The bottom feeder

A couple of months ago I wrote about a case from 1812 in which a patient with a massive facial injury was kept alive by lemonade injected into the rectum. Coincidentally I’ve just come across this report, published in 1878 in the American Practitioner, which covers rather similar territory. It aroused considerable interest at the time, since it suggested a novel method of feeding patients with stomach cancers and other illnesses that made it impossible to eat.

The author, Austin Flint I, was an eminent New York medic, visiting physician to the Bellevue Hospital in Manhattan and president of the state medical society. ‘Rectal alimentation’ means feeding via the rectum. The article deals with several such cases, one of them so extraordinary that his colleague Dr Charles Bliss – who was also involved in the patient’s care – was reluctant to publish it, suggesting that their account would not be believed. But luckily Dr Flint did eventually persuade him otherwise.

Mrs. B., aged thirty-five years, had a severe attack of hemorrhage from the bowels in March, 1871, which was preceded by the discharge from the rectum of nearly a quart of fetid pus.

That sentence is really no way to begin the weekend, is it? Many apologies.

Prior to this time she had had repeatedly vomiting of bloody and purulent matter, with inability to retain any food in her stomach for many consecutive days. The hemorrhage from the bowels continued for several days, the quantity generally being from two to four ounces daily, but on one day it was quite profuse.

Dr Flint does not suggest a diagnosis, and I am at a loss to provide one. The discharge of blood and pus from the rectum suggests something rather serious – perhaps ulcerative colitis? – but the later symptoms do not necessarily fit.

This was followed by persistent vomiting, which was excited by everything taken into the stomach, even a spoonful of water and small pieces of ice. Under these circumstances, injections of beef broth were resorted to.

By ‘injections’ Dr Flint means enemas: the beef broth was administered via the anus.

After a short time, “Liebig’s extract of meat” was substituted for the beef broth.

You may know that name: this is the same Liebig who popularised the Liebig condenser, a piece of equipment almost ubiquitous in school chemistry laboratories. Justus von Liebig was one of Germany’s greatest industrial chemists. Among his many inventions was a method of producing a concentrated liquid meat extract, which appeared on the market in the 1860s – the forerunner of the stock cube.

This was injected for several weeks with the addition of warm water, but early in June, 1871, milk instead of water was added. Two teaspoonfuls of the “extract”, in a teacupful of milk, were injected after intervals of from three to five hours, together with sometimes a half or a whole teaspoonful of laudanum.

Quite large dose of opium – but Dr Flint observes that this patient ‘had been accustomed to take opiates freely’.

This treatment was continued until July 23, 1871, when another hemorrhage occurred, preceded as before by a discharge of fetid pus. It was then impossible to introduce into the rectum nutriment, and the stomach was intolerant of it, so that the patient became greatly exhausted from inanition.

Luckily the bleeding stopped after a few days, so the enemas could continue.

The hemorrhage recurred at intervals until April 26, 1872, always preceded by a purulent discharge; but the amount of blood at each attack was diminished. Meanwhile she was nourished by the rectum. Her general condition improved, and, at the date just named, she was able to visit her sister at Yonkers, carrying with her the meat extract and her syringe, and depending on alimentation by the rectum.

One hopes that she took her ‘meals’ in private, rather than administering them at the dinner table while the rest of the family cleared their plates.

In July, 1872, she was able occasionally to take a little milk and lime-water into the stomach without exciting vomiting. During all this time blood and pus were now and then vomited. From that date up to the date of Dr. Bliss’s communication, namely January, 1874, she was nourished chiefly by the stomach, and her health had slowly improved.

Still not a word about the possible cause of her malady. But now Dr Bliss casually throws in another symptom:

During the period embraced in the history just given, she had at times a discharge of pus from the umbilicus.

This adds an interesting new dimension to the case. Discharge from the navel can be caused by local infection, but it is often a sign of congenital abnormality. Does this offer any hint towards a diagnosis? Maybe.

The most commonly encountered congenital abnormality of the gastrointestinal tract is Merkel’s diverticulum, characterised by a bulge in the lower intestine. Many people are never aware that they have the condition, but when symptoms do appear they can included vomiting, bloody diarrhoea and even umbilical pain or infection. So perhaps this was the cause of this woman’s sufferings – but if anybody more expert than me would like to suggest an alternative, please do leave a comment below.

Dr. Bliss concludes his communication by saying: — “From the first week in March, 1871, until the last of June, 1872, I have no reasonable doubt that she subsisted solely on the injections.”

A period of some fifteen months. Dr Flint adds that he and his colleague both believed that their patient was honest and had no reason to deceive them.

The story does not exactly have a happy ending, since the woman’s illness was chronic: Dr Bliss reported a few years later that she was still affected by the condition. She was also afflicted by occasional seizures described as epileptic in nature, and had abscesses in her ears.

During all this period — namely, five years — she has much of the time depended on rectal alimentation; and she has steadily used the combination of meat extract and milk. From time to time she has been able to take into the stomach and retain milk, with cracker, toast and poached egg.

In his conclusion, Dr Flint coins a most unusual phrase:

The restriction of the rectal diet to meat extract and milk, is an important fact in the history of the case.

And of what should the ideal ‘rectal diet’ consist? This is a subject to which Dr Flint has devoted considerable thought – and the final section of his article:

Thus far, in the cases which I have had the opportunity of observing, the articles of diet employed have been the “meat solution,” and the “pancreatic meat emulsion” of Leube, “Liebig’s extract of meat,” with milk, milk either alone or combined with egg, beef, mutton and chicken broths.

The ‘pancreatic meat emulsion’ sounds most unpleasant. As so often in a medical paper, Dr Flint concludes that Further Research is Necessary.

These varieties have severally proved satisfactory, but it is desirable to determine more accurately than our present knowledge enables us to do, the combinations and variations which render rectal alimentation more effective, and also whether the range of rectal diet may not with advantage be extended.