Title: Treatment of hemorrhoids, and other non-malignant rectal diseases
Author: Agnew, William Penn
Language: English
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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




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