Mrs G was a wealthy woman in her 60s who was accompanied by her husband. They had played a wonderful round of golf that sunny day, but she had developed increasing abdominal pain with each successive hole, and by the end of it she was in agony.
They came to hospital dressed in their classy tweed golf attire, and when we walked into her cubicle she lay perfectly in her bed while he read his luxury-watch magazine.
As usual, I started with an open-ended question so she could tell me from the beginning about her complaint and the evolution of it. I had already seen her blood tests and her X-rays and scans. Her blood tests showed she had a pancreatitis, and this was confirmed by her history and examination. She did not have gallstones, but they had given a dinner party the night before, and had consumed perhaps a little more alcohol than they would normally.
“What did you drink?” I asked.
“Brandy. We always drink brandy,” she replied.
I explained that it looked as if the pancreatitis episode might have been caused by alcohol, given that we had excluded all other causes and that the episode followed their dinner party. This upset both of them greatly.
“Can she ever drink alcohol again?” her husband asked with a worried look on his face.
“Unfortunately, there is no threshold over which we can accurately predict when she might develop pancreatitis,” I replied, then reiterated that this was a mild episode, but that people can be severely ill or die with it. Sometimes our best recommendation in such a scenario is abstinence, I explained, but obviously a patient has to make their own decisions.
She listened to all this, and said she would try to negotiate a safe amount of alcohol that she could drink on a daily basis.
“I’m sorry I can’t be more helpful with regard to the amount of alcohol you can drink safely,” I said, “but it seems this episode will settle quickly, and you should be able to go home in the next 24 to 48 hours.”
We said goodnight, and I left the room.
A moment later, her husband ran out after us, having just remembered an important detail. We stopped in the hallway to hear what he wanted to add. “We usually drink French brandy. Very expensive French brandy,” he said. “But we ran out and had to drink a much cheaper brand. Could that be why she has the pancreatitis?”
“I don’t think so, sir,” I heard my registrar reply.
*
A 35-year-old woman came to see me in clinic with an anal problem. The referral letter said that she had a large fleshy growth at the anal verge, and it was impairing her ability to work. It sounded awfully uncomfortable. We had a brief conversation about how long it had been there, if it was causing her pain and if it was bleeding.
I spread her buttocks apart in search of the large fleshy growth, but was disappointed to find a tiny little tag at what I would call the 12 o’clock position. She had a bit of extra flesh at the top of the anal verge, just behind the perineum. I completed a thorough check to make sure I was not missing anything. Gloves, lubricant jelly over the index finger, gentle internal examination of the anal canal, digital rectal examination, then a tube to examine the rectum and another tube to look inside the anal canal and check for haemorrhoids. The examination revealed no other findings.
Just this small, pathetic bit of extra tissue.
“Is this what you are worried about?” I asked her. “I would leave that well alone.” I then went on to explain that the procedure to remove the tag was not worth the trouble because it was so small and it was benign. It was barely worth mentioning.
“But I can’t work,” she said.
“What work do you do?”
“I am a high-end escort and I’ve been losing work because of this.”
I pushed down my absolute astonishment and filled out the booking for an excision under anaesthetic.
*
It was back when I was a registrar in urology that I had first become aware of nether-region preoccupations. In particular, I discovered that some men seem to like placing foreign bodies in their urethra – the tube that runs from the tip of the penis to the bladder. Men ejaculate and urinate through this hole. Why would someone want to push solid objects up there? One man let barely a day go by after being sent home before he put his toothbrush back into his penis – and not handle first. This guy’s penis had been forced to swallow a toothbrush whole, brush first. Why? But, even more importantly, why not the handle first? Still, maybe he was marginally saner than the razor blade guy. Yes, razor blades.
In general surgery, it is more common to encounter foreign bodies in the rectum. This was a highlight for all young surgical registrars, largely because of the storytelling.
Most of the time, the foreign body is retrievable simply by putting the victim to sleep – thanks to the anaesthetist – so that the voluntary sphincter mechanism of the anus no longer puts up a fight. I can honestly say I never had a female patient present with a rectal foreign body, whereas the male is a true victim because he has usually just been walking through the house minding his own business. It is always so unfortunate that he was going down the stairs naked and unaware of the Barbie doll lurking at the bottom until he slipped and fell on top of her. Or that the broom was standing upright when he slipped from the porch. Or that there were knitting needles standing on the bathroom floor when he hopped out of the shower. I learnt that some homes are incredibly dangerous, especially for men walking around naked in the presence of fruits and vegetables, light bulbs and jars. Stairs are the worst. You never know what is lying, or standing, at the bottom of them…
One patient was in his 20s and presented as a little confused. He had been at a party the night before, and now more than 12 hours later entered the acute assessment unit dressed casually in jeans and a T-shirt.
“What brings you to hospital?” the registrar asked. This was the sort of standard, open-ended question we are taught in medical school to ask so as to allow the patient to partake freely in the discourse.
“I think I have vegetables in my rectum,” he replied.
After a moment of unimpressed silence (the days are difficult enough without people trying to be mysterious), the registrar repeated, “You think you have vegetables in your rectum?”
“Yes,” the young man said, as if it was of no consequence, and apparently unwilling to divulge more than was asked of him.
“What makes you think that you have vegetables in your rectum?”
“I went to a party last night, and some vegetables went missing.”
More silence.
“What vegetables went missing?”
“A cucumber and a carrot.”
“And what makes you think they are in your rectum?”
“I don’t remember the end of the party. All I know is that vegetables went missing because I counted them before, and I am pretty sure they are in my rectum.”
It was not even a full moon.
*
After having escaped a drug raid, Mr D arrived at the emergency department looking panicked and dishevelled. That morning, the cops and their canines had knocked his door down and disrupted his sweet reveries. The liquid ecstasy in his cupboard jolted him into action. He placed every drop he had into the nearest jar, pushed it up his anus with brute force and jumped out of the window. Then, worried that he might disrupt his insides, Mr D headed straight for the hospital and asked the kind doctors in the emergency department for assistance. He was a thin guy with greasy hair and an air of nervousness about him, but who could blame him? He was probably ashamed of what we were about to find.
Sleeping peacefully under a general anaesthetic, and far away in a land of dreams without the police breaking down his front door, he was in the standard position for foreign body retrieval from his rectum: flat on his back with his legs in stirrups. We were surprised when a gloved finger into the rectum demonstrated just how big the jar was. Grabbing it was difficult. It would not budge. The male pelvis can be very narrow, as Mr D’s was, and the jar had firmly lodged itself in the warm embrace of his pelvic walls. Fingers and even the smallest hands failed, as did both the forceps and ventouse vacuum normally used to grab a baby’s head during a difficult vaginal delivery.
Time passed, and another specialist was called to theatre to assist. The big guns. This surgeon was the rectum specialist.
Still no luck. The decision was then made to open Mr D’s abdomen, make a hole in his rectum and retrieve the jar that way. This time, success!
Much to our horror, he had used a well-secured 250-millilitre jar. The maths did not quite add up – a few drops of liquid ecstasy in a huge jar stuffed up his anus seemed somewhat Darwinian. And, much to his horror, he woke with a far bigger scar than he’d anticipated and no doubt a very sore anus.
Plans were made to see him again in a few weeks, largely to assess his continence. With all the handling and instrumentation, we were worried. Surely he would have trouble holding onto his faeces with a disrupted sphincter.
Alas, he has not been seen since.
Taken with kind permission from the number one book on the Nielsen bestseller chart, On Call: Stories from My Life as a Surgeon, a Daughter and a Mother by Ineke Meredith (HarperCollins, $39.99), available in bookstores nationwide.
