A system of practical medicine. By American authors. Vol. 2

by Unknown

Chloride of zinc and caustic potassa are even more unsatisfactory agents for this purpose than the acid, as they are very violent in local destruction and their action is very difficult to limit. The use of caustic potassa was last revived by Amussat, but failed to find favor from his contemporaries, and soon fell into merited disuse. Van Buren says: "From recent experience with the thermo-cautery of Paquelin, I am disposed to regard it as more manageable than nitric acid, and at least equally efficient." Allingham mentions favorably the strong carbolic acid as a substitute for the nitric as an application to vascular and granular surfaces. The reckless method employed by the older surgeons of cutting off internal piles with the knife or with scissors, without any precautions against bleeding, is merely mentioned in condemnation. Usually no serious symptoms are to be expected after operations for hemorrhoids, but to this general rule there are exceptions. Morton knows of two consecutive cases of tetanus after this operation performed in a hospital in this city, and both terminated fatally. One of the most common occurrences after the ligation of piles is retention of urine, generally lasting for a day or two and requiring the use of the catheter.

HEMORRHAGE FROM THE RECTUM.—Bleeding from these parts is more usually of a venous than an arterial character, but in some cases of hemorrhoids the bleeding is either arterial or arterio-venous. The latter occurs upon the detachment of a polypus, but not necessarily of a polypoid growth. Arterial or mixed bleeding occurs in carcinoma and in rodent ulcer, and also from the stumps of badly-occluded piles. In cases of vicarious menstruation from the rectum the venous blood simply oozes from the surface of the over-congested mucous membrane. This condition should be readily diagnosed by the physical properties of the blood and from the history of the patient. In almost all cases of bleeding near the anus it will be possible to pick up the vessel or the bleeding point on a tenaculum and ligate with silk, which is the most satisfactory method to the surgeon. The rectum has been dragged down with volsella forceps to apply a ligature to a point high up, but in some of these cases the acupressure pin with the twisted suture will be found more convenient. Should hemorrhage occur after the ligation of piles which cannot be checked by ligature, such as a general oozing, pass all the ligatures through a hole made in the centre of a small round sponge, then tie them across a piece of stick (thus constructing a sort of tourniquet), and twist this around. Van Buren cites a case in which a sudden laceration of the integument and sphincter occurred during forcible dilatation in a case of hemorrhoids in a very broken-down subject, with very copious hemorrhage. He passed a sponge armed with a double ligature into the bowel, and, directing an assistant to make traction upon the threads, the bleeding was checked. Injecting ice-water and perchloride of iron into the rectum will often check hemorrhage. Allingham prefers the persulphate of iron to any other styptic for this purpose. Passing fragments of ice into the bowel while holding a lump of ice upon the sacrum sometimes answers a good purpose. In many cases of secondary hemorrhage from large venous sinuses in a state of ulceration it will be impossible to ligate, and the use of the ordinary styptics will be but the waste of valuable time: the bowel must be tamponed as follows: Thread a strong silk ligature through near the apex of a cone-shaped sponge, and bring it back again, so that the apex of the sponge is held in a loop of thread. Wet the sponge, squeeze it dry, and fill its meshes with ferric alum or with persulphate of iron. Pass the left fore finger into the bowel, and upon it push up the sponge, apex first, by means of a metal rod or any other convenient body, fully five inches into the rectum. Now fill the rectum below this with cotton-wool filled with the styptic. The bowel having been completely filled, make traction upon the ligatures (thus spreading out the bell-shaped sponge), while with the other hand push up the packing. If this is carefully done no fear of bleeding need be apprehended. In these cases the patient often suffers from collections of flatus, which may be obviated at the time of packing by placing a flexible catheter in the bowel and packing around it. These plugs should remain for at least five or six days, and frequently eight or ten days are none too long. The packing must then be picked carefully away from the sponge. Agnew's rectal chemise answers the same purpose. In describing its application he says: "Through the openings at the end of the largest-sized gum catheter pass a strong silk thread; take three square pieces of the material usually known as mosquito-netting, placing them one on top of the other; at the centre of these squares or pieces make an opening, and pass the catheter through it, securing the two together by the threads. In applying the instrument the different layers of the chemise must be moistened with water, and afterward well filled with the persulphate of iron. It is then conducted some distance into the rectum on a finger previously inserted; after which it is expanded like a parachute by packing between the catheter and its hood with long strips of lint thrust up on the end of a bougie until the bowel is distended on every side. The catheter will serve to conduct away the flatus, and when, after eight or ten days, its removal becomes necessary, this is very easily effected by drawing out the ribbon-like pieces of lint which were used as packing." Another method is to stuff the bowel with fragments of sponge to which threads are tied, the ends of which, protruding from the anus, facilitate their withdrawal. In conjunction with these procedures the patient's pelvis should be elevated. After excision of portions of the mucous membrane the risk of hemorrhage will be lessened by the surgeon introducing through the edges of each incision a few fine sutures.

Enormous quantities of blood may escape into the bowel after operations without any external symptom being apparent until the patient becomes pallid and weak. In other cases the patient will complain of tenesmus and desire to go to stool, or of a sensation of something trickling into the bowel. Upon the recognition of these symptoms search should at once be made for internal hemorrhage.

Rectal Alimentation.

Before taking leave of this very interesting class of diseases and of their modes of treatment, it seems proper to introduce a few remarks upon the subject of rectal alimentation, as it is now a well-recognized and much-practised means of sustaining those whose stomachs are unequal to the work which in health is so easily and unconsciously performed. In the use of the lower bowel as an absorbent surface of alimentary substances many failures have been reported, a fair proportion of which, it is safe to infer, are due to the methods employed, to the nutritive matters employed, and to the condition of the rectum at the time. Firstly, as to the state of the rectum, it must be empty. Wait a reasonable time, say an hour, after stool, so that the gut may be more passive; have the patient in the recumbent posture; direct him to resist tenesmus and to exert both the will and the muscular power to retain the aliment. The syringe must be of hard rubber, must be rectal-ended, and of the capacity of two fluidounces, and perfect in action.

The preparation to be introduced, after being warmed to a temperature of 98° or 99° F., should be very slowly injected with the syringe, which should be also warmed and oiled. The enema must never exceed in amount two fluidounces. If this be rejected, wait a reasonable time and try again, using a less amount. If tenesmus proves an insurmountable barrier to ordinary means, an opium suppository is to be introduced three hours prior to another attempt. It has been suggested, inasmuch as tenesmus is often relieved by the application of cold to the rectum, to introduce the aliment in that state; but this method is open to the objection that rectal digestion would be much less likely to take place under this condition, as the bowel would then have thrown upon it the additional work of warming up the substance prior to absorbing it.

The usual errors made in applying this means of sustaining the patient are, that the injections are too large, are too rapidly introduced, and are not of the proper temperature. Allowing an interval of eight hours between the enemata would afford three in the twenty-four hours, which method has been found to offer the best results. This must be persevered in at regular daily intervals for the patient to derive its full benefit, and there is reason to suppose that the nervous system gets expectant of these daily hours of support, as it does in the case of our ordinary meal-times. An examination of the well-formed daily stools of patients thus sustained will prove how close the analogy is between this and digestion proper.

Next, as to the substances to be employed. The best of these are milk, eggs, concentrated beef-extracts or beef or chicken peptones, and brandy or whiskey of good quality. These substances may be combined in various proportions to suit the individual requirements of the case. A very good mixture for this purpose is two tablespoonfuls of milk, one tablespoonful of whiskey, and an egg, using both the yelk and the albumen. To this add a little salt. This should be well beaten up and properly warmed.

It is well to persevere in the use of these enemata even though at first most of them appear to be rejected, as after a time, the rectum becoming accustomed to their presence, absorption or so-called rectal digestion may take place. This form of alimentation should be kept in reserve in a case of chronic illness until all other methods of sustaining the patient prove insufficient to support life. It is not contraindicated even in some cases of chronic diarrhoea with persistent vomiting and loss of peptic function, advantage being taken of the intervals between the evacuations to introduce a small and very concentrated nutrient enema. In ordinary cases not complicated by diarrhoea the most convenient times will be found to be about seven o'clock in the morning, three in the afternoon, and eleven at night. Wetherill suggests the possibility of forming with solid extract of beef, pepsin, and pure suet a nutrient suppository which might be retained and absorbed in some cases in which it has been found impossible to retain the enemata. A very small addition of white wax, he thinks, would keep these solid during warm weather; if not, the suet might be replaced by ol. theobroma (as in ordinary suppositories), which is probably as likely to be absorbed as the suet.