Ex Libris ', C. K. OGDEN ^"L'N- >-^ PILES, HEMORRHOIDAL FLUXES, PROLAPSUS, FISTULA, &c. PRACTICAL OBSERVATIONS THEREON ; WITH COLOURED DRAWINGS ILLUSTRATIVE OF THESE DISEASES; AND A VARIETY OF ADDITIONAL INTERESTING CASES ON THE MODE OF CURE, BY MEANS SAFE AND EFFECTUAL, FOUNDED ON MANY YEARS OF EXTENSIVE EXPERIENCE; THEREBY AVOIDING THE PAINFUL AND DANGEROUS OPERATIONS OF EXCISION LIGATURE, CAUTERY, OR CAUSTIC. BY ANDREW PAUL, A.B. MB. Trin. Coll. LICENTIATE OF THE ROYAI. COLLEGE OF SIRGEONS. £crnnlf cEBitum- LONDON: JOHN CHURCHILL, 1G. PRINCES-STREET, SOHO; H. RENSHAW, 356. STRAND: FANNIN, DUBLIN; AND TO BE HAD OF ALL BOOKSELLERS. 1840. London : Printed by A. Spottiswoode, New Street- Square. To G. \V. M ADDISON, Esq., OF PARTNEY, LINCOLNSHIRE. Dear Sik, Allow me thus publicly, in behalf of suffering humanity, to thank you for the encouragement you have given me in the prosecution of another Edition of this Work. Though aware that, in dedicating it to you, I may be stepping out of the strict bounds of professional etiquette, I am, nevertheless, not insensible how much the publicity of any new Theory or mode of treatment may be advanced, aided, as mine has been hitherto, by a spirit of philanthropic zeal, such as you yourself have evinced, in promulgating the benefits which, individually, it has been your good fortune to experience. A g A f ?Q IV The principles and the practice which it contains being now matured, I take the liberty of dedicating it to you ; not only as a token of the respect I entertain for your pri- vate worth, but as a medium through which to convey to you the grateful acknowledg- ments of many an afflicted sufferer, to whom, as to yourself, relief has been afforded. With the most sincere wish that you may long live to enjoy the blessing of renewed health thereby afforded you, Believe me, Dear Sir, Your obliged and faithful Friend, ANDREW PAUL. 69. Brook-Street, Hanover-Square, London, January, 1840. PREFACE THE SECOND EDITION. Scarcely three years have elapsed since a former edition of several hundred copies of this work issued from the press. The still prevailing frequency of these diseases must be looked upon as proving, not so much the increasing luxurious habits of that class of society most prone thereto (because mankind, I am con- vinced, live more regularly now than they did half a century back), as in establishing the fact, that two modes of treatment, opposite in their effects, still divide the Profession. In addition to the remarks already made in a former edition, it has been my object in the present one, to lay before the afflicted an analysis of a vast number of cases, which, during the last three years, VI have come under treatment, and have been carefully noted ; and, if number a be any criterion as to the respective merits of operation, or its opponent, the palliative plan of treatment, to leave the question at issue entirely to the discernment of the Reader, who from such data will draw his own conclusions. As the cure of these Maladies, when once esta- blished, becomes the exclusive province of the Surgeon, so, the prevention of disease ought to be, the consideration of mankind at large, as by aiding, without interfering with, Nature's functions, every individual, be he ever so unin- formed, can with certainty anticipate and prevent disease. With a view to that object, I have intended the present edition more for popular than professional perusal. The additional hints given are not founded on any preconceived theory, but are solely dictated by experience ; and however strong the tide may still set in favour of operation, I am nevertheless convinced that, ere long, the sword will become the ploughshare, — operation will give way to milder means, and that, eventually, few or no cases will meet the professional eye, wherein the Patient, VI I one£ twice, or thrice the victim of operation, and worn out by pain, depletion, despondency, and suffering, flies from one medical man to another in pursuit of relief. " Principiis obsta," is a maxim in no one class of diseases so strictly in point. Unfortunately, however, from the delicacy of the subject, these diseases, at first merely local, have made such inroads on the constitution, long ere advice is sought for, as to require weeks, nay months, of persevering patience to subdue. In the detail of cases selected from near a thou- sand examples of some one form of these diseases, 1 have availed myself of those best calculated to show the inefficient aid afforded by operation, though subsequently yielding to milder means ; and have illustrated, by coloured drawings, two cases, one of Piles, the other of Prolapsus, both unsuccessfully operated on : a reference to which will at once exhibit to the Reader the extent to which either may reach. True, " there are few diseases upon which so much has been written ; " but if we take a view of scientific subjects in general, we shall find that those onlv which admit of a double meaning: have Vlll most said about them. Volumes containing the opinions of writers, varying according to the ideas each may entertain, are presented to the public. But the reader will mark the consequence, — a true explanation is eventually arrived at. So it is with every subject which for years divides the medical world. If a Dictionary of Medicine or Surgery is opened, each article, be it doubtful in theory or practice, will be found to occupy pages. Why ? Because the true nature of the Disease, and the proper treatment thereof, have yet to be ascer- tained. Doubt gives rise to reflection, and the latter to action. Is the scientific inquirer prompted by sordid motives of gain ? No, — man's higher and nobler feelings predominate ; a spirit of phi- lanthropy is aroused from witnessing the sufferings, mental as well as bodily, which perchance may be the lot of his nearest and dearest friend ; — this it is which stimulates to inquiry, and which at length leads to improvements in our art, beneficial to society at large. And if, in my endeavour to bring before the reader all the features of these most distressing diseases, I may be thought unnecessarily minute, IX the observation of a deceased author, justly distin- guished in his own country, France, as throughout the world, for his able Treatise on the subject, is, I conceive, sufficient apology. " J'ose croire " neanmois," says Montegre, " que ce sujet est " seulement fatigue, maisnon epnisse ;" and again, "rien n'est encore plus obscure que l'etiologie " generale, et plus difficile que le traitement des *' Hemorrhoides." ERRATA. Page 30. line 13. from top, for " Plate 4. Fig. 1." read " Plate 4. Letter E.' 42. line 5. for « Case 25," read " Case 22." 90. line 10. for "sensation," read "sensations." 117. line 11. for "less," read " to lessen." — line 13. for "bowels," read "bowel." 122. line 4. from bottom, for " Prolapsus Recti," read " Prolapsus He- morrhoidis." PRACTICAL OBSERVATIONS, &c. &c. Few diseases occasion so much mental and bodily suffering as Piles, Hemorrhoidal Fluxes, Prolapsus, and Fistulas. As the delicacy of their situation presents, in the minds of many, an almost insur- mountable obstacle to seek relief; so, when this is sought for, nothing but an endless variety of inefficient applications, or the painful and danger- ous operations by excision, ligature, cautery, or caustic, perplex the afflicted sufferer. Reflection upon these facts must present to every intelligent mind the importance of an easy, safe, and efficient mode of cure, founded on practical observation and experience in the treatment of these distressing complaints. In introducing a new Edition, my object is to B express myself in language so plain and intelligible, that every one capable of reading may be capable of understanding. I have adopted this course, because many of the Treatises, hitherto written upon the subject, abound with technicalities, which, addressed to the Profession alone, are but ill cal- culated to inform the general reader, whose health is all but sacrificed to the ravages of these com- plaints. It is difficult to fix upon any specific causes whence these diseases have their origin ; as so many may concur to produce them. I have endea- voured to arrive at some conclusion on this point, from an analysis of several hundred cases ; and the result has been, that but few are referred to an hereditary origin ; while most, if not all, are trace- able to accidental causes, the most frequent of which are, an indifference in early life to the proper regulation of the bowels ; a heedless inattention to the calls of nature, which, however regularly they may occur, are yet postponed for some trifling oc- cupation, or childish amusement, returning daily with less and less vehemence, and ending at length in a confirmed state of costiveness ; to the injuri- ous discipline of female seminaries, wherein to retire during school-hours, in obedience to Nature's dictates, is but to encounter the tacit censure of the instructress, or the still more galling jeer of the school companion ; to close application to business, coupled with great mental energy ; to indulgence in the pleasures of the table ; and to free and frequent libations in astringent and alco- holic wines; to the sudden and severe vicissitudes of our climate * ; to inattention to the bowels at the cri- tical change of life from girlhood to womanhood, a crisis, on which depends the after comfort or misery of the female sex ; to the better classes of society taking much medicine and little exercise ; — we seldom meet with these diseases among the poorer classes of agriculturists, who take much exercise, and but little physic, who live much in the open air, and whose habits are like clock-work ; artisans in large towns suffer equally with the class of per- sons first described ; — to the use, or to the abuse * I have been informed, on authority to be relied on, that three out of every five persons residing in St. Petersburgh, English residents especially, suffer from Piles in some form or other. B 2 rather, of purgatives. The patient, from the begin- ning of his complaint, feels anxious to use those medicines least likely to be injurious ; but the sim- ple or harmless purgatives being used daily, soon lose their effects, and he will tell his surgeon that he has been in the habit of taking aloes, colo- cynth, rhubarb, or some preparation of mercury, working the medicine off by salts, senna, or castor oil. Irritation, whether occasioned by purgatives, or by full and heating diet, is by much the most fre- quent cause. The effect of an aloetic purge not only causes costiveness for eight and forty hours after its operation ceases, but likewise more or less soreness and spasm of the Sphincters, which con- tinue until the bowels recover their tone. Reple- tion in diet will create the same effect. A French gentleman resident in my house became so partial to the English cuisine, as to eat and drink heartily of every thing placed before him : the conse- quence was, a smart attack of Piles in less than a month after his arrival in England. He assured me he never had an attack of Piles, nor had his bowels been unusually costive previous to the at- tack. I am not prepared to say that these diseases owe their origin, so frequently as has been said on high authority, to pressure of the enlarged liver on the portal and mesenteric veins ; or to impacted scybalae in the cells of the colon ; to the pregnant womb ; or to tumours in the abdomen pressing on the great veinous trunks ; because, how many persons suffer from enlarged liver, and yet have no Piles ; how many die from obstruction of the bowels, the colon after death is found the size of a man's thigh, and no mention is made of Piles ; nor yet the impregnated womb, for every female during pregnancy should suffer from Piles ; nor does the history of tumors in the abdomen lead us to conclude that Piles are a necessary consequence thereof. The patient will describe his complaint as com- mencing at sixteen or eighteen, by a bearing down, accompanied at times with bleeding ; and a tumor, with or without prolapse, ensues. He is told, "he has got the Piles;" a quantity of medicine is forthwith directed, and continued for years, but to no purpose ; he gradually gets worse, a great deal of pain is endured, and years are b 3 6 passed in this miserable state, the sufferer scarcely knowing how to walk or stand. Operation is per- formed once, twice, several times. A large bougie is then recommended, which gives great trouble ; but, on being told "it will accelerate the cure," is persevered in ; ultimately, it is given up, from bringing on spasm. After a while, he finds, to his great distress, a return of the falling down, which is taken for prolapse of the gut : a truss with an ivory egg, or some such contrivance, to support the part, is then had recourse to ; this answers very well, and the patient gets about for some time ; yet he will tell his surgeon, " I now feel " great discomfort from the truss, from what cause " I know not ; it becomes less efficient, causes " great pain in back and loins ;" and the winding up of his story will be, " the complaint did not " come upon me from confined bowels ; I was " never troubled with that; indeed quite the con- " trary ; for, with the exception of this bodily in- " firmity, I have enjoyed uniform good health." Another patient will say, " I never was habitually " costive, though my bowels have refused natural " action for several years, for which a Rhubarb " Pill has been taken daily ;" and again, " I " never recollect going a day without one or more " evacuations, and my bowels are relaxed rather "than costive;" while a fourth patient will say to his attendant, " I have enjoyed all my life a " strong and good constitution, without tendency " to any other complaint except bile, which I " fancied I could guard against, by taking a great *' deal of opening medicine, of which I now, too " late, see the evil ; for the last twelve years I have " been obliged to take some opening medicine " every night, and to vary it, as one kind lost its " effects : " then bleeding sets in ; this is stopped by some strong astringent, only to be succeeded by pain in the part, so excessive as to deprive the patient of sleep for nights; and, ultimately the gut is described as protruding to the extent of a large nut or pigeon's egg, so painful as not to bear pres- sure sufficient for its return, accompanied by great heat in the back and loins, and irritation in the bladder : there is a constant desire to make water, and yet the patient cannot pass but a few drops. Both sexes in common complain of this symptom : the male patient, in particular, describes b 4 the effort to expel the last drops of urine as giving rise to violent spasm and dragging of the Sphinc- ters. The common point of attachment of the muscles in this region will account for his sens- ations. The tumour is tightly grasped by the Sphincters, disabling the patient from standing, sitting, or walking ; he feels great irritation in the neighbouring parts; a stiffness, and sometimes pain, down the back bone, beginning at the nape of the neck, and going down to the shoulder blades, and extending even to the ankles and soles of the feet ; " the whole stomach and bowels are described as " sore." Females generally suffer most from in- ward Piles ; males from Spasmodic Sphincter. Irritation and costiveness, then, are by much the most frequent causes, and the most important evils to be guarded against. No medicine in general use will accomplish this object, without increasing its strength or its activity, and thereby producing all the mischievous consequences which I have elsewhere described in my work on Costive- ness. It is impossible here to enter upon any part of that treatment ; because, what applies to one in- dividual, is totally inapplicable to another ; but the 9 number of patients who have hitherto been com- pletely relieved from this obstinate condition of the bowels, warrants the assertion, that the simple means hereafter to be mentioned are sufficient in themselves to restore their natural action, where no morbid obstruction exists, without the aid of drastic medicines ; and further, that the constant use of such medicines can never cure habitual costiveness ; on the contrary, will increase it to an alarming and even fatal extent. EXTERNAL PILES. The patient feels an excessive itching at the verge of the Anus, a sense of tightness of the Sphinc- ters, sudden darting pains coming on in paroxysms, and, at intervals, a sense of weight in the Anus and Perineum ; a throbbing, tingling sensation is felt within, evidently from the increased flow of blood to and in the vessels of the part ; the nerves are thereby pressed upon, and the Sphincters con- tract with spasm. If any flaps of loose skin sur- round the Anus, they now become tense, exceed- 10 ingly tender to the touch, and so teazing to the patient as not to permit him to remain five minutes in one posture. These tumors I have never seen livid, as has been stated. If the patient has com- mitted any excess, he will feel flying pains in his back and loins, a powerless sensation in his limbs; his pulse is hard and contracted, his countenance sallow and dingy ; great flatulence ; frequent but ineffectual efforts to pass water, and to relieve his bowels. I cannot say I have ever seen outward Piles traversed " with varicose veins." I have seen them of all shapes and sizes, with broad and narrow foot-stalks, smooth or nodulated on the surface ; one, two, or three; — a cluster of them will surround the Anus. I have seen them, in their most in- flamed state, of a tallowy, dropsical appearance, re- sembling the scrotum of children afflicted with Hydrocele. I have never known them to bleed, unless when punctured ; if they suppurate, and the matter gets exit, the Pile is obliterated. The patient thus afflicted is desired to live low ; he takes some mild aperient, the bowels are gently moved, the circulation in the parts becomes tranquil, the symptomatic fever subsides, he remains quiet 11 and avoids exercise, the spasm of the Sphincters ceases, the tumors lessen, and in a few days, from three to six, he recovers from the attack ; each succeeding one, however, becomes more severe. When these Piles become flaccid, the skin sur- rounding the Anus is thrown into fringes; and in order to prevent a recurrence of the attack, the patient seeks advice ; he is recommended to have the skin removed ; the operation of circumcising the Anus is performed, and the result is a con- tracted Anus, a very formidable disease, which calls for operation, or subjects him to a tedious, harassing, and ineffectual treatment by dilatation.* INTERNAL PILES Are of two kinds, and assume totally different ap- pearances. The first, by much the most frequent, have broad bases ; consist of a number of gorged, * Since writing the above, a case of this kiivd has come under treatment. The point of my little finger would barely pass the outlet ; such was the extent to which the wound in cicatrising had contracted. 12 turgid, and varicose veins, covered with thickened, knotty, and rough mucous membrane, of a dark purple or ripe damson colour : these diminish by pressure, and momentarily fill again, by desiring the patient to strain. Their situation, generally above, frequently corresponds with the sphincters : if above, they are larger and rounder ; if within the grasp of these muscles, they assume a flattened form ; small ulcers are often detected on their sur- face, and when examined through a glass, a quan- tity of gelatinous mucus, resembling frog-spawn, is noticed underneath the mucous membrane : this mucus is identical with what is passed by stool : if not inflamed and turgid, they are nearly painless when handled. The second consist of pendulous folds of mucous membrane. Their situation is either above, or at- tached to, the sphincters. In the first, they present themselves as nipple-like bodies, attached to narrow foot-stalks ; in the second situation, as flattened tongue-like excrescences, less livid, more florid than the former, and bleed on being touched ; if examined through a glass, they have a net-work of minute vessels on their surface. They often occur simul- 13 taneously with the first, or varicose kind; and when the patient strains, the former will be seen pre- senting in the centre, while the latter form the cheeks of the tumor. They do not decrease by pressure of the finger, and fill again, as do the first described ; they are not of the same colour, unless when long under the influence of the sphincter's action ; they are not very sensible to the touch ; they receive their blood through minute capillary vessels ; hence are not knobby, or rough, as the first described : both are accompanied with quan- tities of gelatinous mucus. If interspersed with fissures, or warty excrescences, these are accom- panied with a discharge of matter, which soils the linen ; both are very liable to Prolapsus, with or without more or less of the mucous membrane. The ordinary exertion of walking, even standing long, of eating, of laughing, talking, sneezing, coughing, will bring them down. Their origin and increase are usually as follows. A patient will tell his surgeon, " that for costiveness, during a re- " sidence abroad, perhaps in India, he feels satis- " fied he has had too frequent recourse to laxatives " and warm injections, such as salts, cream of 14 M tartar, Seidlitz powders, and acid decoctions, " as lemon and tamarind drinks j that he has had " the fever of the climate, — ague, perhaps, — " and has taken doses of calomel from time to " time, for the cure of bilious complaints, as " well as to assist salivation ; after a time, va- " rying from three to ten years, he will feel " an inward Pile, which, when protruded, gives " him considerable pain ; if he has a motion in " the morning, this Pile is sure to come down ; if " he has no motion in the early part of the day, " the protrusion seldom occurs, and he is not in- " convenienced ; for which reason, he postpones " his visit to the water-closet till towards evening, " because the tumor rarely descends when in bed ; " there may be a discharge of blood, it may be " copious or scanty." When the bowels are re- laxed, there is always more or less of the gelatinous fi'og-spawn mucus evacuated after the motion, which is accompanied with straining ; and then it is he suffers most from inflammation of the protrud- ing parts, the return of which is extremely painful to him, and his only relief is in remaining quietly stretched on a conch. 15 The first kind, the varicose, if removed with knife or ligature, will end in serious, if not fatal, results, as the following case will show. A gen- tleman, aged 68, consulted me under the fol- lowing circumstances : — " From embarking in a " speculation so far back as forty years, which ended " in the loss of thousands, and occupied thirteen " years of the intervening time in putting an end " to legal proceedings consequent thereon ; during " which he was * screwed up' to a high state of " nervous excitement, and all this time was " subject to be sent into the garden as many " as from three to twelve times a day ; taking, h however, luckily enough, little medicine for all " this inconvenience. From eating vegetable mar- " row and stewed Kiswick codlings, in 1826, he " had, in the succeeding twenty hours, nearly as " many moves ; next day, from fifteen to seventeen, " cramp, prostration, deafness, and loss of voice, " unable to speak but in a whisper, and fed by " lapping liquids from a feather ; he felt something " protruding at the rectum, with excessive heat " of the part ; by signs, he endeavoured, as well " as he could, to direct his surgeon's attention to 16 " the part, who, on examining the rectum, ex- " claimed in his native patois, * A'e, mon, what an "awfuPile!' This was forthwith returned j ope- '* ration by the knife some time after was per- " formed, and the bowel stuffed with sponge-plugs. " The fourth night, the bandage getting loose, and "the sponges being expelled, a * terrific hemor- " rhage' in his sleep occurred, which reduced him " again from ten stone ten, to between seven and " eight, as the Cholera had done before. Plugs " were again inserted ; but on the third night he " became hysterical from inflammation, and the " sponges were withdrawn." Suffice it to say, that at the expiration of twelve months, Prolap- sus followed, for which a truss, with spring pad, was used ; but the part fell below the pad, giving my unfortunate patient excruciating torture, and, almost at death's door, he at last applied to me for relief. The case of the Rev. G. J. (page 90.) is another, out of many instances, wherein operation by exci- sion had well nigh released the sufferer by dis- solution. The second form of Piles, though not so dan- gerous to meddle with, is frequently followed by Hemorrhage. In both, a relapse is inevitable; yet both are sure to yield, eventually, to the treatment by Pressure and Percussion, hereafter to be mentioned. The warmest advocate for Opera- tion, the late Mr. George Bushe, of Xew York, speaks doubtfully of excision. His remarks are as follows : — " That excision is not likely to be " attended with Hemorrhage I deny, for I have " performed the operation several times, and, after " it, have had to tie up arteries, plug the rectum, " and, in one instance, to apply the actual cautery. " Indeed, I so nearly lost two patients, that, when " left to my own choice, I no longer have recourse " to this operation." Unless we touch the cut surfaces with the actual cautery, as recommended by Dupuytren, he adds, "we cannot free the " patient from the danger of Hemorrhage, and " this is a barbarous operation." Frequently it has been asserted that bleeding Piles are an in- dication of health : it has been admitted by the Profession that they are, occasionally, an assistant in preserving health ; but Mr. Howship remarks, in his " Treatment of the most common Diseases of c 18 " the Lower Intestines," p. 209., "that when bleed- " ing has once taken place, it may naturally be " expected to return, and almost invariably does " so, and this return of bleeding, either from its " frequency or its extent, uniformly impairs, and " sometimes destroys, the constitutional health." These repeated losses of blood eventually lessen the powers of the system, while they introduce habits that, unless attended to, frequently prove of the most serious consequence ; and the truth of Mr. Howship's observations is now well known. The Surgical Operations performed for the cure of Hemorrhoidal Tumors and Prolapsus, are known to occasion extreme suffering, and, in many cases, to be quite inefficient. Mr. Thomas Copeland, in his " Observations on Diseases of the Rectum," published 1824, p. 143., gives the case of " a gen- " tleman about thirty-five years of age, in good " health, and subject to no other complaint, ex- " cept now and then an eruption on the skin, had " several Hemorrhoidal excrescences. He had " been for a long time of a costive habit of body, " and usually suppressed his efforts to evacuate " the contents of his bowels until the evening ; 19 for the pain and difficulty he experienced in returning the tumors again into the Rectum interrupted his avocations. He suffered con- siderable loss of blood at each time of going to stool. When the excrescences were without the rectum, they discharged a great quantity of thin sanious matter. On examination, three of these tumors were discovered; and after he had emptied the bowels, and the tumors were pro- truded, a double ligature was passed through the centre one, and tied on each side of it. As he did not feel any great degree of pain in this part of the operation, the other two smaller ones were also included each in a ligature. He took an opiate immediately afterwards, and went to bed without much uneasiness. The two first days he passed tolerably well : his bowels were open ; he repeated his opiate each night, and lived very abstemiously. On the third day he became feverish, the pulse weak and quick, and in the evening, nausea and vomiting came on, with pain in the abdomen, and retention of urine. The Catheter was introduced, and about a pint of urine evacuated, which gave him great c 2 20 " ease ; his bowels were emptied by a mild purg- " ative. On the fourth day, the nausea, hiccough, " and affection of the bladder, were very consi- " derably increased, with great pain in the ab- " domen, and a weak, quick, intermitting pulse. " The only ligature which had not separated was " cut off; but, the symptoms augmenting rapidly, " he died on the morning of the fifth day." In the preface to the publication just referred to, page 10., Mr. Copeland says : — " On the subject " of the removal of the hemorrhoidal excrescence, " the result of my experience has been somewhat " different from what I had been led to expect by " the writers who have treated of this affection. I " have not always found it a secure and safe ope- " ration. Other surgeons, also, have met with in- " stances of great danger, and even death, produced " by the free extirpation of these tumors." The other case is thus narrated by Mr. Salmon, in his "Practical Observations on Prolapsus of the Rectum," 1831, page 93- case 13. "A merchant " consulted me, in the beginning of February last, " respecting a Prolapsus of the Rectum. He had " undergone removal of the disease by ligature 21 " twice. The first operation took place in the year " 1828, when three ligatures were used ; the se- " cond in 1830, when one only was applied. The " first operation confined him to bed for five days, " during the whole of which time he suffered a " good deal of pain, and was kept under the in- " fluence of opiates. For many days after the " ligatures separated, he endured great agony in " the parts, more especially when he went to the " closet. The second ligature came away three " days after it was applied, and did not give him " anything like so much pain as at first. Although " he certainly obtained relief from the operations, " he had, nevertheless, always felt as if there was a " something wrong in the bowel, his motions not " passing comfortably, and requiring much straining " to get rid of them. He also had an obstruction " in the urinary canal. Upon examining the rec- " turn, I found an extremely powerful and broad " Sphincter, and the calibre of the intestine so much " lessened, at six inches from the exterior, that I " could not pass a Bougie of larger size than No. 8. " Upon his making an effort to bring the Prolapsus " into view, I discovered that it was, in some de- c 3 m gree, composed of the remnants of the columns of the rectum, to which the ligatures had been applied ; one of these portions, in particular, was indurated, and of a cartilaginous texture. The mucous membrane, all round the inner verge of the orifice, was baggy, and of a purplish hue, and formed the greatest portion of the mass which impeded the passing of the evacuations ; there was, likewise, a single internal Hemorrhoid at the lower and left side of the bowel. In this case, after a few introductions of the bougie, which certainly facilitated the passing of the evacu- ations, I removed the pile, and pared off various portions of the elongated membrane, just within the Sphincter ; but I was apprehensive of doing harm if I removed the indurated remnants from the operation by ligature, and therefore did not do anything to them. There being no prominent points in the swelling, I found some difficulty in fixing the pins, so as to keep the bowels everted, from which cause the operation was longer about than usual. In the end it did very well, and re- moved most of the sufferings and the bleeding which the patient usually experienced when he 23 " first consulted me. I saw this gentleman lately: " he says, he readily admits that he has experienced " relief from the operation in all points but one ; " but that he thinks the difficulty of voiding his " motions is almost as bad as ever. This circum- " stance, which I told him was referrible to the " power of the Sphincter, would only be removed " by a division of this part. He was, however, " disinclined (which I do not wonder at) to under- " go any more suffering. I took the occasion of " this visit to ask him his opinion of the two ope- " rations by ligature and excision. To which he " replied, 'Why, as to the pain I suffered, I would " rather undergo ten of your operations than one " by ligature. But I think the latter appeared to " do me most good ; for you see I was free from " Prolapsus for nearly two years after the first " ligature was applied, and for almost a twelve- " month after the second ; whereas it is now three " months or better since you operated upon me, " and yet I have this difficulty of passing my " motions.' " Remarks. — I have given this gentleman's " case almost in the words which took place be- c 4< 24 11 tween us when he narrated his feelings to me. I " am desirous of doing so, with a view of drawing " the attention of my readers to the important " questions it involves. I consider the Prolapsus, " as well as the contracted state of the bowel, to " have originated in the condition of the Sphincter; " and I confess I think I should have acted more " wisely if I had attempted to remedy this evil, " instead of removing the Prolapsus ; which ope- " ration, although it has been of service, has been " so only by removing the effect, instead of the " cause in which this gentleman's sufferings origi- " nated. I was not, however, at the time I per- " formed the operation, sufficiently clear, as I now " am, upon the point, of where the Sphincter should " be divided in those instances where, from its " preternatural powers, we may consider it has " produced the Prolapsus : I mean, whether the " cause or the effect should be first administered " to. I have no hesitation in now stating, that in " all instances where the Prolapsus occurs, in con- " sequence of a contracted or preternaturally " powerful Sphincter, we had better remove this " evil before we undertake any operation upon the " diseased mass." 25 These operations have been performed in France with more fatal results than in this country ; the usual practice now, where many tumors exist, is to tie one, two, or three at a time, and to allow the patient to recover before the rest are operated on. This method is, of course, less dangerous ; but the time occupied, and the suffering endured, by such lengthened treatment, is much better imagined than described. Having briefly explained what is understood by the different denominations of Piles, it is only necessary to observe that Bleeding Piles, last described, become finally so enlarged from chronic and long-continued irritation, produced by violent straining, and the imprudent use of Purg- atives, that they are perpetually forcing their way through the Sphincters, and carrying with them the transverse folds of the lining membrane of the rectum, the whole having the appearance of large masses, or red or livid vascular tumors. This last state I wish to designate Prolapsus Hemor- rhoidis, to distinguish it from the true Prolapse, which consists of mucous membrane alone. These cases differ much in their characters ; where the Sphincters are relaxed from age or local debility, 26 the part subject to Prolapse falls upon every effort to walk, seldom occasioning pain, but becoming dis- tressingly uncomfortable from the constant discharge of mucus, not unfrequently mixed with blood. The only mechanical invention hitherto used for the purpose of keeping up this mass, is a spring Truss, at the end of which is affixed a knob of ivory, which, pressing on the verge of the Anus alone, but partially sustains these tumors. This truss exerts but single pressure, namely, from with- out. The want of efficient means to keep the parts above the Sphincters, and to retain them there when replaced, renders the use of this truss but an imperfect alleviation, and is wholly inefficient in diminishing the disease itself: besides, it makes uncomfortable pressure in walking, compelling the patient to abandon its use from the chafing and heat it occasions, which is frequently complained of as a greater annoyance than the falling of the gut itself: moreover, however carefully replaced, the parts will protrude alongside of the egg, and in this situation get nipped, owing to the spasm of the Sphincters : this gives rise to incalculable suffering, and frequently ends in inflammation, 27 abscess, or fistula. Now, my Metallic Bougie combines double pressure, namely, within, by its egg supporting the Prolapse in situ, thereby pre- venting an interruption to the circulation in the parts ; and without, by means of its handle press- ing on the verge of the anus, by which the parts are not only duly supported, but the tone of the Sphinc- ters, whether too powerful, as in spasm, or too weak, as in old age and paralysis, is likewise restored. I have made an improvement in, or rather added an assistant to, the Bougie, in affording this double support, — namely, a suspensory spring bandage, which, in obviating the inconvenience occasioned by the truss above described, gives to the Bougie that degree of support necessary for keeping up the Prolapse ; this contrivance, however, is re- quired in extreme cases alone. Where the Sphinc- ters are powerful in their contraction, the Prolapse, if down for any time, becomes exceedingly painful ; the cause of this is obvious, as these muscles, en- circling the fallen parts, tightly pinch them, and no relief is obtained until they are returned. To accomplish this, no more effectual way can be taken by the patient than simply placing himself 28 in a chair or upon a sofa, inclining his body back- wards, at the same time raising his feet, and, in this position, applying warm fomentations with a large sponge ; at the same time, every endeavour should be made by the pressure of the sponge with the fingers on the prolapsed parts, to return them gradually above the Sphincters ; when this has been accomplished, cold water may be imme- diately applied externally, and, by attention to the bowels, and an observance of the instructions to be more fully detailed, a relapse is not much to be apprehended. I have recommended an Ice- bladder under certain circumstances, which fre- quently restores the parts to their proper place, and materially serves in getting down the tume- faction. It should not, however, be too long continued, as mortification might ensue. In the use of this, as of every other remedy, the opinion and guidance of the Surgeon are indispensable. Where the Prolapse of these tumors is easily returned with the finger, and falls only with an evacuation, a little care and attention, with the occasional use of the Bougie, will speedily prevent the disease increasing, or being of the slightest 29 inconvenience ; but where skill and experience are wanting in the management of these diseases, they are sure to increase progressively, and, in some cases, the inflammatory symptoms terminate in an abscess, which forms in the middle of the tumor, and which may degenerate into a fistula. PROLAPSUS. Prolapsus of the Rectum afflicts all ages. It is alike a disease of the morning, of the noon-day, and of the evening of life. It presents itself in two forms : first, either a fold simply of the mucous membrane protrudes (see PI. 1. fig. 1.) ? or secondly, a protrusion of larger bulk, as in PI. 4., consisting of the muscular pillars of the Rectum, together with the Sphincters and mucous membrane everted, resembling in shape a cask flattened from before backwards, the surface of which represents a number of concentric rings (see PI. 5.) like those of the windpipe, the highest of which, or those nearest the buttock, are livid and dry, and welted with distended varicose veins ; or, 30 this portion of the tumour will appear knotted, if complicated with Piles, as is seen in PI. 1. fig. 2. The rings towards the extremity of the tumor are less in size, and closer together, the surface is moistened with gelatinous mucus, and approaches more to a crimson or dull copperish colour. The mucous membrane is highly flocculent, resembling the everted eyelid in purulent Ophthalmia; minute points of ulceration will be observed, and at the extremity of the tumour will be seen a slit or fissure, extending either from before backwards or from side to side, with a flake of gelatinous mucus within its lips, as is seen in PI. 4. fig. 1. : the tumor may reach the length of two, three, four, and even five inches ; frequently there is a Pro- lapse within a Prolapse. Of this, I lately met with an instance — a gentleman who came over from France to consult me. The internal loose pouch of the Rectum first protruded ; and, by continued straining, next descended a doubled fold of that portion of the gut immediately above : the tumor- al together measured 4^ inches. This gentleman had been twice operated on by excision, and twice by caustic. Both will occur in infancy, the first 31 most commonly so. The Prolapse is found highly vascular and sensible in early life ; it generally commences after weaning in weaklv scrofulous constitutions, is the result of unwholesome food, teething, or diarrhoea ; or, if the child has reached the age of five, seven, or ten years, may be occa- sioned by stone in the bladder, or by acid urine. The child feels an irresistible desire to go to stool, strains violently, unconscious, and therefore re- gardless, of the consequences. Violent fits of pas- sion, crying, the form of the Pelvis, the straight course of the gut, and the want of resistance from the Bladder, which at this early period is but partly placed in the Pelvis, the weakness of the membranes which connect and hold the organs of this cavity in situ, and the straight course of the extremity of the back bone, — all these causes co- operate to render Prolapse at this period of life a frequent occurrence. In old age, on the other hand, it is the result of general weakness of all the muscular apparatus, and of this part in particular ; irritation at the neck of the Bladder j a frequent, yet ineffectual desire to pass water ; great and long continued efforts at 32 stool ; Diarrhoea ; a residence in a hot climate, during which Calomel has been unsparingly taken ; the long-continued use of warm injections. The patient will say he feels no pain unless the part remains down some considerable time : the un- easiness experienced differs from that of internal Piles, the part aches, and gives to the patient a sense of fainting — a sinking feel. The Prolapse, if of long standing, is not very sensible ; it bears handling, and, when methodically pressed upon, returns with comparative ease ; when the finger is passed in, it feels as it were in a vast cavity, the walls of which are flabby ; they do not feel un- usually hot; the Rectum sound when passed, meets with slight obstruction, as it gets entangled in the loose folds of the gut, and may lead the surgeon to think he has " hit off" a stricture; sometimes the Prolapse is studded with small Polypi, which have narrow stems and smooth surfaces, in colour corresponding to the surrounding mucous mem- brane, insensible to the touch, not disposed to bleed, and differing totally from the inward Piles before described; these Polypi are the only tu- mors which ought to be, or can be tied with safety; 33 — their removal, however, will not cure the Pro- lapse as asserted on high authority. Cramp inva- riably accompanies this form of Prolapse, with the aged especially, which is most distressing at night; a sensation is felt as of worms in the gut : one patient told me he fancied at times " a live frog " crawling within him ; " the itching and tingling, so often complained of, occur generally at bed- time ; involuntary discharges of Feces frequently happen during sleep, rendering the patient miser- able — he dreams of it — he awakes in tears ; he fancies an accident has happened, — sometimes it has, oftener, it has not ; he feels a constant desire to visit the water-closet, though he has been already there, and has passed a copious evacuation ; yet, he tells his surgeon, he feels as if something were still to pass — he has a frequent desire to make water — he is sure his bladder is full, yet he passes but a few drops of urine, which is generally extremely pale. Diarrhoea, more frequently than costiveness, accompanies the Prolapse, which requires constant and long-continued doses of opium. I may here observe that this form of the disease is invariably injured by local astringents, whether D 34 vegetable or mineral, the latter, especially, oc- casion heat and burning in the part. The only remedy that will alleviate, and eventually cure the disease, is a long-continued use of my Douche Bath, mentioned at page 52., the shock of the water giving tone to the languid muscles — the patient suffers from weak digestion and great flatu- lence. If Hemorrhage occurs he is blanched, his features become tallowy, his feet and ankles swell ; if a man of forty or fifty, he soon looks sixty or seventy — his hair turns grey — his spirits become wretchedly depressed — he dreads each succeeding visit to the water-closet, yet he knows he must go ; his appetite fails him, he picks his food, nothing is relished ; yet it has been stated on the highest authority, that during repeated Hemor- rhages the appetite becomes ravenous, this I have never known to be the case ; the patient at times has spasm of the eyeballs, and shooting pains through the temples. He constantly thinks of his infirmity ; he broods over his sufferings by day, they haunt him during his broken slumbers by night; he will all but entreat of his attendant to put an end to him, as life is insupportable. The 35 depletions continue, the whole system becomes deranged, and the sufferer flies from one medical man to another; nowhere can he find relief; as his pain and debility increase, so his want of con- fidence and hope of ultimate cure decrease; he becomes irritable and nervous, and his existence one of misery to himself and painfully afflicting to those around him ; such is an imperfect outline, though not an overdrawn picture, of his sufferings. He is recommended operation ; this is performed once, twice, nay as many as six, ten, or even four- teen times. An Honorable Baronet, taking up his pen, wrote me the number of times he had been " cut and sewed," and the dates of the operations during an interval of twelve years, with as much accuracy as if they had been the events but of yes- terday. The disease thus treated has returned in a more aggravated form. The late Mr. Mackenzie gives his own case as follows : — "It is now thirteen years since I was first " attacked with excessive itching at the orifice of " the Rectum, which was followed by Piles, He- " morrhage, and, finally, by Prolapsus Recti, or " falling of the Rectum. In the different stages d 2 36 " of these diseases, I advised with many of the " Faculty, both in the country, on the Continent, " and in London ; but although endless experi- " ments were made, and quackery resorted to, " the relief I obtained proved only of a tem- " porary nature ; and in defiance of all my endea- " vours the Prolapsus or internal membrane of the " Rectum, and the powerful vessels charged with " blood, protruded daily through the Sphincters, " at the time of evacuation, and thus became " almost strangulated by the contraction of the " muscle, until at last I found considerable diffi- " culty in returning it ; thus was existence ren- " dered incessant in bodily pain and mental " anxiety. Copious depletions began to take " place after evacuation, and issued in a stream " from a large rupture of the hemorrhoidal vein, " the stoppage of which appeared to defy the " ingenuity of every medical man with whom I " advised. Finding my bodily health rapidly de- " dining, I determined to take the opinion of " Sir Astley Cooper, who immediately recom- " mended an operation ; to this, however, I at " once objected. I afterwards saw Mr. Aber- 37 " nethy and Mr. Lawrence : the former told me " he would not recommend an operation, as " Hemorrhage might follow, and the consequences " prove dangerous ; with these and other con- " flicting opinions, it cannot be matter of wonder " that I felt alarmed for my ultimate recovery." Stricture of the Rectum is considered by some practitioners as the primitive cause of Hemor- rhoids and Prolapsus : it may be possible that such cases have occurred, but they are extremely rare j I am of opinion that Stricture of the Rectum is the effect and not the cause of these diseases. Irritation occasioned by Hemorrhoids, any local excitement, or a disordered state of the digestive organs, is almost invariably attended by spasmodic Stricture of the Rectum ; and the passage in this case will actually resist the introduction of a Bougie. Hoffman states that an elderly man, who had imprudently suppressed the hemorrhoidal dis- charge, was seized with violent pain in the bowels, and such a contracted state of the Rectum, that it was not possible to force up any thing in the shape of a clyster : frequently it occurs from the thickening of the transverse folds or shelves of the d 3 38 Rectal Mucous Membrane, arising from inflam- mation. These Spasmodic Strictures will ge- nerally disappear when the cause is removed, or yield to very simple treatment without the use of Bougies. I disapprove of the frequency and ap- parent indifference with which bougies of con- siderable length and size are passed up the Rec- tum, and often by those who possess but an im- perfect knowledge of the delicate structure of the parts, or the direction of the natural course of the canal ; and this is done with the intention of removing that contraction which unskilfulness is frequently the cause of producing. To relieve these strictures is by no means difficult under the management of a careful and scientific surgeon ; and it is important he should possess considerable experience, because it is no uncommon occurrence for portions of the gut to be forced up with the bougie ; and thus an obstruction is created diffi- cult to be distinguished, in its unyielding resist- ance, from that of Stricture. Hence an erroneous opinion is formed that Stricture exists. I use myself a sound, with a long flexible metallic stem, mounted with a conical bulb at either extremity ; 39 I introduce this, curved to the course of the gut, and having once explored the bowel, I never after perform this operation ; nor do I permit my patient to resort to such rough means. Bougies have been passed daily, to the great distress, and often lasting and serious injury of the patient. Acci- dents have also occurred where bougies, guided by unskilful hands, have ruptured the coats of the bowel, and in some instances, proved fatal. In cases of Spasmodic Stricture which occurs in dif- ferent parts of the Rectum, the use of bougies, as before observed, should be entirely avoided. Attention to the bowels, with cold water injec- tions, will generally afford the necessary relief, by allaying the local irritation. I am led to make these remarks from the mania that seems to exist for passing bougies ; and from a positive conviction that Stricture, as well as other more permanent injuries, often arise from their frequent and im- prudent use. Mr. How r ship, speaking of passing bougies for Stricture in the same treatise previously quoted, says, page 26., " The want of attention to this " principle (alluding to passing bougies unneces- d 4< 40 " sarily) is, I am convinced, frequently productive " of great misery. A patient I lately had com- " plained, when he gave me the history of his dis- " order, that one of the surgeons who had pre- " viously attended him had put him to extreme " torture in using the bougie, — a circumstance," says Mr. Howship, " that must have favoured the " formation of a large abscess found after death." Dr. James Johnstone, in his " Essay on Indiges- tion," (pp. 103, 104.), observes, " Strictures of the " Rectum will be so completely imitated in dis- if ordered states of the digestive organs, that the " passage will resolutely resist the introduction of '* a bougie, thereby confirming the inexperienced " practitioner in the belief of permanent organic " Stricture. This treatment not unfrequently pro- " duces the very disease which it is pretended " to remove, by the officious interference of " bougies, without proper attention to the con- " stitutional disorder on which it depends." The practice of passing bougies upon every trifling affection of the Urethra is equally censurable, and liable to the same objections ; but this opinion is by no means rare : it was frequently the subject ±1 of severe animadversion in the lectures and prac- tice of the late Mr. Abernethy. Attempts have been made to relieve Prolapsus and Hemorrhoids by passing a bougie, three inches in circumference, through the Sphincter, two or three inches up the Rectum, and retaining it there as long as the patient can endure the pain ; the calibre of the Sphincter, which is spasmodically contracted, and highly sensitive from a previous costive state of the bowel, will rarely bear an instrument of this size without giving the patient extreme pain, and must protract the cure. A lady lately under treatment for inward Piles declared to me that the agony and suffering endured from an attempt to pass a wax bougie half an inch in diameter and twelve in length, confined her to her bed for a week, and that no advantage whatever had been attained thereby. The passing of bougies of such lengths and sizes has been resorted to from a belief that the Sphincter muscles are too powerful, and that they counteract the natural desire of the bowel to void its contents : straining consequently follows, and the gut is forced down ; but this opinion is founded in error, for, in the majority of cases, the 42 Sphincters are not powerful enough. A spasmodic contraction of the Anus, a totally different disease, as will be hereafter shown, may exist ; but this will subside under proper treatment, as exemplified in Case xxv. It has been said that Prolapsus of the Rectum in adults is an incurable disease, but my experience enables me to say that this opinion is erroneous ; and to establish the fact more satis- factorily, I have given, in the last edition, a few out of many hundred aggravated cases of Prolapse which I have succeeded in effectually curing within the last three years. Where a Prolapsus is easily returned with the finger, and falls only with an evacuation, a little care and attention, with the occasional use of my Bougie and Ointment, will speedily prevent the disease increasing, or being of the slightest inconvenience ; but where skill and experience are wanting in the management of these diseases, they are sure to increase progressively, and, in some cases, the inflammatory symptoms terminate in an abscess, which arises in the middle of the tumor, and frequently degenerates into a fistula. It is a remarkable fact, that out of the great number who have written on the subject, not 43 one, either ancient or modern, appears to have been a sufferer. The prevalence of the complaint renders this the more extraordinary. Mr. Cope- land, in his third edition of " Observations on the principal Diseases of the Rectum and Anus," says, page 173., " The appearances of the disease are so " well known, that it is unnecessary to describe " them ; but the principle of cure is not, I believe, " so well understood as it is capable of." The truth of this confession does honour to Mr. Cope- land, and it would be more creditable if other eminent members of the profession would state to their patients that operation is no cure, but, on the contrary, in nine cases out of ten an aggravation of the disease. I ought, however, to bear this in mind, that, on a moderate calculation, fifteen or twenty years frequently elapse before any new science obtains notice and publicity, and double that time before it is recognised, particularly when it interferes with long established practice. A patient is rarely met with whose previous treatment has not tended to aggravate the disease, such as the frequent use of aperients, the unskilful use of warm injections, the injudicious application 44 of suppositories employed for temporary relief, together with stimulating injections ; all of which tend to an increased irritation of the Rectum, and must therefore produce a greater determination of blood to, and an enlargement of, the Hemorrhoidal vessels : to the operations, whether by ligature, excision, cautery, or caustic. To one or all of these baneful evils, may be attributed the rapid increase and lasting affliction of these painful dis- eases. Mr. Calvert was the first surgeon to whom the idea of a cure by internal pressure occurred. In his " Treatise on Hemorrhoids, Prolapsus, &c." after speaking of the great benefit which results from pressure on external tumors, he says, p. 87., " when the tumors are more internal, pressure " cannot be employed in the same manner." Not- withstanding this remark, Mr. Calvert did not abandon the hope of success in attaining this important object, for at p. 184., after relating the case of a lady having Hemorrhoidal tumors so numerous and so large, as nearly to fill up the passage of the Rectum, he adds, " I made trial " of tents of prepared sponge, which I formed 45 " into bodies of a pyramidal form, and rounded as " much as possible ; but I found that they did not " swell out equally, and that they formed incon- " venient knots. I also made use of tubes of calf " and sheep gut, distended with air, and with tepid " water ; but these were difficult to introduce, " though they did not give pain.* I got a turner " to make me a wooden peg in the form of a cone, " and blunt at the point, and of such a length that " the whole of it could be introduced within the " Rectum ; it remained there for some time with- " out inconvenience, and the patient took it out " and replaced it. In order to withdraw it easily, " I attached a ribbon to it, by way of handle, " smeared it with ointment, and then introduced " it within the gut." To shorten the extract, a complete cure was effected by this wooden peg ; and had this gentleman's life been spared, there is little doubt but that he would have carried this successful experiment to that state of practical * The late Mr. George Bushe, of New York, took the hint from Mr. Calvert, and got made, shortly before his death, an instrument for suppressing hemorrhage after operation, on pre- cisely the same principle. 46 utility now acquired by my Metallic Bougies. I may add, that to myself the hint has proved of practical utility, because I have had constructed upwards of fifty sorts of Bougies on a like principle, and with a similar view. I have had them con- structed with a screw, by which contrivance the mucus can be washed out, and the instrument kept free from any offensive effluvia. I may here observe, that as no two cases resemble each other in every particular, so do I find that an instrument applicable in one form of these diseases is wholly inadmissible in another. The Gum Elastic Bougie I consider highly objectionable ; it is with difficulty introduced, and, when so, proves a source of great discomfort ; besides, the advantage which a Bougie, made of metal, possesses over one made of the former material, entitles my Bougie to the decided preference given it. Caoutchouc being a bad con- ductor of heat, the parts, pressed upon by an in- strument of this material, feel hot ; metal, on the contrary, being a good conductor, much of the heat occasioned by the increased flow of blood to the part is conveyed away by the stem and handle, thereby acting as does a cold lotion on an inflamed 47 part, by evaporation. In severe cases of Pro- lapsus, I have invented a hollow bougie, through which the contents of the bowels, previously re- duced to a proper consistence by medicine and appropriate diet, pass without Prolapse succeed- ing, as the circumference of the Bougie keeps the bowel from collapsing under the combined efforts of the muscular apparatus, diminishing thereby the amount of straining, and supporting in its proper position the superabundant, or elongated mucous membrane. The Douche Bath, likewise, used in a particular way, facilitates the efforts at stool, the evacuation frequently passing away without the patient being conscious of its so doing. Since the last edition of this work was published, I have added to my ointment some valuable ingredients, which tend to increase its absorbent powers, and to render its application altogether painless : these means, aided by aperient pills and powders, my vegetable Tonic, and preparation of Sarsaparilla, I have never known to fail.* From a perusal of the last edition of this work * These medicines can be had of Hannay and Co., 63. Oxford Street. 48 some have fallen into an error, which it is important should be corrected ; the fault has no doubt arisen from the want of more detailed explanation. It has been supposed that the use of the bougie and ointment may be resorted to in cases of Hemorrhage and Prolapse, without attending to the origin, pro- gress, and present state of the disease ; and, what is still more important, without reference to diet, habits of life, or the regular action of the bowels ; in short, it has been supposed that the Bougie of itself would act as a charm, and that nothing be- yond its mere possession was essential to effect a cure. To guard in future against such serious mistakes, it is necessary to state that, inasmuch as all cases differ more or less in some essential points, so must the use of the bougie and the mode of treatment be regulated — for instance, the often er the attack and the more copious the depletion, the greater would be the risk in some constitutions of causing its immediate suppression : therefore, to diminish the predisposition gradually, and to mo- derate the violence of the attacks, much care and attention are required. In cases of Prolapse the exciting cause should be well investigated, or the 49 Bougie never can be used with any hope of producing a favourable result ; but where the disease only assumes the incipient symptoms, itch- incr and irritation, no such caution in the use of the Bougie is required. It has been found that the most obstinate cases of Hemorrhage proceeding from ruptured veins, or from tumours, and pro- lapse, will yield to this mode of treatment in two or three weeks, and in a month or six weeks effect a complete cure. In some stages of these complaints the Hemor- rhoidal Tumors become so tender, irritable, and inflamed, that it is difficult to wear the Bougie the first two or three days for more than ten or twenty minutes at a time ; but when the parts become more indurated, and are rendered from its use less susceptible of pain, it can be worn two or three hours, or during the whole night, without the least inconvenience, and scarcely with a consciousness of its being retained. Aperients most particularly to be denounced as being injurious are, aloes, colocynth, calomel, and castor oil ; and, as a substitute (where neither habitual costiveness nor morbid obstruction exist), E 50 the use of such wholesome food as may be found gently to move the bowels once a day must be trusted to. One of the powders, an hour before breakfast, with or without a pill the previous night, aided by Lavement, as administered by my Douche Bath, will be found sufficiently powerful to solicit the quiet and tranquil passage of the feces from the bowels. It is too manifest to admit of doubt, that where extreme constipation and hardened feces exist, the injection of a pint of warm water-gruel, with a dessert spoonful of castor oil, will dissolve the feces, or so far soften and loosen them, as to pro- duce an easy evacuation ; and it is equally certain that a daily indulgence in this mode of relieving the bowels will inevitably bring on a Prolapsus, where the slightest disposition to the" disease exists. The instances of this result are so common, that a reference to any particular case will not be so satisfactory to the mind of the reader as that of drawing his attention to the simple fact of the re- laxing powers of warm fomentations when applied to any part of the human frame. Nothing can be more erroneous than the supposition, that there is 51 any danger to be apprehended from the injection of cold water. Its beneficial effects have now un- dergone the test of experience in cases of Hemor- rhage and Prolapsus ; and that it has improved the general health of the most delicate constitutions, both male and female, nobody can deny. In the depth of winter the intense cold of the water may be a little diminished, but not so unless the bowels are found too speedily to eject it from any griping pain it may occasion. Medicated injec- tions, in a variety of forms, as applicable to other diseases, are productive of the most beneficial re- sults ; and the time is fast approaching when they will supersede the prevalent and abominable use of quack and purgative medicines. It is remarkable that out of the variety of inject- ing apparatus which have been invented, none could be found possessing all the necessary qua- lities which are essential to the ease and comfort of those who use them ; and I was under the neces- sity of getting them constructed upon a plan of my own, by which the whole operation is performed when standing in front of a wash-hand stand, in about half a minute, thus avoiding the troublesome, e 2 52 dangerous, and perplexing ceremony of sitting on one chair, and placing the basin on another. Where injections are daily used, the simplicity of the operation, and the expedition with which it is effected, are both considerations of the first im- portance. For persons in health, in order still further to render this duty less troublesome, I have con- structed a small apparatus, in which a sufficient quantity of water can be conveyed in the pocket or reticule to the water-closet, and injected with the greatest facility. Superior to all the apparatus, however, hitherto contrived for the health and comfort of the afflicted, nay more, as a luxurious piece of furniture, when placed in the boudoir or dressing-room, even of those blessed with health, is my Douche Bath, or Fountain, drawings of which are represented, plates 6. 7., figs. 1, 2, 3, and 4. The advantages of shower-bathing in cases of Nervous Debility, Sciatica, Lumbago, Paralysis, the Neuralgic Affections of the Face and Head, Nerves of the Arm, and of the Lower Extremities, are well known. The application of water by means of a shock or jet, medicated or simple, natural or arti- 53 ficial, hot or cold, is so essential in restoring tone and vigour to the nervous system, allaying spasmodic pains, be they Rheumatic, Neuralgic, or arising from Dyspepsia, improving the circulation of the skin, strengthening the absorbents, exhalents, and inter- nal organs, that few persons are to be found in the upper and middle classes of society in the British Islands, who, if suffering from one, or from a com- plication of these diseases, have not visited, and thereby derived benefit from, the respective water- ing-places, either inland or adjacent to the sea, which are celebrated, each in its way, in this coun- try and on the Continent ; whilst among the lower classes, in England especially, the want of means by this description of persons, in procuring for themselves the luxuries and restoratives of a watering-place, puts such remedies beyond their reach. Yet we find that even amongst individuals in this grade of society attention to cleanliness, by which the skin, and, through its agency, the inter- nal organs, are kept in proper tone and vigour by daily ablution, is more scrupulously attended to than what their situation and avocations might e 3 54 lead the more opulent of their fellow-creatures to imagine. The baths of Harrogate, Buxton, Bath, and in- deed every mineral water in our own country pos- sessing sulphur, and on the Continent those of Barege and Bagneres de Bigorre, are notorious for their efficacy in cases of diseased and stiffened joints, skin complaints, and stomach and liver de- rangements. Accordingly we find the mechanical contrivances at these deservedly celebrated places of fashionable resort equally various towards ac- complishing the different indications of treatment, which disease, in its ever-varying and Protean cha- racters, assumes, driving its victims to the fountain heads of these celebrated springs to seek relief from suffering and woe : thus it is we see the varieties of contrivance endless, whether for the partial or complete immersion of the body, the steaming of the surface by vapour, either general, or directed against a particular joint, or along the course of a morbidly diseased nerve. Such accurately adapted means to ends are the Douches and bath-rooms (excavations, more properly, in the mountain rocks, as at Barege), justly celebrated for the numberless instances of recovery — super-human — because Nature's purest element aptly applied by the inge- nuity of man is the good Samaritan in all these cases, towards which the All-wise Author of our Being has ordained these Agents of His Na- tural World to contribute in restoring to health and ease poor helpless — because indiscreet — and fallen man. As a substitute for these agents of Nature and of Art, a variety of causes has given me opportunities such as few medical men, engaged in the turmoil of general practice, can command, and to which I am mainly indebted for the final accomplishment of my object in the contrivance such as I now submit to the notice of the afflicted. Douches, to their action of Simple Water, add ■percussion to a greater or less degree of the parts against which they are directed ; hence the ad- vantage I have derived from the Fountain in ques- tion, to which I attribute my great success in the treatment of Piles, Hemorrhages, and Prolapsus of the Womb and Rectum. But a few years have elapsed since the profes- sion and society at large were strongly nreiudiced against the use of cold water in the treatment of e 4 56 these diseases ; and since, my early attempts to intro- duce this hitherto dreaded, yet eventually, salutary application of Nature's simple element — have been looked upon as Quixotic — yet my experience, during the past three years, has so fully established my conviction of its perfect safety, whether out- wardly applied by percussion, or inwardly adminis- tered by Lavement, that further comment is need- less. The means, however, of applying cold water have been so imperfect, or, at best, trifling and complicated, that few persons are induced to resort to this simple remedy, from the trouble and fatigue necessarily undergone by sponging ; and the use of the ordinary Bidet, a machine, from the posture of the patient when seated, as he must be, astride, is eminently calculated to make matters worse, tend- ing to bring down the Prolapse, independent of the mess that unavoidably attends its use. All these imperfections are removed, the party sitting on the Douche in the same posture as at the water-closet, while the complications of tubing, screwing, and piping, are done away with ; at least this trouble may not occur once in a week : besides, at the one sitting the patient can not only direct the stream 57 of water against, but if need be into, the Bowel. Privacy, as well, has been secured, as every thing is inclosed in a lock-up case ; the pan is as readily emptied as filled; and all that can be required in the invalid's boudoir or dressing-room is a water- can filled with water. The apparatus is alike applicable as a foot-bath : in cases of Sprains, Contusions, or Rheumatic Af- fections of the Joints, it is equally efficacious, as water hot or cold, medicated or simple, can be applied. In Ringworm, I have proved it a valuable aux- iliary in cleansing the diseased portions of skin, and in applying medicated or other lotions. In all Uterine Discharges, whether too profuse, weakening, or suppressed, it is an agent equally valuable. In Leucorrhcea especially, and in the Spasmodic Affections of the Sphincter Muscles of the Anus, Fistula, and the distressing smarting pain subsequent to alvine evacuations in the cos- tive habit, the application of cold water in this way has acted like magic. After the laborious daily toils of professional life, whether active or sedentary, bodily or mental ; .58 the fatiguing sports of the field, as well as the weariness and discomfort following the amusements of the ball-room, the Douche must prove a luxury, if used a short time previous to going to rest. The mucous discharge attendant on Piles and Hemor- rhage is speedily and safely checked ; and if the patient commands the advantage of a sea-side residence during a portion of, or for the entire year, sea-water used in this way proves a valuable auxiliary to other treatment. I cannot close these brief remarks upon injec- tions without observing, that the knowledge and use of this salutary assistant in all cases of Con- stipation and Disease of the Lower Bowel is en- tirely in its infancy ; and though thousands resort to it for relief, yet, from want of proper instruc- tions, they are certain to err in some important point, and compelled to give it up in despair, or pursue it with difficulty and annoyance. In another Treatise, on the Prevailing Causes of Constipation, I have entered more fully into the use of my in- jections — because I feel convinced, that the more they arc resorted to upon the principle I have now adopted, the less frequent will be all those dread- 59 fill, distressing, and complicated diseases to which the Rectum and parts adjacent are so peculiarly liable. From the decided manner in which my objections to purgatives in almost every stage of these complaints have been stated, it may perhaps be unnecessary for me to caution my readers against the use of stimulating injections, an evil equally injurious with drastic medicines. A daily evacuation of the Bowels is indispens- ably essential to the general health and comfort of every individual. By long retention the feces become altered in their chemical properties. In cases of Hemorrhoidal Tumors the necessity of a daily evacuation is still more important, because, in addition to the above evils, the hardened feces force down the inner coat of the Bowel, and create an irritation and swelling, the effects of which it is impossible for any surgical or mechan- ical skill to subdue, whilst Constipation is suffered to exist. As there have been frequent instances, from unskilful management, of laceration and rupture of the Bowel, attended with serious and even fatal consequences, I recommend that the tube intro- 60 duced into the Rectum for daily use (if a syringe be the instrument employed), should not exceed two inches in length. My Douche Bath, how- ever, is so constructed, that any quantity of water can be thrown into the Bowel sufficient to procure an evacuation, without the introduction of any tube whatever. Cold water may at any time be beneficially applied when the Prolapsus or Piles are com- pletely returned, but not before this has been accomplished. A common objection exists in the minds of the public generally, which has been, I regret to add, rather countenanced by the Pro- fession, against the use of cold water injections. Independent of my own experience to the con- trary, I think myself borne out in advocating its safety, by the simple fact of both cold and hot fluids being taken into the stomach with impunity. If the organisation of the vital structure of the stomach is an objection to common practice in this respect, how much less so is the injection of cold water into the Lower Bowel, whose functions are incomparable in importance with those of the stomach. I have found the foregoing means sue- 61 ceed in arresting Hemorrhages from the Bowel, and in threatening miscarriages. In the latter case I can unhesitatingly vouch for their efficacy from repeated instances of their success ; one in particular, that of a lady, threatened with pre- mature delivery, wherein the application of cold water, both by injection, ablution, and percussion, arrested the Hemorrhage.* Cold water may at any time be applied by those who are in the full enjoyment of health by means of this apparatus ; and I anticipate that the time is not far distant, when this will form an essential piece of furniture in the dressing-room of every person solicitous of health and comfort. The healthy state of the Rectum is so important to the ease and comfort of our existence, that the effort of every individual, who thinks he can improve the mode of alleviating the diseases which inter- rupt its functions, should be received with con- sideration and respect. * This lady persevered in the daily use of cold hip-bathing during the subsequent stages of pregnancy, and gave birth, after a short labour, to a full-grown child. Such was her faith in this salutary agent, that she continued the daily use of my Douche Bath throughout the winter. 6 C 2 If we examine with care the volumes written in past and present times upon Diseases of the Rec- tum, analyse the ideas they contain, and weigh well their relative modes of treatment, we shall not only discover much obscurity and contra- diction, but feel it impossible to arrive at any conclusion conformable with that clear and dis- tinct solution of facts which is so essential to direct our judgment. The frequent return of Prolapsus Recti after operation demands the pa- tient and attentive investigation of those who are engaged in the performance of it. I can vouch for the truth of this observation from having my- self met with several instances in which the opera- tion had been performed once, twice, and in one most obstinate and protracted case even a third time, by surgeons of the first eminence and ex- perience in the treatment of these complaints, without the patient's gaining permanent relief. I have therefore uniformly recommended the plan of treatment herein laid down, the success attend- ing which has been such as to set aside ail neces- S3 sityfor operation. The following analysis of cases sufficiently warrants me in making this assertion : — 63 Of 445 cases within the last two years and a half, 221 had been operated on twice ; in 197 of these cases a relapse had occurred during a period varying from nine months to six years ; 78 had been thrice operated on ; while in the remaining 146, operation had been performed chiefly by ligature, once: of this number 126 were females, whose respective ages did not average 40 : of the residue, 196 were under 50 ; 15 exceeded Go ; 17 under 20 ; 65 from 30 to 45, while 7 were children under 10 years j 2 of this number were girls, and 5 boys. To those afflicted with Hemorrhoids the con- stant practice of taking hot liquids must be preju- dicial, their tendency being to debilitate. Having already recommended in another Trea- tise the use of such wholesome food as may be found gently to move the bowels once a day, it may perhaps improve this suggestion to caution the reader, who has been accustomed to a generous and somewhat stimulating diet, from running into an entirely opposite mode of living, and thereby occasioning not only an injury to his health ge- nerally, but producing a torpid state of the bowels. 64 The mention of this point is the more necessary, from its having been found that several patients, who have placed themselves under treatment, ap- pear to have previously reduced their mode of living, in some instances, to a rigid system of abstinence almost incredible ; and, likewise, from an erroneous opinion of lessening the depletion and irritation, or other sensations which are common to these complaints, such as Indigestion, pains in the pit of the stomach, legs, arms, loins, irritation in the womb, vagina, and bladder, a depression of spirits, and various other affections, all of which I have found gradually diminish, and ultimately disappear, upon the removal of the cause. A gentleman, set. 34, lately wrote me that he had abstained wholly from animal food for twelve months ; he adds, however, as indeed might naturally enough be expected, " even a cup of tea now turns sour on my stomach." 65 FISSURES, ULCERATIONS, ABSCESSES. These complaints most frequently accompany the Varicose Internal Piles and the Spasmodic Sphincter ; they likewise precede the formation of Fistula, though quite distinct from the latter. They are slow in healing, contrary to what occurs in Fistula when properly treated. They can be easily recognised by the offensive discharge of matter with or without blood ; the smell of this discharge is so characteristic of the mischief within, as at once to establish in the mind of the experienced sur- geon the existence of one or more of the above diseases. The patient feels extreme smarting pain during and subsequent to an evacuation, with burning heat in and around the Anus. When the finger is passed up, hard and rough ridges will be felt, corresponding to the Sphincters. These Fis- sures, Ulcerations, and Abscesses may be seated on the mucous membrane lining the Sphincters, their most common situation ; or they may be noticed at the bottom of the depressions, inter- spersed among a group of Varicose Piles. In this F 66 situation they may be overlooked by the inexperi- enced, unless narrowly searched for, which is best done by desiring the patient to strain, and when the cluster of Piles is protruded, gently separating the tumours : if a Fissure, it is readily detected by the ash-coloured lymph which coats it ; if a spot of Ulceration, it most nearly resembles the Thrush of infants ; and if an Abscess, it will be found the size of an issue pea, with a minute point of ul- ceration penetrating therein, precisely resembling the opening of an Anthrax or Carbuncle. These diseases never accompany a pure case of Prolapse, as described at p. 29. ; they are frequently associated with eruptions around the Anus, with Leprosy, Eczema, Prurigo Senilis in this situation, as will hereafter be described, and add much to the tor- ments of the latter complaints. There is always a weeping from the Anus, either of a yellowish or brownish colour, or it may be colourless, giving to the linen when dry the appearance of a stain from starch. They are best and easiest healed by some strong astringent, vegetable rather than mineral. Before all, however, in its effects, is ablution and percus- 67 sion with cold water by means of my Douche, and the after dressing, by means of my Ointment and Bougie. The water may be medicated or sim- ple, natural or artificial. It has been recommended for the cure of this class of diseases to divide the Sphincters into the Fissure, Ulcer, or Abscess. This operation I have never found it necessary to perform ; indeed, have never had occasion to think of it. I look upon it as both barbarous and cruel ; and I feel convinced, from what I have both seen and heard, that incontinence of feces, a never- failing consequence of division of these muscles, is an evil which renders the remedy worse than the disease. In illustration of the truth of these remarks I refer the reader to Case xxii. in this Treatise ; this gentleman has, within the last few days, favoured me with a call ; and on inquiring of him, whether he thought the proposed operation was ever likely to be necessary, his reply was, that he has now ob- tained so much controul over the complaint by the means I recommended, which have already completely released him from pain, as to make him feel easy in his own mind should a relapse ever occur. F 2 68 In short, cold water outwardly applied, as well as inwardly administered by percussion and lave- ment, the aperient medicines, Tonic, and Sarsa- parilla, together with Bougie and Ointment, are quite sufficient to accomplish a cure. In order the more effectually to apply the Ointment, I arm my Bougie with sponge smeared therewith; which, when passed into the Bowel, is so tightly grasped by the Sphincters as to press the sponge to the very bottom of the cleft or fissure. If cathartics are administered, the agony thereby endured equals that which accompanies Constipation. We must, therefore, endeavour to avoid the two ex- tremes, Constipation and Diarrhoea. In one case of acute suffering during defecation, I was com- pelled to get made a hollow Bougie attached to a handle, through which the feces, previously re- duced to a proper consistence by medicine and lavement, and aided by the ordinary efforts at stool, passed away, thereby preventing any portion of the evacuation, however small, to come in contact with, or get lodged in, these irritable cracks and furrows. The instrument is passed up the gut, well oiled inside and out, and held there by its handle, 69 until the effort has been completed. I have recom- mended this Bougie with great success in Pro- lapsus of a large size. The instrument, being metal, is readily cleansed by being held under the stream in the trap, as it jets from the water-closet cistern, and may be conveyed to and from the cabinet in tne pocket or reticule. It is likewise constructed so as to enable the patient, if he pleases, to inject through it any quantity of liquid he may think requisite, previous or subsequent to the motion. In all such cases it is of great moment that the patient inject both before and after an evacuation ; as the smallest lodgement of feculent matter in the fissure, or in contact with the ulcer, or lodged in the cavity of the abscess, gives excruciating pain. FISTULA. This disease has been so well described, its pa- thology so well understood, its symptoms so well detailed, and the treatment hitherto practised so universally known, that to the afflicted it may seem F 3 70 matter of surprise when told, that the disease can be cured without the knife, seton, or caustic. True, I have performed the operation many times by cutting ; and, strange to say, by the aid of my Douche, have not only controlled hemorrhage when a considerable vessel has been cut, but have succeeded in effecting a complete cure in the un- paralleled short time of eight days — the day of operation included. However, I can affirm from experience, that, in six weeks at farthest, Fistula, and all its evils, can be cured without operation — namely, by pressure, by astringent ointments, lo- tions, and, above all, by percussion with cold water, medicated or simple. And I doubt not that, ere long, this mode of curing Fistula in Ano, when sufficiently known and appreciated, will supersede operation altogether. The practitioner in exten- sive business will undoubtedly meet with patients whose opinion is, that operation is the sine qua non; in such cases he is left no other alternative but the knife. Yet operation, however adroitly executed, and the subsequent dressings of the wound (on which the cure depends), be they over so carefully made, will not prevent such a gap remaining in the 71 Sphincters, as to protect the patient from the after consequences — incontinence of feces when the bowels are at all loose ; an evil from which persons endure not only bodily but mental suffering, and to such an extent as to make many declare they would much rather have carried about with them their original complaint. I have given, in another work, Costiveness, the case of a gentlemen whom I advised, as a dernier ressort, to wear a Bougie constructed exclusively and adjusted to the wide gaping outlet of the Anus ; the Sphincters, cellular membrane, and muscular fibres of the Rectum having been all but destroyed by a succession of abscesses in this situation. Little expecting, as I then did, ever to have had a second interview with my patient, the reader may guess my astonishment on hearing from his own lips, a year after, that my apparatus had not only pre- vented the -accident (incontinence of feces) to which he referred all his distress, but that, when the Bougie was withdrawn, the few remaining relics of muscular fibre had actually assumed the office of a Sphincter, thereby enabling him to con- trol the action of the gut, provided the bowels F 4s 72 were not relaxed. Fistula will exist much longer than has been imagined, without making much ravage in the parts, provided the constitution is sound. In a case lately under my care, wherein I had to open several fistulous canals, the patient stated he had been troubled with discharge two years: his disease had begun by External Piles; these flisappeared, and he had them internally : these likewise vanished, when Fistula formed. This man, being valet in a nobleman's family, na- turally felt anxious to retain his situation — a lucrative one — which, through his master's in- dulgence, was kept open for him. As time was, therefore, to him an object, I performed the oper- ation upon a Friday, and, by the aid of my Douche, which he daily used at my house previous to the dressing, the succeeding Friday found him in his situation, the wounds being completely healed. In bringing this cure to so speedy an issue, my patient told me he derived great benefit from the Aperient Pills, Powders, and Alimentary Tonic, elsewhere noticed. In the summer of 1837 I nac l occasion fo treat a case of Fistula, caused by an Abscess which had 73 formed subsequent to the operations by excision and ligature for Prolapse, which my patient had undergone the previous November, on which occa- sion a considerable quantity of mucous membrane had been removed, and the edges brought together by ligature. This was a case treated by pressure and astringents, and eventually got well. See Case I. p. 100. SPASMODIC SPHINCTER. Of all diseases, excepting Cancer, which can occur in this situation, I know none which excites our feelings of sympathy more than that now under consideration, nor one which more loudly calls for relief. Yet, strange it seems, that during the long and extensive experience of such men as Bailie and Colles, but two cases of this disease had been seen by them ; whereas, during the past two years, five cases have occurred to myself. A pa- tient applies under the following circumstances: — " That ten years since he suffered from costiveness and pain in passing his motions, alternating with Remittent Fever, Influenza, or some such epidemic, 74 returning at intervals whenever the bowels become costive ; he feels a dread in going to the water- closet, yet he knows he must go, for, if postponed one day, his sufferings will be tenfold the next. If the evacuation is at all hard, he feels it, in transitu, * cutting the part asunder/ At times the relief of the bowels is accomplished with com- parative ease, and he is in hopes to escape for one day at least; in a short time, however, varying from ten minutes to three quarters of an hour, pain of a burning smarting kind comes on : he will describe this pain as like that which he would suppose produced by the cereing iron applied to the gut ; it comes and goes in paroxysms, which makes him writhe on the floor in strong muscular convulsion, his face becomes livid, his hips strongly contract, his hands are clenched, perspiration breaks from every pore. In this state of suffering he will be kept from six to fourteen hours, when he will describe the ' winding up ' of the paroxys- mal pain as 'pulsatile.'" In this state he seeks for advice, and derives partial benefit therefrom, so as not to suffer to any great extent ; his home insures to him the most regular habits : after a 15 time he is induced, from the degree of amend- ment he may have experienced, to undertake a journey to a friend's house ; he sits up perhaps three or four hours later than was his wont ; he may have forgotten his lavement case ; he misses the conveniences and comforts of his home; he feels himself next morning hot and uncomfortable; is unusually costive, and has not the means at hand whereby to relieve his bowels; he strains vio- lently at the water-closet ; he succeeds ; at same time he feels something give way, or the sensation is that of the Sphincters being rent asunder ; and he experiences a return of all his agony — in which state his medical attendant finds him. Ul- ceration, Abscess, or Fissure of the Mucous Mem- brane, sometimes does, and sometimes does not, accompany the disease; if present, the surest way of detecting them is by examining the finger after it has been withdrawn — spots of matter, with or without blood, or a brownish discharge, is sure to be observed ; which discharge, let it vary ever so much in appearance, possesses the unerring proof of the existence of a breach in the Mucous Mem- brane, a most offensive smell, different altogether 76 from that of the feces : in short, this symptom present, there is no need whatever for the surgeon to torture his patient by introducing a Speculum ; at best but a rude and clumsy instrument, be it ever so dexterously handled. The gelatinous mucus which accompanies the different kinds of Piles and Prolapsus, never partakes of this smell. The Sphincters, under the influence of Spasm, are unusually powerful ; they grasp the finger tightly ; there is noticed an alternate elevation and depression — a rising and falling of the Anus, which to the finger feels burning hot. The inner surface of the Sphincters has a roughish, uneven, or gra- nulated feel, very unlike that velvety smoothness which it possesses in its healthy state. They are reluctant to yield when their antagonists, the muscles employed in defecation, obedient to the will, are called into action : hence a source of agony to the patient. The violent and 'long-con- tinued pain during and subsequent to an evacu- ation, compels the patient to stretch himself for hours on the sofa. This pain may be relieved by pressure, as was the case with a lieutenant- colon el in the artillery, lately under treatment, who told 77 me he never got relief from pain until, mounting his horse, he had ridden six or eight miles at a smart trot. There is a great desire to go to stool, with violent bearing down, followed by a slight exudation of mucus only. The Bladder becomes extremely irritable, the urine deposits a brick-dust sediment if symptomatic fever is present ; at other times, it is as pale as that of an hysterical female. The pain, during the height of the Spasm, extends around the hips into the perineum, the small of the back, down the thighs, even to the soles of the feet. The countenance bespeaks the sufferings the patient endures ; the features are drawn and pinched ; the eyes assume a sallow tinge j the patient becomes dejectedly thoughtful and mad- deningly irritable ; he cannot bear to be spoken to, and feels disposed to find fault and quarrel with every thing and with every one around him. In short, his entire mind seems wrapped up in reflect- ing on the paroxysm that is past, and in gloomy forebodings for the future. In the treatment of this most distressing of all rectal complaints, the simpler the means, and the least irritating these means are, the better. Our 78 only object should be to soothe — to lull suffering ; stimulants are out of the question ; escharotics are maddening to the afflicted. I have long since de- nounced them, satisfied they do much harm, and never any good. In one case, hereafter detailed, they drove the patient, already in despair, almost to distraction. The remedies I have found always to succeed are mild aperient Pills and Powders, Anodyne Ointments, the preparation of Sarsaparilla before mentioned, and the jet d'eau by means of my Douche, directing the water to be medicated, and the apparatus to be constantly at hand, so that the sufferer may promptly apply his remedy the moment he feels the slightest warning of a returning paroxysm : the water may be rendered still colder by the addition of a bladder of ice placed in the pan. These means, I can assure the afflicted, have never failed ; for the truth of which many an afflicted sufferer is this day ready to bear testimony. I am aware that nothing short of division of the Sphincters is considered a radical cure for this complaint ; yet even its warmest ad- vocates have admitted that danger attends the operation. Sir B. C. Brodie lost a patient on whom 79 he had operated. " A lady," he states, "of a pe- " culiarly susceptible nervous system, immediately " after the operation fell into a state of hysterical " syncope ; from this she recovered after three or " four hours, but she died at the end of a week " from Inflammation of the Pleura and Peritoneum, " the shock of the operation having excited in- " flammation in these parts." Sir B. C. Brodie goes on to say, that " no inconvenience follows " division of the Sphincter." Yet I have lately met with three cases operated on, two of them so far back as 1827, one of them is detailed in my work on Costiveness, the other had been operated on by an honourable baronet : the brother of the latter patient having lately been under my care for Spasmodic Sphincter, and naturally dreading the unpleasant results of operation, as evidenced in his brother's case, felt reluctant to submit to so severe an ordeal with the prospect of incontinence of feces, though assured, in despite of all his rea- soning to the contrary, that operation was the sine qua non. Having resolved on coming to town, which he did in the early part of the past sum- mer, the true nature of his disease was then 80 ascertained ; and moreover, that the Piles, for which he had previously consulted me by letter, were the effect not the cause of the Spasm. The appropriate treatment, as heretofore given, was recommended, and persevered in on his return home, and in the short space of six weeks from his leaving town he wrote to assure me that he had nearly got rid of his malady. This gentleman has favoured me with a call since the text has been written, to thank me for a recovery complete so far, and to assure me that, by perseverance with the means which I recommended, he feels satisfied he will never again be troubled with the same complaint. The third case is that of my instrument maker, on whom I operated for Fistula now two years back ; yet he suffers from a similar annoyance at times, when his bowels are relaxed. Now, if these affections of the Sphincter Muscles (for the reader will observe that division of these muscles has been practised alike for Ulcers, Abscesses, Fissures, Spasm, and Fistula) can be cured by means short of the knife, I do not think we are justified in at once proposing operation. Let the practitioner rather 81 make trial of the more simple remedies, such as I have detailed ; if these fail, which in no case have they done in my practice, then operation, with all its risks and annoyances, is the dernier ressort. ERUPTIONS AROUND THE ANUS. Of these I have witnessed a variety, from the simple excoriation, the effect of acrid mucus and looseness of the bowels, of lotions, ointments, &c. to the inveterate Psoriasis or Tetter. The first or simple form is usually a disease of infancy, arising from inattention to cleanliness, to a heated state of the blood, or to a surfeit either in eating or drinking. This species of eruption can be promptly put an end to ; the skill of the nurse alone is sufficient to effect a cure : not so the more inveterate, and, of the entire catalogue of skin diseases, the most obstinate to heal, Psoriasis or Tetter of the skin surrounding the Anus. A patient applies with the following symptoms :■ — " A " distressing itching in and around the Anus, pre- " ceded by long-continued, and accompanied with G 82 " obstinate costiveness for months or years. He " feels an itching, stinging, smarting pain within tlie " gut ; he fancies a worm crawling, or a bee buz- " zing within the pouch of the Rectum, accom- " panied at intervals with throbbing pain/' The itching (worse by far than pain) is frequently in- sufferable ; it comes on at a particular period, generally about the time of going to, or getting warm in, bed. So regular is this periodical visit- ation, that the patient will sit up for hours in hopes of averting the attack : in vain does he try to parly with the enemy, whose visits are, ague- like, inevitable and certain : he endeavours to lessen the violence of the attack by sponging with cold water, or seating himself on a marble flag- stone, or upon some other equally cold substance. The itching, after a time, varying from a quarter to an hour and a half, alters its character to that of burning smarting pain, during which the patient's fingers are unceasing in their efforts to relieve ; blood is drawn, and the recently formed skin is abraded. On inspection, the skin surrounding the Anus is found in spots of a silvery whiteness, or of a bright scarlet colour: if the former, it* partakes of Leprosy ; if the latter, Eczema or Tetter. Fissures in the skin, running in converging radii towards the verge of the Anus, intersect the erup- tion ; these exude a colourless acrid discharge ; the region of the Anus smokes on exposure ; there will be noticed an alternate elevation and depres- sion of the Anus ; the fissures or cracks in the skin will be seen to penetrate into the Bowel along the Mucous Membrane. The contraction of the anal outlet is much more considerable externally than internally ; this contraction will reach to such an extent, as not to admit the point of one's little finger. The lower margin of the Sphincters will, when the finger is passed up, be found doubly as contracted as the upper. In a case, hereafter to be mentioned, this contraction with difficulty ad- mitted my little finger (by no means a large one). If the bowels are costive, each succeeding effort at the water-closet dilates these fissures, giving rise to excessive pain : hence the patient postpones his visit to the closet for a day or two, only to submit, eventually, to a vast deal of suffering. Nor does the pain occasioned at stool subside with the com- pletion of the act : it will, as in the case of Spas- g 2 84. modic Anus, continue for a longer or shorter time. The patient is unable to rest in one posture a single moment ; he feels feverish and un comfort- able, and, in the act of washing, inserts the finger to scratch and press upon the part, the finger acting like the stem of my Bougie, in making pres- sure on the dilated vessels. He flies by instinct to cold water ablution : this, however, affords him but temporary ease : he remains the early part of the night sleepless ; the return of morning finds him exhausted and worn out ; nor, till then, does he obtain repose. If subject to bilious attacks, the eruption at such times is aggravated, becoming the index to the internal derangement : so it is with eruptions of the face, which are the outward sign of the inward mischief. The afflicted pa- tient if excited, as is too often the case with the over-zealous clergyman in his pulpit, or the advo- cate in a court of justice, or the courtier in the heated reception-rooms of a palace levee, is sure to have a return of the paroxysm : hence life becomes a continued scene of expectant suffering. An erup- tion at the angles of the lips, around the nose, or on the chin, frequently accompanies exacerbations 85 of the anal eruption. Observation confirms me in the opinion, that absorption of the excrementitious portion of our food, too long pent up in the cells of the colon, is the frequent cause of eruptions of the skin, more especially that portion surrounding the Anus. The importance, then, of keeping a strict watch over the regular functions of this portion of the alimentary canal is self evident. We should not direct an active purgative in the first instance, which will disturb the patient's bowels three, six, or nine times in the succeeding twenty-four hours. Our remedies should combine only just so much of the aperient properties as will aid Nature's efforts to move the bowels; at the same time, will exert an influence on the secretions of the skin. Accordingly I have directed to be made a preparation of Sarsa- parilla which neutralises acidity, acts powerfully on the pores of the skin, and gently moves the bowels. Aperient Pills I likewise prescribe, composed of vegetable extracts prepared from the expressed juice of plants indigenous to these islands, the properties of which were highly extolled near 200 years ago : these extracts are the expressed juice taken just before the season of flowering, and eva- g 3 80 porated without the aid of heat. I have added to the catalogue of medicines some Aperient Pow- ders ; and in another work * have advised the use of a Medicated Soap for Scald Head of children, which soap is alike efficient in local eruptions around the Anus and Genitals. When the erup- tion partakes of the Prurigo Senilis, and extends to the female organs, coupled as it most frequently is with Inward Piles, the itching becomes insupport- able ; in such a case the introduction of my Bougie, smeared with the ointment, per Anum, affords certain relief. Percussion by water like- wise, medicated or simple, hot or cold, materially expedites a cure. Various escharotics, as con- centrated solution of Lunar Caustic, &c. &c. have been tried, but these drive the patient almost crazy. In short, the less we irritate, and the more we soothe the angry skin, the more certain will be the benefit and the comfort afforded. We must not limit ourselves within a certain time to effect a cure ; tithe, in such a case, should be no object. These eruptions will come and go ; therefore the patient must persevere : nor should he relinquish * An Essay on Ringworm, Itch, and Tetter. 1838. 87 the means found effectual short of two months after every vestige of the eruption has disappeared ; in less than this time we cannot pronounce a radical cure. I cannot conceive how a cautious cure of these eruptions can possibly expose the patient to worse consequences, or in any way endanger life, pro- vided the surgeon endeavour to regulate the bowels and to keep them so. The late Dr. Lettsom supposed that these eruptions were the safeguards to the constitutions of persons otherwise predis- posed to Apoplexy or to Gout. My experience has never led me to the same conclusion ; and I ques- tion much, whether or not the sufferer would rather undergo the risk (were there any), than endure the torments of these distressing complaints. A gen- tleman declared to me that, had it been his lot to have undergone quarantine on his way from Italy to England, whither he came in the summer of 1837 to consult me, during the time Cholera raged in the Neapolitan dominions, he must have fallen a victim to the diseases (Eczema and Con- tracted Anus) under which he suffered. He had g 4 88 however, luckily for himself, procured and read my work on Piles previous to his leaving Rome ; and, during his sojourn at Leghorn — the then qua- rantine depot between the two countries, bethought himself of trying the means therein advised, by which the subsequent privations and hardships undergone in the lazaretto — not the most com- fortable abode under such afflictions — were ren- dered endurable. Subsequent to his arrival in London he continued but a fortnight under treat- ment, and, when taking leave, assured me that the benefit he experienced made him feel regard- less of any privation he might have to encounter on his return to Rome, his then residence. Within the last three months he has been gazetted as Consul to a Foreign Court. The opinion of the writer quoted above I have combatted on the same grounds that I have done the hitherto supposed, though now, I am happy to say, exploded notion of the injurious tendency of cold water injections. I have more than once witnessed an extensive aphthous state of the mouth coupled with anal eruptions ; in fact, a group of symptoms all point- 89 ing to the one cause, — Irritation of the Mucous Membrane. It will be observed, that the principal object of this Treatise is to explain to the afflicted the means by which I am enabled to afford them not temporary, but permanent relief from their suf- ferings. The mind, instead of brooding over the consequences of a doubtful and dangerous oper- ation, is at once relieved by a mode of cure, the efficacy and safety of which must be obvious to every one, more particularly so to those who are the victims of these painful and distressing com- plaints. Every class of society has felt, and will long live to feel, the happy influence of this treat- ment. SPASMODIC STRICTURES OF THE URETHRA. The treatment hitherto followed for strictures in this situation has not been sufficiently preventive ; in other words, remedies have not been tried in the intervals between theattacks of Retention of Urine, be they partial or complete. As in Ague, so in the diseases now under con - 90 sideration, the interval is the time to renovate the constitution generally, and, more particularly, to allay local Spasm, whether muscular or organic. With this view, local and general tonics should be resorted to. Of the former alone I wish now to speak, and can with confidence recommend to the afflicted, Aspersion, by means of my Douche Bath, not only to the Perineum but to the adjacent parts: this may be applied hot or cold, medicated or simple, according as the sensation of the patient may dictate. I am not aware that Percussion, as a means to allay local Spasm, has ever been sug- gested, much less thought of, by the Profession. Spasm of the canal of the Urethra, if muscular, is like cramp in a limb. It consists in irregular action ; one muscle, or set of muscles, being more contracted than another. If organic, it depends on the contractility, or power to contract, of the parie- tes of the tube itself: its walls being repeatedly the seat of inflammation or irritation, lymph is deposited, so that the tube thus narrowed, when acted on by Spasm, is contracted to the diameter of the smallest crow-quill, or finest knitting needle. In either case, whether the Spasm be muscular or 91 organic, Aspersion proves efficient : if muscular, by allaying irritation ; if organic, by quieting irri- tation and inflammation; and subsequently, in the latter case, promoting absorption of the effused lymph, just as the tumefaction of a fractured limb is got down by cold lotions. Now the shock, or jet of water, to the Perineum by means of my Douche, eventually accomplishes both objects, — namely, quiets Spasm, and stimu- lates the absorbents to remove the lymph ; thus at length enabling the sufferer to relieve the bladder. By the application of water, hot or cold, medi- cated or simple, as his surgeon may deem fit, is the patient certain of releasing himself from an agony of suffering inconceivable to those who may not themselves have experienced, or witnessed it in others. This the sufferer is sure to accomplish in the way already mentioned, without having re- course to instruments of any kind, much less to medicines, which upset both head and stomach. Every experienced surgeon must know the sym- pathy that exists between the Head, Stomach, and Urinary organs. Moreover, such is the influence 92 of the mind on the local complaint, that I have repeatedly known the patient compelled, from the mere apprehension of an accident, to retire to the nearest place of convenience ; nay, even the dread of damp feet, as in walking the streets of London during the hottest summer weather, owing to the w r atering-carts, has compelled him to walk the length of a street to secure a dry crossing. In company also, his fears get the better of his con- trol over the bladder ; and if he has been induced to partake of wine, particularly if he tastes a variety, though at most he may drink but two or three glasses, the desire to pass water becomes so ur- gent as to render him fidgety and nervous. Under such distressing circumstances the daily morning and evening use of my Douche Bath has never failed to afford ease and comfort. By adopting this simple course, at the same time applying cold, per Anum, as by lavement, not only will the impression of this salutary agent be conveyed through this channel, the Rectum, to the Bladder, but the bowels will be kept thereby in an easy comfortable state. I am in the habit of directing a variety of medicated Douche Baths, which tend materially 93 to increase the impression on the nerves in this part. All interference with instruments, be they what they may, whether Caustic, Gum Elastic, Wax, or Catgut Bougies, Trocars, Urethra Sounds, cutting down on and dilating the Stricture, is rendered unnecessary, and the risk of Abscess, or Fistula in the Perineum, consequently guarded against. To persons thus afflicted, the apparatus I con- ceive to be invaluable. The possession and use thereof render surgical interference unnecessary : should the latter, however, be decided on, and the fistulous canals laid open, no more effectual agent can be employed towards accomplishing a speedy cure of the wound than Percussion and Aspersion, by means of astringent liquids. The attention of the profession has been en- gaged for some years past in testing the efficacy of cold water dressings in the cure of old Ulcers of the legs, and the result of such trials has hitherto proved most satisfactory. I am not aware that the application of Nature's simple element, by an apparatus such as I have described, has ever been suggested by any surgeon in the treatment of 94 Fistula or of Ulcers ; I deem it therefore well worthy the consideration of every hospital sur- geon, as I conceive no obstacle whatever exists to the application of cold water by means similar to those described, and regulated in strength according as the Ulcer may be "indolent or irritable." I have elsewhere noticed the speedy cure of the wound in the short space of eight days, after operation for Fistula in Ano ; and, with a similar view, should recommend to the managing com- mittees and surgeons of extensive metropolitan hospitals, an apparatus so contrived, as that the jet may strike either directly on its exit from the rose-tube, or inversely, that is, after rising to a certain height and falling in a shower, to strike the Ulcer merely with the force which the weight of each individual drop conveys. At the Barege Baths, I have been informed, the jet of water rises from the floor, and, after reaching a certain height, in its fall strikes against the diseased part. The effect of water thus applied in cases of old Gun- shot Wounds and Exfoliation of Dead Bone is to open the wound anew, cause a fresh growth of granulation from the surface of the sound bone, 95 which eventually separates, and, as it were, expels the old and deadened shell : hence the celebrity of these far-famed mountain springs, medicated as they are by the greatest of all chemists, Nature. In my Essay on Ringworm I have detailed the • success attendant on Medicated Lotions, by means of percussion to the Superficial Ulcerations of the Head, and have so constructed my Douche Bath, by a simple contrivance, as to admit of the application of medicated water by aspersion, to the Scalp even of the infant in the arms, with- out the slightest risk of convulsion, or injury to the sight. I have thus far but briefly noticed the variety of diseases wherein the Douche has been rendered available ; and propose, at some future time, di- recting the attention of the Profession more par- ticularly to Cold Water Aspersion, by a mass of practical evidence now in course of accumulating, which will, I trust, at no distant period, establish its importance as a therapeutical agent, as well as one of the greatest improvements in Modern Surgery. 96 CASE I. PILES, HEMORRHAGE, PROLAPSUS, AND FISTULA. Rev. G. J., a clergyman of the Established Church, and chaplain to a large public institution in this metropolis, the arduous duties of which he has performed with persevering zeal and truly Christian piety while his health permitted, applied to me for advice, January 21st, 1837. The state- ment of his case I give in his own words : — " The first time I had an attack of Piles, which " were external, I was but eighteen, thirty years " ago, since which time they have gradually grown " upon me. " Twenty years since, I began to suffer severely " from Inward Piles and Prolapsus. I have been " confined to my bed from four to six weeks " together, in the most excruciating torture from " violent inflammation, and protrusion of the gut; 97 " have undergone two operations by ligature, the " first of which, three years ago, afforded me re- " lief for about a twelvemonth, when I found my- " self again a sufferer. " At Christmas 1835 my bodily anguish was " greatly augmented by the most tremendous " bleeding whenever I had a motion, creating ex- " cessive debility accompanied by indigestion, " cramps, most violent pains in the left eye and " temple ; excessive difficulty attended the act of " returning the Prolapsus, which invariably came " down with my motions at the closet. " I was forced to leave my duties in other hands, " and retire to the country to recruit my strength. " Four months elapsed, when I returned not much ".benefitted, to resume my duties, and in a fort- " night the most profuse bleeding, pains in the " head, &c. returned, with the Prolapsus, which " had never left me. " In October, I was operated on a second time " by a most eminent and experienced surgeon, " with ligature, when three large Piles, within the " Rectum, were removed ; but I am inclined to " think my life was nearly sacrificed, so intensely H 98 " did I suffer, and so extreme was my weakness, " that even now, at the expiration of three months, " I am unable to resume my duties. I have all the " symptoms already of the disease returning, and " slight Prolapsus with my motions, itching around " the Anus, with much pain after evacuation ; a " sense of weight when standing or sitting ; my " lungs are also delicate with cough and ex- u pectoration, quick breathing, fluttering of the " heart," (the latter symptoms clearly the result of repeated Hemorrhages,) "bowels and stomach " much deranged." From a catalogue of such formidable symptoms the reader will conclude, as I did myself, that little prospect of relief could be held out to my patient, who, in truth, appeared nearly worn out with mental and bodily suffering ; yet after a lapse of a fortnight, during which time a second, and in his then debilitated state, no less formidable an enemy, Influenza, assailed him, he writes me as follows : " Before I had the happiness of knowing " you, digestion made life a burthen to me ; now " although any thing but what I could wish it, still " it is greatly amended ; then I could take no food, 99 " now I can partake of a simple diet, and have no " dread of the consequences ; the Prolapse, after " using your means a few days, now rarely appears, " nor has there been a return of Hemorrhage " (this he dreaded at our first interview). " Is not this wonderful, my dear Sir, and has " not God, as I mercifully prayed he would, pros- " pered your handy work, and added a blessing to " your endeavours to afford me relief? " For thirty years of my life has this scourge of " the human race been growing upon me, and in- " corporating itself as it were with my constitu- " tion, during twenty of which I may almost have " quoted Saint Paul, and said, ' I die daily.' " " I do not think any statement, save that of the " lady, of whose dreadful case you have given an " engraving, equalled my misery ; that of the lieu- " tenant is almost slight, judging by description, '• to the intensity of suffering I have undergone, " and now in one fortnight to be comparatively " well ; I could almost have fancied myself in a " delightful dream, but praised be Almighty God , " it is reality. " To you, my dear Sir, who have been the h 2 100 " talented, as well as generous, medium, through " whom He has been mercifully pleased thus early " to give me healthful ease, I know not what to " say : as the benefit is of inestimable value, so " language cannot do justice to my feelings. " May I never forget the boundless debt of gra- " titude which I owe to the Divine dispenser of 11 the blessing, nor to the good Samaritan, who has " so disinterestedly served and healed me. " Believe me to be, " My dear Sir, " Your grateful Friend and Servant, " G. J." " A. Paul, Esq." * * 1839. — I have, within the last few days, seen this gentle- man, who has continued in the enjoyment of uninterrupted health. There has been no return of Hemorrhage nor Prolapse. The Fistula, he thinks, rather served than injured him. (See pp. 72, 73.) 101 CASE II. ENLARGEMENT OF THE HEMORRHOIDAL VEINS. A gentleman, residing in Greenock, writes as follows, April 2. 1838. " I have for many years been troubled with an " irritableness of my Rectum, attended with very " great itching, especially in bed, when it becomes " inflamed and tender with swelling; and, although " I seldom see blood, there is a secretion." This gentleman was supplied with two Bougies and Ointment, and every necessary instruction for their use ; and on the 29th of the same month (April) an answer was received to the following effect. " I duly received your letter and the two " Bougies, and have since been acting according " to your explicit instructions, and now find myself " little incommoded with the itching. I have found " little inconvenience from using the Bougie. I " never continued it beyond two hours and a half h 3 102 " in a day, although I could have worn it longer. " I see but little inflammation now about the parts; " my bowels are generally very regular. I am in " great hopes that, through the assistance and ad- " vice received, I am to get rid of a complaint " that has annoyed me for years." On the 7th of June, in a subsequent letter, he announced himself perfectly recovered, and quite satisfied with the treatment. REMARKS. It is evident from the itching and swelling which this gentleman complained of, that a considerable distension of the hemorrhoidal veins had taken place ; and nothing but the prompt assistance which he received from the use of the Bougie and Ointment could have prevented the ultimate formation of tumours, or such a varicous state of the parts as to terminate in their protrusion through the Sphincter. 103 CASE III. HEMORRHOIDS. In the month of January of this year I was con- sulted personally by a major-general in the army, aet. 55, strong, muscular, yet spare habit, a sufferer from costiveness, hereditary and acquired, for years ; had spent much of his military life in the East Indies, yet lived most temperately. After sitting in a cold, damp pew, during morning Ser- vice, not clad as the severity of the day required, he felt an unusual itching, tingling sensation, like that of a worm crawling within the Anus, then a tumor which protruded during an evacuation, and subsequently when walking, accompanied by mucous discharge, and, occasionally, bleeding. On examining the gut a tumor, hard to the finger Q*" cartilage, was detected on the left, and a little above the upper margin of the Sphincters, the size of a pigeon's egg. As a proof of the degree of h 4 10i< costiveness which this gentleman experienced, nine of the Pills, a wine glass of the Senna and Gentian Mixture, and two Powders were taken ere he procured relief from the bowels. He used my Douche, and persevered in the use of the Bougie, Ointment, and cold water percussion, during two months, at the end of which time I was pleased to find that for several weeks prior to his last visit, he had discontinued all medicine, relying on the Douche alone, which secured the daily relief of the bowels, and, with it, a return of bodily health and energy of mind, to which he had been a stranger for years. CASE IV. PILES PROLAPSUS HEMORRHOIDS. January 4. 183 ( J. — The Reverend Mr. clergyman of the Established Church, eight years a sufferer from Prolapse and Hemorrhage, much 105 reduced in flesh, of a pale tallowy chlorotic com- plexion, had been twice operated on by a surgeon of character in the treatment of these complaints, and, subsequently, by another surgeon of long standing in the profession, both assuring him of a cure : on examination, the protruding part is found to consist of irregular folds of turgid mucous mem- brane, studded with condylomatous-like tumors, more fleshy than veinous in consistence. The Sphincters are powerful, so much so as to compel him to use long and moderate pressure on the tu- mors. States he has lost, at times, immense quan- tities of blood ; the anal region is much sunken. I made a strong astringent application. 22d. — Tumors lessened in size, though more tender ; no protrusion during meals, and a very trifling one when walking. Applied the astringent a second time, which gave more pain than did the first application. 25th. — Considerable irritation with sfight He- morrhage, since the last application, depicted in his countenance, which is haggard and drawn. He feels, however, a sense of adhesion, as if the ca- libre of the Sphincter were contracted ; yet on 106 passing the finger, this seems more relaxed. Less spasm, no Prolapse this day, though he has walked from his residence, a distance of two miles. 29th. — This morning has had an easy, comfort- able motion, such as he has not had for years, the gut easily returnable afterwards. No bleeding ; looks much improved, and appetite still on the increase. March 18. — Has returned from Brighton an altered man. No protrusion during meals or when walking ; " never thinks now of such a thing." Scarcely any protrusion at stool, the Prolapse slip- ping up with the slightest effort. This gentleman used my Douche Bath, Bougies, and Ointment locally, while internally I desired him to take my Tonic Liqueur, Sarsaparilla, and Aperient Pills, and Powders — the first during the continuance of Hemorrhage, the latter to regulate the bowels, — with the most decided benefit. REMARKS. This, out of many other cases, is a most satis- factory illustration of the advantages of pressure, 107 percussion, and astringents, over operations. He looked upon his application to me as a forlorn hope, little calculating on a cure. In conversation with me, during his first visit, I was forcibly struck with the practical truths of his conclusions : " If," said he, " the gut contains so many folds one " above the other, you remove one by string or " knife only for another to come down ; whereas, " instead of drawing down, you should push up " and support in situ those displaced folds." He little expected, then, that his remarks, on the very threshold of treatment, should be so soon verified. By accident, when at the sea-side, he injected sea- water into the bowels, which I had desired him to use only by percussion. This error he found of service, as the mass of feces became considerably augmented at every evacuation, with- out either heat, irritation, or pain ensuing. 108 CASE V. PROLAPSUS HEMORRHOIDIS. A gentleman, residing in a large provincial town in the South of Ireland, consulted me when in London, in September, 1838, for Inward Piles, which constantly protruded when walking, and likewise during meals. At night, during sleep, they protrude, giving him great uneasiness, and obliging him frequently to take his stick to bed with him, the knob of which, at the handle-end, he used in pressing against the tumors until returned. His bowels are extremely costive, and, at times, he is troubled with Diarrhoea, Hemorrhage, and dis- charges of gelatinous mucus. The disease has been upon him for five years. A variety of con- trivances have been tried to no purpose : a truss is the only thing which gives him partial relief, but his truss merely keeps the tumors within the verge, where they become grasped by the Sphincters, giving him excessive pain. My patient, at times, 109 laboured under extreme depression and lowness of spirits, from which, on his return to his native country, he suffered more than he recollected to have done on previous occasions. This I attri- buted to his journey to and from London, the excitement, and irregular hours, both in meals and rest, consequent thereon, together with exposure to inclement weather. He kindly permitted my artist to sketch the tumors, which, by straining at the water-closet, he succeeded in bringing fully into view as represented in Plate 3. In the month of November of the same year, I received a letter from him, which I here insert in his own words : — " From the great interest you took in my un- " fortunate case of Prolapsus Ani, the present " communication will be alike interesting to you, " as it may be encouraging to others who may be " suffering under the same distressing complaint. " After my arrival at home, I was almost entirely " confined to the house for some weeks, expe- " riencing great lassitude, debility, and depression " of spirits, and unable to use the least exertion, " together with a greater degree of Prolapsus than 110 " I ever had. I steadily proceeded according to " your instructions, and am happy to say that, for " the last few weeks, I have wonderfully recovered " my health and spirits, and am able to walk with " ease several miles daily. The Prolapsus has " considerably decreased. The feces which, for " several years, at intervals, were loose, have now " a natural and healthy appearance, and are voided " without any pain ; I have not voided any blood, " and neither take or require any medicine. I " shall be much obliged if you will favour me " with an egg-shaped Bougie of one inch in dia- " meter in the fullest part, when an opportunity " offers. I read your excellent work on Gostive- " ness with much pleasure and profit. Should it " find its way into every family and be daily con- " suited, I expect the craft would be in danger." And most sincerely do I trust, for the benefit of mankind at large, that my patient's example may be followed by the afflicted, from a firm conviction in my own mind that the treatment therein laid down is as yet in its infancy, and when sufficiently known and practised, there will be but henceforth a tithe of the cases such as that detailed by my Ill patient, in comparison with what hitherto must have met the eye of every surgeon of experience. I have not had any further communication with the gentleman above alluded to, and conclude, from his silence since his letter as above quoted, that he no longer needs advice. CASE VI. PROLAPSE AND PILES. Last January I was waited upon by the Reverend Mr. G., a clergyman residing in Essex, under the following circumstances: — eight years a sufferer from Piles, Prolapse, and most profuse Hemorrhage ; his frame reduced to a mere ske- leton ; countenance haggard, drawn, and pinched; complexion a dingy, tallowy hue ; had been twice operated on by a surgeon of distinguished and long-established merit, and subsequently by a hospital surgeon of eminence. Since which time he had consulted an Honourable Baronet alike 112 eminent for his writings on these diseases, however without effect, though assured by all that operation would be his cure. Two irregular folds of turgid mucous membrane protrude, which are studded with Piles warty on the surface, but not callous, more fleshy than veinous. The Sphincters are powerful in their action, so that he experiences both diffi- culty and pain in returning them ; bowels tolerably regular, has lost at times immense quantities of blood. On exploring the rectum with my finger and sound, I found several loose folds giving more or less resistance according to their situations in pass- ing up the instrument ; the removal of which, by knife or ligature, remarked my patient, " is but " temporary relief;" for, added he, "as the gut is " full of folds, you remove one by string or knife " only for another to come down." Two days after this conversation, I applied a strong astringent liquid to the excrescences, and desired the daily use of my Bougie and Douche. He said, speaking of my preparation of Sarsaparilla, "it makes me hungry ; I am now always craving food, never before." I continued the application of the astrin- gent once a week, and ultimately sent him to 113 Brighton. From accident, he unintentionally in- jected sea-water into, whereas I had desired it to be only used against, the Anus. The effect was to increase the mass of feculent matter, and to give to the parts a feeling of contraction. The following March he returned from the sea-side an altered man ; had gained strength and flesh ; bleeding had ceased. No Prolapse either at stool or when walking, or during meals ; even the exertion of eat- ing, formerly, was sure to bring it down ; "?wiv it never troubles me." Formerly, he added, the He- morrhage at other than the times of evacuating was frequently so profuse as to soak through drawers, trowsers, nay, even from the necessity there was for pressure, stained his surplice when performing duty of a Sunday. CASE VII. PROLAPSUS HEMORRHOIDS. A gentleman, set. 62, consulted me, through his medical attendant, in August last, for the fol- i Ill lowing symptoms, as detailed in his written state- ment : — " As far back as 1813 I felt symptoms of Piles, " with continued bleeding at every stool ; in 1816 " they protruded and bled profusely, until, in " 1824, I was forced to give up all active em- " ployment, being tormented with increasing pain " and debility, accompanied with a dreadful de- " gree of Tenesmus, that I could not attend further " to my duties. " I have tried all methods of relief, and find " none, excepting for a day or two after the action " of any purgative I may have taken. My bowels " protrude with the slightest exertion, and I can- " not walk for half a mile without being under " the necessity of retiring somewhere to endeavour " to force the tumor up. Some days they pro- " trude more than others ; yesterday they were " down five times, attended with a cutting sen- " sation, as though a ligature were tied round " them ; while other days they do not protrude, " excepting at the closet. The size, as near as I " can judge, is an inch diameter, and from one " inch and a half to two inches in length. I have 115 " no pain with an evacuation, but an uneasy sen- " sation before, and also after, until the parts are " returned. The colour, a pale red, and, occa- " sionally, an amber. I lay the origin of the dis- " ease to fatigue, exposure to weather of all sorts, " occasional bad and short food. In fact, I com- " prehend every thing when I say, I was with the " army all through the Peninsular campaign, under " Lord Wellington ; and, latterly, exposed a good " deal at night in Ireland, after the illicit distillers. " I am at present reduced to the greatest degree " of debility — induced, I believe, from the tone " of my stomach being destroyed by the continual " repetition of medicine." REMARKS. That strong purgatives contributed to bring this gentleman into the state above described, I have little doubt. The case, though now under treat- ment, is given to illustrate the baneful conse- quences of purgatives repeatedly administered, as the tone of the stomach and bowels appears all but gone. Since the above had gone to press, I have i 2 116 learned that this gentleman, on a late occasion, travelled, with his son, a distance of 14 miles, which he had not done for twelve years before. CASE VIII. PILES AND HEMORRHAGE. In May, 1838, a gentleman from New York consulted me respecting Bleeding Piles, from which he suffered twenty years. His person spare, and extremely thin. Some years since had profuse bleeding, which was arrested by cold injections, and by cold cream, introduced per Anum ; is rather of a costive habit ; suffers from a slight Prolapse when walking ; itching, and, at times, tingling in the gut. Had consulted Dr. Mott and many other surgeons and physicians at New York, without deriving any benefit. The slightest exertion, that of writing especially, brings down the Prolapse. I passed the sound, which caused him to faint, previous to which he felt something " go up " be- 117 fore the sound. I advised him the use of my Bougies, Tonic, and Douche Bath. In the fol- lowing July he called upon me, having been to Ireland and Scotland, during which time the Pro- lapse never appeared, or gave him the slightest in- convenience, with the exception of a slight eversion of the lip of the bowel during an evacuation, which immediately "slips up" when the effort ceases. During his stay in London he had frequent calls made upon him in exercise, both of mind and body ; the Prolapse, however, still continued less. Even during scenes calculated to try the strongest nerves, the bowels never gave any symptom of protruding, though on one occasion, when wit- nessing a review in Hyde Park, in the presence of Royalty, he was compelled to stand three hours and a half on a barrel : the same number of mi- nutes in a similar posture, ere he reached England, had invariably occasioned his malady. REMARKS. From the soft and flabby state of the gut as examined by the finger, I am disposed to attribute i 3 118 the Prolapse not only to relaxation of the mucous membrane of the Rectum generally, but in some particular portion of the gut, to an entanglement, if I may so speak, of the transverse and longitu- dinal folds, which the efforts at stool, and the hardened masses of feculent matter combined, never failed to force down. The itching and tingling at times indicated a loaded state of the vessels, which, if not timely at- tended to, ultimately ends in Hemorrhage. CASE IX. A gentleman, aged 45, out of Worcestershire, consulted me for Piles, Prolapse, and Hemorrhage, in the month of May, 1838. Three years af- flicted ; Hemorrhage periodical, and at times to such an alarming extent as to cause fainting; the bleedings from time to time ceased, by the aid of styptics and acids. Knows no cause for the complaint ; never bleeds so long as the bowel remains up ; but the instant it protrudes, 119 the blood "squirts" from him in a florid stream, only at the water-closet. His complexion is fair; eyes blue ; his hair, during the period above stated, has turned a silvery white ; skin of hands and face tallowy, and cedematous ; but for the Hemor- rhages, he says, he should be perfectly well. I supplied him with every thing needful for the treatment of his case. In the month of June following, the bleeding had entirely ceased; in the ensuing autumn I was gratified on finding, in a letter I received, the agreeable information ot progressive improvement. He writes as fol- lows : — " My dear Sir, " It is now time for me to communicate with " you, if solely for the purpose of offering you " my grateful acknowledgements, which I now " tender, for the benefits already derived from " your valuable advice, and with a view of pro- " fiting by your further suggestions." And, speaking of one of my medicines, he further adds, " The Tonic was, doubtless, of infinite service. M On the whole you may fully rely on my yielding i 4 120 " implicit obedience to your advice, as I feel as- " sured of obtaining incalculable advantage from " its good effects." CASE X. HEMORRHOIDS. A gentleman of fortune, residing in the country, fifty-two years of age, applied in April of this year, for an excruciating pain in the Rectum, which came on with an evacuation, and continued the greater part of the day. He appeared to imagine that it proceeded from a small red pimple-like excrescence upon the integument at the margin of the Anus ; but, as most of these excrescences are merely local complaints, arising from cuticular se- cretions in the parts, the view taken of the symp- toms did not coincide with his, as to the cause from whence his pain originated : a subsequent con- versation confirmed this opinion, as he stated that, a short time previous to his seeking advice, si- milar excrescence had been excised without in any 121 way diminishing the pain in the Rectum. This gentleman had consulted several surgeons, but with so little success, that he began to consider his case hopeless, and was, in consequence, extremely irri- table and weakly. He was recommended to try the use of the Bougie for a short time ; this he consented to do, and remained in town about ten days for the pur- pose, during which time he became so much better as to return to his home perfectly satisfied of ulti- mate cure. He called in the month of July, to say the pain had returned again, and, by the advice of another surgeon, he had applied a bread and water poultice for three weeks, which had relieved him considerably, but, at the same time, he admitted the benefit he had received from the use of the Bougie. On the 5th of September following, a letter was received from him, wherein he states, " with " regard to the Bougie, I tried it after the first " week of the poulticing, and could not bear it " more than half an hour j at the end of a fort- " night I wore it about an hour, and in three weeks " I could wear it longer — perhaps two or three " hours, with ease." 122 REMARKS. When this gentleman first applied for advice, there was nothing in the symptoms of his case which could lead to a doubt as to the nature of his complaint ; but the excited state of his mind, pro- duced from the variety of opinions he had pre- viously taken, rendered it extremely difficult to fix his attention to the adoption of any particular mode of treatment. Sometimes he would pass Rec- tum Bougies from the apprehension of Stricture ; and at others, he attempted to persuade himself that he had Fistula in Ano. He is now restored to perfect health, and has called more than once to express his conviction that this mode of treatment alone effected his cure. CASE XL PROLAPSUS RECTI. An officer in the Royal Navy, aged forty-eight, applied in September 1830, with a Prolapsus of 123 the Rectum. The detail of this gentleman's suffer- ings is of a nature so uncommon, that he was requested to furnish the particulars of his case as near as he could recollect : this he has kindly done in the following letter, given verbatim : — " Dear Sir, " It was in the early part of 1810, 1 first became " afflicted with external Piles, which were then " relieved by very simple remedies : in the latter " part of the same year a copious discharge of " mucus came on, attended with an almost constant " burning sensation in the Rectum, which was fol- " lowed by a painful bearing down, the acuteness " of which rendered me incapable of following any " employment. On a voyage to the West Indies " in 1812, I had a most dreadful attack : the Rec- " turn came down an immense size, and remained " so for nearly three weeks, during which time I " lay on my back, supported by pillows under " each side of my knees. So painful were the " protruded parts, that I could not bear any thing " to touch them. Warm water fomentations were " recommended to be used by the surgeon of the 124 " ship ; and, at his request, I frequently, during " the day, sat over a tub of boiling water and tar, " which, though it afforded a temporary relief, " yet, I am now convinced, increased the com- " plaint, because the discharge of mucus became " much greater after, and the Prolapsus constantly " falling, attended with acute pain. In this dis- " tressing state I continued for four years, when, " in 1816, I was a little relieved by daily copious " discharges of blood, which ran from me in an " immense quantity at the time of evacuation ; these " bleedings, however, had no effect in keeping the " Prolapsus in its place. In this dreadful state I " continued for fourteen years, quite incapable of " any employment, and an outcast from all society. " The pain upon some occasions was so agonizing, " that I used frequently to rise from my bed in the " middle of the night and walk for hours in the " roads, not caring what became of me. " As you requested me to be as short as possible " in my statement, I have not attempted to detail a " hundredth part of what I have endured, or even " to enter upon the endeavours of various medical " men and others to relieve me. I believe it was YZ5 " about September 1830, I first made my situation " known to you, when you immediately assured me " of your ability to effect a perfect cure. I was " certainly little disposed then to give credit to " such a possibility. I will now cut my narrative " short. By pursuing your admirable mode of re- " lieving the bowels, and wearing your Metallic " Bougie for about three months, my bleeding " ceased, my pains entirely left me, and my Pro- " lapsus never comes down, not if I walk twenty " miles in a day. My state of health has been ex- " cellent ever since ; and it only remains for me " to express the grateful remembrance I shall ever " retain for your skill in restoring me to the enjoy - " ment of perfect health, after twenty years of, I " think, unexampled suffering." REMARKS. When I first attended this patient, the size of his Prolapsus is very accurately shown in PL 1. Fig. 2. ; and that of Fig. 1., in same Plate, repre- sents its present state, which, however, it only assumes by making a considerable effort to force it down. 126 CASE XII. HEMORRHAGE. A gentleman residing in Wales, about thirty years of age, states his case in writing as follows 15th of August, 1837 : — " Hemorrhage on every effort to pass the feces, " but there is no protrusion. At intervals there is " much vascular action around the Anus, and conse- " quent enlargement of the vessels, producing much " pain. The disease is of three years' standing. " The bloody discharge is generally accompanied c< by mucus, and the belief of the patient is, that " the seat of the disease is within, or very near the " grasp of the Sphincters. The disease must have " originated in costiveness, produced by sedentary " habits. The pain is frequently mitigated by an " injection of cold water, but the discharge con- " tinues without any intermission. Styptics have " been used in vain." This gentleman was supplied with the Bougie 127 and Ointment, together with ample instructions, through the medium of his brother, who called with the above letter, and stated that his brother's health was extremely delicate, in consequence of his having lived for some time past almost entirely on oatmeal, fearing to partake of any other food, lest it should increase the depletions. In consequence of this information, he was recommended a more generous diet. On the 23rd Sept. a long letter was received relative to the great improvement in the state of his bowels from following the in- structions, and they now, he says, "act regularly " once a day, and consequently have not occasion " for any medicine whatever." On the 23rd Nov. he was again heard from, and after relating the particulars of his past proceedings, he states, "the " discharge is considerably diminished, and some- " times it disappears for two or three days, then it " will return again, but certainly in a small quan- " tity ; and this is certain, that the parts are ge- " nerally free from pain of any kind, and I am " now (barring a slight cold) in very good general " health.'' In a subsequent letter received from this patient, 128 the Hemorrhage had again returned, and would not yield to the Bougie and former treatment. It soon became evident that a rupture of a vein had taken place much higher up ; and wax Bougies were resorted to, but without producing any per- manent relief. Ivory Bougies, made to correspond in shape with the curve of the Rectum, were sent him. One was retained all night without the slightest difficulty, and by gradually increasing the size, a few weeks' perseverance suppressed the Hemorrhage ; and in January 1838, he came to London, quite stout, and in excellent health, when he stated that the means recommended had pre- served his life. CASE XIII. PROLAPSUS RECTI. A gentleman, aged about fifty, applied for ad- vice, 25th Sept. 1838, for a Prolapsus Recti with which he had been afflicted for several years. It 129 was constantly falling when he walked, and became so extremely painful, that he was obliged to stop and force it up. He was of a costive habit, and had been accustomed to have his stools at night with an injection of warm water : his general state of health was good. He was advised to use the Bougie and Ointment, and some general instructions were given him as to the mode of relieving his Bowels. On the 15th Oct., twenty days after his first visit, he called to say he had followed the instructions, and felt so much improved, that the Prolapsus had only fallen once since he had used the Bougie, which he wore during the night without the slightest inconveni- ence. He further remarked, that the Prolapsus was considerably diminished in size, and that he had no doubt the cure would be complete ; but if not, he promised either to write or call and inform me. He was about to leave town, and, from his silence since that time, it may be concluded the lure was complete. k J 30 REMARKS. It was not thought prudent to advise this gentle- man to alter his time of evacuation from night to morning, because it appeared he had habituated himself to the practice for a considerable time ; but the obvious reasons why an evacuation after breakfast is more natural and healthy than at night, were pointed out to him, and he was advised to effect a change, when he felt relieved from the Prolapsus. Cases of Prolapsus Recti, nearly simi- lar to this gentleman's, greatly exceed in number all other forms of diseases of the Rectum which usually present themselves ; and in no instance has the treatment failed to afford complete relief in thirty-nine out of every forty cases. 131 CASE XIII. PROLAPSUS HEMORRHOIDS. A nobleman, aged forty-five, became a patient, 18th September, 1837, for what he considered a Prolapsus of the Rectum, and which had annoyed him at intervals four or five years. He described it as falling with every evacuation, and at times bleeding profusely : but the greatest in- convenience he sustained was occasioned from its falling every time he took a longer walk than usual, when it invariably bled, and put him to con- siderable pain. The Prolapsus, he said, was then protruded and bleeding. The parts were examined, and a large Hemorrhoidal Tumour was found protruding about three quarters of an inch below the margin of the Anus. This was imme- diately returned above the Sphincter, and the smallest size Bougie introduced, which afforded him such complete relief, that he resolved to walk home with it. In ten days this gentleman returned k 2 132 to say he was so much better that he anticipated a perfect cure. At this interview, some general instructions were given him for the relief of his Bowels, and he was advised to persevere in the use of the Bougie. On the 7th November follow- ing, he was so far recovered as to be enabled to leave off the use of the Bougie by day, and wear it at night only. The Tumor had not fallen once from the time he first introduced it ; and he felt no apprehension of its being again troublesome. The Hemorrhage had gradually subsided, and his general health greatly improved. REMARKS. In stating this case I have felt it necessary to call it Prolapsus Hemorrhoidis, or falling of the Hemorrhoidal Tumor — a designation which, I believe, the disease has not yet received ; but, in my opinion, rendered necessary, in order to dis- tinguish its true character from that of Prolapsus Recti, or falling of the Rectum. 133 CASE XIV. PROLAPSUS RECTI. A watch-case maker, of Clerkenwell, aged 34, applied Dec. 1. 1838, in a dreadful state of suffer- ing from what he called outward Piles. He had been afflicted about three years, and at times was so bad he could not sit at his work. His debility and exhaustion were great. Upon examination, instead of Piles, a portion of gut was discovered, about the size of a large walnut, which had been forced down by the administration of purgatives to relieve costiveness, and cool the parts, as he termed it. The gut was found so tender he could scarcely allow me to touch it : and from its having been occasionally in this state for nearly three years, the intention of attempting to return it at once was abandoned, and the gradual application of external pressure, by means of an instrument constructed for the purpose, was tried. In three weeks this poor fellow was completely restored to health, and ex- it 3 134 pressed himself truly grateful for the relief he had experienced. REMARKS. It appears that this patient's disease was com- pletely misunderstood. The gut had been taken for a Pile, and he was, in consequence, purged, leeched, and reduced to a mere skeleton ; indeed, the whole system of treatment was calculated to increase the disease. Such cases have been met with, and have all yielded to the same mode of treatment. CASE XV. PROLAPSUS RECTI. A lady of rank applied in April, 1834. She briefly stated her case by letter ; but its represent- ation was of such an extraordinary character, as to 135 be scarcely credited. The real cause, however, of her sufferings was at once ascertained to be Pro- lapsus of the gut, which came down with an evacuation, six inches in length, and eight inches in circumference at the base, tapering off gradually to about six inches in circumference at the extre- mity. It appeared in a perfectly healthy condition, but became very tender on exposure to the air, vide Fig. 3. The domestic in attendance, returned the Prolapsus with great skill and dexterity. The sympathy which this amiable and afflicted lady ex- cited, at the narration of her sufferings, induced him to remain two days in attempting to afford her relief by preventing the gut from falling at the time of evacuation ; but all his mechanical contrivances proved unavailing. At fourteen years of age her sufferings appear to have commenced, and from delicacy, she was pre- vented naming it. The disease at length produced such distressing consequences that longer conceal- ment became impossible. Her station in life pro- cured for her the first medical assistance, and an operation was performed by securing the gut in six or eight ligatures ; but in a few months it again k 4 136 protruded in an equally aggravated form, and six similar operations were performed in the short space of seven years, not less than two inches of gut was taken off at each operation, which, to- gether with the present descent of six, make a total of eighteen inches. To give any thing like a narrative of this melan- choly case would occupy every page of this pub- lication. For nearly five years, this lady has never ■- risen from a horizontal position, and upon the least attempt to place her feet upon the ground a tremor immediately pervades the whole muscular and ner- vous system, and renders the effort impracticable. Since the publication of the foregoing, in 1836, a similar and equally severe, though not hopeless case, has occurred to me. The Patient, however, is in a fair way of recovery. CASE XVI. A respectable tradesman at the West End of the town, fifty years of age, applied, April 1., 1836, 137 relative to a preternatural spasmodic contraction of the Sphincter muscle, which occasioned such excruciating pain after a motion in the morning, that he was compelled to lie for several hours on tha sofa, and neglect his business. He had been under the care of a surgeon (eminent for the treat- ment of these diseases) for some time, and every effort had been used by him to mitigate the disease without success. A division of the Sphincter muscle was at length proposed, as the only means left of alleviating the patient's sufferings. This proposition was at first resisted, but an augment- ation of suffering at length induced him to consent. A short interval however elapsed, and the patient met with my Treatise, which induced him, the fol- lowing morning, to detail the particulars of his case to me, and, after an attentive investigation of all the circumstances, I told him an operation such as he had described was not only a desperate remedy, but quite unnecessary. The patient immediately proposed to place himself under my care ; in one week the most painful symptoms subsided, and in a month he was enabled to attend his business as 138 usual ; he is now in perfect health, and, as far as this disease is concerned, will continue so. REMARKS. This case has been selected, out of many of a similar character, first, because the patient courted publicity, and next, because it is of recent occur- rence, and attended with unusual severity. Divi- sion of the Sphincter has already been alluded to, an operation, the necessity for which I feel still more inclined to question, from the uniform success that has attended my mode of treatment. CASE XVII. The following letter has been received from a clergyman of high reputation for piety and Chris- tian feeling, and agreeably to his wish, published verbatim : — 139 " My dear Sir, " Being aware of your intention of publishing a " second edition of your work, I am induced, from " motives of benevolence, to bear testimony from " my own happy experience to the safety, simpli- " city, and efficacy of the means you have dis- " covered for the removal of one of the most " painful and distressing diseases to which human " nature is subject. At the age of twelve or thir- " teen years (a period of life usually exempt from " such sufferings) I experienced the first symp- " toms of Piles ; during the interval from this time " up to my forty-eighth year, I passed through " many seasons of severe and protracted suffering, " when I providentially saw an advertisement of " your Treatise, which having read, I addressed " to you a letter, from which the following is an " extract : — " About twelve months since I underwent the " operation by ligature for the fifth time, and I " have nothing to look forward to, but a constant " repetition of this distressing operation during " the remainder of my life, unless I can be bene- V fited by your mode of treatment, which appears * k G 140 to me rational, and I am anxious to give it a fair trial. " By the regular use of the means you had the kindness to prescribe, every degree of inconveni- ence (but a slight degree of Prolapsus after an evacuation) is prevented, and as two years, the usual interval between the operations, are past, I have now reason to believe that, through the Divine blessing, the painful and distressing dis- ease which more or less has accompanied me through life, is entirely removed. And if the discovery of a remedy, which in its application is attended with little pain and no danger, for a malady — common beyond the conception of those who are unacquainted with medical prac- tice, and which embitters life, and either directly, or by inducing other diseases, brings multitudes to a premature grave — be a benefit, I cannot but regard you as an instrument in the hand of a merciful God, for promoting the welfare of mankind. " If further particulars of my case, or additional information, as to the safety and success of the remedy, would be satisfactory to any suffering 141 " fellow-creature, I beg to assure you that a letter, " addressed (post paid) to the Rev. F. R., Post " Office, Reading, will receive due attention. With " much gratitude for your kindness, " I remain, my dear Sir, " Yours most faithfully, "My 31. 1830." " F. R." CASE XVIII. PILES PROLAPSUS. A gentleman, residing in Exeter, aged 56, con- sulted me, by letter, Dec. 1836, for the following symptoms : — Piles for the last twenty years ; pro- trusion of the fold of the bowel inside the Sphincter after evacuation ; irritation and spasm of the Sphincter extreme; bowels never moved, except by medicine. He writes, " I have never had a con- " tinued Prolapse, but for some days after evacua- " tion the excessive soreness of the prolapsed part 142 " was so great " (this was during a severe attack in the autumn of 1833,) " that I could not return " it without using warm applications, but as you " direct, as soon as I had done so, used cold." He was advised to try the different remedies which have been found effectual in similar cases, the good effects of which he states in a letter, dated January 14th, 1837. " I am na PPy to inform you I am so " much better, that, but for occasional irritation, " and which is near the verge of the Rectum, I " should say I am as well as I can ever hope to be ; " I have taken no medicine since I wrote to you. " The Bougie I have worn once or twice a day " or night, until the last three days, when I have " left it off, but think I shall resume it occasionally, " as I find still Prolapsus after stool, without inflam- " mation, much smaller and more easily returned." This gentleman has been occasionally subject to gouty attacks for the last twenty years ; to these he attributes, in a great measure,. the constipated state of bowels and disordered stomach ; — on this point, he adds in his last letter, " since the use of my " daily enemas, I have had no gouty pains or sick- " ness, but much better health and spirits." 143 Nov. 1839. — This patient I have learned has succeeded in effectually curing himself, by a steady perseverance in the treatment recommended. CASE XIX. PILES, IN WHICH OPERATION FAILED. A lady (set. 45), who had recently perused my work, submitted the following statement of her case for opinion, in the month of March last. " About eighteen years since, I first suffered " from what I considered Piles, occasioned by a " violent and long-continued bowel complaint. A " Tumor protruded, unattended by any bleeding, " but exceedingly painful. This was described to " a Medical Gentleman in a provincial town, who " advised an ointment which enabled the Tumor " to be returned, and afterwards an astringent " lotion was made use of. " In a few days I was relieved in a great measure 144 " from suffering, but have never since been wholly " free from inconvenience. " About five years after the period above alluded " to, a Tumor again appeared, and by the advice " of another Medical Gentleman, of high reputation " for skill, I was induced to have it removed by a " ligature being first applied, and afterwards the " lancet. This removal afforded me much relief u for some time. My constitution is naturally de- " licate, but until the period alluded to at the " commencement of this statement, my health had " been tolerably good : since then my debility has " been extreme. I am now unable to attend to " the ordinary engagements of my house ; and in " despair at ever getting relief, am induced to make " a trial of your remedies." REMARKS. The reader will observe, that a long-continued bowel complaint, unpreceded by costiveness, will occasion the disease j and that an interval, varying from three to twelve years, may elapse from the 145 time of operation, before the same, or some other more severe form of these complaints, returns, which they invariably do, in a tenfold aggravated form. It must be evident to those conversant with the nature of these complaints, that, by timely arresting the increase of Hemorrhoidal Tumors, all the complicated diseases resulting from their formation are subdued. In the case above stated, the preternatural enlargement of the Hemorrhoids would have evidently proved destructive to the general health of the patient, essentially affecting the functions of the stomach, and the whole of the digestive organs. CASE XX. VARICOSE INTERNAL PILES — HEMORRHAGE. Mr. G. W. M. consulted me in November, 1838, as follows : — Internal Piles, which always protrude during an evacuation, and occasionally when walking ; the Tumors are varicose, rough, L 146 and knotty on the surface, as in PI. 1., Fig. 2.; livid in colour ; become turgid by straining, and diminish by pressure ; not painful to the touch, unless when long down ; they then throb and smart ; Hemorrhage on one occasion to an alarm- ing extent ; feels constantly as if a lodgment of feces were in the Rectum, which cannot, yet ought to, come away ; the relief of the Bowels never accomplished by one visit to the closet ; generally regulates his Bowels by taking a great deal of walking exercise. He was supplied with my Douche Bath, Ointment, Bougies, and Medi- cines, and towards the latter end of the succeed- ing month I received a letter, in which, after ex- pressing the pleasure he felt in reporting favourably, he adds, " I have strongly recommended several " friends to submit to your admirable mode of " treatment, which I am now perfectly satisfied " you possess, in such cases as mine." 147 CASE XXI. VARICOSE INTERNAL PILES, FISSURES AND ULCERATIONS. Lieut.-Col. R. consulted me in July, 1838 ; the statement of his case I copy from his letter, as follows : — "I became afflicted with Bleeding " Piles in 1826, which increased to such an extent " that, in November, 1829, an operation with " ligature was performed by Mr. C, a surgeon in " London, and two Piles were removed, which " stopped the Hemorrhage, but left me very weak " for years. I have for the last twelve months " been again a sufferer, with occasional bleeding, " an occasional excruciating pain in the Rectum, " on an evacuation, which continues the greater " part of the day, and at times so violent, that I " am obliged to lie for hours on the sofa. Bowels " generally costive ; often a desire to go to stool, " which is attended with most violent straining, " and a slight discharge of mucus, with a painful L 2 148 " bearing down of the Gut." On examination with the finger, I found on the left side, a ridge running the entire depth of the Sphincters, hard as whip-cord, and giving to the finger the sen- sation of a rough wart ; the matter which ad- hered to the finger was brownish, streaked with blood, and exceedingly offensive ; the pain in this situation was excessive. On desiring Colonel R. to strain, a cauliflower group of Piles, hard and traversed with varicose veins, and with broad basis, presented ; and in the interstices I discovered two fissures, an inch in length, coated with lymph ; hence the source of the offensive discharge : his Bowels were so obstinately costive, that the or- dinary aperient medicines never produced an eva- cuation. I was therefore compelled to direct a Senna and Gentian mixture, and the preparation of Sarsaparilla and Achillaea Millefolium, and I applied a more astringent ointment than what I generally prescribe. The following February he states himself much better, the discharge consi- derably lessened, the bowels more obedient, less straining, and the Piles considerably diminished. In July his costiveness was so far removed as that 149 half of one of the aperient powders moved his bowels freely, which he seldom took once a week ; this improvement he attributed to the Sarsaparilla and Achillea : as a slight stain appeared on his linen, I prescribed the Ointment so highly recom- mended by Dr. Copland, and, since then, by the late Mr. George Bushe, of New York. Two days after Colonel R. returned, and stated he had worn, the Bougie armed with sponge smeared with this Ointment, half an hour, that the result was heat, irritation, and increase of the discharge, with most uncomfortable oppression at the chest and stomach, loss of appetite, confusion of ideas, and, to repeat his own words, made him " excessively uncom- fortable : " absorption of one ingredient of the Ointment (extract of Belladonna) had evidently taken place. Colonel R. has used my Douche Bath with great success. REMARKS. During the time my patient continued under treatment, he repeatedly gave up the system in h 3 150 despair, disheartened by the repeated failures to overcome the obstinately costive habit, while un- der the treatment of other Surgeons of the highest eminence in London ; and had I not assured him that time with me was no object, that by mild means, persevered in for months, he would ulti- mately overcome the torpid state of bowels, I feel satisfied I should have been as unsuccessful as others had been before me. Moreover, this case exemplifies, most strongly, the injurious effects of prescribing cathartics in such a case, a practice re- commended previous to consulting me'; because, if we whip and spur, the crude mass of food is carried down the intestines half digested ; hence unfitted to pass this portion without creating, as any foreign body would do, irritation in the lining of the Rectum. 151 CASE XXII. SPASMODIC SPHINCTER. Mr. B., ast. 50, applied by letter for advice under the following distressing circumstances : — Ten years afflicted with external Piles, which brought on a periodical intermittent attack (pro- bably a kind of Ague, as he resided in Lincoln- shire). With the exception of the complaint, has enjoyed an excellent state of health ; is most temperate and regular in his habits. Has no warn- ing of the complaint, except during and after an evacuation, when he feels an uneasiness — a tight- ness rather — • and internal smarting, in the early stage of the attack : this subsides after an hour or so, but in the course of another hour throbbing sensations commence, and a great fulness of the Bowel ensues. As the complaint advances, greater pain is felt on going to stool, which, as at first, subsides, but in a less degree, and the rest of the symptoms increase to such an extent that the pain l 4 152 is almost insupportable. Internally, the passage feels to be closed ; externally, a few small Piles, the size of a pea, encircle the Anus. The attack varies in continuance from eight to fourteen hours after an evacuation, accompanied with great in- clination to make water during the paroxysm, which, though voided in small quantities, affords but a trifling degree of ease ; there never has been any Hemorrhage from the Bowel. This gentleman adopted the use of the various remedies up to the end of September, with material benefit. " I then experienced an unusual symp- " torn in the part, violent itching in and around " the Anus." In the Spring and Summer of this year (1839), however, he became materially worse, all his symptoms, pain especially, increased ; when, at the earnest solicitation of his friends, he was in- duced to consult two surgeons of eminence in his neighbourhood. An ulcerated Pile was seen on examination, to which Caustic was forthwith ap- plied ; the torments my Patient endured for two succeeding days after this application, can be easier conceived than described. Though a man inured to suffering, he well nigh gave himself up as lost j 153 division of the Sphincters was recommended, and persisted in, despite of all the arguments of my Patient (a reflecting and reasoning man); before, however, submitting to operation, he thought of coming to Town, in order that a personal inter- view might throw perhaps some light upon his case. In the month of June I had the pleasure of a visit, when, the true nature of the disease being revealed, I at once recommended remedies calcu- lated to soothe, not to irritate, the neuralgia of the Sphincters, with the use of my Douche Bath (which was not in existence when he first consulted me) during his stay in London. I introduced a cone of sponge moistened and smeared with Anodyne Paste, and never shall I forget the scene that ensued. He lay writhing on the floor, his face livid, and streaming with perspiration ; pupils dilated, hands clenched, hips as rigid as a board j pulse small, frequent, and intermittent. I advised him to omit the introduction of the sponge, to use the Douche medicated, and to screw in the tube No. 4., by which means the introduction of the lavement Pipe became unnecessary. Suffice it to say, that in August last, I had the gratification to 154 find, in a letter I received, that, considering the suffering he had endured, he stated himself won- derfully better, throwing up the water without the aid of a syringe, which now is such an easy and almost imperceptible operation, that when he feels more heat than usual he uses it occasionally during the day. " All my friends congratulate me on the " improvement of my looks j I walk with compa- " rative ease ; appetite good ; sleep sound and re- freshing. My medical friends," he adds, "are " still of opinion that I must undergo the operation " they recommended as absolutely necessary; but "lam happy to say my present feelings do not at " all bear them out in that opinion." CASE XXIII. FISSURE AND ULCERATION. Mr. F., aet. 56, from Oxfordshire, consulted me personally in September 1837- Body corpu- lent, short neck, profuse perspiration bedewing the face, neck, and chest ; apoplectic diathesis ; 155 had a fit six months back, from which he recovered by bleeding and Purgatives. In the previous Ja- nuary he suffered much from the then epidemic, Influenza, since which time he has felt a burn- ing sensation in the fundament, as if the Anus was rubbed with chaff, (by profession a farmer) ; he feels a sort of gathering pain at the lower part of the bowel, with a discharge of corrupt matter ; bowels regular two or three times daily ; eats heartily ; drinks but little, that little table beer, gin, or brandy and water. On examination with the finger, the Sphincters are found strong, and contract powerfully ; pain felt on the left side, as the finger is withdrawn, which is smeared with a sanious and most offensive brownish discharge. The nature of the complaint being obvious, I ad- vised him medicated enemata, my Pills, Tonic, and Bougie armed with sponge and smeared with ointment ; far from cold lavements driving the blood to his head, as he had been warned they would be sure to do, he described his sensations, from their use, vastly improved j he no longer went about his business in that dogged, listless, abstracted, and sleepy manner so characteristic of his previous 156 state ; his powers of mind improved with the bodily amendment. . Having had occasion, the succeeding summer, 1838, to go into Oxfordshire on a visit to a near neighbour of his, I took advantage of the opportunity to inquire after his health in person. I found him all life, energy, and bustle, foremost to lead his men in the "harvest home," the abun- dance of which afforded sufficient evidence of his being a shrewd and practical agriculturist. REMARKS. This case, with another which presented itself to my notice in the autumn of 1837, wherein the monthly ordeal of leeching, cupping, purging, blis- tering, and, in addition thereto, seton in the neck, — the means endured previous to our interview, but subsequently discontinued, — are sufficient evi- dence that an apoplectic fit may not only be anti- cipated, but, should it have occurred prior to the patient submitting, as in the foregoing instance, to my mode of treatment, will be prevented ever after occurring ; and likewise that a cautious and gra- dual checking of the discharge can never expose the Patient to succeeding attacks. 1.57 CASE XXIV. LEPROUS ERUPTION AROUND THE ANUS. Mr. L., aet. 50, from Plymouth, consulted me in November, 1837 j sallow complexion, spare habit. Present symptoms as follows : a distress- ing itching in and around the Anus, periodically returning to the minute on getting into bed, which led him to think he was troubled with worms ; a quantity of loose flabby skin, the re- mains of External Piles, surrounds the Anus ; the Sphincters are powerfully strong, the Mu- cous Membrane lining them feels hard and rugged ; outside, and for the extent of an inch around the Anus, is seen a patch of eruption, as white as a shilling from the Mint ; this patch is interspersed with cracks, exuding a colourless acrid discharge ; the fissures or cracks in the skin meet, converging like radii towards the margin of the Anus ; he feels ready to tear the parts to pieces, and for two or three hours remains in perfect 158 misery from the distressing itching in and around the Anus. I directed him to use my Ointment and Bougies ; to inject, and to use ablution twice or three times daily. In a letter I received from this gentleman, last year, he writes as follows : — " Dear Sir, — I take " advantage of a friend to send you an account of " myself, which you will be pleased to find very " favourable. The itching has almost ceased, and " I have great hopes of (D. V.) altogether being " set free from an annoyance, that has troubled " me these twenty years, — thanks to your skill." CASE XXV. ECZEMATOUS ERUPTION AROUND THE ANUS. Rev. Dr. B. consulted me in May, 1838. Had suffered from Prolapse and Hemorrhage five years since, for which operation had been performed ; around the Anus, an eczematous eruption exists 159 of a rose colour, interspersed with fissures, exuding an ichorous discharge, which stains his linen a yellow colour ; the surface smokes on exposure j when heated from exercise during his pastoral avo- cations, or when animated in his pulpit, especially during hot weather, the itching becomes intolerable ; he can scarcely control his actions, from the inces- sant worry caused by the eruption ; has consulted the most eminent medical men in Edinburgh and Glasgow, without experiencing the slightest be- nefit j thinks the disease commenced with intense study, and much confinement to the house. I advised him the use of my Bougie and Ointment, with cold applications, and the use of the Medi- cated Soap, as recommended in my work on Ring- worm ; from the combined effects of which he speedily recovered, the eruption gradually drying up. 160 CASE XXVI. CONTRACTED ANUS AND ERUPTION. Mr. H., from Yorkshire, consulted me for a con- tracted state of the Anus, so small as not to admit the point of my little finger (by no means a large one) ; excoriation externally, heat and scalding, itching, tingling and throbbing within, amounting to pain ; weight and discomfort, so much so as to prevent him from walking any distance ; the uneasi- ness comes on when warm in bed : has taken a deal of medicine, Cubebs especially ; his surgeon advised division of the Sphincters ; no Stricture of the Rectum. On attempting to pass my finger, a hard rugged ridge, corresponding to the posterior commissure of the Sphincters, is felt ; the external margin of the Sphincters is that most contracted ; the cracks in the skin all converge, like radii, towards the centre. He used my Douche Bath during this visit j and on calling a few days after, his report was, that its operation had made him 161 feel better than lie had done for years ; he had experienced great relief from the itching. As I have not heard from this gentleman since my interview in July last, I presume the eruption has disappeared, and the contracted Anus gives him little if any inconvenience. REMARKS. The contraction above stated evidently arose from the eruption : all new skin contracts ; each succeed- ing evacuation tearing open the newly formed skin, cicatrisation one day, is followed by laceration the next ; the accompanying inflammation caused deposition of lymph in the interstices of the mus- cular fibre, and in the cellular and adipose structures, which occasioned such a thickening of the verge, especially at its external margin, as to give to the ringer, when passed in, precisely the feel of the os uteri, in the fourth month of pregnancy. In examining the nature and progress of many hundred cases which have come under my care within the last three years, I find so little variation in their characters from those already stated, that M to augment the number would only obtrude a repe- tition of unnecessary detail upon my readers. It will be observed, that it is not essentially ne- cessary in all cases to examine the parts where the disease is seated ; an accurate description from the patient, either personally or in writing, will gene- rally enable me to form a pretty correct judgment. When I deviated from the long established mode of operating for the cure of these diseases, doubts (the offspring of an anxious mind) beset me on every side ; but the uniform success of the prac- tice has dissipated all my fears, and given me that confidence which alone can result from expe- rience. Mr. Carmichael, one of the first Surgeons practising in Dublin, to whom I have had the ho- nour of dedicating a former Edition of this Work, writes me as follows : — "I consider their use," (speaking of my Bougies,) "as one of the most " important improvements in modern Surgery." Hemorrhage and Prolapsus had occurred in the case of a lady, respecting whom he wrote me; as likewise in the case of a gentleman referred to me, both of which, had not the bleeding been arrested, by the timely use of my Bougie with other means, would, 163 eventually, have ended in Marasmus, Dropsy, and Death. Mr. C.'s opinion, in corroboration of my own, I have the pleasure of again submitting to the Public and the Profession generally. POSTSCRIPT. Since writing the foregoing remarks on the cer- tain consequences of removing pendulous flaps of skin from around the outlet of the Anus, the Work of the late Mr. G. Bushe, of New York, has fallen into my hands, wherein I find his views coincide with my own. In the explanation to Fig. II., Plate 2., the Author says, " Indeed, such a pro- " ceeding would be inevitably followed by contrac- " tion of the Anus," and adds, "both Hay and " Kirby committed this error." I am happy in having it in my power to bear testimony to the merits of this book ; it is the work of a master pen, as such I recommend it. And how- ever our views on the subject of operation may differ, yet I cannot but avail myself of the present opportunity to avow my high opinion of the Au- thor's practical knowledge of, and research in, Dis- 164 eases of the Rectum ; at the same time that I take pleasure to myself) at this distant period (now six- teen years), in recognising an old acquaintance and quondam fellow pupil, then House Surgeon, if I mistake not, in the Richmond Hospital, Dublin ; and for whose straightforward honesty, talents, and professional zeal, as the pupil of the late respected Surgeon Todd, I then entertained esteem, as I now feel regret, for the loss of one, who, had he been spared, would have proved an ornament to his Profession. No author in this country (England), if I ex- cept Montegre in France, has treated so ably, prac- tically, and in so few words, on a catalogue of diseases which, during the last half century, have attracted so much the notice of surgeons. PALMAM QUI MERUIT, FERAT. THE END. London : Printed by A. Sfottiswoode, New- Street- Square. PLATE I. Fig. 1. Represents Prolapse of a fold of Mucous Membrane alone, described, pages 29. 125. Fig. 2. Represents a case of Prolapsus Hemorrhoidis. See pages 25. 30. 104. 108. 113. and 125. Fig:l y i JKa:Z. V i # g. EXPLANATION OF PLATE IV. This drawing represents a case of Prolapse of Mucous Membrane and of the Sphincters everted, 3^ inches in length. Cured by Astringents and Percussion, by means of medicated liquids as used in my Douche Bath. a. The first or highest ring of the Prolapse, livid, dry, and welted with turgid varicose veins. See page 29. b. Florid thickened Mucous Membrane, resembling the everted eyelid in Purulent Opthalmia. See page 30. c. A spot whereon grew a small Polypus. See page 32. d. d. Extent of the fissure through which the feces had to pass, and which extends from "before backwards on the face of the Tumor." See page 30. e. A flake of gelatinous Mucus within the lips of the Fissure. See page 30. FlaJbe. 4. SFairZctrul lobttog. EXPLANATION OF PLATE V. This drawing is given to represent not only the " flat- tened cask-like appearance " which the Prolapse assumes, but likewise the concentric rings, resembling those of the Windpipe, described at page 29. It also represents the " slit or fissure from side to side," as the previous plate does the same, from before back- wards. See page 30. TZabt ■'■ 2Tcurland. Z*Z?ioJ THE PATENT PORTABLE DOUCHE BATH OR FOUNTAIN. 7 f *y - ,.- -■ ~ ft* ~~* t A€T ©IF B7SW©. TJBQE i'"i i BUG B TTM NOW PUBLISHED, Price os. PRACTICAL REMARKS ON COSTIVE NESS; Illustrated with a variety of interesting Cases, showing the im- portance of strict attention to the regulation of the Bowels during early life, thereby avoiding Piles, Hemorrhages, and Prolapsus. By Andrew Paul, A.B. M.B. Trinity College, Surgeon. 69. Brook Street, Hanover Square. Also, by the same Author, price 5s. AN ESSAY ON RINGWORM, ITCH, AND TETTER; With coloured Drawings illustrative of these Diseases ; toge- ther with some Important Hints to Parents, and to the Ma- naging Committees of Public Charitable Institutions. The above diseases are cured, in the most simple way, by means of a medicated soap, in preference to mercurial oint- ments and lotions heretofore in use. LONDON: CHURCHILL, 16. PRINCES STREET, SOHO. FANNIN, DUBLIN; BARLOW, BIRMINGHAM; GRAPPEL, LIVERPOOL; M'LACHLAN AND STEWART, EDINBURGH. A 000 020 461 o . - ■-■■: ■ ■ ' <-■:■>■ ' :;?■■'. , ■ ■■>■"-- '