FIFTY CASES OF RECTAL SURGERY. BY B. MERRILL RICKETTS, M. D. Reprinted from Mathews' Medial Quart&dp, July, 1894. LOUISVILLE: JOHN P. MORTON & COMPANY. 1894 Fifty Cases of Rectal surgery. BY B. MERRILL RICKETTS, M. D. CINCINNATI, OHIO. [Written for Mathews' Medical Quarterly.] Although rectal disease offers one of the most fruitful and available branches of surgery, it seems to have been the most sadly neglected. In consequence thereof statistics avail but lit- tle, in that but few cases have been tabulated as compared with other kinds of surgery. Although cancer, stricture, fistulas, hemorrhoids, ulcers, fis- sures, etc., have been recognized from time immemorial as the more common conditions existing within and about the rectum, the treatment, until within a comparatively recent date, was of but little consequence. The progress in their management, how- ever, has been as varied within recent years as in the management of any other class of surgical cases. Lives are not only saved, but prolonged, comfort given and pain relieved in these conditions so often found about the anus. It is my personal experience in the treatment and good results obtained in these various conditions which prompts me to offer the following observations upon fifty subjects on whom I have operated for the various conditions herein mentioned : 2 RICKETTS: FIFTY CASES OF RECTAL SURGERY. Number Sex Chloroform.... Cocaine Duration OPERATION. Cancer Syphilis Tuberculosis.. Stricture Hemorrhoids.. Fistula Fissures Ulcers Extensive Loss of Time. Sphincter REMARKS. 1 25 M. W. 1 6 yrs... Cautery, ligature and cut. Yes 2 1 1 Yes Yes 2 wks.. Good Good recovery. Cured. 2 28 M. w. 1 4 yrs... Ligature Yes 3 4 dys... Good Cured. 3 57 M. w. 1 8 yrs... Clamp & cautery, division Yes 4 1 Yes 3 dys... Good Cured. 4 51 M. w. 1 6 yrs... Clamp and cautery Yes 6 Yes Yes 2 dys... Good Cured. 5 >6 M. w. 1 Life ... Clamp and cautery Yes 7 5 Yes 3 wks.. Good Very slight trouble remaining. 6 29 M. w. 1 yrs Clamp a cautery, division Yes 4 Yes Yes Yes 1 wk... Good Cured. 7 31 F. w. 1 4 yrs... Ligature Yes 1 None.. Good Cured. 8 JI M. w. 1 2 yrs... Ligature Yes 2 None.. Good Cured. 9 35 M. w. 1 3 yrs... Ligature Yes 1 None.. Good Cured. 10 >9 F. w. 1 % yrs Division, knife 1 1 dy.... Good Cured. 11 35 M. w. 1 9 mos.. Curette and cautery + Bad.. Died eighteen weeks later. 12 45 F. w. 1 2 wks.. Curett'd,extensive slough Yes Yes Poor. f Died three days later. Slough about 1 sphincter. 13 34 M. w. 1 2 yrs... Division, knife Yes 1 Yes 2 dys... Good Cured. 14 48 M. w. 1 3 yrs... Division, clamp & cautery Yes 1 1 Yes Idy.... Good Cured. 15 65 F. w. 1 18 mos.. Division with finger Yes 1 1 Yes 1 wk... Good Cured. 16 28 M. w. 1 3 yrs... Division with finger Yes 1 Yes 2 dys... Good Improved. 17 26 M. w. 1 1 yr Division, knife Yes 1 10 dys... Good Cured. 18 40 M. w. 1 14 yrs... Knife Yes 2 3 wks.. Good Cured. 19 38 M. w. 1 2 mos.. Knife 1 2 dys... Good Cured. 20 34 M. w. 1 i yr Clamp and cautery 3 1 Yes Good Cured. SUMMARY. RICKETTS: FIFTY CASES OF RECTAL SURGERY. 3 <=21 29 M. W. 1 3 wks.. Knife 1 1 wk... Good Cause: Gonorrheal(?). Cured. <=22 24 F. w. 1 10 dys... Knife Yes 1 1 wk... Good Cause: Rectal connection.(?)Cured. <=23 38 M. w. 2 wks.. Knife 1 10 dys... Good Trauma. Cured. <=24 44 M. w. 10 dys... Knife 1 2 wks. Good Cause: Gonorrheal(?). Cured. 29 M. w. 3 wks.. Knife Yes 1 2 wks.. Cause: Gonorrheal(?). Cured. '>26 32 F. w. 1 2 wks.. Knife 1 3 wks.. Cause: Gonorrheal(?). Cured. <=27 39 M. w. 1 1 wk... Knife 1 2 wks.. Cause: Gonorrheal(?). Cured. <=28 F. w. 1 10 dys... Knife 1 4 dys... Cause: Trauma(?). Cured. 29 46 M. w. 15 mos.. Knife Yes 1 2 dys... Good Cured. 30 37 M. w. 1 3 mos.. Clamp and cautery 2 Yes 2 dys... Good Cured. 31 25 M. w. 1 7 mos.. Ligatures 6 Yes 3 wks.. Good Cured. 32 28 M. w. 1 8 yrs... Finger 1 Yes 1 wk... Good J Improved, operation repeated three 33 31 M. w. 1 2 yrs... Clamp and cautery 3 Yes 5 dys... Good ( times. Cured. 34 42 M. w. 1 6 mos.. Knife Yes 1 4 dys... Good Cured. 35 4 M. w. 1 (?) Knife 1 2 wks.. Good Cured. 50 M. w. 1 3 yrs... Used finger 1 Yes g Good Improved. 45 F. c. 1 4 yrs... Finger 1 Yes 3 dys... Good Improved. 38 29 F. w. 1 314 vrs Finger 1 Y'es 2 wks.. Good Improved and operation repeated. 39 37 M. w. 1 5 yrs... Finger 1 Yes 5 dvs... Good Improved and operation repeated. 40 34 M. c. 1 2 yrs... Finger 1 Yes 2 dys... Good Improved and operation repeated. 41 29 M. c. 1 3 yrs... Finger 1 Yes 4 dys... Good Improved. 42 F. w. 1 8 yrs... Finger 1 Yes 10 dys... Good Improved. 43 49 F. w. 1 3*4 yrs Finger Yes 1 Yes 6 dys... Good Improved. 44 62 M. w. 10 mos.. 1 Yes Bad.. Nothing done. Carcinoma. 45 48 F. c. 1 7 mos.. 1 Yes Bad.. Nothing done. Carcinoma. 46 47 M. w. 1 1 yr 1 Bad.. Nothing done. Carcinoma. 47 26 M. w. 1 3 yrs... Finger and knife Yes 1 1 2 dvs... Good Improved. 48 46 M. w. 1 2 yrs... Yes 1 mo... Good Whitehead's operation. Cured. 49 33 M w. 1 7 yrs... Yes 5 wks.. Good Whitehead's operation. Cured. 50 42 M. w. 1 5 mos.. t None.. Good Removed foreign body. * Ischio-rectal abscess. t Carcinoma. J Injury. g Few days. 4 RICKETTS: FIFTY CASES OF RECTAL SURGERY. The following deductions are made from the foregoing table : 1. White 46 2. Colored 4 3. Males 38 4. Females 12 5. Syphilitic 22 6. Tubercular 8 7. Hemorrhoids (seventeen patients) 48 8. Fistulas 23 9. Strictures 10 10. Fissures 7 11. Ulcers 7 12. Cancers 4 13. Extensive . . 23 14. Chloroform 42 15. Cocaine 3 16. Average age 36-f-years 17. Loss of time (average) l-pweek 18. Operations 47 19. Cured 33 20. Improved 12 21. Not operated upon 3 22. No deaths 0 In conclusion I will say that to do rectal surgery it is neces- sary to have the patient completely anesthetized, and that the use of chloroform is the quickest and best means of securing it. Cocaine has been used in this kind of work very unsatisfactorily. I do, however, give this drug the preference in minor surgery. As to the clamp and cautery, I rely wholly upon them in removing hemorrhoids of any size or number, it being the safest and quickest method, and enables the patient to be up and about sooner than after any other procedure. The application of the actual cautery to the entire number of ulcers and fissures at one sitting under the complete anesthesia has been the most efficacious means of destroying them that I have found. Division of fistula? with the bistoury has not failed in any RICKETTS: FIFTY CASES OF RECTAE SURGERY. 5 attempt to obliterate them, without in a single case destroying the function of the sphincter. Of the eight cases of ischio-rectal abscess we find five occur- ring at the time or immediately following an acute gonorrhea. Fistulse resulted, and were operated upon in each .of the eight cases. I believe that acute gonorrhea is the most frequent cause of ischio-rectal abscess in the male; however, an acute inflamma- tory process, due to any cause, is as likely to produce an abscess, the contents of which may escape into the rectum. It is interesting to note that thirty of the cases were either tubercular or syphilitic. In the four cases of carcinoma the dis- ease had progressed to such a degree as to render it unwise to attempt a radical operation, except toward the last when colot- omy should have been resorted to but was refused. Case No. 50 was unique in that in falling from a table a piece of ducking, one and a quarter inches square, was driven along the side of the rectum by a chair leg. The foreign body remained concealed for five months without detection, until I was consulted. A portion of the sphincter was torn away, but its office remains good at the present time. The average loss of time is but little for surgical cases of this nature.