Rectal Disease 
OF UTERINE ORIGIN. 
BY 
CHARLES P. STRONG, M.D., 
OF BOSTON, 
Physician to Out Patients, Massachusetts General Hospital; Surgeon 
to Out Patients, Free Hospital for Women. 
\Reprinted from the Boston Medical and Surgical Journal, 
of February 18; a886.] 
BOSTON : 
CUPPLES, UPHAM & CO., Publishers, 
ffilh (Corner Book Atore. 
1886. RECTAL DISEASE OF UTERINE ORIGIN.1 
BY C. P. STRONG, M.D. 
Nearly every subject in gynaecology has been so 
thoroughly written about and illustrative cases so multi- 
plied that it was with surprise I noted the lack of defi- 
nite and detailed information regarding the causative 
influence of uterine disorders in cases of rectal disease. 
The literature of the subject, as found in the larger 
text-books is but the most general statements, while 
in monographs it is treated more from the point of 
view of the recta] specialist than the gynaecologist. It 
being my fortune to have several patients whose symp- 
toms were mainly or entirely rectal, I sought to find 
some classification of symptoms or of lesions recorded, 
that would aid me in determining just how far I was 
justified in attributing their condition to uterine dis- 
ease. My search was so unproductive that I have 
been encouraged to contribute the results of my per- 
sonal observations and a few illustrative cases with the 
hope of adding, although it be but little,- to the general 
knowledge. 
There are certain symptoms that suggest at once 
rectal examination ; constipation alternating with diar- 
rhoea, frequent and ineffectual attempts at defecation, 
painful defecation, haemorrhage, muco-purulent dis- 
charges, sensations of fullness in the rectum with gen- 
eral reflex disturbances of the digestive tract; and 
when one finds, associated with these symptoms, the 
lesions, internal haemorrhoids, subacute and chronic 
proctitis accompanied usually with fissure of anus and 
often with ulceration of the rectal mucous-membrane, 
certainly an investigation of the uterus and its adruxa 
1 Read before the Obstetrical Society of Boston, December 12,1885. 2 
is demanded. 1 do not intend to imply that these con- 
ditions necessarily mean uterine disease, for there is a 
vast number of other sources from which they may 
arise, but rather, that when uterine disease does cause 
rectal trouble, these are the symptoms, and these 
lesions present, and that cure will be more certain and 
speedy, and relapses less frequent, proportionally to 
the attention paid to the uterine complication. Cer- 
tain conclusions, too, I formed as to the nature of the 
uterine disorders that would produce these lesions : 
first, uterine malpositions, especially retroflexion when 
adherent, and retroversion, prolapse associated with 
laxity of the vaginal walls ; second, periuterine cellu- 
litis, most markedly when retrouterine and hardening 
and fixing the anterior rectal wall. 
There are several reasons for the disturbing effect 
of uterine malposition upon the rectum, but the im- 
portant one is the disturbance of the veinous circula- 
tion in the lower part of the bowel, which has both a 
mechanical and physiological explanation. The inter- 
nal haemorrhoidal veins, valveless and thin-walled, as 
they emerge from beneath the mucous membrane 
through the muscular coat of the rectum, pass through 
openings that are readily compressed ; also, this lower 
part of the rectum is especially rich in its nerve sup- 
ply, and the mal-placed uterus, depressing the rectal 
wall at this spot, acts as a stimulus, producing contrac- 
tion of the muscular coat of the intestine, which oc- 
cludes the veins and dilates their terminal branches. 
So far the conditions are analogous to those occurring 
during normal defecation, and if now the uterus were 
raised all would be well, but it maintains its place and 
under the stimulus of its presence the contractions of 
the muscular wall become constant, the dilatation of 
the veins is permanent, and internal haemorrhoids are 
produced. Passive congestion of the area drained by 3 
the veins ensues, and with this a sub-acute inflammation 
of the mucous membrane leading to increased secretion 
and loss of epithelial covering, thus adding new fac- 
tors for further disturbance. Coincident with these 
changes the usual alterations in the uterus consequent 
upon its displacement, continue rendering it more and 
more a source of irritation to the rectum. When the 
uterus is in its normal position and movable, although 
it may press firmly against the rectal wall it stimulates 
no contractions, because of the deficient nerve-supply 
at this point of the rectum, and because its position is 
so constantly varying ; if, however, it is fixed by adhe- 
sions a new element is introduced, the condition is then 
analogous to a rectal stricture, formed by retro-uterine 
cellulitis, an obstacle is opposed to the normal descent 
of faeces preventing the regular and complete empty- 
ing of the rectum, irritating masses may be retained in 
the dilatations above and below, causing ulceration of 
the mucous membrane, and starting a new series of 
evil results. 
There are two conditions that I pass over, content 
with merely naming them, their dependence upon uter- 
ine complications and their treatment being so obvious, 
haemorrhoids during pregnancy, rectocele from a pro- 
lapsed uterus. 
I have preferred not to enter too minutely into the 
various pathological changes that may occur in the rec- 
tum in consequence of uterine disease, because that 
would involve considerable theoretical discussion and 
necessitate a consideration of the mutual reflex distur- 
bances, and my purpose in this paper has been only to 
record the results of my personal observations, there- 
fore I pass at once to the cases I have selected as 
illustrative of the types of uterine disease whose symp- 
toms are mainly rectal. 
Case I. Haemorrhoids, internal and external, with 4 
profuse haemorrhages and chronic proctitis. Caused by 
an enlarged and retroflexed uterus. Recovery with- 
out rectal treatment. 
Mrs. X., widow, five years past the menopause, 
complexion anaamic and sallow, suggestive of malig- 
nant disease. For ten years has suffered from haem- 
orrhoids, which during the past two years have given 
her no rest night or day. Severe constipation, partly 
acquired as each dejection was accompanied by loss of 
blood, not infrequently to such an extent as to cause 
syncope. Protrusion of masses from the rectum at 
each defecation with abundant mucous discharge. Fre- 
quently confined to bed for several consecutive days. 
She had about exhausted the medical treatment of the 
rectum, having sought relief from many sources and 
refusing the operation that was finally urged upon her 
by all whom she consulted. As to the uterine symp- 
toms, she had none, except backache, which of course 
could be readily explained by the condition of the rec- 
tum and her general poor health. The anus was sur- 
rounded by a fringe of haemorrhoids, not inflamed but 
full of blood. Slight straining on the patient's part 
protruded about three quarters of an inch of the rec- 
tum turgid, streaked with blood and mucus ; the nu- 
merous veins dilated to their utmost limit. The mucous 
membrane was thickened and here and there denuded 
of the epithelium, bleeding at the gentlest touch. 
Passing the finger up the rectum at the distance of an 
inch and a half to two inches it came against a firm 
globular mass occupying the whole calibre of the canal, 
suggesting at once a large rectal polypus, but noticing 
its apparent relation to the cervix as felt through the 
rectal wall, the diagnosis of retroflexion with adhesions 
was made and confirmed by vaginal examination. The 
uterus was much enlarged, three and a half inches was 
the internal measurement, although the catamenia had 5 
not appeared for five years. Both walls of the vagina 
were also lax. Owing to the tenderness of the rectum 
it was a mutter of considerable difficulty to replace the 
uterus, but this was successfully accomplished by pack- 
ing for two months, and then a retroflexion pessary 
readily retained it in its normal position. The ameli- 
oration of the symptoms when the pessary was substi- 
tuted for the packing and the uterus lifted well for- 
ward was most marked and immediate. Bleeding 
ceased at once and has never recurred during the fif- 
teen months she has been under my observation. 
Regular daily dejections, without pain, have been 
established. The internal haemorrhoids have almost 
disappeared and the external ones form merely a fringe 
of hypertrophied skin. The uterus has decreased one- 
half inch in size and the patient's general health and 
strength has improved in a corresponding degree. 
This case is especially interesting, because from the 
first visit to the last, a week ago, the only treatment 
has been directed to the uterus, notwithstanding all 
the symptoms were rectal. There has only once been 
any indication of a relapse. After an absence of three 
months, the patient returned and stated that for a few 
weeks past she had been troubled by the old sensation 
of fullness in the rectum, unaccompanied, however, 
by any graver symptoms. Examination showed that 
the uterus had bent backwards over the upper bar of 
the pessary and was pressing into the rectum. Re- 
placement of the uterus and the insertion of a slightly 
longer pessary effectually cured this symptom. 
Case II. Subacute proctitis with fissures of the 
anus, dependent upon a slightly prolapsed uterus. 
Rectal treatment ineffectual until the uterus was re- 
placed. Cure. ' 
Mrs. X., aged forty, multipara, of exceptionally 
nervous temperament, has suffered since puberty with 6 
various uterine disorders, and has been under constant 
treatment for years. When she first consulted me, 
two years ago, there was dysmenorrhcea, leucorrhcea, 
inability to stand or walk, backache, and a host of kin- 
dred uterine symptoms, but during the past two years 
or more these had been overshadowed by rectal dis- 
turbances ; constant pain in the rectum, acute suffer- 
ing so intense during defecation that the act was post- 
poned to as infrequent intervals as possible, profuse 
muco-purulent discharges, slight staining of the stools 
with blood. One of the most prominent symptoms, 
which she called "rectal neuralgia," was pain of 
severe character about the anus and lower part of 
the rectum, induced by surface chilling of the body, 
so that even in summer she never approached an open 
window without protecting herself by a thick shawl. 
Ether was necessary for an examination, and there 
was found the following conditions : a slight fissure of 
the anus; subacute inflammation of the rectal mucous 
membrane, extending quite as high up as the rectum 
could be exposed to view, the surface streaked with 
lines of pus and thick glairy mucus, and studded with 
minute, red, granular elevations, looking not unlike 
grains of red pepper. The uterine condition was not 
encouraging. Both tubes were dilated, especially the 
left one, which appeared about three-quarters of an 
inch in diameter, and outside these tubes there was 
considerable inflammatory deposits. The uterus lay 
about an inch below its normal level, pressing back 
firmly into the rectum. Rectal treatment was at once 
begun by stretching the sphincter, cleansing the 
mucous membrane and applying a strong solution of 
nitrate of silver. For several weeks a varying treat- 
ment was employed, including absolute rest in bed, hot 
rectal douches and astringent applications, but beyond 
the improvement caused by the healing of the fissure, 7 
her symptoms were but little benefited. Then the 
uterus was raised and kept free from the rectum by a 
pessary, and coincident with this manoeuvre there was 
steady gain. The purulent discharges ceased and the 
pain disappeared. An examination four months ago 
showed a perfectly normal appearance of both rectum 
and anus. There has been no relape. The uterine 
condition and enlarged tubes have also improved, 
contrary to my expectations, under mild treatment, 
and except considerable dysmenorrhoea, the patient 
declares herself perfectly well, although it will be some 
time yet before I shall venture to permanently remove 
the support. The so-called " rectal neuralgia " is now 
never noticed. The rectal treatment of this case that 
was attended with the most benefit was the employ- 
ment of suppositories of iodoform ancLhydrastin night 
and morning. 
Case III. Chronic proctitis, with anal fissure de- 
pent upon cellulitis, extending behind the uterus and 
involving the anterior rectal wall, combined with pro- 
lapse of the uterus and left ovary. Improvement. 
Mrs. X., thirty-six years. As with the preceding 
cases, the symptoms for which relief were sought were 
rectal. As stated by the patient, there was pain, dis- 
charge from rectum, resembling the white of eggs, or 
else yellow; inability to have a movement without 
employing both physic and enema, and often three or 
four enemata were required. The pain accompanying 
defecation is excruciating, often patient faints ; and 
the rectum is never free from a feeling of fullness and 
soreness. The rectal symptoms were not very chronic, 
having lasted but six months, but for about a year, in 
consequence of a fall, patient had suffered from serious 
uterine troubles, for which she had received beneficial 
treatment. Previously to this accident she had been 
in good health. For the past three months, she had 8 
been in bed most of the time. Examination under 
ether revealed the presence of several superficial fis- 
sures in the posterior part of the anus ; the rectal mu- 
cous membrane was thickened, of a dusky hue, and 
thickly sprinkled over the surface were minute ulcera- 
tions, varying in sizes from a pin head to a split pea. 
Pus and mucous abundantly present. On the anterior 
wall was a projection caused by the fundus of the 
uterus, which was firmly bound there by cellular in- 
flammation, thus acting as a direct mechanical obsta- 
cle to the descent of the faeces. The rectal wall was 
so thickened and undurated, it could not be depressed 
to permit examination above. The uterine conditions 
were, a hypertrophied uterus over three inches in 
depth, lying low in the pelvis and rendered immovable 
by a mass of cellulitis, which involved as well the left 
ovary and the anterior rectal wall. From the sequence 
in time of the rectal and uterine diseases, it was quite 
evident that the former was dependent upon the latter ; 
but until there was some improvement in the condition 
of the rectum it was hopeless to attempt any manipu- 
lations leading to re-position of the deplaced organs. 
Fortunately the most acute and troublesome rectal 
symptoms, the painful defecation and discharge of pus, 
improved by the dilatation of the sphincter, the use of 
hot rectal douche with weak solutions of nitrate of 
silver, and employment of the iodoform suppositories, 
so that very soon it was possible to treat the uterus 
directly- The* gain was so rapid when the cellular 
effusion was absorbed and the uterus became movable, 
that rectal treatment was then entirely abandoned. 
At the end of five months the only reminder of the 
previous trouble were constipation, which was easily 
controlled by a laxative, and the presence of consider- 
able raucous discharge, if the patient was long on her 
feet, showing that the rectum was still affected by the 
pressure of the prolapsed uterus and ovary. 9 
The patient refused to wear a support, and so I have 
reported this case as improved, not cured, for I have 
no doubt that a recurrent attack of cellulitis will bring 
on her rectal symptoms again. It is about a year since 
she passed from my immediate observation, and there 
has been no opportunity since that time to make a 
local examination, but I have been informed that she 
is attending to her duties, and is not apparently an in- 
valid. 
Case IV. Chronic proctitis, with deep ulcerations 
and fissure of the anus, dependent upon a retroflexed 
and adherent uterus. Rectal treatment ineffectual 
until supplemented by replacement of the uterus. 
Cure. 
Mrs. X., thirty-two years, multipara. Consulted me 
in November, 1883. Her symptoms were both uterine 
and rectal, but the latter assumed the greater promi- 
nence. From the graphic and intelligent history she 
furnished, I make an extract of the important points. 
Since the establishment of her catamenia, at the age of 
seventeen, she suffered greatly from dysmenorrhoea, 
backache, and bearing-down pains ; symptoms exag- 
gerated by constantly standing, as her duties as teacher 
demanded. In 1871 constipation became a symptom 
of increasing prominence, and to this was joined haem- 
orrhage at each defecation. Usually she made several 
abortive attempts to secure a dejection before being 
successful, and was subject to constant pain in the rec- 
tum. For four years she was under treatment by diet 
and medicine, and then, passing into other hands, was 
examined and cured of fissure of the anus by dilatation 
of the sphincter. There was very great gain in the 
rectal symptoms after this treatment for several months, 
but the uterine symptoms remained unchanged, and 
slowly the rectum returned to its former condition. 
In 1879 she had an attack of peritonitis, and after con- 10 
valescence from this she thus describes her condition: 
" There were five or six daily attempts at defeca- 
tion, the fteces were hard, dry, and in small pieces, not 
over an inch and a half long and shaped like the handle 
of a silver dinner knife, having on one edge a streak 
of bright red blood and considerable amount of green- 
ish yellow matter on the end." With these conditions 
unchanged the patient was married two years later, 
that is, in 1881. Marital life and duties exerted a 
most pernicious effect. She failed steadily, and when 
I first saw her, two years later, she was in a deplora- 
ble condition : emaciated, exhausted by pain, spending 
most of her time in bed, unable to walk or even stand 
for any length of time. She said she did not mind the 
backache or dysmenorrhoea, but that the trouble in the 
rectum was " killing her." At first I thought there 
must be malignant disease of the rectum to produce 
such depressing symptoms, but recognizing the sharply 
retroflexed uterus pushing into the rectal walls, and 
the presence of adhesions, I determined to try uterine 
treatment alone. A few attempts convinced me of 
the impracticability of accomplishing anything by this 
plan until there was greater tolerance of the rectum 
toward the necessary manipulations. Under ether the 
sphincter was dilated, showing several superficial and 
one deep fissure, and permitting the escape of a gush 
of blood and pus. When the sphincter was fully 
opened and'the speculum in position, a single ulcera- 
tion appeared, extending from the anus to a point 
about five inches up the bowel and involving the entire 
circumference of the rectum, except a strip of mucous 
membrane, varying from one-half to three-fourths of 
an inch in width, on its anterior aspect. This little 
strip of membrane was swollen and boggy from infil- 
tration, and there were deposits of lymph on the sur- 
face from which the epithelium was very easily de- 11 
tached. A dark, grayish, dirty-looking coating cov- 
ered the surface of the ulceration, exposing an easily 
bleeding granular base on its removal. Whatever the 
remote cause of this state of affairs might be, there was 
evidently but one course of treatment to pursue, and 
that was to promote as rapidly as possible the cicatri- 
zation of the rectum. I thoroughly curretted through 
the slough and granulations to a firm base and then 
brushed over with nitric acid, using the greatest care 
not to encroach upon the little remaining strip of mu- 
cous membrane. For three weeks the patient was kept 
absolutely recumbent in bed, and then for an equal 
space, allowed to move only about her room, spending 
most of the time upon the lounge. The medical treat- 
ment was a broth and beef-tea diet, aloin as a laxative, 
and enemeta of hot water, and iodoform suspended in 
liquid vaseline. The rectum at first would reject two 
ounces of hot water immediately, but at the end of six 
weeks would retain three pints and more for about fif- 
teen minutes. At the end of ten weeks there was 
most gratifying improvement, but still the symptoms 
were not all gone. Blood and pus had disappeared 
from the dejections, there was almost no pain accom- 
panying them, but the frnces retained their peculiar 
shape, and there was still the sensation of fullness in 
the rectum, inducing frequent attempts at defecation. 
Examination showed, that the rectum was now com- 
pletely cicatrized and the fissure healed. There was 
no change in the uterine condition. The patient was 
competent to attend to the rectal treatment and faith- 
fully obeyed all my instructions, but after resuming 
her household duties, and being upon her feet a con- 
siderable portion of the day, she reported in July, five 
months subsequent to the operation, that the old rec- 
tal symptoms were returning, and she was alarmed lest 
she should relapse into her former state. Under its 12 
improved condition the rectum was tolerant of the 
course of packing that was necessary to raise the 
uterus, and this treatment was carried out until the 
adhesions were so far stretched that a pessary could 
be introduced to complete the cure. I abandoned the 
packing for the pessary sooner than is my custom, be- 
cause of the irritating effect upon the rectum, and also 
because vaginismus made the operation of packing 
both tedious and painful. Immediately upon the suc- 
cessful replacement of the uterus, the remaining rectal 
symptoms disappeared and have never since returned. 
I saw the patient two weeks ago, and she said that she 
now had a regular daily evacuation of perfectly formed 
faeces, unaccompanied by pain or mucous discharge, 
that there was no abnormal sensation whatever refera- 
ble to the rectum, that she never took a laxative to 
secure a dejection. In a word, as she stated it, "I 
never should know I had a rectum." 
In reporting the foregoing cases, I have purposely 
refrained from entering upon the particulars of either 
the uterine or the rectal treatment, that the attention 
might not be drawn from the point under discussion 
by a confusing mass of details, and for the same 
reason have omitted mention of uterine complications 
that had no especial significance in this connection. 
The cases have been selected from among a number 
as especially illustrative of the type of rectal diseases, 
that are dependent upon a uterine cause. That the 
cause of the rectal trouble was a direct consequence of 
the removal of the existing uterine lesions, not a coin- 
cidence, is shown by the fact, that, with one exception, 
Case III, the patients had previously received rectal 
treatment for years, improving but never getting thor- 
oughly well, and always relapsing.