CHAPTER Xni. (Part 3)

violent effort to expel a mass of hard faeces, the rectal wall has given ' Op. cit., p. 80., « Detroit Lancet, Oct., 1879. « Op. cit., p. 43. * Op. cit., p. 80. 282 DISEASES OF THE RECTUM AND ANU8. • way. Mayo* relates one such case in a woman of forty, in whom the ruptnre was in the recto-vaginal septum, about two inches within the bowel. Ashton' reports a similar case and Bushe' another. Such a rup- ture may be either verticalor transerse, will be marked by sharp pain at the moment of the accident, and will be followed by a discharge of blood. It is doubtful whether it ever occurs without previous disease of the wall of the bowel. The consideration of gun-shot wounds cotnes more properly within the scope of military surgery. They are always complicated with in- juries of other parts, and are generally fatal from extravasation of urine or faeces. The complications which may attend a wound of the rectum have already been hinted at. They are haBmorrhage, either primary or secondary; fsBcal infiltration; purulent infiltration; peritonitis; emphy- S8Bma; hernia; invagination; and later, stricture and fistula. WhenfsBces are forced out of the rectum into the adjacent tissue, diffuse inflammation and gangrene will probably result, and the condition must at once be met by free incisions and free drainage, as has been described in the chapter on abscess. The danger of faecal infiltration may be lessened by a diet which shall prevent fluid passages, and by the free use of opium. A dilatation or a free division of the sphincter is also to be recommended, so that a free outlet may be accorded to the contents of the bowel. Emphysaema, as a result of a perforation, is generally confined to the perineum, but may be diffuse.^ It is very apt to be fatal from diffuse inflammation and septicaemia, due to the putrid nature of the gas, and is to be met by free incisions. Wounds of the bladder or urethra communicating with the rectum are to be met by providing for the free issue of the urine. This may be done by catheterism, by aspiration, or by free division of the sphincter. Where none of these complications exist, a fresh wound of the rectum may close by first intention, and an effort should always be made to secure this by rest in bed, by emptying the bowel, and keeping it empty by frequent washings with water, and by the use of opium. Healing by granulation will, however, be the rule. In some cases, such, for exam- ple, as laceration in child-birth, sutures may be at once applied. Alimentation by the Rectum. — The fact that certain substances may be absorbed into the general circulation through the mucous membrane of the rectum has been abundantly proved by physiological experiment and clinical experience. The close anatomical resemblance between the inverted follicles of the rectum and the intestinal villi render an analogy * Op. cit., ]). 13. ^ Op. cit., p. 152, ' Op. cit., p. 69. ^Lancet, Jan., 1860, p. 89. ALIMENTATION BY THE &ECTUM. 28S in function extremely probable without experimental proof; but such proof is easily obtainable. A solution of salt, in the proportion of one part to eighty of water, injected into the rectum will disappear com- pletely in the course of an hour — so completely, that an eyacuation at the end of that time will be found to contain no more than the usual quantity.' The fluid extract of rhubarb may be detected in the urine in about an hour after being injected into the rectum by the characteristic red color caused by the addition of caustic potash.' Bouisson,' after injecting beef-tea into the rectum, found the lacteals charged with fluid. Savory,* in his experiments on the relative rapidity of this absorption by the stomach and rectum, found that strychnia in solution acts more quickly by the rectum, but that in powder the relation was reversed. Quinine should be given in larger doses by the rectum than by the mouth, while chloral and belladonna are readily absorbed by the former. Curare, on the contrary, acts more quickly by the rectum (CI. Bernard). Cubebs and copaiba both act equally well by the rectum; and water charged with sulphuretted hydrogen gas is rapidly eliminated in the dog by respirg^tion, as may easily be proved by the usual test with a salt of lead. The fact of absorption being admitted, the next question is as to the power of digestion before absorption, and upon this point there has been considerable discussion of late, and much difference of opinion. The theory that the follicles of Lieberkiihn may take on a vicarious action, and secrete a digestive fluid under the stimulus of albuminous food placed in contact with the epithelium has its upholders, but has never been absolutely proved.* Another theory is that food introduced into the rectum excites secre- tion by the gastric and intestinal follicles, and that, in the absence of food in the stomach the digestive fluids thus secreted pass down into the rectum and there act upon the injected materials. * Still another theory is that, instead of digestive fluids descending to act upon the food, the latter ascends to be acted upon by the fluids in the small intestine, and is there fitted for absorption.^ This theory has * Liebig: Animal Chemistry. ^ Smith: Supplementary Rectal Alimentation, and Especially by Defibrinated Blood, as Applicable to a Large Range of Cases in which Nutritive Enemeta have not Heretofore been Employed. Read before the N. Y. Acad, of Med., February 20th, 1879. 'Diet. Encyc, Art. Rectum. 4Gaz. Med., 1864. ^C. H. Stowell: Is Food Digested in the Rectum? The Medical Advance, January, 1879. •A. Flint, Trans. N. Y. Acad, of Med., Feb. 20th, 1879, and " Cases Illustrative of Rectal Alimentation, with Remarks," Amer. Practitioner, Jan., 1878. ^ H. F. Campbell: Rectal Alimentation in the Nausea and Inanition of Preg- nancy — ^Intestinal Inhaustion an Important Factor and the true Solution of its Efficiency. Trans. Gynaecological Soc, 1879. 284 DISEASES OF THE BBOTITM AND ANUS. grown out of certain facts which have recently come to light regarding the reversed peristaltic power of the bowel. Injected matters such as blood and milk colored with madder may be found on joo^^-mor^^w ex- amination evenly distributed ovei: the coats ofthe intestine for a consider- able distance above the rectum, and this is in itself a simple argument in proof of a reversed action of the bowel. But there are many stronger ones. Dr. Battey, in an article on the " Permeability of the entire alimen- tary canal by enema, with some of its surgical applications/" details some experiments of his own by which he succeeded, in the cadaver, in passing an injection from the rectum through the whole length of the digestive canal, and out of the mouth. He also gives certain cases in which what he has accomplished on the dead subject has been done by nature in the living patient. In this way he accounts for the undoubted fact that patients will often complain of tasting in the mouth a substance like castor-oil which has been administered by the rectum; and for the fact that the ingredients of an enema, or a suppository, have occasionally been actually vomited. Dr. Harris, of Milledgeville, Ga.,' has recently re- ported a case in which clear beef-tea^ enemata were vomited after an operation for ovariotomy. Jaccoud records a case of fsecat vomiting which occurred in his wards at the Lariboisi^re, in 1867, in a young woman who was admitted with hysterical convulsions. For eight days this person, at least once, and sometimefs twice, in the twenty-four hours, vomited veritable fasces, dense, solid, cylindrical, of a brown color, and with the normal faBcal odor, coming evidently from the large intestine. Jaccoud witnessed the act himself, and so also did Dieulafoy, and he characterizes it as actual defecation by the mouth. Apart from the passing disgust which followed the act, the patient ate as usual, and continued in her ordinary health, except in the absence of normal action of the bowels. All possibility of deception seems to have been rigorously excluded. Within a fortnight the woman was seized with grave tjrphoid fever and died. Careful exam- > Virg. Med. Monthly, vol. v., 1878. Note.— Dr. Battey makes a claim to priority in having established the <* entire X>ermeability of the canal to enema," which though no doubt perfectly just as far as his own experiments go, is refuted in the Med. and Surg. Hist, of the War, Med., vol. ii., p. 836, foot-note, by the following references. A. Guaynerius: Tractatus de fluxibus. Cap. 2, Lyons Ed., 1534. History of a man who vomited suppository placed in the rectum. J. Matthias de Gradibus, Practicia de uSjgritudinibus stomaci. Cap. 5, de- -vomitu, fol. 213, Venice Ei , 1502; History of girl who constantly vomited her suppositories even after they had been tied with a string to keep them in the rec- tum. Morgagni, references to numerous similar cases. * Quoted by Campbell, loc. cit. ALIMBNTATIOK BY THB RBGTUH. 2S5 ination of the body disclosed no mechanical obstruction whateyer in the intestinal canal. The ileo-csecal yalve was normal. ' By one of these three explanations it is attempted to overcome the obvious physiological objections to rectal alimentafcion which arise from the facts that albumen is not diffusible, or if so at all, only very slowly and in very small quantity; and that to be absorbed it must first be changed by digestion into albuminose. Another and very practical way of overcaming the obstacle has been suggested by Dr. Chadwick* which consists in placing the enema directly into the small intestine by means of an aspirator — a procedure which might be considered as not unat- tended with danger. Michel' has found the obstacle insurmountable and has, therefore, come to a conclusion unfavorable to the absorption of the nutritive matter of the substances injected. The theoretical difSculty of the digestion of albuminoid substances has been practically overcome in a very simple manner which is nothing more or less than artificialUy digesting such substances, either before or after their administration, by mixing with them a certain quantity of pepsin or freshly prepared jiancreas. Catillon* has performed the fol- lowing instructive experiments in this connection. He fed two dogs for two months with injections of eggs. The first had eggs only and lived with difficulty and with considerable loss of weight; the second had gly- cerin and pepsin mixed with the eggs and lived in an apparently normal manner, the weight and tempef^tilre remaining constant. After thirty- seven days the pepsin was stopped, when the animal began to lose weight and the temperature fell 3^ Fahr. The conclusion is plain that for nu- trition the digestive ferments must be associated with the food, or in other words that they must be transformed into peptones. In another 'series of experiments the same author has demonstrated that the same result is obtained by peptones prepared artificially. There would seem to be no doubt, in the light of the abundant clinical evidence which has now been accumulated, that life may be supported indefinitely, without loss of weight, by the proper administration of properly prepared enemata. Flint* refers to one case in which life was so sustained for fifteen months, and in which the feeding had been mainly of this kind for five years. For the convenience of the practitioner, the following formulas for nutritive enemata have been collected. The first is the one used by ^ Van Buren: On Phantom Stricture, etc. Amer. Journal Med. Sci., October, 1879. ' Amer. Joum. of Obstet, viii., Nov., 1875, Qaz. Hebdom., 1879. ^ Meeting of French Ass. for Advancement of Science at Bheims, 1880. Abstract in Brit. Med. Jour., Sept. 18th, 1880, p. 485. » New York Med. Record, 1878, p. 56. 286 DISEASES OF THE KEOTUM AND ANUS. Mayet and approved by Brown-Sequard.* Take of fresh pancreas of the ox from one hundred and fifty to two hundred grammes, and of lean meat from four hundred to five hundred grammes. Bruise the pancreas in a mortar with tepid water at a temperature of 37® C. and strain through a cloth. Chop the meat and mix it thoroughly with the fluid which has thus been strained after separating all the fat and tendi- nous portions. Add the yolk of one egg. Let stand for two hours and administer at the same temperature after having cleansed the rectum with an injection of oil. This quantity is estimated by Brown-S6quard to be sufficient for twenty-four hours' nourishment and should be admin- istered in two doses. Where the pancreas cannot be readily obtained, the folio wing formula may be found useful.* To a basin of good beef- tea add one-half a pound of loan, raw beefsteak pulled into shreds. At about the temperature of the body add one drachm of fresh pepsin and half a drachm of dilute hydrochloric acid. Place the mixture before the fire and let it remain for four hours, stirring frequently. The heat must not be too great or the artificial digestive process will be stopped altogether. It is better to Kave the mixture too cold than too hot. Sometimes a little more pepsin may be needed which may be ascertained by stirring with a spoon. If alcohol is to be given, it should be added at the last moment. Eggs may also be added, but should be previously well beaten. This preparation is said to be well borne for a long time. * The formula of the late Dr. Peaslee was as follows: Crush one pound of beef muscle fine, and add to it one pint of cold water. Allow it to macerate three quarters of an hour and then raise gradually to the boil- ing point. Allow it to boil two minutes and no more. The favorite in- jeotion of Dr, Flint is milk 5 ij-> whiskey 5 ss., and the half of. an egg. This he administers every three hours, day and night. But these simple enemata, no matter what their merits may be or may have been in the past (and we are inclined to wonder whether all attempts at alimentation before the admixture of pancreas was thought of, have been as useless as Catillon's experiments would indicate) are now generally replaced by those of artificially digested meat. In the year 1878, many experiments were made in New York with defibrinated blood as an enema, and the conclusions reached were em- bodied by Dr. A. H. Smith in the paper already referred to and were as follows: '^1. That defibrinated blood is admirably adapted for use in rectal alimentation. » Ga«. Hebdom., Nov. aist, 1879. « Gaa. Hebdom.. Nov. 14th, 1879. * Rennie: Case of seTere cut throat; with some remarks on the administrao tion of nutritive enemata. Lanoet, Oct. 33d, 1881. ALIMBNTA.TION BY THM RECTUM. 28T 2. That in doses of sixty to one hundred and eighty grammes (two to «ix ounces) it is usually retained without any inconvenience, and is fre- quently so completely absorbed that very little trace of it can be dis- covered in the dejections. 3. That, administered in this way once or twice a day, it produces, in about one-third of the cases, for the first few days, more or less consti- pation of the bowels. 4. That, in a small proportion of cases, the constipation persists, and even becomes more decided the longer the enemata are continued. 6. That in a very small percentage of cases irritability of the bowels attends its protracted use. 6. That it is a valuable aid to the stomach whenever the latter is inadequate to a complete nutrition of the system. 7. That its use is indicated in all cases not involving the large intestines, and requiring a tonic influence which cannot readily be -obtained by remedies employed in the usual way. 8. That in favorable cases it is capable of givmg an impulse to nutri- tion, which is rarely, if ever, obtained from the employment of other remedies. 9. That its use is wholly unattended by danger.'' However useful and nutritious these enemata may be, there is one practical objection to them which I have occasionally met with and have been unable to overcome. The sight of the blood, its administration, -and its subsequent voiding are not calculated to impress the mind of a nervous and delicate lady pleasantly — on the contrary, they sometimes •excite the most profound disgust. No one form of enema should be continued for too long a time, and, -as a rule, patients will be found to thrive the best upon an alternating -diet of milk and egg, with preparations of beef and pancreas; alcohol being given as it is indicated. The rectum proper will seldom accom- modate more than six ounces of fluid, and this is the usual quantity for An enema; but the sigmoid flexure will hold much more than this; and for myself, I much prefer what may be called the colonic to the rectal method, because the injections are better retained, cause less irritation, may be given in larger quantity, and hence need not be so often re- peated. The best apparatus for this purpose is a small-sized, soft-rubber, flexible rectal bougie,, the end. of which will accommodate the smallest end-piece of the ordinary Davidson's syringe. This should be well oiled, and the fluid to be injected should be forced through it once or twice till it is well warmed, and the air is entirely forced out. The tube is intro- duced into the sigmoid flexure after the syringe has been connected. . In this way, all over-distention of the rectum and consequent desire of the patient to immediately evacuate what has been administered is avoided. The enema should be administered slowly, and by the physician himself rather than the nurse or. relative of the patient