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CHAPTER XII.

ABSCESS NEAR THE RECTUM.

Abscess or abscesses forming in the vicinity of the rectum demand especial attention, and more prompt treatment than when occurring in most external parts of the body, in consequence of the evils immediately depending upon them, and the sequelae arising from implication of the bowel.

Purulent formations in the neighbourhood of the rectum are not of infrequent occurrence, from the nature of the tissue surrounding the terminal portion of the intestinal canal, which is especially prone to suppurative action; and in this locality the predisposition is increased by the looseness of the tissue itself, by its being unsupported by surrounding parts, by the numerous blood-vessels that exist there, and their liability to congestion from position and other causes.

Abscesses near the rectum occur under various circumstances; they may be idiopathic, and either acute, subacute, or gangrenous; they occur after fevers and diseases of a debilitating character, and in these cases appear critical; they may be produced by cold and damp, as sitting on stone benches, on the wet ground, or a wet seat while driving: they also arise from various causes in connection with diseases of the rectum, as in stricture of that part; with the existence of internal and external piles; with ulceration of the lacunar and perforation of the coats of the intestine, the result of inflammatory action arising from the entanglement of the faeces in the follicles, or other causes mentioned in the Chapter on Inflammation of the Rectum. Constipation and accumulation of faecal matter in the rectum and colon will induce the formation of abscess by causing congestion of the vessels, which is increased during defecation by the violent straining to expel the hardened excrement. Foreign bodies penetrating through the tissues of the intestine and sphincter muscle into the cellular membrane, such as fragments of bones and other substances that have been swallowed: injuries from without, as blows or wounds, lead also to suppurative action.

Abscesses sometimes present near the rectum connected with disease in other parts, as with caries of the spine, ilium, or sacrum, with disease of the hipjoint, and with affections of the uterus, prostate gland, &c. They are also met with in patients labouring under various organic diseases, either of the liver, heart, or lungs: phthisical patients are often sufferers from abscesses near the rectum, which generally lead to the formation of fistula in ano.

The acute idiopathic abscess is generally preceded by thirst, dryness, and heat of skin, scanty and highcoloured urine, and, in fact, by the usual symptoms of pyrexia. In the part itself there will be heat, pain, throbbing, tumefaction, and more or less redness of the integument. These symptoms continue for a few days, when at length pus is formed, rigours frequently marking its advent. When suppuration has been fairly and fully accomplished, the feverish symptoms subside, and the patient generally becomes cool and comparatively easy. Although the swelling may now be considerable, and the part exquisitely painful to the touch, the acute throbbing previously experienced diminishes, and is superseded by a dull, heavy sensation. If no surgical means be adopted to evacuate the matter, nature will form an opening for its discharge either externally through the integument, or internally through the intestine.

The subacute abscesses generally form far from the surface, and frequently contain a considerable quantity of ill-conditioned pus: at first they do not occasion much pain or inconvenience; a sensation of bearing down of the rectum is experienced by the matter pressing upon it, but as it increases in quantity it gives rise to severe and distressing symptoms; there will be violent spasm attended with great pain; there will also be a constant desire to go to stool, although the bowels are free from faecal accumulation. In other cases there will be no local symptoms of the existing mischief, and the constitutional ones may be obscure and perplexing. Sir Benjamin Brodie* mentions the case of a gentleman he attended, in whom an abscess formed by the side of the rectum, and who was not conscious of any local symptoms. He had been for some time subject to headache and languor, and was obliged to go home and lie down during the day. The first notion he had of the existence of the purulent collection was its bursting one day while he was walking.

As mentioned, the pus in these abscesses is not of a healthy character; it is, for the most part, of a dark colour, and frequently excessively fetid: the latter circumstance may be owing to its contamination with faeces entering by a small aperture in the intestine, though I suspect it more frequently depends on the transudation of gases or fluids; indeed, the stench is often much more fetid and offensive than any unlimited quantity of feculent matter.' In a case I operated on in 1853, the foetor was intolerable, and * 'Medical Gazette,' vol. xvi., p. 26.

a free use of the chloride of lime was necessary in the ward of the infirmary where the patient was; and I remember a similar case, some years since, at University College Hospital: in neither could any connection with the bowel be detected, and they both healed without forming fistula, or requiring anything more than keeping the incision from closing till the cavity had filled from the bottom.

Gangrenous abscess usually occurs in those whose constitutions have been impaired by luxurious living, or by debauchery and excesses. The symptoms commence with rigours attended with fever: the pulse at first is full and hard, the tongue is coated, the skin dry and hot, there is great thirst, loss of appetite, and general restlessness; but the character of the symptoms soon changes, the fever becomes of the adynamic type, the pulse is then weak, quick, and irregular, the countenance flushed, the tongue becomes brown and dry in the centre, and the edges red and glazy, and, in the worst forms, the lips and teeth are covered with sordes. The secretions and excretions are disordered, extreme debility and prostration are present, accompanied with more or less stupor. With the early constitutional symptoms a deep-seated pain near the rectum is complained of, which increases and becomes of a burning character; if the part be examined, hardness will be found, which rapidly extends,

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