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Charles B. (Charles Boyd) Kelsey.

Surgery of the rectum and pelvis online

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very generally effectual, consists in a lotion of carbolic acid. The
formula is :

^ Acid, carbolici | ss.

Glycerinse i i.

Aquse 1 iij.

M.

This may be applied at night, and if found to be too strong
may be diluted by the patient. In a more dilute form it may
also be continued for a considerable time after all symptoms have
ceased.

For the sake of those who have never encountered an obstinate
case of this disease, but who are pretty sure at some time to have
both knowledge and ingenuity taxed to tlie utmost, I will give one
or two more formulee which have been found reliable :



368 SURGERY OF THE RECTUM AND PELVIS.

I}, Sodse biboratis 3 ij.

Morph. liydrochlor gr. xvi.

Acidi liydrocyanici dil .... | ss.

Glycerinse § ij.

Aquse ad | viij.

M.

This should be applied to the part four or five times in the
twenty-four hours. Dr. Bulkley has also recommended the follow-
ing as being useful, and I have often found it so :

^ Ungt. picis 3 iij.

" bellad 3 ij.

Tr. aconit. rad 3 ss.

Zinci oxidi 3 i.

Ungt. aquse ros 3 iij.

M.

The following prescription has also been very efficient in my
hands. I am indebted for it to Dr. Salisbury :

B Menthol 3 i.

Simple cerate § ij.

Oil sweet almonds 1 i.

Carbolic acid , 3 i.

Pulv. zinci ox 3 ij.

M. Apply morning, noon, and night, after cleansing the parts.

An ointment of chloral and camphor, a drachm of each to the
ounce, is also at times effectual in allaying itching.

There are two other skin diseases, either of which may be the
cause of pruritus — herpes and erythema. Herpes at the margin of
the anus is the same as when seen on the lips. In tlie latter case it
heals spontaneously, in the former a dressing may be necessary.

This may consist simply of a dry powder such as zinc or bismuth,
or of one of the lotions already mentioned. Erythema will be found
chiefly in fat people, where it is due to contact of the opposing cu-



CONSTIPATION — Pi:iIIiITUS. 369

taneous surfaces. It also is best treated bj^ the application of dry-
powders, and by separating the opposed surfaces by a layer of dry
sheet lint or old muslin.

These are the most palpable, and perhaps also the most common,
causes of pruritus, but there are many cases in which tlie cause is
not so easily discoverable, because it is a constitutional and not a
local one. Where no local cause can be detected, a careful inquiry
must be instituted with regard to the patient's general health and
habits. If chronic constipation be present, this must first of all be
overcome, for this is in itself an efficient cause for the disease.

Another not infrequent cause of pruritus is derangement in the
function of the liver. This may or may not be associated with con-
stipation. It must be treated by general dietetic measures, the dilute
mineral acids, occasionally by doses of podophyllin, active out-of-
door exercise, and cold and friction applied to the hepatic region.

In women uterine disorders must be looked for and cured before
very much will be accomplished in the treatment of pruritus ; and
the urine must be examined for sugar in obstinate cases, for diabetes
will sometimes give rise to incurable pruritus.

In case none of these causes can be found to account for the itch-
ing, errors of diet must be searched for, and corrected when found.
Anything like excess in smoking or in alcoholic drinks will keep up
the disease, and in men these habits must be carefully regulated, if
indulged in at all.

The disease will sometimes be encountered in stout, full-blooded
persons who live well and perhaps incline to the gout, and who show
no other signs of disorder. In such, active exercise and plainer liv-
ing, with cold bathing of the part at night and morning, and the use
of a lotion of carbolic acid, will often effect a speedy cure.

On the other hand, the disease may be present in exactly the op-
posite class of persons, the overworked and worried professional or
business man, and it is in this class of cases alone, where the itching
seems to be purely a nervous symptom, that arsenic is indicated. It
may be combined with quinine and cod-liver oil, and carried up to
its full physiological effect.

In old cases, which resist milder measures, I have worked many
cures by putting the patient under ether and applying the Paquelin

24



370 SUEGERY OF THE RECTUM AND PELVIS.

cautery lightly to the whole afEected surface. Where there is much
induration, a few stripes may be made entirely through the derma ;
where the cause is an old eczema without much infiltration, the entire
surface may be lightly brushed over with the white hot cautery.
When the burns thus made have healed, the patient will generally be
cured.

In this way, then, the physician must undertake the cure of a
case of pruritus ani ; and not by the administration of any single
lotion or ointment to allay the itching, which is but the symptom of
some local or general condition. In every case the cause must be
found and removed if success in the treatment is to be gained.

I know of no disease of the rectum or anus in which there is a
better chance for the practitioner to show his general knowledge and
skill. If a case be undertaken in this way, and the treatment be in-
telligently followed by both doctor and patient, a cure may generally
be effected ; sometimes in a very few days, but at others only after
prolonged effort and many discouragements. The prognosis should,
therefore, be guarded at the outset, lest the patient be led to expect
a too speedy relief ; and in some cases, in spite of the best of care,
the disease will frequently return, and the patient can scarcely at
any time consider himself as perfectly cured.



Wounds and Foreign Bodies.

Wounds of the rectum may be either contused and lacerated, or
incised. The latter most frequently result from surgical operations,
and may be intentionally inflicted, as in the operations for fistula or
for the removal of tumors ; or the result of accident, as in the opera-
tion for stone.

Contused and lacerated wounds are generally the result of acci-
dent, and perhaps the most frequent cause of such an injury is the
perforation of the bowel with an enema tube, a bougie, or a urethral
sound.

The gravity of this accident will depend upon two factors—
whether the perforation of the bowel is above the peritoneum, and
whether the enema has been deposited in the perirectal tissues. The



WOUNDS AND FOREIGN BODIES. 371

latter complication will be followed by abscess and peritonitis, and
will result either in death or in stricture and hstula. If the wound be
uncomplicated by the injection, the mere puncture may heal sponta-
neously. It is oblique from below upward, and this greatly favors
spontaneous healing without fecal extravasation.

Dr. Achilles ]N"ordmann, of Basel, has published a description of
twenty-five bowel lesions due to the administration of enemata. They
include three complete perforations, and ulcers and wounds of vari-
ous depths and sizes. The causes of these wounds seem to have
been the use of defective instruments, ignorance of the anatomy of
the rectum, catching the transverse folds on the end of the tube, ex-
treme irritation of the mucous membrane of the bowel, and obstruc-
tions caused by such conditions as a foetal head, an enlarged pros-
tate, or a misplaced uterus.

As a rule, these lesions are to be found on the anterior wall from
one to seven centimetres from the anus. They are not always easy to
diagnosticate, as other foreign bodies or caustics may produce simi-
lar appearances. Tubercular or hemorrhoidal ulcers may be mis-
taken for them. A perforating w^ound generally results in serious
periproctitis, which may end fatally, or in stricture.

Esmarch has met with four cases of this injury, none of which
were fatal, though attended by much local trouble. Velpeau de-
scribes eight cases, six of which ended fatally. Passavant observed
five cases, one fatal. Chomel has had two fatal results. There are two
preparations in St. Bartholomew's Hospital showing the results of
this accident, one in a man, the other in a child ten years of age (Es-
march).

Besides these most common injuries, man}^ others may be enu-
merated. The person may fall upon a sharp body, as the point of an
umbrella (Bushe), may be caught upon the horn of an animal (Gun-
drum, Ashton), or may be impaled upon a spike (Esmarch).

Thompson describes the case of a man, aged eighteen, who stated
that he had fallen about four feet, in a sitting posture, on to the end
of the upright shaft of a smith's hammer, which he described as hav-
ing entered his seat for a considerable but unknown distance, and
requiring some amount of force in its removal, which w^as accom-
plished by a lellow-workman. He had very little pain at the time of



372 SURGERY OF THE KECTUM AXD PELVIS.

the accident, and walked about a mile to the infirmary without much
trouble.

On examination only some slight bruising was found around the
anus, with a little blood-stained mucus. Per rectum nothing was
detected. The abdominal walls were quite flaccid. Examinations
caused no pain. He complained, however, of a slight, continuous,
aching pain just above the pubes. Soon after admission he passed
both urine and fseces, the former normal, the latter soft and streaked
with blood. Some hours later he passed another motion, with a con-
siderable quantity of clotted blood ; the suprapubic pain also be-
came more intense, but the abdominal walls still remained flaccid, the
face was very pale, the pulse rather weak, and the extremities cold ;
but the patient appeared to be in good spirits, answered questions
readily, and did not feel unwell. He remained in this condition un-
til midnight, when the abdominal pain became more severe. Symp-
toms of collapse gradually came on, and he died at 8 a.m.

At the necropsy, on the same morning, the peritoneum was every-
where found intense!}^ injected, and in part presented a thin layer of
lymph. There was a marked laceration in the recto-vesical pouch a
little to the right of the middle line, which led into a triangular
opening in the wall of the rectum about three inches from the anus ;
this aperture was triangular, its base measuring one inch and a half,
its sides an inch each. At the brim of the pelvis, on the right side,
was a laceration of the peritoneum covering the psoas, with bruising
of the subjacent muscle. The mesenteric glands were enlarged and
inflamed. The abdominal cavitj^ contained a small quantity of hard
fffices ; there was also found a piece of cloth corduroy two inches
long and one inch and a half in breadth, corresponding in texture to
the patient's trousers and to an aperture in their seat.

In such cases the accident may be immediately fatal from collapse,
and the wound in the rectum may be complicated by a wound of the
peritoneum or of any of the adjacent organs. The body which has
done the injury may also be so firmly implanted as to require great
force and an anaesthetic for its removal.

The rectum is not infrequently lacerated in childbirth ; and
although such wounds are generally of slight extent, Bushe relates
a case in which the child's head was passed through the anus.



WOUNDS AND FOREIGN BODIES. 373

It has also happened tliat in a violent effort to expel a mass of
hard faeces the rectal wall has given way. Mayo relates one such
case in a woman of fort}^, in whom the rupture was in the recto-
vaginal septum, about two inclies within the bowel. Asliton reports
a similar case, and Bushe another. Such a rupture may be either
vertical or transverse, will be marked by a 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. (See Rectal Hernia.)

Tlie consideration of gunshot wounds comes more properly within
the scope of military surgery. They are always complicated with
injuries of other parts, and are generally fatal from extravasation of
urine or fseces.

The complications which may attend a wound of the rectum have
already been hinted at. They are hemorrhage, either primary or
secondary; fecal infiltration ; purulent infiltration ; peritonitis; em-
physema ; hernia ; invagination ; and later, stricture and fistula.

When fseces are forced out of the rectum into the adjacent tissue,
diffuse inflammation and gangrene will probablj^ result, and the con-
dition must at once be met by free incisions and free drainage, as has
been described in the chapter on abscess. The danger of fecal infil-
tration 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 ac-
corded to the contents of the bowel.

Emphysema, 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 septicsemia, 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 ma}^ close by first intention, and an effort should always be
made to secure this by rest in bed, by emptying the bowel, and keep-
ing it empty by frequent washings with water, and by the use of



374 SURGERY OF THE RECTUM AND PELVIS.

opium. Healing by granulation will, however, be the rule. In some
cases — such, for example, as laceration in childbirth — sutures may
be at once applied.

As Ball points out, the proper method of treatment for punctured
wounds low down in the rectum is free incision through the sphincter
up to the wound to allow of drainage.

Of gunshot wounds of the rectum during the Civil War, Otis col-
lected 103 cases, with a mortality of 42.7 per cent.; in 34 of these the
bladder also was wounded, with a mortality of 41.17 per cent.

Foreign Bodies which have teen Swallowed.

Medical literature is f uU of curious cases in which foreign bodies
have been swallowed, either accidentally or by design, and have in
some cases passed the full length of the alimentary canal and been
safely voided with fseces, or in others have become entangled in the
mucous membrane and given rise to much trouble.

Every practitioner is familiar with cases of peach-stones and coins
which have been accidentally swallowed, and knows how generally
such substances take care of themselves and cause no symptoms
after once passing the CBsophagus. Much larger substances, such as
whole or partial sets of false teeth, and the various things with which
performers in travelling shows entertain an audience, may also be
passed in safety.

To show what nature is capable of in this line, it may be well to
enumerate the substances which were swallowed and safely voided by
a certain lunatic, now become famous.

The patient stated that she had been swallowing nails, etc., and a
dose of castor oil brought away two pieces of faience one or two cen-
timetres long and about the same breadth, two nails, and a pebble.
During the following six weeks she passed nineteen large pointed
nails, a screw seven centimetres long, numerous fragments of glass and
china, a piece of a needle, two knitting needles, fragments of whale-
bone, etc., amounting in all to three hundred grammes. During all
this time the patient ate and drank as usual, and seemed in ordinary
health.

Professor Agnew " saw in the dissecting room of the Philadelphia



WOUNDS AND FOREIGN BODIES. 375

School of Anatomy a female subject, afterward learned to have been
insane, in whose intestinal canal from jejnnum to rectum were found
three spools of cotton, partially unwound ; two roller bandages, one
of them two and a half inches wide and one inch thick, the other was
partially unrolled, one end being in the ileum, the other in the rec-
tum ; a number of skeins of thread, a quantity being packed tightly
in the caecum ; and, finally, a pair of suspenders.'-

Professor Gross records the " case of a man who swallowed a bar
of lead, ten inches long, upward of six lines in diameter, and one
pound in weight, whilst performing some tricks of legerdemain,"
which was removed by gastrotomy, and the patient recovered in two
weeks. He also mentioned another case in which a teaspoon was
swallowed whilst the patient was in a paroxysm of delirium, which
was removed from the ileum by enterotomy, recovery taking place
in a few weeks.

It would be beyond the scope of a work such as this to attempt
to deal with the whole question of foreign bodies in the alimentary
canal, and the accidents which may attend them. In a general way,
the prognosis is good unless the foreign body be a very ragged one,
or a large, sharp one, like a fork ; and the treatment consists in giv-
ing a diet, like bread and fruit, which will cause copious stools, with
little drink, and the avoidance of exercise such as walking.

If complications arise, they must be treated on general surgical
principles ; and at the present day no patient would be allowed to
die from the effects of a foreign substance in the stomach or intes-
tines without a surgical operation for its removal, provided only the
diagnosis were clear.

The complications which may attend the detention of such sub-
stances in the rectal pouch just above the internal sphincter are
ulceration with perforation, hemorrhage, and abscess. Ulceration
may be caused by the pressure of a large body, and may cover a con-
siderable space ; or it may be caused by the pressure of the sharp
ends of a smaller body, in which case the spots of ulceration will be
smaller, and may be located at two opposite points in the rectum.
As a result of ulceration there will be more or less pain, purulent dis-
charge, and perhaps also a sharp hemorrhage from the erosion of a
vessel. When perforation of the wall of the bowel has occurred,



'.llo SURGERY OF THE RECTUM AND PELVIS.

inflammatory action is almost sure to be excited in the surrounding
parts, and tliis may vary greatly in its extent and gravity.

If tlie injury be above the point of reflexion of the peritoneum, it
may cause either a localized or a general peritonitis. A general peri-
tonitis caused in this way will be fatal, as it is also generally ac-
companied by more or less extravasation of faeces. A circumscribed
peritonitis with formation of an abscess is a less fatal complication.

Under these circumstances the usual signs of pelvic abscess will
be present — fever, pain on pressure, tympanites, painful defecation
and urination — and by careful examination a tumor may be dis-
covered, either through the rectum or at the bottom of the iliac fossa.
Such cases, when the tumor is on the right side, are often mistaken
for cases of appendicitis, but the tumor is not in the same location ;
it is deeper and nearer the median line.

Such an inflammation may terminate in resolution, provided the
cause be discovered and removed ; but the usual termination is in
suppuration, and the pus, if not removed by the surgeon, ma}^ find
its way into the general peritoneal cavity or into the bladder or rec-
tum. Abscesses of the superior pelvi-rectal space have alread}^ been
described, and those which are due to foreign bodies in the bowel do
not differ from them in general character.

When the focus of inflammation is located below the reflexion of
the peritoneum, the prognosis is less grave. Phlegmonous abscess
may form in the ischio-rectal fossa, and must be treated according to
the rules alreadj^ laid down ; but here the difliculty is well within
the reach of the surgeon, and a cure may confidently be looked for
by proper care.

Foreign Bodies Introduced per Anum.

A classification of these cases is useless. The foreign bodies may
be introduced through traumatism ; by the patient in an honest en-
deavor to relieve himself of piles or prolapse ; by the surgeon for the
purpose of relieving rectal disease. They are often introduced in a
spirit of revenge or of trickery ; and most often of all they are lost
in the practice of an unnatural vice. Edward II. is said to have met
his death by having a red-hot iron thrust into the rectum. "We



WOUNDS AND FOREIGN BODIES. 377

seized the king," said one of the murderers, "and threw liim forcibly
upon the couch, and, wliilst I kept liini tliere by the assistance of a
table, with a pillow on his face, Gurney inserted through a horn-tube
a red-hot iron into his bowels."

A punishment for adultery among the Greeks is said to have been
the introduction into the rectum of a peeled radish covered with hot
ashes ; and cases in which patients have fallen upon sharp and fra-
gile objects, such as the wooden pickets of a fence, which have
broken off and remained in the rectum, are on record.

The list of foreign bodies which have been lost in the rectum by
ignorant persons, in attempts to check a diarrhoea or to prevent the
descent of piles or prolapse, is a very long one, and includes such
substances as bottles, sticks of wood, and round stones, some of
them of a size relatively enormous ; and the use of the rectal pouch
by criminals for the purposes of concealment is well known to the
police.

In the Museum of Anatomy and Pathology at Copenhagen is a
longish, oval, flat stone, about six and three-quarter inches long, two
and a half inches wide, one and a half inches thick, and weighing
nearly two pounds, which a patient in Bornholm introduced into his
rectum to prevent prolapse, from which he had for a long time
suffered. The stone was extracted by a surgeon, Frantz Dyhr, in
1756.

A little case, with very ingenious housebreaking and other thieves'
instruments, was found by Dr. Closmadeuc at the necropsy of a man
in the prison at Vannes. The man had died of acute peritonitis,
from which he had suffered seven days. During his illness a hard,
rather large body was felt in the left side of the hypogastrium ; he
said that it was a piece of wood containing money, which he had
introduced into the rectum ; this, on exploration in the meantime,
was found empty.

On section, the case, which was cylindro-conical in form, lay in
the transverse colon, with its apex directed toward the caecum ; it
was of iron, and was wrapped in apiece of lamb's mesenteiy ; it
weighed about twenty-three ounces, was about six and a third
inches long and five and a half in circumference, and contained
thirteen tools and some coins.



378 SURGERY OF THE RECTUM AND PELVIS.

A depraved sexual appetite has been mentioned as accounting for
the presence of many foreign bodies. It is known that sexual or-
gasm may be excited by stimulating the reflex power of the rectum,
and it is probable that at the moment when the orgasm is at its
height the body used to produce it is allowed to escape fiom the
hand and is lost within the bowel. This is a habit which will never
be acknowledged by its victims, but which may often be assumed to
exist by the surgeon in depraved patients.

The bodies used for this purpose are generally smooth, long, and
round, such as glass bottles and pieces of wood.

It would be interesting to enumerate the foreign bodies which
have been removed from this part of the body, and the list would be
startling from the strangeness of the different articles; but enough
has been said to indicate that almost anything, from a conical stone
to a club or a coffee-cup, may be encountered by the surgeon, and to
indicate the size of the body which the sphincter will allow to pass.
Among them may be mentioned beer glasses, mushroom bottles,
wooden pepper boxes, wine bottles of all kinds, lamp chimneys, and
a part of the wooden handle of a baker's shovel twenty-two centi-
metres in length.

A foreign substance may remain in the rectum for a considerable
time and finally be expelled spontaneously, as in the following case
reported by Weigand.

"A farmer, aged sixty-eight years, of a robust constitution, but
somewhat stupid, introduced into the anus a cylindrical piece of
wood for the purpose of relieving his obstinate constipation. How-
ever, he performed the manipulation so unskilfully that the piece of
wood broke and remained partially within the rectum. All attempts
made to remove the foreign body failed ; two days later he suf-
fered from abdominal and lumbar pains, dysuria, and constipation.
Weigand, being consulted by the physician, recognized the symp-
toms of enteritis. As the introduction of a finger into the rectum



Online LibraryCharles B. (Charles Boyd) KelseySurgery of the rectum and pelvis → online text (page 28 of 41)