CHAPTER XII. IMPACTED F^CES AND FOREIGN BODIES. (Part 2)

moderate sum. He died seven days later."' Napoleon relates a case of considerable historic interest where the ali- mentary canal was used for the purpose of secreting dispatches. * Randolph Wmslow, Maryland Medical Journal, March, 1880. « Arch. G^n. de M6d., 3e Serie, 1839, p. 353 (Poulet). 17 258 DISEASES OF THif RECTUM AND ANUS. "When I commanded at the siege of Mantone, shortly before the surrender of this fortress, a German was arrested while endeavoring to enter the city. The soldiers, who suspected him of being a spy, searched him without success; they then threatened him in their own language, which he did not understand. Finally a Frenchman was called who spoke German slightly, and who threatened him, in bad German, with instant death if he did not at once disclose all he knew. He accompanied this threat with furious gestures, drew his sword, placed the point of it upon his belly, and said he was going to slit him open. The poor German, frightened and not understanding the jargon of the French soldier, imagined, when he saw him threatening his belly, that his secret was dis- closed, and cried out that it was unnecessary to slit him open, and. that if he waited a few hours it could be obtained in the natural manner. This gave rise to fresh questions; he stated that he was the bearer of dis- patches for Wurmser, and that he had swallowed them as soon as he found himself in danger of being captured. He was carried to my headquarters, whither several physicians were summoned. It was proposed to admin- ister a purgative, but they stated that it was best to await the operation of nature. He was then confined to a room under the surveillance of two staff officers, one of whom was constantly near him. After several hours the expected object was found. It«was inclosed in wax, and was as large as a nut. When opened it was found to be a dispatch written in the hand of the Emperor Francis, and which requested him not to be dis- couraged and to hold out a few days longer, when he would aid him with a strong column." Napoleon, upon these indications, left with his troops and completely defeated Alvinzi at the passage of the P6. 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 giving 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 intestines without a surgical operation for its removal, provided only the diagnosis were clear. The complications which may attend the detention of such substances in the rectal pouch just above the internal sphincter are ulceration with perforation, haemorrhage, and abscess. Ulceration may be caused by the pressure of a large body, and may cover a considerable 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 ^ Memorial de Sainte Helene, t. ii., p. 468 (Poulet). IMPACTED F^BOES AKD FOBEION BODIES. 259 more or less pain^ purulent discharge^ and perhaps also a sharp hsemor- rhage from the erosion of a vessel. When perforation of the wall of the bowel has occurred, inflammatory action is almost sure to be excited in the surrounding parts, and this may vary greatly in its extent and grav- ity. If the injury be above the point of reflection of the peritoneum, it may cause either a localized or a general peritonitis. A general peritoni- tis caused in this way will be fatal, as it is also generally accompanied by more or less extravasation of faeces. A circumscribed peritonitis with formation of an abscess is a less fatal complication. Under these circum- stances 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 discovered, 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 perityphlitis, 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 <5ause be discovered and removed; but the usual termination is in suppu- ration, and the pus, if not removed by the surgeon, may find its way into the general peritoneal cavity or into the bladder or rectum. Abscesses of the superior pelvi-rectal space have already been described, and those which are due to foreign bodies in the bowel do not diifer from them in general characters. Spontaneous cure may follow the rupture of such an abscess into the rectum or bladder, but an incurable fistula is more apt to result even after the foreign body has been discharged. In one such case I was able to withdraw the pus through the abdominal wall with the aspirator, and subsequently, when the abscess cavity again filled up, I incised it through the rectum just behind the prostate. This opening was kept from clos- ing by the daily introduction of the end of the index-finger, and the ab- scess finally healed very kindly — a result which was in great measure due to the fact that the patient was a child of twelve years, and not an adult. When the focus of inflammation is located below the reflection 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 already laid down; but here the difficulty 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 endeavor to relieve himself of piles or pro- lapse; 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 m the practice of an unnatural vice. Edward II. is said to have met his death by having a red-hot Iron thrust into the rec- tum. ["We seized the king," said one of the murderers, "and threw him forcibly upon the couch, and, whilst I kept him there by the assist- 260 DISEASES OF THE SECTUM AND ANUS. anoe of a table^ with a pillow on his face, Ournej inserted through a horn-* tube a red-hot iron into his bowels." Gross, Vol. ii., p. 627.] The case of the prostitute into whose rectun^ the students of the Uni- yersity of G-ottingen introduced a pig's tail, butt end first, is as follows: ^'Some students had formed the plan of playing a practical joke on a prostitute; they determined to push into her anus a frozen pig's tail. They cut the hairs very short in order to make them sharper and rougher,, then dipped it in oil, and forcibly introduced it into the woman's anus,, with the exception of a portion three fingers* breadth in length, which remained outside. Several attempts were madd to extract it, but,' as it could only be withdrawn against the hairs, the bristles entered against the mucous membrane, and gave rise to excruciating pain. In order to relieve it, various oily remedies were given by the mouth, and the attempt was made to dilate the anus with a speculum in order to extract tho tail without violence, but it was unsuccessful. Severe symptoms devel- oped, violent vomiting, obstinate constipation, very high fever, and intense pains in the abdomen. Marchettis was summoned on the sixth day. This physician, having been informed of what had happened, in- vented a very simple and ingenious device. He took a hollow reed, one end of which he prepared so that he could easily ii^troduce it into the anus, and completely inclosed the pig's tail in this reed, in order to with- draw it without pain. For this purpose he attached to the tail, by the end which projected from the anus, a stout wax thread which he passed into the reed. With one hand he pushed this form of canula into the rec> tum, and held the cord in the other, to prevent the tail being pushed in still further. He succeeded in completely inclosing the tail, and promptly relieved the patient.'" 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 fragile objects, such as the wooden pickets of a fence, which have broken off and re- mained in the rectum, are on record. The list of foreign bodies which have been lost in the rectum by ignor- ant 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 bot- tles, s ticks 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 long ish oval flat stone, about 6} inches long, 2^ inches wide, 1^ inches thick, and weighing nearly two pounds, which a patient in Bornholm intro- duced into his rectum to prevent prolapse, from which he had for a long 1 Hevin, p. 880. DiPAOTED F^CES AND JPOBSIGN BODIES. 261 time suffered. The stone was extracted by a surgeon, Frantz Dyhr, in 1756.* Reali operated in 1849, in the hospital at Orvieto, on a peasant who nine days previously had introduced a piece of wood into the rectum for the purpose, as he said, of economizing his food, and preventing it irom passing out too quickly. He had violent pain. On exploration, the finger could feel the base of the piece of wood lying in the hollow on the sacrum, and surrounded by the broken mucous membrane. As re- peated attempts at extraction led to no result, Beali made an incision in the right iliac region, and found that the foreign body lay in the sigmoid flexure, which it had dilated and pushed to the middle line nearly as far as the umbilicus; he incised the intestine, removed the foreign body, and closed the intestinal wound by Jobert's method. The patient was treated by purgatives (!) and had entero-peritonitis and abscess in the iliac fossa, but recovered, and two years afterwards was in perfect health. The foreign body was a piece of chestnut wood of the shape of a trun- cated cone, 10 inches long, and about 3^ or 4 inches in diameter. A little case with very ingenious housebreaking and other thieves' in- 48truments was found by Dr. Closmadeuc at the necropsy of a man if the prison at Vennes. 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 mean time, was found erdpty. On section, the case, which was cylindro-conical in form, lay in the trans- verse colon, with its apex directed towards the caecum; it was of iron, and was wrapped in a piece of lamb's mesentery; it weighed about 23 ounces, was about 6^ inches long, and 6^ in circumference, and contained 13 tools and some coins.' "A monk, desiring relief from a severe colic from which he was suf- iering, was advised to introduce into the rectum a bottle of Hungary water, in the cork of which there was a small opening, through which the water gradually distilled into the intestine (these bottles are usually long). He pushed it so far that it entered the rectum altogether, whereat he was greatly astonished. He could neither have an evacuation nor Tcceive an enema, inflammation and death were apprehended. A mid- wife was consulted in order to see whether she could introduce her fin- ger and extract the bottle, but she was unable to do it. Forceps, a ripping-iron, and- anal speculae were useless. It could not be broken; this would have been more disastrous as the pieces of glass would have wounded him. Finally, a little boy, eight or nine years old, was found, > Bull, de la Sec. de Chir., 1878, p. 660. ' London Med. Record, Dec. 15th, 1878. Abstract of Studsgaard's paper read before Soc. de Chir., Paris, Oct. 9th, 1878. S62 DISEASES OF THE BEOTITM AND ANUS. who introduced his hand, and had sufficient address to cure the good monk." ' A depraved sexual appetite has been mentioned as accounting for the presence of many foreign bodies. It is known that sexual orgasm may^ be excited by stimulating the reflex power of the rectum, and it is prob- able that at the moment when the orgasm is at its height, the body used, to produce it is allowed to escape from the hand and is lost within tho 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. The following case is one in point, and the age of the patient is suggestive, for this vice is said to be more common in old men than in others — ^men whose physical powers have not kept pace with their desires. " On the afternoon of March Ist, 1848, a young man consulted Par- ker with regard to his father, whom he had brought into the hospital After beating around the bush and manifesting considerable shame and embanassment, he stated that his father, named Loo, who was sixty years old, had passed the previous night in a house of prostitution. Overcome by«drink and opium, the old debauchee conceived the strange notion of pushing a goblet, two and a half inches in diameter and three and a half inches long, into the vagina of his partner. During the night, while Loo was completely intoxicated, the woman attempted to revenge herself. She carefully introduced the bottom of the goblet into the rec- tum, placed the end of the opium pipe, which was a foot and a half long, into the goblet, and pushed it into the rectum. The goblet dis- appeared and had been retained twenty-four hours. A piece of the edge, about half an inch long, had been broken off by the friends in attempts; at extraction. The glass was firmly fixed, and it was very difficult to pass the finger between it and the rectum. Parker, determining to break it, employed a cephalotribe and removed it in pieces, taking care to pro- tect the parts with cotton. The most difficult part was the extraction of the glass, which was very irritating. It was done, but not without diffi- culty, by making it see-saw from side to side. Considerable haemorrhage occurred, which was arrested with sulphate of copper and alum. The man recovered in two weeks."' 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, aitd to indicate the size of the body which the sphincter will allow to pass. Among them may be ' M6m. de TAcad. de Chirurgie. ' Amer. Joum. of the Medical Sciences, 1849, p. 409. IMPACTED F^CES AND FOBEIGN BODIES. 263 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 shoyel twenty-two centimetres 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. However, he performed the manipulation so unskilfully that the piece of wood broke and remained partly within the rectum. All attempts made to remove the foreign body failed; two days later, he suffered from abdominal and lumbar pains, dysuria, and constipation. Weigand being consulted by the physician, recognized the symptoms of enteritis. As the introduc- tion of a finger into the rectum did not demonstrate the presence of a foreign body, he restricted himself to combating the inflammatory symp- toms and pain (calomel, enemata, narcotics, leeches). On the eleventh day a purulent, sanguinolent, fetid fluid was evacuated, after which the patient felt markedly relieved; but it was impossible to discover any trace of the piece of wood. Weigand then expressed serious doubts as to whether a foreign body was really contained in