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the anus. Commencing at the upper end and at right angles with this, another deep incision is made, extending to the left border of the sacrum. This triangular flap is now quickly dissected up, thus laying bare the coccyx and a portion of the sacrum. The coccyx is next enucleated; the greater and lesser sciatic ligaments are divided close to the bone, and, with scalpel or scissors, the portion of the sacrum it is proposed to remove is separated from the subjacent tissues. Now, with suitable bone pliers or chisel, the exposed portion of the sacrum may be removed. The portion of bone removed may be a triangular piece, exactly corresponding with the integumentary incision; or, starting from the left edge of the bone, the cut may extend in a curved or oblique line downward and across, thus removing the entire lower end of the sacrum. The latter is seldom necessary, as the removal of the smaller portion ordinarily gives a sufficiently free field for operation. If the disease is confined to the anal end of the rectum the removal of the coccyx and retracting the dissected flap may give ample field for operation without removing any portion of the sacrum. In all cases, while the success of the operation should not be jeopardized in attempting to save the sacrum, only such portion should be removed as may be necessary, and never above the lower edge of the third foramen. To go farther up would involve dividing important nerves. Thus far there has been little hemorrhage and no important nerves have been injured. The rectal pouch is now exposed and may be readily dissected from surrounding tissues. Care must be taken, however, when releasing its anterior wall lest the genito-urinary organs be injured, the bladder and prostate, or vagina being in close apposition.
The rectum should be released to a point at least an inch above the limits of the disease, and gentle traction applied to see if the gut can be drawn down to supply the place of the portion to be removed. If the disease extends far up, the peritoneum will have to be opened, and if the mesentery is short it must be divided, which should be as far from the wall of the bowel as possible. This should be done and the peritoneal cavity closed by careful suturing before the rectum has been divided, lest, notwithstanding the utmost care, escaping contents infect the peritoneal cavity. The limits of the disease having been discovered, we have to decide whether the operation shall be extirpation of the entire lower portion of the rectum, including the anus and sphincters, which will, of course, be necessary if the latter tissue is involved, or excision of the diseased section, thus leaving the anus and sphincters intact and allowing an end-to-end union of the divided gut. Whichever operation is chosen, with an under packing of gauze to protect the wound from any small amount of infectious matter that may escape, two gauze ligatures should be tied around the rectum above the disease and the gut divided between them. If extirpation has been decided upon, the rectal pouch is lifted from the wound and the remaining portions, including the sphincters, quickly removed. This is attended by a profuse flow of blood from the hemorrhoidal vessels, but it can usually be checked by firmly packing the wound with two or three sterilized towels, which, being removed, any vessels still bleeding may be ligated.
The divided end of the rectum should now be cleansed with some germicidal wash, and, with its gauze ligature remaining, it is brought down and stitched to the remaining anal tissues. It is often too short to admit of this. In that case, it is deflected and brought to the surface as near the location of the anus as possible. This may be at the upper angle of the wound. Indeed, if the orifice cannot be at the anal site, rather than put undue tension upon the gut, the upper angle of the wound should be chosen.
If excision is chosen, no little skill will be required in so suturing together the ends as to protect against the escape of gas or fluids until union is complete. This is best accomplished by a double row of sutures, the first including the mucous and muscular layers, and the second after the manner of Lembert, by bringing the outer surfaces together with sutures extending through the walls to, but not piercing, the mucous membrane. If everything goes well, union should be complete in four or five days. Some watching will be required lest there result a cicatricial stricture. Whether the operation be excision or extirpation, the wound should be closed with deep supporting sutures of silkworm gut and superficial catgut. Drainage should be provided by a wick of gauze for two to four days.
A case in which I recently operated is instructive in showing the liability to failure in apparently favorable cases, and especially in having the apparent failure modified by obtaining desirable results that could not be anticipated.
Mrs. J. came to me in March with the following history: During the last five years she has borne five children. All of the labors were hard. Three were very tedious, and in four forceps were used. The last labor was in January. She had been in labor twenty-four hours when forceps were applied. During the delivery the operator was surprised to see a free flow of fresh blood from the rectum. She said attacks of bleeding from the anus had been frequent since the birth of the last child nearly two years before. , Since no pain attended the bleeding, she thought it was piles and unworthy of notice. Pains through the sacrum she had attributed to something else. These pains had of late become more and more severe, until they were almost unendurable, preventing sleep at night and interfering with her work during the day. They were not confined to the sacrum, but extended to the hips and down the legs. One sister had died of cancer of the rectum, otherwise the family history was good. Considering the drain of frequent child-bearing, the constant pain she suffered, and the loss of blood, which was at this time of almost daily occurrence, she was in a remarkably good physical condition. She was well nourished, and with the exception of a little puffiness under the eyes, showed slight cancerous cachexia. With the exception of a few enlarged hemorrhoidal veins around the anus, the lower end of the rectum was healthy. About an inch and a half above the sphincters was found a cancerous mass, involving the entire intestinal wall, and so impinging upon the lumen of the gut as to make the passing of the finger impossible, An examination per vaginam showed that the vaginal wall had not been invaded by the disease, it being freely movable over the growth, as, indeed, seemed the growth itself in its relation to surrounding tissues. Moreover, as far as examination through the vaginal wall could reveal, the extent of the disease was limited and the upper portion of the rectum healthy. Here was a case apparently most favorable for the Kraské operation.
She was admitted to the Massachusetts Homæopathic Hospital and prepared for operation according to the method already described. After the coccyx and a portion of the sacrum had been removed, great vascularity of tissues was encountered, and, as dissection around the mass of diseased rectum advanced, the hemorrhage was quite profuse, but easily controlled. As expected, an inch of healthy rectum was found between the sphincters and the diseased mass, thus far making possible excision and coapting the divided ends of the gut, which is the result always sought for.
The rectum being free in its entire circumference, an attempt was made to draw sufficient healthy gut from above to allow the application of ligatures and its section. A careful examination showed that the disease had extended up the posterior wall of the rectum and had caused firm adhesions to the promontory of the sacrum. A short mesentery could have been divided, but here was a condition that could not have been discovered before the operation, that blocked all further advance. We could only look for such relief as colotomy might afford at some near future day.
Excepting a small opening left for the wick of drainage gauze, the wound was completely closed with deep silkworm gut and superficial catgut sutures. There was a most remarkably profuse serous discharge, quite saturating the mass of dressings during the first few hours. This gradually lessened in quantity, and at the same time changed to pus. The patient proved quite intractable, turning from side to side, and even lying on her back, in spite of persuasive arguments and the watchfulness of nurses. As a result, the wound did not heal well. Hydrogen peroxide was used for a time, and then calendula water with better results. I wish to observe here that, while I recognize the value of hydrogen peroxide as pus-destroyer in cleansing suppurating surfaces and cavities, I have come to question its use where rapid repair of tissue by granulation is desired. It seems to retard granular growths, perhaps by destroying the new granular construction cells along with the pus.
From the third to the tenth day she suffered more or less from pain in her legs, her knees and feet being hot and swollen, like rheumatism. There was also elevation of temperature. Whether this was really rheumatism, to which she said she was subject, or the effects of the operation, is an open question. Under such remedies as bryonia and rhus the pain and swelling subsided. She suffered little other pain, and expressed great gratitude for the operation, because it had given complete relief from the intense sacral pain before complained of.
She was kept on strictly liquid diet—meat broths, malted milk, raw eggs, cream, etc. At the end of a week an attempt was made to evacuate the bowels by the aid of cathartics, but it was only after three days of trial that it was accomplished. It was determined to induce an evacuation every second day and continue the liquid diet. She soon, however, rebelled against the diet, and it seemed necessary to extend the bill of fare; hence milk, meat, some bread and a little fruit were added to the list. The bowels were moved with less freedom and finally ceased altogether. Notwithstanding the restricted diet and the free flow of pus, she kept up a good degree of strength and the emaciation was less than might have been expected.
The sacral wound was now healing rapidly, and I hoped that it might be complete before colotomy, which I knew could not be long deferred, would be necessary. In this I was disappointed. After two weeks had passed without defecation, although some gas had escaped, obstinate vomiting set in, which soon became stercoraceous. Signs of exhaustion increased. The pulse was weak, soft, 100; temperature, 96.6°. I decided that an emergency operation was demanded, and made an inguinal colotomy in the evening, May 12, six weeks from the time of the primary operation.
It was evident that immediate vent must be given to the distended bowels. To do that before adhesions have formed between the protruding intestine and the peritoneal-covered edges of the abdominal wound adds greatly to the dangers of the operation, in that it leaves an open way for fecal discharges to find entrance to the abdominal cavity. To avoid this danger and at the same time to provide immediate outlet for the accumulated gas and fecal matter, I devised a method that, as far as I know, has never been used before. I provided an aluminum tube 5-8 inch in diameter, 2 inches long, with a deep flange on one end. It was, indeed, a drainage tube cut short. Also a rubber tube 3 feet long. After the gut had been brought out and the retaining stitches put in, I encircled a 1-inch diameter surface of the most prominent portion of the intestine with a Lembert suture of silk. After having packed gauze around the intestine, I made a crucial incision and immediately buttoned in the tube with the rubber attached, and by means of the Lembert suture, as a purse string, drew the intestine closely around it. The metal tube was carefully supported with the gauze dressings so as to prevent traction on the intestine, and the patient put to bed with the free end of the rubber immersed in a jar of carbolized water. The device worked perfectly in giving free escape of gas and feces until the second day, when the protruding intestine was removed.
The colotomy necessitated her lying on her back for several days, to the utter neglect of the partially-healed sacral wound. As feared, the condition here rather grew worse.
Careful attention, however, and feeding the granulations with bovinine induced rapid repair. The patient's general condition rapidly improved. She suffered almost no pain. At times some pus and mucus escaped in small quantities from the anus. For its healing, as well as constitutional effects, I ordered her to inject into the rectal end of the divided gut a solution of salicylic acid at least twice daily.
At the end of two months after leaving the hospital, she reported herself as about and in fairly good condition.