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diff --git a/old/69288-0.txt b/old/69288-0.txt deleted file mode 100644 index 68d8b13..0000000 --- a/old/69288-0.txt +++ /dev/null @@ -1,2927 +0,0 @@ -The Project Gutenberg eBook of Treatment of hemorrhoids, and other -non-malignant rectal diseases, by William Penn Agnew - -This eBook is for the use of anyone anywhere in the United States and -most other parts of the world at no cost and with almost no restrictions -whatsoever. You may copy it, give it away or re-use it under the terms -of the Project Gutenberg License included with this eBook or online at -www.gutenberg.org. If you are not located in the United States, you -will have to check the laws of the country where you are located before -using this eBook. - -Title: Treatment of hemorrhoids, and other non-malignant rectal diseases - -Author: William Penn Agnew - -Release Date: November 3, 2022 [eBook #69288] - -Language: English - -Produced by: deaurider and the Online Distributed Proofreading Team at - https://www.pgdp.net (This file was produced from images - generously made available by The Internet Archive) - -*** START OF THE PROJECT GUTENBERG EBOOK TREATMENT OF HEMORRHOIDS, AND -OTHER NON-MALIGNANT RECTAL DISEASES *** - - - - - - - TREATMENT OF HEMORRHOIDS, - AND OTHER - Non-Malignant Rectal Diseases. - - BY - W. P. Agnew, M. D. - - SAN FRANCISCO, CAL. - R. R. PATTERSON, PRINTER, 429 MONTGOMERY STREET, - 1890. - - Entered according to Act of Congress, in the year 1890, by - W. P. Agnew, M.D., in the office of the Librarian of Congress at - Washington. - - - - -INTRODUCTORY. - - -In preparing this hand-book, the object will be to give in plain -and comprehensive language, as briefly as possible and with little -discussion, a few general rules, which if even approximately observed, -can but lead to success in the treatment of all non-malignant rectal -diseases commonly known, and for which the general practitioner will not -infrequently be called upon for relief. - -Hemorrhoids, being by far the most common among this class of ailments, -and the greatest bone of contention regarding the best manner of -effecting a radical cure, will take precedence in our consideration, and -receive the attention that their importance and dignity justly merits. - -It is an indisputable fact that until within the past few years, -an operation for the radical cure of hemorrhoids was considered so -formidable an undertaking, that their treatment, outside of palliative -measures, was almost entirely eschewed by the general practitioner. - -“No fact is better known to the profession,” says Dr. S. S. Turner, U. S. -Army, “than that nearly all men, doctors not excepted, will suffer more -than the pain and inconvenience of a thousand operations, rather than -undergo an operation for removal by any of the methods in vogue. The fame -of some specialists who are distant enough to ‘lend enchantment to the -view,’ will generally induce people of large means when life has become -something of a burden, to place themselves under their care and take what -they offer.” - -“But unfortunately, piles are by no means limited to people of large -means. The greater number of sufferers must take what the general -practitioner can give and will not take the cutting and crushing -operations until compelled by dire necessity, and are only too glad of a -less heroic alternative which offers them hope of relief. For this body -of sufferers, the operation by carbolic acid injection offers a means -of relief to which they will readily submit. In a sufficient number and -variety of cases to justify me in having an opinion upon the question of -its merits, I have never met with anything which I have regretted.” - -With these stubborn and uncompromising facts confronting us on the one -hand, and a full appreciation of the superiority, the simplicity, the -safety and certainty of the operation by carbolic acid injection on the -other, the writer has no alternative other than to espouse, and proclaim -his honest conviction and hearty support in favor of the latter method -of cure; and essays to point out in this little publication, in a plain, -comprehensive and a practical way, what has been acquired by personal -observations and experiences, and all in all, believed to be the best -manner of applying this truly scientific and greatly superior method. A -method, the discovery of which, I feel prepared to say, marks an epoch in -the history of medicine, unrivaled in advancement by the treatment of any -other disease or class of diseases to which the human family is subject. - -“There is no organ that is so prone to become diseased as the rectum. -There is no class of cases so little understood and treated as rectal -diseases. There are no diseases so annoying and painful, and at the -same time producing such dire results on the general system, directly -and reflexly, as rectal diseases. For years Rectal Surgery has been -principally in the hands of itinerants, whose remorseless greed for -money has caused them to treat for revenue only, and to play the vampire -on all that fall into their clutches. It is high time for the general -practitioner to gather up all the information possible, in order to be -able to treat all patients suffering from rectal disease, and thereby -drive the itinerants back to their previous occupation of tilling the -soil.”—(Yount.) - -Nowhere in medical lore do we find suitable instructions whereby -the beginner may knowingly and intelligently engage in a rectal -examination—what to expect, where and how to find it, and how to pursue -each succeeding step in applying the treatment. Writers either presume -too much on the part of those who have not had experiences, or, are so -habituated to the use of general anæsthesia in accomplishing the objects -sought, that milder means have been seriously neglected. Finding many, -otherwise well informed practitioners, at a great disadvantage in this -respect, was a leading incentive to the hurried preparation of the -following few pages. - - - - -HEMORRHOIDS. - - -The division of piles into internal and external, is naturally suggested -by their observation and study, and clearly defined by designating -all hemorrhoidal tumors originating above and within the grasp of the -external sphincter as internal, while those situated external to or -outside of the external sphincter, when the latter muscle is closed and -the bowel not protruded, are external. - -It matters not what form of tumor presents itself for treatment, whether -of the capillary variety, distinguishable in being of small size, flat -or sessile, made up of the terminable branches of the arteries, the -beginning of the veins and the capillaries which join them, punctated, -granular surface with thin covering and likely to bleed on the least -provocation, or the arterial hemorrhoid with the arteries and veins -freely anastomosing, larger, and presenting the glazed appearance of -a very ripe strawberry, liable to inflammation, erosion, prolapse and -hemorrhage; or the venous hemorrhoid, hard or soft, not very sensitive, -blue and sluggish, which Kelsey says may result from the other two -varieties or arise _de novo_ and bleed _per saltum_; or any form of -external hemorrhoid, cutaneous tag or like redundant tissue, they are all -treated alike and with like good results, by the operation of injection -and the use of the preparation herein recommended. - - -EXAMINATION. - -After obtaining something of a history of the case, you will have -ascertained whether or not there is an inordinate protrusion at stool, -its nature and if it has to be replaced. In the latter event the patient -is directed to go to the closet or use a commode and make an effort to -strain out the bowel. If not successful, use an injection of warm water, -or select a time immediately after the usual hour for evacuation, which, -if it occurs early in the day, may be deferred by the will power of the -patient to a later hour. - -This will bring to view any and all large hemorrhoids located on the -upper margin of the internal sphincter, as well as those situated between -the sphincters, their being caught in the grasp and button-holed like by -the external muscle. - -Should the prolapse not be sufficiently great or the piles sufficiently -large to be thus caught and held out for inspection, let the patient -lie on either side, with knees well drawn up, and instructed to strain -down and extrude the parts as much as possible, assisting by gently -pulling down and everting the mucous membrane at the verge of the anus -with the thumbs. It is always better to precede by an injection of warm -water, which may not only unload the rectum and give the patient greater -confidence in the effort to extrude the parts, but washes away the mucous -and retained feces in and about the sphincters. When the examination has -been carried to this point and no satisfactory cause found to explain -the trouble complained of, the finger and speculum will be required to -complete the diagnosis. - -The finger is of little use in diagnosing soft hemorrhoids that form on -the upper margin of the internal sphincter and lay back in the rectal -pouch; being hindered by the pressure of the muscles and a like feel -imparted by the bowel. - -Bear in mind that you need not look for hemorrhoids higher up than the -upper margin of the internal sphincter, a distance of not more than an -inch from the verge of the anus, and if of any appreciable size, will -always show at stool. Where to look, what to look for, and how to find -it, is a question that often confronts the beginner, and it will not be -out of place here to firmly impress the following rule: See all that can -be seen and treat all that can be treated without the aid of a speculum. - - -DIAGNOSIS. - -There is not much probability of confounding hemorrhoidal tumors with any -other abnormality in the vicinity of the rectum. The different varieties -of internal hemorrhoids, a description of which is given on page 7, -may confuse, but as stated before, no discrimination is necessary in -applying the treatment for the purpose of effecting a radical cure, the -one great object to be attained. Where several distinct tumors exist, -they are usually arranged in rows on either side, not up and down, but -antero-posteriorly, with the long diameter of each tumor at its base, -parallel to the antero-posterior diameter, or, if the muscles were -dilated, to the circumference of the rectum. - -If situated on the upper margin of the internal sphincter there may be -several isolated tumors thus arranged on one side, while they may have -all coalesced, or originally have formed into one continuous hemorrhoidal -mass on the opposite side, Fig. 1. Or there may be one continuous -hemorrhoidal mass on either side, separated only by an anterior and -posterior commissure, Fig. 2. In some instances when the bowel is -prolapsed and constricted by the external muscle, the branches of the -middle hemorrhoidal veins that anastomose and encircle the upper part of -the internal sphincter, may be so dilated and distended as to present an -unsightly appearance, reminding the anatomist of the circle of Willis; -at the same time a few capillary or sessile tumors may be seen studded -around at different points. - -[Illustration: FIG. 1.—Internal hemorrhoids prolapsed and held out by the -constriction of the sphincter. J. Junction of skin with mucous membrane. -E. Everted bowel.] - -There can be no mistake in discriminating between a large hemorrhoid -and the bowel, but to distinguish a small, blanched hemorrhoid, located -on the upper margin of the internal sphincter from an irritated and -saggened portion of the bowel, when looking through a speculum, is more -difficult. The bowel presents a more smooth and continuous surface, -while the hemorrhoid is more uneven and irregular, and bleeds freely -when scratched. Sometimes a victim of piles will call and speak of his -piles having come down and are hanging out. On inspection a large fold -of mucous membrane will be seen protruding on one side, which has been -mistaken by physicians for a hemorrhoid, but the tumor will be found -immediately above and possibly on the opposite side. - -From polypi hemorrhoids may be distinguished by their spongy like -texture, easy to bleed when scratched, more painful, history, shape, -manner of arrangement, etc. Polypi are considered as a hypertrophy of -the normal elements of the mucous membrane and the sub-mucous connective -tissue. If originating from the former they are soft, if from the latter -hard and fibrous, are often pediculated or club-shaped, sometimes grow -rapidly, not painful unless within the grasp of the sphincter, may arise -entirely above the sphincters, and are rarely of a glandular, villous -or bleeding surface. Should a mistake be made and a polypus thoroughly -injected, the result would be nothing more than a permanent removal of -the offending growth. - -[Illustration: FIG. 2.—Prolapsed internal hemorrhoids, showing a -continuous hemorrhoidal mass on either side, with an arterial pile on the -left, all completely eradicated by two operations.] - -The external hemorrhoid does not elicit the thought or command the -dignity of his neighbor, the internal pile, but usually makes himself -known more forcibly in his incipient stage of formation, caused by -the rupture of a venule of the inferior hemorrhoidal vein, allowing -extravasation and infiltration, which may lead on to inflammation and -suppuration, or the clot absorb and result in an external cutaneous -tag, subject to œdema, itching, induration, etc. On pulling down the -mucous membrane at the verge of the anus, sometimes a slight fullness -or bulbous-like expansion of an exposed part of a superficial vein will -be seen, which should not be mistaken by the novice for an incipient -hemorrhoid. - - -TREATMENT. - -It is quite common for those afflicted with piles to call for treatment -while suffering from an attack, sometimes called the hemorrhoidal state. -This is not a favorable time to operate. Reduce all local congestion and -inflammation first, by palliative measures, such as hot water douches, -injections into the rectum of equal parts of Fl. Ext. Hamamelis and -Pinus Canadensis (dark) in a little water, or water and glycerine if the -latter is not repelled by an irritated bowel. At the same time open up -the portal circulation by the use of equal parts of sulphur and cream of -tartar, a teaspoonful in syrup or mixed with sugar, once or twice a day -for a few days, or any other suitable means to put the bowel and piles at -rest. Often patients will know what will relieve them of this condition -better than the physician, as what relieves one will sometimes aggravate -another. - -In all cases of large growths, whether the patient is in a comparative -state of ease or not, a similar preparatory treatment before operation -will shrinken the tumors and lessen the tendency to local congestion and -pain. Sulphur should not be taken within two or three days of operation -since it continues its action about that length of time after dosage; but -the bowels should be sufficiently evacuated previously to enable them -to be held for four days afterwards, by any agreeable cathartic, or by -_flushing of the colon_. This will be unnecessary in the treatment of -small growths. - -The same course should be pursued to expose the tumors for operation, as -was named under the head of examination. In some instances, where the -tumors are not very large but exceedingly irritable (arterial), it might -be quite difficult, even though the bowel be partially prolapsed, to -expose them sufficiently for a good operation. In such event, paint the -protrusion with a 5 per cent. solution of cocaine and allow the patient -to sit, for a few moments, over a vessel containing a small quantity of -steaming hot water. This will engorge the tumors, relax and materially -aid in handling the parts. - -As a precautionary measure in _all operations by injection_, to prevent -the medicine from extending too deeply into the tissue of the gut by -gravity, or the overflow from running down on the outside of the pile and -over the bowel, let the patient lie on the side opposite to the tumor to -be treated, so that the preparation will gravitate to the apex rather -than its base of attachment. - -[Illustration: FIG. 3.] - -Smear vaseline on the opposite side of the bowel and anus and over any -piles that may show on that side, which, as the patient is now placed, -are on the lower or under side and will catch any and all waste and -overflow of medicine. As a further protection pack or hold absorbent -cotton underneath the tumor being operated upon. If the tumor be small -and partially obscured, the end of the finger may be held back of it to -act as a counterforce while introducing the needle; or a double, slide -tenaculum may be used to pull and hold it down for the same purpose, -being careful not to remove the tenaculum when once applied until after -the operation, as the least prick or scratch of a hemorrhoid will cause -a free flow of blood and greatly hinder the sight when it is desirable to -watch the action of the injection compound. - -Should any portion of the injection compound fall on the muco-cutaneous -surface, unless the latter be heavily coated with vaseline, or protected -with cotton, it will excoriate and probably cause a great deal more pain -and soreness than the operation itself. In operating through a speculum -such risk is avoided by the sides and floor of the instrument, which -afford a protection to the surrounding parts; that is, if the precaution -regarding position when operating is duly observed, to wit: always -operate with the tumor pendent, or with its attachment on the upper side. - - -FORMULA. - -Make a glycerite of tannin in the proportion of 4 drachms (Squibb’s) -tannic acid to 1 oz. (Price’s) glycerine. When the solution is complete, -add 2 drachms each of (Squibb’s) salicylic acid and borax, putting in the -salicylic acid first; stir over lamp, using a glass rod and porcelain -dish, until dissolved, being careful not to burn. If any dirt or sediment -be seen it had better be strained now through a piece of wet cheese -cloth, while yet hot, into a two-ounce vial. - -Select a No. 1 grade of carbolic acid, say Calvert’s, and barely liquify -it by distilled water. Pour ½ ounce of the liquified carbolic acid in -a clean graduate, and add ½ ounce of the glycerite of the salicylate -of borax and tannin, previously made. Do not be sparing in giving the -carbolic acid full measurement, if not a little in excess. - -When the combination is effected with the acid, a floculent precipitate -will occur, which should all clear up within two or three days, -otherwise something will be found wrong either in the purity of the -chemicals used or the manner of effecting the combination. - -Too much importance cannot be attached to the purity of the ingredients -entering into this preparation, as anything unnecessarily irritating -should be scrupulously avoided. I have tried synthetic carbolic acid and -found the odor of tar decidedly stronger, and believe it much more acrid -and irritating than the commoner preparations. Neither can I see that -anything is gained in using vegetable glycerine. - -Inject from 3 to 30 minims, or more, according to the size of the tumor. -There is no rule to regulate the quantity by count. The object is to -inject a sufficient quantity to permeate the entire substance of the -tumor, its texture being much more spongy than the surrounding tissue, -and not extend beyond its base of attachment. - -Here is where many make a mistake in the injection of hemorrhoids. Some -are prone to use too much, even though the solutions be weak, and apply -it too deeply, reaching to and destroying the muscular coat of the bowel, -causing prolonged pain, deep sloughing, etc. While others use too little, -which may act as a foreign body or local irritant, producing a central -slough and a slow breaking down of the disturbed growth. - -A tumor, properly injected, cannot inflame, because there is nothing -to inflame, the circulation is stopped and thus it is as effectually -strangulated as by a ligature, with the advantages of the immediate local -_anæsthetic_, _antiphlogistic_, _auterant_ and _antiseptic_ properties -of carbolic acid. The base of attachment heals, while the dead tissue, -which is rendered non-inflammatory and antiseptic, disintegrates and is -thrown off between the third and fourth day, a process that fortifies -against secondary hemorrhage. - -There is a medium ground to be taken, in regard to the quantity as well -as the strength of carbolic acid to be used, with a little room for -variation on either side; yet there must, in point of reasoning and fact, -be a limit somewhere. If a little more should be used than is necessary -to permeate the entire substance of the tumor, the result will not be -disastrous, but may excite a little more local disturbance and pain. On -the other hand, if a little less be used, the operation will be equally -as effective and is probably the better side to err upon, provided the -discrimination be not carried too far. - -A similar dilemma confronts us respecting the strength. After trying the -weaker solutions and watching their effects, I have concluded that the -solution should contain not less than fifty per cent. of carbolic acid, -combined with the glycerine of the salicylate of borax and tannin,[1] -the latter in such proportions as to produce an immediate astringent -effect. Tannic acid not only keeps the carbolic acid within limits by -its non-irritating astringent effect, but of itself combines with a -certain portion of the albumen of the blood and other tissue, forming an -_insoluble albumenoid_. The salicylic acid and borax, original with Dr. -Q. A. Shuford, of Tyler, Texas, gives the preparation more consistency -and seems to lessen the irritative properties of the carbolic acid. - - [1] Original. - -A weak, thin, watery solution, aside from doing poor work, is much more -liable to diffuse itself and be carried into the circulation like a -hypodermic of morphia, than a solution sufficiently strong to act as a -cauterant, destroying the tissue, forming a compact and an insoluble -coagulum and strangulating the circulation at once. - -A solution, weak or strong, when deposited to any depth beneath the -surface, with live tissue and the circulation passing on all around -it, will of necessity excite pain, inflammation and a slough, the same -as a splinter in the flesh. The properties of carbolic acid being -non-inflammatory in their nature, will often, where a small quantity -is used diluted, produce an adhesive inflammation, an induration and a -contraction in a tumor, by destroying the capillaries where applied. - -[Illustration: FIG. 4.—External hemorrhoid before operation.] - -[Illustration: FIG. 5.—Three days after operation, with coagulum still -attached by pedicle.] - -It is always desirable, when operating on external hemorrhoids, to see -that quite a goodly portion of the cutaneous surface, especially at -the summit, is effected by the preparation applied inside the capsule; -otherwise it will become inflamed in order to let out the interior -coagulum, which I have often seen come out on the third day intact, and -in one unbroken cystic-looking mass, Fig. 5. The same rule obtains -regarding internal hemorrhoids, having thick, unyielding coats. - -Puncture the tumor at the most accessible point, preferably with the -needle, nearly parallel with, or at an acute angle to its base, carrying -the point of the needle to about the center of the tumor, if it be globe -shaped, or equi-distant from base to apex, if it be elongated, with the -face or opening of the needle toward the apex. Be sure the needle is -inserted beyond the proximal end of its opening, which is not always -observable in treating small growths; but may be tested by forcing the -piston of the syringe a little, and if the end is not sufficiently buried -the medicine will show around it on the outside. - -Inject the first few drops the same as you would a hypodermic of morphia, -then slowly, drop by drop, watching its action by change of color on the -surface of the pile. This change of color on the surface is quite marked -with hemorrhoids of delicate covering, less so with those possessed -of more tough and fibrous coats. Hold the needle in position a moment -and if the quantity injected does not appear sufficient, turn the nut -on the piston with which you have previously gauged approximately the -quantity to be injected, back a few rounds and throw in more. Puncture -large elongated tumors in two, three, or four places. The compound -diffuses itself slowly and no doubt extends some farther than is always -apparent at the time of operation. Withdraw the needle carefully; it may -be necessary to force out a few drops of the preparation at the point -of entrance, for the purpose of sealing up the puncture to prevent the -escape of blood and medicine together, which, however, never amounts -to much. If, after withdrawing the needle, some of the injection fluid -runs out, unmixed with blood, take it up with absorbent cotton, since it -indicates that the quantity at that particular part is superfluous. Now -dry the surface of the tumor or tumors with absorbent cotton, smear with -vaseline and return within the bowel. - -A tumor properly injected immediately becomes hard. There are septa or -compartments in elongated growths which do not permit the medicine to -pass through readily, and if a soft section is noticed, it has not been -penetrated, although will doubtless break down with the general mass. -I have seen a liberal injection into the middle one of three tumors -connected and arranged in a row, so cut into those on either side that a -single reddened column like appeared afterwards on the extreme outside, -(Figs. 6 and 7). - -[Illustration: FIG. 6.—Three internal hemorrhoids before operation.] - -[Illustration: FIG. 7.—After a liberal injection into the middle tumor.] - -Large hemorrhoids must not be exposed too long after injection, since -there is always more or less swelling produced around the tumor by the -stoppage of circulation and the presence of a foreign body. Return the -side not operated upon first, then the other, and if the tumor has -considerable length, let it go in endwise. The patient can often return -the protrusion with least pain. - -A little practice will enable any one to see the simplicity of the -entire procedure. If you should make a mistake when operating through a -speculum, and land the whole charge into a fold or saggened portion of -the bowel do not be alarmed, as it will only be a little more painful and -longer in healing. Injection into internal hemorrhoids is not painful to -any degree, therefore if the patient complains much you might suspect -that you are invading the tissue of the bowel. With some, the injection -into external hemorrhoids is quite painful at the first contact of -medicine, but immediately thereafter subsides. Where the tumor is very -sensitive, external or internal, precede by a hypodermic of from three -to five minims of a five per cent. solution of cocaine. Introduce the -needle point barely underneath the covering of the growth and force out -one drop. This will anæsthetize enough to allow further penetration, when -another drop can be thrown in. By this time you can approach the interior -to a sufficient depth to inject from three to five drops more, and -anæsthesia will be immediate and complete. There need be no fears from -cocaine absorption, since the carbolic acid compound will catch and hold -the cocaine all within the body of the tumor before it can be absorbed -and enter the general circulation. - -From one to two hours after operation, the carbolic acid looses its local -anæsthetic effect and what I have called the after pain commences, caused -by the presence of a foreign body acting on the peripheral nerve at a -point where the line of demarkation forms. This pain varies in intensity -with the sensibility of the patient and surface of attachment of the -tumor or tumors. Some will not complain at all, saying the discomfort is -not as great as the suffering from an attack of piles; while others will -make considerable fuss, requiring an opium and belladonna suppository: - - ℞ Opii Pulv. Optim. gr. xii - Ext. Bellad. gr. iv - Ol. Theobrom. ʒ iii - - M. et Ft. Sup. No. xii. - -The pain does not usually continue longer than from twelve to fourteen -hours, unless aggravated by undue exercise, or other similar causes, -being replaced by a feeling of soreness, which is sometimes reflected -down the limb or up to the bladder. - -The treatment after the operation should be markedly palliative: hot -water sponge compresses, hot water sitz-baths, and hot poultices are -great as long as pain and soreness are complained of, together with opium -suppositories, _pro re nata_. If the extent of the operation requires -constipation of the bowels, enemas should be dispensed with until after -the expiration of four days. Then hot slippery elm water, flaxseed tea, -or corn starch as prepared for stiffening clothes, may be used, as well -as a soothing suppository: - - ℞ Bism. Subnit. - Iodoformi ā ā ʒ i - Opii Pulv. gr. v-x - Ext. Bellad. gr. v - Ol. Eucalypti gtt. vi - Ol. Theobrom. ʒ iiss - Ol. Olivæ gtt. x - - M. et Ft. Sup. No. xii. - - The oil of eucalyptus will almost completely disguise the odor of - iodoform. - -In old people who lack sufficient vitality to quickly heal a broken -surface, coat with bismuth, bismuth and oxide of zinc ointment, oxide of -zinc powder, reduced resin cerate, eucalyptol, etc. - -Eucalyptol is a sovereign remedy to stimulate healthy granulatious, -after a broken surface has lost its freshness or acquired some age, in -the proportion of ½ dr. to 1 oz. oxide of zinc ointment, containing a -small quantity of stramonium or opium and belladonna. Or, ½ dr. to 1 oz. -vaseline with 1 dr. oxide of zinc. - -Anything that excites and keeps up pain is hurtful. Severe, continuous -and prolonged pain is an indication that the changes are not going on in -a satisfactory manner. It should always be subdued as much as possible. -Suppositories containing glycerine, castor oil, or anything productive of -much pain, should be wholly discarded. - -Temporary sympathetic paralysis of the bladder, or spasmodic stricture of -the urethra may occur, being relieved by hip baths or the catheter; the -latter is very seldom required. Enjoin as little straining as possible. -Many of the worst cases, in otherwise healthy people, will speak of -holding the bowels as being the greatest difficulty encountered during -the entire course of treatment. A little flatus will sometimes produce an -annoying titilation of the muscles. It has been suggested that a small -tube be introduced at such times for relief. - -A certain amount of moisture begins to exude the second day after -operation, particularly noticeable from external hemorrhoids, and a -peculiar smell when the coagulum is thrown off. This should not be -interpreted as suppuration. - -It would not be reasonable to suppose that all cases will behave alike. -The local and constitutional disturbance will, of course, depend upon the -size or surface of attachment of the tumor or tumors and the nervous and -physical condition of the patient. It is best to require patients to lay -up for a few days after operation on large hemorrhoids, or when more than -one of small size are taken, even though they do not complain. - -In people enjoying average health, with internal hemorrhoids located -on both sides, take one side at a time, making two operations of the -treatment. In a case like Figure 1, not an uncommon form, it will be -better to operate on all the five smaller tumors first, while they are -exposed and kept out by the aid of the large one on the opposite side. -Should the large growth be taken first, it may be impossible for the -patient to hold down the bowel sufficiently afterwards to operate on any -one of the five small fellows, and a speculum will be called into use; -this will prolong the treatment, as few will submit to the operation on -and the manipulation of all five tumors through the slot of a speculum -at one sitting. Small isolated piles can be treated singly, and the -patients allowed to go about their business. It is these bad cases, where -the patient knows the importance, prepares and lays up for treatment, -that we should make as short work of as possible; those who have been -great sufferers, and possibly the operation on one small tumor would so -arouse the others that the suffering would be as much, if not more, than -if all had been treated at the same time. Not unfrequently the piles on -the opposite side, and left for a second operation, will set up the howl -and cause more pain and suffering than the side treated; especially may -you look for such alarm if you allow any of the injection compound to -fall on their unprotected surface. A patient once observingly remarked -that it must be a peculiar kind of medicine that caused pain when brought -in contact with the outside of a pile, but none when applied to the -interior. - -As regards pain, it might be briefly stated that little can be done in -the vicinity of the rectum, it matters not what strength of carbolic -acid is used, or plan of treatment adopted, without causing more or less -discomfort in all cases, amounting to actual pain and suffering for a -brief period in others. Not at the time of operation, for that in itself -is practically painless, but during the process of cure. - -This cannot be wondered at, when considering the extreme sensibility of -the parts and amount of tissue involved and actually removed by a radical -operation. Yet it is no greater in the majority of instances and not as -much in extremely _irritable piles_, as that caused by the periodical -squirting in of a few drops of carbolic acid and water, extending over -a period of weeks, and even months, that is neither safe, certain, -or otherwise satisfactory; and often brings discredit upon a process -which, if properly understood and rationally applied, has no approach to -comparison in any other method of cure. - -Some physicians fear to use anything stronger than a little carbolized -water and glycerine, lest they produce carbolic acid poison, embolism or -a slough. This is a mistake, the dangers they seek to avoid are coupled -with such uncertain and illogical practice. - -Dr. E. H. Dorland, Chicago, Ill., says: “When a compact coagulum is -formed, and the muscular layer of the bowel is not touched by the styptic -it is impossible to do harm, all the learned theory to the contrary, -notwithstanding. A weak solution forms little globules in a tumor, and we -can imagine one so small as to be carried into the circulation.” - -To effect a radical cure, it is desirable to get rid of the tumor bodily, -not by shrinking or contraction into a hard knot, or by inflammatory -destruction, but by a separation of the spongy and vascular growth -from the normal tissue of the body, the same as if dissected off root -and branch. This is obtained by putting a sufficient quantity of the -preparation recommended just where you want it, and such results will -invariably follow. I have seen internal hemorrhoids, about the third -day after operation, become so friable that they could be crumbled off -similar to a piece of cheese. The preparation can be relied upon to -extend just as far as you put it and no farther, and will remove as much -of the tissue as permeated. It will extend farther, and permeate more -readily the structure of a pile than the sound tissue, because the former -is much more spongy and cellular, allowing the preparation to be easily -forced and diffused throughout its integrity (Fig. 8). A pile, properly -injected, should appear the next day after operation perfectly dead, as -if boiled or cooked, and of a leaden color. - - -NEEDLE AND SYRINGE. - -A gold or platinum pointed needle should be used, fitted with a screw -to gauge the depth of insertion, and of sufficient caliber to allow the -preparation to pass through freely. There are several makes admirably -adapted to this purpose, Fig. 9. A common hypodermic would be utterly -useless. - -[Illustration: FIG. 8.—Section of hemorrhoid showing internal spongy -structure (Esmarch).] - -A common glass barrel, metal bound, hypodermic syringe is all that is -needed. It should be provided with side handles. Draw the medicine -into the syringe before screwing on the needle, force out the air and -gauge the nut on the piston for about as many minims as thought will be -required. - -When a syringe is not kept in constant use the piston will dry out and -stick to the barrel. This is remedied by setting the nut on the piston -when laying the syringe away, so that the piston will not quite go to the -bottom of the barrel. When it is desired to use the syringe, screw back -the nut, say sixteenth of an inch, and take up the syringe with thumb -on the piston handle and finger on the cap at the other end, and press -together, thus freeing the piston. - -[Illustration: FIG. 9.—Syringe, needle and flexible silver canula.] - -A heavy, open face watch glass with a center facet is a good receptacle -for the injection compound before drawing it up in the syringe. - - - - -ACCIDENTS - - -MARGINAL SWELLING AND ABSCESSES. - -Marginal swellings and abscesses, appearing the third or fourth day -after operation, are produced by excessive irritation. I have never seen -them occur except when the patient disobeyed instructions and exercised -inordinately. One instance, in a case of long standing, where the piles -occupied both sides of the rectum between the sphincters, I operated -on both sides and injected every tumor at one sitting, enjoining rest -and quiet. He afterwards rode a long distance and walked a half mile, -which caused an unusual amount of pain and soreness; not content with -this he took a dose of castor oil, when a very painful marginal swelling -occurred. Being a strong man up to this time he had used no palliative -measures whatever, and only then informed me of his suffering. Hot water -and a sponge soon eased the pain and a superficial abscess developed; it -was slit up and a good recovery followed. - -According to my observation and belief, piles situated just above the -verge and in proximity to the network or plexus of nerves surrounding -the anus, are more prone to cause a marginal swelling than others, -particularly if improperly or two deeply injected, and an irritating -quality of carbolic acid be used. It might also be stated that pain -varies in intensity as it approaches the verge, one of the most acutely -sensitive surfaces of the body. A small sensitive pile not larger than -a salmon egg, situated within the grasp of the external sphincter, will -keep up a titilation and contraction of the muscle sufficient to disturb -and put ill at ease the entire animal economy. - -A swelling or lump which often appears immediately after injection of -piles of any considerable size just above the verge, is of no consequence -and will subside within a few days. A similar swelling sometimes results -from a severe attack of internal hemorrhoids, which some speak of as the -developing of an external pile, but I do not see that such formations are -anything more than marginal swellings, caused by the irritation above. - - -SECONDARY HEMORRHAGE. - -About the time the tumor is thrown off, between the third and fourth -day, and sometimes later, before the healing surface becomes strong, or -should the portal circulation become obstructed and the hemorrhoidal -vessels congested, secondary hemorrhage may rarely occur. It is easily -controlled by the use of Monsel’s Salt, to which a little morphia should -be added, carried in a small piece of wet absorbent cotton, and held -on the ruptured vessel by the end of the finger until the hemorrhage -ceases. A few minutes will usually suffice. Knowing where you operated -will be a guide to the place of application. The injection of a strong -solution of tannic acid will be sufficient in mild cases. I have never -known a secondary hemorrhage, following carbolic acid injection, amount -to anything more than an easily controlled venous hemorrhage. Am inclined -to think secondary hemorrhage is most likely to occur when a pile breaks -down from a partial injection, leaving the vessels unprotected in places, -or from an injection too deeply into the substance of the bowel; yet, I -have seen all these conditions time and again without the least tendency -to hemorrhage. - - -CARBOLIC ACID POISON AND EMBOLUS. - -With a fifty per cent. solution of carbolic acid and the combination -given, carbolic acid poison and embolus are entirely out of the question. -The only danger of embolus lies in the too sparing use of a weak solution -of carbolic acid, injected slowly into the unobstructed calibre of a -coursing vein. While a strong solution quickly and generously applied -would destroy the tissue and obliterate the vessel as effectually as the -hot iron. - - -SLOUGHING. - -The extensive sloughing that I have heard of so much I have never -experienced, and am not able to conceive of such an occurrence, except -it be in a very low state of vitality; but can imagine how a pile would -slough if a few drops of carbolic acid were deposited in the center, or -deeply into its base, leaving the apex and greater portion of the growth -with a free circulation. A weak solution taking effect in the interstices -of the most tender part of a hemorrhoid, but not sufficiently strong to -attack the more fibrous portion, would doubtless result in inflammation -and slough. A pile with a thin delicate covering and internal structure -can be cured by an injection of water, while those of a more tough and -fibrous character would only be exasperated by such annoying treatment -and behave in a bad manner. - -In looking over the comments of Kelsey, Andrews and others regarding the -injection of hemorrhoids, it appears quite evident that they have not -given the subject scientific study. It would seem that representative men -and authorities, after a knowledge of the brilliant results following -the treatment in many cases, attended by accidents in others, would seek -to know and try to obviate the cause or causes of these unexplained -irregularities. - -They never improved upon the method in its primitive and undeveloped -state, but seemed willing to magnify and enlarge upon all the accidents -and complications arising from and following the indiscriminate use -of all sorts of injection compounds, in the hands of the ignorant and -inexperienced, and in diverse and unfavorable conditions for treatment. - -How about the old methods? Only a few months since my attention was -attracted to a gentleman of prominence, in middle life, strong body -and good habit, who had been operated upon for the removal of piles -by ligature. He was seven months in recovering, during which time two -fistulas developed. I do not mention this case as an isolated one, -because we all know that excessive and prolonged pain, causing in some -instances lock-jaw and death, retention of urine, sloughing and stricture -by contraction of tissue, abscess, fissure, fistula, intractable -ulceration, hemorrhage, immediate or secondary, great and lasting -prostration and slow recoveries, saying nothing about the dangers of -anæsthesia etc., are not uncommon when the old methods are practiced. - -About the time that Kelsey, after having deposited five drops of a -carbolic acid solution in the center of a large tumor, observed it -looking dark, angry and inflamed from the intrusion of a foreign -substance, would have been a fitting moment for a full dose of carbolic -acid, of suitable strength and in sufficient quantity to pervade -the entire structure and form a compact coagulum; strangulating the -circulation, cauterizing the tissue and thereby checking the inflammatory -action at once; then followed up by the liberal application of hot water -and a sponge. - -The method that I adopt and recommend for the removal of piles, not only -does the work neater and cleaner than the more heroic measures in vogue, -but robs the patient of the terrors of etherization, as well as the -dreaded consequences incumbent upon and more or less inseparable from -operations of violence, in a peculiarly organized and sensitive locality; -and, as Dr. E. F. Hoyt, of New York, says: “There is not a hemorrhoidal -case possible but what can be obliterated by this means; and I am at a -loss to explain why so many cling to methods that carry so much havoc -and suffering. If every college in the land would have this subject -demonstrated by men of experience and learning, all other means would -soon lose recognition.” - -I shall not take up time and space in enumerating cases but will briefly -mention three of quite recent date, and of more than common interest on -account of some of the associated history given. - -Manuel L., aged 39, capitalist, had arranged his business affairs and -prepared for the possible results of a ligature operation. All being in -readiness, he was placed on the operating table by a prominent surgeon, -who, upon examination, found the hemorrhoids to look so formidable in -appearance that he refused to proceed further, stating that the operation -might prove fatal. - -On his first visit to me, he was asked to use the commode and strain out -the piles, which presented to view a large, continuous hemorrhoidal mass -encircling nearly one-half the bowel on one side, with five distinct and -typical tumors on the other, similar to Fig. 1. He was directed to lie -on the operating chair with the large growth oil the upper side, and -about 30 minims of the carbolic acid preparation was injected in three -different places in the mass, the protrusion returned and the bowels -constipated for four days; after which the bowels were moved by an enema -of slippery elm water, when not a vestige of the growth could be seen, -and no pain. - -He put his hand back to push in the bowel, as he had been accustomed for -the past eight years, and found it gone; whereupon he said if this had -occurred in the day of miracles, he would think me Jesus Christ. One -operation is all that is required for the remaining five tumors, and both -piles and prolapsus are cured by two operations. In fact, the smaller -tumors should have been taken first, when the opportunity to get at them -was much better. - -The only inconvenience suffered was from an effort to hold the bowels, -and the after-pain, which lasted about 14 hours, but was not severe; -during which time an opium suppository was introduced every two or three -hours. He stated that he was just getting over an attack of _La Grippe_ -and had been purged pretty freely, consequently did not evacuate the -bowels previous to operation, but advised a liquid diet for the first -three days. - -George P., aged 37, druggist, had a continuous hemorrhoidal mass -occupying both sides of the bowel when protruded, being separated only by -an anterior and a posterior commissure. Glaring fibrous bands seemed to -bind down the enlargements in places, presenting anything but an inviting -case. He also had an arterial hemorrhoid attached just above the verge, -constantly hanging out and exciting the external sphincter; looked like -and was about as large as a medium sized strawberry, irritable and eroded. - -The history of the case and the extreme ungainly appearance of the -protrusion induced me to have it photographed. It is approximately -represented in Fig. 2, but does not show the fibrous bands. The patient -was placed on the side opposite the larger mass, which was injected at -four different points. The bowels were constipated for four days by the -occasional introduction of an opium suppository and then moved by enema, -when the man shed tears of joy on having no pain at stool and finding -no protrusion on that side. The next operation took the other side, -together with the strawberry, and the case discharged, cured of piles and -prolapsus. - -Both of these gentlemen had been told time and again that the carbolic -treatment was ineffectual and dangerous. One ex-army surgeon and college -professor said he would not attempt any of the heroic operations in the -second case, as there was too much tissue involved; that he would only -agree to treat it by making local applications twice a week. - -And further, he would not promise any results inside of ten months, -asking twenty dollars per month. He would not swerve from his opinion, -and could not say that a permanent cure would then be effected. - -Mrs. Jane D., nearly 80, afflicted many years, had consulted fifteen -different physicians, all of whom refused anything more than temporary -relief because of extreme age; having always been considered delicate, -with cataract now forming in both eyes. Would be satisfied if she could -live not more than two years after a cure. - -The tumors were “old bronzed veterans,” tough and unyielding. One side -was taken at each operation and although confined to the bed mostly for -the first seven or eight days after operation, could get out and in at -any time without assistance. Had no constitutional disturbance, never -missed a meal and was able to get up and down stairs inside of eight days -unattended. - -The dead piles embraced in the coagula were much longer in separating -from the bowel, and base of attachment longer in healing than in the -average case. Hot water sponge compresses were used frequently, together -with opium suppositories for the first 24 hours, then occasionally for -the next three days; after which hot water irrigation and iodoform -suppositories. Later bismuth, eucalyptol and oxide of zinc ointment. An -occasional dose of sulphur and pot. bitart. was given and the bowels -moved by flushing of the colon; which was resorted to but twice. - -In this case the edges of the thickened, calloused mucous membrane of the -bowel where it joined the hemorrhoids, appeared to be so cartilaginous -in places, that I expected hard ridges would be left; but they all -disappeared and softened down by the use of eucalyptol, buckthorn and -stramonium ointment. At one point a small polypus sprang up, which -withered from the injection of a few drops of pure carbolic acid, like a -tender sprout, after being frozen, under a scorching sun. - -The lady could not repress her feelings of emotion, in expressing -gratitude for the services rendered, but gave way and freely cried. -Although in rather poor circumstances, she did not think a charge of -fifty dollars sufficient and afterwards returned, saying that she felt -that she would not die happy unless I was better paid, and insisted upon -my taking another “twenty.” - - -RESUMÉ. - -Do not operate during an attack of piles. - -Operate with the tumor, or tumors, on the upper side. - -Handle the parts with extreme gentleness and deliberation. - -See all that can be seen and treat all that can be treated without the -aid of a speculum. - -Protect the under parts from excoriation by waste and overflow of -medicine. - -Evacuate the bowels previously and constipate for four days after -operation on large growths, or when several small tumors are taken at one -time. - -Hot water sponge compresses, _early_, _often_ and _continuously_, are -indispensable and unequaled for the relief of a pain, swelling and -soreness. To be effective it should be applied as hot as can be borne. - -Wait until the soreness disappears before performing a second operation. -This will require from one to two weeks, according to the extent of the -first operation and the physical condition of the patient. - -Take great pains and care to perform a neat operation. A certain amount -of ingenuity and tact are required, which, unfortunately, all do not -possess. If a bungling job be made, the bowel punctured, a pile injected -on one side only and the surfaces excoriated, do not attribute an -unnecessary amount of pain and suffering to the preparation used or the -method employed. - -As a general alterative and curative agent in many diseases, and -particularly to relieve and prevent hemorrhoidal congestion in rectal -troubles, sulphur in small doses, persisted in for some time, probably -has no equal. The most convenient form for administration is a palatable -tablet (Wyeth & Co.), containing 2½ grains, or 5 grains with 1 grain of -cream of tartar. Reference to the learned articles on the physiological -and therapeutical uses of sulphur, by Dr. John V. Shoemaker, published -in the _Dietetic Gazette_, Sir Alfred B. Garrod in the _Lancet_, and in -Ringer’s hand-book of therapeutics, will be amply repaid. - -[Illustration: FIG. 10.—Position for operating, or making a rectal -examination. Engraving kindly furnished by Sharp & Smith, who manufacture -one of the best office and operating chairs combined, on the market. It -works without “cranks,” “levers,” or “ratchets.” Upholstering is entirely -protected during an operation. - -It is unnecessary for a lady to disrobe herself for examination, or -suffer immoderate exposure. A cloth cover should be used, when a lady -patient is placed on the chair, the same as in gynæcological practice.] - - - - -RECTAL EXAMINATION. - - -The first step to be taken in making an examination of the rectum, where -disease of this organ is present or suspected, will be to obtain a -history of the case as given by the patient, supplemented by questions -naturally suggested. This will furnish an idea of what might be looked -for, but the patient’s interpretation will often be found quite erroneous -and misleading. - -Should there be an undue protrusion at stool, pursue the same course -recommended for the examination of internal hemorrhoids. If protrusion -be absent, direct the patient to lie on the side with knees drawn up, -separate the buttocks and inspect the anus; or, in other words, all that -presents to view externally at the terminal orifice of the rectum. Now -draw down and evert the mucous membrane at the verge with the thumbs, -asking the patient at the same time to extrude the parts as much as -possible. This will enable you to see all there is half an inch or more -above the entrance. - -Next, anoint the finger, pass in gently and examine all the surface -limited by the sphincters, a distance upwards of not over an inch, -being careful lest you be deceived by the mobility of the tissue, when -introducing the finger, and a small marginal growth be carried up and -appear as one of internal origin. - -Any one familiar with vaginal examinations can detect a rough or a broken -mucous membrane, an indurated spot or prominence as soon as touched. -Next, feel above the internal sphincter, keeping in mind the anatomy of -the parts, turn the finger slowly, posteriorly you can hook it behind the -muscle. Here is situated the bottom or floor of the rectum which forms a -cul-de-sac (Fig. 11). By asking the patient to strain down moderately, -its surface will be thrown up against the end of the finger and in this -manner properly explored. - -[Illustration: FIG. 11.—Lateral section of rectum; normal curve. R. -Rectal pouch. C. _cul-de-sac_ of the rectum. E. S. External sphincter. I. -S. Internal sphincter. H. Hilton’s white line. P. Position of prostate -gland.] - -A digital examination reveals, in the normal state, a soft, velvety, -unbroken mucous membrane, the parts pliable and yielding, with no reflex -excitability of the sphincters. The position and sensibility of the -uterus should be noted in the female, and size of the prostate gland in -the male of advanced years. - -The first three or three and a half inches of the rectum can be brought -within reach of the finger. Explorations farther up will require a rectal -sound and a long tubular speculum. Nine-tenths of all rectal ailments are -found within the first two inches. Therefore, few general practitioners -will ever be called upon to treat anything beyond the reach of the finger -or the scope of a common speculum. - -All hemorrhoids of any appreciable size, or other tumorous growths in -the same vicinity, will show at defecation and can be treated while the -parts are extruded. All abrasions, ulcerations, indurations, etc, are -discoverable by the sense of touch. Hence, it will be seen that the uses -of the speculum are narrowed down to a few in number. Namely: in that -of bringing to view for observation and treatment diseased surfaces -previously located; small, soft hemorrhoids and other minor affections -which may have escaped detection by a careful digital examination. - -Then, in view of the foregoing facts, and in consideration of the -anatomical formation of the parts, being a collapsable tube, highly -sensitive and extremely difficult of accessibility, quite unlike the -vaginal canal, which is closed at one end, more capacious and dilatable, -and designed by nature to be approached from the exterior, a speculum -should be so constructed as to not only be easy of introduction and -withdrawal, but to exclude all the surface except a limited portion, and -permit the greatest amount of available light possible to fall on the -exposed part shown _in situ_. - -The greatest barrier to the successful use of a speculum is the unruly -external sphincter and the excessive mobility of the mucous and -muco-cutaneous surfaces. The upper margin of the external sphincter -terminates beneath the junction or the skin with the mucous membrane, -which place also marks the beginning of the internal sphincter and its -junction with the external muscle by a more dense connective tissue, -sometimes appearing as a white line at the muco-cutaneous junction called -the white line of Hilton. - -According to Dr. Andrews, Hilton has demonstrated that the locality where -the two muscles join by the intervention of this fibrous ring forming the -anal verge, the junction of the skin and mucous membrane, and the exit of -the branches of the pudic nerve, is identical. - -[Illustration: FIG. 12.—Author’s Rectal Speculum.] - -The internal sphincter is a collection of the circular fibres of the -muscular coat of the bowel, about five-eighths of an inch in width, -and constitutes in reality the terminus of the gut. For the external -sphincter is a thin band of distinct and separate muscular fibres, -elliptical in shape, between three and four inches from its anterior to -its posterior extremity, and expands out around the margin of the anus -like the flaring end of a trumpet; with its superficial layer in close -relation to the skin which it draws down in radiating folds. - -With this understanding of the anatomical relations, it will be seen -that the external muscle contributes so slightly to the length of the -canal, that it might be considered wholly on the outside, where it guards -closely the entrance, and is nowise concerned in an examination with a -speculum except as a feature of incumbrance. - -To correct an erroneous idea that there is any considerable depression -or space intervening between the muscles, we mean, when we say between -the sphincters, the distance bounded by the fibrous ring uniting the two -muscles below, and the upper portion of the internal muscle above. More -simplified, we mean all the surface included between the upper margin of -the internal sphincter and its junction with the external muscle at the -anal verge. - -All examinations with a speculum should be preceded by an enema of -warm water to wash away the mucous and retained feces in and about the -sphincters. Let the patient lie on either side, turning partially on the -chest, with knees drawn up, the one uppermost more firmly flexed on the -abdomen, and hips so elevated that the speculum, when introduced points -or inclines downward, and admits of strong natural light to fall in -parallel rays to its axis. - -Warm the speculum by _dry heat_ over a single blast kerosene stove, where -gas is not convenient. A suitable kerosene stove is an indispensible -adjunct to an office for heating instruments, water, etc., causing no -smell and leaving no deposit of sut on the bottom of vessels as done -by gas or alcohol. Use _white_ vaseline as a lubricant; everything that -tends to whiteness helps the sight. The vaseline may be squeezed from a -tin-foil tube, and the finger not soiled in preparing the speculum for -insertion. - -[Illustration: FIG. 13.—A suitable Kerosene Stove for office use. It is -clean, safe, cheap, portable and has perfect combustion.] - -To prevent the loose tissue from rolling up and being pushed in with the -speculum, the patient may assist by holding the upper buttock away, while -the physician introduces the instrument with one hand and retracts the -opposite buttock with the other. - -Introduce slowly, giving time for the muscles to relax, bearing in mind -that all movements about the rectum and anus must be extremely easy and -gentle. The proximal end of the slot must be carried and kept above -the external sphincter during the entire course of the examination. It -matters not what kind of a speculum is being used, the value of the -instrument will greatly depend upon its power to hold this muscle out of -the way. - -A closed end speculum, with a proportionate slot and smooth corners, can -be slowly rotated without any difficulty where the mucous membrane is not -very loose and baggy and no prominences in the route. But if a hemorrhoid -be in the way it will immediately drop in the slot and further progress -is thus impeded. - -When examining above the internal sphincter, especially posteriorly, -where the bottom or floor of the rectum forms a cul-de-sac, direct the -patient to strain down a little; this effort will throw the mucous -membrane out into the speculum, at the same time spreads out and smooths -its surface. In looking through a speculum this cul-de-sac of the rectum -sometimes appears as a vacancy behind the internal sphincter, and has -been mistaken and treated as an ulcer cavity. It often contains a liberal -supply of mucous. - - - - -FISTULA. - - -Fistula in the recto anal region so far exceeds that in any other -locality, that its overwhelming predominence here almost entitles it to -the exclusive right of the term; while, to those who have given this part -of the physical organism special study, the word itself, calls to mind a -local condition of disease that is anything but an easy one to manage. - -In point of frequency fistula is next akin to hemorrhoids, but a much -less desirable complaint to treat. Allingham states that the number of -cases occurring in hospital practice is greater. That two-thirds of -all the cases operated upon of the in patients at St. Mark’s Hospital, -London, were fistula. The most frequent cause assigned being abscess. A -failure of the abscess to heal, leaving a sinus or sinuses, is explained -by the presence of loose areolar tissue and fat, excessive mobility of -the parts by the action of the sphincters, respiration, coughing and -sneezing, and a strumous diathesis. - -In consequence of an occasional failure of the muscles to regain their -power after division by the knife, elastic ligature or galvano-cautery -wire in the treatment of fistula, leaving the subject in a pitiable -state of incontinence of feces, which has resulted in several well -authenticated cases in suicide, new and rational methods have been -devised for the relief of this very troublesome and unpleasant affection. - -Kelsey says: “A permanent incontinence of feces is _always_ considered -by the patient a very poor exchange for fistula, which was causing -comparatively little suffering and annoyance.” - -The fact that such a deplorable condition does sometimes follow complete -section of the sphincters, and that we have no means of knowing -previously when it may or may not occur, I submit the question to all -thinking, conscientious and painstaking physicians: Should we not seek -the adoption of any efficient means of treatment, whereby such risk is -wholly avoided? - -About the first of March, 1890, Daniel Mc., aged 35, who a few months -before had been operated upon by a reputable surgeon for a simple, -uncomplicated fistula, sought my acquaintance, exhibited his condition -and related his experiences. - -The fistula originated from a small abscess, with its internal opening -between the sphincters, the external scarcely an inch outside the anus, -and was not of long standing. The operation consisted in a division of -the external muscle with the greater portion of the internal; he was -put on a liquid diet, bowels confined for fifteen days and kept in a -recumbent posture. - -The incision was slow in healing, between three and four months; his -health, which was formerly good, has been greatly impaired ever since -the operation. The external sphincter has lost its power altogether and -the internal muscle greatly weakened, which necessitate the wearing -of a clout whenever the bowels become a trifle loose, and he lives -in constant fear of soiling himself by allowing the escapement of the -least quantity of flatus. The time lost, the money expended, and the -unfortunate condition in which he finds himself eight months after the -operation, have so thoroughly embittered him against the cutting process, -that he spares no pains and loses no opportunity to influence every one -with whom he comes in contact, against all such heroic and uncertain -measures. - -For the purpose of obviating these very unsatisfactory and highly -objectionable results, we have a choice of any one, or all of three -different methods, viz: treatment by injection, treatment with the -fistulatome, and treatment by the galvano-cautery as practiced by Dr. -Shotwell; who, fully appreciating the dangers of muscular section, has -hit upon a plan both new and commendable. - -[Illustration: FIG. 14.—Varieties of Fistula. (Gosselin.)] - -The sub-cutaneous, or sub-mucous fistula can be cocainized and slit up -with a pair of scissors, and the tract cleansed and cauterized with -a solution of carbolic acid, a comparatively trivial affair; but the -external blind, the internal blind, the complete, the complete with -diverticula etc., are varieties which call forth a decidedly greater -amount of ingenuity and thought in bringing them to a successful issue. - -The treatment by injection, sometimes classified as a “non-operative -method,” has been so successful in the hands of many, that it is stoutly -affirmed that any case curable by the usual heroic methods is equally -curable by this method. Different preparations have been used, chief of -all being carbolic acid, ranging in strength from 50 per cent. up. - -In adopting the carbolic acid treatment, probably the better way after -preparing the sinus, will be to use a 95 per cent. the first time -and subsequently a 50 per cent. solution; protecting the parts from -excoriation by any suitable unguent and absorbent cotton. Hot water -compresses to relieve pain and reduce swelling. Iodoform, Eucalyptol, -etc., in the _interim_. Judgment will be required in not making too many -irritant applications and granulation thus hindered for want of rest. - -The object is to destroy the pyogenic membrane by the cauterizing effects -of the acid and get up a granulating carbolic acid sore. It may be -necessary to evacuate the bowels and constipate for several days to give -the muscles rest, or resort in extreme cases to divulsion. The sinus -must have constant, free external drainage until the healing process is -complete. Allingham recommends the introduction of the small end of a -bone collar button to keep the orifice open, with a hole drilled through -its centre for drainage. - -As a preliminary step the external orifice should be dilated with a -laminaria tent or other appropriate means. The fistulous tract explored -with a common probe and thoroughly cleansed with hot water introduced -through a flexible silver canula; which is also used for the injection of -a 5 or 10 per cent. solution of cocaine to obtund the sensibility. - -[Illustration: FIG. 15.—Bone Stud] - -Concerning the carbolic acid treatment Allingham says: “Since the -publication of my last edition I have cured many patients by dilitation -of the sphincters and the use of the bone stud and carbolic acid. One -practical point I would mention. The further the external aperture is -from the sphincter the more likelihood is there that the sinus will heal. -This is shown as well in the cases of spontaneous cure as in my own -successes. You must always enjoin rest after a strong application, and -watch that not too much inflammation be set up.” - -The fistulatome shown in fig. 16, is a contrivance which is perhaps -destined to take the lead in the treatment of fistula generally. It is so -constructed that the fine cutting blades close on themselves, while the -instrument, which is probe pointed, is being introduced, but immediately -open on withdrawal, and thus catch up and cut through the fistulous -membrane. - -[Illustration: FIG. 16.—Fistulatome with blades extended.] - -Who the inventor of this clever device is, I have been unable to -ascertain, having seen it claimed by three different physicians, one of -whom speaks of curing 76 per cent. of all cases treated by one operation. -That is by drawing the fistulatome through the tract once. Cases of long -standing require that the instrument should be turned at right angles -and drawn through the second time and possibly repeated later on, or a -tenotome employed to scarify any remaining indolent sinus. - -It will be readily seen, however, that a fistula with a side pocket, -branch or diverticulum, would hardly be reached by this method; although -the blades are so formed that they draw the membrane of a dilatable -pouch to them from the sides. In such cases a little ingenuity would be -required in finding these diverticula, for the purpose of scarifying them -with a tenotome. - -The preparation of the sinus and the after-treatment are the same as -already mentioned. Also evacuation of the bowels and constipation by the -use of an opium suppository, even to the dilitation of the sphincters, -if thought necessary to bring about a cure. In rare instances, where -divulsion has been practiced and while yet under the influence of -anæsthesia, it might be advisable to lay open the cavity by cutting -_from_ the sphincters, pockets traced, scarified and partitions divided. - -[Illustration: FIG. 17.—Flexible Silver Canula.] - -In relation to treatment, Andrews says: “The truth is, that anal fistulæ -have a natural tendency to recovery, and are held back from it mainly by -two things. - -1. “The unfavorable effect of the undrained septic fluids within the sac. - -2. “The tightness of the external opening, which prevents free drainage, -and keeps the sac distended with this putrid pus. - -“It is demonstrated by Dr. Mathews on the one hand and by the experiments -of quacks on the other, that by controlling these two conditions, many -cases will heal spontaneously. It follows that among the thousands of -patients subjected to cutting operations by surgeons for this disease, -there are many who might be cured by much milder means.” - -Shotwell’s operation consists in straitening out of the fistulous tract -with a steel probe, having an eye at its distal end, which is carried -entirely within the bowel whether the fistula is complete or not. He next -pierces the solid structure about three-eighths of an inch farther from -the anus with a lance-pointed probe also having an eye near its end, -parallel with the first probe, until its end is seen penetrating the -bowel a little beyond. - -The eyes of the probes are then threaded with the opposite ends of a No. -24 platinum wire about ten inches in length, and both probes withdrawn, -leaving the wire _in situ_ forming a loop; both ends are now secured -to an electrode, the current turned on and the loop drawn through the -partition. Little, if any, dressing is required, but the bowels must be -kept locked up for at least a week. This of course involves the use of -general anæsthesia. - -A word to the beginner, in the prevention and detection of fistula. Since -abscess is the most prolific source, proper attention to the abscess by -poulticing, early lancing, the sinus washed with hot, heavily carbolized -water, allowed free drainage, the bowels evacuated, constipated and the -muscles put at rest for a few days, will doubtless be successful in -forestalling its almost certain fistulous sequence. - -Dr. Hoyt strongly recommends divulsion of the sphincters, immediately -after opening the abscess, as an unfailing remedy in preventing fistula. - -Annoyance by itching, a slight discharge and soreness at times in a -circumscribed spot, with previous history of abscess, might be considered -a sure sign of fistula. But the patient may give the same symptoms -with no knowledge of previous abscess, or other cause pointing to the -formation of a fistula. Yet, on inspection, a small opening with pouty -lips, or a closed cicatricial depression not much larger than a pin-head, -will be found. This is the external ring or opening of a fistula, and if -closed, may resist the introduction of a probe sufficiently to create the -belief that no sinus exists. - - - - -ULCER, STRICTURE, ETC. - - -A solution of continuity, varying from a slight abrasion of the mucous -membrane to a marked degree of destruction of tissue, comes within the -scope and meaning of rectal ulcer. - -A deep-seated, non malignant type of rectal ulceration, complicated with -stricture, fistula, etc., is not so very common, and seldom met with -outside of hospital practice. - -The less serious and more simple varieties, such as may be productive of -considerable systematic disturbance through reflex excitability, without -attracting much, if any attention locally, are the forms most frequently -seen by the general practitioner. - -With few exceptions, rectal ulcer is insidious in its nature; in some -instances passing on to the stage of stricture, which alone may be -the first symptom to cause alarm, as the following recent case will -illustrate. - -Mr. C⸺, aged thirty-three, married, applied for the treatment of -hemorrhoids. He stated that the only inconvenience suffered was from -constipation. That the piles did not come out and were never very sore -but he had seen a little bloody mucous at times and had a constant -desire to go to stool. A free evacuation and relief being obtained only -after the feces were made liquid by the injection of warm water. - -On the introduction of the finger I found about one-inch and a half from -the anus, an annular stricture which almost entirely occluded the bowel, -with ulceration and gummata below. More close inquiry elicited the fact -that the stools were not much larger in circumference than a lead pencil. -He had noticed the trouble not more than two months before. There was a -previous history of chancroid at the age of 19, with no constitutional -symptoms. - -It is claimed that organic stricture does occur without previous -ulceration by interstitial deposit and thickening, and ulceration follow. -But this must be considered exceptional. The ulcerative process usually -precedes, and through efforts at repair, cicatricial bands are thrown -out, producing a narrowing and contraction of the canal, either in places -or throughout the circumference of the bowel. - -[Illustration: FIG. 18.—Rectal Bougies.] - -Electrolysis may be tried for the relief of stricture before resorting to -the usual methods of breaking up by forced dilitation. If divulsion be -decided upon it should be complete at one operation. Should the fibrous -bands be strong and unyielding, nicking the edges with a probe pointed -bistoury is advantageous. - -On account of severe hemorrhage and other untoward symptoms likely to -follow a complete division of the stricture, the galvano-cautery is -decidedly preferable to the common proctotomy knife. A duplicature of the -peritoneum coming down to within about three and a half inches of the -anus anteriorly, should not be lost sight of in operations on the rectum. -The persistent use of bougies will be necessary for a long time after -divulsion. - -Stricture is mostly of syphilitic origin. Of the seventy cases, tabulated -by Allingham, ten of the number were found in men and sixty in women, -showing a great predominence in the latter; and none were more than three -and a half inches above the rectal orifice. - -It is not an easy matter to diagnose between the advanced stages of -non-malignant rectal ulcer and cancer. Both may be accompanied by tender, -condylomatous growths or flaps of skin outside the anus, bathed with -an ichorous fluid. The characteristic, unremitting pain of cancer may -be absent in its formative stage, and in this respect insidious in its -approach, the same as the non-malignant ulcer. - -Allingham speaks of a very rare species of rectal ulcer, which he terms -rodent or lupoid, that is superficial, does not implicate the surrounding -parts, devoid of hard edges or surface, very painful and only cured by -complete extirpation. - -I have intentionally omitted the early symptoms and course of rectal -ulcer for the purpose of giving audience to Dr. A. C. Hall, who, in -a communication to a medical journal, writes the following lucid -description: - -“Rectal ulcer is a more common disease than is generally supposed. -Unfortunately the symptoms are generally obscure, and the patient suffers -but very little, if any pain, and consequently consults his physician for -some of the reflex symptoms, rather than for the initial disease itself; -and very often these reflex symptoms are vainly treated till the patient -and physician are both thoroughly disgusted and disheartened. There is -one maxim which every physician should always bear in mind, and that -is, _always suspect rectal ulcer in every case of protracted or chronic -diarrhœa_. I have reports from eighty-six pension surgeons, in which -they estimate that they have examined two thousand cases, where chronic -diarrhœa was the alleged cause of disability in applicants for pensions. -Of these two thousand cases of chronic diarrhœa, eighty-seven per cent. -had rectal ulcers, and fully ninety per cent. of those who claimed -chronic diarrhœa as their disability and who had no ulceration were -rejected, because their proofs of the disease, aside from the ulceration -were too meagre. Thus the strongest and most prominent symptom of rectal -ulcer is _chronic diarrhœa_. - -“The diarrhœa is generally more troublesome in the morning. The patient -often on arising feels an urgent desire to go to stool. This act is often -very unsatisfactory, for he passes very little feces and a great deal -of wind. Occasionally these small stools are covered with a jelly-like, -or white of an egg substance, or the motion may be only a jelly-like -mucous, with no feces. There is generally more or less tenesmus, or -a disagreeable feeling, as if the rectum was imperfectly evacuated. -Sometimes the patient will be compelled to go out two or three times -before breakfast, and he may in the later attempts to have a stool, pass -lumpy or scybalous feces, covered with mucous, and often streaked with -blood. There sometimes exists, as a symptom of rectal ulcer, a desire -to go to stool when cold drinks are taken. But generally the diarrhœa -and tenesmus subside soon after breakfast, and the patient has no more -trouble until the next morning. A great many, or I might say a majority -of those suffering from rectal ulcer consult the physician for some -symptom or other that suggests anything else but the rectum, but by close -questioning, and following up the symptoms, one can soon tell whether -they are reflex or otherwise. - -“In cases of rectal ulcer of long standing, there is always more or less -cachexia, or peculiar waxy, sallow, unhealthy complexion, which sometimes -alone points significantly towards the disease. - -“There is often more or less enlargement of the liver and spleen, -especially the spleen. - -“In advanced cases, the diarrhœa comes on at night as well as morning, -and defecation is accompanied with pain and griping. Another almost -characteristic sign of rectal ulceration, is alternating diarrhœa and -constipation. The bowels remain constipated for a considerable while, -then diarrhœa supervenes, and is accompanied by severe and excruciating -colicky pains, and often nausea. Persons subject to chronic diarrhœa -always dread to take a physic to relieve a temporarily constipated state, -for it will almost invariably put them to bed. - -“In extreme cases, infiltration and thickening of the sub-mucous and -muscular coats supervene, as a result of nature’s effort to repair the -lost tissue. This thickening may be so extensive as to threaten and -actually produce stricture. It will often convert the rectum into a -passive tube, through which feces and fluids trickle, the patient having -little or no control over the sphincters. - -“The passage of hardened feces and the pressure of internal hemorrhoids -and polypi are the most common causes of rectal ulceration. The lodgment -of foreign bodies, such as fish bones, cherry stones and plum seeds that -have been swallowed, and which act as irritants and produce ulceration. - -“In women the pressure of the fœtal head on the rectum during childbirth -is a frequent cause of ulceration, likewise the pressure of a misplaced -uterus. - -“On examination, by means of a speculum, the ulceration will be found -about an inch or an inch and a half from the anus, generally on the -posterior wall, but often on the anterior wall. - -“When the ulcer is on the anterior wall, there is more or less -irritability of the bladder, and seminal emissions or impotency. The -ulcer itself may be round, oval or elongated, radiating or following the -columns of Morgagni. The ulcer may present ragged, interrupted elevated -edges, or they may be sharp cut and regular, as though cut with a sharp -punch. The edges are sometimes hard and gristly, or may be soft and with -no elevation above the surrounding tissues. The surface of the ulcer -is often clean, and healthy looking granulations may be seen, or the -ulcerated surface may be loosely covered with a greyish, grumous scum, -that is offensive, and decidedly unhealthy for the patient. Underneath -this scum there is often found an ulcerated spot, that is apparently -lifeless, and will require much attention, locally and constitutionally, -to prevent its rapid extension. In this form of rectal ulcer there is -always more or less marked cachexia. It is the indolent ulcer, occasioned -by the gradual breaking down of the tissues, that produces the grave -constitutional disturbances and death. It is the small, round, or oval -ulcer, with elevated, hardened edges, that produces the many and various -reflex nervous symptoms, which are misleading and troublesome.” - -[Illustration: FIG. 19.—Rectal Irrigator.] - -In all cases of rectal ulcer of any considerable gravity, absolute -rest, both of the parts and the body, is to be maintained. Hot water -irrigations and a complete destruction of the diseased surface by -carbolic acid, are the first things to be thought of, together with a -liquid diet. - -Convert the ulcer into a carbolic acid sore and use an iodoform -suppository. In fact the treatment is very similar to that recommended -as an after treatment in a bad case of hemorrhoids, with such variations -as the ingenuity will suggest. Bismuth, oxide of zinc, eucalyptus, -mercury, resin cerates, etc. - -Have found no use for iodine, nitrate of silver or acid preparation of -iron, which corrode and destroy instruments in the treatment of rectal -diseases. - - -FISSURE, OR IRRITABLE ULCER. - -Of all the diseases of the rectum, considering the apparent -insignificance of the lesion, this heads the list as a pain producer. -Fissure has characteristics peculiar to itself and I do not think, as is -claimed, that its location, just above the muco-cutaneous junction or -Hilton’s line, where the nerve supply is the greatest, explains these -characteristics; neither do I think it of traumatic origin. - -No other ulcer, wound or abrasion in the same locality produces the pain -that identifies a fissure. - -[Illustration: FIG. 20.—Fissure, complicated with polypi.] - -It might be compared to a rhagade or chap in the web between the toes or -fingers. In its recent state it presents the appearance of a longitudinal -tear of from three to five-eighths of an inch in length, looking raw and -bloody, with ragged and somewhat everted edges; and may be complicated -with polypi (Fig. 20), or a hemorrhoid occupy its base, called the -“sentinel” pile. - -It is aroused from its slumbers by a mechanical disturbance of the -slightest nature, hence the name irritable. The act of defecation being -followed by a dull, sickening, sometimes lancinating pain lasting -three hours or more, incapacitating the subject from labor. The mere -introduction of the finger may produce a deathly pallor and possibly -syncope. - -Ask the patient to extrude the parts, then gently pull down the mucous -membrane and apply a ten per cent. solution of cocaine to the tract with -a camel’s hair brush or silver canula attached to a hypodermic syringe; -carrying the solution fully to the top of the fissure, which may be out -of sight. If any unguent has been used about the fissure it should be -subjected to a hot water irrigation before using the cocaine, as cocaine -will not take effect on a greasy surface. - -When the tract is sufficiently anæsthetized to introduce a speculum, -apply on the end of a probe wrapped with cotton, 95 per cent. carbolic -acid, and prescribe the following ointment for daily use: - - ℞ Acidi Salicyl. ʒ ss - Vaselini ℥ ss - - M. - -If unsuccessful after making two or three thorough applications of -carbolic acid, inject into and beneath the bed of the fissure, in a -sufficient number of places to encompass its length, possibly two, a few -drops of the hemorrhoidal compound; and produce a slough. The object is -to destroy the original ulcer and convert it into some other form that -will heal. I have never seen a resulting sore from carbolic acid that was -slow to heal. - -A physician who had been a great sufferer from the effects of a fissure -informed me that he had been etherized twice and the sphincters -thoroughly stretched, and had submitted to incision three times, all of -which had proved fruitless, and was finally permanently cured by the use -of salicylic acid and vaseline. - -[Illustration: FIG. 21.—Ointment Applicator.] - - - - -PROLAPSUS RECTI. - - -A prolapse of all the coats of the rectum, amounting in some instances -to complete invagination, is of such rare form, occurring mostly during -infancy, that it might be considered practically out of the list of -rectal ailments. - -Prolapse of the mucous coat of the bowel is not an uncommon affection, -and is a frequent complication of internal hemorrhoids. When the -hemorrhoids are cured the prolapsus usually disappears. - -It is natural for the mucous membrane at the lower end of the rectum, by -its loose attachment to the muscular coat through the cellular layer, to -roll down and become somewhat everted during the act of defecation. It is -only when this condition becomes excessive and the protrusion so great -that it does not return of its own accord, that it is called prolapsus of -the first degree and treatment required. - -Should it occur independently or persist after the removal of piles, a -cure may be easily effected by the injection of from eight to ten minims -of a ten per cent. solution of carbolic acid, beneath the mucous membrane -in the cellular structure, at points where it is desirable to take up -a fold. The needle may be introduced in a line with the axis of the -rectum, varying from one-fourth, one-half of an inch or more from the -muco-cutaneous junction, and even as high up as the upper margin of the -internal sphincter. - -This can be done while the membrane is prolapsed, or through the slot -of a speculum. The latter is preferable on account of the sides of the -slot limiting the distribution of the medicine. Anything that will excite -an adhesive inflammation or a change in the cellular coat will have a -similar effect. - -The following preparation is effective: - - ℞ Acidi Salicyl. - Sod. Bibor. ā ā ʒ i - Glycerinæ ℥ i - - M. - -Take six drachms of this preparation and add carbolic acid 40 minims. - -If it be desirable to remove a thickened fold or bunch-like appearance -of the mucous membrane, inject the same as you would piles, using the -hemorrhoidal compound. It will slough off neatly and heal readily. It is -peculiar of the injection of internal piles or of the same strength of -medicine into or beneath the mucous membrane, that it tightens and takes -up a slack of the membrane permanently, without apparent lessening of -the calibre of the gut. It is also peculiar of the treatment and cure -of internal hemorrhoids by injection, that no cicatrix, cicatricial -tissue or contraction results, unless the operation has been extensive, -involving both sides, and an active inflammation has been excited by -extraneous causes. - - - - -RECTAL POCKETS AND PAPILLÆ. - - -Concerning the frequency of the diseased conditions to which the names -rectal pockets and papillæ are applied, and their being such prolific -sources of mischief as claimed by those who first caught up the craze and -exaggerated the facts, a few brief comments may not be out of place. - -That there are such morbid changes, and that they are more or less -hurtful through reflex excitability can not be successfully disproved. -That their appearance suggests the titles they have received is also -undeniable. And the fact of their having been brought to notice in an -irregular way, does not militate in the least against the existence of -such affections, or the fitness of the terms used to designate them. - -If it be true, as stated by enthusiasts on the subject of rectal pockets -and papillæ, that they are frequently found in old, deep-seated, chronic -diseases, where the presence of rectal trouble is never suspected by any -local signs, we have, then, a sufficient reason to account for their -having escaped the notice of specialists. - -Andrews makes a labored effort, and with apparent success, to show that -the so-called “pockets and papillæ” are normal structures. That the -pockets are the _sacculi Hornei_ (Fig. 22), which are little depressions -situated just above and intimately connected with the verge of the -anus, caused by the reticulated arrangement of bands of muscular and -connective tissue, beneath a delicate mucous membrane and deepened by -the corrugating action of the sphincter ani. That the papillæ are little -dot-like prominences frequently found between the lower ends of the -_sacculi Hornei_, and when somewhat enlarged resemble in appearance the -_carunculœ myrtiformes_ of the vagina. That these little papillæ, with -their adjacent “pockets,” constitute the so-called “pockets and papillæ” -of the itinerant. - -[Illustration: FIG. 22.—S. _Sacculi Hornei._ P.P. Papillæ, magnified -three diameters. (Andrews.)] - -[Illustration: FIG. 23.—P. _Bone fide_ rectal pocket with adjacent -papillæ, not magnified at all.] - -I have seen just what Dr. Andrews very correctly describes, and will say, -after carefully reading his explanation, I am fully convinced that he -never saw what is meant by the discoverer of rectal pockets and papillæ. -And further beg to say that the doctor must concede that there are -others, who are not itinerants, capable of identifying a diseased surface -when they see it, and pointing out its place of location. - -[Illustration: FIG. 24.—Other varieties of papillæ and a simple form of -rectal pocket.] - -It will be seen by a reference to the appended clipping, that Andrews has -been making his microscopical dissections nearly an inch below where -true rectal pockets are found. And I can conscientiously attest that true -papillæ bear no resemblance, in the least, to his papillæ or _carunculœ -myrtiformes_ at the anal verge. - -[Illustration: FIG. 25.—Represents figure 22, showing reticulated -arrangement under post mortem relaxation. C.C.C. Columnæ recti. S. -Sacculi Hornei. P.P. Papillæ. (Andrews).] - -Rectal pockets are doubtless a duplicature of the mucous membrane, -forming cul-de-sacs with their mouths looking upwards. They are removed -through a speculum by raising the outer wall with a blunt hook and -excised with a pair of scissors, or slit through their center with a -knife, and carbolic acid applied to the remaining flaps. - -[Illustration: FIG. 26.—Author’s Knife-hook for slitting down pockets.] - -Papillæ may be seen in three different forms. One, a white, flat or -sessile process, resembling the half of a split pea, but not quite so -large. Another, a small, white, rather stiff projection on either side -of a large pocket. The other, a slender, perfectly flexible, worm-like -vegetation, possessed of a white or transparent top, Figs. 23 and 24. -They appear to spring out of the mucous membrane similar to a polypus, -and can be snipped off at their base with little loss of blood and -trifling pain. - -“The usual location of pockets and papillæ is at a point about an inch -from the anus, at the upper margin of the internal sphincter, where the -large distended pouch of the middle portion of the rectum is abruptly -puckered down to the narrow limits of its last inch. - -“These pockets are curious formations, and have received very little -attention from writers upon rectal disease, and they have been almost -entirely overlooked by anatomists, as well as pathologists. Whether they -belong to the anatomy or not, I am unable to state with any certainty, -but I know for certain, however, that they are not always present. I know -also that they can almost always be found in cases of old, deep-seated, -chronic diseases, and that the removal of these pockets in this class of -cases is followed by the most happy results. - -“When these pockets are present, they always occasion a spasmodic -contraction of the sphincter ani, a condition which is most frequently -observed in those cases that are developing some deep seated -constitutional disease. Their removal in this class of cases is -invariably attended by more or less improvement of the patient’s general -condition and circulation. - -“In form and character these pockets may be long and narrow channels, -and ulcerated at the bottoms; short (cul-de-sacs) or broad mouthed and -pointed at the bottom. These pockets create a great amount of irritation -to the nervous system. No matter what shape, condition or location they -may be in, by reflex irritation they produce a long train of nervous -symptoms that cannot be remedied until they (the pockets) are removed. - -“Papillæ are conical processes of mucous membrane, of variable size, -shape and location. They have no relationship with rectal pockets, for -they very frequently exist independently of them. - -[Illustration: FIG. 27.—Pratt’s curved scissors.] - -“I look upon these conditions as being the most mischievous of rectal -disorders, because they always occasion a tonic spasm of the internal -sphincter, and this alone makes excessive demands upon the powers of the -sympathetic nerve. They are common in all forms of chronic disease. I -know of no reason why these conditions, which I have described should -have been so long overlooked, and their importance have remained -unappreciated. - -[Illustration: FIG. 28.—Long blunt hook.] - -“Unless it be that their presence is unattended by local symptoms, -and hence they have failed to attract the attention of either patient -or the physician. But in view of the fact that they occur in so many -chronic conditions, and the additional fact that marked benefit almost -invariably follows their removal, I insist upon it that no obstinate -case of chronic disease has been properly examined until their presence -or absence has been ascertained. The most happy and the most marvelous -results that I have ever seen in the practice of medicine and surgery -have followed the removal of pockets and papillæ, and in thus bringing -them to your notice, I do so in the confident belief that a proper -appreciation of their importance on your part will add materially to your -resources in battling with disease, and in helping those who apply to you -for relief.” (Pratt.) - - - - -PRURITIS ANI. - - -Excluding all discoverable local causes whereby the presence of this -obstinate affection may be explained, such as piles, ulcer, fistula, -oxyuris vermicularis, eczema marginatum, etc., and take the disease -unalloyed, or as it may exist in a state pure and simple, and assure a -patient thus afflicted that he can be quickly and permanently cured, -would not only be presuming too much, but would be stepping beyond the -legitimate bounds of all past recorded experiences. - -To furnish something of an idea to those who are not already familiar -with this seemingly trivial yet rebellious complaint, I here quote the -language of Dr. Hoyt, who uses words somewhat extravagantly in the -beginning but palliates his feelings down later on with _lotio niger_. - -“With what anguish its unhappy victims battle through innumerable -sleepless nights fighting this demon of so-called local epilepsy, with -its long array of itching, burning, exuding, corroding, exhausting, -and blaspheming characteristics, as though they had been brewed by the -chemistry of hell. The whole organization becomes a chaotic discord, the -disposition is cruelly warped, the countenance shows a sad picture of -living woe, the carriage is nearly lost to all laws of equilibrium, and -the complete being merges into a throbbing phantom of despair, trembling -upon the very threshold of idolized suicide. - -“Of course I speak of the most aggravated cases, instances that seldom -occur within the experiences of general practitioners. Wherefore -then these phenomena? What is the mighty influence that yields so -much distress, as all these objective symptoms are but an appearance -outflowered by some subtle and specific force. The meager literature -upon this subject hobbles upon the crutches of hypothetical inferences, -telling you _perhaps_ it is capillary congestion or chronic proctitis, -or neurotic hyperæsthesia or eczema, or malaria, suggesting a panoramic -array of remedial agencies all unsatisfactory, thereby confessing to a -sad condition of helpless empiricism. - -“My comprehension of this subject compels me to endorse the parasitic -theory, though it may excite your disapproval, and perhaps your ridicule, -yet it can be easily verified by directing your management towards the -destruction of the parasite, when all symptoms will disappear. Mercury is -quoted as nearly a specific for the annihilation of these marauders, and -the very best method of administration is by using Lotio Niger. - -“Thrice daily the patient should relax, the respiration of the cutaneous -surface by the free application of hot water, just as hot as it can be -comfortably endured. Then immediately afterwards _while the skin is made -absorbent_ by the action of the liquid heat, it should be saturated -with this medicine in the most thorough manner. Within three days time -the itching will be reduced fifty per cent., but the complete result is -attained only after a continued use of from four to eight weeks. - -“In many cases there will remain points or patches where the agent does -not seem to act, and to these I usually apply the regular unguentum -hydrargyri. Avoid all soaps and ointments except as above stated, thereby -preventing the obstruction to absorption of the remedy as it has to enter -the pores of the skin in order to act upon these energetic enemies that -hold their victims under such a terrible bondage.” - -It is characteristic of pruritis for the paroxysms of itching to come on -mostly after the patient gets warm in bed, at which time the annoyance -may be further increased by a moisture or exudation about the anus. - -In longstanding cases the skin becomes thickened, horny in texture, and -loses its pigment and elasticity. Sometimes portions of the radiating -folds will become so hypertrophied and elongated, from the effects of -gouging and scratching, that they look like and are sometimes called -external piles, which in reality are nothing of the sort, but properly -speaking would come within the range and meaning of non-syphilitic -condylomata. - -I have successfully removed these formations by the same process adopted -for the cure of piles. They go through similar changes after injection -and open up a cavity surrounded by a ragged, thick, calloused skin, -which, after first being cocainized, can be trimmed off with a pair of -scissors. If there are several large tabs I do not operate on all at one -sitting. - -[Illustration: FIG. 29.—Thickened condition of the skin in pruritis -(Esmarch).] - -In the treatment of pruritis ani, a thorough search for a local cause and -its removal will find a lasting reward in the results obtained. - -Of the obscure local causes, perhaps animal and vegetable parasites are -the most difficult to find. The injection of a decoction of quassia bark -or lime water and carbolic acid, will be efficacious in dislodging the -oxyuris vermicularis, which may or may not be seen, like small pieces of -white thread lodged between the anal folds. - -For the vegetable parasites, tricophyton, etc., (microscopical) -sulphurous acid ranging from 50 per cent. up is an old tried remedy. -Immoderate eating, drinking coffee, and smoking excites the itching with -some. Whenever it be decided that no local or constitutional disease -can be found as an assignable cause, and that it is purely neurotic -in character, we commence to grope in the darkness for remedies. What -relieves one will not another; and what relieves for a time will lose its -effects altogether. - -Hot water compresses, a little short of scalding, are good for relief and -a good intercurrent remedy. Among the remedies highly recommended are -linseed oil, thuja occidentalis, carbolic acid, _citrine ointment_, oil -of cade, oxide of zinc, compound tincture of green soap, black wash, and -_galvanism_. The anode is placed over the perineum and base of scrotum -and the cathode against the anus or within the grasp of the sphincters. -Claimed to be a specific. Nerve stretching by divulsion of sphincter -muscles is also recommended. - -Formulæ: - - ℞ Ung. Citrini ʒ ii - Balsam. Peru ʒ iss - Acid. Carbol. gr. xx - Sulphuris ʒ iii - Cerat. Simp. vel Lanolini ℥ i - - M. - - ℞ Hyd. Chlor. Mit. ℈ iv - Adipis ℥ i - - M. Said to be specific for pruritis ani or vulvæ. - - ℞ Hyd. Chlor. Mit. ʒ i - Balsam. Peru ʒ iss - Acid. Carbol. gr. xx - Lanolini ℥ i - - M. et sig. Apply after hot sponging. - - ℞ Ol. Cadini ʒ i - Acid. Salicyl. gr. xv - Ung. Zinci Oxidi q. s. ft. ℥ i - - M. - - ℞ Saponi viridis } - Ol. Cadini } ā ā ℥ i - Alcohol. } - - M. (Kelsey). - - ℞ Liq. Carbon. Detergentis (Wright’s). - Glycerinæ ā ā ℥ i - Zinci Oxidi } - Calamini Prep. } ā ā ℥ ss - Sulphuris Precip. } - Aquæ Puræ ℥ vi - - M. (Allingham). - - - - -DIVULSION. - - -Forced dilitation as a means of relief and cure for certain forms of -rectal trouble, although a much abused and somewhat barbarous practice, -has positive and undoubted merits. It is only justified, however, in -peculiar and isolated cases. - -The wholesale stretching of the sphincter ani muscles as a “cure all” is -certainly to be deprecated as unscientific, illogical, and without the -advantages or benefits claimed for it by rattling and noisy fanatics. -Divulsion injudiciously employed may be followed by a long and tedious -recovery, complicated with very undesirable sequelæ and thereby excites -much adverse criticism. - -The case of a lady recently came under my observation, who, although -in average health, complained a little as many women do, and thought -she was troubled with hemorrhoids. Through the advice of her physician, -a college professor, she submitted to the operation of stretching on -general principles. Irritability of the rectum followed, with soreness -and continued pain. Finally two large sympathetic buboes developed, which -suppurated, and were slow in healing. This happened a little over a year -ago, I am reliably informed, and she has not yet fully recovered. - -A number of cases have come to my notice where stretching was practiced -for the cure of piles, imaginary spasmodic stricture, etc., without the -least benefit, except, possibly, that accruing to the physician. - -[Illustration: FIG. 30.—Graduated Rectal Dilators. (Pratt’s).] - -A young married man, foreman of a printing-office, complained at times -of slight pain in the region of the liver. His physician, an editor of -a medical journal, made an examination of the rectum with a speculum, -and informed him that it would be necessary, to preserve his health, to -undergo the operation of stretching the sphincters. - -The day was appointed and hour set for the operation, which, fortunately -for the young man, was “nipped in the bud” by the physicians arriving a -little late; and through the advice of a friend he seized the opportunity -and “skipped out,” came to my office, and was examined. His bowels were -regular, there was no history of rectal disease, and not the least sign -of any; nor was there a shadow of an excuse for an operation. - -The cases in which divulsion seems to be of greatest benefit are found -mostly among women of a peculiar high nervous tension or organization, -where the muscles become hypertrophied from repeated spasm, and -constipation resulting from ineffectual efforts to expel the feces. In -such cases forced dilitation is followed by the most satisfactory results. - -It should be accomplished with patient lying on the side, and under the -most profound anæsthesia. Rectal dilators, which distribute the force -evenly all around, may first be used, then the thumbs, or the thumb of -right hand and index finger of the left, or two fingers of each hand, to -completely paralyze the muscles. The process should be slow and gentle, -and caution exercised lest the tissue give way from the application of -undue force. - -Local causes should always be sought, and excluded if practical, before -heroic measures are adopted for the relief of spasmodic sphincter. There -are instances where tightness of the sphincters exist, superinducing -constipation, etc., not traceable to any appreciable cause. These cases -may be relieved without the aid of general anæsthesia, by graduated -dilators or rectal bougies, accomplishing little at a time, daily or -tri-weekly. - -When constipation depends upon inertia, or a lack of expulsive power -of the rectum, I think moderate dilitation advisable and decidedly -beneficial. - - - - -POLYPUS. - - -These innocent growths can be successfully removed, when within reach and -most of them are, without the loss of blood or the infliction of pain, by -carbolic acid injection to act as a styptic and deaden the sensibility, -while the scissors is used to sever their connection with the bowel. - -Allusion is made, in speaking of the diagnosis of hemorrhoids, to -the different forms and varieties of polypi, consequently no further -description of them will be given here. Polypi, being more dense and -fibrous than hemorrhoids, are not readily permeated by the injection -compound. Neither can the hemorrhoidal needle be used with any advantage -unless they be large and soft in structure. Therefore a small hypodermic -needle is selected and 95 per cent. carbolic acid. This strength of -carbolic acid is not only a powerful styptic and cauterant, but its -fluidity permits it to be forced throughout the fibrous structure with -ease. - -The action of the acid should extend fully to the base of the polypus, -which is then clipped off a little outside of the line. The stump goes -through similar changes to that of hemorrhoids after injection. In long -or pediculated polypi, it will only be necessary to apply the acid at the -base sufficiently to intercept the circulation before excision. - -A little cocaine may be used first, if the parts are very sensitive, and -the same precaution should be taken with regard to the protection of -the adjacent and surrounding parts from the excoriating effects of the -carbolic acid, as recommended when operating on hemorrhoids. - - - - -PROCTITIS. - - -Inflammation of the rectum, like any other phlegmasia, may arise -traumatically or idiopathically; by contiguity of structure or continuity -of surface. The acute symptoms are very much like acute dysentery, which -disease, in my opinion, nearly always extends to the rectum, causing the -characteristic symptoms of weight, tenesmus and straining at stool. - -Irritable rectum in the absence of diarrhœa is diagnostic of the -complaint. The bladder and prostate may be affected through sympathy, -and colicky pain reflected to the small intestines or stomach. In the -more chronic forms, constipation, tenderness and the cul-de-sac partially -filled with mucous are distinguishing features. - -Carbolized hot water irrigation, prepared hot corn starch, slippery elm -water, bismuth, etc, together with a suppository of iodoform, bismuth -and opium, or bismuth, opium, belladonna and calomel, will be found -serviceable in the acute stage. About a half tumbler full of a saturated -solution of chlorate of potash, injected slowly and retained for ten or -fifteen minutes, is said to effect a cure by one or two injections. - -Chronic proctitis, also called irritable rectum, and sometimes rectal -catarrh, with symptoms that might be expected to emanate from a disease -of the mucous membrane, rarely amounting to a diffuse thickening of the -rectal walls, is treated similarly, except less palliative. Combinations -of eucalyptol, iodoform and bismuth; or eucalyptol ½ dr., oxide of zinc 1 -dr., vaseline 1 oz., are highly recommended after the rectal douche. - -Some physicians hold that chronic inflammation of the rectum is a disease -of more frequent occurrence than all other rectal diseases combined. And -equally as pernicious, causing many functional and even organic troubles -through reflex action. - - - - -FLUSHING THE COLON. - - -I have always been loath to admit the value of a thing which did not -come from an authoritative source. A little retrospective medicine, -however, is sufficient to teach any of us that many important discoveries -have been made without the free-will and full consent of “acknowledged -authorities;” and that it is not positively necessary for progressive -physicians to first obtain their permission before being allowed to think -and act for themselves. - -Flushing the colon is a discovery of intrinsic worth, brought to notice -in an irregular way, and has its place as a remedial agent with which -every physician should become familiar. If you doubt its efficacy, and -want a free evacuation of the bowels without taking physic, lie on the -back and inject into the rectum slowly with a bulb-syringe one-half -gallon or more of hot water, and you will get it inside of fifteen -minutes. - -I do not see that Dr. A. W. Hall, who claims in his health pamphlet to -be the father of the process, and whose name bears the titles of Ph.D. -and LL.D., and consequently deserving of the respect of an educated man, -makes out a clear case in defense of his “New Hygienic Treatment” as a -life-giving principle, _either_ in health or disease. - -His argument is certainly unphysiological, and we are left to infer that -nature has been derelict in the construction of man, which he has been -instrumental in supplementing. If he were to confine himself to disease -alone, his reasoning would appear more plausible; but he claims that -people enjoying good health, with no physical ailment whatever, should -wash out the colon. - -[Illustration: FIG. 31.—Flushing the Colon.] - -No doubt Dr. Hall has been greatly benefited by flushings of the colon, -as also have many others, which offers some apology for the enthusiasm -and interest he manifests in the “new revelation;” but we shall be -compelled to look to others for the pathological conditions in which it -will be found of greatest service. - -Respecting the colon itself, there are two very diverse conditions, -with their concomitant symptoms, in which flushing will be found of -great benefit. The one a diseased condition of the mucous membrane, of a -chronic dysenteric or an ulcerative character. The other, a sluggishness -or torpidity of the bowel belonging to a constipated habit. - -The most easy, simple and efficient manner of practicing the flushings, -according to my experience, is by assuming the position shown in the cut. -A piece of oil-cloth, rubber-cloth, or a newspaper may be used to protect -the carpet. One or both feet are allowed to rest on the floor, and the -hips can be raised by the slightest exertion for a few moments, any time -it is desirable to hold and hasten the water down the incline. - -Beginners should use a common bulb syringe, with water rather hot, -varying in quantity as they become accustomed to the process, from a -quart to a gallon or more, and a bulb-full squeezed out slowly, with -intervals between, giving it time to pass out of the rectum into the -colon. On regaining the erect posture, if the rectum be loaded with -feces or distended with water, the desire to expel its contents may be -irresistible, especially if air has passed through the syringe; although -a little practice will enable any one to exert great control over his or -herself in this respect. - -Dr. F. H. Etheridge (_Trans. Chicago Med. Soc._) gives a number of -cases of impacted colon, where daily flushings, extending over a period -of from one to three months in each case, were followed by the most -grateful results. This, too, after the persistent use of drugs had almost -hopelessly failed to even afford temporary relief. - -Without segregating the cases, some of the diseased conditions mentioned -in connection with his patients were dyspepsia, characterized by -anorexia, acid and bitter eructations, bad taste in the mouth, gaseous -distention, gastric weight and pain. Also cephalalgia, chills, vertigo, -chloasmic spots, _muddy sclerotics_ and _complexion_, insomnia, ennui, -eczema, psoriasis, dysuria, etc. - -He says: “Daily movements of the bowels are no sort of a sign that the -colon is not impacted; in fact, the worst cases of costiveness that we -ever see are those in which daily movements of the bowels occur. The -diagnosis of fecal accumulations is facilitated by inquiring as to the -color of the daily discharges. A black or a very dark green color almost -always indicates that the feces are ancient. Prompt discharge of food -refuse is indicated by more or less yellow color. It would be interesting -to inquire why fresh feces are yellow and ancient feces are dark. - -“Absorption of the feces from the colon leads to a great many different -symptoms; amongst others, anæmia, with its results, sallow or yellow -complexion, with its chloasmic spots, furred tongue, foul breath, and -muddy sclerotics. Such patients have digestive fermentations to torment -them, resulting in flatulent distention, which encroaches on the cavity -of the chest, which in excessive cases may cause short and rapid -breathing, irregular heart action, disturbed circulation in the brain, -with vertigo and headache. An over-distended cæcum, or sigmoid flexure, -from pressure, may produce dropsy, numbness or cramps in the right or -left lower extremity. - -“I have often questioned whether chloasmic spots were not due to fecal -absorption. These spots are pigmentary matter deposited under the skin. -It is a physiological fact that all pigments originate in the liver. In a -condition of health their abnormal deposit we never see. It is only when -the patient is not well, in some way, that these spots are noticed. They -are infinitely more common in women than in men. It is easy to see that -their sedentary life is more apt to lead in them to the filling of the -colon. Absorption from the colon produces a poisoned blood, which in turn -deranges every organ of the body, among others the liver. It is possible -that the action of light, as in photographs, contributes in some way to -precipitate the deposits of these chloasmic spots, because we see them -chiefly upon the parts of the body exposed to light.... - -“The use of a long rectal tube is unnecessary. The patient should be -placed in a genu-pectoral position, the shoulders thus being lower than -the hips. The water will be made to descend while anatomically ascending -the intestines. Patients can be made to receive from one to six pints of -water in this position without the slightest trouble. One of the effects -of the water is to distend the colon, and in that way pressing away the -walls of the loculi from the accumulations that fall into the current -of water and are passed out while the water is leaving the intestine. -The patient will oftentimes complain of severe tormina, checking the -current of water for a few seconds, and will be followed by complete -relief. The presence of such a strange foreign body in the intestine as -hot water in many cases excites prodigious peristaltic activity, thus -producing the tormina. Plain hot water is all that is necessary to use; -the water should be hot; cold water, or tepid water, will not do. It will -produce great suffering. One patient took the flushings for a fortnight, -returning vowed she would never use any more because they produced such -terrific cramps. Upon inquiry it was found that she was using tepid -water. The subsequent use of hot water by her was never followed by a -cramp. Upon many patients this large amount of water acts as a vigorous -diuretic. Where patients suffer as well from renal insufficiency, I am -in the habit of telling them to use a pint or a pint and a half of hot -water after the flushing has passed away, and to lie upon the back with -hips elevated for half an hour. Thus retaining the water, it will act -as a powerful diuretic. Some patients can administer this flushing with -greatest ease, while others will develop a most phenomenal awkwardness. I -am in the habit of telling patients to kneel in the bath-tub, who are at -all awkward about using these flushings.” - - - - -REFLEXES. - - -The lower end of the rectum is richly supplied with both sensory and -sympathetic nerves. The sensory greatly predominating at the verge, -making it one of the most acutely sensitive surfaces of the body. In -ascending upwards the sensory gradually give place to the sympathetic, -until little sensibility is imparted by the touch three inches from the -entrance in a normal condition. - -This accounts for the hidden cause of so many reflexes, having their -seat of origin from lesions an inch or more above the anus, where the -sensibility is not always sufficiently great to attract attention. - -It has been claimed that obscure rectal disorders may so undermine the -nervous system by reflex irritation, allowing the inroad of general -systemic disease, that many die yearly from this as the primary cause, -without ever knowing the source and origin of the fatal malady. - -That migratory pain, headaches, dyspepsia, sleeplessness, palpitations, -sexual weakness, nervousness, despondency, irritability, and a general -breaking down of the system, may all be caused by a small ulcer or other -irritation of the rectum, which has passed unnoticed by either physician -or patient. - -Nearly every physician is familiar with the white ring around the mouth -extending up the sides of the nose, produced by the presence of pin worms -in the rectum, or a fatal lock-jaw caused by a broken off needle or rusty -nail in the foot. Such illustrations alone, are sufficient to demonstrate -conclusively the power of this dynamical disturbance called reflex action. - -While there is doubtless unwarrantable exaggeration concerning rectal -reflexes by some, there are many unpardonable oversights by others. A -case was reported in the _Medical Record_ where all preparations were -made to operate for organic stricture of the urethra, which, perchance, -proved to be a reflex from a small rectal fissure. When the fissure was -cured the spasm ceased. A case of roaring in the right ear was relieved -by the cure of a fistula, says Dr. Rorick, who also speaks of two other -similar cases. - -A very remarkable case occurred in my own practice, where the right -testicle had been enlarged to the ordinary size of a well developed case -of orchitis for some years, and had resisted all manner of treatment, -completely disappeared after the removal of hemorrhoids. The case of -hemorrhoids, which was one of the worst I ever saw, is represented in -Fig. 2. - -Another case was that of a merchant, who suffered frequently from a -sensation of drawing and weight in the back of the head and neck. When -these attacks came on, his memory became so badly impaired that he was -rendered unfit for the transaction of business. He noticed during the -attacks that there was a feeling of heaviness in the rectum, swelling -and tightness of the sphincters, and a lack of expulsive power at stool. - -Examination revealed several pockets and papillæ of the variety shown -in Fig. 23, which was taken from this case. Have not been apprised of -any return of the trouble since an operation for the removal of these -abnormalities. - -As evidence that physicians should be a little more vigilant in the -observation and study of rectal reflexes, the case of a very talented -and influential lady of this State might be appropriately instanced. -Her general health had been greatly impaired for a long time, with -unexplained and repeated outbursts of sickness. Several prominent -physicians were consulted, to whom she called attention to a little -uneasiness, at times, in the rectum with an irritable bladder. They -all examined the rectum, in their way, and ridiculed the idea of local -disease, but went on treating the reflex symptoms, with nothing more than -temporary relief. - -The successes of a local specialist in the treatment of hemorrhoids by -the Brinkerhoff system, whose ignorance of anatomy was such that he -denominated the sphincters “dispenser” muscles, induced her to pay him a -visit. He found a well defined superficial rectal ulcer, and exhibited it -to one of the previously named doubting physicians. The ulcer was quickly -healed and the lady restored to health. - -She became so enthused over the result, that she took up the study of -rectal diseases for the benefit of others, as a missionary, so to speak; -and it is needless to say that the physicians who failed to detect the -cause of her trouble did not reap any of the emoluments of her labors, -but there were several irregular practitioners who were ready listeners, -took in some handsome fees as a reward. Her motto, true to a grateful -nature, was to “praise the bridge that carries you over.” - - - - -CONDYLOMATA. - - -Condyloma, from _kondulos_ _Gr._, a “knot,” or “tubercle,” may be applied -to any small, hard tumor, flaps, tabs of flesh or wart-like excrescence -about the anus, whether of syphilitic or non-syphilitic origin. - -They may take the form of one of the radiating folds, or flattened -transversly by the pressure of the buttocks, and consist of a hypertrophy -of the skin from localized inflammation or irritation, and sometimes -continue to grow after the cause has been removed. - -A cutaneous tag as a relic of an external hemorrhoid, after it has lost -its identity and become dense in structure, is properly a condyloma; -also a warty vegetation developed from the papillary layer of the derma. -Certain forms of condylomata are pathognomonic of ulceration and other -serious changes going on above. The discharge at the anus producing these -fleshy tags. - -Some writers prefer to limit the meaning of the word to certain varieties -of growths about the anus. But it appears less liable to confuse, to use -it in a literal and a generic sense; making the varieties associated with -their causes, qualifying terms: as syphilitic, non-syphilitic, warty, -cancerous, innocent, etc. - -The objection to cocainizing condylomatous growths of any size, and -excising them, is the annoyance from the bleeding that sometimes follows, -which will often break through a heavy crust of Monsels’ salt. The -prettiest way to remove them is by galvano-cautery. When electricity is -not at hand, carbolic acid injection is equally as effective. It may be -necessary where the skin is thick and horny in texture, to afterwards -trim off the remaining ragged edges with the scissors. - - - - -NEURALGIA. - - -Neuralgia of the rectum as a clinical entity is rare indeed. Mention is -made here simply in acknowledgment of the affection, having met with but -one case, and that in a very nervous and delicate lady, who maintained -that she was cursed with a rectal ulcer. - -In obedience to this idea her physician had examined the rectum, under -anæsthesia, and found what he called a rectal ulcer at a point where the -uterine cervix rests on the rectum. His diagnosis was, no doubt, founded -upon her belief, and as an apology for the examination and treatment -resorted to, which put her to bed for six weeks. - -There were no symptoms of rectal ulcer, other than pain, and no lesion -found by a digital examination or seen through a speculum. She insisted -on taking chloroform and a more thorough examination made. This was done -without revealing anything more than what had already been ascertained, -and the diagnosis of neuralgia confirmed. - -Pain continued, periodical or irregular, in the absence of mechanical -pressure (uterine) or structural lesion, in the region of the sphincters, -or higher up, is diagnostic. If in the sphincters alone, dilitation may -be sufficient. When higher up, constitutional treatment with galvanism is -advised. - - - - -APPENDIX. - - -Injection formula of:— - -Dr. Shuford. - - ℞ Sodæ Bibor. - Acidi Salicyl. ā ā ʒ i - Glycerinæ ℥ i - Acidi Carbolici ℥ iii - - Misce. - -Dr. Yount. (5 per cent. sol.) - - ℞ Acidi Carbolici gr. xxiv - Aquæ Destil. ℥ i - - Misce. - -(3 per cent. sol.) - - ℞ Acidi Carbolici gr. xviss - Aquæ Destil. ℥ i - - Misce. - -Dr. Green. (A traveling pile doctor.) - - ℞ Acidi Carbolici ℥ i - Creosoti gtt. x - Acidi Hydrocyan. gtt. i - Olei Olivæ ℥ i - - Mix and unite by heat in a water bath. Inject enough - to turn the tumor an ashen grey color. - -Rorick. - - ℞ Acidi Carbolici 40 per cent. - Fl. Ext. Ergotæ 15 ” - Glycerinæ 15 ” - Aquæ Dest. 30 ” - - Misce. - -Brinkerhoff. - - ℞ Acidi Carbolici ℥ i - Olei Olivæ ℥ v - Zinci Chloridi gr. viii - - Misce. - - Largest piles, 8 minims. - Medium piles, 4 to 8 ” - Small piles, 2 to 3 ” - - - - -ERRATA. - - - Page 5, 1st line, _there in_ for _there is_. - ” 17, _Weaker solution_ for _Weaker solutions_. - ” 22, _Bism. Subuit._ for _Bism. Subnit._ - ” 22, _Iodoformis_ for _Iodoformi_. - ” 23, _Resin Cirate_ for _Resin Cerate_. - ” 52, _After the treatment_ for _The after-treatment_. - ” 57, _Three inches_ for _Three and a half inches_. - ” 64, _Incisions_ for _Incision_. - -Transcriber’s Note: The errata have been corrected. - - - - -INDEX. - - - Abscess, 47, 53 - - Allingham, 47, 50, 51, 57 - - Andrews, 31, 43, 52, 67 - - - Brinkerhoff, 97 - - - Condylomata, 93 - - - Divulsion, 78 - - Dorland, 26 - - - Errata, 97 - - Etheridge, 86 - - - Fissure, 62 - - Fistula, 47 - - Flushing the Colon, 13, 36, 84 - - - Hall, 58, 84 - - Hemorrhoids, 7 - Varieties of, 7 - Examination of, 8 - Diagnosis of, 9 - Treatment of, 13 - Injection of, 19 - Injection formula, 15 - After-pain, 21 - After-treatment, 22 - Accidents, 29 - Marginal Swelling and Abscesses, 29 - Secondary Hemorrhage, 30 - Carbolic Acid Poison, 31 - Embolus, 31 - Sloughing, 31 - - Hilton, 41, 43 - - Hoyt, 33, 54, 72 - - - Kelsey, 31, 48 - - - Mathews, 52 - - - Neuralgia, 94 - - - Pratt, 72, 79 - - Proctitis, 82 - - Prolapsus Recti, 65 - - Pruritis Ani, 72 - - - Rectal Pockets and Papillæ, 67 - - Rectum, 41 - - Resumé, 37 - - Ringer, 38 - - Rorick, 97 - - - Shuford, 17, 96 - - Sphincter Muscles, 41, 43 - - Sulphur, 13, 38 - - Shoemaker, 38 - - Sir Alfred B. Garrod, 38 - - Syringe and Needle, 27 - - - Turner, 3 - - - Ulcer, Stricture, etc., 55 - - - Yount, 5, 96 - - -*** END OF THE PROJECT GUTENBERG EBOOK TREATMENT OF HEMORRHOIDS, AND -OTHER NON-MALIGNANT RECTAL DISEASES *** - -Updated editions will replace the previous one--the old editions will -be renamed. - -Creating the works from print editions not protected by U.S. copyright -law means that no one owns a United States copyright in these works, -so the Foundation (and you!) can copy and distribute it in the -United States without permission and without paying copyright -royalties. Special rules, set forth in the General Terms of Use part -of this license, apply to copying and distributing Project -Gutenberg-tm electronic works to protect the PROJECT GUTENBERG-tm -concept and trademark. 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