CHAPTER XVIII. FOREIGN BODIES IN THE RECTUM. WE may be called upon to remove, by mechanical means, various substances from the rectum, either in consequence of their obstructing this outlet, producing inflammation, or interfering with the integrity of the intestine. These substances may be divided into two classes, one being formed in the body, the other being introduced from without. To the first class belong biliary, intestinal, and fæcal concretions; while the second will include a long list of heterogeneous substances which have been swallowed, either accidentally or intentionally, or introduced into the rectum through the anus by the individuals themselves with a view to obviate costiveness, from a morbid state of the imagination, or by accident, or they may have been introduced by other persons from feelings of mischief or revenge. Those swallowed either by accident or intentionally, in consequence of a perverted condition of the mind, include portions of bones, the bones of fish and small birds, the stones of fruit, coins, knives, pins, needles, nails, sealing-wax, brown paper, cedar pencils, &c.; and among the variety of substances that have been introduced through the anus, according to the testimony of accredited authors, may be mentioned, bottles, pots, cups, a knitting-sheath, a shuttle with its roll of yarn, a pig's tail, ferrules, rings, pieces of wood, ivory, metal, horn, cork, bone, &c. Foreign bodies that have been swallowed do not usually occasion much inconvenience in their passage through the intestinal canal, though it is sometimes marked by considerable irritation. Should the substance not be discharged with the fæces, but become entangled in the rectum, it will give rise to inflammation accompanied by tenesmus, violent straining, and perhaps prolapsus; by perforation of the tissues of the intestine it will lead to the formation of abscess and fistula; or partial or total obstruction may be produced, followed by enteritis or peritonitis: these effects will be greatly influenced by the size, form, shape, and nature of the substance. When intestinal or fæcal concretions are the cause, the symptoms are gradual in their accession, and are preceded by signs of derangement of the stomach, liver, and bowels: at first, the local disturbance is marked by a feeling of weight, distension, and pain in the rectum, followed by obstinate constipation, great straining to relieve the bowels, attended with more or less prolapsus of the mucous membrane and congestion of its vessels; and if the patient be not relieved, enteritis, peritonitis, and death will ensue. When the foreign substance has been introduced through the anus, the symptoms are more rapid in their development, and if the bowel has been at the same time injured, they will be more or less serious in their character in proportion to the extent and nature of the lesion. It is seldom that we can gain any information from the patient when the substance has been swallowed, as it often happens that he is unconscious of the circumstance; but if it has passed into the rectum from without, the patient may then be able to make us acquainted with its nature and the manner of its introduction, unless he be of unsound mind, or was insensible at the time of the occurrence. For extracting the various foreign substances it may be our duty to remove, instruments of different sizes and shapes, and effecting different objects, will be required, much depending on the form of the body to be extracted, and the material of which it is composed, and on the ingenuity and tact of the surgeon. Should the substance be a bottle, or jar of glass or earthenware, it will be a good plan to insert slips of thin ivory, wood, or gutta percha between it and the bowel, and thus form a tube around it which would greatly facilitate its extraction, and protect the intestine from injury, in case the bottle or jar should be broken. The anus being very dilatable, it will be rarely necessary to divide the sphincters, unless the foreign body be sharp and angular, and has penetrated the intestine, in which case an incision on one or both sides may be required. The position of the patient should be on the side, with the knees drawn up towards the chin, and the buttocks projecting over the edge of the bed or couch, or, if deemed more convenient, he may be placed in the same position as for the operation of lithotomy. Some years since I removed an ivory tube from the rectum of a woman, who was under my care, suffering from dyspepsia and torpor of the bowels, to which she had been subject for a considerable time. The rectum being in a relaxed condition, besides prescribing medicines to be taken by the mouth, I had directed her to inject a slightly astringent enema morning and evening: the apparatus she used for the purpose consisted of a pig's bladder, into the neck of which was tied a smooth ivory jet, and on this occasion, while using it, the tube was forced from it into the rectum; she immediately sent for me, and I saw her within half an hour of the accident: on making an examination, the tube was felt immediately above the margin of the internal sphincter; it was extracted without difficulty, a pair of oesophagus forceps being used for the purpose. Three years since, a physician was suddenly seized, while walking, with severe irritation and pain at the anus: on his return home he bathed himself with hot water, but it failed in affording any relief: the finger being introduced within the anus, a portion of bone was felt and removed; it was a piece of mutton bone, with very sharp angular corners, and had it not been extracted thus early, doubtless it would have perforated the intestine. In the early part of 1856, I received an urgent request from a professional friend to visit him immediately, he being suddenly seized with a severe and sharp pain at the fundament. When I saw him, he was lying on a sofa, and was afraid to move, as the least motion produced the sensation of something running into him. On making an examination, the sphincter was found contracted; the finger introduced into the bowel came in contact with a fish-bone, one end of which had perforated the intestine about a quarter of an inch above the anal margin. With a pair of polypusforceps, I grasped its upper extremity, and pushing them upwards, drew the bone out of the tissues; then with the point of it resting on the index finger of the left hand, I removed it without difficulty or causing any pain. No evil consequences followed. We shall more often be called upon to remove from the rectum intestinal and alvine concretions than any other substances: I have had on several occasions to free the bowel of accumulated and indurated fæces. These cases occur mostly in females, and depend on the greater capacity of the pelvis permitting of accumulation, combined with the very general habit in them of postponing the calls of nature: when it occurs in men, they are generally advanced in years, or are the subjects of paralysis. A lithotomy scoop is the best and most convenient instrument for our purpose; but if that be not at hand, the handle of a tablespoon is a very good substitute: with either of these, and the forefinger of the other hand, there will be no difficulty in effecting the object. After we have emptied the bowel as far as we can reach, enemata of warm soap and water, or olive oil, with decoction of barley, should be injected into the bowel by a long elastic tube, as often as may be deemed necessary, so as to entirely free the intestines; after which cold water or slightly-astringent enemata must be used to restore the tone of the bowel lost by the distension to which it had been subjected. Mr. Lacy,' of Poole, in May, 1853, removed piecemeal from the rectum of a lady, a concretion "at least fifteen inches in circumference." The outer part of it consisted of concentric layers of what looked like red sandstone, and which proved, on examination, to be a compound of iron and magnesia. The interior was a softer mixture of the earthy and ferruginous matters, with many thousands of strawberry and other seeds. Mr. Jones, of Llandyssul, removed three concretions from the rectum of a farmer; two of them were as large as a man's fist. "The concretions consisted of layers of a substance of a brownish color, much harder than leather, each of them containing a plum-stone for a nucleus." Sometimes ascarides nestle in the rectum in such numbers that they require to be removed manually, which is to be effected in the same manner as fæcal collections, but we cannot thereby remove the whole; and as they rapidly increase if any remain, additional means must be had recourse to: our end may be effectually accomplished by injecting from two to eight ounces, according to the age of the patient, of infusion of quassia; or olive oil, or turpentine in gruel, may be used: a dose of jalap, calomel, and aromatic 1 "Pathological Transactions," vol. vi, p. 203. powder should be prescribed to be taken early in the morning, and by these means the bowels will be thoroughly cleared. An important point, and one frequently overlooked in these cases, is to remove the debility of the intestines that always exists and favors the development of these entozoa: the bitter infusions and mineral acids are the best medicines for this purpose; they will prevent the great secretion of mucus which forms the nidus of these parasitical creatures the bowels must at the same time be kept regular by purgatives. The subjoined are some of the curious and interesting cases of foreign bodies in the rectum which are on record :— Nolet,' surgeon to the Marine Hospital at Brest, relates the case of a monk, who, in order to cure himself of a violent colic, introduced into the rectum a bottle of Hungary wine, having previously made a hole through the cork, to permit the fluid to flow into the intestine. In his desire to accomplish his object, he pushed the bottle so far that it completely entered the gut. Various means were tried to remove it without effecting the object; at last, a boy between eight and nine years of age succeeded in introducing his hand into the bowel, and withdrew the bottle. Tuffell, in 1813, removed a flask of crystal from the rectum; but was obliged to break it before he could accomplish its removal. Dessault, in endeavoring to remove a porcelain jelly pot, of conical form, and about three inches in length, fractured it in several pieces; however, he succeeded in removing them without injuring the intestine. Buzzani,2 in the year 1777, at Turin, extracted from the rectum of a man a teacup, which the patient had himself introduced, for the purpose of dilating the bowel. Morand3 records the two following cases: A man about sixty years of age presented himself at the Hôpital de la Charité, complaining that the pipe of a syringe had entered his rectum. Gerard introduced his finger, and felt a foreign body, which he removed with a pair of lithotomy forceps. It proved to be a large knitting-sheath of boxwood, six inches in length. A weaver, who 1 "Observations curieuses sur des Phénomènes Extraordinaires qui regardent particulièrement la Médecine et la Chirurgie."-Obs. xxxiii, p. 103. 2 "Lancet," 1855-6, p. 23. 3 "Mém. de l'Acad. Roy. de Chirur.," Paris, 1700. |