A Clinical Lecture on Common Diseases of the Rectum

C. Heath
1891 BMJ (Clinical Research Edition)  
WV E are constantly having in the wards cases of severe disease of the rectum-I mean cases of piles whvich require operation, *cases of fistula, and cases of cancer. I propose to-day to speak rathier of the commoner cases of disease of the rectum, suchi as you will meet withi among out-patients and in your own lractice later on. Ordinarily the rectum performs its funntion without anl y disagreeables, and whenone e has a hlealthty evacuation of the bowels there is a feeling of relief whlich is
more » ... relief whlich is somewhlat remarkable. That evacuation, of course, slhould be perfectly painless, and in the great majority of instances it is so; but you will find, whlen you get into practice, that patients will complain to you in te e first place that they cannot get the bowels open, and then perhiaps they will say that whleii theyhave had them opened they suffer such pain that they dread every operation. With regard to the question whether a daily action of the bowels is essential to good healthl, I may say that no doubt, with the great majority of persons, a daily action is a necessity, but still you inay meet with people who are a little different in that respect, and wvill go two, or even three or four, days without evacuation and without any discomfort. I mention that because it is well to consider the idiosyncrasy of each individual. It is of no use, where you have torpid bowels and a weak condition of the muscular fibre generally, sucl as you meet with for instance in elderly females and ana-mic persons, to try and force them by violent purgation into the ordinary dailyhabits of healthy people. Of course, if you take a healthy person, you have there a standard, but you may find variations from it for which you must be prepared. As to the time at which the bowels should be opened, that of course, in manycases, is a matter of simple convenience. The busy man, going off to catch a train immediately after breakfast, had better perhaps havehis bowels opened at night, but a person whohas a little leisure, and, moreover, is able to enjoy that matutinal pipe which, I am told, is so extremely useful in producing an alvine action, may well repair to the water closet after breakfast ; but take my word for it, that patients whohave anything the matter with the rectum, who suffer in any way upon the dischlarge of fTeces, should, as a rule, have their bowels opened at night; and the reason is obvious. The action of the bowels takes place more conveniently after theyhave undressed: tllat is an important point in connection with women who wear tight stays-whleni they are in their dressing-gowns or niglhtgowns tlhey have much more power to empty the bowel than at any other tiime, and immediately after they have done so they can repair to bed, where they can lie in a horizontal position for eight or -ten hours, so that any little inconvenience, any disarrangement of the vascular supply of the bowel passes off, and in the morning they are quite well. If there is any difficulty about the action of the bowels patients are only too ready to fly to purgative medicine. You ;have only to read the advertisement columns of the newspapers to see wlhat fortunes are made by purgative pills. Thle great secret of those pills is that they are extremely nmild, so that it takes half-a-dozen to produce any action, and tlle patient will very soon get through a box of twenty or twentylive, and then will have to buy another box. There is a sort of popular idea that anythling like aloes is very apt to do harm to the lower bowel. I believe that is a pure delusion. Patients wlho lhave trouble about the rectum can use aloes without any particular disadvantage; indeed, I tlhink it is rather a good drug to prescribe, because it has a stimulating effect upon the lower bow-el. Then, besides purgatives which are not to be liad recourse to unnecessarily, we have ordinary Laxatives, and the fashionable laxative of the present day is some form of mineral water. You find large quantities of mineral waters advertised, which are more or less artificial in their manufacture, and which can be drunk in quantities, say, of a wineglass in a tumblerful of warm water before breakfast, producing an alvine evacuation soon after breakfast. That is an example of the kind of thing people are now in the habit of taking. But there are very much older remedies; for example, there is sulphur, a teaspoonful or two of which may be conveniently taken in milk. The old-fashioned confection of senna has been superseded now pretty muclh by the nicer preparation of compound liquorice powder, a teaspoonful or two in a little water early in the morning or over-night producing an easy evacuation in the morning. Then there are methods of attackin-g the bowel itself. By far the simplest and the best method-very little used in this country, comparatively speaking-is the ordinary enema. You will find that enemata are very seldom prescribed nowadays, but if you have cold water thrown up into the bowel with a simple Higginson's syringe, such as I hold in my hand, you will help many patients to produce an evacuation comfortably, without any distressing strain. There is no need for any complication of reservoirs or anything of that kind for the water which you throw up the bowel. In the present days of water-closets, all that the patient has to do is to empty out the pan of the water-closet, fill it up with cold water, and, having previously filled the syringe, thein introduce the pipe into the bowel, and inject a pint or a pint and a half of water. After waiting a few minutes, the strain upon the sphincter becomes a little strong; the evacuatioin takes place, and the faeces are brought away with the enema. It is curious how little these enemata are used in this country as compared with France. In England there is a sort of modesty about these things, and you will find that people object to an enema when its use is very advisable. Many women in particular, who have a somewhat feeble lower bowel, deriv-e great advantage from throwinig up cold water into the bowel at the time of the action. Then there is another thing thathas conme into faslhion of late--the injection of small quantities of glycerine, wlhichl nio doubt in many cases is extremely useful. The chemists sell small syringe for the purpose.holding from one to tWvo drachms, and patients have got into the habit of throwing up a small quantity of glycerine just within the sphincter, and in a few minutes the aetion is produced. In many cases-I will not say in all-it is really a very efficient remedy. Another thing that I may mention I have known for a great many years, but I lind very few people comparatively know of it. The difficult.y which many persons experience in getting rid of a mass of firces which has been lodged in the up per part, of the rectumii and become a little inspissated andhard, can be got over entirely by pressure with the finger just beyond the tip of the coccyx. There is plenty of room between the tip of the coccyx and the anal orifice for the finiger te be pressed against the rectum, and you will find that theh.ird motion which has lodged in the rectum is pushed out thro-h -,h the sphincter, and being once through it is promptly passed, and the softer matter follows easily enough. You must be prepared somietimes to find that a woman who is having apparently a healthy evacuation daily yet retains in the upper part of the rectum large masses of faeces in the shape of balls. It is very remarkable lhowfheces get retained in this way. 1 cannot tell you why it shouldlhappen with one patient more than another, but I have -seen it over and over again; the ftces rub against one another, and become formed into distinct balls, which remain there, and wlhich the patient cannot get rid of by any voluntary effort. I am quite sure this is much more common than is generally supposed. I have met with it many times, and always in women, Inot necessarily women who have borne families, but generally elderly women; they complain that thev are never comfortable, that they never get that feeling of relief they shlould have, but are always straining and bearing down almost as if ini labour, anid at last matters come almost to a stoppage. It tlheni becomes a question of clearing out these hard balls of feces with a liLhotomy scoop or the handleof a table spoon, wlhich will.do oIn an emergency. In that manner you can evacuate the bowel in a waythat the patient cannot do for herself. It is quite worti [1616]
doi:10.1136/bmj.2.1616.1299 fatcat:vo52dvf7r5awrbahmu3bkvhau4