REPORT ON 
DISEASES OF THE RECTUM 
JOSEPH M. MATHEWS, M: D., 
Professor of Prmciples and Practices of Surgery and Diseases of the Rectum in the Kentucky 
School of Medicine, Louisville; Visiting Surgeon to Louisville City Hospital; 
Visiting Surgeon to Saints Mary and Elizabeth Hospital; 
Member of the American Medical Association, 
Kentucky State Medical 
Society, etc. 
Read before the Kentucky State Medical Society, at Winchester, June 24, 1886. 
LOUISVILLE, KY. 
Printed by The Bradley & Gilbert Company. 
1886. Report on Diseases of the Rectum, 
J. M. MATHEWS, M. D. 
As your Committee on Diseases of the 
Rectum, I desire to report on four subjects 
which pertain to that special line of study, 
viz: 
x. Operations for cancer of the rectum. 
2. Operations on the rectum under 
whisky. 
3. The sphincter muscles in disease. 
4. A new operation for fistula in ano. 
Before detailing the two cases of cancer 
operated on, I wish to state as succinctly 
as possible, some views and observations 
which an experience of some years has 
taught me. 
x. I do not believe that cancer is hered- 
itary ; hence its appearance in families, as 
by family history, is, in my opinion, purely 
by chance. 
2. In my experience scirrhus cancer has 
been the form most often met with in the 
Tectum, and not epithelioma, as taught by 
:the authorities. 
3. I do not believe that colotomy is justi- 
fiable for cancer of the rectum. 
4. In the observation, which covers many 
•cases of cancer of the rectum, the disease 
has occurred, in a majority of patients, un- 
der the age of forty years; in two instances 
under twenty. 
5. In the majority of cases observed by 
me the symptoms recited by authors as be- 
ing characteristic, if not pathognomonic of 
cancer, were absent, viz.: excessive pain, 
hemorrhage, and odor. 
6. I do not believe that the “facial ex- 
pression” of the patient, which is dwelt 
upon with so much stress by authors, ever 
•exists, save as the result of fear and anxiety 
.about their condition. 
7. If the cachexia of cancer exists, I do 
not believe that life is ever prolonged by 
any operation, except it be to overcome ob- 
struction in the bowel. 
8. In cases of cancer beyond all cure, I 
believe that we are justified in giving suffi- 
cient opium to quiet pain, if pain exists, 
even at the risk of establishing the opium 
habit. 
With these observations you will permit 
me to recite the operations upon two cases 
of cancer by two different methods. 
CANCER OF THE RECTUM. 
Case i. Mr. B. consulted me, in com- 
pany with his family physician, and gave 
the following history : Had complained for 
six months or more with burning pain at de- 
fecation, which radiated up the back and 
down the thighs. Had for some time a 
morning diarrhea, accompanied by a muco- 
purulent discharge. Upon examination a 
hard growth was detected, situated dorsally, 
but inclined to the left side, above the in- 
ternal sphincter muscle about one and a 
half inches, in size as large as a silver half 
dollar. No stricture was apparent. The 
growth was denuded of mucous membrane; 
was not movable. From it the discharge 
mentioned came. The rest of the gut was 
healthy. I suggested to the physician that 
the growth be removed. He agreed, and 
the patient was put under chloroform, and 
we practiced the operation, so well thought 
of by the Germans, of scraping or scooping 
out the growth. Having divulsed the 
sphincter, and the parts being held apart by 
retractors, I took a lithotomy scoop and 
persistently scraped away all of the tumor, REPORT ON DISEASES OF THE RECT UM. 
3 
and only ceased when it was evident that 
healthy tissue had been reached. Hemor- 
rhage, which was not excessive at any time, 
was easily controlled by pressure, no vessels 
being tied. The wound, which was of some 
depth, was packed with absorbent cotton 
well powdered with persulphate of iron. 
The retractors were removed and the pati- 
ent given an opiate. At no time, however, 
was the pain very great. The bowels were 
confined for five days; a purgative was then 
given, and the dressing came away with the 
action. The rectum was syringed daily, 
with equal parts of water and listerine, until 
the wound was entirely healed, all the dis- 
charge ceasing. Up to this date, four years 
after the operation, no disposition to return 
has been noticed. A section of the tumor 
was examined under the microscope and 
pronounced epithelioma. 
and the entire growth was removed. It 
was impossible to bring the gut down and 
attach below, as advised by so many— 
which procedure, however, I could never 
get my consent to advocate. The sutures 
in these cases do much damage, and the 
accumulation of pus is, of course, to be ex- 
pected. The stitches give way, and the re- 
sult is not as favorable as when the wound 
is left open and so dressed. The whole 
space of excision was packed with carbolized 
cotton, a T bandage applied, and the pati- 
ent given opiates sufficient to quiet pain- 
He was cared for by the local physicians, 
who, at the end of two months, reported the 
whole surface healed and the patient in a 
much more comfortable condition. Bowels 
moved freely and with but little pain. Up 
to this writing no return is noticed. A 
section of the tumor was submitted to Pro- 
fessor Dudley S. Reynolds, who examined 
it under the microscope and pronounced it 
epithelioma. 
Case 2. I was sent for to go to an interior 
town to remove a pronounced cancer of the 
rectum from a man sixty-two years of age. 
I found, upon examination, that the growth 
began just above the sphincter muscle, but 
did not involve it. It extended at least two 
inches up the gut, involving at least two- 
thirds of its circumference. The prostate 
gland was not affected. The cachexia was 
plainly discernable and the neighboring 
glands enlarged. Although I told him that 
I could not promise any thing, he insisted 
upon the removal of the growth, which was 
now blocking the bowel to an appreciable 
degree. He was prepared for the operation, 
and, with the assistance of four physicians, 
it was done after the following manner: The 
patient was anesthetized; a free dorsal in- 
cision was made down to the sacrum, com- 
ing out at and over the coccyx, keeping as 
near the median line as possible. A slip of 
the knife cut the middle hemorrhoidal artery; 
considerable difficulty was experienced in 
securing it. The levator ani muscles were 
then carefully dissected up. It was found 
that the attachments and infiltration of tissue 
was very great, and the operation was 
necessarily done very slowly. The vessels 
were secured as the operation proceeded, 
OPERATIONS UPON THE RECTUM UNDER 
WHISKY. 
Perhaps the most painful of all surgical 
diseases is fissure of the anus, or irritable 
ulcer of the rectum. For its cure two oper- 
ations are recommended, viz., divulsion of 
the sphincters, and division with the knife. 
Either of these is a most painful operation, 
and can not be done without chloroform. 
There are many patients averse to taking an 
anesthetic, and in many cases the surgeon 
is averse to giving it. Meeting in my prac- 
tice such cases, and recognizing that an 
operation was imperative, I have operated 
a number of times by administering whisky 
in lieu of chloroform. Such procedure has 
been limited to fissure and irritable ulcers of 
the rectum; but, of course, it could be 
practiced in any affection calling for surgical 
treatment where an anesthetic was neces- 
sary. It is not the purpose of this paper to 
discuss the moral involved, if there be any, 
but suffice to say that I believe that no love 
for liquor or its effects would be induced, 
but the contrary might obtain. 
The manner of administration that I have REPORT ON DISEASES OF THE RECTUM. 
4 
practiced is, viz: Get the very best article 
of whisky possible. Begin by giving on an 
empty stomach one or two ounces, and re- 
peat every twenty minutes until the full 
effect is obtained, as is evidenced in the 
drowsy, sleepy condition of the patient. 
My experience is that it takes from eight to 
twelve ounces to get this effect in the adult 
male. Of course habit in taking engenders 
a capacity for large amounts, and with this 
agent, as with many drugs, an idiosyncrasy 
may exist, which must be ascertained. 
Women are affected much more quickly and 
with less quantity than men, and children 
require but little whisky to get full effect. 
The same can be said of the aged. 
tion for the cure of his condition, because 
he was sure of some heart affection. He 
consulted me, and an examination revealed 
the condition that he suspected. I advised 
him to substitute whisky for chloroform and 
have the operation done. He consented, 
and I went to his home, sixty miles away, 
and did the operation. When I reached 
him he was “dead drunk,” according to 
directions, and divulsion was freely made, 
with the patient not evincing by the least 
sign that he suffered any pain. He after- 
ward told me that he remembered absolutely 
nothing of the operation. 
In this connection I desire to state that 
the anesthesia necessary to divulse the 
sphincters in an irritable condition must be 
more profound than that which would be 
necessary to extract a cataract. This has 
been the observation of both Dr. Rey- 
nolds and Dr. Coomes, who have given 
chloroform for me in these operations. 
Hence it is that I regard this, one of the 
most painful of all surgical operations; and 
if whisky would answer in these, it would 
in major operations of surgery, especially 
those requiring a long time for their perform- 
ance, as the effect of the agent does not 
soon wear off. I cite only two cases, but I 
have used the method in a number, and al- 
ways with good result. I do not believe it 
advisable to use it save in those cases where 
for sufficient reasons the surgeon declines 
to use the usual anesthetics, but I do believe 
that in these excepted cases it will be found 
an excellent substitute. 
Case i. Judge X., of Indiana, came to 
me for the treatment of a very irritable ulcer 
of the rectum, which was encroaching on 
the external sphincter muscle. For months, 
as he expressed it, his life had been a 
torture. He had cultivated a constipated 
habit, preferring this to the suffering that he 
experienced at each movement of the 
bowels. He objected to taking chloroform 
for the reason that he had been told that he 
had heart trouble. Although assured, after 
a careful examination of his heart, that he 
had no such trouble, he was persistent in 
his refusal to take an anesthetic. He was 
in splendid health, excepting this local 
trouble. I suggested to him the whisky 
plan, to which he assented. He went to 
his hotel and took the whisky according to 
directions until he had taken one pint in 
one hour. I visited him and did the opera- 
tion by divulsion of the sphincters, and 
dividing the same with the knife in addi- 
tion. Being called away that hight, I did 
not see him again for three days, at the ex- 
piration of which time I saw him in the 
rotunda of his hotel, and he told me that he 
did not remember a thing of the operation, 
and really did not know that I had been 
there until informed of the fact. 
After an experience of a score of years in 
rectal surgery I am more and more im- 
pressed with the importance of the part 
played by the sphincter muscles in disease, 
not only in local manifestations, but in pro- 
ducing obscure symptoms which oftentimes 
lead the physician into a false diagnosis. I 
desire to recite a few cases that go to prove 
his assertion, and add that they are but at 
sample of many that have fallen under my 
observation. 
THE SPHINCTER MUSCLES IN DISEASE. 
Case 2. Dr. H. had suffered from an ir- 
ritable ulceration of the rectum for a year 
or more. In consequence he had aban- 
doned his practice. Had feared the opera- REPORT ON DISEASES OF THE RECTUM. 
Case i. Mr. H. G. came to me, accom- 
panied by his physician, from a distant town 
in the South. The following history was 
elicited : About four years before he began 
to suffer with “cramps” in the abdomen. 
No special attention was paid to this, nor 
were they at that time associated with any 
rectal affection. Later on the patient com- 
plained of decided dyspeptic symptoms and 
an aching sensation around the anus. This 
sensation was not particularly referable to 
his stools, but was more or less vacillating 
as to time. Eventually pain was complained 
of as radiating over the sacrum and lumbar 
region and down the thighs. Whether im- 
aginative or not, it was thought by the pa- 
tient that his trouble was aggravated by 
eating, even of the most digestible diet. In 
consequence of this his physician enjoined 
an abstemious diet, and upon this he was 
kept for several years. Notwithstanding all 
treatment he grew gradually worse, until his 
physician suspected malignant growth. 
During the interim he was sent to different 
watering places and to the sea coast, but to 
no avail. He began to lose flesh rapidly, 
and at the time that I first saw him had lost 
about forty pounds. I examined him care- 
fully for rectal trouble, but could not find a 
trace, except that the sphincter grasped my 
finger tightly upon its insertion, but the pa- 
tient complained of no pain. I advised 
that a second examination be made, under 
chloroform, adding that I would attend to 
any trouble that might exist while he was 
under the anesthetic Having the assist- 
ance of two physicians, he was chloro- 
formed, and with different speculums I ex- 
amined the rectum, but no disease was 
found. Acting upon the idea that his com- 
plaint was a nervous one, I divulsed the 
sphincters forcibly, nothing more. The re- 
sult was that ever after he ate what he 
pleased and complained of no more pain. 
He has gained flesh ever since, and to-day 
weighs two hundred pounds, a gain of forty. 
statement of her daughter’s condition. 
From the fact that she gave such an accu- 
rate description of a painful dysmenorrhea, 
and believing that the uneasy sensation 
about the anus was reflex, I suggested that 
she consult a gynecologist. This she did; 
and he informed me that, in his opinion, the 
trouble originated and was kept up by a dis- 
placed womb. For this he had her wear a 
supporter and take medicines prescribed. 
This treatment was followed with great care 
for many months, but without the least ben- 
efit. She believed that her trouble was in 
the rectum. Seeing that she placed great 
stress upon this, I got her to consent to take 
chloroform, and allow me to do whatever 
was necessary. To this she readily con- 
sented. Chloroform was given; no rectal 
disease was found, but the sphincters were 
forcibly dilated. She left the infirmary in 
one week. After three weeks her physician 
wrote me, saying: “Miss B. is a changed 
girl; she no longer complains of anything, 
and is now continually on the go, where, 
before this, she would not venture out of 
the house. What did you do ? ” 
The recitation of these two cases I think 
quite sufficient to explain that in these ob- 
scure rectal cases, with symptoms that are 
vague and point to other trouble, an inves- 
tigation of the sphincter should be made. 
That which evidences that it is the source 
of trouble is its irritability, with or without 
pain, upon examination. 
As a factor in producing and keeping up 
a constipated habit, I am sure that this state 
of the sphincter muscles is the greatest of all 
causes. The late Dr. Cowling recognized 
this fact, and said to me, just before his death, 
that he believed that stretching the muscles 
would do much in overcoming constipation. 
In all cases where it has been necessary to 
divulse in rectal diseases, when constipation 
was co-existent, it has been my observation 
that said habit was overcome. Acting upon 
Dr. Cowling’s suggestion, and the result as 
stated in these cases, I have quite often 
divulsed the sphincter ani muscles for long- 
continued constipation, always with most 
Case 2. Miss B. was sent to me tor treat- 
ment by her physician. She was accompa- 
nied by her mother, who gave a detailed 6 
REPORT ON DISEASES OF THE RECTUM. 
excellent results. Recognizing the vast 
amount of trouble that constipation breeds, 
and knowing the difficulty that is generally 
met in overcoming the habit, I would re- 
spectfully advise the divulsion of the sphinc- 
ters as a most excellent method of cure. 
moisture, which assists in its withdrawal. 
After this dilatation, I take Otis’ improved 
urethrotome, with small point; closing the 
instrument tightly, it is pushed gently as far 
into the sinus as it will go, and then, by the 
aid of the screw attachment, dilate the sinus. 
When this is done, the turning of the screw 
at the side of the instrument will cause the 
concealed knife to protrude at the distal end 
according to the measurement desired. 
The instrument is then carefully withdrawn, 
cutting through the wall of the sinus 
throughout its whole length. The cut, as 
will be perceived, has been made sub- 
cutaneously, and the pain is insignificant. 
What hemorrhage takes place is easily con- 
trolled by pressure. In several instances I 
have turned the instrument and reinserted, 
practicing the same procedure upon the op- 
posite side, at one sitting. If this is not 
thought advisable, the patient is allowed to 
go for several days before repeating the 
operation, which is to include the other side. 
The advantages that I claim for the opera- 
tion are, viz.: Over the injection plan it 
must take precedence for the reason, as 
above stated, that the injection of any agent 
that is commonly used for such purpose 
does not accomplish what is desired. The 
sinus is lined by a thick pyogenic mem- 
brane which will, in many cases, resist the 
action of said agents; hence it is impossible 
to get healthy granulations. With this in- 
strument both the top and the bottom on 
each side, if necessary, can be cut through, 
thereby insuring a good granulating surface, 
and this, too, without pain. Over the liga- 
ture, either elastic or non-elastic, it possesses 
the advantage of cutting through both top 
and bottom, or each side of this thick mem- 
branous sinus, while the ligature can not 
possibly go through any portion but the top 
of the sinus, as it cuts its way out, leaving, 
of course, the callous bottom, which in 
many cases would refuse to heal, it being a 
positive rule in surgery in the operation for 
fistula, established by Mr. Salmon, that the 
bottom of all these tracts must be divided to 
insure a cure. Again, in using the ligature 
A NEW OPERATION FOR FISTULA IN ANO. 
Many operations have been devised for the 
cure of fistula in ano, all of which have had 
as their chief aim the substitution of some 
remedy more pleasant than the knife; 
hence, we have the elastic ligature, the in- 
elastic ligature, injections, etc., all of which 
have served some good purpose, but none 
of which have succeeded in supplanting the 
knife in all cases. Very much can be said 
in favor of each method, but certain it is 
that their employment is restricted to excep- 
tional cases. Injections are of but little 
avail in old standing cases, for the reason 
that the membrane lining the sinus is of 
such thickness and composition that it re- 
sists medication. If the healing process is 
established at all it is at the external orific 
only, and this is not desirable. 
When the ligature is used, either the 
elastic or non-elastic, the top portion only 
of the fistula is divided, leaving the bottom 
untouched, hence deviating from a rule in 
surgery which is imperative, viz.: “Fistu- 
lous sinuess must heal from the bottom.” 
It was to obviate this difficulty that I devised 
the method which I shall describe briefly. 
The plan is this: Taking the ordinary ex- 
ploring probe, it is inserted into the external 
orifice of the fistula to determine, if possi- 
ble, that only one sinus exists. Fortunate- 
ly the majority of fistulse are of this kind. 
Being satisfied of this fact, I then take a 
long, slender laminaria tent and push it 
gently into the fistulous sinus to the fullest 
extent that it will go. This is allowed to 
remain for several hours, keeping the pa- 
tient under observation during the interim, 
at the end of which time it is withdrawn. 
The procedure causes but little if any pain. 
The laminaria tent is preferable to sponge, 
for the reason that it furnishes its own REPORT ON DISEASES OF THE RECTUM. 
7 
the sphincter muscle or muscles must of ne- 
cessity be cut through by the ligature, if 
the internal opening be above them. In 
the operation with the instrument, the mus- 
cle is not divided or interfered with. Over 
the knife it can be claimed, (1) that this 
operation dissipates all horror in those pa- 
tients that dread the knife; (2) that excess- 
ive hemorrhage is avoided; (3) the sphinc. 
ter muscles are not cut; (4) the patient is 
not confined to bed or taken from business. 
of London, has done me the compliment of 
embodying and indorsing in his last work 
on Diseases of the Rectum), I still main- 
tain to be correct, viz.! that the plan is 
painful, inefficient, dangerous, and does not 
effect, as Mr. Allingham says, a permanent 
cure. By said method patients are of ne- 
cessity kept under observation and treat- 
ment for an indefinite length of time. By 
the plans of treatment as advocated by all 
scientific surgeons, patients with piles are 
radically cured in comparatively a few days, 
with no danger, and by proper manipula- 
tion with but little pain. It is the rarest 
thing that I keep patients under observation 
longer than ten days. My plan is to adopt 
the method best suited to each individual 
case. It is very seldom that my patients 
lose more than a few days from business, 
and the cure is radical. This can not be 
said of the injection plan. Where there is 
such unanimity of opinion among authors in 
regard to this matter, the wonder is that any 
man of scientific attainments should indis- 
criminately use injections of acid into well- 
formed tumors. If used at all, let it be 
in the small, bleeding capillary pile; 
In the majority of cases which I have 
treated by this method, I have done so 
without them knowing that anything in the 
nature of an operation had been done. 
Exhibiting the instrument to them, the knife 
being concealed in its case, they have never 
known other than that it was a probe. If 
I find, after waiting a few days, that a suffi- 
cient depth was not reached, the instrument 
is again inserted and the same procedure 
practiced. The patient is kept under obser- 
vation a sufficient length of time to be as- 
sured of a perfect cure. Where pus cavities 
are found, or many sinuses exist, of course 
this operation is not advised, but in the 
selected cases mentioned I am sure that the 
advantages claimed for it will be realized. 
A score of cases in my practice attest its 
value. 
Before closing my report let me impress 
that there is no surgical patient but needs 
the most careful supervision in the treat- 
ment of his case. It may appear a simple 
thing to ligate a pile or lay open a fistula, 
but the after treatment in regard to hygiene, 
sepses, drainage, etc., is just as important 
as in the cases of the major operations in 
surgery. 
There is nothing specially new in the 
treatment of haemorrhoids. The same views 
as expressed in my report to this society in 
1877 in regard to the injection of piles with 
carbolic acid (which report Mr. Allingham, 
HAEMORRHOIDS.  
JOSEPH M. MATHEWS, M.D., 
LOUISVILLE, KENTUCKY. 
PRACTICE LIMITED TO 
DISEASES OF THE RECTUM.