieved and the patient live ; but it 
must often be in the power of the patient to prevent the accumulation taking 
place. 
In thus attributing constipation to defective secretion, or imperfect muscular 
action of the lower bowels, I am practically borne out by the facts which I have 
narrated. But it may still be inquired, to what remoter influence is the 
origin of constipation to be attributed ? 
To exemplify my meaning :-I was consulted in the case of a young lad), 
one of whose symptoms was obstinate constipation of the bowels, requiring 
that she should take nightly from twenty to thirty grains of compound 
extract of colocynth, to produce an action of the bowels the following day. 
She had been ill four years, and her sufferings had commenced with severe 
pain across the belly, and obstinate costiveness. After a fortnight's illness 
the constipation yielded ; but one leg became feeble, and the knee of that 
side was frequently spasmodically bent. This complication of palsy and 
spasm soon after affected the opposite leg; afterwards one hand became 
feeble and contracted. These symptoms grew upon her ; but she retained a 
remarkably fine complexion, and had the appearance, when making no 
exertion, of perfect health. I entertained little doubt that all the symptoms 
in this case originated in an affection of the spinal marrow. The vertebral 
column was indeed perfectly straight and even ; but the patient often expe- 
rienced pain at the lower part of the dorsal portion, and pressure there gave 
her uneasiness. I recommended that issues should be made at the lower 
part of the back. The remedy was followed by great relief of all her symp- 
toms. The legs seemed less weak, the knees were not so frequently or so 
painfully contracted, and the bowels acted with half the usual dose of dras- 
tic purgatives. This improvement, however, was temporary only ; and, 
disappointed of obtaining permanent relief, this patient consulted other 
surgeons, as she had consulted several before she applied to myself. She 
died six months afterwards; and, on examining the spinal chord, it was 
found for the length of two inches in a state of softening at its lumbar 
portion. 
This is one of a numerous class of cases in which constipation of the 
bowels is found to depend upon spinal irritation, and in which the abdomi- 
nal symptoms are the first which show themselves after the invasion of the 42 
OBSERVATIONS ON 
disease. The reaction of the one organ upon the other is very remark- 
able. 
An amendment of the state of the bowels is an evidence of a temporary 
alleviation of the spinal disease. The neglect of relieving the bowels by 
medicine is followed by an aggravation of the nervous symptoms. 
But is there in general any parallel connection between deficient secre- 
tions of the alimentary canal, and an affection of any other organ ? 
Without connecting costiveness of the bowels in general with disorder of 
any other single organ, it is yet evident that the state of the abdominal sys- 
tem which determines it is influenced sympathetically by the state of the 
other bodily functions; and that there are certain laws upon which its 
occurrence depends, and rules by attending to which it may in general be 
prevented. 
All the bodily functions are capable of being influenced by, and subjected 
to, habit. Nothing conduces more to the healthy action of the bowels than 
attention to this principle. By observing regularly the same period or 
periods in the twenty-four hours for the relief of the bowels, whatever has 
been formed or accumulated in them is found to be prepared at the recur- 
rence of those periods for elimination, and to have been brought to the 
rectum for that purpose. 
Habits of regular bodily exercise promote the due action of the bowels. 
Neglect or excess in exercise equally interfere with this function. 
If proper exercise cannot be taken, it is requisite to substitute for it an 
altered diet, or the use of aperient medicine, or of injections. It is not 
found that the daily use of aperient remedies, when needed on this account, 
renders the bowels afterwards insensible to the ordinary stimuli. Upon 
resuming wholesome exercise, the spontaneous action of the bowels returns. 
II. The instruments that are required under different circumstances to be 
introduced into the rectum, are the wax bougie, the flexible tube, and the 
tube of the injecting syringe. 
A good wax bougie should admit of being rendered perfectly pliant and 
flexible by immersion in hot water. Except in this state, a bougie cannot 
be introduced with safety beyond four inches into the rectum. Even when 
it has been rendered pliant, a bougie introduced into the intestine generally 
meets with some degree of obstruction after passing from five to six inches. 
The nature of this obstruction is readily shown by anatomical inspection. 
The end of the instrument catches against the lax walls of the rectum, and 
pushes before it the substance of the gut as a blind sac. Under these cir- 
cumstances, if force is used, the instrument tears the intestine, and passes into 
the cavity of the belly. 
No adroitness can prevent the rectum being thus caught up in sacs by the 
bougie. But some nicety of observation is required to distinguish the yield- 
ing resistance which such a sac offers, from the resistance of a stricture. It 
is very certain that surgeons are occasionally thus misled, and assure their 
patients that they have stricture when there is none. 
When the resistance is a sac of intestine that the instrument has tempo- 
rarily produced, it will follow, that if the instrument is drawn back a little, 
and then again passed forward with the direction slightly altered, it will 
keep the channel of the intestine, and not sacculate it at the same place as 
before. I met with a case some years ago, in which the symptoms led me 
to think that there was stricture in the sigmoid flexure of the colon. To 
ascertain the point, I passed a bougie three feet in length into the bowel: 
the bougie was something more than half an inch in diameter. It continu- INJURIES AND DISEASES OF THE RECTUM. 
43 
ally caught in the manner which I have described; but by withdrawing it 
slightly when this happened, and again pressing it gently on, I succeeded in 
introducing the instrument its entire length with very little inconvenience to 
the patient. 
A bougie from half an inch to three quarters of an inch in diameter is 
quite large enough for the examination of the rectum. If such an instru- 
ment pass easily and without pain along the bowel, it may be safely presumed 
that there is no contraction. 
Before introducing a bougie, a double bend should be given to it, one 
corresponding with the curvature of the sacrum, the second with the incli- 
nation of the sigmoid flexure of the colon to the left. The surgeon should 
however bear in mind, in reference to this second point, that the bowel occa- 
sionally inclines to the right side instead of to the left; and if he meet with 
any ambiguous resistance, he should, by withdrawing the instrument a little, 
and again passing it forward with an altered direction, endeavor to find the 
natural course of the gut. 
I have described the method by which instruments may be safely introduced 
a considerable height into the bowel; but it will be seen from the remarks 
which follow, that it is rarely necessary to pass instruments a greater distance 
than four or five inches. 
In the introduction of the flexible tube, the same precautions are to be 
used as in the introduction of the wax bougie. Its elasticity renders this 
instrument perhaps more liable to catch up the bowel than even the bougie. 
The tube should terminate in a smooth round end with two large apertures 
at its sides. The great point which cannot be too strongly impressed upon 
the mind of the practitioner, is the extreme delicacy of the part, and the 
readiness with which it will tear under very moderate pressure. 
The tube which forms the extremity of the ordinary injecting syringe is 
generally too long and too narrow. The part introduced into the bowel 
should not be more than an inch and a half in length, and the extremity 
should be a portion of a sphere, exceeding half an inch in diameter. I have 
already mentioned cases in which the rectum was torn by the common in- 
jecting syringe. Mr. Stanley very recently showed me another example of 
this accident. A female had died suddenly from inward hemorrhage, owing 
to the rupture of one of the Fallopian tubes. She had not labored under 
disease of the rectum; but a lavement had been administered. The mucous 
coat of the intestine, which was looked at in the examination, was found 
raised and torn for a short extent at a little distance within the sphincter, 
evidently from violence done by the tube of the injecting syringe. 
But it is not only immediate laceration and rupture of the bowel which is 
to be apprehended from the incautious use of instruments. There is every 
reason to believe that mechanical hurts occasionally give rise to malignant 
disease of the rectum, and that roughness and want of care in the employ- 
ment of instruments are capable of producing cancer in this part. 44 
OBSERVATIONS ON 
CHAPTER VII. 
On Stricture of the Rectum. 
The canal of the urethra is particularly subject to two kinds of obstruc- 
tion, which are called spasmodic and permanent stricture. The first results 
from a temporary contraction of the muscular fibres surrounding one part of 
the urethra: the second consists in a partial thickening and loss of extensi- 
bility in the lining membrane of the canal, the consequence of a slow pro- 
cess of inflammation. Corresponding affections are met with in the oesopha- 
gus, but in this canal they are of much rarer occurrence than in the urethra. 
When a local cause of obstruction forms in the oesophagus, it is more fre- 
quently an ulcer or a scirrhus than a stricture. The rectum resembles the 
oesophagus in its affinities for disease, and stricture is as rare in it as ulcera- 
tion and scirrhus are common. 
Spasmodic stricture of the urethra is so frequently seen, and is so uniform in 
its character, that no doubt remains as to its source and nature. It occurs at 
a definite point of the urinary canal, which is narrow and interposed be- 
tween two dilatable parts, and which is surrounded and compressible by 
muscular fibres. When the spasm is present, an instrument may be passed 
with facility to this point, when its progress is abruptly stopped. If, how- 
ever, it is then gently pressed against the resistance, the spasm in a short 
time is found to yield, the instrument passes into the bladder, and the patient 
is relieved. 
Spasmodic stricture of the cesophagus is a much rarer affection - the follow- 
ing is an instance in which it occurred. 
A German about five and twenty years of age applied to me for advice. 
He stated, that he thought he had a tumor in his oesophagus, which inter- 
fered with deglutition. He could swallow liquids only, and of those but 
little at a time. His voice had the peculiar character which attends ulcera- 
tion of the larynx. I conjectured from this and other symptoms, that the 
obstruction in the cesophagus was spasmodic, excited by disease in the adja- 
cent organ. A common-sized bougie was firmly resisted at the commence- 
ment of the oesophagus ; a smaller instrument was stopped at the same part: 
but upon gentle pressure being made it passed. By using larger and larger 
bougies, the spasmodic contraction of the cesophagus was in a few days 
entirely removed. 
Spasmodic stricture of the cesophagus commonly has its seat at its com- 
mencement, that is to say at the point where the canal presents the opening 
of a narrow cylinder, at the termination of the conical and capacious bag of 
the pharynx. This part is in some degree analogous to the seat of stricture 
in the urethra. 
But what part of the rectum is the seat of spasmodic stricture ? From my 
own experience, I am disposed to think that no single point is more liable 
to this affection than another. The cases, however, which I have met with, 
and have considered of this nature, have been any thing but satisfactory. 
They have left me with the impression that the upper part of the rectum, 
and the sigmoid flexure of the colon, are liable to irregular contractions of INJURIES AND DISEASES OF THE RECTUM. 
45 
their muscular tunic capable of obstructing the passage of the feces and of 
making resistance to the introduction of instruments. This irregular action 
is generally dependent upon a vitiated state of the secretions; and is more 
frequently relieved by a regulated diet and alterative medicines, and the use 
of injections, than by the employment of instruments. Nevertheless the 
use of the bougie is sometimes beneficial in spasmodic contraction of the 
rectum. 
One of the best instances which I can give of this disorder is the follow- 
ing : it contains a very useful lesson as to its treatment. The patient is a 
physician, who is now through his own judicious management at length 
restored to perfect health. The extract which I shall quote from a letter, in 
which, at my request, he favored me with an outline of his case, that had 
several times been the subject of communication with me before, will convey 
to the reader an idea of the suffering which may attend this kind of disorder. 
" In my life,'! says the writer of this communication, " I never knew what 
it was to have a single action of the bowels without the aid of medicine, or 
to be free for many hours together from all wretchedness of disorder and of 
remedies in conjunction, excepting for two short intervals of time, during 
one of which I trusted simply to the use of injections of warm water, and 
during the other when I took the white mustard seed, and that with so sin- 
gular an affect, that for a while I thought I had quite got rid of my complaint. 
With the exception of these two intervals, I have never been able till lately 
to say there is in life that which is worth living for, or, in other and 
more proper words, I did not know what it was to wish to live. To say 
nothing of the medical discipline which I have undergone again and again, 
I have been examined and treated for stricture of the rectum and of the sig- 
moid flexure of the colon for years, and for years never passed any thing 
from tny bowels larger than a horse-bean, if solid, or of the little finger, if of 
a softer consistence. Oftentimes have I been quite incapacitated for exer- 
tion, and never able to enter upon my professional duties with any thing 
like alacrity or cheerfulness. It is now nearly two years ago since I came to 
the resolution of abandoning all remedial measures : to leave off at once 
physic, injections, and the bougie : to take nothing in the shape of food that 
could by possibility irritate the stomach or bowels, and to leave them to act 
of and for themselves, when they could no longer retain their contents. 
I had, as you may suppose, difficulties in bringing about so entire a change. 
At first I suffered much inconvenience from a sense of fulness in the bowels 
and in the head. But this I contrived to obviate by the very occasional use 
of an injection of warm water, determining with myself to overcome the dis- 
position to contraction by making the contents of the lower bowels the means 
of dilating them. By a steady perseverance in this course of discipline, I 
have perfectly recovered; know nothing now of that distress of feeling, 
which for at least twenty years made life burthensome to me ; I have seldom 
or ever occasion to have recourse to medicine, and then only as a man in 
perfect health would do. I should tell you that at one time such was the 
state of the stricture in the rectum, that the largest sized urethra bougie alone 
would pass, and that at another the contraction was so far in the intestine 
that a bougie of three feet in length was considered necessary to reach it." 
It may be useful to place in contrast with the preceding case another, 
which I shall again give in the words of my patient. In this instance the 
idea of abandoning medicine appears likewise to have been tried, but not 
with an equally good effect; for it led to a very serious attack of obstruction 
of the bowels. In this instance the use of the bougie has proved salutary 46 
OBSERVATIONS ON 
There exists indeed in this patient so determinate a point at which the bowel 
appears narrowed, that it is doubtful to me whether he does not labor under 
permanent stricture of the rectum, in addition to that tendency to general irre- 
gular contraction of the adjacent bowel, which constitutes spasmodic stricture. 
"A gentlemen, now in his fifty-eighth year, who from early youth had 
been subject to a very irregular action of the bowels, amounting frequently 
to an alternation of costiveness and dysentery, was about fifteen years ago 
strongly urged to abstain from medicine, and to let the bowels alone. This 
experiment was tried with great resolution. In spite of much suffering and 
increasing feverishness, the patient took no medicine for more than a week. 
Inflammation however ensued. Intolerable pain in the abdomen, and simul- 
taneous vomiting and purging, reduced him to an alarming state in the middle 
of the night. Skilful medical assistance was fortunately obtained without 
loss of time, and the acute symptoms were subdued. The patient's general 
health however grew worse. His bowels were never at rest. Acrid mucus 
was incessantly formed, and frequently passed, leaving the sufferer in a state of 
great weakness. Blood was sometimes observed in the mucus. Scarcely any 
thing was passed without great effort and pain. Spasmodic contractions of the 
rectum were constantly attendant on every attempt to ease it. Great emacia- 
tion and prostration of muscular power took place, as also restlessness at night 
amounting sometimes to the most painful startings from sleep. After a few in- 
effectual attempts to perform a cure, treating the case as one of liver derange- 
ment, he confined himself to the use of the common purgatives for the pa- 
roxysms of the complaint, and of a small quantity of rhubarb and ginger before 
dinner, for the daily symptoms. Though very slowly, yet he improved from 
year to year; but owing to the unsettled state of the bowels, he could hardly 
venture out of his house. By the advice of a friend, he tried about two years 
ago, the daily use of lavements by means of Read's syringe. He has used 
nothing but tepid water. At first the lavement produced great nervous 
weakness; but this symptom disappeared in a short time. At present he 
enjoys a certain degree of comfort and ease, which entirely depends on the 
use of the lavement early in the morning. From a local examination it has 
lately been ascertained, that the rectum is contracted to about half an inch 
diameter, at a distance of about five inches from its termination. The daily 
passing of a wax bougie, softened by heat, is attended with little or no pain. 
The distension of the contracted part by this mechanical means relieves the 
spasmodic contractions, which the patient frequently feels a little above the 
sigmoid flexure." 
I shall conclude my remarks upon the subject of spasmodic stricture of the 
rectum with the following case, which was communicated to me by Mr. 
Crosse of Norwich. I will give-it in his own words. It is unnecessary to state 
that that very eminent provincial surgeon was not the practitioner through 
whose mismanagement the fatal termination of the case was produced. 
The case is one in which the coats of the intestine were remarkably thin 
and feeble, which seems to have given rise to an imperfectness in the action 
of the bowels, which was erroneously considered to proceed from stricture. 
In every point of view this serious case is full of interest. 
" A young woman of delicate frame was supposed to have stricture of the 
rectum, which led her medical attendant to employ in no very gentle man- 
ner a firm bougie. After much difficulty the instrument was made to pass; 
but the patient in a few hours became very ill, vomited, and was chilly, and 
in about forty-eight hours died. It was found that the bougie had per- 
forated the coats of the bowel at the sigmoid flexure, about seven inches INJURIES AND DISEASES OF THE RECTUM. 
47 
from the anus, and had entered the peritoneal cavity. The preparation, 
which is in my collection, shows the rectum to be capacious for an inch or 
two next the anus; but all the rest of the bowel preserved, being a length 
of eight or nine inches, is very contracted, so that it would only admit a 
small instrument half an inch in diameter; and at the same time its coats 
are very delicate and attenuated, readily allowing the bougie, in the hands 
of a boisterous surgeon, to perforate them. There is a great abundance of 
adipose substance and of fatty appendages about the sigmoid flexure of the 
colon. The bowel presents no thickening or partial contraction, but a small- 
ness of calibre generally, with remarkable delicacy and thinness of the coats- 
accounting for the presence of symptoms, during the life of the patient, 
which might have led to the supposition that that stricture existed." 
Permanent stricture of the rectum consists in a partial thickening of the 
submucous coat of the bowel, and of the adjacent cellular texture; through 
which means a smooth ring is formed, generally from a third to half an inch 
in depth, which projects into and narrows the channel. Sometimes the 
thickening does not include the whole circle of the intestine, but a segment 
only. It is presumable that this thickening results from chronic inflammation. 
The ordinary seat of stricture of the rectum is from two and a half to four 
inches from the orifice of the gut. But sometimes it occurs at a greater dis- 
tance, at six to seven inches for example; and a contraction of the same na- 
ture is occasionally met with in different parts of the colon. 
The symptoms of stricture of the rectum are the common and necessary 
consequences of the excretory canal being narrowed at one part. 
The faeces are passed in small and narrow and flattened portions. The 
quantity voided at a time is inconsiderable, from the effort required to pass 
it through the stricture. The bowel being thus insufficiently relieved, the 
effort has to be repeated frequently during the day; and it is only after many 
efforts that all its contents are passed. The narrowed portion of the canal 
is extremely sensible; which is owing partly to the thickening which forms 
it being originally produced by an inflammation, partly to the irritation of the 
mucous lining of the stricture, which is occasioned by the more forcible pres- 
sure of the faeces against it. When the bowels act, in addition to a sense of 
obstruction in the part, pain is experienced and tenesmus, and mucus is 
voided; and at other times a sense of weight and tightness, with general 
uneasiness, is felt. The habitual confinement of the bowels alternates with 
periods of looseness and purging. Uterine irritation, irritation of the bladder 
and urethra, numbness and pain down the thighs and legs, are occasionally 
concomitant symptoms. 
But if these symptoms are common to every affection by which the channel 
of the rectum is narrowed, in what manner is a case in which they occur 
proved to be a stricture ? 
It has been mentioned, that the seat of stricture, in nineteen cases out of 
twenty, is near the orifice of the bowel; that is to say, within the distance 
which admits of examination by the finger. In common cases, therefore, 
no difficulty exists in identifying the disease: the finger may be passed into 
the smooth and firm narrow ring which forms the stricture; and a demon- 
stration may be thus obtained that no other disease is present. 
The treatment of ordinary cases of stricture of the rectum is no less sim- 
ple in practice than satisfactory in its results. In stricture of the rectum, as 
in stricture of the urethra, if a bougie of a size calculated easily to fill the 
stricture be passed through it daily, or every second, third, or fourth day, ac- 
cording to the irritability of the patient, and retained for from ten minute* 48 
OBSERVATIONS ON 
to a quarter of an hour after each introduction, the pressure of the bougie 
causes the absorption of the lymph, by which the inflammatory thickening 
around the canal has been produced; the patient is able gradually to intro- 
duce larger and larger instruments, and the channel is at length restored to 
its original calibre. 
A diet carefully regulated, the use of mild aperient medicines, of injections 
of tepid water, and of anodyne suppositories, are important accessories in the 
treatment of stricture of the rectum. 
In the use of instruments for contraction of the rectum, the point to be 
constantly thought of is gentleness. If any considerable degree of force be 
used, the bowel may be torn. If pressure be made against the stricture with 
too large an instrument, the adjacent and sound part of the bowel is likely 
to yield sooner than the stricture. The canal of the urethra is often torn in 
this manner by the pressure of an instrument too large to enter the strictured 
part. In stricture again of either canal, if by dexterous management an 
instrument too large is successfully forced through the contracted part, it may 
yet produce most serious consequences. If such an instrument is forcibly 
passed into a stricture of the urethra, the patient in a few hours after the 
operation is seized with a rigor, and symptomatic fever follows, which will 
last several days. 
If similar violence be done to the rectum, the surgeon being anxious ra- 
pidly to complete the dilatation of the stricture within twenty-four hours, 
shivering supervenes, as in the former instance: but here it has a more se- 
rious character; it is probably the precursor of peritonitis, to which the 
patient may in a few days fall a sacrifice. There is a singular consent be- 
tween the pelvic mucous passages and the peritoneum. If a stricture either 
of the vagina or of the rectum be roughly dealt with, peritonitis is liable to 
ensue ;• notwithstanding that the violence is done at a part of either canal, 
which is not covered with peritoneum. 
Such violence is not merely mischievous, but it is utterly unjustifiable on 
any ground; it can be used only through a mistake of the principle of dila- 
tation ; the object of which is not mechanically to stretch the narrowed canal, 
but to excite the absorption of that which thickens and contracts it. 
In some instances the process of dilitation is very slowly accomplished, 
the stricture being sharp, firm, and narrow. There is a variation of treat- 
ment applicable to such cases, which consists in dividing the stricture in one 
or more places with a probe-pointed knife. The effect of this operation is 
for the time to give considerable freedom to the passage through the stric- 
ture. But the incisions quickly repair themselves; and the part again con- 
tracts, unless prevented by the use of the bougie. 
The following is a case in which I employed this practice successfully. 
Cornelius Cox, aetat. 28, was admitted into the Middlesex Hospital with 
stricture of the rectum, beginning two inches from the orifice: it was circu- 
lar, but broader towards the sacrum than towards the bladder. He had la- 
bored under the ordinary symptoms of stricture for a considerable period. 
Four months previously to his admission, the urine had begun to flew in part 
through the rectum. The first treatment adopted in this case, was the intro- 
duction of an elastic catheter into the bladder, which was retained in the 
urethra, in the expectation that the urinary fistula would be closed through 
this means. After a few days, however, the instrument produced irritation 
of the bladder, and it was discontinued. But some advantage had been 
obtained by its use. Before this time the water flowed on each occasion in 
large quantities into the rectum: now the quantity was much less; and INJURIES AND DISEASES OF THE RECTUM. 
49 
sometimes the whole contents of the bladder appeared to be discharged 
through the urethra. 
The next measure which I adopted, was the division of the stricture of 
the rectum. The division was made in a direction towards the sacrum. 
After the operation a short portion of soft wax bougie was introduced into 
the rectum, and retained there, being removed only when necessary, in order 
that the bowels might act. Under this treatment, the patient went on favor- 
ably : the channel of the rectum continued open, and for days together no 
urine passed by it. Before however his recovery was completed, the patient 
left the hospital, and I lost sight of him. 
The division of a stricture of the rectum is not entirely free from risk of 
one description. I divided in a woman a stricture of the rectum, situated 
within three inches of the anus. In this case, as in the preceding, the di- 
vision was made in a direction towards the sacrum. The wound bled at the 
time, but not to an extent to make me apprehensive of its return. A few 
hours afterwards, however, very serious hemorrhage supervened. This was 
arrested by the introduction of a pledget of lint saturated with a strong styp- 
tic solution, which was applied to the divided stricture. But the patient 
had lost so much blood, that I thought it not improbable that I should be 
compelled to look for and tie the bleeding vessel on account of a return of 
hemorrhage. 
•Except therefore under peculiar circumstances, I am not disposed to re- 
commend the division of a stricture. The operation is painful: it does not 
render the use of the bougie unnecessary; and it is liable to be attended with 
a considerable loss of blood. 
It is not always easy to distinguish stricture of the rectum from incipient 
carcinoma. 
A lady about forty-five years of age had suffered severely from piles, which 
were removed five years ago by the ligature. They did not grow' from the 
fore part of the rectum. Some months after this, the lady began to feel a 
tightness and sense of obstruction in the rectum. These sensations gradually 
became more distressing: much effort and straining were necessary to pass 
the faeces, which were narrow7, flattened, and in fragments. After twro years 
of suffering, this patient consulted me. There was an induration, w7hich 
began two inches within the rectum, and occupied two-thirds of the circum- 
ference of the gut. The central and broadest part of the induration was 
towards the vagina; at this part, it was two-thirds of an inch in depth. The 
part was acutely sensible. I recommended that the bowels should be relieved 
every morning by means of a lavement of tepid water, and that a soft wax 
bougie should be introduced into the narrowed part every second day. 
Under this treatment, combined with the occasional use of aperient medi- 
cine, a decided amendment took place: the narrowred part yielded to a cer- 
tain extent, and there was a proportionate alleviation of all the symptoms. 
But in a short period the patient became worse again; the introduction of 
the bougie now7 gave more pain; it was therefore discontinued. The passage 
was indeed certainly freer, but the induration towards the vagina wras not 
lessened. Under these circumstances, I wished Mr. Copeland to see the case 
with me. The impression which the examination made upon our minds was, 
that the disorder was likely to prove carcinoma. 
The plan which the patient followed was slightly modified. The use of 
the bougie for a time was not resumed. The increased sensibility of the 
part went away. But it was not long before the patient again complained 
of the contraction returning; upon which the bougie was again used, bat 50 
OBSERVATIONS ON 
for a shorter period than on the first occasion. Since then at intervals the 
patient has occasionally had recourse to this remedy again. She is now ma- 
terially better: the narrowing has lost its doubtful character: the induration 
is less in extent, and the projecting band has little more than the character 
of a thickened fold of mucous membrane. Some discharge of matter per 
vaginam took place, and continued for several weeks, about a year ago. I 
am disposed to think that it proceeded from the induration, which may have 
suppurated, and the abscess have broken into the vagina at that time. 
When a narrow stricture of the rectum has existed for some time, the in- 
creased pressure of the faeces upon the bowel above the stricture first dilates 
it, and at length causes it to ulcerate. There are two preparations in the 
museum of King's College, which well exemplify this occurrence. In one 
of these, the stricture of the rectum is situated two inches from the orifice: 
three ulcers are seen in the canal above it leading into fistulous sinuses which 
opened near the anus. In this specimen, as it is often seen after long-con- 
tinued stricture of the rectum, a strong oblique band extends across a part of 
the dilated intestine behind the stricture. Such bands probably result, not 
from effusion of lymph, but from the process of ulceration undermining and 
partially detaching portions of the surface. 
In the second preparation to which I have referred, openings in the 
bowel above the stricture are seen to lead into a large and thick sac, which 
is situated between the uterus and vagina on the front, and the rectum be- 
hind : the sac contained nearly a pint of liquid fecal and purulent matter. 
The nature of the affection was not suspected before death. The patient 
labored under symptoms which were considered those of dysentery. 
In this instance, the stricture occurred at the junction of the sigmoid 
flexure of the colon and of the rectum. Stricture so high in the intestine is 
extremely rare. The following additional examples, the account of which 
was given me by Mr. Caesar Hawkins, will therefore be acceptable to the 
reader. 
"One of these cases is that of a woman, who had no evacuation from the 
bowels for sixteen days before she died, and who had for some years been 
subject to somewhat similar attacks of constipation. The stricture was 
situated just where the rectum commences, about seven inches from the anus; 
and was so contracted, as only to leave a valvular aperture capable of re- 
ceiving in its present state a moderate-sized bougie. The bowel above the 
stricture was very much dilated, being about five inches in diameter, divided 
into two portions by a band which extended upwards from the strictured 
part." 
"The second case was that of a woman, who was admitted into St. 
George's Hospital, under the care of Dr. Seymour, with continued constipa- 
tion ; and, as the usual means were unsuccessful, I was desired to see her. I 
found the rectum very capacious, dilated probably by numerous injections, 
which however had all returned without fecal matter; but no disease was 
perceptible in it. I passed carefully a flexible oesophagus tube belonging to 
Weiss's stomach-pump, and about twelve inches from the anus met with 
an obstruction through which the tube passed, and evidently entered solid 
faeces, above where the injections had before reached, which adhered to the 
end of the tube. I do not remember whether any faeces came away in con- 
sequence of injections passed to this height through the tube; but at all 
events very little was thus got rid of, and the patient died about three days 
after her admission in consequence of the confinement of faeces. There was 
a very firm stricture about the situation I have mentioned, scarcely admitting INJURIES AND DISEASES OF THE RECTUM. 
51 
the end of the little finger to pass through it, partially ulcerated, but not of 
a scirrhous nature." 
There is a case, the nature of which has been explained by Mr. Earle in 
a paper in the Medical Gazette, that deserves to be considered under the 
head of stricture. It originates indeed in an opposite state of the parts, and 
is the result of that great laxity and dilatation which is liable to be produced 
by frequent large accumulations of faecal matter in the rectum. When the 
rectum is in this condition, the upper portion of the gut is liable to be in- 
vaginated, or to form a prolapsus within the lower. 
The late Mr. Chevalier, in an essay in the tenth volume of the Medico- 
Chirurgical Transactions, described this stage of the complaint, and advised 
the best method of relieving it. The suffering which attends it is con- 
siderable. Imperfect action of the bowels, frequent and ineffectual attempts 
to void the faeces, and a discharge of large quantites of puriform mucus are 
the symptoms; but the exact nature of the disorder can only be ascertained 
with certainty through an examination. Regulated diet; gentle aperient 
medicine; the mildest injections first, and afterwards astringent injections; 
and support and tone given to the bowel by the use of the bougie, are the 
obvious and efficient remedies in this disorder. 
Mr. Earle has further observed, that the prolapsed internal fold is liable to 
become inflamed, thickened, indurated; the opening through it contracted ; 
and that in this state the previous symptoms and distress become greatly ag- 
gravated. 
The symptoms of this affection are particularly likely to be ambiguous; 
as there is a capacious sac below the stricture, in which faeces may be accu- 
mulated, and occasionally be discharged of the natural quantity and appearance, 
even when nearly absolute obstruction has supervened higher in the canal. 
An examination by the finger or with the speculum is essentially requisite 
to establish the nature of this anomalous complication of disease. 
This complicated disorder is to be palliated, and sometimes admits of 
being cured, by the use of the remedies already mentioned : only that the use 
of the bougie is now of much more importance ; which is to be carefully 
guided (and in this there is often difficulty) to the contracted opening of the 
prolapsus. 
The patient experiences sensible relief when the bougie can be passed into 
the aperture of the gut, and the prolapsed portion gently carried upwards 
upon it. To remove the accumulated f®cal matter, to soothe the increased 
sensibility of the bowel, to dilate the contracted aperture of the prolapsed 
portion, and subsequently to restore tone to the intestine, are the objects 
which are to be accomplished. 
There yet remain to be considered, under the present head, affections 
corresponding with spasmodic and permanent stricture, which occur at the 
■orifice of the gut. These are spasmodic contraction, and permanent thicken- 
ing and narrowing of the sphincter. 
Spasmodic contraction of the sphincter is a kind of cramp. It often comes 
on suddenly. The patient who has gone to bed quite well, awakes in 
violent pain. The sphincter muscle is hard and in strong action, so that the 
finger cannot without great difficulty be passed into it. In some cases these 
paroxysms occur daily, in others only two or three times a year. In some 
the attack comes on gradually, and after producing uneasiness for seve- 
ral days, gradually wears off"; in others it is sudden in its invasion, and sudden 
in leaving the patient. 
This complaint generally depends upon a confined state of the bowels; 52 
observations on 
and a brisk cathartic at night, with an aperient draught in the morning, will 
often relieve it. In some cases the patient finds it sufficient to use a lave- 
ment of warm water, upon which the spasmodic contraction wears off. 
If the pain is very severe at night, an ounce of tepid water, with twenty 
drops of the liquor opii sedativus, may be injected into the bowel, and at the 
same time purgative medicine taken. It is better to use opium in this form 
than as a suppository. In the latter shape, the remedy by the mechanical 
irritation which its presence excites, has a tendency to excite the sphincter 
to stronger action. 
Sometimes the spasm is relieved by extending the circular sphincter mus- 
cle, and keeping itsffibres on the stretch. The patient for this purpose may 
introduce a large mould candle into the anus. 
There are cases in which this disease produces long continued and most 
serious suffering; in which the anus becomes permanently contracted and 
hardened, constituting therefore a permanent stricture, and generally com- 
bining both permanent and spasmodic contraction. The motions are passed 
with an effort and with pain, and all the common symptoms of stricture of 
the rectum are present. 
In this more aggravated form, the complaint will yet often yield to simple 
treatment; such as the observance of a regulated diet, the use of gentle ape- 
rient medicine, the daily use of the bougie, and lavements of tepid water. If 
these milder means are insufficient, the sphincter is to be divided, and the 
wound by the introduction of threads of lint, is to be made to heal by 
granulation from the bottom. 
CHAPTER VIII. 
Of Cancer of the Rectum. 
The most formidable disease of the rectum, from its severity, its fatal 
character, and its frequency, is carcinoma. This complaint is liable to occur 
at every period of life. I have seen it in one instance at the age of twelve; 
most frequently between the ages of twenty and forty ; but hardly less often 
at a more advanced period of life.* The disease is occasionally produced by 
some local injury, such as a blow upon the part; but it may be presumed 
that the tendency to its formation is originally inherent in the frame, and is 
only brought into activity by the cause to which it is attributed. 
[Cancer of the rectum is ordinarily slow in its progress, so that its victims 
may live several years before they sink under it. It is attended with great 
pain and suffering of various kinds. The severity of the disease, however, 
in every case admits of palliation ; and in many instances the patient may be 
raised to a state even of comfort by surgical skill. 
Cancer of the rectum, like other affections of this part, is more frequent in 
women than in men; a difference, the causes of which are to be sought in 
* At the Middlesex Hospital there is a separate endowment, originating in munificent 
donations by the grandfather of William Whitebread, Esq. M. P. and by the late Mrs. Staf- 
ford, for patients afflicted with cancer; on which account a great number of patients afflicted 
with carcinoma apply at that institution for admission or relief. INJURIES AND DISEASES OF THE RECTUM. 
53 
the varying conditions of the uterus and in the shape of the female pelvis. 
The womb during its enlargement in pregnancy interrupts the free return of 
blood by the hemorrhoidal veins, and mechanically obstructs the action of 
the bowels. In the unimpregnated state, the periodical congestion of the 
uterus cannot fail of extending its influence to the vessels of the rectum. 
The straightness of the sacrum again in women, and the general expansion 
of the pelvic bones at the inferior outlet, deprive the lower part of the bowel 
of that pressure and support which appear to conduce to the healthy state of 
the visceral organs. Something too there may be in the less-regular relief 
of the bowels and of the bladder, and their frequent over-distension, which 
result from the natural, but in this instance prejudicial delicacy of women. 
The symptoms of cancer of the rectum are, local pain, sometimes of a dull 
aching character, at other times acute and lancinating, with a sense of 
weight and confinement in the part, pain and uneasiness extending round the 
loins to the pubes, numbness in the hips and thighs. These sensations are 
aggravated upon walking, standing, or sitting, and are relieved by the 
recumbent posture. The act of evacuating the bowels increases the pain 
and distress. The faeces are either liquid, or are passed in small fragments 
and by repeated efforts; blood, matter, mucus, are expelled with them. 
The patient, if a female, suffers in addition irritation of the bladder, pain in 
making water, incontinence of urine, bearing down of the uterus. The 
difficulty and occasional obstruction of the passage of faeces produce fits of 
distension and pain and tenderness of the abdomen accompanied with hiccup 
and vomiting. 
The physical changes in the parts, which give rise to these symptoms, are 
contraction and a peculiar induration of the canal, with ulceration of its 
mucous lining. The induration of the canal results from the formation of 
scirrhus in the muscular coat of the bowel. The disease assumes two differ- 
ent appearances, according to the quantity of the morbid growth which is 
present. 
The two following diagrams, made after specimens in the anatomical mu- 
seum of King's College, exemplify either form of carcinoma. In each figure 
the rectum is supposed to be laid open by a longitudinal section, and placed so 
as to exhibit the inner surface and one of the cut edges. 
In the variety of carcinoma of the rectum which is figured in the follow- 
ing page, the thickening is inconsiderable; but the mucous membrane is 
abraded, the muscular coat is hard, firm, gristly, and the canal of the bowel 
is narrowed. The muscular fibre of the bowel is partly converted into, 
partly contained in, firm, gristly, fibrous substance. I have not seen this 
form of the disease extend quite to the anus; but it commonly begins from 
an inch to an inch and a half within it; the disease generally occupies from 
four to five inches of the bowel, but I have seen it involve as much as six- 
teen inches. The change from the healthy to the diseased state on the side 
towards the anus is often very gradual. Above, the diseased structure always 
terminates abruptly, meeting a raised uneven ulcerated edge of mucous 
membrane. 
The second or fungoid variety is characterised by considerable thickening, 
caused by the presence of a quantity of scirrhous deposit greater than in the 
preceding instance. The scirrhus matter, grey, fibrous, not perfectly opaque, 
gristly, as in the first kind, is of a looser and more succulent texture. 
The opposite diagram is copied from a specimen, in which the morbid 
growth occupied the cylinder of the gut for the length given in the figure, be- 
ginning abruptly at four inches from the anus, and terminating abruptly above. 54 
OBSERVATIONS ON 
Fungoid scirrhus at its commencement, generally occupies a portion only 
of the circumference of the bowel, and is felt as a hard tumor, situated about 
three inches within the gut, and commonly upon its anterior surface, with 
the mucous membrane as yet unbroken. The growth of the scirrhus is lia- INJURIES AND DISEASES OF THE RECTUM. 
55 
ble to extend in each direction, upwards to the sigmoid flexure of the colon, 
and downwards so as to implicate the anus and to throw the adjacent integu- 
ment into firm hard knots. Similar disease sometimes originates in and is 56 
OBSERVATIONS ON 
confined to the sigmoid flexure of the colou, and is occasionally met with at 
parts of the great intestine still higher. 
In either form of the disease, the fat external to the rectum, is liable to 
assume a firm and crisp texture, resembling the state of the adipose mem- 
brane met with around a cancerous mamma. 
The severity of suffering in cancer of the rectum bears no proportion to 
the quantity of bowel implicated in it. There are two ways in which the 
disease proves fatal. In general, the patient consumes gradually, worn out 
by long-continued suffering. In other instances, the disease produces com- 
plete obstruction of the bowels, and the patient perishes more quickly. This 
form of the malady is attended with the severest distress. Complete obstruc- 
tion of the bowels rarely occurs, except in the fungoid variety, that is to say, 
when there is a large mass of gristly substance in the intestine. But I have 
known the disease terminate in fatal obstruction, and with the most aggra- 
vated suffering, when the mass of fungoid scirrhus occupied no more than 
the last three inches of the rectum. 
The treatment to be pursued in carcinoma of the rectum, is the following. 
The pain is to be allayed by opiates. Solid opium, the acetate and muri- 
ate of morphia, the extract of stramonium, are each in their turn available. 
Opiates act more promptly and efficiently in this disease when taken into the 
stomach, than when applied in injections or suppositories to the rectum. If 
administered in the latter form, the subacetate of lead may be advantageously 
combined with them. 
The bowels are to be regularly relieved. In general, a dram of the leni- 
tive electuary taken over night, with an injection of tepid water the follow- 
ing morning, if it can be used without pain, will be sufficient for this purpose. 
When these means fail, stronger purgative medicines must be employed. 
But the next object to relieving the bowels in all disorders of the rectum, is 
not to irritate them by exciting unnecessary action. A few drops of laudanum 
should be taken immediately after the action of the bowels. 
The canal of the bowel is to be dilated, if it be so narrowed by the disease 
as to obstruct materially the passage of the faeces. This may be done by 
means of the rectum bougie; and if the disease be of the kind represented 
in the first figure, very great and certain benefit ensues from this practice. 
In some cases even of fungoid scirrhus, I have found decided advantage 
from the occasional use of the bougie. But in both cases the bougie is to 
be used very cautiously, and occasionally only. 
Towards the fatal period of the worst cases, when the canal is much ob- 
structed, the use of the flexible tube to wash out and unload the bowel above 
sometimes becomes necessary. 
The local abstraction of blood, which is of such important use in retarding 
the progress of carcinoma of the mamma, is of trifling and but occasional 
service in cancer of the rectum. 
The two following cases will serve as examples of the ordinary progress 
of the disease. 
Mary Ann Welham, setat. 31, was admitted into the Middlesex Hospital, 
in June, 1832. Two years before, when in a weak state, and recovering 
from an ague, she was brutally ill treated, and kicked upon the fundament. 
The injury was followed by bleeding from the bowel, swelling, and pain in 
passing the feces. After a few days, the parts recovered from the immediate 
effects of the injury ; but she continued at times to pass blood, and to expe- 
rience pain and uneasiness in the rectum. In six months from the infliction 
of the injury, the symptoms were established under which in an aggravated INJURIES AND DISEASES OF THE RECTUM. 
57 
state she suffered at the time of her admission. These symptoms consisted 
of pain in the rectum, with aching or throbbing pain at the sacrum and 
loins extending round the hips to the pubes, frequent urgency to empty the 
bowels, incontinence of urine, irritation of the bladder, and bearing down of 
the womb. The faeces were passed in small flattened fragments, and with 
blood and matter; the belly was swollen and tender. The symptoms were 
greatly aggravated, unless she preserved the recumbent posture. 
On examining the rectum, the peculiar condition of the part was found, 
which is represented in the first figure. The mucous membrane began to 
be wanting about an inch within the sphincter; and beyond this, as far as 
could be reached, the bowel felt firm and hard, and excoriated. The bowel 
was greatly contracted at two inches from the orifice. 
By using the remedies which have been recommended, this patient was 
in the space of a month restored to comparative comfort. She has obtained 
and continues to receive the greatest benefit from the use of the bougie, 
which she is now able to pass herself. This benefit, however, is obtained 
through the occasional use of the instrument: if she persists in its use for 
any length of time, the practice is found to produce irritation and increase 
of suffering. At first a common urethra bougie would alone pass : in time, 
she was able to pass a bougie half an inch in diameter. When the use of 
the bougie has been temporarily discontinued, the bowel again contracts, of 
which she becomes aware, through the increasing pain and difficulty in passing 
the feces. The bougie is then again employed with relief. 
This person is now in the female cancer ward of the Middlesex Hospital, 
in which patients who are once received are allowed to remain for life. 
Thomas Pettit, aetat. 36, was admitted into the Middlesex Hospital, in 
March, 1833. Eighteen months ago, he was attacked with a looseness of 
the bowels, which lasted three months. At first the complaint, by his ac- 
count, was simple diarrhcea: afterwards he passed blood and mucus, with 
pain and straining. When this disorder ceased, the bowels became confined, 
and he experienced an increasing difficulty in voiding their contents. The 
characteristic symptoms of carcinoma of the rectum then gradually super- 
vened. He began to experience shooting pain in the rectum, pain at the 
sacrum on stooping or sitting; a sensation of tightness and of inward swel- 
ling in the rectum; difficulty in passing the feces, which come away in little 
short pieces, or liquid, and are commonly preceded by a slight discharge of 
fluid, like white of egg and blood; frequent calls to empty the bowels. 
Upon examination there is felt, at three inches within the anus, a mass 
of carcinoma having a ragged opening in the middle, through which the 
passage of the feces takes place. The parts are exactly in the condition 
represented in the second figure in this chapter. It is impossible to say how 
far the scirrhus extends. This patient's sufferings have been so greatly miti- 
gated by the remedies which have been used, that he has voluntarily left the 
hospital, attending only occasionally as an out-patient. 
The treatment pursued has been exactly that above recommended. More 
benefit indeed then I expected, has been derived in this case from the use of 
the bougie. At first I ventured to introduce an urethra bougie, a short dis- 
tance only into the carcinoma; but the patient is now able to pass for seven 
inches a rectum bougie five lines in diameter. 
Instances of fungoid scirrhus occasionally present themselves, in which the 
quantity of the malignant growth is so considerable, and the sensibility ot 
the part so great, that the bougie cannot be introduced or borne. When this 
is the case, the channel may be enlarged by the division of the scirrhus. No 58 
OBSERVATIONS ON 
ill consequence follows the operation, and great relief is obtained by it. Of 
course, this practice is only applicable when the part to be divided is within 
reach of the finger. 
Mary Woolgrove, aetat. thirty-two, was recently admitted into the Mid- 
dlesex Hospital. In the year 1818, she had been cut for fistula, and since 
that time had never been entirely free from occasional discharges of blood 
and mucus from the bowel. But it was not till three years and a half ago, 
that pain and obstruction and other symptoms of carcinoma appeared. At 
the period of her admission she was greatly extenuated, having suffered for 
several weeks constant painful purging of liquid matter. The anus was in- 
durated, and surrounded with scirrhus nodules partly in a state of ulceration. 
Upon an examination of the rectum, the finger was stopped at an inch within 
the gut by a mass of fungoid scirrhus, through which an urethra bougie 
could only be passed. By means of opiates, the pain which this patient suf- 
fered was mitigated, and the purging checked : I then tried to enlarge 
the passage by the use of bougies. But the attempt was ineffectual, and 
violent liquid purging returned. Under these circumstances, I determined 
to divide the scirrhus. For this purpose I introduced the blade of a strong 
straight probe-pointed bistoury upon the fore-finger of the left hand, and 
divided the scirrhus towards the sacrum, gaining space enough to allow the 
finger to be passed further into the bowel. I then divided in the same 
manner the part beyond. The scirrhus terminated, as I have anticipated, 
at three inches within the anus, so that the operation was entirely successful. 
It has given the patient great relief, who now has a free passage through the 
part, which is besides less sore and painful than before. 
The instances which I have given are aggravated cases of the two princi- 
pal forms of carcinoma of the rectum. The occurrence and distinctness of 
these two forms of disease I have repeatedly verified by post mortem exami- 
nations. I observe, in looking over my notes,' that I have never seen the 
first form, that namely which is unattended with thickening, in men. The 
second I have seen in both sexes. 
When carcinoma of the rectum comes before the practitioner as a hard 
swelling situated just within the anus, with a mucus surface as yet unbro- 
ken, the use of the bougie is not needed for the dilitation of the channel, 
and would be prejudicial by hastening the ulcerative stage of the disease. 
But other expedients suggest themselves; and we are led to inquire, whether 
the disease may not admit of excision, or whether the entire termination of 
the rectum, including with the diseased part a portion of the adjacent sound 
bowel, may not be removed. 
Mr. Crosse, of Norwich, communicated to me the following particulars of 
a case in which he performed excision of a carcinoma with temporary benefit 
to the patient. 
" James Rayner, aged thirty-nine years, found some inconvenience about 
the rectum for four years previously, but continued his occupation as a hack- 
ney coachman up to the time of his admission into the hospital. For three 
months he had occasionally passed blood, and suffered from a portion of the 
bowel, as he supposed, prolapsing at each motion. He invariably returned 
the prolapsus, and without much difficulty. During all this period he suffered 
more or less pain in the left thigh, which lately had been severe, and 
extended down to his toes. 
" I found a tumor shaped like a mushroom, two inches in diameter, 
situated on the left side of the rectum just within the sphincter : it was hard, 
ulcerated in the centre, and beset with enlarged glands the size of kidney INJURIES AND DISEASES OF THE RECTUM. 
59 
beans, which could be felt deeper in the rectum. This tumor was so situated 
as to cause distressing tenesmus ; and at each effort the mass protruded, with 
bleeding and much pain, though frequently no faeces passed. I apprehended 
it to be of a malignant character, but thought to relieve the great pain and 
tenesmus, and prolong life by removing the tumor. I proceeded to the 
operation by placing the patient in the usual position for lithotomy ; and 
introducing my finger and thumb into the bowel, I grasped and brought 
down the tumor so as to render it visible without the sphincter. I began to 
cut away the tumor at the part deepest in the bowel, stopping to secure each 
considerable bleeding vessel as I went on, the hold I maintained of the 
tumor enabling me to pull it down, and keep the bleeding surface accessible. 
Four ligatures were thus applied, before I separated the last remaining por- 
tion of the basis of the tumor. One artery, however, continued to bleed, to 
secure which, before the patient was removed from the table, I cut freely 
through the sphincter ani towards the patient's left side, and expanded the 
bowel by Weiss's three-bladed speculum-thus gaining a view of the bleed- 
ing artery, which was readily secured by tenaculum and ligature. I plugged 
the wound with shred lint (charpie'), kept the buttocks exposed to the air, 
and directed the constant application of cold water. There was no subse- 
quent hemorrhage. The patient gained ease; was made an out-patient in 
about three weeks, having a small unhealed surface still remaining, but from 
which he suffered so little that he thought himself in good health, and 
resumed his occupation of a hackney-coachman. After two months he 
returned, with an increase of the disease. A thin foetid matter was furnished 
by an ulcerated surface at the anus ; scirrhous tumors were felt within the 
rectum ; and though he suffered less than before, having neither prolapsus 
nor tenesmus, he was soon confined to his bed from the rapid increase of the 
disease. Scirrhous tubercles spread over the buttocks upon the skin ; the 
discharge of both urine and faeces was ultimately impeded by scirrhous 
tumors occupying the pelvis; and the patient died between five and six 
months after the operation I have described. I was precluded from making 
a post mortem inspection." 
But we may go further, and inquire whether a part of the entire cylinder 
of the bowel may not be removed along with the scirrhus-the matrix of 
the disease with the disease itself. 
M. Lisfranc recommends and has several times performed excision of the 
lower part of the rectum, in cases in which the finger can be passed com- 
pletely beyond the limits of the disease, and the intestine at three or three 
and a half inches from the anus is ascertained to be healthy. 
I performed this operation in the case of a woman about forty years of age, 
in whom the inner surface of the bowel began to be ulcerated half an inch 
within the orifice. The ulcer extended round the rectum, and was upwards 
of an inch in breadth: there was considerable induration. The patient had 
suffered long and severely, and could not quit the recumbent posture. 
The steps of the operation were, first, an oval incision through the skin 
around the anus, at a distance of half an inch from the mucous membrane; 
secondly, dissection of the bowel from the adjacent parts, and securing the 
vessels as they were cut through; thirdly, division of the bowel, by which 
the already isolated part, including the disease, was separated from the sound 
bowel above. 
The results of the operation were as follows. The patient expressed a 
strong sense of relief and comfort almost immediately after it was concluded. 
She felt, to use her own expressions, that the cause of her previous sufferings 60 
OBSERVATIONS ON 
was gone. In a month her appearance became surprisingly altered. The 
extenuation and distress of countenance that had before been so remarkable, 
left her, and she became a fat and cheerful and comely person. I was now 
apprehensive of one of two alternatives-either that the hollow cylindrical 
cicatrix leading to the bowel would contract and form a troublesome stric- 
ture-or that as the sphincter was completely removed, there would be 
distressing incontinence of faeces. Neither of these evils, however, occurred, 
The cicatrized surface did not contract; and unless the bowels were in a very 
loose state, the patient was always aware when their action was likely to 
take place. But a serious evil ensued, which I had not anticipated, and 
could not obviate. Prolapsus of the bowel came on ; some length of intes- 
tine was gradually pushed out in a state of eversion ; and the mucous surface, 
irritated by exposure and pressure, became a new and constant source of 
uneasiness. 
About two years after the operation, this patient died of an attack of 
abdominal inflammation. The mucous membrane adjoining the cicatrix 
had begun anew to ulcerate. 
This is the only case in which I have removed a portion of the entire 
cylinder of the gut. It has left me with the impression, that in instances of 
carcinoma of the rectum, in which the disease is confined to the extremity 
of the bowel, and is attended with great and otherwise unmitigable suffering, 
the operation should be performed. 
I shall close this chapter with the narration of a case, in which I regret 
that I did not contemplate this operation at a sufficiently early period. It 
will serve, in addition, to illustrate other features of the disease; especially 
the occasional slowness of its progress, and some peculiarities of shape and 
appearance which the scirrhous growth may assume. 
William Bond, aetat. 30, was admitted into the Middlesex Hospital in De- 
cember, 1828. He stated, that as long as he could recollect, a protrusion had 
taken place from the rectum whenever the bowels acted, and that expulsion 
of the faeces was always preceded by a discharge of mucus. Until four 
months before his admission, the complaint had been unattended with pain. 
During the latter period he hat? continually experienced a sense of numbness 
and aching within the rectum, with variations only in its severity. When 
the bowels acted, a peculiar substance invariably came down; its shape and 
size is represented in the figure below. 
This substance he could readily return 
by pressure. Its texture looked not un- 
like that of a common polypus of the nose, 
but it had greater firmness. The disc of 
the tumor was more vascular than the 
pedicle, and it bled readily upon being 
handled. It was quite insensible. Upon 
examining the rectum, the pedicle of the 
tumor was found attached to the fore- 
part of the bowel, behind the prostate 
gland. There was some little hardness of 
the rectum at this part. 1 removed the 
protruding tumor by the ligature, which 
gave little pain, but caused some irritation 
of the bladder. In a fortnight the patient 
left the hospital, having got rid of the tumor, but with some hardness re- 
maining where it had been attached. He came back again after three INJURIES AND DISEASES OF THE RECTUM. 
61 
months, complaining of a sense of obstruction and uneasiness in the rectum. 
I now found the fore-part of the rectum occupied by nodular masses, which 
to the touch appeared of the same substance with the original tumor. They 
were increasing rapidly. By drawing them out with the tenaculum, and 
making an incision at their bases, I contrived to include the whole in three 
ligatures. They came away, but the malignant growth returned. The 
tumor now grew rapidly, and the patient gradually sank. At three inches 
from the orifice of the gut, the bowel was perfectly sound. The disease was 
fungoid scirrhus. 
In fungoid scirrhus the morbid growth occasionally deviates in parts from 
the character which has been above assigned to it, and is, with complete 
opacity, whiter, and of a more doughy consistence. But this appearance is 
rare; and it is still rarer to meet with true medullary disease confined to or 
originating in the rectum. 
CO'NCLITSION. 
Upon looking over the preceding pages, which have now passed through 
the press, I see that it is necessary to anticipate or to notice the following 
corrections and omissions. 
It would have been better to have treated the subject of simple ulceration 
of the rectum under a distinct head from laceration; and to have joined with 
the former an account of follicular ulceration of the rectum and colon,-of 
phagedenic ulceration of the rectum,-and of the condition of the intestine 
in dysentery. Follicular -and phagedenic ulcerations of the rectum are, 
however, extremely rare. The former are generally fatal, and the latter re- 
quire to be treated on principles unconnected with the place of the disease. 
I have omitted to treat the ungrateful subject of natural imperforation of 
the anus; and to notice the occasional distress produced in the rectum by 
the presence of foreign bodies, which have passed undigested through the 
alimentary canal. These, however, are only injurious, when they produce 
pain or obstruction; and their presence is ascertained by the means adopted 
to relieve or to investigate the symptoms which they occasion. 
THE END.